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Extracapsular Cataract Extraction and Posterior Chamber Intraocular Lens Implantation Combined With Trabeculectomy in Patients With Glaucoma
Extracapsular Cataract Extraction and Posterior Chamber Intraocular Lens Implantation Combined With Trabeculectomy in Patients With Glaucoma Steven T. S i m m o n s , M . D . , D a v i d Litoff, B . A . , D a n A . N i c h o l s , M . D . , Mark B. S h e r w o o d , M . D . , and George L. Spaeth, M . D .
We reviewed 75 consecutive cases of extracapsular cataract extraction and posterior chamber intraocular lens implantation combined with trabeculectomy in 69 patients with glaucoma. The mean preoperative intraocular pressure was 19.3 mm Hg on an average of 2.3 glaucoma medications. Visual acuity improved in 58 eyes (77%) at two months, with an average improvement of 3.3 and 3.6 lines at two and 12 months, respectively. Of the 75 eyes, 49 (65%) achieved a visual acuity of 20/40 or better; three patients (4%) had further deterioration in vision at the completion of followup because of progressive glaucoma or macular disease. Postoperatively, the average intraocular pressure was 3.8 and 3.0 mm Hg lower than the preoperative level at two and 12 months (F < .001) on 0.63 and 0.79 glaucoma medications, respectively. However, 27 (36%) of the 75 eyes had a recorded intraocular pressure greater than 30 mm Hg and 30 (40%) had a pressure 7 mm Hg or more above their preoperative level during the first six months after surgery. Despite improved long-term control of intraocular pressure, detectable conjunctiva! filtering blebs were present in only 31 (41%) of 75 eyes at two months and in seven
Accepted for publication Aug. 14, 1987. From the William and Anna Goldberg Glaucoma Serv ice, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania (Drs. Simmons, Nichols, Sherwood, and Spaeth) and the Glaucoma Service, Al bany Medical College, Albany, New York (Dr. Simmons and Mr. Litoff). This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. (Dr. Simmons), the Northeastern New York Sight Conservation Society (Dr. Simmons), and the Interna tional Glaucoma Association (Dr. Sherwood). Reprint requests to Steven T. Simmons, M.D., Depart ment of Ophthalmology, Albany Medical College, Alba ny, NY 12208.
(12%) of 56 eyes at 12 months. Hyphema occurred in 34 (45%) of the cases. THE SURGICAL MANAGEMENT of cataract in the
patient with glaucoma has changed in the last ten years in response to the development of extracapsular surgical technique, intraocular lens implantation, and new filtering proce dures. The combination of intracapsular cata ract extraction with guarded filtering proce dures was first reported in the mid 1970s. 16 In theory, there were two potential benefits to the combined surgery: the avoidance of transient increases in intraocular pressure in the initial postoperative period and long-term improve ment in intraocular pressure control with one surgical procedure while removing the visual impairment. Recently, these techniques have been modified using an extracapsular cataract extraction combined with posterior chamber intraocular lens implantation. 710 Although long-term pressure control was noted to be improved, the ability of the combined proce dure to protect against transient increases in intraocular pressure was not addressed. 7 1 0 We reviewed 75 consecutive cases of extra capsular cataract extraction combined with tra beculectomy and posterior chamber intraocular lens implantation in an attempt to assess this surgical procedure's ability to reach its theoret ical goals.
Material and Methods We reviewed 75 consecutive cases of extra capsular cataract extractions combined with trabeculectomies and posterior chamber intra ocular lens implantations performed between January 1984 and December 1985. All patients
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were being treated for glaucoma and had an average preoperative intraocular pressure of 19.3 mm Hg (range, 11 to 39 mm Hg) on an average of 2.3 glaucoma medications (range, one to four medications). Patients who had undergone previous intraocular surgery, ex cept for laser surgery, were excluded from this study. No exclusions were made for age, cause of the glaucoma, or other ocular disease such as age-related macular degeneration. Preoperatively, all patients received a stan dard ophthalmologic examination, which included best corrected visual acuity, gonioscopy, and detailed ophthalmoscopic exam ination. Intraocular pressure was measured before surgery by applanation at least twice, separated by more than 24 hours, while they were receiving medications. The average of these measurements was used as the preopera tive intraocular pressure. All procedures had been performed on an inpatient basis with an average stay of 3.5 days. During the hospitalization, intraocular pres sure measurements and a complete ophthalmo logic examination were performed twice daily. Each patient underwent routine examinations periodically during the initial postoperative period and at two, six, and 12 months. Best corrected visual acuity, intraocular pressure, ocular medications, and the condition of the conjunctival filtering bleb and fundus were recorded at each visit. Surgical procedure—After appropriate local or general anesthesia, traction sutures were placed. In the limbal-based procedure, a limbal-based conjunctival flap was created su periorly, approximately 10 mm posterior to the corneoscleral limbus in a three-layered open ing. In the fornix-based procedure, a superior limbal peritomy was performed. In each proce dure, the limbal area was cleaned and hemostasis obtained. A 2 x 3-mm, rectangular scleral flap was created superiorly in most cases. In a few cases, a triangular scleral flap was made in a similar fashion. After an anterior chamber paracentesis and a stab wound under the scler al flap, an anterior capsulotomy was performed under sodium hyaluronate. If pupillary dilata tion was not adequate, a sector iridectomy or multiple sphincterotomies were performed be fore anterior capsulotomy. The corneoscleral incision was extended laterally, creating a 120degree incision. The incision was performed underneath the scleral flap, along the posterior border of the future sclerectorhy. After removal of the nucleus, the corneoscleral incision was
closed laterally. The lens cortex was removed with an automated irrigation-aspiration device. The posterior capsule was polished. A standard C-loop posterior chamber intraocular lens was placed, within the capsule if possible, under sodium hyaluronate (Healon). The incision was then closed laterally in both directions to the borders of the scleral flap. The sodium hyaluro nate was removed from the anterior chamber with an automated irrigation-aspiration device, and acetylcholine was injected into the anterior chamber. A 1.5 x 2-mm sclerectomy was per formed under the scleral flap, followed by a peripheral iridectomy. If a sector iridectomy was performed, the sclerectomy was placed overlying the iridectomy, which was not closed with a suture. The scleral flap was secured at the two posterior corners with additional 10-0 nylon sutures. The anterior chamber was re formed through the paracentesis and filtration assessed. If excessive filtration was noted, fur ther sutures were placed. In the fornix-based procedures, the conjunc tiva was pulled down over the corneoscleral incision and sutured in place using interrupted 10-0 nylon sutures. In the limbal-based proce dure, the conjunctival incision was closed in two layers using a running 8-0 chromic collagen suture. Betamethasone was injected into the inferior subconjunctival space upon comple tion of the surgery.
