Combined Approach to Phacoemulsification and Trabeculectomy Results in Less Ideal Refractive Outcomes Compared With the Sequential Approach

Cataract surgery combined with glaucoma surgery

PURPOSE OF REVIEW

This review evaluates the surgical management of glaucoma in patients undergoing cataract surgery. Combining both procedures present challenges in balancing intraocular pressure (IOP) control, minimizing postoperative complications, and achieving optimal refractive outcomes.

RECENT FINDINGS

Recent studies highlight the effectiveness of combined glaucoma and cataract surgeries, with traditional filtering surgeries and MIGS showing significant IOP reduction. The abundance of long-term studies shows that MIGS can offer an effective and safer alternative when carefully tailored to meet the specific needs of each patient.

SUMMARY

Combining glaucoma and cataract surgery is a promising approach for patients with coexisting conditions. While traditional surgeries offer robust IOP reduction, MIGS procedures offer better safety profiles with fewer complications and more predictable refractive results. Surgeons must carefully consider the timing and choice of procedures, with further research required to develop standardized treatment algorithms.

Factors Associated with Refractive Prediction Error after Phacotrabeculectomy

PURPOSE

To compare refractive prediction errors between phacotrabeculectomy and phacoemulsification.

METHODS

Refractive prediction error was defined as the difference in spherical equivalent between the predicted value using the Barrett Universal II formula and the actual value obtained at postoperative one month. Forty-eight eyes that had undergone phacotrabeculectomy (19 eyes, open-angle glaucoma; 29 eyes, angle-closure glaucoma) were matched with 48 eyes that had undergone phacoemulsification by age, average keratometry value and axial length (AL), and their prediction errors were compared. The factors associated with prediction errors were analyzed by multivariable regression analyses.

RESULTS

The phacotrabeculectomy group showed a larger absolute prediction error than the phacoemulsification group (0.51 ± 0.37 Diopters vs. 0.38 ± 0.22 Diopters, p = 0.033). Larger absolute prediction error was associated with longer AL (p = 0.010) and higher intraocular pressure (IOP) difference (p = 0.012). Hyperopic shift (prediction error > 0) was associated with shallower preoperative anterior chamber depth (ACD) (p = 0.024) and larger IOP difference (p = 0.031). In the phacotrabeculectomy group, the prediction error was inversely correlated with AL: long eyes showed myopic shift and short eyes hyperopic shift (p = 0.002).

CONCLUSIONS

Surgeons should be aware of the possibility of worse refractive outcomes when planning phacotrabeculectomy, especially in eyes with high preoperative IOP, shallow ACD, and/or extreme AL.

Premium Intraocular Lenses in Glaucoma-A Systematic Review

The incidence of both cataract and glaucoma is increasing globally. With increasing patient expectation and improved technology, premium intraocular lenses (IOLs), including presbyopia-correcting and toric IOLs, are being increasingly implanted today. However, concerns remain regarding the use of premium IOLs, particularly presbyopia-correcting IOLs, in eyes with glaucoma. This systematic review evaluates the use of premium IOLs in glaucoma. A comprehensive search of the MEDLINE database was performed from inception until 1 June 2023. Initial search yielded 1404 records, of which 12 were included in the final review of post-operative outcomes. Studies demonstrated high spectacle independence for distance and good patient satisfaction in glaucomatous eyes, with positive outcomes also in post-operative visual acuity, residual astigmatism, and contrast sensitivity. Considerations in patient selection include anatomical and functional factors, such as the type and severity of glaucomatous visual field defects, glaucoma subtype, presence of ocular surface disease, ocular changes after glaucoma surgery, and the reliability of disease monitoring, all of which may be affected by, or influence, the outcomes of premium IOL implantation in glaucoma patients. Regular reviews on this topic are needed in order to keep up with the rapid advancements in IOL technology and glaucoma surgical treatments.

Comparison of refractive outcomes after combined cataract and glaucoma surgery: trabeculectomy and glaucoma drainage device implantation

PURPOSE

To investigate the refractive outcome of combined cataract surgery and glaucoma drainage device (GDD) implantation compared with trabeculectomy and cataract surgery.

SETTING

Department of Ophthalmology, National University Health System, Singapore.

DESIGN

Retrospective cohort study.

METHODS

206 eyes were enrolled for analysis: 50 had combined cataract surgery and trabeculectomy (trabeculectomy group), 50 had combined cataract surgery and GDD implantation (GDD group), and 106 had cataract surgery alone (control group). Refractive prediction error and absolute prediction error of each glaucoma surgery group were compared with the control group. Subgroup analysis was performed in the following axial length (AL) subgroups: short (<22.5 mm), medium (≥22.5 to <25.5 mm), and long (≥25.5 mm).

