Trabeculectomy function after cataract extraction

Comparison of Outcomes of Deep Sclerectomy, Canaloplasty, and Viscocanaloplasty: A Multicenter Study

PRCIS

Deep sclerectomy (DS) and canaloplasty provide better intraocular pressure (IOP) control than viscocanalostomy. DS required less glaucoma medications but more interventions to reach the target IOP.

PURPOSE

To compare real-world outcomes of 3 non-penetrating glaucoma surgery (NPGS) techniques.

METHODS

Retrospective, cohort study of consecutive patients undergoing canaloplasty (CP), deep sclerectomy (DS), and viscocanalostomy (VC), across 9 European glaucoma units. Four intraocular pressure (IOP) criteria were used to define success at 2-year follow-up: (A) IOP≤21 mmHg and ≥20% reduction; (B) IOP≤18 mmHg and ≥20% reduction; (C) IOP≤15 mmHg and ≥25% reduction; (D) IOP≤12 mmHg and ≥30% reduction. Secondary outcomes included IOP control, BCVA, number of medications over time, risk factors for failure, complications, and post-operative interventions. Success was distinguished as qualified or complete, if reached with or without antiglaucoma medications, respectively.

RESULTS

Six hundred eyes (545 patients) undergoing standalone CP (201 eyes), DS (200 eyes), and VC (199 eyes) were included. Qualified success rates of CP, DS, and VP at 24 months were, respectively: (criterion A) 85.1%, 67.6%, and 64.6%; (criterion B) 85.1%, 66.1%, and 58.6%; (criterion C) 76.6%, 55.5%, and 39.0%; (criterion D) 27.7%, 28.5%, and 22.1%. Success rates were significantly different across the 3 techniques ( P =0.04 or below), except for complete success according to criterion A ( P =0.07). Mean IOP(±SD) reduced from 25.2 (±6.9), 20.5 (±6.7), and 22.7 (±7.2)mmHg preoperatively to 13.1 (±3.1), 12.9 (±4.5), and 14.7 (±4.6)mmHg at postoperative year 2 in the CP, DS, and VC groups, respectively ( P <0.001 between preoperative and postoperative time points for all groups).

CONCLUSIONS

All 3 NPGS provide sustained IOP reduction, but DS and CP provide better success rates and IOP control. Success rates were low for the most stringent cutoffs, suggesting that other techniques such as trabeculectomy may be indicated when a very low target IOP is demanded.

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.

Effect of Phaco-trabeculectomy versus Phacoemulsification on Refractive Outcome - A Prospective Observational Study

Purpose

To compare the refractive outcomes of phaco-trabeculectomy versus phacoemulsification.

Methods

This prospective observational study included 75 eyes, 42 eyes with cataract and glaucoma that underwent phaco-trabeculectomy, and 33 eyes with cataract that underwent phacoemulsification. The primary outcome measures were the assessment of mean prediction refractive error and absolute mean prediction refractive error, measured during biometry with a target refraction of more than -1 diopter.

Results

The mean age of the study population was 60.3 ± 4.5 years (SD) in the phaco trabeculectomy group (Group 1) and 64.24 ± 3.2 years (SD) in the phacoemulsification group (Group 2). The mean prediction error in group 1 was -0.21 + 0.88 diopters, and in group 2, it was -0.24 + 1.42 diopters, with absolute mean prediction errors of 0.72 + 0.68 diopters in group 1 and 0.71 + 0.97 diopters in group 2. A statistically significant shift in myopic and hyperopic prediction error was noted for 0 to 1 diopter, and a change above one diopter was not substantial.

Discussion

This discussion examines the challenges associated with refractive outcomes following combined cataract and glaucoma filtration surgery. The study found considerable variability in achieving the target refraction, with prediction errors generally within one diopter, consistent with other research. The study's limitations, including a short follow-up period and variations in surgical techniques, are acknowledged as possible factors that may contribute to refractive errors and astigmatism.

Conclusions

The predicted refractive errors in both groups were similar, with equal myopic and hyperopic shifts noted, and a statistically significant change was observed from 0 to 1 diopter.

The effect of cataract surgery on lowering intraocular pressure

PURPOSE OF REVIEW

To review the literature evaluating the effectiveness of cataract surgery alone and cataract surgery in combination with other procedures and surgeries on intraocular pressure (IOP) in patients with ocular hypertension and glaucoma.

RECENT FINDINGS

Recent studies of large trials have shown the IOP-lowering effect of cataract surgery and the beneficial effect of minimally invasive glaucoma surgery (MIGS). More studies are being published on when to use cataract surgery alone, with MIGS, or with traditional glaucoma surgeries for both primary open angle glaucoma and primary angle closure glaucoma.

SUMMARY

Patients with ocular hypertension and visually significant cataracts would benefit from cataract surgery alone to lower intraocular pressure. Patients with mild to moderate glaucoma would likely benefit from cataract surgery and MIGS to achieve a lower IOP. Patients with more advanced glaucoma would benefit from cataract surgery combined with a traditional incisional glaucoma surgery. Clear lens extraction can be used in patients with primary angle closure and early primary angle closure glaucoma. In patients with more advanced disease, phacoemulsification and another glaucoma surgery is likely to be required to achieve IOP control. MIGS are starting to be used in angle closure glaucoma, although more research needs to be done to define its role.

Preserflo MicroShunt Implantation: A Narrative Review of Its Standalone Benefits vs. Combined Use with Phacoemulsification in Managing Open-Angle Glaucoma

Glaucoma and cataract often coexist. Patients with both conditions who qualify for surgical treatment may undergo either a combined surgical procedure or sequential treatments such as cataract surgery followed by an antiglaucoma procedure. A combined procedure with phacoemulsification is related to an increased risk of fibrosis of the filtering bleb; however, it is a rational approach for patients with high intraocular pressure and clinically significant lens opacification. Trabeculectomy has been a traditional filtration procedure for decades, effectively lowering intraocular pressure. It is highly effective; however, it may cause sight-threatening complications. The Preserflo MicroShunt, introduced less than a decade ago in the field of glaucoma surgery, has shown similar hypotensive efficacy to trabeculectomy, and is a less invasive procedure with a better safety profile. Despite their shared mechanism of action to reduce intraocular pressure, the two procedures differ in the extent of scleral incision and filtration bleb morphology, which may influence the extent of the post-surgery inflammation process. This review evaluated and compared reports on the efficacy and safety of Preserflo MicroShunt implantation as a standalone procedure versus combined with cataract removal in surgical treatment for patients with open-angle glaucoma and concomitant cataract.

