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Combined cataract and trabeculectomy surgery in eyes with pseudoexfoliation glaucoma
ARTICLE
Combined cataract and trabeculectomy surgery in eyes with pseudoexfoliation glaucoma Bradford J. Shingleton, MD, Kristy B. Wooler, OD, Carla I. Bourne, MD, Mark W. O’Donoghue, OD
PURPOSE: To assess the short- and long-term effect of uneventful phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and trabeculectomy on intraocular pressure (IOP) and glaucoma medication requirements in eyes with pseudoexfoliation glaucoma (PXG) and compare the results with those in eyes that had uneventful phacoemulsification only (reported in a previous study of the same cohort of pseudoexfoliation eyes). SETTING: Private practice, Boston, Massachusetts, USA. DESIGN: Comparative case series. METHODS: A retrospective analysis was performed of consecutive PXG eyes that had uneventful combined phacoemulsification and trabeculectomy by the same surgeon. The change in IOP, glaucoma medication requirements, and logMAR corrected distance visual acuity was compared between the combined surgery group and the phaco-alone group. RESULTS: The combined-surgery group (n Z 138) had statistically significant reduced mean IOP and glaucoma medication requirements through 10 years postoperatively (P<.018). The change in IOP and glaucoma medication requirements was greater in the combined-surgery group than in the phaco-alone group (n Z 240); this was statistically significant up to 7 years postoperatively (P<.022). The reduction in mean postoperative IOP was greater in eyes with a higher mean preoperative IOP. In the combined-surgery group, 13.8% of eyes required subsequent laser trabeculoplasty, glaucoma surgery, or both. CONCLUSIONS: Uneventful phacoemulsification, IOL implantation, and trabeculectomy resulted in significant long-term reduction in IOP and glaucoma medication requirements in eyes with PXG. Combined procedures resulted in greater and more longstanding reductions in IOP and glaucoma medication requirements and fewer 1-day postoperative IOP spikes than phacoemulsification alone. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:1961–1970 Q 2011 ASCRS and ESCRS
Pseudoexfoliation (PXF) is an age-related systemic condition characterized by the production and accumulation of abnormal fibrillar extracellular material.1 The gray–white flaky material is deposited on virtually all tissues of the anterior segment of the eye as well as throughout the human body.2 Pseudoexfoliation has long been associated with an increased risk for cataract development2 and is the most common identifiable cause of secondary open-angle glaucoma (OAG).3 Pseudoexfoliation glaucoma (PXG) tends to be more severe than primary open-angle glaucoma (POAG), manifesting higher mean intraocular pressure (IOP), greater optic nerve damage at the time of diagnosis, and a poorer response to medical therapy, often necessitating earlier surgical intervention.4 As Q 2011 ASCRS and ESCRS Published by Elsevier Inc.
a consequence, eyes with PXF require intraocular surgery related to cataract and IOP at a higher rate than eyes without PXF.5 Combined cataract and glaucoma surgery has been reported to be an effective treatment for patients with PXG.6 The results of combined procedures in PXG patients have been found to be comparable to those in POAG patients.7 In a small population study, Merkur et al.8 found phacoemulsification alone to be a reasonable option for initial IOP management in patients with PXG and visually significant cataract, but without advanced optic nerve damage. In a large population study of more than 1000 eyes,9 we found that uneventful temporal clear corneal phacoemulsification with posterior chamber intraocular lens (PC 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2011.05.036
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IOL) implantation resulted in a modest reduction in IOP for 3 years in PXF eyes and a reduction in glaucoma medication requirements for up to 7 years. Higher preoperative IOP was associated with a greater IOP reduction. Eyes with PXG and a preoperative IOP greater than 25 mm Hg had a mean reduction in IOP of approximately 10 mm Hg at 3 years. Thus, the decision to perform cataract surgery alone or in combination with trabeculectomy is of particular interest in the treatment of patients with PXG and a visually significant cataract. The purpose of this study was to assess the shortand long-term effect of uneventful combined phacoemulsification, PC IOL implantation, and trabeculectomy in eyes with PXG. These results were compared with those in eyes with PXG that had uneventful phacoemulsification alone as reported in a previous study of the same cohort of PXF eyes.9 PATIENTS AND METHODS This retrospective analysis comprised consecutive eyes with PXF that had uneventful phacoemulsification with PC IOL implantation in combination with trabeculectomy (combined-surgery group) by the same surgeon (B.J.S.) from 1991 to 2008. This analysis is the most recent report in a series of more than 1200 eyes with PXF that had cataract surgery.9–11 Patients were identified as having PXG based on slitlamp biomicroscopic examination; gonioscopy; dilated optic nerve head examination; visual field analysis; and history of treatment with topical glaucoma medications, previous glaucoma laser surgery, or both. Eyes with previous glaucoma filtration surgery were excluded from data analysis. The basic surgical technique for combined phacoemulsification, IOL implantation, and trabeculectomy was similar for all patients in this study. Topical or peribulbar anesthesia was used. Single-site and separate-site combined procedures were performed. The results with single-site versus separatesite approaches in OAG have been published.12 Conjunctival flaps were mobilized in a limbal-based or fornix-based manner. The results with fornix-based versus limbal-based conjunctival flaps in OAG were previously reported.13 In single-site procedures, limbal-based or fornix-based conjunctival flaps were mobilized. Bleeding was controlled with underwater diathermy. A partial-thickness scleral flap was mobilized superiorly in a rectangular, triangular, or
Submitted: January 30, 2011. Final revision submitted: April 26, 2011. Accepted: May 5, 2011. From Ophthalmic Consultants of Boston (Shingleton, Wooler, Bourne, O’Donoghue), Boston, Massachusetts, and the University of South Florida (Bourne), Tampa, Florida, USA. Corresponding author: Bradford J. Shingleton, MD, Ophthalmic Consultants of Boston, Center for Eye Research and Education, 50 Staniford Street, Suite 600, Boston, Massachusetts 02114, USA. E-mail: [email protected].
trapezoidal configuration. The eye was entered under the scleral flap with a keratome. An ophthalmic viscoelastic device (OVD) was placed in the anterior chamber, and a limbal paracentesis incision was made. A 360-degree anterior capsulorhexis, nuclear cortical hydrodissection, and phacoemulsification of the nucleus were performed. Residual cortical material was then removed by irrigation/aspiration (I/A); the posterior capsule was left intact in all cases. An OVD was placed in the capsular bag, and a PC IOL was implanted in the capsular bag. The OVD was evacuated from the eye. In eyes with a widely dilated pupil, intraoperative carbachol was injected into the anterior chamber to achieve miosis. A posterior lip sclerectomy was performed under the scleral flap with a Kelly Descemet punch (Storz Ophthalmics). The size of the sclerectomy was 0.5 mm 1.0 mm. A peripheral iridectomy was not routinely performed but was used in all cases with a shallow chamber or iris prolapse. The results with and without surgical iridectomy in combined phacotrabeculectomy have been reported.14 The scleral flap was closed with buried interrupted 10-0 nylon sutures. The chamber was deepened through the paracentesis with a balanced salt solution to achieve a normal IOP, stable anterior chamber depth, and slow, steady egress of fluid under the sclera flap. The conjunctiva was closed, ensuring watertight closure after the anterior chamber was deepened; closure was confirmed using fluorescein strips. All patients received topical pilocarpine, prednisolone acetate 1%, and antibiotic drops. A patch and metal shield were placed over eyes having peribulbar anesthesia. Oral acetazolamide (500 mg sequel) was administered in the recovery room to all patients without a sulfa allergy. In eyes having a separate-incision approach, a temporal keratome incision was made. An OVD was instilled in the anterior chamber. A limbal paracentesis incision was placed. A 360-degree anterior capsulorhexis, nuclear/cortical hydrodissection, and phacoemulsification of the nucleus were performed. The residual cortical material was removed by I/A; the posterior capsule was left intact in all cases. An OVD was placed, and a PC IOL was implanted in the capsular bag. The OVD was evacuated from the eye, and the chamber deepened with intraoperative carbachol if pupil miosis was required. The temporal keratome incision and paracentesis were closed with interrupted buried 10-0 nylon sutures. At this time, the surgeon switched to the superior aspect and a fornix-based or limbal-based conjunctival flap was mobilized. A rectangular, triangular, or trapezoidal scleral flap was mobilized. The eye was entered at the anterior reflection of the scleral flap with a super blade. A 0.5 mm 1.0 mm posterior lip sclerectomy was performed under the scleral flap with a Kelly Descemet punch. A peripheral iridectomy was not routinely performed but was used in all cases with a shallow chamber or iris prolapse. The scleral flap was closed with interrupted buried 10-0 nylon sutures. The chamber was deepened through the paracentesis to achieve a stable anterior chamber, normal IOP, and steady egress of fluid under the scleral flap. The conjunctiva was closed; watertight closure was confirmed using fluorescein strips. All patients received topical pilocarpine, prednisolone acetate 1%, and antibiotic drops. A patch and metal shield were placed over eyes receiving peribulbar anesthesia. Oral acetazolamide (500 mg sequel) was administered in the recovery room to all patients without a sulfa allergy. In some eyes, cellulose sponge pledgets soaked in mitomycin-C (MMC) (0.4 mm/cc concentration) were
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Table 1. Patient demographics. Characteristic Eyes (n) Male (n) Female (n) Mean age (y) G SD
Combined Surgery
Phaco Alone
138 42 96 76.6 G 6.7
240 70 170 78.2 G 7.0
applied intraoperatively. One to 4 pledgets were used, with a broader zone of application in cases performed after 2001. All pledgets were placed subconjunctivally after conjunctival flap creation but before scleral flap mobilization; the pledgets were kept in place for 30 seconds to 4 minutes. After the pledgets were removed, the subconjunctival space was copiously irrigated with a balanced salt solution. Postoperatively, patients were seen at 1 day and 1 week, with other visits scheduled as necessary. Postoperative use of laser suturelysis and subconjunctival injection of 5-fluorouracil (5-FU) was based primarily on bleb configuration and IOP. Eyes with flat blebs, episcleral fibrosis, higher IOPs, or a combination were candidates for laser suturelysis and 5-FU. Patients were placed on a tapering schedule of topical prednisolone acetate 1%, topical antibiotic, and topical nonsteroidal antiinflammatory drops over 6 to 8 weeks. Glaucoma status determined the need for additional glaucoma medications. If the IOP level was thought to be too high for the status of the optic nerve and visual fields, glaucoma medications were added. Absent allergies or specific contraindications, topical glaucoma medications were typically added in the following order: b-blocker, a-agonist, carbonic anhydrase inhibitor, prostaglandin agonist. Systemic carbonic anhydrase inhibitors were rarely used.15 Preoperatively and at all postoperative office visits, corrected distance visual acuity (CDVA), IOP, and the number of glaucoma medications required were recorded. Visual acuity was measured using projected Snellen charts and then converted into logMAR values.16 Intraocular pressure was measured using Goldmann tonometry. The combined-surgery group was statistically analyzed alone and in relation to a previous study group consisting of 240 eyes with PXF and glaucoma that had phacoemulsification with IOL implantation but without filtration surgery (phaco-alone group).9 Table 2. Intraocular pressure over time in the combined-surgery group. Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Failure in the combined-surgery group was defined as either or both of the following: (1) the need for subsequent laser trabeculoplasty and/or glaucoma surgery due to elevated IOP or the need for subconjunctival autologous blood injection/surgical bleb revision due to pathologic hypotony (defined as any IOP associated with reduced vision and choroidal folds with or without disc edema, cystoid macular edema, and choroidal detachment); (2) less than a 20% reduction in IOP with or without glaucoma medication at the final postoperative visit. For statistical analysis, SPSS software (SPSS, Inc.) was used to analyze means for statistical significance. Histograms were constructed to verify normality for the variables: IOP, postoperative change in IOP, glaucoma medications required, postoperative change in glaucoma medications required, and logMAR visual acuity. All variables were normally distributed with the exception of logMAR visual acuity. Two-tailed paired-samples t tests were used to compare preoperative and postoperative measurements within the combined-surgery group. Two-tailed independent t tests for the equality of means were used to compare variables between the combined-surgery group and the phaco-alone group as well as for comparisons in the surgical procedure analysis. One-way analysis of variance was used to validate the significance of the multiple t tests. The IOP spikes on the first postoperative day were analyzed using the hypothesis test of the equality of 2 proportions; P values of 0.05 or less were considered statistically significant. Data are presented as the mean G standard deviation (SD). LogMAR visual acuity was the only variable that was not normally distributed. Both the preoperative and postoperative logMAR visual acuities were bimodally distributed with 1 group distributed around 0.30 and the other around 1.25. The latter group centered on 1.25 represented outliers and numbered 35 preoperatively and 25 postoperatively in the combined-surgery group. Nonparametric Wilcoxon signed-rank and Mann-Whitney tests were used with paired and independent-sample t tests to analyze logMAR visual acuity data.
