Comparative Clinical Study of Medically Controlled Nonsevere Chronic Primary Angle-closure Glaucoma with Coexisting Cataract Surgically Managed by Phacoemulsification as against Combined Phacotrabeculectomy

Efficacy and Safety of Different Types of Intraocular Pressure-Lowering Surgeries in Patients with Primary Angle Closure (PAC) or PAC Glaucoma: Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

To compare the intraocular pressure (IOP)-lowering effect of different types of surgery available in the literature using a network meta-analysis (NMA) based on a systematic review.

METHODS

PubMed and the Cochrane database were searched. Randomized clinical trials involving surgical interventions for high IOP for PAC (primary angle closure) or PACG (primary angle closure glaucoma) were included. Descriptive statistics and outcomes were extracted. Bayesian NMA was performed to compare the IOP-lowering effect and the change in the number of antiglaucoma drugs required between baseline and endpoint, as well as success rates.

RESULTS

This NMA included 21 articles with 1237 eyes with PAC or PACG. Interventions were characterised as phacoemulsification (phaco), trabeculectomy, goniosynechialysis (GSL) with viscoelastic or blunt device, goniosurgery (GS) (trabeculotomy or goniotomy), micro-bypass stent (Istent®), endocyclophotocoagulation (ECPL) or various combinations of these procedures. Phaco+GSL [-1.73 (95%CrI: -3.53 to -0.13)] and phaco+GSL+GS [-3.92 (95%CrI: -6.91 to -1.31)] provided better IOP lowering effects than phaco alone. Phaco+trabeculectomy [-3.11 (95%CrI: -5.82 to -0.44)] was inferior to phaco+GSL+GS. Phaco+trabeculectomy [-0.45 (95%CrI: -0.81 to -0.13)] provided a better outcome in terms of reducing the need for antiglaucoma drug compared to phaco alone. There were no differences between the other surgeries in terms of reduction of antiglaucoma drug number and IOP lowering effect. Success rates were similar for all surgical procedures.

CONCLUSIONS

Phaco+GSL+GS showed the most promising results for lowering IOP. Phaco+trabeculectomy resulted in a significant reduction in the number of antiglaucoma drugs compared to phaco alone.

The Treatment of Primary Angle-Closure Glaucoma with Cataract: A Systematic Review and Meta-Analysis of Randomized Controlled Trails

BACKGROUND

Currently, there is no generally approved surgical treatment for patients with primary angle-closure glaucoma (PACG) and co-existing cataracts. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of phacoemulsification and phacotrabeculectomy in PACG patients with cataract.

METHODS

Diverse databases were searched, including PubMed, MEDLINE, EMBASE, Cochrane Library, Chinese Journal Full-text Database (CNKI), Wanfang database, and China Science and Technology Journal Database, for randomized controlled trials (RCTs) on phacoemulsification and phacotrabeculectomy for the treatment of PACG published up to 30 June 2021. ReviewManager (RevMan) version 5.4 software was used for the meta-analysis, and the effective quantity of measurement data was measured by the mean difference (MD) and 95% confidence interval (CI). The effect of counting data was measured by odds ratio (OR).

RESULTS

Our search of the databases identified 14 RCTs that satisfied the search criteria. Meta-analysis of these 14 RCTs showed that at the 1 month postoperative follow-up, intraocular pressure (IOP) of patients in the phacoemulsification group was higher than that of patients in the phacotrabeculectomy group (MD 2.04, 95% CI 1.42-2.65; P < 0.00001). However, the postoperative IOP was not significantly different between the two groups at the 3, 6, and 12 months postoperative follow-ups (P = 0.52, P = 0.51, and P = 0.05, respectively). More medications for IOP reduction were required by patients in the phacoemulsification group compared with those in the phacotrabeculectomy group at 3 months postoperation (MD 0.76, 95% CI 0.33-1.18; P = 0.0005), 6 months postoperation (MD 0.66, 95% CI 0.15-1.18; P = 0.01), and 12 months postoperation (MD 0.76, 95% CI 0.22-1.30; P = 0.006). Patients in the phacoemulsification group obtained better best corrected visual acuity (BCVA) than those in the phacotrabeculectomy group (MD - 0.17, 95% CI - 0.34 to - 0.01; P = 0.04) at 3 months postoperation, but there was no significant difference in BCVA between the two groups at 6 and 12 months postoperation (P = 0.33 and P = 0.56, respectively). The deepened anterior chamber was more obvious in patients in the phacoemulsification group versus those in the phacotrabeculectomy group (MD 0.61, 95% CI 0.03-1.18; P = 0.04). Patients in the phacoemulsification group experienced fewer postoperative complications than those in the phacotrabeculectomy group (OR 0.27, 95% CI 0.17-0.42; P < 0.00001).

CONCLUSION

Our results provide evidence that phacotrabeculectomy has advantages over phacoemulsification for the treatment of PACG in terms of better IOP and reduced medication need during the early stage post surgery. However, in terms of the complication risk, phacoemulsification is the more secure treatment option.

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.