Trabeculectomy in Patients With Primary Angle-closure Glaucoma

Comparison of Long-Term Effects Following Phacoemulsification Combined with Goniosynechialysis and Trabeculectomy in Patients with Primary Angle-Closure Glaucoma and Cataract

INTRODUCTION

Goniosynechialysis (Phaco-GSL) is a logical therapeutic approach for patients with primary angle-closure glaucoma (PACG) and cataract. The aim of this study was to compare the long-term effectiveness and safety of Phaco-GSL and trabeculectomy (TRB) in the management of PACG with coexisting cataract.

METHODS

A review was conducted on 96 Chinese patients (96 eyes) with PACG and cataract from Peking Union Medical College Hospital (PUMCH). Among them, 56 patients underwent Phaco-GSL, while 40 underwent TRB. Intraocular pressure (IOP), best corrected visual acuity (BCVA), use of supplemental antiglaucoma medical therapy, surgery success rates, and complications for both procedures were assessed.

RESULTS

The average follow-up period was 50.3 ± 18.7 months in the Phaco-GSL group and 61.2 ± 15.1 months in the TRB group. At the final follow-up, IOP decreased from 27.0 ± 11.1 mmHg to 13.5 ± 2.1 mmHg in the Phaco-GSL group and in the TRB group IOP decreased from 27.1 ± 7.7 mmHg to 16.5 ± 5.5 mmHg. The long-term postoperative IOP in the Phaco-GSL group was significantly lower than that in the TRB group. There was a statistically significant reduction in medication usage in both groups, with the TRB group having a higher number of postoperative medications at the final follow-up. The incidence of postoperative complications was significantly higher in the TRB group compared to the Phaco-GSL group.

CONCLUSIONS

Phaco-GSL is the recommended surgical approach for Chinese patients with primary angle-closure glaucoma (PACG) and cataract. Compared to traditional TRB, eyes undergoing Phaco-GSL show a reduced requirement for antiglaucomatous medications, improved management of IOP, decreased risk of complications, and higher long-term cumulative probability of treatment success for patients with PACG.

Trabeculectomy: Does It Have a Future?

The trabeculectomy (TRAB) procedure has undergone various modifications to increase the long-term surgical success and safety profiles. The main issues with TRAB include short and long-term complications, that are more common with the concomitant use of anti-fibrotic agents. While many surgeons have predicted the demise of trabeculectomy amidst newer non-penetrating glaucoma surgeries, it is still the gold standard procedure for patients with an advanced or rapidly progressing disease and for those patients who need very low intraocular pressures. This review article is unique in summarizing the evolution of trabeculectomy and its efficacy compared to neoteric shunt procedures while trying to predict if trabeculectomy has a future in the modern surgical world. We have compared the outcomes and complications of trabeculectomy to all the surgical procedures available to date and have tried to evolve an algorithm to help surgeons to decide on their preferred technique.

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.

The outcome of transscleral cyclophotocoagulation for the management of acute angle closure

PURPOSE

To investigate the outcome of transscleral cyclophotocoagulation (TCP) in the treatment of acute angle closure (AAC) refractory to medical treatment.

METHODS

This is a retrospective interventional case series. The inclusion criteria include patients diagnosed with AAC who had TCP. Pre-TCP and post-TCP intraocular pressure (IOP), visual acuity, and AAC treatment were analyzed. The complications and the results of subsequent treatments including lens extraction if performed were also assessed.

RESULTS

Thirteen eyes (13 patients) met the study criteria. The median time to TCP from presentation was 5 days (range 3-30 days). The mean presenting IOP was 56 ± 6 mm Hg (range 48-70 mm Hg) and the medically treated mean IOP before TCP was 40 ± 5 mm Hg (range 34-52 mm Hg). All patients (100%) responded to TCP. The mean post-TCP IOP at day 1 and months 1, 3, 6, 12, and 24 were 19, 23, 19, 19, 18, and 17 mm Hg. There was 1 case of hyphema post-TCP. Lens extraction ± goniosynechialysis was performed in 10 patients (77%) from 1 month post-TCP onwards. The mean IOP prior to lens extraction was 26 mm Hg (range 19-32 mm Hg). The mean IOP 3 months after lens extraction was 15 mm Hg (range 8-19 mm Hg). The mean number of topical IOP-lowering medications 12 months post-TCP was 1.1.

