Anterior Chamber Angle Changes in Primary Angle-closure Glaucoma Following Phacoemulsification Versus Phacotrabeculectomy: A Prospective Randomized Clinical Trial

PRCIS

We used anterior segment optical coherence tomography to investigate anterior chamber angle in primary angle-closure glaucoma (PACG) eyes following phacoemulsification and phacotrabeculectomy. Angle widening was significantly greater after phacoemulsification up to 6 months after the surgery.

PURPOSE

To compare anterior chamber angle following 2 common surgeries for PACG.

METHODS

One hundred ten glaucoma patients were evaluated in this single center, prospective, randomized clinical trial. Those with concomitant PACG and senile cataract and without a history of ocular surgery, trauma, or chronic miotic use were recruited. Monocular patients were also excluded. Finally, 52 eligible subjects were randomly assigned to phacoemulsification ("Phaco" group, 25 eyes) or phacotrabeculectomy ("Combined" group, 27 eyes) surgeries. A swept-source, anterior segment optical coherence tomography device (CASIA SS-1000 OCT) was used to image the anterior segment. Mask graders used the images to measure the following parameters before and 1 week, 1 month, and 6 months after surgery: angle opening distance at 500 µm, trabecular iris surface area at 500 µm, and trabecular iris angle at 500 µm.

RESULTS

There was no significant difference between study groups regarding best-corrected visual acuity, intraocular pressure (IOP), and the number of glaucoma medications in preoperative or postoperative visits (P>0.076). Also, the measured angle parameters were not statistically significantly different between the 2 groups before surgery (P>0.123). After surgery, all measured parameters were significantly increased in both groups (P<0.0001). At the 6-month follow-up, nasal angle opening distance at 500 µm was 0.383±0.027 vs. 0.349±0.017, trabecular iris surface area at 500 µm was 0.141±0.007 vs. 0.125±0.005, and trabecular iris angle at 500 µm was 40.1±12.9 vs. 34.6±3.1 in Phaco and Combined groups, respectively (P<0.0001 for all).

CONCLUSIONS

Anterior chamber angle widening by anterior segment optical coherence tomography was observed in PACG patients following surgery and was significantly greater after phacoemulsification compared with combined phacotrabeculectomy at all time points. Similar IOP and medication burden were noted for up to 6 months as secondary outcomes. The contribution of angle changes to the IOP-lowering effect of phacoemulsification in PACG eyes needs further study.

Clinical Efficacy and Safety Outcomes of Micropulse Transscleral Diode Cyclophotocoagulation in Patients With Advanced Glaucoma

PRECIS

Micropulse transscleral cyclophotocoagulation (MPTCP) is only moderately effective in lowering intraocular pressure (IOP) and is useful as an adjunct procedure to other glaucoma surgeries. There was a small risk of loss of vision, prolonged hypotony, and phthisis bulbi.

AIM

The aim of this study was to determine the efficacy and safety of a single MPTCP treatment for an Asian population with advanced glaucoma.

METHODS

This is a retrospective single-center study of 207 eyes (207 patients) with advanced glaucoma which underwent first-time MPTCP between January 1, 2008, and March 31, 2018. Success was defined as IOP of 6 to 21 mm Hg or ≥20% reduction in IOP without an increase in glaucoma medication from baseline, and without glaucoma reoperation. The IOP, best-corrected visual acuity, and number of glaucoma medications were also analyzed.

RESULTS

The mean (SD) age was 64.9±16.9 years. The mean follow-up duration was 18.7±16.2 months. The rate of success at postoperative years 1 and 2 follow-up was 44.1% and 32.6%, respectively. The median survival time of MPTCP was 9.0 months and 85 (40.9%) eyes received reoperation. The mean IOP decreased from 31.5±12.0 mm Hg preoperatively to 22.1±10.3 and 23.8±11.8 mm Hg at postoperative years 1 and 2, respectively (P<0.0001). The mean number of glaucoma medications was reduced from 3.3±1.0 preoperatively to 2.6±1.1 and 2.4±1.1 at postoperative years 1 and 2, respectively (P<0.0001). Significant complications included prolonged hypotony [1 eye (0.5%)], phthisis bulbi [7 eyes (3.4%)], and best-corrected visual acuity reduction [29 eyes (13.9%)].

