The safety and efficacy of combined phacoemulsification and trabeculectomy with releasable sutures

Real life experience following combined excimer laser trabeculostomy and phacoemulsification in eyes with ocular hypertension or mild glaucoma and cataract

OBJECTIVES

To assess the efficacy and safety of combined phacoemulsification and excimer laser trabeculostomy (ELT) in eyes with cataract and mild controlled glaucoma or ocular hypertension (OHT).

METHODS

Single-centre analysis of eyes that underwent phacoemulsification and ELT between 2017 and 2021. Change in intraocular pressure (IOP), glaucoma medication requirements, corrected distance visual acuity (CDVA), complications and re-interventions were evaluated. Success was defined as a reduction ≥20% from preoperative IOP, an IOP ≤ 14 mmHg or a reduction in glaucoma medication requirements with an IOP equal or lower than the preoperative IOP.

RESULTS

Mean follow-up was 658 ± 64 days. Mean preoperative IOP was 17.76 ± 4.88 mmHg, it decreased to 15.35 ± 3.10 mmHg at 1 year (n = 37) (p = 0.006) and to 14.00 ± 3.78 at 3 years (n = 8) (p = 0.074). Mean number of glaucoma medication requirements decreased from 2.02 ± 1.0 preoperatively to 1.02 ± 0.96 at 1 year (n = 37) (p < 0.001) and to 1.63 ± 0.92 at 3 years (n = 8) (p = 0.197). Complete success was achieved in 17.7% of eyes and qualified success in 54.8%. Two eyes of 2 patients had early postoperative hyphema. Two eyes of 1 patient underwent filtering surgery 2 months after the procedure, and 2 eyes of 1 patient underwent laser trabeculoplasty 3.8 years after the procedure due to uncontrolled IOP.

CONCLUSIONS

Combined phacoemulsification and ELT is effective and safe in eyes with mild glaucoma or OHT and cataract. It significantly reduced IOP and glaucoma medication requirements 1 year after surgery.

Early macular thickness changes after trabeculectomy and combined phaco-trabeculectomy

Purpose:

To assess postoperative changes in central retinal thickness (RT) following trabeculectomy and combined phaco-trabeculectomy using spectral domain-optical coherence tomography.

Methods:

In a prospective interventional comparative study, 64 consecutive glaucoma patients who underwent trabeculectomy (32 eyes) or phaco-trabeculectomy (32 eyes) were included. A macular thickness map using the Early Treatment Diabetic Retinopathy Study circles of 1 mm, 3 mm, and 6 mm was the standard to evaluate the 9-subfield thickness preoperatively and again at 1 and 3 months after surgery. Four subfields in each of the 3 mm and 6 mm rings were considered parafoveal and perifoveal regions, respectively.

Results:

Preoperative measurements were similar in the two groups, except patients in the combined group which were older (P = 0.002). The mean RT in the combined phaco-trabeculectomy group at month 1 was significantly higher than baseline measurements at central subfield retinal thickness (CSRT) (P = 0.01), temporal (P = 0.001), and inferior (P = 0.04) parafoveal and temporal (P = 0.01), superior (P = 0.02), and nasal (P < 0.001) perifoveal quadrants; however, RT changes in the trabeculectomy-only group were not statistically significant at months 1 and 3 (P > 0.05). The increase in the temporal perifoveal RT of the combined phaco-trabeculectomy group persisted at month 3 (P = 0.01), while the RT in other sectors returned to preoperative values. The two treatment groups did not differ in terms of changes in the CSRT over time (P = 0.37). In addition, no difference was observed between the treatment groups regarding the parafoveal RTs at each time points (0.06 ≤ P ≤ 0.29).

Conclusions:

There was no significant difference in the pattern of changes of CSRT and parafoveal RT between trabeculectomy and combined phaco-trabeculectomy treatment groups up to 3 months after surgery. Some detectable increase in RT in the combined phaco-trabeculectomy will reverse to baseline values 3 months after surgery, except in the temporal perifoveal region.