RESULTS The combined-surgery group comprised 138 eyes. Fifty-eight eyes had previous laser trabeculoplasty, with 4 also having had laser iridectomy. Six eyes had Table 3. Number of glaucoma medications required in the combined-surgery group. Mean Glaucoma Medications (n) G SD
Mean IOP (mm Hg) G SD Eyes (n) 122 121 85 57 69 42 21
Preoperative Postoperative 21.6 G 7.5 21.5 G 7.5 20.9 G 5.9 21.1 G 6.4 21.5 G 7.2 20.7 G 5.1 22.0 G 5.5
IOP Z intraocular pressure *Compared with preoperative IOP
16.1 G 10.3 16.1 G 6.4 14.2 G 4.7 14.7 G 5.5 14.9 G 6.0 16.9 G 6.9 15.5 G 10.0
P Value* .000 .000 .000 .000 .000 .001 .018
Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 128 123 85 57 70 43 21
Preoperative Postoperative 2.3 G 1.2 2.4 G 1.3 2.3 G 1.2 2.4 G 1.0 2.3 G 1.1 2.1 G 1.0 2.1 G 1.4
0.1 G 0.4 0.2 G 0.6 0.4 G 0.8 0.5 G 0.9 0.8 G 1.1 1.0 G 1.2 1.0 G 1.3
P Value* .000 .000 .000 .000 .000 .000 .003
*Compared with preoperative number of glaucoma medications required
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Table 4. Comparison of preoperative and postoperative visual acuity in combined-surgery group. Mean CDVA (LogMAR) G SD Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n)
Preoperative
Postoperative
P Value*
Wilcoxon
128 123 84 57 71 43 21
0.64 G 0.4 0.65 G 0.4 0.60 G 0.4 0.63 G 0.4 0.59 G 0.3 0.59 G 0.4 0.54 G 0.3
0.64 G 0.4 0.39 G 0.4 0.24 G 0.3 0.32 G 0.4 0.37 G 0.4 0.52 G 0.5 0.52 G 0.6
.882 .000 .000 .000 .000 .444 .838
.441 .000 .000 .000 .000 .161 .485
CDVA Z corrected distance visual acuity
previous laser iridectomy without laser trabeculoplasty. Table 1 shows the patients’ demographics. The mean patient follow-up was 1729.3 days G 1332.3 (SD) (4.7 G 3.7 years; range 1 day to 5108 days). One eye had a 1-day follow-up. Table 2 shows the effect of combined cataract and trabeculectomy surgery. There was a statistically significant reduction in IOP over preoperative values at all time intervals from 1 day to 10 years postoperatively. Similarly, there was a statistically significant reduction in mean glaucoma medications required at all time intervals up to 10 years postoperatively (Table 3). Although the need for postoperative glaucoma medications gradually increased with time, the mean glaucoma medications required remained lower than the preoperative level at all follow-up intervals. The mean logMAR CDVA in the combined-surgery group improved significantly at all time intervals from 1 month to 5 years postoperatively compared with preoperative levels (Table 4). In eyes with better logMAR acuity (!1.00), the mean logMAR visual acuity remained improved for a longer period postoperatively (from 1 month to 10 years). These results were
confirmed by the nonparametric Wilcoxon signedrank test. There was no statistically significant difference in preoperative or postoperative logMAR visual acuity between the combined-surgery group and the phacoalone group. In most eyes with poorer preoperative visual acuity (R1.00), the cause was a dense cataract (n Z 21). Other causes included advanced glaucoma (n Z 5), a history of hemiretinal vein occlusion (n Z 1), and dense amblyopia with staphyloma (n Z 1). The cause of the poorer preoperative visual acuity could not be determined in 7 eyes; 6 of the charts had been destroyed, and 1 chart could not be located after other data were recorded previously. In eyes with poorer postoperative visual acuity (R1.00) at the most recent follow-up visit, the causes included advanced glaucoma (n Z 12), hemorrhagic choroidal detachment (n Z 1), macular scarring from agerelated macular degeneration (n Z 2), neovascular glaucoma with history of hemiretinal vein occlusion (n Z 1), epiretinal membrane/macular pucker (n Z 1), dense amblyopia with staphyloma (n Z 1), hypotony (n Z 1), and corneal edema secondary to herpes
Table 5. Postoperative change in IOP. Change in IOP (mm Hg) Combined-Surgery Group Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 122 121 85 57 69 42 21
Mean 5.59 5.35 6.76 6.46 6.59 3.81 6.52
Phaco-Alone Group %
Eyes (n)
25.9 24.9 32.3 30.6 30.7 18.4 29.6
240 216 111 69 69 22 7
IOP Z intraocular pressure
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Mean 3.46 0.99 1.58 0.77 0.09 0.23 2.86
%
P Value
19.9 5.7 9.1 4.4 0.5 1.4 20.3
.000 .000 .000 .000 .000 .022 .440
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simplex keratitis (n Z 1). The cause could not be determined in 5 eyes; 4 of the charts had been destroyed and 1 chart could not be located after other data were recorded previously. Sixty-seven eyes in the combined-surgery group had argon laser trabeculoplasty before combined phacoemulsification and trabeculectomy. In these eyes, there was a statistically significant postoperative reduction in IOP and glaucoma medications required at all follow-up time intervals. In the 71 eyes in the combined-surgery group that had no previous laser trabeculoplasty, there was a statistically significant reduction in IOP and glaucoma medications required at all follow-up intervals up to 7 years postoperatively. The postoperative change in IOP was statistically significantly greater in eyes with previous laser trabeculoplasty than in those without previous laser trabeculoplasty at the 1-day and 1-month interval only. There was no statistically significant difference in the change in glaucoma medications required at any follow-up interval between eyes with previous laser trabeculoplasty and eyes with no previous laser trabeculoplasty. The postoperative change in IOP was greater in the combined-surgery group than in the phaco-alone group. These changes were statistically significant at all follow-up intervals, except the 10-year interval (Table 5 and Figure 1). The phaco-alone group had a mean increase in IOP and the combined-surgery group a mean decrease in IOP on the first postoperative day. The postoperative change in glaucoma medications required was also greater in the combined-surgery group than in the phaco-alone group. These changes were statistically significant up to 7 years postoperatively (Table 6). In the combined-surgery group, the mean preoperative IOP level had a significant effect on the mean postoperative IOP reduction. The higher the mean preoperative IOP, the greater the reduction in the mean postoperative IOP. This finding was statistically significant from 1 day to 5 years postoperatively
Figure 1. Postoperative change in IOP (IOP Z intraocular pressure).