CONCLUSION

Single first-time MPTCP for advanced glaucoma eyes was moderately effective in lowering IOP but >50% failed by 1 year.

Outcomes and risk factors for failure after trabeculectomy in Taiwanese patients: medical chart reviews from 2006 to 2017

AIMS

To determine long-term outcomes and risk factors for failure after mitomycin C (MMC)-augmented initial trabeculectomy (IT) in Taiwanese patients.

METHODS

We reviewed medical records of patients with glaucoma undergoing IT during December 2006-December 2016. We defined complete success as an intraocular pressure (IOP) of >5 or ≤21 mm Hg or IOP reduction of ≥20% from baseline without supplemental medications and qualified success as the aforementioned IOP levels with or without supplemental medications. Kaplan-Meier survival and Cox proportional analyses evaluated success rates and risk factors for failure, respectively.

RESULTS

We enrolled 190 patients (237 eyes; mean age: 54.0±15.3 years; mean postoperative follow-up period: 68.4±35.1 months). Mean IOP and glaucoma medications decreased from 22.2±10.8 to 14.4±5.2 mm Hg (p<0.001) and 3.0±0.7 to 1.8±1.2 (p=0.015), respectively, at the last visit. Cumulative qualified success rates were 93.9%, 93.0%, 86.5% and 67.1% at the 1, 2, 5 and 10 years follow-up, respectively; however, only 7.7% of the eyes reached complete success at the last visit. Eyes with poor preoperative visual acuity were associated with low qualified success rates (HR=1.689, p=0.027); patients aged >70 years had higher complete success rates than did those aged ≤70 years. Five cases (2.11%) exhibited bleb-associated complications.

CONCLUSION

Despite satisfactory long-term success rates, most eyes needed medication for IOP control, supporting the notion of predisposed scarring vitality in patients of Chinese ethnicity following MMC-augmented trabeculectomy.

Phacoemulsification Versus Phacotrabeculectomy in Primary Angle-closure Glaucoma With Cataract: Long-Term Clinical Outcomes

PRECIS

Phacotrabeculectomy was more effective in reducing intraocular pressure (IOP) and glaucoma drugs than phacoemulsification alone in primary angle-closure glaucoma (PACG) eyes with cataract but was associated with more postoperative complications, up to 5 years after surgery.

PURPOSE

The purpose of this study was to compare long-term clinical outcomes of phacoemulsification versus phacotrabeculectomy in PACG eyes with cataract.

PATIENTS AND METHODS

The 2 initial prospective randomized controlled trials recruited PACG eyes with cataract using the same criteria and randomized these eyes to receiving either phacoemulsification or phacotrabeculectomy. Clinical data up to 5 years of follow-up were pooled for retrospective analysis.

RESULTS

Clinical data of 35 patients in the phacoemulsification group and 44 patients in the phacotrabeculectomy group were analyzed. At 5 years after surgery, the mean IOP was decreased by 20.7% and 29.5% from before surgery to 5 years after phacoemulsification and phacotrabeculectomy, respectively (P<0.001 for both groups). Phacotrabeculectomy was significantly more effective than phacoemulsification in reducing IOP up to 5 years after surgery (P<0.001). At 5 years, the mean number of glaucoma drugs required±1 SD was 1.6±1.2 in the phacoemulsification group, and 0.7±1.0 in the phacotrabeculectomy group (P=0.004). Phacotrabeculectomy was associated with more postoperative complications than phacoemulsification up to 5 years (25 complications in the phacotrabeculectomy group versus 6 in the phacoemulsification group, P<0.001).

CONCLUSIONS

Phacoemulsification alone reduces IOP and the need for glaucoma drugs in PACG eyes with cataracts for up to 5 years. Phacotrabeculectomy was more effective in reducing IOP and glaucoma drugs than phacoemulsification alone but was associated with more postoperative complications, up to 5 years after surgery.

Prospective Study on Ex-PRESS Implantation Combined with Phacoemulsification in Primary Angle-Closure Glaucoma Coexisting Cataract: 3-Year Results

PURPOSE

To evaluate the feasibility, efficacy, and safety of Ex-PRESS implantation combined with phacoemulsification surgery in primary angle-closure glaucoma (PACG) with cataract.

