Cataract surgery outcome in patients with non-glaucomatous pseudoexfoliation

Outcome of manual small incision cataract surgery in patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma

PURPOSE

The study aimed to analyze the surgical outcome of manual small incision cataract surgery (MSICS) in patients with pseudoexfoliation syndrome (PXF) and pseudoexfoliation glaucoma (PXG) and compare them with those of controls.

SETTINGS AND DESIGN

This prospective, observational, and comparative study included 150 cases of PXF with cataracts, 150 cases of PXG with cataracts, and 200 cases of cataracts without PXF as controls.

METHODS

MSICS was performed in all cases under peribulbar anesthesia. Intraoperative complications, if any, were noted. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), and postoperative complications were recorded at follow-up on day 1, day 7, and after 1 month.

STATISTICAL ANALYSIS USED

IBM SPSS 24.0 statistics, SPSS South Asia Pvt Ltd.

RESULTS

Lines of improvement in BCVA were significantly better in the control group (8.7 ± 1.7) than that in the PXF (7.5 ± 2.1) and PXG groups (6.4 ± 2.7). IOP significantly decreased from baseline to 1 month postoperatively in the PXG group than in the PXF and control groups (mean difference: 3.8 ± 7.5 mm Hg). Intraoperative iridodialysis and zonular dialysis were significantly high in the PXG group with a proportion of 4 and 20%, respectively. Postoperative choroidal detachment and hyphema, six cases each, were found significantly high in the PXG group.

CONCLUSION

Although the BCVA improvement was less and the complications were high in patients with pseudoexfoliation, especially those with PXG, the reduction in IOP was significant. MSICS can be considered favorably in patients with PXF and PXG, with adequate precautions to manage anticipated complications.

Swept Source Optical Coherence Tomography Analysis of a Selected Eye's Anterior Segment Parameters in Patients with Pseudoexfoliation Syndrome

Background: Pseudoexfoliation syndrome (PEX) is a systemic, age-related disorder characterized by the production and accumulation of pseudoexfoliation material. To date, detailed characteristics have not been published regarding the iridocorneal angle and cornea in patients with pseudoexfoliation syndrome determined through swept source optical coherence tomography (SS-OCT). Methods: A total of 150 eyes of patients with pseudoexfoliation syndrome (ages 69–86 years) and 166 eyes in a control group (ages 54–79 years) were analyzed. Results: The central corneal thickness in the PEX group was 549.56 μm and was slightly (insignificantly) higher than that of the control group (540.56 µm). The anterior chamber of the eye was visibly shallower in patients with PEX syndrome than in those of the control group (2.49 mm vs. 3.07 mm; p < 0.001). The Fourier analysis parameters of the cornea showed multiple differences between the PEX and control groups. With respect to iris area, the parameters showed statistically significant differences between the PEX and control groups in all four quadrants of the eye. No statistical significance was found in the PEX group for the iridocorneal angle parameters, or corneal and lens parameters depending on gender and age. Conclusions: PEX syndrome is characterized by a significant impact on the anterior eye segment, including higher anterior and posterior keratometric values, lower anterior chamber depth, higher iris thickness, and narrower angle parameters. The characteristic anterior eye segment features of PEX syndrome can be detected using SS-OCT, which could potentially assist clinicians in properly managing the disease.

Impact of Pseudoexfoliative Syndrome on Effective Lens Position, Anterior Chamber Depth Changes, and Visual Outcome After Cataract Surgery

Purpose

To compare the effective lens position (ELP), anterior chamber depth (ACD) changes, and visual outcomes in patients with and without pseudoexfoliation syndrome (PEX) after cataract surgery.

Design

Prospective, randomized, fellow-eye controlled clinical case series.

Methods

This prospective comparative case series enrolled 56 eyes of 56 consecutive patients with (n = 28) or without PEX (n = 28) and clinically significant cataract who underwent standard phacoemulsification and were implanted with single-piece acrylic posterior chamber intraocular lenses (IOLs). The primary outcome parameters were the ACD referring to the distance between the corneal anterior surface and the lens anterior surface, which is an indicator of the postoperative axial position of the IOL (the so-called ELP) and distance corrected visual acuity (DCVA).

Results

Before surgery, the ACD was 2.54 ± 0.42 mm in the PEX group and 2.53 ± 0.38 mm in the control group (p = 0.941). Postoperatively, the ACD was 4.29 ± 0.71 mm in the PEX group and 4.33 ± 0.72 mm in the normal group, respectively (p = 0.533). There was no significant difference in ACD changes between groups (PEX group: 1.75 ± 0.74 mm, control group: 1.81 ± 0.61 mm, p = 0.806) and DCVA pre- (p = 0.469) and postoperatively (PEX group: 0.11 ± 0.13 logMAR, control group: 0.09 ± 0.17 logMAR, p = 0.245) between groups.

Conclusion

Preoperative and postoperative ACD, as an indicator of ELP, between PEX eyes and healthy eyes after cataract surgery showed no significant difference. Phacoemulsification induced similar changes in eyes with PEX compared to healthy eyes.