Results Seventy-five eyes of 69 patients underwent extracapsular cataract extraction combined with trabeculectomy and posterior chamber in traocular lens implantation. Primary openangle glaucoma was the most common preoper ative diagnosis (Table 1). Mean preoperative visual acuity was 20/100 (range, 20/40 to count ing fingers). The average preoperative intraoc ular pressure was 19.3 mm Hg, with 41 of the 75 TABLE 1 PREOPERATIVE DIAGNOSES
DIAGNOSIS
NO. OF EYES (N = 75)
Primary open-angle glaucoma Pigmentary glaucoma Pseudoexfoliation glaucoma Chronic angle-closure glaucoma
49 7 4 15
% 66 9 5
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TABLE 2 POSTOPERATIVE VISUAL ACUITY 2 MONTHS
12 MONTHS
(N = 75)
(N = 55)
VISUAL ACUITY
NO.
(%)
NO.
(%)
20/40 or better 20/50 to 20/80 20/100 or worse Compared to preoperative level Improved Unchanged Worsened
40 19 16
(53) (25) (21)
33 10 12
(60) (18) (22)
58 12 5
(77) (16) (7)
45 7 3
(82) (13) (5)
eyes (54%) having an intraocular pressure below 20 mm Hg. Ten eyes (14%) had recorded pressures greater than 25 mm Hg at the time of surgery. Postoperatively, visual acuity improved in 58 eyes (77%) at two months and 45 of 55 eyes (82%) examined at 12 months. There was an average improvement of 3.3 and 3.6 lines at two and 12 months, respectively (Table 2). Most patients had against-the-rule astigmatism at the time of their final refraction. The amount of astigmatism averaged 2.15 diopters (2.23 diop ters for patients with a fornix-based conjunctival flap and 1.96 diopters for those with a limbal-based flap), with the highest recorded astigmatism being 5.25 diopters. Visual acuity remained unchanged in 12 eyes at two months (Table 2). Of these 12, six subse quently showed an average of 3.2 lines of visual improvement. There was no apparent reason for the slow recovery of visual acuity in this population. Of the remaining six eyes, visual acuity failed to improve in five. This failure was probably secondary to their underlying glauco ma. In this group of five patients, three had marked increases in their intraocular pressure in the initial postoperative period (average, 22 mm Hg above the preoperative baseline). At tempts to document visual field progression proved inconclusive. One patient had further deterioration of his vision on subsequent follow-up. Fluorescein angiography showed this visual loss to be caused by age-related macular degeneration. At the two-month follow-up visit, five pa tients were noted to have visual deterioration. Four of these five patients in subsequent follow-up examinations had a mean improve ment of 3.5 lines. In the remaining patient the
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visual loss was secondary to progressive glaucomatous damage. This patient had document ed uncontrolled intraocular pressure and visual field deterioration. She underwent a transscleral Nd:YAG cyclodiathermy one month after surgery, but her vision did not improve. At the 12-month postoperative interval, visu al acuity in ten eyes remained unchanged or worsened (Table 2). Two of these patients had initially shown a visual improvement at two months. Both of these patients developed cystoid macular edema, which was documented by fluorescein angiography. Postoperative intraocular pressure at the two-, six-, and 12-month intervals averaged 15.7, 15.6, and 16.3 mm Hg, respectively (Table 3). There was no statistically significant differ ence in intraocular pressure between the fornix-based and limbal-based procedures at any time interval (P > .05). At each time inter val, the average intraocular pressure was statis tically lower than the preoperative intraocular pressure (P < .001). Wide fluctuations in intraocular pressure were noted throughout the postoperative peri od, particularly during the hospital course. Of the 75 eyes, 22 (29%) had a pressure greater than 30 mm Hg and 46 (61%) had a pressure greater than 20 mm Hg during their hospital stay (Table 4). During the first six postoperative months, 59 (79%), 27 (36%), and eight (11%) patients had an intraocular pressure greater than 20, 30, and 40 mm Hg, respectively (Table 5). Preoperatively the patients were receiving an average of 2.32 glaucoma medications. Postop eratively 64 of the 75 eyes (85%) were main tained on fewer medications throughout the follow-up period. Only four eyes (5%) required more medications than were used preopera-