MATERIALS AND METHODS

This is a prospective, nonrandomized study. A total of 34 eyes of 34 subjects were enrolled. The assessments were conducted preoperatively and postoperatively at 1 week and 1, 3, 6, 12, 18, 24, 30, and 36 months. The assessments included intraocular pressure (IOP), best-corrected visual acuity (BCVA), the number of glaucoma medications, corneal endothelial cell density (ECD), and related complications, if any. The anterior segment structure was also assessed by anterior segment optical coherence tomography based on the anterior chamber depth (ACD), angle opening distance (AOD500), and trabecular-iris angle (TIA). A complete success was defined as a controlled IOP between 5 and 21 mmHg without medications.

RESULTS

The complete success rates at 12, 24, and 36 postoperative months were 91.2%, 81.7%, and 78.3%, respectively. The mean preoperative IOP was 28.43 ± 12.93 mmHg and decreased to 15.35 ± 4.02 mmHg at 3 years postoperatively (P < 0.001). The number of medications decreased from 2.47 ± 1.89 at baseline to 0.28 ± 0.76 at 3 years postoperatively (P = 0.001). BCVA was 0.83 ± 0.58 at baseline and 0.51 ± 0.33 at 3 years postoperatively (P = 0.008). The ACD, AOD500, and TIA significantly increased at 3 months postoperatively compared with baseline (P < 0.001). ECD at 3 months and 3 years postoperatively were both significantly lower compared with baseline (P = 0.03), but was not significantly different between 3 months and 3 years postoperatively (P = 0.07). The device-related complications identified were hypotony (5.8%), hyphema (2.9%), and iris touch (2.9%), which the incidence rates were all very low.

CONCLUSIONS

Ex-PRESS implantation combined with phacoemulsification was effective for lowering IOP in PACG coexisting with cataract. The device-related complication was rare.

Comparison of the long-term outcomes of resident versus attending performed trabeculectomy

Purpose

To compare the long-term outcomes obtained by residents and attending surgeons performing trabeculectomy.

Methods

After reviewing medical records of the patients, 41 residents performing trabeculectomy under supervision of attendings were compared to 41 attendings performing trabeculectomy. The primary outcome measure was the surgical success defined in terms of intraocular pressure (IOP) ≤ 21 mmHg (criterion A) and IOP ≤ 16 mmHg (criterion B), with at least 20% reduction in IOP, either with no medication (complete success) or with no more than 2 medications (qualified success). IOP, number of glaucoma medications, surgical complications, and visual acuity were analyzed as secondary outcome measures.

Results

Mean age of the patients was 59.5 ± 8.6 years in the resident group and 59.6 ± 12.31 years in the attending group (P = 0.96). Furthermore, mean duration of the follow-up was 62.34 ± 5.51 months in the resident group and 64.80 ± 7.80 months in the attending group (P = 0.10). The cumulative success according to criterion A was 87.8% in the resident group and 85.3% in the attending group (P = 0.50). Moreover, according to criterion B, it was 87.8% and 83% in the resident and attending groups, respectively (P = 0.62). Repeated glaucoma surgery was required in 12.2% and 2.4% of the patients in the resident and attending groups, respectively (P = 0.09). Rate of complications was 12.2% and 4.8% in the resident and attending groups, respectively (P = 0.23).

Conclusion

There were comparable results with respect to success rates and complications between residents and attending surgeons performing trabeculectomy in the long-term follow-up.

Time Heals All Wounds: Obstacles in Glaucoma Surgery from an Asian Perspective

Glaucoma is the leading cause of irreversible blindness worldwide and is a particular burden on the Asian population. Glaucoma surgeries such as trabeculectomy and glaucoma drainage implants are routinely performed to lower intraocular pressure (IOP) to prevent disease progression. However, scarring of the filtering bleb limits their long-term success and Asian eyes are more at risk. Although this is so, many existing studies have been done on Caucasian patients, but few have focused solely on Asian patients. Intraoperative anti-metabolites such as Mitomycin-C (MMC) and 5-Fluorouracil (5-FU) are the current mainstay of adjunctive treatments to reduce scarring, and in this review, we evaluate the evolution, benefits and side effects of these agents. Recently, newer methods of wound modulation including anti-vascular endothelial growth factor (VEGF) agents and collagen implants are also being investigated as part of a multi-pronged approach to tackle this problem. Some opportunities exist to limit scarring post-operatively, but it is an ongoing battle.