Uneventful Phacoemulsification after Trabeculectomy in Pseudoexfoliation Glaucoma versus Primary Open-Angle Glaucoma

INTRODUCTION

Conflicting results have been reported on phacoemulsification in the filtered eyes with open-angle glaucoma. In this study, we aim to compare the effect of phacoemulsification after trabeculectomy between pseudoexfoliation glaucoma (XFG) and primary open-angle glaucoma (POAG).

METHODS

Consecutive patients with XFG and POAG who underwent uneventful phacoemulsification after trabeculectomy with 5-fluorouracil (TRAB-PHACO group) were reviewed retrospectively and matched to patients who underwent trabeculectomy only (TRAB group). Comparisons were performed for IOP, medication numbers, and success rates. Surgical failure was defined as IOP >21 mm Hg or IOP ≤21 mm Hg with additional medication or glaucoma surgery. Survival analysis was investigated by Kaplan-Meier test and the factors influencing final success by multivariate logistic regression analysis.

RESULTS

The records of 204 patients were reviewed. In XFG, when compared with the baseline, increase in IOP became statistically significant at the at 24-month visit in the TRAB-PHACO group (p = 0.002), at the 6-month visit (p = 0.001) in the TRAB group and remained so throughout the follow-up. In the TRAB-PHACO group, increase of glaucoma medications was statistically significant only at the last visit (p = 0.001) in XFG, at the 6-month visit (p = 0.02) in POAG and remained so throughout the follow-up. Two glaucoma types did not differ statistically from one another in terms of survival analysis. In the TRAB group, the additional glaucoma surgery was more common in XFG compared to POAG (p = 0.02). The trabeculectomy failure after phacoemulsification was related with an IOP spike >25 mm Hg at postoperative first 24h (p = 0.04).

CONCLUSIONS

In the filtered eyes with XFG, uneventful phacoemulsification may delay time-related worsening in IOP control and may decrease the additional glaucoma surgery need.

Intraocular Pressure Control Following Phacoemulsification in Eyes With Pre-existing Aurolab Aqueous Drainage Implant

PURPOSE

The aim was to investigate intraocular pressure (IOP) control after phacoemulsification in adult glaucomatous eyes with a functioning nonvalved Aurolab Aqueous Drainage Implant (AADI) compared with eyes that did not have cataract extraction post-AADI.

METHODS

In this retrospective study, we reviewed records of 47 patients (47 eyes) who had a clear corneal phacoemulsification after AADI placement with a minimum of 2 years of follow up. The control group included 89 patients (89 eyes) who had a functional AADI at 1 year, minimum of 3 years of follow up post-AADI implantation, and no cataract extraction. The main outcome measure was failure (IOP >21 mm Hg or increased by >20% from prephacoemulsification level requiring at least 1 additional glaucoma medication, IOP ≤5 mm Hg, reoperation for glaucoma, or loss of light perception vision).

RESULTS

The median interval between AADI and phacoemulsification was 11.5 months (range: 4 to 68 mo), and the mean follow-up time after phacoemulsification was 35.6±6.4 months. The cumulative probability of failure was 14% (95% confidence interval=6%-31%) in the phaco group and 6% (95% confidence interval=3%-13%) in the control group at 2 years (P=0.11). Mean IOP was reduced from 16.5±4.5 mm Hg preoperatively to 15.4±4.7 mm Hg at 2 years after phacoemulsification (P=0.10). Mean LogMAR visual acuity improved from 1.1±0.6 preoperatively to 0.6±0.7 at 2 years after phacoemulsification (P<0.001).

CONCLUSIONS

In eyes with a pre-existing AADI, phacoemulsification resulted in visual improvement without a significant rise in IOP or increased risk of AADI failure after 2 years follow up.

The effect of uneventful cataract surgery in pseudoexfoliation glaucoma with or without previous mitomycin C-augmented trabeculectomy

PURPOSE

To analyze the effect of uneventful cataract surgery on intraocular pressure (IOP) in pseudoexfoliation glaucoma (PXG) eyes with and without a history of Mitomycin C-augmented trabeculectomy.

METHODS

Eyes with PXG that had underwent uneventful cataract surgery were enrolled. The IOP and the medication numbers before cataract surgery, and 1, 3, 6, 12, 18, 24 months after cataract surgery, and at the last visit were recorded in PXG with and without previous trabeculectomy. Failure was defined as IOP > 21 or ≤ 21 mmHg with additional medication or surgery. In the postoperative first 24 h, IOP > 50% above baseline was defined as an IOP spike.

RESULTS

In the trabeculectomized eyes (n = 37), the increase in the mean IOP (p = 0.024) and the increase in the mean number of medications (p = 0.007) was significant at the last visit when compared with baseline. In the non-trabeculectomized eyes (n = 42) there was a significant decrease in the mean IOP (p = 0.016) and in the mean number of medications (p = 0.038) at the last visit. Twelve eyes (32.4%) in trabeculectomized group and six (14.3%) in the non-trabeculectomized group experienced failure. An IOP spike was seen in one eye in the trabeculectomized group, in 15 eyes in the non-trabeculectomized group (p < 0.0001). The IOP spike was a significant risk factor for failure (p = 0.027).