TABLE 3 POSTOPERATIVE INTRAOCULAR PRESSURE 2 MONTHS
6 MONTHS
12 MONTHS
FORNIX LIMBAL FORNIX LIMBAL FORNIX LIMBAL INTRAOCULAR ^ = 4 7 ) ^ = 2 8 ) (|J = ^ (f) = 2 8 ) (N = ^ ( N = 2 1) PRESSURE (mm Hg) NO. (%) NO. (%) NO. (%) NO. (%) NO. (%) NO. (%)
0to9 10 to 19 20 to 25 26 to 30 >30
4 (9) 4(14) 4 (9) 3(11) 1 (3) 0 (0) 34 (72) 19 (68) 32 (73) 21 (75) 25 (74) 18 (86) 6(13) 4(14) 5(11) 3(11) 6(17) 3(14) 2 (4) 1 (4) 1 (2) 1 (3) 1 (3) 0 (0) 1 (2) 0 (0) 2 (5) 0 (0) 1 (3) 0 (0)
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TABLE 4 RANGE OF HIGHEST RECORDED INTRAOCULAR PRESSURE DURING HOSPITALIZATION NO. OF EYES (N = 75)
INTRAOCULAR PRESSURE
NO. OF EYES
(%)
7 22 17 7 22
Oto 10 mm Hg 11 to 19 mm Hg 20 to 25 mm Hg 26 to 30 mm Hg >30 mm Hg
TABLE 5 RANGE OF HIGHEST INTRAOCULAR PRESSURE RECORDED OVER FIRST SIX MONTHS
(9) (29) (24) (9) (29)
tively. At each examination, approximately 50% of the patients required no glaucoma med ications to control their intraocular pressure (Table 6). The most common topical medica tions used were timolol, dipivefrin, and pilocarpine. No patient received cholinesterase in hibitors during the study. Forty-six (61%) of the eyes received pilocarpine preoperatively, while 24 (32%) required pilocarpine postoperatively. Despite the improved intraocular pressure and reduced number of ocular medications, only 31 (41%), 16 (22%), and seven (12%) of the patients had a detectable conjunctival filtering bleb at two, six, and 12 months, respectively. No statistically significant difference was noted between eyes with a limbal-based or fornixbased conjunctival flap (P > .05). The most common complication noted was hyphema (Table 7). Of the 28 patients who underwent the limbal-based procedure, 20 (71%) had a hyphema during their postopera tive course. When compared to those having the fornix-based procedure, a statistically sig nificant difference was noted between the two groups (P < .001). In patients with an intraocu lar pressure greater than 30 mm Hg during their hospital course, there was a slightly inTABLE 6 COMPARISON OF PREOPERATIVE AND POSTOPERATIVE GLAUCOMA MEDICATIONS
NO. OF MEDICATIONS
0 1 2 3 or more
PRE OPERATIVE (N = 75) NO.
0 14 32 29
(%) (0) (18) (43) (39)
2MOS
6MOS
12MOS
(N = 75)
(N = 73)
(N = 56)
NO. (%)
NO. (%)
NO. (%)
43 (58) 18 (24) 13(17)
35 (48) 22 (30) 16 (22) 0 (0)
28(50) 13 (23) 14 (25) 1 (2)
1 (D
INTRAOCULAR PRESSURE
(N = 75)
(%)
16 20 12 9 10 3 5
(21) (27) (16) (12) (13) (4) (7)
10 to 19 mm Hg 20 to 25 mm Hg 26 to 30 mm Hg 31 to 35 mm Hg 36 to 40 mm Hg 41 to 45 mm Hg >45 mm Hg
creased percentage of hyphema for the two groups (45% fornix-based vs 72% limbalbased); however, no direct correlation could be made. Cystoid macular edema was diagnosed in six patients (8%) with little difference between the two procedures. Seven patients (9%) required a posterior capsulotomy during the follow-up period. Further glaucoma procedures were per formed in four patients (5%), including Nd:YAG cyclodiathermy, trabeculectomy, ther-
TABLE 7 COMPLICATIONS FORNIXBASED (N = 47) COMPLICATION
Hyphema Cystoid macular edema Capsular opaciflcation requiring capsulotomy Uncontrolled intraocular pressure requir ing subsequent surgery Displaced intraocular lens Sterile endophthalmitis
NO.
(%)
LIMBALBASED (N = 28) NO.
(%)
TOTAL (N = 75) NO.
(%)
14 (30) 20 (71) 34 (45)
P<.001
(8)
NS
7
(9)
NS
(4)
4
(5)
NS
0
(0)
1
(1)
NS
0
(0)
1
(1)
NS
(9)
(7)
3
(6)
4 (14)
3
(6)
1
1
(2)
1
(2)
*NS, not significant.
DIFFERENCE*
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mal sclerostomy, and cyclocryotherapy. One patient was noted to have a displaced intraocu lar lens, which required surgical relocation, and one patient had a sterile endophthalmitis. None of the patients had shallowing of the anterior chamber that required intervention.