Factors correlating with failure to control intraocular pressure in primary angle-closure glaucoma eyes with coexisting cataract treated by phacoemulsification or combined phacotrabeculectomy

PURPOSE

To identify clinical factors correlating with failure to control intraocular pressure (IOP) in primary angle-closure glaucoma (PACG) eyes with cataract after phacoemulsification or phacotrabeculectomy.

DESIGN

Retrospective analysis of two prospective randomized controlled clinical trials.

METHODS

Primary angle-closure glaucoma eyes with cataract received phacoemulsification or phacotrabeculectomy. Failure was defined as having IOP of 21mm Hg or greater, or requiring glaucoma drugs to maintain an IOP of less than 21 mm Hg, or having had additional IOP-lowering surgery. Factors correlating with failure at 24 months after surgery were identified using logistic regression model.

RESULTS

One hundred twenty-three PACG eyes with cataract and receiving phacoemulsification (n = 62) and phacotrabeculectomy (n = 61) were analyzed. With univariate analysis, factors associated with failure included a higher preoperative IOP, a higher preoperative requirement for glaucoma drugs, absence of plateau iris configuration, and phacoemulsification alone. With multivariate analysis, factors associated with failure included a higher preoperative IOP [odds ratio (OR), 1.732 per increase in IOP of 5 mm Hg], a higher preoperative requirement for glaucoma drugs (OR, 1.913), and performance of phacoemulsification alone (OR, 10.24).

CONCLUSIONS

In PACG eyes with cataract, higher preoperative IOP and increased requirement for glaucoma drugs correlate with failure to control IOP after phacoemulsification or phacotrabeculectomy. Phacotrabeculectomy is more likely than phacoemulsification to achieve IOP control.

Phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle-closure glaucoma without cataract

OBJECTIVE

To compare phacoemulsification versus trabeculectomy with adjunctive mitomycin C in medically uncontrolled chronic angle-closure glaucoma (CACG) without cataract.

DESIGN

Prospective, randomized clinical trial.

PARTICIPANTS

Fifty medically uncontrolled CACG eyes without cataract of 50 patients.

INTERVENTION

Patients were randomized into undergoing either phacoemulsification or trabeculectomy with adjunctive mitomycin C. After surgery, patients were followed up every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for glaucoma drugs.

RESULTS

Twenty-six CACG eyes were randomized to receive phacoemulsification, and 24 eyes underwent trabeculectomy with mitomycin C. Phacoemulsification and trabeculectomy resulted in significant and comparable IOP reduction at 24 months after surgery (reduction of 8.4 mmHg or 34% for phacoemulsification vs. 8.9 mmHg or 36% for trabeculectomy; P=0.76). Over first 24 months, trabeculectomy-treated eyes required on average 1.1 fewer drugs than phacoemulsification-treated eyes (P<0.001). However, trabeculectomy was associated with significantly more surgical complications than phacoemulsification (46% vs. 4%; P=0.001). Eight (33%) of 24 trabeculectomy eyes demonstrated cataract during follow-up.

CONCLUSIONS

Both phacoemulsification and trabeculectomy are effective in reducing IOP in medically uncontrolled CACG eyes without cataract. Trabeculectomy is more effective than phacoemulsification in reducing dependence on glaucoma drugs, but is associated with more complications.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Phacoemulsification versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts

OBJECTIVE

To compare phacoemulsification alone versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma (CACG) with coexisting cataract.

DESIGN

Prospective randomized clinical trial.

PARTICIPANTS

Fifty-one medically uncontrolled CACG eyes with coexisting cataract of 51 patients.

INTERVENTION

Recruited patients were randomized into group 1 (phacoemulsification alone) or group 2 (combined phacotrabeculectomy with adjunctive mitomycin C). Postoperatively, patients were reviewed every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for topical glaucoma drugs.