Combined and stand-alone XEN 45 gel stent implantation: 3-year outcomes and success predictors

PURPOSE

To evaluate the 3-year treatment outcomes of XEN 45 gel stent in open-angle glaucoma patients.

METHODS

In this prospective, single-centre interventional study, consecutive eyes with uncontrolled intraocular pressure (IOP) or signs of disease progression despite medical treatment underwent XEN implantation either alone or combined with phacoemulsification (Phaco + XEN).

MAIN OUTCOME MEASURES

Surgical success was defined as 'complete' when 36-month unmedicated IOP was ≤15 mmHg with a relative IOP reduction ≥ 20% from medicated baseline, while the definition of qualified success allowed no more medications than at baseline. Other definitions of success with different IOP thresholds were also analysed. Secondary outcomes included mean IOP reduction, changes in ocular hypotensive medications and rates of reoperations.

RESULTS

Out of 149 eyes initially included, 92 eyes (61.7%) of 68 patients had complete 3-year data (XEN: n = 26; Phaco + XEN: n = 66) after 38.2% were lost to follow-up. Mean age was 76.3 ± 9.1 years, and 66.2% were female. Mean medicated IOP decreased from 20.8 ± 7.4 mmHg (21.0 ± 7.4 [XEN] vs. 20.0 ± 6.9 mmHg [Phaco + XEN]) at baseline to 13.1 ± 3.4 mmHg (12.9 ± 2.9 [XEN] vs. 12.9 ± 3.4 [Phaco + XEN]) at 3 years (-37.0%; p < 0.001). Medications decreased from 1.9 ± 1.3 (2.4 ± 1.5 [XEN] vs. 1.9 ± 1.2 [Phaco + XEN]) to 0.4 ± 0.9 (0.3 ± 0.8 [XEN] vs. 0.5 ± 0.9 [Phaco + XEN]) (-78.9%; p < 0.001). Complete success and qualified success were achieved in 29.0% and 31.0% of eyes, respectively. Needling revision was performed in 51 eyes (55.4%), and 26.1% underwent reoperations. Risk factors for surgical failure included male gender (odds ratio [OR]:3.6; p = 0.03), diagnosis of POAG (OR: 4.5; p < 0.01) and undergoing needling revision (OR: 4.6; p < 0.01). While the type of procedure had no effect on the outcomes of PEXG, POAG eyes undergoing combined surgery had significantly higher rates of failure (OR: 7.29; p = 0.023). Most patients stable at 12-month remained so through to 3 years.

CONCLUSIONS

At 3 years, XEN gel stent implantation achieved clinically significant IOP and medication reduction despite relatively high rates of needling and reoperations. Identifying patients at risk preoperatively may help optimize surgical outcomes.

Phacoemulsification vs manual small incision cataract surgery in eyes affected by pseudo exfoliation syndrome with grade II and III cataracts

PURPOSE:

To compare the postoperative alteration of central corneal thickness (CCT) and visual outcomes between phacoemulsification (group A) and manual small incision cataract surgery (MSICS) (group B) in grade II and III nuclear cataracts (NS II and III) with pseudoexfoliation syndrome (PXF).

METHODS:

It is a double masked prospective randomised interventional study. A total of 60 eyes of 60 patients were assigned randomly to either the phacoemulsification (group A) or MSICS (group B) groups. All eyes had nuclear sclerosis grade II and III (LOCS II grading system) with pseudoexfoliation material either over the pupillary margin, anterior lens capsule, or both. All surgeries were done by a single surgeon. Postoperative evaluation was scheduled on the 1st, 30th, 90th, and 180th-day. Statistical analyses were done using appropriate methods. Outcome of the study were measured with changes in central corneal thickness (CCT), Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) and the spherical equivalent in the operated eye up to 6 months post surgery.

RESULTS:

The mean preoperative CCT showed no difference between the groups (0.9659). The mean rise in CCT on the 1st postoperative day (POD) showed a significant difference between the groups {24.65 (SD 9.32) [group A (Phacoemulsification)] and 33.34 (SD11.68) [group B (MSICS)] (P < 0.0023)}. At the 1st, 3rd, and 6th month postoperative visits, there was no significant difference. The mean uncorrected distance visual acuity (UDVA) on the 1st POD was 0.189 (SD 0.118) in Group A and 0.302 (SD 0.121) in group B (P < 0.0005) which was significantly better with the phacoemulsification procedure. At the 1st month it was 0.039 (SD 0.084) in group A and 0.148 (SD 0.089) in group B (P < 0.004), which remained almost stable after that. The mean corrected distance visual acuity (CDVA) at the 1st, 3rd, and 6th-month postoperative visits showed no significant difference (P 0.8). The mean spherical equivalent was 0.29 in group A and 0.8 in group B.

CONCLUSION:

In moderately hard nuclear cataracts with PXF, phacoemulsification provides better unaided visual outcomes with less endothelial dysfunction than MSICS in the immediate and subsequent postoperative period.