Discussion Of the 75 cases reviewed, most attained im proved visual acuity and long-term control of intraocular pressure after extracapsular cata ract extraction combined with trabeculectomy and posterior chamber intraocular lens implan tation. Visual acuity improved an average of 3.3 lines by two months and 3.6 lines by 12 months. As reported previously, 8 visual recov ery in some patients tended to be longer than that reported for patients who had undergone cataract extraction with intraocular lens im plantation alone. The intraocular pressure postoperatively was significantly lower than that preoperatively, dropping an average of 3.6, 3.7, and 3.0 m m H g at two, six, and 12 months, respectively (P < .001). This improved control was found even though 85% of the patients took fewer glauco ma medications postoperatively. Of the 55 pa tients examined at 12 months, 28 (51%) were not receiving any glaucoma medications. Unfortunately, intraocular pressure increas es were not completely prevented by the place ment of a trabeculectomy. McGuigan and asso ciates 11 reported 62% of patients with glaucoma who underwent an extracapsular cataract ex traction with posterior chamber intraocular lens implantation had a recorded pressure in crease greater than 7 mm Hg in the initial postoperative period. In a similar study, Sav age and colleagues 12 reported approximately 72% of their patients had recorded pressures greater than 5 mm Hg above baseline. In our study, 33% of the patients had pressure in creases greater than 7 mm Hg during their hospital course when compared to their preoperative baseline. In the 25 eyes that had such an increase, the increase tended to be severe, with 68% (17 eyes) having a pressure rise greater than 15 mm Hg during this period when com pared to the preoperative baseline. Additional ly, 29% (22 eyes) of the total population during this period had a recorded intraocular pressure greater than 30 mm Hg. In the first six months, the percentage of
469
patients having a pressure rise greater than 7 and 15 mm Hg above baseline increased to 40% and 28%, respectively, while 36% of the pa tients had a recorded intraocular pressure greater than 30 mm Hg. In comparison to Mc Guigan and associates' 11 and Savage and associ ates' 12 findings, there was improved control of intraocular pressure during the initial postop erative period, but our study demonstrates the need to monitor these patients closely during the postoperative period in order to allow for the appropriate use of pressure-lowering treat ment. Despite the improved long-term control of intraocular pressure, the gradual disappear ance of functioning conjunctival filtering blebs during the 12 months was discouraging. In this series, only seven of 56 patients (12%) had conjunctival filtering blebs present at 12 months. No clear difference was noted between the limbal-based and fornix-based conjunctival flaps. Because of a probable underlying selec tion bias (limbal-based procedures being per formed on those patients with more advanced or uncontrolled glaucoma), a definitive conclu sion cannot be made. However, no clear benefit can be seen in this study to performing the technically more difficult limbal-based proce dure. Additionally, a statistically significant difference was found in the frequency of post operative hyphema in the limbal-based group (P < .001). Without a clinically apparent conjunctival filtering bleb, the reason for improved control of intraocular pressure is unclear. The. in creased use of miotic agents has been suggest ed as a possible reason for the improved control after cataract surgery. In this study, however, nearly twice as many patients were taking miotic agents before surgery than in the postoper ative period. This hypothesis would also not explain the improved control in those eyes receiving no ocular medications. Bigger and Becker13 have hypothesized that aqueous humor production is reduced in the first few years after cataract surgery in patients with glaucoma. In studying the outflow facility of patients undergoing intracapsular cataract extraction, they found that only hyposecretion could explain the postoperative improvement or stabilization of intraocular pressure consid ering the measured changes in outflow facility. This mechanism alone, however, cannot ex plain the pressure reduction found in our pa tients. If this were the only mechanism in volved, then extracapsular cataract extraction
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a l o n e w o u l d yield r e s u l t s similar to t h o s e f o u n d in o u r s t u d y . T h i s h a s n o t b e e n t h e case in p r e v i o u s s t u d i e s of e x t r a c a p s u l a r cataract ex t r a c t i o n s in p a t i e n t s w i t h glaucoma. 1 U 2 ' 1 4 In light of t h e s e findings, a f u n c t i o n a l role of t h e t r a b e c u l e c t o m y in t h e a b s e n c e of a clinically d e t e c t a b l e conjunctival filtering bleb m u s t b e q u e s t i o n e d , as well as t h e l o n g - t e r m s u c c e s s of the intraocular pressure control.
References 1. Rich, W.: Cataract extraction with trabeculec tomy. Trans. Ophthalmol. Soc. U.K. 94:458, 1974. 2. Bregeat, P.: Cataract surgery and trabeculec tomy at the same time. Klin. Monatsbl. Augenheilkd. 167:505, 1975. 3. Spaeth, G. L., and Sivalingam, E.: The partial punch. A new combined cataract-glaucoma opera tion. Ophthalmic Surg. 7:53, 1976. 4. Stewart, R. H., and Loftis, M. D.: Combined cataract extraction and thermal sclerostomy versus combined cataract extraction and trabeculectomy. Ophthalmic Surg. 7:93, 1976. 5. Jerndal, T., and Lundstrom, M.: Trabeculec tomy combined with cataract extraction. Am. J. Oph thalmol. 81:227, 1976. 6. Johns, G. E., and Layden, W. E.: Combined trabeculectomy and cataract extraction. Am. J. Oph thalmol. 88:973, 1979.
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7. Jay, J.: Extracapsular cataract extraction and posterior chamber intraocular lens insertion com bined with trabeculectomy. Br. J. Ophthalmol. 69:487, 1985. 8. Haber, C , and Rene, C : Lens implantation combined with trabeculectomy. Trans. Ophthalmol. Soc. U.K. 104:574, 1985. 9. Percival, S. P. B.: Glaucoma triple procedure of extracapsular cataract extraction, posterior chamber lens implantation, and trabeculectomy. Br. J. Oph thalmol. 69:99, 1985. 10. Shields, M. B.: Combined cataract extraction and guarded sclerectomy. Reevaluation in extracap sular era. Ophthalmology 93:366, 1986. 11. McGuigan, L. J. B., Gottsch, J., Stark, W. J., Maumenee, A. E., and Quigley, H. A.: Extracapsu lar cataract extraction and posterior chamber lens implantation in eyes with preexisting glaucoma. Arch. Ophthalmol. 104:1301, 1986. 12. Savage, J. A., Thomas, J. V., Belcher, C. D., and Simmons, R. J.: Extracapsular cataract extraction and posterior chamber lens implantation in glaucomatous eyes. Ophthalmology 92:1506, 1985. 13. Bigger, J. F., and Becker, B.: Cataracts and primary open-angle glaucoma. The effect of uncom plicated cataract extraction on glaucoma control. Trans. Am. Acad. Ophthalmol. Otolaryngol. 75:260, 1971. 14. Handa, J., Henry, J. C , Krupin, T., and Keates, E. U.: ECCE and PC-IOL implant in glauco ma patients. ARVO Abstracts. Supplement to Invest. Ophthalmol. Vis. Sci. Philadelphia, J. B. Lippincott, 1986, p. 167.