CONCLUSION

Uneventful cataract surgery may have significant negative effect on the IOP control in the trabeculectomized PXG eyes. After cataract surgery, the non-trabeculectomized PXG eyes had a higher risk of IOP spike and an IOP spike may be a risk factor for failure.

Phacoemulsification after trabeculectomy in uveitis associated with Vogt-Koyanagi-Harada disease: intermediate-term visual outcome, IOP control and trabeculectomy survival

PURPOSE

To evaluate the visual outcome, intraocular pressure control and trabeculectomy survival after phacoemulsification in eyes with prior trabeculectomy in uveitis associated with Vogt-Koyanagi-Harada disease (VKH).

DESIGN

Retrospective comparative study.

METHODS

Eyes with uveitic glaucoma associated with VKH who underwent mitomycin C (MMC)-enhanced trabeculectomy were included. Eyes were divided into two groups: the first study group included eyes that later underwent cataract surgery in the form of phacoemulsification, and the second control group included eyes that did not have cataract surgery. The main outcome measures were changes in the visual acuity, intraocular pressure (IOP), the number of antiglaucoma medications, IOP control and trabeculectomy survival.

RESULTS

There were no significant differences in the final visual acuity (0.78 (±0.9) and 0.92 (±1.1), p = 0.80)) nor IOP (14.21 mmHg (±5.8) and 12.16 mmHg (±6.1), p = 0.29), but there was a difference in the antiglaucoma medications (1.58 (±1.5) and 0.53 (±1.0), p = 0.02) between the study and control group, respectively. There was no difference in the overall trabeculectomy survival (p = 0.381, Log Rank), but more eyes in the study group converted to qualified success after phacoemulsification and required more medications to control the IOP.

CONCLUSION

Phacoemulsification after trabeculectomy seems to be a safe procedure in eyes with combined vision threatening complications of VKH, although the visual improvement was limited. Nevertheless, more medications were required to control the IOP, resulting in less absolute and more qualified trabeculectomy success. Therefore, patient counseling before surgery is essential.

Glaucoma control after phacoemulsification in eyes with functioning glaucoma filtration surgeries: trabeculectomies versus glaucoma drainage devices

PURPOSE

Several studies have demonstrated decompensation of intraocular pressure (IOP) control following phacoemulsification in eyes with a functioning trabeculectomy. Limited evidence base suggests that this effect is minimal in eyes with functioning glaucoma drainage devices (GDD). The aim of this study was to report on glaucoma control after phacoemulsification in eyes with a functioning GDD compared to eyes with a functioning trabeculectomy.

METHODS

Single-centre retrospective comparative study of patients with a functioning non-valved GDD (Baerveldt 350; Johnson & Johnson Surgical Vision) or trabeculectomy undergoing phacoemulsification. Glaucoma outcomes including IOP, cup:disc ratio (CDR), global retinal nerve fibre layer (RNFL) thickness and visual field mean deviation (MD) are reported. Failure was defined as IOP rise > 20% from baseline.

RESULTS

Fifteen eyes with a functioning trabeculectomy and twenty-three eyes with a functioning GDD with 24-month post-phacoemulsification data were identified. Mean IOPs were significantly lower in the trabeculectomy group at month 24 compared to the GDD group, 9.5 and 15.9 mmHg (p = 0.001) respectively. At month 12, there was significant worsening on MD in GDD group compared to trabeculectomy group, - 20.0 dB and - 11.3 dB respectively (p = 0.03). A greater proportion of eyes failed in the GDD group compared to the trabeculectomy group, N = 15 (65%) and n = 7 (47%), p = 0.26.

CONCLUSION

As with functioning trabeculectomies, phacoemulsification should be approached with similar caution in eyes with functioning GDD. An existing GDD is at least as likely to fail following clear corneal phacoemulsification as an existing trabeculectomy and non-augmented GDDs may be at greater risk.

Refractive Outcomes of Uneventful Cataract Surgery in Pseudoexfoliation Syndrome and Pseudoexfoliation Glaucoma

Purpose

To compare the refractive outcomes after cataract surgery between patients with and without pseudoexfoliation, and to evaluate the risk factors of refractive error.

Methods

Retrospective review of 210 eyes with pseudoexfoliation (study group) and 510 normal eyes (control group) that underwent uneventful phacoemulsification with intraocular lens implantation. The study group included pseudoexfoliation syndrome and pseudoexfoliation glaucoma (PXG) subgroups. The main outcome measure was refractive error, defined as the difference between the target refraction and postoperative refraction in diopter (D). A refractive error >±1.0 D was identified as a large-magnitude refractive error. The frequency of the large-magnitude refractive error was compared between study and control groups, and also between each subgroup and normal eyes. The factors influencing refractive error were analyzed by logistic regression.

Results

There was a significantly higher frequency of a refractive error >± 1.0 D and hyperopic error >1.0 D in the study group than in the control group (p = 0.001 and p = 0.003, respectively). In the multivariate logistic regression analysis, PXG and poor preoperative visual acuity were related with a large-magnitude refractive error (p = 0.001 and p = 0.02, respectively) Refractive error >± 1.0 D and hyperopic error >1.0 D were noted more often in PXG eyes that had an intraocular pressure spike >25 mmHg at postoperative first 24 hours (p = 0.01 and p=0.03, respectively).

Conclusions

The eyes with pseudoexfoliation were at a high risk for refractive error, especially in the presence of glaucoma. In PXG, the only significant risk factor for refractive error was observed to be the presence of an intraocular pressure spike.

Long-term outcomes of initial trabeculectomy in glaucoma associated with granulomatous and non-granulomatous uveitis

PURPOSE

To evaluate the outcomes of initial trabeculectomy in granulomatous and non-granulomatous uveitis.

METHODS

Retrospective comparative study of 68 eyes that underwent an initial trabeculectomy.