RESULTS

In total, 206 eyes were examined. There was no statistically significant difference in the overall refractive prediction error between the GDD (0.00 ± 0.54 diopters [D]) and the control group (0.10 ± 0.53 D, P = .58). There was significant myopic refractive prediction error in the trabeculectomy group (-0.18 ± 0.88 D, P = .020). In eyes with short AL, a greater absolute prediction error was observed in the GDD group (-0.75 ± 0.43 D, P = .039).

CONCLUSIONS

Apart from a significant deviation in short AL eyes, combined cataract surgery and GDD implantation demonstrated no significant postoperative refractive prediction error.

Long-term outcomes of prediction error after combined phacoemulsification and trabeculectomy in glaucoma patients

Background

To investigate long-term outcomes of prediction error after phacotrabeculectomy and to determine risk factors that may cause unstable prediction error after phacotrabeculectomy in glaucoma patients.

Methods

A total 120 eyes of 120 patients who had underwent uncomplicated phacotrabeculectomy (combined group) or phacoemulsification (phaco-only group) were included. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) were measured before and after surgery, and anterior segment parameters including anterior chamber depth (ACD), lens vault (LV), and anterior vault (AV) measured using anterior-segment optical coherence tomography were compared between the two groups. The mean absolute error (MAE) at 3, 6, 12, and 24 months postoperatively were compared. Risk factors associated with unstable prediction error (MAE ≥ 0.5) were investigated in the combined group.

Results

In both groups, BCVA was improved and IOP was decreased significantly. MAE at 3, 6, 12, 24 months postoperatively were not significantly different between two groups. The risk factors for unstable prediction error after 12 months of phacotrabeculectomy were old age and LV. Whereas, the only factor predicting unstable prediction error after 24 months of phacotrabeculectomy was LV. The cut-off value of LV for predicting unstable refractive error analyzed by the ROC curve was 0.855 mm.

Conclusions

Phacotrabeculectomy may be an effective treatment with stable long-term outcomes of prediction error similar to phacoemulsification in patients with glaucoma. However, elderly patients or patients with large LV may be predisposed to unstable prediction error after phacotrabeculectomy.

Refractive outcomes of cataract surgery in patients receiving trabeculectomy-a comparative study of combined and sequential approaches

BACKGROUND

Cataract surgery in combination with or after trabeculectomy is often required for improving vision in glaucoma patients. Intraocular pressure (IOP) changes may influence refractive outcomes after cataract surgery. We compared refractive outcomes of the combined and sequential approaches in managing glaucoma and cataract.

METHODS

This retrospective case-control study included 52 patients (57 eyes) who underwent phacotrabeculectomy (combined group) and 39 patients (42 eyes) who underwent phacoemulsification at least three months post-trabeculectomy (sequential group). The IOP and refraction prediction error were compared at three months after cataract surgery. Univariate regression analyses were used to assess risk factors for the postoperative refraction prediction error.

RESULTS

Anti-glaucomatous medications were not administered to either group. The mean postoperative IOP (12.96 vs. 13.80 mmHg; P = .392), refraction prediction error (-0.32 ± 1.53 vs. -0.47 ± 1.14 D, P = .594), mean absolute error (1.02 ± 1.18 vs. 0.8 ± 0.93 D, P = .320), and surgically induced astigmatism (1.85 ± 1.40 vs. 2.16 ± 1.16 D, P = .161) did not differ significantly between the combined and sequential groups. In the sequential group, the refraction prediction error correlated to the IOP change, with a 1-mm Hg rise resulting in a -0.07-diopter shift between the expected and observed refraction (r = -0.380, R² = 0.144, P = .013); no such correlation was observed in the combined group.

CONCLUSION

Both approaches resulted in similar effective IOP control and accurate intraocular lens predictability. The IOP change affected the postoperative refraction prediction error only in the sequential approach.

Long-term comparison of postoperative refractive outcomes between phacotrabeculectomy and phacoemulsification

PURPOSE

To compare long-term postoperative refractive outcomes between phacotrabeculectomy and phacoemulsification, both with posterior chamber intraocular lens implantation.

SETTING

Department of Ophthalmology, Konyang University, Kim's Eye Hospital, Myung-Gok Eye Research Institute, Seoul, South Korea.

DESIGN

Retrospective comparative study.