We reviewed 75 consecutive cases of extracapsular cataract extraction and posterior chamber intraocular lens implantation combined with trabeculectomy in 69 patients with glaucoma. The mean preoperative intraocular pressure was 19.3 mm Hg on an average of 2.3 glaucoma medications. Visual acuity improved in 58 eyes (77%) at two months, with an average improvement of 3.3 and 3.6 lines at two and 12 months, respectively. Of the 75 eyes, 49 (65%) achieved a visual acuity of 20/40 or better; three patients (4%) had further deterioration in vision at the completion of followup because of progressive glaucoma or macular disease. Postoperatively, the average intraocular pressure was 3.8 and 3.0 mm Hg lower than the preoperative level at two and 12 months (F < .001) on 0.63 and 0.79 glaucoma medications, respectively. However, 27 (36%) of the 75 eyes had a recorded intraocular pressure greater than 30 mm Hg and 30 (40%) had a pressure 7 mm Hg or more above their preoperative level during the first six months after surgery. Despite improved long-term control of intraocular pressure, detectable conjunctiva! filtering blebs were present in only 31 (41%) of 75 eyes at two months and in seven
Accepted for publication Aug. 14, 1987. From the William and Anna Goldberg Glaucoma Serv ice, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania (Drs. Simmons, Nichols, Sherwood, and Spaeth) and the Glaucoma Service, Al bany Medical College, Albany, New York (Dr. Simmons and Mr. Litoff). This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. (Dr. Simmons), the Northeastern New York Sight Conservation Society (Dr. Simmons), and the Interna tional Glaucoma Association (Dr. Sherwood). Reprint requests to Steven T. Simmons, M.D., Depart ment of Ophthalmology, Albany Medical College, Alba ny, NY 12208.
(12%) of 56 eyes at 12 months. Hyphema occurred in 34 (45%) of the cases. THE SURGICAL MANAGEMENT of cataract in the
patient with glaucoma has changed in the last ten years in response to the development of extracapsular surgical technique, intraocular lens implantation, and new filtering proce dures. The combination of intracapsular cata ract extraction with guarded filtering proce dures was first reported in the mid 1970s. 16 In theory, there were two potential benefits to the combined surgery: the avoidance of transient increases in intraocular pressure in the initial postoperative period and long-term improve ment in intraocular pressure control with one surgical procedure while removing the visual impairment. Recently, these techniques have been modified using an extracapsular cataract extraction combined with posterior chamber intraocular lens implantation. 710 Although long-term pressure control was noted to be improved, the ability of the combined proce dure to protect against transient increases in intraocular pressure was not addressed. 7 1 0 We reviewed 75 consecutive cases of extra capsular cataract extraction combined with tra beculectomy and posterior chamber intraocular lens implantation in an attempt to assess this surgical procedure's ability to reach its theoret ical goals.
Material and Methods We reviewed 75 consecutive cases of extra capsular cataract extractions combined with trabeculectomies and posterior chamber intra ocular lens implantations performed between January 1984 and December 1985. All patients
©AMERICAN JOURNAL OF OPHTHALMOLOGY 104:465-470, NOVEMBER, 1987
465
466
November, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
were being treated for glaucoma and had an average preoperative intraocular pressure of 19.3 mm Hg (range, 11 to 39 mm Hg) on an average of 2.3 glaucoma medications (range, one to four medications). Patients who had undergone previous intraocular surgery, ex cept for laser surgery, were excluded from this study. No exclusions were made for age, cause of the glaucoma, or other ocular disease such as age-related macular degeneration. Preoperatively, all patients received a stan dard ophthalmologic examination, which included best corrected visual acuity, gonioscopy, and detailed ophthalmoscopic exam ination. Intraocular pressure was measured before surgery by applanation at least twice, separated by more than 24 hours, while they were receiving medications. The average of these measurements was used as the preopera tive intraocular pressure. All procedures had been performed on an inpatient basis with an average stay of 3.5 days. During the hospitalization, intraocular pres sure measurements and a complete ophthalmo logic examination were performed twice daily. Each patient underwent routine examinations periodically during the initial postoperative period and at two, six, and 12 months. Best corrected visual acuity, intraocular pressure, ocular medications, and the condition of the conjunctival filtering bleb and fundus were recorded at each visit. Surgical procedure—After appropriate local or general anesthesia, traction sutures were placed. In the limbal-based procedure, a limbal-based conjunctival flap was created su periorly, approximately 10 mm posterior to the corneoscleral limbus in a three-layered open ing. In the fornix-based procedure, a superior limbal peritomy was performed. In each proce dure, the limbal area was cleaned and hemostasis obtained. A 2 x 3-mm, rectangular scleral flap was created superiorly in most cases. In a few cases, a triangular scleral flap was made in a similar fashion. After an anterior chamber paracentesis and a stab wound under the scler al flap, an anterior capsulotomy was performed under sodium hyaluronate. If pupillary dilata tion was not adequate, a sector iridectomy or multiple sphincterotomies were performed be fore anterior capsulotomy. The corneoscleral incision was extended laterally, creating a 120degree incision. The incision was performed underneath the scleral flap, along the posterior border of the future sclerectorhy. After removal of the nucleus, the corneoscleral incision was
closed laterally. The lens cortex was removed with an automated irrigation-aspiration device. The posterior capsule was polished. A standard C-loop posterior chamber intraocular lens was placed, within the capsule if possible, under sodium hyaluronate (Healon). The incision was then closed laterally in both directions to the borders of the scleral flap. The sodium hyaluro nate was removed from the anterior chamber with an automated irrigation-aspiration device, and acetylcholine was injected into the anterior chamber. A 1.5 x 2-mm sclerectomy was per formed under the scleral flap, followed by a peripheral iridectomy. If a sector iridectomy was performed, the sclerectomy was placed overlying the iridectomy, which was not closed with a suture. The scleral flap was secured at the two posterior corners with additional 10-0 nylon sutures. The anterior chamber was re formed through the paracentesis and filtration assessed. If excessive filtration was noted, fur ther sutures were placed. In the fornix-based procedures, the conjunc tiva was pulled down over the corneoscleral incision and sutured in place using interrupted 10-0 nylon sutures. In the limbal-based proce dure, the conjunctival incision was closed in two layers using a running 8-0 chromic collagen suture. Betamethasone was injected into the inferior subconjunctival space upon comple tion of the surgery.