RESULTS

The mean follow-up was 74.18 and 74.86 months in both groups (p = 0.95). The intraocular pressure decreased from 40.03 mmHg ( ± 7.2) and 36.48 mmHg ( ± 11.3) to 14.00 mmHg ( ± 6.2) and 13.48 mmHg ( ± 5.7), the number of medications decreased from 3.73 ( ± 0.7) and 3.58 ( ± 0.9) to 1.00 ( ± 1.4) and 1.13 ( ± 1.4) on the last follow-up (p < 0.01) in the granulomatous and non-granulomatous groups, respectively. More eyes in the granulomatous uveitis group developed delayed postoperative complications like cataract, transient hypotony and glaucoma progression. Success rates were 64.9 and 71.0%, while failure rates were 35.1 and 29.0% in both groups (p = 0.84).

CONCLUSIONS

Trabeculectomy seems to have comparable IOP control and survival in granulomatous and non-granulomatous uveitis. Nevertheless, more eyes in the granulomatous uveitis group developed late-onset complications.

Effect of phacoemulsification surgery on intraocular pressure and function of bleb after trabeculectomy

PURPOSE

To evaluate the effect of phacoemulsification (PE) surgery on intraocular pressure (IOP) control and morphology of filtering bleb in eyes that have previously had trabeculectomy in the long-term.

METHODS

This retrospective study included 98 eyes of 93 patients who had undergone trabeculectomy first and then PE surgery. The IOP, morphology of bleb, the number of glaucoma medication of each patient before PE, and 1 day, 1 month, 3 months, 1 year, 2 years after PE, and at the last visit were recorded. The need for additional glaucoma medication or glaucoma surgery were noted. Surgical success was defined as 6 mmHg ≤ IOP ≤ 21 mm Hg at the 3rd month, 1st year, and 2nd year follow-up visit, without additional medication or surgery.

RESULTS

Before PE the IOP was ≤ 21 mmHg in all of the eyes. At the last visit, the IOP was ≤ 21 mmHg in 6 eyes with fewer glaucoma medication, in 24 eyes with the same number, and in 36 eyes with more. There was an increase in the number of glaucoma medications on each visit (p < 0.05). There was a statistically significant difference in bleb morphologies between before PE and each visit after PE (p < 0.001). Surgical success after PE was obtained in 52 eyes, additional glaucoma medication was needed in 36 eyes, and additional surgical procedures were required in 14 eyes.

CONCLUSION

Phacoemulsification surgery may increase the number of glaucoma medications and the mean IOP and also may reduce the function of bleb in eyes that underwent trabeculectomy.

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.

Trabeculectomy followed by phacoemulsification versus trabeculectomy alone: The Collaborative Bleb-Related Infection Incidence and Treatment Study

PURPOSE

This study aims to compare the rate of surgical failure after trabeculectomy followed by phacoemulsification vs trabeculectomy alone for 5 years.

METHOD

A total of 1,098 eyes of patients with glaucoma who underwent trabeculectomy with mitomycin C at 34 clinical centers included in CBIITS were analyzed. During follow-up, some eyes were treated with phacoemulsification because of cataract progression. The patients were divided into the "trabeculectomy followed by phacoemulsification" and "trabeculectomy alone" groups, and surgical probabilities were compared. Surgical failure was defined on the basis of mean IOP as follows; < 20% reduction in preoperative IOP or IOP ≥ 21 mmHg (criterion A), IOP ≥ 18 mmHg (criterion B), or IOP ≥ 15 mmHg (criterion C).

RESULT

In total, 40 eyes were treated with trabeculectomy followed by phacoemulsification and 208 with trabeculectomy alone. Preoperative intraocular pressure was 22.1 ± 8.7 mmHg in the trabeculectomy followed by phacoemulsification group and 20.5 ± 6.3 mmHg in trabeculectomy alone group (P = 0.47). The 5-year cumulative probabilities of success in the trabeculectomy followed by phacoemulsification and trabeculectomy alone groups were respectively 40.0% and 59.1% for criterion A (P = 0.01), 35.0% and 52.9% for criterion B (P = 0.01), and 25.0% and 37.5% for criterion C (P = 0.08). Cox proportional hazards regression model indicated that shorter time gap between trabeculectomy and phacoemulsification was associated with surgical failure.

CONCLUSION

Phacoemulsification following trabeculectomy adversely affects surgical outcomes. In particular, a shorter time gap between trabeculectomy and phacoemulsification reduces the probability of success.

Impact of Cataract Surgery on Filtering Bleb Morphology Identified Via Swept-source 3-dimensional Anterior Segment Optical Coherence Tomography

PRéCIS:: Analysis of filtering bleb morphology using swept-source 3-dimensional anterior segment optical coherence tomography (3D AS-OCT) indicates that phacoemulsification can negatively impact the morphology of preexisting filtering blebs.

PURPOSE

To identify the cross-sectional morphologic changes in successful filtering blebs after phacoemulsification using swept-source 3D AS-OCT.

MATERIALS AND METHODS

In total, 30 phakic eyes of 29 patients with successful filtering blebs after primary trabeculectomy were included in this retrospective cohort study. Success was defined as intraocular pressure (IOP)≤15 mm Hg and a>20% reduction in IOP without glaucoma medication or additional glaucoma surgery after trabeculectomy. The subjects were classified into 2 groups according to whether they had undergone phacoemulsification or not after trabeculectomy: a phaco group and a control group. Filtering blebs were examined using swept-source 3D AS-OCT and evaluated for quantitative parameters, including maximum bleb height, maximum bleb wall thickness, and the ratio of the hyporeflective space of the bleb wall.

RESULTS

Sixteen eyes were assigned to the phaco group and 14 eyes to the control group. The eyes in the control group showed no significant differences in IOP or in any of the 3D AS-OCT parameters at any of the follow-up timepoints. In the phaco group, the mean IOP increased significantly after phacoemulsification (P=0.003). Furthermore, the eyes in the phaco group showed a significant decrease in maximum bleb height (P=0.030), maximum bleb wall thickness (P=0.006), and the ratio of the hyporeflective space of the bleb wall (P=0.011) between prephacoemulsification and 1-year postphacoemulsification.