The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia

Purpose: To evaluate and compare the safety and efficacy of combined two-site phacoemulsification and trabeculectomy surgery with mitomycin C (MMC) in glaucoma-cataract patients with retrobulbar or topical anesthesia.

Patients and methods: A retrospective, nonrandomized review of consecutive phacotrabeculectomy patients with a minimum follow-up time of 6 months, no previous glaucoma surgeries, and a preoperative visual acuity (VA) greater than light perception. The main outcome measures were preoperative and postoperative VA, intraocular pressure (IOP), use of glaucoma medications, and complications. A complete surgical success required an IOP from 6 to 18 mm Hg, no visually devastating complications, no return to surgery, and no use of glaucoma medications. Qualified success allowed the use of up to two glaucoma medications. Anesthesia groups were compared by student t-tests and log rank comparison of Kaplan-Meier survival rates.

Results: Eighty-seven eyes (83 patients) met inclusion criteria, with a mean follow-up of 19 ± 12 months (6-57 months). The average eye gained 3.1 ± 4.9 lines of VA, lost 4.0 ± 7.1 mm Hg of IOP, and decreased 1.0 ± 1.3 glaucoma medications. Retrobulbar and topical anesthesia groups had statistically equivalent mean changes in VA (p = 0.910), IOP (p = 0.268), and use of glaucoma medications (p = 0.964). Postoperative complication rates were also statistically similar (p = 0.580). Complete success was greater in the retrobulbar group (p = 0.006), however, qualified success was equivalent in both groups (p = 0.769).

Conclusion: Two-site phacotrabeculectomy with MMC in West Indian patients is as safe and effective for glaucoma-cataract patients with topical anesthesia as it is under retrobulbar anesthesia, and without short-term losses in VA and the chance of serious complications from injection.

How to cite this article: Rodriguez R, Alburquerque R, Sauer T, Batlle JF. The Safety and Efficacy of Two-site Phacotrabeculectomy with Mitomycin C under Retrobulbar and Topical Anesthesia. J Curr Glaucoma Pract 2016;10(1):7-12.

Surgical outcome of safe surgery system trabeculectomy combined with cataract extraction

PURPOSE

To determine the efficacy of safe surgery system trabeculectomy combined with manual small incision cataract surgery/phacoemulsification in primary glaucoma coexistent with cataract.

METHODS

This is a retrospective analysis of 105 cases who underwent single-site combined surgery between January 2008 and December 2009. Safe surgery system trabeculectomy with diffuse and posterior application of mitomycin C was performed in all cases. Cataract extraction was done either by Manual Small Incision Cataract Surgery (MSICS) or phacoemulsification. Main outcome measures were success rate of trabeculectomy, as determined by four different IOP goals and incidence of postoperative complications. Analysis was performed using R-2.15, and the significance was tested at 5% level.

RESULTS

The minimum follow-up period was 12 months. The overall success rates (with or without medication) when safe surgery system trabeculectomy was combined with MSICS were 91, 70, and 51% for IOP ≤18, ≤15, and ≤12 mm Hg, respectively, and target IOP was achieved in 72% cases. The mean IOP reduction was 43.8% with MSICS and 42.08% with phacoemulsification. The surgical outcome was not significantly different for both techniques. Postoperative complications were infrequent and comparable.

CONCLUSION

The Safe Surgery System Trabeculectomy combined with cataract surgery offers excellent IOP control with minimal postoperative complications. It offers an effective and improved solution for primary glaucoma coexistent with cataract found in developing countries.

Lowering of IOP by echothiophate iodide in pseudophakic eyes with glaucoma

PURPOSE

We retrospectively investigated the intraocular pressure (IOP)-lowering effects of echothiophate iodide (EI) as adjunctive treatment for pseudophakic glaucoma patients who were receiving maximal medical therapy (MMT), including the newer class of medications, i.e., prostaglandin analogs, alpha-2 agonists, and topical carbonic anhydrase inhibitors.