CONCLUSIONS

Transscleral cyclophotocoagulation is effective and safe in reducing IOP in patients with AAC refractory to medical and laser peripheral iridotomy treatments. We advocate that TCP should be considered early in the management of AAC refractory to medical treatment to avoid irreversible optic neuropathy.

Intravitreal ranibizumab injection combined trabeculectomy versus Ahmed valve surgery in the treatment of neovascular glaucoma: assessment of efficacy and complications

BACKGROUND

Researches have shown anti-vascular endothelial growth factor (VEGF) agent is effective in treating neovascular eye diseases. The purpose of this study is to evaluate the efficacy and safety of intravitreal ranibizumab (IVR) injection combined trabeculectomy in the treatment of neovascular glaucoma (NVG), and compared it with Ahmed valve surgery.

METHODS

Thirty-six NVG patients (37 eyes) from the First Affiliated Hospital of Zhejiang medical college, between January 1, 2014 and January 31, 2015, were included in this prospective, interventional clinical study. Eighteen NVG eyes were given IVR injection one week before trabeculectomy. Ahmed valve implantation surgery was performed in nineteen eyes. Ocular pain, best corrected visual acuity (BCVA), intraocular pressure (IOP) and surgical complications were evaluated before and after the surgery.

RESULTS

IOP was significantly decreased following IVR injection combined trabeculectomy treatment (baseline 57.1 ± 8.9 mmHg; week 1, 15.2 ± 4.3 mmHg p = 0.000; month 1, 16.9 ± 2.1 mmHg p = 0.000; month 3, 20.3 ± 7.7 mmHg p = 0.000; month 6, 19.7 ± 7.3 mmHg p = 0.000). There was a significant, though modest, BCVA improvement in sighted eyes of IVR group (baseline 2.42 ± 0.68, W1 1.80 ± 0.91, P = 0.013; M1 1.77 ± 0.93, p = 0.011). IVR injection combined trabeculectomy had less postoperative complications and lower failure ratio than Ahmed surgery (IVR 5.6 %, Ahmed 31.6 %).

CONCLUSIONS

The study revealed that IVR injection combined trabeculectomy was an effective and safe treatment for NVG. Compared with Ahmed surgery, IVR injection combined trabeculectomy had less complications and higher success ratio. (Chinese Clinical Registry, TRN ChiCTR-OPN-16008147, 3/24/2016, retrospectively registered).

Managing Primary Angle Closure Glaucoma - The Role of Lens Extraction in this Era

Trabeculectomy has been the gold standard in reducing intraocular pressure (IOP) in glaucoma patients, no matter it is angle closure or open angle glaucoma. However in primary angle closure glaucoma, no matter the lens is cataractous or not, it is likely to be pathological, this thicker than usual lens, with or without a more anterior position, is often regarded as a strong contributing factor to angle closure. Lens extraction, no matter it is cataractous or clear, can theoretically eliminate this anatomical predisposing factor of angle closure, and thus IOP can be reduced. Based on recent results of a number of clinical trials, lens extraction alone or in combination with other IOP-lowering surgeries, may therefore play a more important role in the treating primary angle closure glaucoma. In cases when greater IOP-lowering effect is needed or if drug dependency has to be minimized, combined procedures, such as phacotrabeculectomy, can be considered, but the surgical risk can be higher than lens extraction alone.