CONCLUSION

Phacoemulsification can have a negative impact on filtering bleb morphology, which may lead to an IOP increase.

[Influence of cataract phacoemulsification on eye hydrodynamics in patients with prior trabeculectomy]

At present, phacoemulsification and trabeculectomy are the most widespread surgery methods in cataract and glaucoma treatment, generally recognized as the gold standard. Among elderly patients, comorbid glaucoma and cataract are extremely prevalent, so the order of the two surgeries and the time interval between them are pivotal choices when planning treatment strategy. The reason for it is that almost any eye surgery is considered a risk factor for long-term trabeculectomy effectiveness. In attempts to solve this problem, numerous studies have been conducted on the impact of cataract surgery on filtration bleb scarring. The problem of determining the time interval between surgeries, as well as other treatment nuances, remains relevant despite the long history of research and publications. Some results are cited as general recommendations on treatment tactics (increasing the time interval between operations, using antimetabolite and anti-inflammatory therapy, minimizing intraoperative traumatism). However, currently there are no specific recommendations for one of the most important factors - the time interval between cataract extraction and trabeculectomy.

Success of trabeculectomy surgery in relation to cataract surgery: 5-year outcomes

AIMS

To compare success proportions at 5 years in three surgical groups: group 1, trabeculectomy alone; group 2, trabeculectomy followed by cataract surgery within 2 years; and group 3, trabeculectomy performed on a pseudophakic eye.

METHODS

A retrospective cohort study. 194 eyes of 194 patients were identified with at least 5 years' follow-up post trabeculectomy (N=85, 60 and 49 in groups 1, 2 and 3, respectively).

MAIN OUTCOME MEASURES

1.

PRIMARY OUTCOME MEASURE

intraocular pressure (IOP) at 5 years post-trabeculectomy surgery, 2.Secondary outcome measure: change in visual acuity at 5 years.

RESULTS

At 5 years, the mean IOP (SD) was 12.9 (3.5), 12.5 (4.8) and 12.7 (4.8) mm Hg in groups 1, 2 and 3, respectively. Overall success was almost identical, 58%, 57% and 59% in groups 1, 2 and 3, respectively. There was no significant difference between the groups in terms of percentage IOP reduction, number of medications, proportion restarting medication and reoperation rates at 5 years. Logistic regression for an outcome of failure showed men to be at increased risk of failure OR 1.97 (95% CI 1.10 to 3.52, p=0.02). Nearly 80% of patients retained or improved their vision following their initial trabeculectomy.

CONCLUSIONS

The sequence in which surgery is carried out does not appear to affect trabeculectomy function at 5 years, success being similar to trabeculectomy alone. In our study, men may be at increased risk of failure.

Cataract extraction after deep sclerectomy and its effect on intraocular pressure control

PURPOSE

To estimate the incidence and predisposing factors for cataract extraction (CE) after Deep Sclerectomy (DS) with Mitomycin-C (MMC) and its effect on intraocular pressure (IOP) control.

METHODS

Retrospective study of phakic eyes which had DS with MMC performed over a 5-year period. 179 eyes of 179 patients were included.

RESULTS

Mean age at time of DS was 68.6 ± 9.7 years and mean follow-up was 89.4 ± 29.4 months. 63 eyes had CE and the probability of CE following DS was 0% at 1, 11.6% at 3, 21.0% at 5 and 33.2% at 7 years, with a 50% probability (median survival time) of 10 years. Age was association with increased risk for CE (Hazard ratio 1.05, 95% CI: 1.03-1.08, p < 0.0001). Mean IOP had increased from 11 mmHg to 15 mmHg in the first 3 months and remained higher up to a year (p < 0.001). There was no difference in the probability of maintaining an IOP < 16 mmHg without additional medications or needle revision (p = 0.05,Log-rank test). 20/47 eyes that failed were from the CE group, of which 14 (22.2%) failed prior to CE. Number of eyes on glaucoma medications before CE was 6 (mean edications 0.2 ± 0.5 m) and by last follow-up, 9 eyes were on medications (mean medications 0.2 ± 0.7). Post-CE needle revision was performed on 4 eyes.

CONCLUSIONS

The probability of CE after DS is low, with a gradual increase with time. Increasing age was found to be a statistically significant risk factor. There was a modest increase in IOP after CE and increase use of glaucoma medications.

Phacoemulsification in Eyes With Posttrabeculectomy Choroidal Detachment

Four patients developed choroidal detachment within 3 months after trabeculectomy, documented with b-scan ultrasonography (BUS) and ultrasound biomicroscopy (UBM). Intraocular pressure (IOP) of the patients ranged from 3 to 5 mm Hg. Patients were treated with cycloplegia and steroids without complete resolution of detachment. Twelve months later all patients had developed visually significant cataracts and underwent phacoemulsification and intraocular lens implantation. Procedures were uncomplicated. Visual acuity ranged 0.1 to 0 LogMAR in the first postoperative month. IOP demonstrated an increase of 6 to 8 mm Hg, which was maintained up to 1 year postoperatively. BUS and UBM in the first postoperative month demonstrated a complete resolution of choroidal detachment in all our cases. These patients with choroidal detachment underwent safe and effective phacoemulsification procedures. In addition, choroidal detachment resolved in all our patients, possibly because of intraoperative and postoperative IOP spikes, as well as long-term IOP elevation because of effect of cataract surgery on bleb function.

The Influence of Phacoemulsification on Intraocular Pressure Control and Trabeculectomy Survival in Uveitic Glaucoma

OBJECTIVES

To evaluate the influence of phacoemulsification on intraocular pressure (IOP) control and survival of mitomycin C (MMC)-enhanced trabeculectomy in uveitic glaucoma (UG).