RESULTS

Twenty-seven CACG eyes were randomized into group 1, and 24 CACG eyes were randomized into group 2. Combined phacotrabeculectomy resulted in lower mean postoperative IOP than phacoemulsification alone at 3 months (14.0 vs. 17.0 mmHg, P = 0.01), 15 months (13.2 vs. 15.4 mmHg, P = 0.02), and 18 months (13.6 vs. 15.9 mmHg, P = 0.01). Combined phacotrabeculectomy resulted in 1.25 fewer topical glaucoma drugs (P<0.001) in the 24-month postoperative period, compared with phacoemulsification alone. Combined surgery was associated with more postoperative complications (P<0.001) and more progression of optic neuropathy (P = 0.03), compared with phacoemulsification alone.

CONCLUSIONS

Combined phacotrabeculectomy with adjunctive mitomycin C is more effective than phacoemulsification alone in controlling IOP in medically uncontrolled CACG eyes with coexisting cataract. Combined phacotrabeculectomy is associated with more postoperative complications.

The singapore 5-Fluorouracil trabeculectomy study: effects on intraocular pressure control and disease progression at 3 years

PURPOSE

To report 3-year results of a randomized, controlled trial comparing the use of a single application of 5-fluorouracil (5-FU) with placebo in trabeculectomy surgery.

DESIGN

Prospective, randomized, double-blinded treatment trial.

PARTICIPANTS

Two hundred forty-three Asian patients with primary open-angle or primary angle-closure glaucoma undergoing primary trabeculectomy.

METHODS

One eye of each patient was randomized to receive either intraoperative 5-FU or normal saline (placebo) during trabeculectomy.

MAIN OUTCOME MEASURES

Primary outcome measure was the level of intraocular pressure (IOP). Secondary outcomes were progression of visual field loss, rates of adverse events, and interventions after surgery.

RESULTS

Of the 288 eligible patients, 243 were enrolled and 228 completed 3 years follow-up; 120 patients received 5-FU and 123 received placebo. Trial failure, according to predefined IOP criteria, was lower in the 5-FU group compared with the placebo group, although the difference was only significant with a failure criterion of IOP >17 mmHg (P = 0.0154). There was no significant difference in progression of optic disc and/or visual field loss over 36 months between 5-FU and placebo (relative risk [RR], 0.67; 95% confidence interval [CI], 0.34-1.31; P = 0.239). Uveitis occurred more often in the 5-FU-treated group (14/115 [12%] vs 5/120 [4%]; P = 0.032).

CONCLUSIONS

This is the first masked, prospective, randomized trial reporting the effect of adjunctive 5-FU in trabeculectomy surgery in an East Asian population. The trial shows that an increased success rate can be achieved for several years after a single intraoperative treatment with 5-FU. We conclude that 5-FU is relatively safe and can be routinely used in low-risk East Asian patients.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Phacoemulsification versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma with cataract

OBJECTIVE

To compare phacoemulsification alone versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma (CACG) with coexisting cataract.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Seventy-two medically controlled CACG eyes with coexisting cataract.

INTERVENTION

Recruited patients were randomized into group 1 (phacoemulsification alone) or group 2 (combined phacotrabeculectomy with adjunctive mitomycin C). Postoperatively, patients were reviewed every 3 months for 2 years.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and requirement for topical glaucoma drugs.

RESULTS

Thirty-five CACG eyes were randomized into group 1, and 37 CACG eyes were randomized into group 2. There were no statistically significant differences (P>0.05) in mean IOP between the 2 treatment groups preoperatively and postoperatively, except at 1 month (P = 0.001) and 3 months (P = 0.008). Combined phacotrabeculectomy with adjunctive mitomycin C resulted in 0.80 less topical glaucoma drugs (P<0.001) in the 24-month postoperative period compared with phacoemulsification alone. The differences in IOP control were, however, not associated with differences in glaucomatous progression. Combined surgery was associated with more postoperative (P<0.001) complications compared with phacoemulsification alone.

CONCLUSIONS

Combined phacotrabeculectomy with adjunctive mitomycin C may be marginally more effective than phacoemulsification alone in controlling IOP in medically controlled CACG eyes with coexisting cataract. Combined surgery may be associated with more complications and additional surgery in the postoperative period. Further study is needed to determine whether the marginally better IOP control of combined surgery justifies the potential additional risks of complications and further surgery.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.