Small-incision phacotrabeculectomy versus phacoemulsification in refractory acute primary angle closure with cataract

Background

Acute primary angle closure (PAC) can be refractory to conventional treatment and intraocular pressure (IOP) is beyond control. Surgical intervention should be considered at the moment. The aim of the study was to compare small-incision phacotrabeculectomy (phacotrab, small-incision trabeculectomy combined with phacoemulsification) with phacoemulsification (phaco) in patients with refractory acute PAC and coexisting cataract.

Methods

Analyzed 49 eyes (49 patients) with acute PAC and cataract received small-incision phacotrab (24 eyes) or phaco (25 eyes) randomly. All these cases were refractory to conventional treatment involved the use of preoperative topical IOP-lowering agents, corticosteroids, mannitol, methazolamide and paracentesis to reduce IOP. The effects on best corrected visual acuity (BCVA), IOP, anterior chamber depth (ACD), glaucoma medications, and complications were observed for twelve months.

Results

After operation BCVA of 18 patients (75 %) in phacotrab group and 20 patients (80 %) in phaco group improved compared to preoperative vision. No statistically significant differences in mean BCVA were found between the two groups. The mean postoperative IOP levels at all follow up time points were lower than the mean preoperative IOP in each group (P <0.001). There was statistically significant difference in mean IOP between the two groups only at 12 months postoperatively (P = 0.006). The surgical success rate (without medications, IOP ≤ 21 mmHg) was 83.33 % (20 eyes) and 72 % (18 eyes) in phacotrab group and phaco group respectively at 12 months. No statistically significant differences in the mean ACD were found between the two groups. There were no serious intra- or post-operative complications in the two treatment groups.

Conclusions

Besides phaco, small incision phacotrab may be another effective and safe choice in the treatment of patients with refractory acute PAC and coexisting cataract. Whether phacotrab is more effective in IOP control in the long term needs to be verified in the further.

Targeting a low-teen intraocular pressure by trabeculectomy with a fornix-based conjunctival flap: continuous Japanese case series by a single surgeon

PURPOSE

To examine the medium-term outcomes of fornix-based trabeculectomy (TLE) performed by a single surgeon and to analyze outcome in 3 glaucoma subtypes.

METHODS

Consecutive prospective case series study to examine the 6-month outcome of 106 eyes [primary open-angle glaucoma (OAG), exfoliation glaucoma (XFG), and inflammatory glaucoma (ING)] that underwent TLE with mitomycin C performed by a single surgeon from September 2009 to September 2010 at Tokyo University Hospital. Main outcome measure was survival rates of targeted intraocular pressure (IOP) after TLE. Postoperative complications and procedures were analyzed according to glaucoma subtypes. Life table analyses were then made according to 2 criteria of failure: (1) IOP was >12 mm Hg with or without the use of topical glaucoma medications after 2 consecutive measurements or another surgery was needed; and (2) IOP was >15 mm Hg.

RESULTS

A total of 106 eyes, which consisted of 67 OAG eyes, 23 XFG eyes, 16 ING eyes, were analyzed for 6 months after TLE. Four eyes were reoperated. During and after hospitalization, complications were equally observed and procedures were equally performed in all of the 3 groups. For the first definition, cumulative survival rates at 6 months after surgery in OAG, XFG, and ING cases were 76.0%, 73.9%, and 62.5%, respectively. For the second definition, cumulative survival rates in OAG, XFG, and ING cases were 88.0%, 78.3%, and 68.8%, respectively.

CONCLUSIONS

Six-month outcome of TLE with a fornix-based conjunctival incision by a single surgeon that targeted an IOP<12 mm Hg was not different among 3 types of glaucoma.

Antimetabolites in cataract surgery to prevent failure of a previous trabeculectomy

BACKGROUND

Patients having cataract surgery have often earlier undergone a trabeculectomy for glaucoma. However, cataract surgery may be associated with failure of the previous glaucoma surgery and antimetabolites may be used with cataract surgery to prevent such failure. There is no systematic review on whether antimetabolites with cataract surgery prevent failure of a previous trabeculectomy.