MATERIALS AND METHODS

Retrospective case-control study included 54 eyes from 40 patients with UG who underwent MMC-enhanced trabeculectomy as an initial procedure to treat glaucoma at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia between 2002 and 2014. Eyes were divided into 2 groups: the first group included eyes that later underwent cataract surgery in the form of phacoemulsification, and the second group included eyes that did not have cataract surgery. The main outcome measures were changes in the IOP, the number of antiglaucoma medications, IOP control, and trabeculectomy survival.

RESULTS

There were no differences in the overall trabeculectomy survival of eyes that underwent cataract surgery and those that did not (P=0.681, log-rank) nor the final IOP [15.54 mm Hg (±6.3) in the study group and 13.34 mm Hg (±5.6) in the control group, P=0.247]. However, more antiglaucoma medications were needed to control the IOP after cataract surgery at the last follow-up [1.59 medications (±1.4) in the study group and 0.50 medications (±0.7) in the control group; P=0.009].

CONCLUSIONS

UG eyes that underwent phacoemulsification following MMC-enhanced trabeculectomy required more medications to control the IOP than those that did not undergo cataract surgery and therefore less IOP control. Such changes in IOP control did not affect the overall trabeculectomy survival rate.

Co-management of cataract and glaucoma in the era of minimally invasive glaucoma surgery

PURPOSE OF REVIEW

This review discusses the options available to be used in conjunction with phacoemulsification cataract surgery to control intraocular pressure. We present a strategy for planning which surgery should be performed based on goals of care.

RECENT FINDINGS

New clinical evidence for using the CyPass, Kahook and Xen45 devices has been published recently and is summarized.

SUMMARY

Cataract and glaucoma frequently exist together. Because the field of glaucoma surgical care is expanding and cataract surgery is becoming progressively safer, it is important to frequently re-evaluate our treatment paradigms. We review and evaluate current studies and treatment options.

Effect of different incision sites of phacoemulsification on trabeculectomy bleb function: prospective case-control study

Background

The aim of this study was to compare superior and temporal clear corneal incisions of uneventful phacoemulsification and in-the-bag intraocular lens implantation on intraocular pressure control and the bleb morphology in eyes that have undergone previous successful trabeculectomy.

Methods

In this Prospective case-control study, a total of 100 eyes of 100 patients previously undergone trabeculectomy without antimetabolites, divided into two groups. Group A (temporal group) including 50 patients underwent phacoemulsification with a temporal corneal incision and group B (superior group) including 50 patients underwent phacoemulsification with a superior corneal incision. Comparisons between the two groups were performed after one year of follow-up regarding Intraocular pressure changes, bleb morphology score using the Wuerzburg bleb classification score and any added glaucoma medications.

Results

At the last visit, the mean intraocular pressure for the temporal group was 17.55 ± 1.47 (p = 0.51) and for the superior group was 16.90 ± 1.71 (p = 0.85); the difference between the two groups was insignificant (p = 0.21). Regarding the bleb morphology, the mean bleb morphology score in the temporal group was 10.50 ± 0.95 (p = 0.19) and for the superior group was 10.20 ± 1.06 (p = 0.01).There was an insignificant difference in the bleb grading morphology regarding both groups (p = 0.35).

Conclusion

Our study demonstrates that phacoemulsification whether done with a clear temporal or clear superior wound, does not affect intraocular pressure, bleb morphology or function after one year of follow-up in eyes following previous successful trabeculectomy. Furthermore, cataract surgery may be performed safely in eyes with functioning filtering blebs.

Trial registration

ISRCTN91835217 ‘retrospectively registered’ Date Of registration 6/6/2017

Safety And Efficacy Of Achieving Single-Digit Intraocular Pressure Targets With Filtration Surgery In Eyes With Progressive Normal-Tension Glaucoma

PURPOSE

Whereas achieving intraocular pressure (IOP) targets ≤ 10 mm Hg typically requires surgical intervention, we sought to examine the safety and efficacy of trabeculectomy in normal-tension glaucoma (NTG).

METHODS

Patients with progressive NTG undergoing trabeculectomy with preoperative IOP ≤ 15 mm Hg during the 12-month period before surgery were identified at a single academic institution. Failure was defined as IOP reduction <20% below baseline (criteria A), <30% (criteria B), or <40% (criteria C), reoperation for glaucoma, or loss of light perception vision.

RESULTS

Thirty eyes of 28 patients (mean age, 73 ± 8.7 y) were enrolled with a mean follow-up period of 50 ± 31 months. Mean postoperative IOP (8.6 ± 2.9 mm Hg) and medications (0.6 ± 1.0) at final follow-up was significantly (P<0.001) reduced compared with before surgery (13.2 ± 1.4 mm Hg and 2.5 ± 1.2, respectively). The cumulative probability of failure during 5 years of follow-up was 32% (criteria A), 48%, (criteria B), and 67% (criteria C). The probability of successfully achieving an IOP goal ≤ 10 mm Hg was 68% at 4 years of follow-up.

CONCLUSIONS

Trabeculectomy is a safe and effective method for achieving single-digit IOP targets in NTG eyes with progression at low IOP.

Lens Extraction for Management of Coexisting Cataract and Post-filtering Surgery Ocular Hypotony

Purpose:

To evaluate the safety and efficacy of phacoemulsification for management of post-filtering ocular hypotony.

Methods:

This prospective interventional case series study recruited 21 consecutive patients with an established diagnosis of ocular hypotony with or without maculopathy. Clear corneal incision phacoemulsification was done for all patients. Nineteen cases that completed a follow-up of at least 6 months were considered for final analysis.

Results:

Mean baseline intraocular pressure (IOP) was 2.95 ± 1.43 mm Hg, which increased to 8.84 ± 4.67 mm Hg at 6 months (P < 0.001). Hypotony was resolved in 13 cases (68%) at 6 months while 6 cases (32%) showed persistent hypotony at this time point. Postoperative IOP change at all follow-up time points was not correlated with patient age, time interval between filtering surgery and phacoemulsification, baseline IOP, baseline anterior chamber depth and IOP on the first postoperative day. Three cases (16%) showed filtering bleb failure with dramatic IOP rise around the first postoperative month and required glaucoma medication for IOP control. No significant intra- or postoperative complications were noted.