Results Seventy-five eyes of 69 patients underwent extracapsular cataract extraction combined with trabeculectomy and posterior chamber in traocular lens implantation. Primary openangle glaucoma was the most common preoper ative diagnosis (Table 1). Mean preoperative visual acuity was 20/100 (range, 20/40 to count ing fingers). The average preoperative intraoc ular pressure was 19.3 mm Hg, with 41 of the 75 TABLE 1 PREOPERATIVE DIAGNOSES
DIAGNOSIS
NO. OF EYES (N = 75)
Primary open-angle glaucoma Pigmentary glaucoma Pseudoexfoliation glaucoma Chronic angle-closure glaucoma
49 7 4 15
% 66 9 5
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TABLE 2 POSTOPERATIVE VISUAL ACUITY 2 MONTHS
12 MONTHS
(N = 75)
(N = 55)
VISUAL ACUITY
NO.
(%)
NO.
(%)
20/40 or better 20/50 to 20/80 20/100 or worse Compared to preoperative level Improved Unchanged Worsened
40 19 16
(53) (25) (21)
33 10 12
(60) (18) (22)
58 12 5
(77) (16) (7)
45 7 3
(82) (13) (5)
eyes (54%) having an intraocular pressure below 20 mm Hg. Ten eyes (14%) had recorded pressures greater than 25 mm Hg at the time of surgery. Postoperatively, visual acuity improved in 58 eyes (77%) at two months and 45 of 55 eyes (82%) examined at 12 months. There was an average improvement of 3.3 and 3.6 lines at two and 12 months, respectively (Table 2). Most patients had against-the-rule astigmatism at the time of their final refraction. The amount of astigmatism averaged 2.15 diopters (2.23 diop ters for patients with a fornix-based conjunctival flap and 1.96 diopters for those with a limbal-based flap), with the highest recorded astigmatism being 5.25 diopters. Visual acuity remained unchanged in 12 eyes at two months (Table 2). Of these 12, six subse quently showed an average of 3.2 lines of visual improvement. There was no apparent reason for the slow recovery of visual acuity in this population. Of the remaining six eyes, visual acuity failed to improve in five. This failure was probably secondary to their underlying glauco ma. In this group of five patients, three had marked increases in their intraocular pressure in the initial postoperative period (average, 22 mm Hg above the preoperative baseline). At tempts to document visual field progression proved inconclusive. One patient had further deterioration of his vision on subsequent follow-up. Fluorescein angiography showed this visual loss to be caused by age-related macular degeneration. At the two-month follow-up visit, five pa tients were noted to have visual deterioration. Four of these five patients in subsequent follow-up examinations had a mean improve ment of 3.5 lines. In the remaining patient the
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visual loss was secondary to progressive glaucomatous damage. This patient had document ed uncontrolled intraocular pressure and visual field deterioration. She underwent a transscleral Nd:YAG cyclodiathermy one month after surgery, but her vision did not improve. At the 12-month postoperative interval, visu al acuity in ten eyes remained unchanged or worsened (Table 2). Two of these patients had initially shown a visual improvement at two months. Both of these patients developed cystoid macular edema, which was documented by fluorescein angiography. Postoperative intraocular pressure at the two-, six-, and 12-month intervals averaged 15.7, 15.6, and 16.3 mm Hg, respectively (Table 3). There was no statistically significant differ ence in intraocular pressure between the fornix-based and limbal-based procedures at any time interval (P > .05). At each time inter val, the average intraocular pressure was statis tically lower than the preoperative intraocular pressure (P < .001). Wide fluctuations in intraocular pressure were noted throughout the postoperative peri od, particularly during the hospital course. Of the 75 eyes, 22 (29%) had a pressure greater than 30 mm Hg and 46 (61%) had a pressure greater than 20 mm Hg during their hospital stay (Table 4). During the first six postoperative months, 59 (79%), 27 (36%), and eight (11%) patients had an intraocular pressure greater than 20, 30, and 40 mm Hg, respectively (Table 5). Preoperatively the patients were receiving an average of 2.32 glaucoma medications. Postop eratively 64 of the 75 eyes (85%) were main tained on fewer medications throughout the follow-up period. Only four eyes (5%) required more medications than were used preopera-