(Table 7 and Figure 2). The change in IOP was greater in the combined-surgery group than in the phacoalone group for each preoperative IOP level at each follow-up period, although not all associations were statistically significant (Table 8). Because the eyes were stratified into each preoperative IOP and follow-up interval, the number of eyes in each subgroup became too small for statistical analysis in many cases. This was especially true for the small number of eyes with a preoperative IOP greater than 25 mm Hg that had extended follow-up postoperatively. Intraocular pressure spikes greater than 30 mm Hg on the first postoperative day occurred in 11 eyes (8.3%) in the combined-surgery group and in 41 eyes (17.1%) in the phaco-only group. The difference in the frequency of IOP spikes was statistically significant between the combined-surgery group and the phacoalone group (P!.0199, 2 tailed). In eyes having combined surgery, the first failure group comprised 4 eyes requiring laser trabeculoplasty, 14 eyes requiring glaucoma surgery for elevated IOP, and 1 eye requiring surgical treatment for pathologic hypotony, all at the initial postoperative intervention. Of the 14 eyes requiring glaucoma surgery
Table 6. Postoperative change in number of glaucoma medications required by group. Combined-Surgery Group Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 128 123 85 57 71 43 21
Mean Change (n) G SD 2.2 G 1.2 2.2 G 1.2 2.2 G 1.0 1.9 G 1.2 1.5 G 1.5 1.2 G 1.4 1.0 G 1.6
Phaco-Alone Group Eyes (n) 207 187 100 60 63 16 4
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Mean Change (n) G SD 1.3 G 1.0 0.7 G 1.0 0.6 G 1.0 0.5 G 1.0 0.4 G 1.4 0.8 G 1.4 0.3 G 0.5
P Value .000 .000 .000 .000 .000 .000 .272
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Table 7. Impact of preoperative IOP on IOP reduction in the combined-surgery group. Change in IOP (mm Hg) Eyes with Preop IOP !21 mm Hg Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 64 67 49 30 42 24 13
Mean 0.80 0.97 2.41 1.13 2.69 2.96 4.38
Eyes with Preop IOP 21–25 mm Hg
%
Eyes (n)
4.7 5.7 14.0 6.8 15.4 17.0 23.6
34 32 21 18 15 11 4
Mean 6.82 7.22 9.62 11.00 8.67 3.45 4.00
Eyes with Preop IOP O25 mm Hg
%
Eyes (n)
29.8 31.6 42.2 47.5 37.8 15.3 17.4
24 22 15 9 12 7 4
Mean 16.63 15.95 17.00 15.11 17.67 7.29 16.00
%
P Value
50.5 48.0 55.8 47.4 51.8 24.5 50.0
.000 .000 .000 .000 .000 .365 .199
IOP Z intraocular pressure
for elevated IOP, 6 had secondary filtration surgery, 6 had bleb revisions, 1 had diode laser cyclophotocoagulation treatment, and 1 eye required tube shunt implantation as the initial postoperative surgical intervention. Six eyes in this failure group required more than 1 procedure for elevated IOP. The 1 eye with pathologic hypotony required a single subconjunctival autologous blood injection. Nineteen eyes failed during the study period; the mean time to failure was 5.6 G 3.0 years. Figure 3 shows a Kaplan-Meier survival curve. Taking into account censored observations, the curve predicts 90% of eyes in the combined-surgery group will be surviving 5 years postoperatively. Furthermore, approximately 50% of these eyes will survive over a longer period than the study covered. The survival analysis estimates a mean survival time of 11.0 G 0.6 years, where estimation is limited to the largest censored survival time.
Figure 2. Impact of preoperative IOP on postoperative IOP reduction in eyes having combined phacoemulsification and trabeculectomy (IOP Z intraocular pressure).
Of the 119 eyes that did not fail by the first criteria, 39 (32.8%) had less than a 20% IOP reduction at the final postoperative visit. Thus, 58 of 138 eyes (42.0%) failed when judged by both criteria. In the combined-surgery group, 5 eyes had intraoperative complications, including zonule weakness (3 eyes) and posterior capsule tear (1 eye). One eye became firm before phacoemulsification as a result of presumed intraoperative aqueous misdirection. All eyes with intraoperative complications were excluded from analysis. In the combined-surgery group, 87 eyes had singlesite incision surgery and 34 eyes had separate-site incision surgery. The only statistically significant difference in the postoperative change in IOP between the 2 subgroups was at 1 day, when eyes with separate-site incisions had a greater reduction in IOP than eyes with single-site incisions. The only statistically significant difference change in glaucoma medications required between the 2 subgroups was at the 1-month follow-up, at which time eyes with separate-site incisions had a greater reduction in glaucoma medications required than eyes with single-site incisions. There was no statistically significant difference in logMAR visual acuity between the 2 subgroups at any postoperative visit. Eighty-five eyes had combined surgery with a fornix-based flap, 72 as single-site and 13 as separatesite procedures. Thirty-six eyes had limbal-based flaps, 15 as single-site and 21 as separate-site procedures. There was no statistically significant difference in the postoperative change in IOP, glaucoma medications required, or postoperative change in logMAR visual acuity between eyes with fornix-based flaps and eyes with limbal-based flaps. However, eyes with limbal-based flaps had a statistically significantly greater reduction in IOP than eyes with fornix-based flaps at 1 day. There was no statistically significant difference in the postoperative change in IOP, glaucoma
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Table 8. Impact of preoperative IOP on IOP reduction by group. Combined-Surgery Group Postop Interval/Preop IOP 1 day !21 mm Hg 21–25 mm Hg O25 mm Hg 1 month !21 mm Hg 21–25 mm Hg O25 mm Hg 1 year !21 mm Hg 21–25 mm Hg O25 mm Hg 3 years !21 mm Hg 21–25 mm Hg O25 mm Hg 5 years !21 mm Hg 21–25 mm Hg O25 mm Hg 7 years !21 mm Hg 21–25 mm Hg O25 mm Hg 10 years !21 mm Hg 21–25 mm Hg O25 mm Hg
Phaco-Alone Group
Mean DIOP (mm Hg)
Eyes (n)
Eyes (n)
Mean DIOP (mm Hg)
P Value
64 34 24
0.80 6.82 16.63
189 37 14
4.40 2.16 5.79
0.000 0.000 0.032
67 32 22
0.97 7.22 15.95
170 35 11
0.21 3.60 11.18
0.138 0.007 0.213
49 21 15
2.41 9.62 17.00
81 24 6
0.14 5.17 10.33
0.002 0.003 0.071
30 18 9
1.13 11.00 15.11
52 15 2
1.02 5.67 10.50
0.061 0.005 0.371
42 15 12
2.69 8.67 17.67
57 11 1
1.02 4.27 5.00
0.001 0.099 0.342
24 11 7
2.96 3.45 7.29
20 2 d
0.15 4.00 No data
0.094 0.911 No data
13 4 4
4.38 4.00 16.00
7 d d
2.86 No data No data
0.778 No data No data
DIOP Z postoperative change in intraocular pressure
medications required, or postoperative change in logMAR visual acuity between eyes with single-site fornix-based flaps and eyes with separate-site fornixbased flaps. There was no statistically significant difference in the postoperative change in IOP or postoperative change in logMAR visual acuity between the 2 subgroups at any interval. However, there was a statistically significant difference in postoperative change in glaucoma medications required at all intervals up to 7 years, with the eyes with separate-site limbal-based flaps having a greater reduction in glaucoma medications required than eyes with single-site limbal-based flaps. (Note that the sample sizes in these 2 subgroups were small.) Three (4.2%) of 72 eyes with single-site fornix-based procedures and 1 (6.7%) of 15 eyes with single-site limbal-based procedures had subsequent laser trabeculoplasty. There was no statistically significant difference between the 2 surgical subgroups. Ten (13.9%) of 72 eyes with single-site fornix-based procedures, 3 (20.0%) of 15 eyes with single-site limbal-based
procedures, and 2 (9.5%) of 21 eyes with separatesite limbal-based procedures required subsequent surgical intervention. Again, the differences between the surgical subgroups were not statistically significant. Intraoperative MMC was used in 104 eyes in the combined-surgery group. The mean time of application was 1.42 minutes (range 0.5 to of 4.0 minutes). The only statistically significant difference between eyes that received intraoperative MMC and those that did not was that eyes not receiving MMC had a greater reduction in logMAR visual acuity at the 5-year follow-up. However, there were only 5 eyes in the non-MMC group for comparison of this variable at 5 years. The sample size for eyes that did not receive MMC intraoperatively was smaller than 30 eyes at all follow-up intervals. Intraoperative pupil manipulation was required in 32 eyes (23.2%) in the combined-surgery group. Twenty-three eyes required pupillary stretch, 4 had sphincterotomies, 3 required iris retractors, 1 required a Malyugin ring, and 1 required both pupillary stretch
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Figure 3. Kaplan-Meier survival curve for eyes in the combinedsurgery group.
and iris retractors to achieve adequate pupil dilation at the time of surgery. There was no statistically significant difference in the postoperative change in IOP and logMAR visual acuity between eyes that required intraoperative pupil manipulation and eyes that did not. Eyes with pupil manipulation had a greater reduction in glaucoma medications required at all postoperative intervals up to 5 years than eyes without pupil manipulation. However, the sample size of the pupil manipulation group was less than 30 eyes at all follow-up visits. Postoperatively, 16 eyes (11.6%) in the combinedsurgery group required bleb needling to achieve further IOP reduction; the mean number of needlings was 1.2 times per eye (range 1 to 2). Bleb needling was performed with a 5-FU injection in all cases. Eleven (68.8%) of these eyes achieved a 20% or greater reduction in IOP at the final postoperative visit after the bleb needling. Two eyes (12.5%) that had bleb needling required subsequent glaucoma surgery, and 1 eye (6.3%) had subsequent laser trabeculoplasty. Two eyes did not achieve a 20% or greater reduction at the final postoperative follow-up visit but did not have further laser or surgical intervention. The only statistically significant difference between eyes that required bleb needling and eyes that did not was that eyes that received bleb needling had a greater IOP reduction at the first postoperative visit. Bleb needling was used most frequently in eyes with flat blebs, episcleral fibrosis over the trabeculectomy site, or with more advanced optic nerve damage that required a lower IOP.