METHODS

Postoperative refractive outcomes were compared between patients with cataract and coexisting primary or secondary open-angle glaucoma (OAG) who had phacotrabeculectomy (combined group) and patients with cataract with or without coexisting OAG who had phacoemulsification alone (phaco-only group). The refractive prediction error, mean absolute error, and median absolute error were compared between groups. Subgroup analysis based on preoperative axial length (AL) was performed (medium >22.0 to <24.5 mm; medium-long ≥24.5 to <26.0 mm; long ≥26.0 mm).

RESULTS

The combined group comprised 51 eyes and the phaco-only group, 74 eyes. The mean interval between surgery and refraction measurement was 14.70 months ± 10.80 (SD) (median 13.0 months) and 4.81 ± 4.97 months (median 2.0 months), respectively. Postoperatively, there was no statistically significant between-group difference in the following mean values: refractive prediction error, -0.05 ± 0.64 versus -0.04 ± 0.52 (P = .905); mean absolute error, 0.46 ± 0.44 versus 0.38 ± 0.36 (P = .258); median absolute error, 0.32 (interquartile range [IQR], 0.17, 0.67) versus 0.28 (IQR, 0.13, 0.54) (P = .297). Subgroup analysis also did not show significant differences between the 2 groups (all P > .05).

CONCLUSION

The long-term postoperative refractive outcomes of phacotrabeculectomy and phacoemulsification alone were not significantly different in eyes with OAG, regardless of preoperative AL.

Rotational stability of a new multicomponent intraocular lens

Purpose

To evaluate the rotational stability of the Precisight multicomponent intraocular lens (MCIOL) following primary implantation and after enhancement procedures.

Patients and methods

Prospective, single-center study of eyes that underwent routine cataract surgery with implantation of a non-toric MCIOL, (Precisight, InfiniteVision, Optics, Strasbourg, France). The axis of the MCIOL was measured with a line bisecting the two dialing holes in the front lens. Intraoperative orientation was determined using a digital surgical guidance system while the postoperative orientation was determined using slit-lamp imaging. Two populations were analyzed: eyes that only underwent cataract surgery (PRIM) and eyes that also underwent enhancement (ENH), consisting of surgical front optic exchange. Both populations had 3 observation visits: first implantation (P-Op); 3 months (3mo) and 6 months (6mo) after primary surgery. The ENH group had an additional fourth visit that corresponded to the enhancement surgery (E-Op). The main outcome measure was mean absolute change in MCIOL orientation (degrees). The effects of axial length (AL) and anterior chamber depth (ACD) on IOL rotational stability were examined.

Results

Thirty-three eyes received MCIOL of which 29 had usable orientation images. Of these, 12 were in the PRIM group and 17 underwent ENH. Regarding the mean absolute rotation, among PRIM eyes, P-Op to 3mo was 3.03±2.45 degrees; P-Op to 6mo, 2.28±1.54 degrees; and 3–6mo, 2.37±1.56 degrees. Among the ENH eyes, P-Op to 3mo was 3.09±1.68; E-Op to 6mo, 2.71±3.30 and P-Op to 6mo, 3.62±3.42. There were no significant differences in the IOL rotation. There were no statistical differences in rotational stability between the ENH and PRIM groups. There was no correlation between IOL rotation and AL or ACD.

Conclusion

Precisight appears to be rotationally stable. The enhancement procedure does not affect rotational stability.

Contemporary approach to the diagnosis and management of primary angle-closure disease

The primary angle-closure disease spectrum varies from a narrow angle to advanced glaucoma. A variety of imaging technologies may assist the clinician in determining the pathophysiology and diagnosis of primary angle closure, but gonioscopy remains a mainstay of clinical evaluation. Laser iridotomy effectively eliminates the pupillary block component of angle closure; however, studies show that, in many patients, the iridocorneal angle remains narrow from underlying anatomic issues, and increasing lens size often leads to further narrowing over time. Recent studies have further characterized the role of the lens in angle-closure disease, and cataract or clear lens extraction is increasingly used earlier in its management. As a first surgical step in angle-closure glaucoma, lens extraction alone often effectively controls the pressure with less risk of complications than concurrent or stand-alone glaucoma surgery, but may not be sufficient in more advanced or severe disease. We provide a comprehensive review on the primary angle-closure disease nomenclature, imaging, and current laser and surgical management.

Factors Associated with Outcomes of Combined Phacoemulsification and Ahmed Glaucoma Valve Implantation

Purpose

To evaluate outcomes and factors associated with surgical failure in patients who underwent combined phacoemulsification and Ahmed glaucoma valve (AGV) implantation.