TABLE 3 POSTOPERATIVE INTRAOCULAR PRESSURE 2 MONTHS
6 MONTHS
12 MONTHS
FORNIX LIMBAL FORNIX LIMBAL FORNIX LIMBAL INTRAOCULAR ^ = 4 7 ) ^ = 2 8 ) (|J = ^ (f) = 2 8 ) (N = ^ ( N = 2 1) PRESSURE (mm Hg) NO. (%) NO. (%) NO. (%) NO. (%) NO. (%) NO. (%)
0to9 10 to 19 20 to 25 26 to 30 >30
4 (9) 4(14) 4 (9) 3(11) 1 (3) 0 (0) 34 (72) 19 (68) 32 (73) 21 (75) 25 (74) 18 (86) 6(13) 4(14) 5(11) 3(11) 6(17) 3(14) 2 (4) 1 (4) 1 (2) 1 (3) 1 (3) 0 (0) 1 (2) 0 (0) 2 (5) 0 (0) 1 (3) 0 (0)
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TABLE 4 RANGE OF HIGHEST RECORDED INTRAOCULAR PRESSURE DURING HOSPITALIZATION NO. OF EYES (N = 75)
INTRAOCULAR PRESSURE
NO. OF EYES
(%)
7 22 17 7 22
Oto 10 mm Hg 11 to 19 mm Hg 20 to 25 mm Hg 26 to 30 mm Hg >30 mm Hg
TABLE 5 RANGE OF HIGHEST INTRAOCULAR PRESSURE RECORDED OVER FIRST SIX MONTHS
(9) (29) (24) (9) (29)
tively. At each examination, approximately 50% of the patients required no glaucoma med ications to control their intraocular pressure (Table 6). The most common topical medica tions used were timolol, dipivefrin, and pilocarpine. No patient received cholinesterase in hibitors during the study. Forty-six (61%) of the eyes received pilocarpine preoperatively, while 24 (32%) required pilocarpine postoperatively. Despite the improved intraocular pressure and reduced number of ocular medications, only 31 (41%), 16 (22%), and seven (12%) of the patients had a detectable conjunctival filtering bleb at two, six, and 12 months, respectively. No statistically significant difference was noted between eyes with a limbal-based or fornixbased conjunctival flap (P > .05). The most common complication noted was hyphema (Table 7). Of the 28 patients who underwent the limbal-based procedure, 20 (71%) had a hyphema during their postopera tive course. When compared to those having the fornix-based procedure, a statistically sig nificant difference was noted between the two groups (P < .001). In patients with an intraocu lar pressure greater than 30 mm Hg during their hospital course, there was a slightly inTABLE 6 COMPARISON OF PREOPERATIVE AND POSTOPERATIVE GLAUCOMA MEDICATIONS
NO. OF MEDICATIONS
0 1 2 3 or more
PRE OPERATIVE (N = 75) NO.
0 14 32 29
(%) (0) (18) (43) (39)
2MOS
6MOS
12MOS
(N = 75)
(N = 73)
(N = 56)
NO. (%)
NO. (%)
NO. (%)
43 (58) 18 (24) 13(17)
35 (48) 22 (30) 16 (22) 0 (0)
28(50) 13 (23) 14 (25) 1 (2)
1 (D
INTRAOCULAR PRESSURE
(N = 75)
(%)
16 20 12 9 10 3 5
(21) (27) (16) (12) (13) (4) (7)
10 to 19 mm Hg 20 to 25 mm Hg 26 to 30 mm Hg 31 to 35 mm Hg 36 to 40 mm Hg 41 to 45 mm Hg >45 mm Hg
creased percentage of hyphema for the two groups (45% fornix-based vs 72% limbalbased); however, no direct correlation could be made. Cystoid macular edema was diagnosed in six patients (8%) with little difference between the two procedures. Seven patients (9%) required a posterior capsulotomy during the follow-up period. Further glaucoma procedures were per formed in four patients (5%), including Nd:YAG cyclodiathermy, trabeculectomy, ther-
TABLE 7 COMPLICATIONS FORNIXBASED (N = 47) COMPLICATION
Hyphema Cystoid macular edema Capsular opaciflcation requiring capsulotomy Uncontrolled intraocular pressure requir ing subsequent surgery Displaced intraocular lens Sterile endophthalmitis
NO.
(%)
LIMBALBASED (N = 28) NO.
(%)
TOTAL (N = 75) NO.
(%)
14 (30) 20 (71) 34 (45)
P<.001
(8)
NS
7
(9)
NS
(4)
4
(5)
NS
0
(0)
1
(1)
NS
0
(0)
1
(1)
NS
(9)
(7)
3
(6)
4 (14)
3
(6)
1
1
(2)
1
(2)
*NS, not significant.
DIFFERENCE*
IOL Insertion and Trabeculectomy
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mal sclerostomy, and cyclocryotherapy. One patient was noted to have a displaced intraocu lar lens, which required surgical relocation, and one patient had a sterile endophthalmitis. None of the patients had shallowing of the anterior chamber that required intervention.