Postoperatively, 32 eyes (23.2%) in the combinedsurgery group received 5-FU injections; the mean number of injections was 1.9 per eye (range 1 to 5). The only statistically significant difference between eyes that received 5-FU and eyes that did not was a greater mean reduction in IOP at 7 years in eyes receiving 5-FU. The 5-FU injections were used most frequently in eyes with low blebs associated with bleb inflammation, vascularization, or both. Thirty-four eyes (24.6%) in the combined-surgery group required laser suturelysis postoperatively; the mean was 1.1 times per eye (range 1 to 3). The only statistically significant difference between eyes that required laser suturelysis and eyes that did not was a greater improvement in logMAR visual acuity at the 7-year follow-up in eyes that did not receive laser suturelysis. Laser suturelysis was used in eyes with tightly sutured scleral flaps, low blebs, and elevated IOP. Eleven eyes (8.0%) in the combined-surgery group had a bleb leak in the early postoperative period. Three of the eyes developed choroidal detachments with anterior chamber shallowing. All 11 eyes were successfully treated with a bandage contact lens ranging from 1 to 2 weeks. None of the eyes required surgical repair. There were no statistically significant differences in IOP, glaucoma medications required, or logMAR visual acuity at any time between eyes with bleb leaks and eyes without bleb leaks. No late bleb leaks occurred. Twelve eyes had an IOP of less than 5 mm Hg 1 year or more after surgery. All these eyes had good vision without signs of pathologic hypotony. There were no cases of blebitis or endophthalmitis. DISCUSSION Uneventful phacoemulsification with PC IOL implantation and trabeculectomy resulted in a significant long-term reduction in IOP and glaucoma medications required in eyes with PXG and improved logMAR visual acuity. Higher preoperative IOP resulted in a greater reduction in IOP postoperatively. This trend is in accordance with results in previous studies of eyes having phacoemulsification alone.9,17–19 When eyes with PXG and previous laser trabeculoplasty were compared with those without, there was no significant difference in IOP reduction or glaucoma medications required after combined cataract and glaucoma surgery, contrary to that noted with phacoemulsification alone.9 Our results provide some practical guidelines to help surgeons decide whether to perform cataract surgery alone, a combined cataract/trabeculectomy procedure, or glaucoma surgery followed by cataract surgery later in eyes with PXG and a visually
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significant cataract. Phacoemulsification alone, without simultaneous or previous glaucoma surgery, has been shown to result in a small reduction in mean IOP.9 Our current study found that the combined procedure resulted in greater reductions in mean IOP and glaucoma medications required for a longer time than phacoemulsification alone in eyes with PXG. Many eyes with PXG still required glaucoma medications postoperatively; however, the reduction in medications was significantly greater in eyes having combined procedures. There was no statistically significant difference in postoperative visual acuity between the 2 groups. Intraocular pressure spikes greater than 30 mm Hg at 1 day occurred less frequently after combined surgery (8.3%) than after phacoemulsification alone (17.1%).9,20 This is important because early postoperative IOP spikes have the potential to further compromise vision, particularly in patients with advanced glaucomatous optic nerve damage. Many other factors must be taken into account before determining the appropriate surgical procedure for a patient with PXF, a visually significant cataract, and glaucoma. This includes, in part, the extent of optic nerve damage and visual field loss, the target IOP, medication allergies, previous glaucoma treatment, associated eye disease, patient compliance, general health, and age. The level of preoperative IOP is also critical because eyes in the combined-surgery group and eyes in the phaco-alone group with a higher preoperative IOP had a greater IOP reduction. This may be particularly important because in eyes with high preoperative IOP and mild glaucoma, phacoemulsification alone may lower IOP to a satisfactory level. Significant glaucoma damage with high preoperative IOP and a need for even lower postoperative IOP of long duration may direct one to a combined procedure. In general, postoperative complications are more common in eyes with PXF than in eyes with POAG, with or without combined surgery; this may be the result of compromised trabecular outflow, blood–ocular barrier dysfunction, and zonule weakness. As such, all PXF patients must be given realistic expectations about a potentially prolonged postoperative recovery time.4 Furthermore, it is imperative to consider the heightened risk for complications in PXF patients having combined phacoemulsification and trabeculectomy versus phacoemulsification alone. This includes, among others, a higher rate of hypotony and blebrelated issues, such as scarring, encapsulation, and infection. Patients having combined procedures must understand the need for more frequent postoperative follow-up visits than patients having cataract surgery alone and the possible need for adjunctive procedures, such as laser suturelysis, antimetabolite
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injections, bleb needling, and bandage contact lens application, to modulate bleb function. The need for subsequent laser or glaucoma surgery in our series was greater in eyes having combined surgery (13%) than in eyes having phacoemulsification alone (3.7%), even though the mean reduction in IOP was significantly greater in the former group. This is likely because the eyes having a combined procedure tended to have more extensive preexisting optic nerve damage and visual field loss than eyes having phacoemulsification alone, resulting in the need for a lower IOP to prevent further optic nerve damage. We previously reported21 that glaucoma filtration surgery in pseudophakic eyes can significantly improve IOP and glaucoma medications required while sustaining visual acuity in patients with glaucoma. Although this requires a second procedure, it is a viable option in cases in which IOP control fails after phacoemulsification alone and that can tolerate a second procedure. This is a retrospective study with the inherent limitations of data extrapolation. There may be a selection bias in that PXG eyes with more complex disease were followed by the consultant surgeon for longer periods postoperatively. Less problematic patients returned to their referring doctor sooner and because long-term postoperative updates were not received on all eyes, this could have affected the analysis. Even with these caveats, combined cataract and trabeculectomy surgery in eyes with PXG and cataract resulted in significant IOP reduction, glaucoma medications required reduction, and logMAR visual acuity improvement. Combined surgery has an important place in the surgical treatment of eyes with PXG and cataract. This may be particularly so in eyes with advanced optic nerve damage and visual field loss that are not good candidates for multiple operations. REFERENCES 1. Shingleton BJ, Crandall AS, Ahmed K II. Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses. J Cataract Refract Surg 2009; 35:1101–1120 €tzer-Schrehardt U, Naumann GOH. Ocular and systemic 2. Schlo pseudoexfoliation syndrome. Am J Ophthalmol 2006; 141:921–937 3. Ritch R. Exfoliation syndromedthe most common identifiable cause of open-angle glaucoma. J Glaucoma 1994; 3:176–178 €tzer-Schrehardt € chle 4. Conway RM, Schlo U, Ku M, Naumann GOH. Pseudoexfoliation syndrome: pathological manifestations of relevance to intraocular surgery. Clin Exp Ophthalmol 2004; 32:199–210 5. Drolsum L, Ringvold A, Nicolaissen B. Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review. Acta Ophthalmol Scand 2007; 85:810–821. Available at: http://www3. interscience.wiley.com/cgi-bin/fulltext/118515723/PDFSTART. Accessed June 27, 2011
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6. Honjo M, Tanihara H, Inatani M, Honda Y, Ogino N, Ueno S, Negi A, Ichioka H, Mizoguchi T, Matsumura M, Nagata M. Phacoemulsification, intraocular lens implantation, and trabeculotomy to treat pseudoexfoliation syndrome. J Cataract Refract Surg 1998; 24:781–786 7. Landa G, Pollack A, Marcovich A, Rachmiel R, Bukelman A, Zalish M. Results of combined phacoemulsification and trabeculectomy with mitomycin C in pseudoexfoliation versus nonpseudoexfoliation glaucoma. Graefes Arch Clin Exp Ophthalmol 2005; 243:1236–1240 8. Merkur A, Damji KF, Mintsioulis G, Hodge WG. Intraocular pressure decrease after phacoemulsification in patients with pseudoexfoliation syndrome. J Cataract Refract Surg 2001; 27:528–532 9. Shingleton BJ, Laul A, Nagao K, Wolff B, O’Donoghue M, Eagan E, Flattem N, Desai-Bartoli S. Effect of phacoemulsification on intraocular pressure in eyes with pseudoexfoliation: single-surgeon series. J Cataract Refract Surg 2008; 34: 1834–1841 10. Shingleton BJ, Nguyen BK, Eagan EF, Nagao K, O’Donoghue MW. Outcomes of phacoemulsification in fellow eyes of patients with unilateral pseudoexfoliation; singlesurgeon series. J Cataract Refract Surg 2008; 34:274–279 11. Shingleton BJ, Marvin AC, Heier JS, O’Donoghue MW, Laul A, Wolff B, Rowland A. Pseudoexfoliation: high risk factors for zonule weakness and concurrent vitrectomy during phacoemulsification. J Cataract Refract Surg 2010; 36:1261–1269 12. Shingleton BJ, Price RS, O’Donoghue MW, Goyal S. Comparison of 1-site versus 2-site phacotrabeculectomy. J Cataract Refract Surg 2006; 32:799–802 13. Shingleton BJ, Chaudhry IM, O’Donoghue MW, Baylus SL, King RJ, Chaudhry MB. Phacotrabeculectomy; limbus-based versus fornix-based conjunctival flaps in fellow eyes. Ophthalmology 1999; 106:1152–1155 14. Shingleton BJ, Chaudhry IM, O’Donoghue MW. Phacotrabeculectomy: peripheral iridectomy or no peripheral iridectomy? J Cataract Refract Surg 2002; 28:998–1002
15. Shingleton BJ, Pasternack JJ, Hung JW, O’Donoghue MW. Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients. J Glaucoma 2006; 15:494–498 16. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997; 13:388–391 17. Issa SA, Pacheco J, Mahmood U, Nolan J, Beatty S. A novel index for predicting intraocular pressure reduction following cataract surgery. Br J Ophthalmol 2005; 89:543–546. Available at: http:// www.pubmedcentral.nih.gov/picrender.fcgi?artidZ1772653& blobtypeZpdf. Accessed June 27, 2011 18. Poley BJ, Lindstrom RL, Samuelson TW. Long-term effects of phacoemulsification with intraocular lens implantation in normotensive and ocular hypertensive eyes. J Cataract Refract Surg 2008; 34:735–742 19. Suzuki R, Kuroki S, Fujiwara N. Ten-year follow-up of intraocular pressure after phacoemulsification and aspiration with intraocular lens implantation performed by the same surgeon. Ophthalmologica 1997; 211:79–83 20. Krupin T, Feitl ME, Bishop KI. Postoperative intraocular pressure rise in open-angle glaucoma patients after cataract or combined cataract-filtration surgery. Ophthalmology 1989; 96:579–584 21. Shingleton BJ, Alfano C, O’Donoghue MW, Rivera J. Efficacy of glaucoma filtration surgery in pseudophakic patients with or without conjunctival scarring. J Cataract Refract Surg 2004; 30:2504–2509
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First author: Bradford J. Shingleton, MD Private practice, Boston, Massachusetts, USA
Combined cataract and trabeculectomy surgery in eyes with pseudoexfoliation glaucoma Bradford J. Shingleton, MD, Kristy B. Wooler, OD, Carla I. Bourne, MD, Mark W. O’Donoghue, OD
PURPOSE: To assess the short- and long-term effect of uneventful phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and trabeculectomy on intraocular pressure (IOP) and glaucoma medication requirements in eyes with pseudoexfoliation glaucoma (PXG) and compare the results with those in eyes that had uneventful phacoemulsification only (reported in a previous study of the same cohort of pseudoexfoliation eyes). SETTING: Private practice, Boston, Massachusetts, USA. DESIGN: Comparative case series. METHODS: A retrospective analysis was performed of consecutive PXG eyes that had uneventful combined phacoemulsification and trabeculectomy by the same surgeon. The change in IOP, glaucoma medication requirements, and logMAR corrected distance visual acuity was compared between the combined surgery group and the phaco-alone group. RESULTS: The combined-surgery group (n Z 138) had statistically significant reduced mean IOP and glaucoma medication requirements through 10 years postoperatively (P<.018). The change in IOP and glaucoma medication requirements was greater in the combined-surgery group than in the phaco-alone group (n Z 240); this was statistically significant up to 7 years postoperatively (P<.022). The reduction in mean postoperative IOP was greater in eyes with a higher mean preoperative IOP. In the combined-surgery group, 13.8% of eyes required subsequent laser trabeculoplasty, glaucoma surgery, or both. CONCLUSIONS: Uneventful phacoemulsification, IOL implantation, and trabeculectomy resulted in significant long-term reduction in IOP and glaucoma medication requirements in eyes with PXG. Combined procedures resulted in greater and more longstanding reductions in IOP and glaucoma medication requirements and fewer 1-day postoperative IOP spikes than phacoemulsification alone. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:1961–1970 Q 2011 ASCRS and ESCRS
Pseudoexfoliation (PXF) is an age-related systemic condition characterized by the production and accumulation of abnormal fibrillar extracellular material.1 The gray–white flaky material is deposited on virtually all tissues of the anterior segment of the eye as well as throughout the human body.2 Pseudoexfoliation has long been associated with an increased risk for cataract development2 and is the most common identifiable cause of secondary open-angle glaucoma (OAG).3 Pseudoexfoliation glaucoma (PXG) tends to be more severe than primary open-angle glaucoma (POAG), manifesting higher mean intraocular pressure (IOP), greater optic nerve damage at the time of diagnosis, and a poorer response to medical therapy, often necessitating earlier surgical intervention.4 As Q 2011 ASCRS and ESCRS Published by Elsevier Inc.