METHODS

The medical records of all pseudophakic glaucoma patients (24 eyes) under MMT who received supplementary EI 0.125% between January 2002 and December 2003 were reviewed. IOP data and number of medications before, during and after EI treatment were collected.

RESULTS

Adding EI to MMT further reduced IOP in 23 of 24 eyes. Three eyes (12.5%) showed some lowering of IOP, but not enough to be considered controlled (IOP above the target pressure). The mean baseline IOP of 30.4 +/- 8.2 mmHg (median 29 mmHg) dropped at final follow-up (11.2 +/- 3.9 months) to 16.6 +/- 4.2 mmHg (median 17 mmHg, p < 0.0001) in all eyes that had showed effective pressure reduction upon the addition of EI. Their IOP rose to 27.7 +/- 8.0 mmHg (median 28 mmHg, p < 0.001) when EI was discontinued because of commercial non-availability. IOP reduction was > or =20% in 18 (75%) eyes and > or =30% (a mean decrease of 16.7 +/- 8.3mmHg) in 15 eyes (63%). Four eyes (16.6%) required a trabeculectomy despite EI supplement. Five eyes were re-challenged with EI when a small amount was released for sale: their IOP of 26.6 +/- 7.1 mmHg after the first EI discontinuation had dropped to 16.4 +/- 4.3 mmHg (p < 0.0001) and rose to 29.6 +/- 7.1 mmHg when EI was again discontinued. The recorded EI-associated side effects were increased miosis in all eyes and headache (8/24 patients), neither of which were reasons for discontinuation of the drug in any patient.

CONCLUSION

EI substantially decreased the IOPs in pseudophakic glaucoma eyes receiving maximal medical therapy, including the newer class of medications. This drug may be the last resort for post-cataract advanced glaucoma patients and may obviate the need for filtering surgery among the very elderly.

Phacoviscocanalostomy versus cataract surgery only in patients with coexisting normal-tension glaucoma: midterm outcomes

PURPOSE

To compare the midterm efficacy and safety of phacoviscocanalostomy (viscocanalostomy, phacoemulsification, and intraocular lens [IOL] implantation) and cataract surgery (phacoemulsification and IOL implantation) in patients with normal-tension glaucoma (NTG) and cataract.

SETTING

Sensho-kai Eye Institute, Kyoto, Japan.

METHODS

Thirty-one eyes had phacoviscocanalostomy, and 35 eyes had uncomplicated cataract surgery only. The intraocular pressure (IOP), postoperative antiglaucoma medications, and visual outcomes were compared between groups.

RESULTS

The mean follow-up was 34.9 months+/-19.8 (SD) (range 7 to 78 months). At 36 months, the mean preoperative IOP and postoperative IOP were 17.2+/-1.5 mm Hg and 14.1+/-1.6 mm Hg, respectively, in the phacoviscocanalostomy group and 16.7+/-1.4 mm Hg and 15.6+/-3.4 mm Hg, respectively, in the cataract surgery only group. The differences between groups were significant at all time points (P<.05). The success probabilities of the phacoviscocanalostomy group achieving 20% and 30% IOP reductions with (or without) medications were 78.5% (67.4%) and 35.5% (37.4%) at 24 months and 58.0% (44.2%) and 28.0% (26.6%) at 48 months, which were significantly better than the probabilities in the cataract surgery only group, which were 16.0% (9.5%) and 5.7% (2.9%) at 24 months (P<.001 for each comparison, Kaplan-Meier life-table analysis with log-rank test). Based on the modified Aulhorn-Greve classification, the visual acuity and visual fields did not deteriorate in the phacoviscocanalostomy group; the visual fields deteriorated in 6 eyes in the cataract surgery only group during the follow-up (P=.024).

CONCLUSION

Phacoviscocanalostomy lowered IOP and maintained postoperative visual outcomes; it was safe and effective in elderly patients with coexisting NTG and cataract.