Discussion Of the 75 cases reviewed, most attained im proved visual acuity and long-term control of intraocular pressure after extracapsular cata ract extraction combined with trabeculectomy and posterior chamber intraocular lens implan tation. Visual acuity improved an average of 3.3 lines by two months and 3.6 lines by 12 months. As reported previously, 8 visual recov ery in some patients tended to be longer than that reported for patients who had undergone cataract extraction with intraocular lens im plantation alone. The intraocular pressure postoperatively was significantly lower than that preoperatively, dropping an average of 3.6, 3.7, and 3.0 m m H g at two, six, and 12 months, respectively (P < .001). This improved control was found even though 85% of the patients took fewer glauco ma medications postoperatively. Of the 55 pa tients examined at 12 months, 28 (51%) were not receiving any glaucoma medications. Unfortunately, intraocular pressure increas es were not completely prevented by the place ment of a trabeculectomy. McGuigan and asso ciates 11 reported 62% of patients with glaucoma who underwent an extracapsular cataract ex traction with posterior chamber intraocular lens implantation had a recorded pressure in crease greater than 7 mm Hg in the initial postoperative period. In a similar study, Sav age and colleagues 12 reported approximately 72% of their patients had recorded pressures greater than 5 mm Hg above baseline. In our study, 33% of the patients had pressure in creases greater than 7 mm Hg during their hospital course when compared to their preoperative baseline. In the 25 eyes that had such an increase, the increase tended to be severe, with 68% (17 eyes) having a pressure rise greater than 15 mm Hg during this period when com pared to the preoperative baseline. Additional ly, 29% (22 eyes) of the total population during this period had a recorded intraocular pressure greater than 30 mm Hg. In the first six months, the percentage of
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patients having a pressure rise greater than 7 and 15 mm Hg above baseline increased to 40% and 28%, respectively, while 36% of the pa tients had a recorded intraocular pressure greater than 30 mm Hg. In comparison to Mc Guigan and associates' 11 and Savage and associ ates' 12 findings, there was improved control of intraocular pressure during the initial postop erative period, but our study demonstrates the need to monitor these patients closely during the postoperative period in order to allow for the appropriate use of pressure-lowering treat ment. Despite the improved long-term control of intraocular pressure, the gradual disappear ance of functioning conjunctival filtering blebs during the 12 months was discouraging. In this series, only seven of 56 patients (12%) had conjunctival filtering blebs present at 12 months. No clear difference was noted between the limbal-based and fornix-based conjunctival flaps. Because of a probable underlying selec tion bias (limbal-based procedures being per formed on those patients with more advanced or uncontrolled glaucoma), a definitive conclu sion cannot be made. However, no clear benefit can be seen in this study to performing the technically more difficult limbal-based proce dure. Additionally, a statistically significant difference was found in the frequency of post operative hyphema in the limbal-based group (P < .001). Without a clinically apparent conjunctival filtering bleb, the reason for improved control of intraocular pressure is unclear. The. in creased use of miotic agents has been suggest ed as a possible reason for the improved control after cataract surgery. In this study, however, nearly twice as many patients were taking miotic agents before surgery than in the postoper ative period. This hypothesis would also not explain the improved control in those eyes receiving no ocular medications. Bigger and Becker13 have hypothesized that aqueous humor production is reduced in the first few years after cataract surgery in patients with glaucoma. In studying the outflow facility of patients undergoing intracapsular cataract extraction, they found that only hyposecretion could explain the postoperative improvement or stabilization of intraocular pressure consid ering the measured changes in outflow facility. This mechanism alone, however, cannot ex plain the pressure reduction found in our pa tients. If this were the only mechanism in volved, then extracapsular cataract extraction
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a l o n e w o u l d yield r e s u l t s similar to t h o s e f o u n d in o u r s t u d y . T h i s h a s n o t b e e n t h e case in p r e v i o u s s t u d i e s of e x t r a c a p s u l a r cataract ex t r a c t i o n s in p a t i e n t s w i t h glaucoma. 1 U 2 ' 1 4 In light of t h e s e findings, a f u n c t i o n a l role of t h e t r a b e c u l e c t o m y in t h e a b s e n c e of a clinically d e t e c t a b l e conjunctival filtering bleb m u s t b e q u e s t i o n e d , as well as t h e l o n g - t e r m s u c c e s s of the intraocular pressure control.
References 1. Rich, W.: Cataract extraction with trabeculec tomy. Trans. Ophthalmol. Soc. U.K. 94:458, 1974. 2. Bregeat, P.: Cataract surgery and trabeculec tomy at the same time. Klin. Monatsbl. Augenheilkd. 167:505, 1975. 3. Spaeth, G. L., and Sivalingam, E.: The partial punch. A new combined cataract-glaucoma opera tion. Ophthalmic Surg. 7:53, 1976. 4. Stewart, R. H., and Loftis, M. D.: Combined cataract extraction and thermal sclerostomy versus combined cataract extraction and trabeculectomy. Ophthalmic Surg. 7:93, 1976. 5. Jerndal, T., and Lundstrom, M.: Trabeculec tomy combined with cataract extraction. Am. J. Oph thalmol. 81:227, 1976. 6. Johns, G. E., and Layden, W. E.: Combined trabeculectomy and cataract extraction. Am. J. Oph thalmol. 88:973, 1979.
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7. Jay, J.: Extracapsular cataract extraction and posterior chamber intraocular lens insertion com bined with trabeculectomy. Br. J. Ophthalmol. 69:487, 1985. 8. Haber, C , and Rene, C : Lens implantation combined with trabeculectomy. Trans. Ophthalmol. Soc. U.K. 104:574, 1985. 9. Percival, S. P. B.: Glaucoma triple procedure of extracapsular cataract extraction, posterior chamber lens implantation, and trabeculectomy. Br. J. Oph thalmol. 69:99, 1985. 10. Shields, M. B.: Combined cataract extraction and guarded sclerectomy. Reevaluation in extracap sular era. Ophthalmology 93:366, 1986. 11. McGuigan, L. J. B., Gottsch, J., Stark, W. J., Maumenee, A. E., and Quigley, H. A.: Extracapsu lar cataract extraction and posterior chamber lens implantation in eyes with preexisting glaucoma. Arch. Ophthalmol. 104:1301, 1986. 12. Savage, J. A., Thomas, J. V., Belcher, C. D., and Simmons, R. J.: Extracapsular cataract extraction and posterior chamber lens implantation in glaucomatous eyes. Ophthalmology 92:1506, 1985. 13. Bigger, J. F., and Becker, B.: Cataracts and primary open-angle glaucoma. The effect of uncom plicated cataract extraction on glaucoma control. Trans. Am. Acad. Ophthalmol. Otolaryngol. 75:260, 1971. 14. Handa, J., Henry, J. C , Krupin, T., and Keates, E. U.: ECCE and PC-IOL implant in glauco ma patients. ARVO Abstracts. Supplement to Invest. Ophthalmol. Vis. Sci. Philadelphia, J. B. Lippincott, 1986, p. 167.