Phacoemulsification alone versus phacoemulsification combined with trabeculectomy for primary angle-closure glaucoma

Phacoemulsification versus Phacotrabeculectomy in Medically Controlled Primary Angle Closure Glaucoma with Cataract in an Indian Cohort: A randomized controlled trial

PURPOSE

To compare the outcomes of phacoemulsification with phacotrabeculectomy in primary angle closure glaucoma (PACG) eyes with medically controlled intraocular pressure (IOP).

METHODS

Prospective, randomized control trial including 33 eyes of 33 patients who underwent phacoemulsification (Phaco) and 37 eyes (37 patients) who underwent phacotrabeculectomy (PT). The primary outcome measure was survival defined as IOP control (IOP ≥ 6 and ≤ 21 mmHg without antiglaucoma medications (AGM) at different time points. Secondary outcome measures were the rate of visual recovery and complications.

RESULTS

The mean age in years (PT: 58.5 ± 9.8, Phaco:61.6 ± 8.9; p = 0.16), preoperative mean deviation in decibel (PT: -18.7 ± 9.3; Phaco: -16.6 ± 7.9; p = 0.32) and the mean follow up in years (PT: 2.5 ± 1.8; Phaco: 2.8 ± 2.0; p = 0.63) were similar in the two groups. The mean preoperative AGMs were more in the PT group (PT: 2.13 ± 0.97, Phaco: 1.60 ± 0.78; p = 0.01). In both the groups the survival was similar at all-time points (PT: 78% at 1-year and 52% at 5-years, Phaco: 80% at 1 year and 59% at 5 years (P = 0.82). The postoperative visual acuity in LogMAR was significantly better in the Phaco group at 1 month (PT: 0.22 ± 0.38, Phaco:0.06 ± 0.07; p = 0.02). Postoperative AGM (p = 0.68) and rate of visual field progression PT: -0.46 ± 0.41 dB/year; Phaco: -0.38 ± 0.73 dB/year; p = 0.67) were similar in both groups. One eye in PT group developed malignant glaucoma which resolved with laser hyaloidotomy and cycloplegic therapy.

CONCLUSIONS

More rapid visual recovery with similar IOP control and similar visual field stability favor phacoemulsification to phacotrabeculectomy in medically controlled PACG eyes with cataract.

Mitomycin C-augmented Phacotrabeculectomy Versus Phacoemulsification in Primary Angle-closure Glaucoma: A Randomized Controlled Study

PRECIS

Phacotrabeculectomy yielded similar results to phacoemulsification in primary angle-closure glaucoma (PACG) in terms of intraocular pressure (IOP) lowering, glaucoma medications and success rates. Although releasable sutures may have reduced the risk of hypotony; complications and interventions were more common with phacotrabeculectomy.

PURPOSE

To compare the efficacy and safety of phacotrabeculectomy using releasable sutures and adjunctive mitomycin C versus phacoemulsification alone in the management of PACG.

PATIENTS AND METHODS

In total, 63 eyes of 63 PACG patients were randomized to undergo either mitomycin C-augmented phacotrabeculectomy with tight scleral flap closure using releasable sutures aiming at no flow or phacoemulsification alone. The primary outcomes were success rates and complications. Secondary outcomes were IOP and glaucoma medications.

RESULTS

The IOP and glaucoma medications were significantly reduced at 1, 3, 6, and 12 months postoperatively in both groups (P<0.001). There was no statistically significant difference in IOP, IOP reduction, success rates, or survival times between both groups. Glaucoma medications were only significantly lower in the phacotrabeculectomy group at 1 and 3 months. The rates of postoperative interventions and complications were higher in the phacotrabeculectomy group. Complete success, defined as an IOP of 6 to 21 mm Hg on no medications and with no signs of glaucoma progression, was achieved in 58% in the phacotrabeculectomy group, compared with 62% in the phacoemulsification group (P=0.9). Only 2 eyes (6%) in the phacoemulsification group required a subsequent trabeculectomy.

CONCLUSIONS

Trabeculectomy did not seem to add an advantage when combined with phacoemulsification in PACG patients and was associated with more postoperative interventions. Despite the use of releasable sutures to allow titration of the IOP postoperatively, the rate of hypotony and other complications was higher in the phacotrabeculectomy group.

Comparative Evaluation of Phacoemulsification Alone versus Phacoemulsification with Goniosynechialysis in Primary Angle-Closure Glaucoma: A Randomized Controlled Trial

PURPOSE

Comparative evaluation of phacoemulsification (phaco) alone versus phacoemulsification combined with goniosynechialysis (phacoGSL) in primary angle-closure glaucoma (PACG).