Conclusion:

Cataract surgery alone seems promising in resolving hypotony in patients with post-filtering ocular hypotony, and can be considered as an effective treatment modality before proceeding to more complicated procedures.

Bleb-related infection revisited: a literature review

Bleb-related infection (BRI) is one of the serious complications of glaucoma filtering surgery. This literature review is aimed at the evaluation of recent studies related to BRI. The review presented and discussed risk factors, and clinical and laboratory diagnosis emphasizing advances in diagnostic techniques to detect and distinguish the disease as well as to initiate immediate intensive antibacterial treatment. Clinical features of recognized prognostic factors of visual outcome were also presented. The studies showed that the prognosis of blebitis is usually good, unless infection has progressed to endophthalmitis that would signify a poorer prognosis. Despite prompt and intensive treatment of patients with bleb-related endophthalmitis, the outcomes remain unsatisfactory especially with virulent organisms and low initial visual acuity. It has been recommended that early detection and treatment of risk factors and thorough patient education are indispensable in ensuring best prognosis in post-trabeculectomy patients.

Prognostic factors for trabeculectomy failure in a Cuban population

OBJECTIVE

To identify the prognostic factors for mid-term trabeculectomy failure.

METHOD

A prospective cohort study was conducted on 113 eyes (113 patients) that had undergone a trabeculectomy for primary open or closed angle, pigmentary, or juvenile glaucoma. Surgical failure was defined if intraocular pressure was equal or more than 18mmHg with medication (two or more drops), after 1-4 postoperative years. The relative risk was calculated and a logistic regression analysis was performed.

RESULTS

Previous trabeculectomy, preoperative intraocular pressure ≥ 31mmHg, black race, and advanced glaucoma increased the failure risk by 7.9 times (P=.036), 5.3 times (P=.011) and 4.7 times (P=.028, and P=.027), respectively. The addition of two or more factors increased the risk by 6.4 times (P<.001). It was not affected by age, sex, pre-operative drops, or surgical complication.

CONCLUSIONS

Previous trabeculectomy, pre-operative intraocular pressure ≥ 31mmHg, black race, and advanced glaucoma are prognostic factors for trabeculectomy failure, in decreasing order of their association with surgical failure. The addition of two or more factors increased the risk of failure. In those situations, the use of trans- operative anti-metabolites is suggested.

Reasons for Early Ocular Hypertension after Uneventful Cataract Surgery

Purpose

To discuss the reasons for and measurements of early ocular hypertension after uneventful phacoemulsification and intraocular lens (IOL) implantation.

Methods

This was a retrospective review of patients who had early ocular hypertension after cataract surgery from a single-surgeon practice that medications failed to control or required additional surgery from September 2011 to January 2013.

Results

Of the 1270 eyes that had cataract surgery by one surgeon in our department in 16 months, 12 (9.4‰) eyes of 12 patients met the inclusion criteria. The mean postoperative intraocular pressure (IOP) peak was 41 (range 32-62) mm Hg. The median time of initial onset after cataract surgery was 3.5 days (range 1-60 days). Six eyes had antiglaucoma surgery history. Ahmed valve implantation with mitomycin C (MMC) was applied to 4 eyes. Two eyes underwent 5-fluorouracil needling revision with MMC. The IOP dropped in 3 eyes only in the case that the conventional topical corticosteroid agent was stopped, diagnosed as steroid responders. One eye of a patient with diabetes mellitus (DM) developed pseudophakic pupillary block angle-closure glaucoma due to the plasma glucose fluctuations. The IOP was controlled after Nd:YAG laser iridotomies. Residual cortex caused ocular hypertension in 2 eyes and surgical aspirations were performed. Following monitoring of IOP for 6 to 24 months, all eyes were within the normal range.

Conclusions

Patients with history of glaucoma surgery; high myopia, especially in young age; and DM merit particular observation and treatment for possible IOP elevation following cataract surgery.

Effect of phacoemulsification on trabeculectomy function

BACKGROUND

To evaluate the effect of phacoemulsification on trabeculectomy function.

DESIGN

Retrospective case-control study.

PARTICIPANTS

Forty-eight patients who underwent trabeculectomy surgery and had at least 2 years of follow up.

METHODS

Patients were classified into two groups: patients who had phacoemulsification subsequent to trabeculectomy (Trab_phaco, n = 18) and patients who were pseudophakic for greater than 6 months preceding their trabeculectomy (Phaco_trab, n = 30). Groups were matched for length of follow up of 2 years from time of trabeculectomy.

MAIN OUTCOME MEASURES

The primary outcome measures were target intraocular pressure of criteria A, ≤12 mmHg; B, ≤15 mmHg; C, ≤18 mmHg with or without additional topical treatment. A separate measure for bleb function failure was also used; with failure defined as the need for additional topical antiglaucoma therapy or surgical intervention to achieve control of intraocular pressure.

RESULTS

There was no significant difference in achieving each intraocular pressure criterion between groups (12 months, P = 1.0; 24 months, P = 0.330). In the first 12 months, significantly more trabeculectomies in the Trab_phaco group failed, requiring additional intervention to control the IOP (39%) compared with the Phaco_trab (10%) group (P = 0.028). Although this trend continued at 24 months, there were no significant differences in failure rates (P = 0.522).

CONCLUSIONS

Phacoemulsification performed after trabeculectomy significantly increased rates of bleb failure in the following 12 months but not at 24 months.

Cataract Surgery in Eyes with Previous Glaucoma Surgery: Pearls and Pitfalls

The problem of cataract management in the patients of glaucoma who have undergone fltering surgery is a challenging proposition for any surgeon, as the surgery can lead to several complications in the already compromised eye. As glaucoma requires lifelong management, the development of cataract is a significant concern because its treatment may lead to loss of intraocular pressure (IOP) control. This review aims to highlight the intra- and postoperative measures that may increase the chances of bleb survival following cataract surgery. How to cite this article: Dada T, Bhartiya S, Baig NB. Cataract Surgery in Eyes with Previous Glaucoma Surgery: Pearls and Pitfalls. J Current Glau Prac 2013;7(3):99-105.