a consequence, eyes with PXF require intraocular surgery related to cataract and IOP at a higher rate than eyes without PXF.5 Combined cataract and glaucoma surgery has been reported to be an effective treatment for patients with PXG.6 The results of combined procedures in PXG patients have been found to be comparable to those in POAG patients.7 In a small population study, Merkur et al.8 found phacoemulsification alone to be a reasonable option for initial IOP management in patients with PXG and visually significant cataract, but without advanced optic nerve damage. In a large population study of more than 1000 eyes,9 we found that uneventful temporal clear corneal phacoemulsification with posterior chamber intraocular lens (PC 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2011.05.036
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IOL) implantation resulted in a modest reduction in IOP for 3 years in PXF eyes and a reduction in glaucoma medication requirements for up to 7 years. Higher preoperative IOP was associated with a greater IOP reduction. Eyes with PXG and a preoperative IOP greater than 25 mm Hg had a mean reduction in IOP of approximately 10 mm Hg at 3 years. Thus, the decision to perform cataract surgery alone or in combination with trabeculectomy is of particular interest in the treatment of patients with PXG and a visually significant cataract. The purpose of this study was to assess the shortand long-term effect of uneventful combined phacoemulsification, PC IOL implantation, and trabeculectomy in eyes with PXG. These results were compared with those in eyes with PXG that had uneventful phacoemulsification alone as reported in a previous study of the same cohort of PXF eyes.9 PATIENTS AND METHODS This retrospective analysis comprised consecutive eyes with PXF that had uneventful phacoemulsification with PC IOL implantation in combination with trabeculectomy (combined-surgery group) by the same surgeon (B.J.S.) from 1991 to 2008. This analysis is the most recent report in a series of more than 1200 eyes with PXF that had cataract surgery.9–11 Patients were identified as having PXG based on slitlamp biomicroscopic examination; gonioscopy; dilated optic nerve head examination; visual field analysis; and history of treatment with topical glaucoma medications, previous glaucoma laser surgery, or both. Eyes with previous glaucoma filtration surgery were excluded from data analysis. The basic surgical technique for combined phacoemulsification, IOL implantation, and trabeculectomy was similar for all patients in this study. Topical or peribulbar anesthesia was used. Single-site and separate-site combined procedures were performed. The results with single-site versus separatesite approaches in OAG have been published.12 Conjunctival flaps were mobilized in a limbal-based or fornix-based manner. The results with fornix-based versus limbal-based conjunctival flaps in OAG were previously reported.13 In single-site procedures, limbal-based or fornix-based conjunctival flaps were mobilized. Bleeding was controlled with underwater diathermy. A partial-thickness scleral flap was mobilized superiorly in a rectangular, triangular, or
Submitted: January 30, 2011. Final revision submitted: April 26, 2011. Accepted: May 5, 2011. From Ophthalmic Consultants of Boston (Shingleton, Wooler, Bourne, O’Donoghue), Boston, Massachusetts, and the University of South Florida (Bourne), Tampa, Florida, USA. Corresponding author: Bradford J. Shingleton, MD, Ophthalmic Consultants of Boston, Center for Eye Research and Education, 50 Staniford Street, Suite 600, Boston, Massachusetts 02114, USA. E-mail: [email protected].
trapezoidal configuration. The eye was entered under the scleral flap with a keratome. An ophthalmic viscoelastic device (OVD) was placed in the anterior chamber, and a limbal paracentesis incision was made. A 360-degree anterior capsulorhexis, nuclear cortical hydrodissection, and phacoemulsification of the nucleus were performed. Residual cortical material was then removed by irrigation/aspiration (I/A); the posterior capsule was left intact in all cases. An OVD was placed in the capsular bag, and a PC IOL was implanted in the capsular bag. The OVD was evacuated from the eye. In eyes with a widely dilated pupil, intraoperative carbachol was injected into the anterior chamber to achieve miosis. A posterior lip sclerectomy was performed under the scleral flap with a Kelly Descemet punch (Storz Ophthalmics). The size of the sclerectomy was 0.5 mm 1.0 mm. A peripheral iridectomy was not routinely performed but was used in all cases with a shallow chamber or iris prolapse. The results with and without surgical iridectomy in combined phacotrabeculectomy have been reported.14 The scleral flap was closed with buried interrupted 10-0 nylon sutures. The chamber was deepened through the paracentesis with a balanced salt solution to achieve a normal IOP, stable anterior chamber depth, and slow, steady egress of fluid under the sclera flap. The conjunctiva was closed, ensuring watertight closure after the anterior chamber was deepened; closure was confirmed using fluorescein strips. All patients received topical pilocarpine, prednisolone acetate 1%, and antibiotic drops. A patch and metal shield were placed over eyes having peribulbar anesthesia. Oral acetazolamide (500 mg sequel) was administered in the recovery room to all patients without a sulfa allergy. In eyes having a separate-incision approach, a temporal keratome incision was made. An OVD was instilled in the anterior chamber. A limbal paracentesis incision was placed. A 360-degree anterior capsulorhexis, nuclear/cortical hydrodissection, and phacoemulsification of the nucleus were performed. The residual cortical material was removed by I/A; the posterior capsule was left intact in all cases. An OVD was placed, and a PC IOL was implanted in the capsular bag. The OVD was evacuated from the eye, and the chamber deepened with intraoperative carbachol if pupil miosis was required. The temporal keratome incision and paracentesis were closed with interrupted buried 10-0 nylon sutures. At this time, the surgeon switched to the superior aspect and a fornix-based or limbal-based conjunctival flap was mobilized. A rectangular, triangular, or trapezoidal scleral flap was mobilized. The eye was entered at the anterior reflection of the scleral flap with a super blade. A 0.5 mm 1.0 mm posterior lip sclerectomy was performed under the scleral flap with a Kelly Descemet punch. A peripheral iridectomy was not routinely performed but was used in all cases with a shallow chamber or iris prolapse. The scleral flap was closed with interrupted buried 10-0 nylon sutures. The chamber was deepened through the paracentesis to achieve a stable anterior chamber, normal IOP, and steady egress of fluid under the scleral flap. The conjunctiva was closed; watertight closure was confirmed using fluorescein strips. All patients received topical pilocarpine, prednisolone acetate 1%, and antibiotic drops. A patch and metal shield were placed over eyes receiving peribulbar anesthesia. Oral acetazolamide (500 mg sequel) was administered in the recovery room to all patients without a sulfa allergy. In some eyes, cellulose sponge pledgets soaked in mitomycin-C (MMC) (0.4 mm/cc concentration) were
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Table 1. Patient demographics. Characteristic Eyes (n) Male (n) Female (n) Mean age (y) G SD
Combined Surgery
Phaco Alone
138 42 96 76.6 G 6.7
240 70 170 78.2 G 7.0
applied intraoperatively. One to 4 pledgets were used, with a broader zone of application in cases performed after 2001. All pledgets were placed subconjunctivally after conjunctival flap creation but before scleral flap mobilization; the pledgets were kept in place for 30 seconds to 4 minutes. After the pledgets were removed, the subconjunctival space was copiously irrigated with a balanced salt solution. Postoperatively, patients were seen at 1 day and 1 week, with other visits scheduled as necessary. Postoperative use of laser suturelysis and subconjunctival injection of 5-fluorouracil (5-FU) was based primarily on bleb configuration and IOP. Eyes with flat blebs, episcleral fibrosis, higher IOPs, or a combination were candidates for laser suturelysis and 5-FU. Patients were placed on a tapering schedule of topical prednisolone acetate 1%, topical antibiotic, and topical nonsteroidal antiinflammatory drops over 6 to 8 weeks. Glaucoma status determined the need for additional glaucoma medications. If the IOP level was thought to be too high for the status of the optic nerve and visual fields, glaucoma medications were added. Absent allergies or specific contraindications, topical glaucoma medications were typically added in the following order: b-blocker, a-agonist, carbonic anhydrase inhibitor, prostaglandin agonist. Systemic carbonic anhydrase inhibitors were rarely used.15 Preoperatively and at all postoperative office visits, corrected distance visual acuity (CDVA), IOP, and the number of glaucoma medications required were recorded. Visual acuity was measured using projected Snellen charts and then converted into logMAR values.16 Intraocular pressure was measured using Goldmann tonometry. The combined-surgery group was statistically analyzed alone and in relation to a previous study group consisting of 240 eyes with PXF and glaucoma that had phacoemulsification with IOL implantation but without filtration surgery (phaco-alone group).9 Table 2. Intraocular pressure over time in the combined-surgery group. Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Failure in the combined-surgery group was defined as either or both of the following: (1) the need for subsequent laser trabeculoplasty and/or glaucoma surgery due to elevated IOP or the need for subconjunctival autologous blood injection/surgical bleb revision due to pathologic hypotony (defined as any IOP associated with reduced vision and choroidal folds with or without disc edema, cystoid macular edema, and choroidal detachment); (2) less than a 20% reduction in IOP with or without glaucoma medication at the final postoperative visit. For statistical analysis, SPSS software (SPSS, Inc.) was used to analyze means for statistical significance. Histograms were constructed to verify normality for the variables: IOP, postoperative change in IOP, glaucoma medications required, postoperative change in glaucoma medications required, and logMAR visual acuity. All variables were normally distributed with the exception of logMAR visual acuity. Two-tailed paired-samples t tests were used to compare preoperative and postoperative measurements within the combined-surgery group. Two-tailed independent t tests for the equality of means were used to compare variables between the combined-surgery group and the phaco-alone group as well as for comparisons in the surgical procedure analysis. One-way analysis of variance was used to validate the significance of the multiple t tests. The IOP spikes on the first postoperative day were analyzed using the hypothesis test of the equality of 2 proportions; P values of 0.05 or less were considered statistically significant. Data are presented as the mean G standard deviation (SD). LogMAR visual acuity was the only variable that was not normally distributed. Both the preoperative and postoperative logMAR visual acuities were bimodally distributed with 1 group distributed around 0.30 and the other around 1.25. The latter group centered on 1.25 represented outliers and numbered 35 preoperatively and 25 postoperatively in the combined-surgery group. Nonparametric Wilcoxon signed-rank and Mann-Whitney tests were used with paired and independent-sample t tests to analyze logMAR visual acuity data.