Methods

This retrospective and longitudinal study enrolled 40 eyes (38 patients) that underwent combined phacoemulsification and AGV implantation. Visual acuity, intraocular pressure (IOP), and number of antiglaucoma medications were evaluated preoperatively and postoperatively. Complete success was defined as a last follow-up IOP of 6 to 21 mmHg without medication, qualified success as an IOP of 6 to 21 mmHg with medication, and failure as an IOP of >21 or <6 mmHg.

Results

The mean follow-up period was 18 ± 10 months. Preoperative diagnoses were chronic angle closure glaucoma (35.0%), neovascular glaucoma (22.5%), uveitic glaucoma (17.5%), primary open-angle glaucoma (15.0%), and other (10.0%). IOP decreased from a mean of 30.5 ± 8.7 to 14.5 ± 3.7 mmHg at the last follow-up visit (p < 0.001). Treatment was classified as qualified success in 18 eyes (45%), complete success in 15 (37.5%), and failure in seven (17.5%). Twenty-two eyes (55%) showed improvement in visual acuity. The most common postoperative complication was a transient hypertensive phase (five eyes, 12.5%). Tube-iris touch was associated with surgical failure (hazard ratio, 8.615; p = 0.008).

Conclusions

Combined phacoemulsification and AGV implantation is an effective and safe surgical option for patients with refractory glaucoma and cataract. Postoperative tube-iris touch is an indicator of poor prognosis.

Refractive outcomes of phacoemulsification cataract surgery in glaucoma patients

PURPOSE

To evaluate refractive outcomes after phacoemulsification cataract surgery in patients with glaucoma.

SETTING

University of Colorado Health Eye Center, Aurora, Colorado, USA.

DESIGN

Retrospective case series.

METHODS

The incidence of refractive surprise was evaluated in patients with and without glaucoma after phacoemulsification cataract surgery. Refractive surprise was defined as the difference in spherical equivalent of the refractive target and postoperative refraction in diopters (D).

RESULTS

The study comprised 206 eyes in the glaucoma group and 1162 control eyes. The refractive surprise greater than ±0.5 D and ±1.0 D was 29.9% and 4.9% in the control group and 40.3% (P = .0061) and 11.2% (P = .0011) in the glaucoma group. Primary open-angle glaucoma (POAG) (n = 154 eyes), chronic angle-closure glaucoma (n = 18 eyes), and pseudoexfoliation glaucoma (n = 23 eyes) had odds ratios of 1.90 (P = .1760), 14.54 (P = .0006), and 7.27 (P = .0138), respectively, of refractive surprise greater than ±1.0 D compared with patients without glaucoma. Refractive surprise was noted more often in POAG eyes with axial lengths longer than 25.0 mm (P = .0298). Glaucoma eyes had worse mean postoperative corrected distance visual acuity than control eyes (glaucoma: 0.1088 logarithm of the minimum angle of resolution [logMAR]; controls: 0.0358 logMAR; P = .01).

CONCLUSION

Patients with a diagnosis of glaucoma were more likely to have a refractive surprise and/or worse visual outcome after phacoemulsification cataract surgery.

Intraocular Pressure, Axial Length, and Refractive Changes after Phacoemulsification and Trabeculectomy for Open-Angle Glaucoma

PURPOSE

To compare changes in intraocular pressure (IOP), axial eye length (AEL), and refractive outcome in primary open-angle glaucoma patients undergoing cataract surgery and trabeculectomy in dependence of the sequence of surgeries.

MATERIALS AND METHODS

We retrospectively analysed 48 eyes. The changes in refraction, intraocular pressure, and axial eye length were analysed after surgery. In group A (21 subjects), phacoemulsification was performed before trabeculectomy, and in group B (27 subjects), trabeculectomy was performed before phacoemulsification with a minimum time span between interventions of 6 months.

RESULTS

The reduction in IOP and the decrease in AEL after trabeculectomy were significant after 6 and 12 months postsurgery (p < 0.001 each). The decrease in AEL was 0.42 ± 0.11% at 6 months after surgery and 0.40 ± 0.13% after 12 months from surgery; this decrease in AEL was comparable between the groups. The refractive outcome was significantly different between the groups (group A: 0.35 ± 0.75 dpt, group B: -0.05 ± 0.36 dpt, p = 0.018); in group A, trabeculectomy caused a hyperopic shift of 0.34 ± 0.44 dpt (p = 0.002) at 12 months postsurgery.

CONCLUSION

IOP reduction after trabeculectomy causes AEL shortening. The effect on refractive outcome depends on the sequence of surgeries. Better refractive outcome is achieved if phacoemulsification is performed after trabeculectomy.