DESIGN

Prospective, randomized, parallel group, active controlled trial.

PARTICIPANTS

Patients with PACG.

METHODS

A total of 120 consecutive patients with PACG were screened, of whom 80 met inclusion criteria, with PACG uncontrolled on maximal hypotensive therapy and were recruited. Patients were randomized into 2 groups and underwent phaco alone in group 1 or phacoGSL in group 2. The patients were examined at baseline and at 1 week and 1, 3, and 6 months. The anterior chamber angle parameters on swept-source anterior segment OCT (SS-ASOCT) were noted at 1 and 6 months.

MAIN OUTCOME MEASURES

The primary outcome measure was intraocular pressure (IOP) reduction. A reduction in IOP of ≥ 20% from baseline IOP with or without medications was considered a success. Secondary outcome measures included change in the anterior chamber angle temporal parameters, angle-opening distance, trabecular-iris space area and scleral spur angle, surgical safety, visual acuity, and reduction in the number of glaucoma medications postoperatively.

RESULTS

The average age of patients was 58.77±8.14 years and 56.50±9.17 years in groups 1 and 2, respectively (P = 0.31). The mean baseline IOP was 29.48±6.76 mmHg and 30.72±3.88 mmHg in groups 1 and 2, respectively (P = 0.13). Success was obtained in 93.33% of patients in group 1 and 91.18% of patients in group 2 at 6 months (P = 0.39). Mean IOP was 13.17±1.66 mmHg and 13.21±1.97 mmHg at 6 months in groups 1 and 2, respectively (P = 0.001). The reduction in IOP was 55.32% and 56.99% at 6 months in groups 1 and 2 (P = 0.48). Significant widening of the angle parameters was noted at 6 months with an increase compared with baseline values in both groups. In multivariate analysis, the significant predictor of decrease in IOP was the higher baseline IOP.

CONCLUSIONS

Both phaco and phacoGSL are associated with a significant reduction in IOP along with a noteworthy widening of the anterior chamber angle parameters. Both procedures succeeded in reducing the necessity of glaucoma medications postoperatively in PACG eyes. There is no additional benefit of phacoGSL over phaco in PACG.

Surgical outcomes of phacoemulsification/goniosynechialysis with and without endocyclophotocoagulation in patients with chronic angle closure glaucoma

Purpose:

To compare surgical outcomes of patients after phacoemulsification with goniosynechialysis (phaco/GSL) versus phaco with GSL and endocyclophotocoagulation (phaco/GSL/ECP) in patients with chronic angle closure glaucoma (CACG) through 12-month follow-up.

Methods:

A retrospective, nonrandomized, comparative case series was performed. Patients with CACG who underwent phaco in combination with either GSL alone (group 1) or GSL with ECP with intracameral injection of kenalog (group 2) from 2011 to 2018 were included. Group 1 included 6 eyes of 6 patients and group 2 included 11 eyes of 10 patients. All surgeries were performed by a single surgeon (RSA). Primary outcome measures included changes in intraocular pressure (IOP), visual acuity (VA), failure based on IOP (>18 or <6 mmHg at 1 year), and secondary operative procedures and complication rates. Data were analyzed using a paired two-tailed T-test.

Results:

The mean preoperative IOP decreased from 23.5 ± 11.2 to 14.2 ± 2.4 mmHg (P < 0.0073) in group 1 and 24.4 ± 8.2 to 14.5 ± 2.7 mmHg (P < 0.0001) in group 2. The mean % IOP reduction was 33.7% in group 1 and 34.2% in group 2. The mean improvement in VA (logMAR units) was 0.24 (P = 0.085) in group 1 and 0.13 (P = 0.657) in group 2. The mean number of topical meds decreased from 2.50 ± 1.76 to 1.80 ± 1.64 in group 1 (P = 0.513) and from 2.82 ± 1.25 to 1.17 ± 0.98 in group 2 (P = 0.014).

Conclusion:

Phaco/GSL and phaco/GSL/ECP both achieve a significant reduction in IOP without the complications associated with traditional glaucoma filtration surgeries.

Phacoemulsification versus combined phacotrabeculectomy in the treatment of primary angle-closure glaucoma with cataract: a Meta-analysis

AIM

To compare the efficacy and safety of phacoemulsification (Phaco) against combined phacotrabeculectomy (Phacotrabe) in primary angle-closure glaucoma (PACG) with coexisting cataract.

METHODS

By searching electronically the PubMed, EMBASE, Scientific Citation Index and Cochrane Library published up from inception to January 2014, all randomized controlled trials that matched the predefined criteria were included. The quality of included trials was evaluated according to the guidelines developed by the cochrane collaboration. And the outcomes estimating efficacy and safety of two different surgical treatments were measured and synthesised by RevMan 5.0.

