Download Comparison of Combined Phacoemulsification, Intraocular Lens

ORIGINAL CLINICAL STUDY
Comparison of Combined Phacoemulsification,
Intraocular Lens Implantation, and Goniosynechialysis
With Phacotrabeculectomy in the Treatment of Primary
Angle-Closure Glaucoma and Cataract
Xiao-jing Zhao, MD,* Xiu-xia Yang, MD,* Yun-ping Fan, MD, PhD,Þ Bin-hui Li, MD,*
and Qin Li, MD, PhD*
Purpose: This study aimed to compare the efficacy and safety of
combined phacoemulsification, intraocular lens implantation, and
goniosynechialysis with phacotrabeculectomy in the treatment of
primary angle-closure glaucoma (PACG) and cataract.
Design: A comparative case series.
Methods: Sixty-five patients (65 eyes) with PACG and cataract from
the Fifth Affiliated Hospital of Sun Yat-Sen University were enrolled for
this study between October 2009 and July 2011. Of these, 33 underwent combined phacoemulsification, intraocular lens implantation, and
goniosynechialysis (treatment group), and 32 underwent phacotrabeculectomy
(control group). The effects on intraocular pressure, best-corrected visual acuity, anterior chamber angle, number of antiglaucoma medications, and complications were evaluated.
Results: Both the treatment group and the control group had lowered
intraocular pressure, reduced the use of antiglaucoma medications, and
improved vision in patients with PACG and cataract. Complications
were 8 (24.2%) of 33 in the treatment group and 12 (37.5%) of 32 in the
control group.
Conclusions: Combined phacoemulsification, intraocular lens implantation, and goniosynechialysis appears to be a preferred method for the
treatment of PACG and cataract because it seems to have the same efficacy
as phacotrabeculectomy and has much less surgical complications.
Key Words: phacoemulsification, goniosynechialysis, trabeculectomy,
primary angle-closure glaucoma, cataract
(Asia-Pac J Ophthalmol 2013;2: 286Y290)
P
rimary angle-closure glaucoma (PACG), a major cause for
blindness worldwide, refers to a disease of ocular anatomy
associated with papillary block and angle crowding or a combination of both.1 Cataract, a disease of older individuals, is
often concurrent with PACG in patients of old age. To our
knowledge, phacoemulsification and intraocular lens (IOL)
implantation can significantly reduce intraocular pressure (IOP)
of patients with PACG and coexisting cataract.2 Lens extraction alone and its replacement by a much thinner artificial IOL
will increase the anterior chamber depth (ACD); however, in
patients with chronic angle-closure glaucoma (CACG) or
From the Departments of *Ophthalmology, and †Otolaryngology, the Fifth
Affiliated Hospital of Sun Yat-sen University, Zhuhai, China.
Received for publication February 15, 2013; accepted May 2, 2013.
The authors have no funding or conflicts of interest to declare.
Reprints: Li Qin, MD, PhD, Department of Ophthalmology, the Fifth
Affiliated Hospital of Sun Yat-sen University, Zhuhai, China.
E-mail: [email protected].
Copyright * 2013 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.1097/APO.0b013e318299df62
286
www.apjo.org
extensive synechial angle closure, the angle may remain closed by
the peripheral anterior synechiae (PAS).3 Moreover, further surgery aimed to maintain IOP control was needed. Combined
phacoemulsification, IOL implantation, and trabeculectomy has
been proposed for the treatment of CACG.4 To date, combined
phacoemulsification, IOL implantation, and goniosynechialysis
has been applied in the treatment of PACG and cataract, and it is
effective for IOP control in PACG with more than 180 degrees
of peripheral anterior synechia.3 This procedure provided theoretical possibilities of high-quality visual rehabilitation, prevention of IOP spikes, and widening of the angles after lens
removal. In this study, we aimed to compare the efficacy and
safety of combined phacoemulsification, IOL implantation,
and goniosynechialysis with phacotrabeculectomy in the treatment of PACG and cataract.
MATERIALS AND METHODS
Patient Information
Sixty-five patients (65 eyes) from the Fifth Affiliated
Hospital of Sun Yat-Sen University with PACG and concurrent
cataract were recruited in this study between October 2008 and
July 2010, among which 25 were male and 40 were female,
respectively. They were assigned randomly for either combined
phacoemulsification, IOL implantation, and goniosynechialysis
(treatment group) or combined phacoemulsification, IOL implantation, and trabeculectomy (control group). Written informed
consent was obtained for all patients. Inclusion criteria included
(1) having PACG and visual disabling cataract; (2) best-corrected
visual acuity (BCVA) of 0.5 or worse; (3) synechial angle closure
occluding the trabeculum more than 180 degrees of the angle,
confirmed by indentation gonioscopy; (4) IOP greater than
22 mm Hg despite maximally tolerated antiglaucoma medication; (5) no history of ophthalmologic operation; and (6) no severe
systemic disease. Exclusion criteria included secondary glaucoma,
history of uveitis, ocular trauma, or other ocular disease.