XEN Gel Stent in Pseudoexfoliative Glaucoma: 2-Year Results of a Prospective Evaluation

PRéCIS:: This study confirms the safety and efficacy of XEN gel stents in the management of pseudoexfoliative glaucoma 2 years after implantation, with success rates similar to primary open-angle glaucoma regardless of the definition of success.

PURPOSE

To compare the long-term safety and efficacy of XEN gel implant surgery (Allergan Inc., Irvine, CA) in patients with pseudoexfoliative glaucoma (PEXG) and primary open-angle glaucoma (POAG).

SETTING

Prospective, interventional study in a tertiary glaucoma center.

METHODS

A total of 110 eyes of 85 patients with POAG (57 eyes) or PEXG (53 eyes) and uncontrolled intraocular pressure (IOP) despite medical treatment underwent combined XEN+cataract surgery or standalone XEN surgery. Mean IOP, mean number of medications, needling rates, and incidence of adverse effects were compared between the 2 groups. Complete surgical success was defined as an unmedicated IOP≤12, 15, 16, or 18 mm Hg at 2 years, both with and without a 20% reduction from baseline.

RESULTS

Combined XEN+cataract surgery was performed in 72% of POAG and 76% of PEXG eyes (P=0.67), the remainder underwent standalone XEN surgery. Patient characteristics were similar between the 2 groups except for older age for the patients with PEXG (78.5±8.5 vs. 71.3±8.7 y; P<0.005). Mean medicated IOP were 19.8±5.8 mm Hg (POAG) versus 19.8±8.2 mm Hg (PEXG) at baseline (P=0.98), and 14.5±3.6 mm Hg (-26.8%) versus 14.2±3.8 mm Hg (-28.3%), respectively, at 2 years (P=0.75). Mean medications concomitantly dropped from 1.9±1.6 (POAG) versus 2.0±1.3 (PEXG) to 0.6±0.9 versus 0.4±0.7, respectively (P=0.29). Using the 16 mm Hg threshold, 51.4% (POAG) versus 57.1% (PEXG) eyes achieved complete success (P=0.70) at 2 years. The difference in success rates between the 2 groups was not statistically significant under any of the definitions of success. By 24 months, needling was performed in 42.8% (POAG) and 43.2% (PEXG) (P=0.64), with an average time to needling of 162.8 and 134.9 days, respectively (P=0.46). The rates of adverse effects were 30.6% (POAG) and 36.4% (PEXG) (P=0.66), and additional glaucoma surgeries were carried out in 14.3% (POAG) versus 15.9% (PEXG) (P=0.89).

CONCLUSIONS

The XEN gel implant as a standalone or combined procedure demonstrated similar efficacy and safety results in PEXG and POAG eyes.

Efficacy and safety of the ab interno gelatin stent in severe pseudoexfoliation glaucoma compared to non-pseudoexfoliation glaucoma at 6 months

PURPOSE

To compare the efficacy and safety of the XEN45 Gel Stent surgery between patients with and without severe pseudoexfoliation glaucoma.

METHODS

In this retrospective, single-center, comparative chart review, records of 24 eyes of 23 patients with pseudoexfoliation glaucoma and 24 eyes of 23 patients with non-pseudoexfoliation glaucoma with severe glaucoma, defined as uncontrolled intraocular pressure on maximally tolerated medical therapy, were reviewed. All patients were treated with XEN45 Gel Stent surgery, in either a standalone procedure (84.8%) or combined with phacoemulsification (15.2%). Mean intraocular pressure, mean number of intraocular pressure-lowering medications, change in best-corrected visual acuity and needling or rescue surgery rates were assessed. Success was defined as at least 20% decrease in baseline intraocular pressure among treatment-free patients.

RESULTS

Patient characteristics were similar between the groups. At 6 months, intraocular pressure in the pseudoexfoliation glaucoma group decreased by 32% (24.3 ± 9 mmHg-14.8 ± 7 mmHg, p < 0.001), with comparable decrease in intraocular pressure in the non-pseudoexfoliation glaucoma group (22.6 ± 7 mmHg-16.7 ± 6 mmHg, p = 0.011). Similar rates of patients required topical anti-glaucoma therapy (29% vs 22%, p = 0.559), needling (54% vs 37%, p = 0.247), and rescue trabeculectomy (13% in both, p = 1.00) at the last follow-up. However, intraocular pressure decreased more in the pseudoexfoliation glaucoma group among treatment-free patients (-10.1 ± 8.0 mmHg vs -4.1 ± 8.1 mmHg, p = 0.043), and final intraocular pressure was lower in the pseudoexfoliation glaucoma group (12.2 ± 3.5 mmHg vs 15.8 ± 5.7 mmHg, p = 0.044).

CONCLUSIONS

The XEN45 Gel Stent implant demonstrated similar efficacy and safety among severe pseudoexfoliation glaucoma and non-pseudoexfoliation glaucoma patients. Greater magnitude of decreased intraocular pressure occurred among treatment-free pseudoexfoliation glaucoma patients.