RESULTS The combined-surgery group comprised 138 eyes. Fifty-eight eyes had previous laser trabeculoplasty, with 4 also having had laser iridectomy. Six eyes had Table 3. Number of glaucoma medications required in the combined-surgery group. Mean Glaucoma Medications (n) G SD
Mean IOP (mm Hg) G SD Eyes (n) 122 121 85 57 69 42 21
Preoperative Postoperative 21.6 G 7.5 21.5 G 7.5 20.9 G 5.9 21.1 G 6.4 21.5 G 7.2 20.7 G 5.1 22.0 G 5.5
IOP Z intraocular pressure *Compared with preoperative IOP
16.1 G 10.3 16.1 G 6.4 14.2 G 4.7 14.7 G 5.5 14.9 G 6.0 16.9 G 6.9 15.5 G 10.0
P Value* .000 .000 .000 .000 .000 .001 .018
Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 128 123 85 57 70 43 21
Preoperative Postoperative 2.3 G 1.2 2.4 G 1.3 2.3 G 1.2 2.4 G 1.0 2.3 G 1.1 2.1 G 1.0 2.1 G 1.4
0.1 G 0.4 0.2 G 0.6 0.4 G 0.8 0.5 G 0.9 0.8 G 1.1 1.0 G 1.2 1.0 G 1.3
P Value* .000 .000 .000 .000 .000 .000 .003
*Compared with preoperative number of glaucoma medications required
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Table 4. Comparison of preoperative and postoperative visual acuity in combined-surgery group. Mean CDVA (LogMAR) G SD Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n)
Preoperative
Postoperative
P Value*
Wilcoxon
128 123 84 57 71 43 21
0.64 G 0.4 0.65 G 0.4 0.60 G 0.4 0.63 G 0.4 0.59 G 0.3 0.59 G 0.4 0.54 G 0.3
0.64 G 0.4 0.39 G 0.4 0.24 G 0.3 0.32 G 0.4 0.37 G 0.4 0.52 G 0.5 0.52 G 0.6
.882 .000 .000 .000 .000 .444 .838
.441 .000 .000 .000 .000 .161 .485
CDVA Z corrected distance visual acuity
previous laser iridectomy without laser trabeculoplasty. Table 1 shows the patients’ demographics. The mean patient follow-up was 1729.3 days G 1332.3 (SD) (4.7 G 3.7 years; range 1 day to 5108 days). One eye had a 1-day follow-up. Table 2 shows the effect of combined cataract and trabeculectomy surgery. There was a statistically significant reduction in IOP over preoperative values at all time intervals from 1 day to 10 years postoperatively. Similarly, there was a statistically significant reduction in mean glaucoma medications required at all time intervals up to 10 years postoperatively (Table 3). Although the need for postoperative glaucoma medications gradually increased with time, the mean glaucoma medications required remained lower than the preoperative level at all follow-up intervals. The mean logMAR CDVA in the combined-surgery group improved significantly at all time intervals from 1 month to 5 years postoperatively compared with preoperative levels (Table 4). In eyes with better logMAR acuity (!1.00), the mean logMAR visual acuity remained improved for a longer period postoperatively (from 1 month to 10 years). These results were
confirmed by the nonparametric Wilcoxon signedrank test. There was no statistically significant difference in preoperative or postoperative logMAR visual acuity between the combined-surgery group and the phacoalone group. In most eyes with poorer preoperative visual acuity (R1.00), the cause was a dense cataract (n Z 21). Other causes included advanced glaucoma (n Z 5), a history of hemiretinal vein occlusion (n Z 1), and dense amblyopia with staphyloma (n Z 1). The cause of the poorer preoperative visual acuity could not be determined in 7 eyes; 6 of the charts had been destroyed, and 1 chart could not be located after other data were recorded previously. In eyes with poorer postoperative visual acuity (R1.00) at the most recent follow-up visit, the causes included advanced glaucoma (n Z 12), hemorrhagic choroidal detachment (n Z 1), macular scarring from agerelated macular degeneration (n Z 2), neovascular glaucoma with history of hemiretinal vein occlusion (n Z 1), epiretinal membrane/macular pucker (n Z 1), dense amblyopia with staphyloma (n Z 1), hypotony (n Z 1), and corneal edema secondary to herpes
Table 5. Postoperative change in IOP. Change in IOP (mm Hg) Combined-Surgery Group Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 122 121 85 57 69 42 21
Mean 5.59 5.35 6.76 6.46 6.59 3.81 6.52
Phaco-Alone Group %
Eyes (n)
25.9 24.9 32.3 30.6 30.7 18.4 29.6
240 216 111 69 69 22 7
IOP Z intraocular pressure
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Mean 3.46 0.99 1.58 0.77 0.09 0.23 2.86
%
P Value
19.9 5.7 9.1 4.4 0.5 1.4 20.3
.000 .000 .000 .000 .000 .022 .440
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simplex keratitis (n Z 1). The cause could not be determined in 5 eyes; 4 of the charts had been destroyed and 1 chart could not be located after other data were recorded previously. Sixty-seven eyes in the combined-surgery group had argon laser trabeculoplasty before combined phacoemulsification and trabeculectomy. In these eyes, there was a statistically significant postoperative reduction in IOP and glaucoma medications required at all follow-up time intervals. In the 71 eyes in the combined-surgery group that had no previous laser trabeculoplasty, there was a statistically significant reduction in IOP and glaucoma medications required at all follow-up intervals up to 7 years postoperatively. The postoperative change in IOP was statistically significantly greater in eyes with previous laser trabeculoplasty than in those without previous laser trabeculoplasty at the 1-day and 1-month interval only. There was no statistically significant difference in the change in glaucoma medications required at any follow-up interval between eyes with previous laser trabeculoplasty and eyes with no previous laser trabeculoplasty. The postoperative change in IOP was greater in the combined-surgery group than in the phaco-alone group. These changes were statistically significant at all follow-up intervals, except the 10-year interval (Table 5 and Figure 1). The phaco-alone group had a mean increase in IOP and the combined-surgery group a mean decrease in IOP on the first postoperative day. The postoperative change in glaucoma medications required was also greater in the combined-surgery group than in the phaco-alone group. These changes were statistically significant up to 7 years postoperatively (Table 6). In the combined-surgery group, the mean preoperative IOP level had a significant effect on the mean postoperative IOP reduction. The higher the mean preoperative IOP, the greater the reduction in the mean postoperative IOP. This finding was statistically significant from 1 day to 5 years postoperatively
Figure 1. Postoperative change in IOP (IOP Z intraocular pressure).