OBJECTIVES

To assess the effects of antimetabolites with cataract surgery on functioning of a previous trabeculectomy.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2014), EMBASE (January 1980 to June 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to June 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 June 2014. We also searched the Science Citation Index database (July 2013) and reference lists of potentially relevant studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of antimetabolites with cataract surgery in people with a functioning trabeculectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the titles and abstracts from the electronic searches. Two review authors independently assessed relevant full-text articles and entered data.

MAIN RESULTS

We identified no RCTs to test the effectiveness of antimetabolites with cataract surgery in individuals with the intention of preventing failure of a previous trabeculectomy.

AUTHORS' CONCLUSIONS

There are no RCTs of antimetabolites with cataract surgery in people with a functioning trabeculectomy. Appropriately powered RCTs are needed of antimetabolites during cataract surgery in patients with a functioning trabeculectomy.

Anterior chamber paracentesis and pH values in patients with acute primary angle closure

BACKGROUND

To assess the efficacy and safety of anterior chamber paracentesis (ACP) and the changes in pH values in eyes with acute primary angle closure (APAC).

METHODS

This retrospective case-control study involved 22 patients with APAC who underwent ACP (study group) and 21 patients with APAC who did not undergo ACP (control group). Intraocular pressure (IOP) and visual acuity were measured before treatment and 15 min and 24 h after treatment in both groups. The pH of aqueous humor was measured immediately after ACP in the study group.

RESULTS

A total of 43 eyes in 43 patients were reviewed. The IOP 15 min after ACP (23.3 ± 9.6 mmHg) and 24 h after ACP (21.6 ± 12.0 mmHg) were significantly lower than that before ACP (58.6 ± 12.9 mmHg). The IOP 15 min after ACP was significantly lower than the IOP 15 min after conventional treatment (55.4 ± 10.3 mmHg). Visual acuity recovery was achieved earlier after ACP than after conventional treatment. Hyphema after ACP was noted in one eye. The mean pH of the aqueous humor in APAC was 6.99 ± 0.35. The pH of the aqueous humor significantly correlated with the duration of acute IOP elevation and the IOP before ACP.

CONCLUSIONS

ACP is an effective and safe procedure. The pH of aqueous humor is lower in eyes with APAC of longer duration and in eyes with higher IOP at presentation.

Effects of combined phacoemulsification and viscogoniosynechialysis versus trabeculectomy in patients with primary angle-closure glaucoma and coexisting cataract

AIMS

To compare the effectiveness of combined phacoemulsification and viscogoniosynechialysis versus trabeculectomy alone in primary angle-closure glaucoma (PACG) with a coexisting cataract.

METHODS

Thirty-nine Chinese patients (39 eyes) were retrospectively analyzed: 19 patients underwent combined phacoemulsification and viscogoniosynechialysis (group 1), and 20 underwent trabeculectomy (group 2). In both groups, the intraocular pressure (IOP), the number of antiglaucoma medications, the best corrected visual acuity (BCVA), the central anterior chamber depth (ACD), the synechial/apposition angle closure (SAC), and the success rates were assessed.

RESULTS

The median follow-up periods were similar for both groups (10 months). At the last follow-up, the mean IOP was 14.09 ± 6.89 mm Hg and the mean number of antiglaucoma medications was 0.36 ± 0.59 in group 1; in group 2, the mean IOP was 16.48 ± 4.74 mm Hg (p = 0.066) and the mean number of antiglaucoma medications was 1.05 ± 0.99 (p = 0.025). In terms of the mean central ACD and the mean SAC, there were significant differences between the groups (p = 0.0000, respectively). Kaplan-Meier analysis revealed that the cumulative probability of success in group 1 was higher than that in group 2 (p = 0.0051).

CONCLUSION

Compared to trabeculectomy, combined phacoemulsification and viscogoniosynechialysis resulted in a lower requirement for glaucomatous medications, a greater improvement in BCVA, and a higher cumulative probability that treatment would be successful among patients with PACG and coexisting cataracts.