Deterioration of filtering bleb morphology and function after phacoemulsification

BACKGROUND

Trabeculectomy remains the most efficient method of lowering he IOP applied for the treatment of glaucoma refractory to pharmacological treatment. Cataract is concerned as the most frequent late complication of trabeculectomy. The aim of the study was to analyse the effect of phacoemulsification with posterior chamber lens implantation on the morphology and function of filtering bleb in patients after previous successful trabeculectomy.

METHODS

The retrospective study included 122 eyes treated for primary open angle glaucoma, 50 eyes (study group) in which, after a successful trabeculectomy with 5-Fluorouracil, phacoemulsification with posterior chamber lens implantation was performed, and 72 eyes (control group), in which only a successful trabeculectomy was conducted. The surgical success of the trabeculectomy was expressed as IOP < 17 mmHg.

RESULTS

In the group of patients subjected to both trabeculectomy and phacoemulsification, mean IOP was significantly higher than in the group of patients who underwent trabeculectomy after 6 months (p = 0.003), 12 months (p = 0.01) and 18 months (p = 0.007) of observation. The filtering blebs after phacoemulsification in the study group were characterized by a greater reduction, compared to those in the control group. Cox regression survival success was 75% (SE = 5.9; 95% CI: 63.4-86.6), 75% (SE = 5.9; 95% CI: 63.4-86.6), 71% (SE = 5.4; 95% CI: 60.4-81.6) in study group and 92% (SE = 1.8; 95% CI: 91.5-98.5), 92% (SE = 1.9; 95% CI: 88.3-95.7), 91% (SE = 2.0; 95% CI: 87.1-94.9) in control group after 6, 12 and 18 months, respectively.

CONCLUSIONS

Phacoemulsification causes a significant elevation of IOP in the eyes after previous successful trabeculectomy and deterioration of filtering bleb morphology.

Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans

PURPOSE

To investigate the prevalence and predictors of intraoperative and 90-day postoperative ocular complications associated with cataract surgery performed in the United States Veterans Health Administration (VHA) system.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Forty-five thousand eighty-two veterans who underwent cataract surgery in the VHA.

METHODS

The National Patient Care Database was used to identify all VHA patients who underwent outpatient extracapsular cataract surgery and who underwent only 1 cataract surgery within 90 days of the index surgery between October 1, 2005, and September 30, 2007. Data collected include demographics, preoperative systemic and ocular comorbidities, intraoperative complications, and 90-day postoperative complications. Adjusted odds ratios (ORs) of factors predictive of complications were calculated using logistic regression modeling.

MAIN OUTCOME MEASURES

Intraoperative and postoperative ocular complications within 90 days of cataract surgery.

RESULTS

During the study period, 53786 veterans underwent cataract surgery; 45082 met inclusion criteria. Common preoperative systemic and ocular comorbidities included diabetes mellitus (40.6%), chronic pulmonary disease (21.2%), age-related macular degeneration (14.4%), and diabetes with ophthalmic manifestations (14.0%). The most common ocular complications were posterior capsular tear, anterior vitrectomy, or both during surgery (3.5%) and posterior capsular opacification after surgery (4.2%). Predictors of complications included: black race (OR, 1.38; 95% confidence interval [CI], 1.28-1.50), divorced status (OR, 1.10; 95% CI, 1.03-1.18), never married (OR, 1.26; 95% CI, 1.14-1.38), diabetes with ophthalmic manifestations (OR, 1.33; 95% CI, 1.23-1.43), traumatic cataract (OR, 1.80; 95% CI, 1.40-2.31), previous ocular surgery (OR, 1.29; 95% CI, 1.02-1.63), and older age.

CONCLUSIONS

In a cohort of United States veterans with a high preoperative disease burden, selected demographic factors and ocular comorbidities were associated with greater risks of cataract surgery complications. Further large-scale studies are warranted to investigate cataract surgery outcomes for non-VHA United States patient populations.

Predicted refraction versus refraction outcome in cataract surgery after trabeculectomy

PURPOSE

To determine whether the manifest refraction after cataract surgery in eyes that had undergone previous trabeculectomy was different from the predicted refraction.

SETTING

University-based tertiary glaucoma service and 3 glaucoma private practices.

METHODS

Retrospective, interventional, case-control study. The medical records of patients with glaucoma and medically treated glaucoma suspects who underwent cataract extraction between January 1, 2004 and February 11, 2006 were reviewed. The axial length was measured by contact A-scan ultrasonography. The study group included 27 eyes of 25 patients who underwent phacoemulsification with intraocular lens implantation after trabeculectomy, whereas the control group included 52 eyes of 49 glaucoma patients or medically treated glaucoma suspects who underwent phacoemulsification with intraocular lens implantation only. The main outcome measure was the difference between the postphacoemulsification manifest refraction and predicted refraction between the 2 groups.

RESULTS

The difference between the mean final refraction and mean predicted refraction in the study group (-0.852+/-1.056 D) and the control group (-0.501+/-0.542 D) was not statistically significant (P=0.115). The mean intraocular pressure in the study group decreased significantly after trabeculectomy (25.9+/-8.9 to 9.6+/-4.3 mm Hg, P<0.001), and increased significantly after phacoemulsification (9.6+/-4.3 to 12.5+/-5.3, P=0.001). Lower prephacoemulsification intraocular pressure was weakly correlated with a myopic shift in final refraction (r=0.269, P=0.017).

CONCLUSIONS

Though numerous variables can potentially influence the refractive outcome in cataract extraction after trabeculectomy, our study shows that the refractive outcome in these cases remained reasonably predictable. However, lower prephacoemulsification intraocular pressure was weakly correlated with a myopic shift in final refraction.