(Table 7 and Figure 2). The change in IOP was greater in the combined-surgery group than in the phacoalone group for each preoperative IOP level at each follow-up period, although not all associations were statistically significant (Table 8). Because the eyes were stratified into each preoperative IOP and follow-up interval, the number of eyes in each subgroup became too small for statistical analysis in many cases. This was especially true for the small number of eyes with a preoperative IOP greater than 25 mm Hg that had extended follow-up postoperatively. Intraocular pressure spikes greater than 30 mm Hg on the first postoperative day occurred in 11 eyes (8.3%) in the combined-surgery group and in 41 eyes (17.1%) in the phaco-only group. The difference in the frequency of IOP spikes was statistically significant between the combined-surgery group and the phacoalone group (P!.0199, 2 tailed). In eyes having combined surgery, the first failure group comprised 4 eyes requiring laser trabeculoplasty, 14 eyes requiring glaucoma surgery for elevated IOP, and 1 eye requiring surgical treatment for pathologic hypotony, all at the initial postoperative intervention. Of the 14 eyes requiring glaucoma surgery
Table 6. Postoperative change in number of glaucoma medications required by group. Combined-Surgery Group Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 128 123 85 57 71 43 21
Mean Change (n) G SD 2.2 G 1.2 2.2 G 1.2 2.2 G 1.0 1.9 G 1.2 1.5 G 1.5 1.2 G 1.4 1.0 G 1.6
Phaco-Alone Group Eyes (n) 207 187 100 60 63 16 4
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Mean Change (n) G SD 1.3 G 1.0 0.7 G 1.0 0.6 G 1.0 0.5 G 1.0 0.4 G 1.4 0.8 G 1.4 0.3 G 0.5
P Value .000 .000 .000 .000 .000 .000 .272
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PHACOTRABECULECTOMY IN PSEUDOEXFOLIATION EYES
Table 7. Impact of preoperative IOP on IOP reduction in the combined-surgery group. Change in IOP (mm Hg) Eyes with Preop IOP !21 mm Hg Postop Interval 1 day 1 month 1 year 3 years 5 years 7 years 10 years
Eyes (n) 64 67 49 30 42 24 13
Mean 0.80 0.97 2.41 1.13 2.69 2.96 4.38
Eyes with Preop IOP 21–25 mm Hg
%
Eyes (n)
4.7 5.7 14.0 6.8 15.4 17.0 23.6
34 32 21 18 15 11 4
Mean 6.82 7.22 9.62 11.00 8.67 3.45 4.00
Eyes with Preop IOP O25 mm Hg
%
Eyes (n)
29.8 31.6 42.2 47.5 37.8 15.3 17.4
24 22 15 9 12 7 4
Mean 16.63 15.95 17.00 15.11 17.67 7.29 16.00
%
P Value
50.5 48.0 55.8 47.4 51.8 24.5 50.0
.000 .000 .000 .000 .000 .365 .199
IOP Z intraocular pressure
for elevated IOP, 6 had secondary filtration surgery, 6 had bleb revisions, 1 had diode laser cyclophotocoagulation treatment, and 1 eye required tube shunt implantation as the initial postoperative surgical intervention. Six eyes in this failure group required more than 1 procedure for elevated IOP. The 1 eye with pathologic hypotony required a single subconjunctival autologous blood injection. Nineteen eyes failed during the study period; the mean time to failure was 5.6 G 3.0 years. Figure 3 shows a Kaplan-Meier survival curve. Taking into account censored observations, the curve predicts 90% of eyes in the combined-surgery group will be surviving 5 years postoperatively. Furthermore, approximately 50% of these eyes will survive over a longer period than the study covered. The survival analysis estimates a mean survival time of 11.0 G 0.6 years, where estimation is limited to the largest censored survival time.
Figure 2. Impact of preoperative IOP on postoperative IOP reduction in eyes having combined phacoemulsification and trabeculectomy (IOP Z intraocular pressure).
Of the 119 eyes that did not fail by the first criteria, 39 (32.8%) had less than a 20% IOP reduction at the final postoperative visit. Thus, 58 of 138 eyes (42.0%) failed when judged by both criteria. In the combined-surgery group, 5 eyes had intraoperative complications, including zonule weakness (3 eyes) and posterior capsule tear (1 eye). One eye became firm before phacoemulsification as a result of presumed intraoperative aqueous misdirection. All eyes with intraoperative complications were excluded from analysis. In the combined-surgery group, 87 eyes had singlesite incision surgery and 34 eyes had separate-site incision surgery. The only statistically significant difference in the postoperative change in IOP between the 2 subgroups was at 1 day, when eyes with separate-site incisions had a greater reduction in IOP than eyes with single-site incisions. The only statistically significant difference change in glaucoma medications required between the 2 subgroups was at the 1-month follow-up, at which time eyes with separate-site incisions had a greater reduction in glaucoma medications required than eyes with single-site incisions. There was no statistically significant difference in logMAR visual acuity between the 2 subgroups at any postoperative visit. Eighty-five eyes had combined surgery with a fornix-based flap, 72 as single-site and 13 as separatesite procedures. Thirty-six eyes had limbal-based flaps, 15 as single-site and 21 as separate-site procedures. There was no statistically significant difference in the postoperative change in IOP, glaucoma medications required, or postoperative change in logMAR visual acuity between eyes with fornix-based flaps and eyes with limbal-based flaps. However, eyes with limbal-based flaps had a statistically significantly greater reduction in IOP than eyes with fornix-based flaps at 1 day. There was no statistically significant difference in the postoperative change in IOP, glaucoma
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PHACOTRABECULECTOMY IN PSEUDOEXFOLIATION EYES
Table 8. Impact of preoperative IOP on IOP reduction by group. Combined-Surgery Group Postop Interval/Preop IOP 1 day !21 mm Hg 21–25 mm Hg O25 mm Hg 1 month !21 mm Hg 21–25 mm Hg O25 mm Hg 1 year !21 mm Hg 21–25 mm Hg O25 mm Hg 3 years !21 mm Hg 21–25 mm Hg O25 mm Hg 5 years !21 mm Hg 21–25 mm Hg O25 mm Hg 7 years !21 mm Hg 21–25 mm Hg O25 mm Hg 10 years !21 mm Hg 21–25 mm Hg O25 mm Hg
Phaco-Alone Group
Mean DIOP (mm Hg)
Eyes (n)
Eyes (n)
Mean DIOP (mm Hg)
P Value
64 34 24
0.80 6.82 16.63
189 37 14
4.40 2.16 5.79
0.000 0.000 0.032
67 32 22
0.97 7.22 15.95
170 35 11
0.21 3.60 11.18
0.138 0.007 0.213
49 21 15
2.41 9.62 17.00
81 24 6
0.14 5.17 10.33
0.002 0.003 0.071
30 18 9
1.13 11.00 15.11
52 15 2
1.02 5.67 10.50
0.061 0.005 0.371
42 15 12
2.69 8.67 17.67
57 11 1
1.02 4.27 5.00
0.001 0.099 0.342
24 11 7
2.96 3.45 7.29
20 2 d
0.15 4.00 No data
0.094 0.911 No data
13 4 4
4.38 4.00 16.00
7 d d
2.86 No data No data
0.778 No data No data
DIOP Z postoperative change in intraocular pressure
medications required, or postoperative change in logMAR visual acuity between eyes with single-site fornix-based flaps and eyes with separate-site fornixbased flaps. There was no statistically significant difference in the postoperative change in IOP or postoperative change in logMAR visual acuity between the 2 subgroups at any interval. However, there was a statistically significant difference in postoperative change in glaucoma medications required at all intervals up to 7 years, with the eyes with separate-site limbal-based flaps having a greater reduction in glaucoma medications required than eyes with single-site limbal-based flaps. (Note that the sample sizes in these 2 subgroups were small.) Three (4.2%) of 72 eyes with single-site fornix-based procedures and 1 (6.7%) of 15 eyes with single-site limbal-based procedures had subsequent laser trabeculoplasty. There was no statistically significant difference between the 2 surgical subgroups. Ten (13.9%) of 72 eyes with single-site fornix-based procedures, 3 (20.0%) of 15 eyes with single-site limbal-based
procedures, and 2 (9.5%) of 21 eyes with separatesite limbal-based procedures required subsequent surgical intervention. Again, the differences between the surgical subgroups were not statistically significant. Intraoperative MMC was used in 104 eyes in the combined-surgery group. The mean time of application was 1.42 minutes (range 0.5 to of 4.0 minutes). The only statistically significant difference between eyes that received intraoperative MMC and those that did not was that eyes not receiving MMC had a greater reduction in logMAR visual acuity at the 5-year follow-up. However, there were only 5 eyes in the non-MMC group for comparison of this variable at 5 years. The sample size for eyes that did not receive MMC intraoperatively was smaller than 30 eyes at all follow-up intervals. Intraoperative pupil manipulation was required in 32 eyes (23.2%) in the combined-surgery group. Twenty-three eyes required pupillary stretch, 4 had sphincterotomies, 3 required iris retractors, 1 required a Malyugin ring, and 1 required both pupillary stretch
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Figure 3. Kaplan-Meier survival curve for eyes in the combinedsurgery group.
and iris retractors to achieve adequate pupil dilation at the time of surgery. There was no statistically significant difference in the postoperative change in IOP and logMAR visual acuity between eyes that required intraoperative pupil manipulation and eyes that did not. Eyes with pupil manipulation had a greater reduction in glaucoma medications required at all postoperative intervals up to 5 years than eyes without pupil manipulation. However, the sample size of the pupil manipulation group was less than 30 eyes at all follow-up visits. Postoperatively, 16 eyes (11.6%) in the combinedsurgery group required bleb needling to achieve further IOP reduction; the mean number of needlings was 1.2 times per eye (range 1 to 2). Bleb needling was performed with a 5-FU injection in all cases. Eleven (68.8%) of these eyes achieved a 20% or greater reduction in IOP at the final postoperative visit after the bleb needling. Two eyes (12.5%) that had bleb needling required subsequent glaucoma surgery, and 1 eye (6.3%) had subsequent laser trabeculoplasty. Two eyes did not achieve a 20% or greater reduction at the final postoperative follow-up visit but did not have further laser or surgical intervention. The only statistically significant difference between eyes that required bleb needling and eyes that did not was that eyes that received bleb needling had a greater IOP reduction at the first postoperative visit. Bleb needling was used most frequently in eyes with flat blebs, episcleral fibrosis over the trabeculectomy site, or with more advanced optic nerve damage that required a lower IOP.