RESULTS

Five randomized controlled trials were selected and included in Meta-analysis with a total of 468 patients (468 eyes) with both PACG and cataract. We found that Phacotrabe had a greater intraocular pressure (IOP) lowing effect [preoperative IOP: weighted mean difference (WMD)=0.58, 95% confidence intervals (95% CI, -0.53 to 1.69), P=0.31; postoperative IOP: WMD=1.37, 95% CI (0.45 to 2.28), P=0.003], a lower number of anti-glaucoma medications [ risk ratio (RR) =0.05, 95% CI (0.02 to 0.18), P<0.00001] needed postoperatively and less serious damage of optic nerve [risk ratio (RR)=0.48, 95% CI (0.21 to 1.07), P=0.07], but a higher risk of complications [odds ratio (OR) =0.04, 95% CI (0.01 to 0.16), P<0.00001] compared with Phaco. The rest studies indicated that there had no significantly difference between the two surgical methods for postoperative best-corrected visual acuity (BCVA) [WMD=-0.05, 95% CI (-0.14 to 0.05), P=0.32] and loss of visual field [OR=1.06, 95% CI (0.61 to 1.83), P=0.83].

CONCLUSION

Phaco alone compared with Phacotrabe had a better effect in IOP reduction, whereas the security decline. Considering the number of sample size, our results remains to be further studied.

Effect of Goniosynechialysis During Phacoemulsification on IOP in Patients With Medically Well-controlled Chronic Angle-Closure Glaucoma

PURPOSE

To evaluate and compare the efficacy and safety of combined phacoemulsification and goniosynechialysis (PEGS) to phacoemulsification alone (PE) in patients with medically well-controlled chronic angle-closure glaucoma (CACG) with cataracts.

MATERIALS

Thirty eyes diagnosed with CACG and requiring cataract surgery from January 2008 to October 2010 were prospectively randomized, 15 each to PE and PEGS. Changes in peripheral anterior synechiae (PAS), intraocular pressure (IOP), anterior chamber depth, and number of antiglaucoma drugs from baseline to 2 months after the operation were analyzed, as were the type and number of complications.

RESULTS

The PE group showed decreases in PAS (118.67±95.38 degrees) and IOP (2.33±2.38 mm Hg) and a significant reduction in the number of antiglaucoma drugs (0.53±0.83, P<0.05) from before to 2 months after surgery. The PEGS group showed similar decreases in PAS (114.00±90.95 degrees), and IOP (4.53±4.16 mm Hg) and number of antiglaucoma drugs (1.20±1.32) (P<0.05). However, the amount of decline in both the groups did not show any significantly difference in PAS, reduction of IOP, or number of antiglaucoma drugs (P>0.05), The increase in anterior chamber depth from baseline to 2 months after surgery was significantly greater in the PEGS group (P=0.003).

CONCLUSIONS

The IOP-lowering effects of PEGS do not differ significantly from those of PE in medically well-controlled CACG patients with cataract. These results suggest that additional goniosynechialysis during phacoemulsification is not necessary in such patients.

Angle parameter changes of phacoemulsification and combined phacotrabeculectomy for acute primary angle closure

AIM

To evaluate the difference in angle parameters and clinical outcome following phacoemulsification and combined phacotrabeculectomy in patients with acute primary angle closure (APAC) using ultrasound biomicroscopy (UBM).

METHODS

Patients (n=23, 31 eyes) were randomized to receive phacoemulsification or combined phacotrabeculectomy (n=24, 31 eyes). Best-corrected visual acuity (BCVA), intraocular pressure (IOP), the main complications following surgery, and indentation gonioscopy and angle parameters measured using UBM were documented preoperatively and postoperatively.

RESULTS

The improvement in BCVA in the phacoemulsification group was significantly greater than in the combined group (P<0.05). IOP in the phacoemulsification group was slightly higher than in the combined group following 1wk of follow-up (P<0.05), whereas there was no significant difference between the two groups at the latter follow-up (P>0.05). Phacoemulsification alone resulted in a slight increase in the trabecular ciliary processes distance compared with the combined surgery (P<0.05), whereas the other angle parameters showed no significant difference between the groups. Complications in combined group were greater than phacoemulsification only group.

CONCLUSION

Both surgeries effectively opened the drainage angle and deepened the anterior chamber, and IOP was well controlled postoperatively. However, phacoemulsification showed better efficacy in improving visual function and showed reduced complications following surgery.