Postoperatively, 32 eyes (23.2%) in the combinedsurgery group received 5-FU injections; the mean number of injections was 1.9 per eye (range 1 to 5). The only statistically significant difference between eyes that received 5-FU and eyes that did not was a greater mean reduction in IOP at 7 years in eyes receiving 5-FU. The 5-FU injections were used most frequently in eyes with low blebs associated with bleb inflammation, vascularization, or both. Thirty-four eyes (24.6%) in the combined-surgery group required laser suturelysis postoperatively; the mean was 1.1 times per eye (range 1 to 3). The only statistically significant difference between eyes that required laser suturelysis and eyes that did not was a greater improvement in logMAR visual acuity at the 7-year follow-up in eyes that did not receive laser suturelysis. Laser suturelysis was used in eyes with tightly sutured scleral flaps, low blebs, and elevated IOP. Eleven eyes (8.0%) in the combined-surgery group had a bleb leak in the early postoperative period. Three of the eyes developed choroidal detachments with anterior chamber shallowing. All 11 eyes were successfully treated with a bandage contact lens ranging from 1 to 2 weeks. None of the eyes required surgical repair. There were no statistically significant differences in IOP, glaucoma medications required, or logMAR visual acuity at any time between eyes with bleb leaks and eyes without bleb leaks. No late bleb leaks occurred. Twelve eyes had an IOP of less than 5 mm Hg 1 year or more after surgery. All these eyes had good vision without signs of pathologic hypotony. There were no cases of blebitis or endophthalmitis. DISCUSSION Uneventful phacoemulsification with PC IOL implantation and trabeculectomy resulted in a significant long-term reduction in IOP and glaucoma medications required in eyes with PXG and improved logMAR visual acuity. Higher preoperative IOP resulted in a greater reduction in IOP postoperatively. This trend is in accordance with results in previous studies of eyes having phacoemulsification alone.9,17–19 When eyes with PXG and previous laser trabeculoplasty were compared with those without, there was no significant difference in IOP reduction or glaucoma medications required after combined cataract and glaucoma surgery, contrary to that noted with phacoemulsification alone.9 Our results provide some practical guidelines to help surgeons decide whether to perform cataract surgery alone, a combined cataract/trabeculectomy procedure, or glaucoma surgery followed by cataract surgery later in eyes with PXG and a visually
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significant cataract. Phacoemulsification alone, without simultaneous or previous glaucoma surgery, has been shown to result in a small reduction in mean IOP.9 Our current study found that the combined procedure resulted in greater reductions in mean IOP and glaucoma medications required for a longer time than phacoemulsification alone in eyes with PXG. Many eyes with PXG still required glaucoma medications postoperatively; however, the reduction in medications was significantly greater in eyes having combined procedures. There was no statistically significant difference in postoperative visual acuity between the 2 groups. Intraocular pressure spikes greater than 30 mm Hg at 1 day occurred less frequently after combined surgery (8.3%) than after phacoemulsification alone (17.1%).9,20 This is important because early postoperative IOP spikes have the potential to further compromise vision, particularly in patients with advanced glaucomatous optic nerve damage. Many other factors must be taken into account before determining the appropriate surgical procedure for a patient with PXF, a visually significant cataract, and glaucoma. This includes, in part, the extent of optic nerve damage and visual field loss, the target IOP, medication allergies, previous glaucoma treatment, associated eye disease, patient compliance, general health, and age. The level of preoperative IOP is also critical because eyes in the combined-surgery group and eyes in the phaco-alone group with a higher preoperative IOP had a greater IOP reduction. This may be particularly important because in eyes with high preoperative IOP and mild glaucoma, phacoemulsification alone may lower IOP to a satisfactory level. Significant glaucoma damage with high preoperative IOP and a need for even lower postoperative IOP of long duration may direct one to a combined procedure. In general, postoperative complications are more common in eyes with PXF than in eyes with POAG, with or without combined surgery; this may be the result of compromised trabecular outflow, blood–ocular barrier dysfunction, and zonule weakness. As such, all PXF patients must be given realistic expectations about a potentially prolonged postoperative recovery time.4 Furthermore, it is imperative to consider the heightened risk for complications in PXF patients having combined phacoemulsification and trabeculectomy versus phacoemulsification alone. This includes, among others, a higher rate of hypotony and blebrelated issues, such as scarring, encapsulation, and infection. Patients having combined procedures must understand the need for more frequent postoperative follow-up visits than patients having cataract surgery alone and the possible need for adjunctive procedures, such as laser suturelysis, antimetabolite
1969
injections, bleb needling, and bandage contact lens application, to modulate bleb function. The need for subsequent laser or glaucoma surgery in our series was greater in eyes having combined surgery (13%) than in eyes having phacoemulsification alone (3.7%), even though the mean reduction in IOP was significantly greater in the former group. This is likely because the eyes having a combined procedure tended to have more extensive preexisting optic nerve damage and visual field loss than eyes having phacoemulsification alone, resulting in the need for a lower IOP to prevent further optic nerve damage. We previously reported21 that glaucoma filtration surgery in pseudophakic eyes can significantly improve IOP and glaucoma medications required while sustaining visual acuity in patients with glaucoma. Although this requires a second procedure, it is a viable option in cases in which IOP control fails after phacoemulsification alone and that can tolerate a second procedure. This is a retrospective study with the inherent limitations of data extrapolation. There may be a selection bias in that PXG eyes with more complex disease were followed by the consultant surgeon for longer periods postoperatively. Less problematic patients returned to their referring doctor sooner and because long-term postoperative updates were not received on all eyes, this could have affected the analysis. Even with these caveats, combined cataract and trabeculectomy surgery in eyes with PXG and cataract resulted in significant IOP reduction, glaucoma medications required reduction, and logMAR visual acuity improvement. Combined surgery has an important place in the surgical treatment of eyes with PXG and cataract. This may be particularly so in eyes with advanced optic nerve damage and visual field loss that are not good candidates for multiple operations. REFERENCES 1. Shingleton BJ, Crandall AS, Ahmed K II. Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses. J Cataract Refract Surg 2009; 35:1101–1120 €tzer-Schrehardt U, Naumann GOH. Ocular and systemic 2. Schlo pseudoexfoliation syndrome. Am J Ophthalmol 2006; 141:921–937 3. Ritch R. Exfoliation syndromedthe most common identifiable cause of open-angle glaucoma. J Glaucoma 1994; 3:176–178 €tzer-Schrehardt € chle 4. Conway RM, Schlo U, Ku M, Naumann GOH. Pseudoexfoliation syndrome: pathological manifestations of relevance to intraocular surgery. Clin Exp Ophthalmol 2004; 32:199–210 5. Drolsum L, Ringvold A, Nicolaissen B. Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review. Acta Ophthalmol Scand 2007; 85:810–821. Available at: http://www3. interscience.wiley.com/cgi-bin/fulltext/118515723/PDFSTART. Accessed June 27, 2011
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6. Honjo M, Tanihara H, Inatani M, Honda Y, Ogino N, Ueno S, Negi A, Ichioka H, Mizoguchi T, Matsumura M, Nagata M. Phacoemulsification, intraocular lens implantation, and trabeculotomy to treat pseudoexfoliation syndrome. J Cataract Refract Surg 1998; 24:781–786 7. Landa G, Pollack A, Marcovich A, Rachmiel R, Bukelman A, Zalish M. Results of combined phacoemulsification and trabeculectomy with mitomycin C in pseudoexfoliation versus nonpseudoexfoliation glaucoma. Graefes Arch Clin Exp Ophthalmol 2005; 243:1236–1240 8. Merkur A, Damji KF, Mintsioulis G, Hodge WG. Intraocular pressure decrease after phacoemulsification in patients with pseudoexfoliation syndrome. J Cataract Refract Surg 2001; 27:528–532 9. Shingleton BJ, Laul A, Nagao K, Wolff B, O’Donoghue M, Eagan E, Flattem N, Desai-Bartoli S. Effect of phacoemulsification on intraocular pressure in eyes with pseudoexfoliation: single-surgeon series. J Cataract Refract Surg 2008; 34: 1834–1841 10. Shingleton BJ, Nguyen BK, Eagan EF, Nagao K, O’Donoghue MW. Outcomes of phacoemulsification in fellow eyes of patients with unilateral pseudoexfoliation; singlesurgeon series. J Cataract Refract Surg 2008; 34:274–279 11. Shingleton BJ, Marvin AC, Heier JS, O’Donoghue MW, Laul A, Wolff B, Rowland A. Pseudoexfoliation: high risk factors for zonule weakness and concurrent vitrectomy during phacoemulsification. J Cataract Refract Surg 2010; 36:1261–1269 12. Shingleton BJ, Price RS, O’Donoghue MW, Goyal S. Comparison of 1-site versus 2-site phacotrabeculectomy. J Cataract Refract Surg 2006; 32:799–802 13. Shingleton BJ, Chaudhry IM, O’Donoghue MW, Baylus SL, King RJ, Chaudhry MB. Phacotrabeculectomy; limbus-based versus fornix-based conjunctival flaps in fellow eyes. Ophthalmology 1999; 106:1152–1155 14. Shingleton BJ, Chaudhry IM, O’Donoghue MW. Phacotrabeculectomy: peripheral iridectomy or no peripheral iridectomy? J Cataract Refract Surg 2002; 28:998–1002
15. Shingleton BJ, Pasternack JJ, Hung JW, O’Donoghue MW. Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients. J Glaucoma 2006; 15:494–498 16. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997; 13:388–391 17. Issa SA, Pacheco J, Mahmood U, Nolan J, Beatty S. A novel index for predicting intraocular pressure reduction following cataract surgery. Br J Ophthalmol 2005; 89:543–546. Available at: http:// www.pubmedcentral.nih.gov/picrender.fcgi?artidZ1772653& blobtypeZpdf. Accessed June 27, 2011 18. Poley BJ, Lindstrom RL, Samuelson TW. Long-term effects of phacoemulsification with intraocular lens implantation in normotensive and ocular hypertensive eyes. J Cataract Refract Surg 2008; 34:735–742 19. Suzuki R, Kuroki S, Fujiwara N. Ten-year follow-up of intraocular pressure after phacoemulsification and aspiration with intraocular lens implantation performed by the same surgeon. Ophthalmologica 1997; 211:79–83 20. Krupin T, Feitl ME, Bishop KI. Postoperative intraocular pressure rise in open-angle glaucoma patients after cataract or combined cataract-filtration surgery. Ophthalmology 1989; 96:579–584 21. Shingleton BJ, Alfano C, O’Donoghue MW, Rivera J. Efficacy of glaucoma filtration surgery in pseudophakic patients with or without conjunctival scarring. J Cataract Refract Surg 2004; 30:2504–2509
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First author: Bradford J. Shingleton, MD Private practice, Boston, Massachusetts, USA