Our study was approved by the clinical ethics committee of
the Fifth Hospital of Sun Yat-Sen University, and the informed
consent was obtained ahead from each of the patients.
The demographic and medical data of the patient’s groups
are analyzed in Table 1.
Preoperative Routine Eye Examination
Before surgery, all patients underwent a complete ophthalmologic examination, including BCVA, IOP, slit lamp examination, and fundus examination. Visual acuity was measured
with the Snellen visual chart. Contact A-scan biomicroscopy was
performed to calculate IOL power. Peripheral chamber depth was
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Volume 2, Number 5, September/October 2013
the intergroup analysis. P G 0.05 demonstrated significant
difference.
TABLE 1. Patient Information
Treatment
Group
Items
Comparative Study of 2 Ways to Treat PACG
Control Group
Patient no. (eyes)
33
32
Age, mean (SD)
69.6 (7.7) (53Y88) 69.69 (6.95) (51Y86)
(range), y
Male/female
12:21
13:19
Left eyes/right eyes
18:15
14:18
AACG/CACG
21:12
19:13
P
V
0.98
0.66
0.38
0.72
No significant difference was noted between the patient information
before the surgery (P 9 0.05).
determined using slit lamp examination. Gonioscopy was used to
determine the extent of goniosynechia. Ultrasound biomicroscopy
(UBM) was used to measure the central ACD and also to evaluate
the extent of goniosynechia.
Surgical Procedure
All preoperative antiglaucoma medications were continued
up until the operation. All surgical procedures were performed
by 1 experienced surgeon who is capable of dealing with both
cataract and glaucoma surgery. All patients received surgery
within 2 weeks after the acute primary angle closure attack.
In the treatment group, patients underwent combined
phacoemulsification, IOL implantation, and goniosynechialysis.
Topical anesthesia was used for these patients. Standard phacoemulsification was performed through a 3.2-mm clear corneal
track at the 11-o’clock position, followed by posterior chamber IOL implantation. Viscoelastic was injected into the anterior chamber to deepen the chamber and the angle. Three hundred
sixty degrees of the anterior chamber angle was stripped using
viscoelastic. The viscoelastic was washed out through the anterior chamber paracentesis wounds after the operation.
In the control group, retrobulbar anesthesia was used for all
the patients. 5Y0 silk bridal sutures were used to tract the superior rectus muscle. The surgery started with a limbus-based
conjunctival flap without using mitomycin C (MMC); phacoemulsification was performed through a 3.2-mm clear corneal
incision, and a posterior chamber IOL was implanted. Then,
trabeculectomy and iridectomy were performed. The scleral flap
was closed with two 10-0 nylon sutures and 2 releasable sutures
on both sides of the flap.
Postoperatively, Topical Tobradex (4 times daily; Tobradex,
Alcon-Couvreur, Belgium) was prescribed for 4 weeks, and the
antiglaucoma medications were adjusted according to the IOP
response.
Postoperative Routine Eye Examination
Patients were followed up the morning after surgery and
1 week, 1 month, 3 months, 6 months, and 12 months postoperatively. A complete ocular examination was performed each
time, including BCVA, IOP, slit lamp examination, and fundus
examination. Gonioscope and UBM were performed 3 months
(at the forth visit) after surgery to determine the ACD and the
extent of goniosynechia.
Statistical Analysis
Statistical analysis was performed with SPSS 13.0 Software (SPSS, Chicago, IL). Paired-sample t test was performed
within group. Independent-sample t test was performed for
* 2013 Asia Pacific Academy of Ophthalmology
RESULTS
Intraocular Pressure
Table 2 summarized the preoperative and postoperative
IOP in each group. In the treatment group, significant difference
was noted between preoperative and postoperative IOP (mean
[SD], 20.63 [5.41] vs 13.51 [2.96] mm Hg; P G 0.0001). In the
control group, significant difference was observed between preoperative and postoperative IOP (mean [SD], 20.58 [5.25] vs
12.73 [2.48] mm Hg; P G 0.0001). For the intergroup analysis,
no statistical difference was noted between the averaged IOP
at baseline level, 1 week, 1 month, 3 months, 6 months, and
12 months after follow-up (P 9 0.05, Table 3).
Table 4 summarized the preoperative and postoperative
IOP in the acute angle-closure glaucoma (AACG) group. In the
treatment group, significant difference was noted between preoperative and postoperative IOP (mean [SD], 21.64 [4.81] vs
14.16 [2.42] mm Hg; P G 0.0001). In the control group, significant difference was observed between preoperative and postoperative IOP (mean [SD], 20.89 [5.17] vs 13.41 [2.71] mm Hg;
P G 0.0001). Table 5 summarized the preoperative and postoperative IOP in the CACG group. In the treatment group,
significant difference was noted between preoperative and postoperative IOP (mean [SD], 19.96 [4.19] vs 13.28 [2.69] mm Hg;
P G 0.0001). In the control group, significant difference was
observed between preoperative and postoperative IOP (mean
[SD], 20.13 [4.83] vs 13.94 [2.39] mm Hg; P G 0.0001).
Best-Corrected Visual Acuity
For the 12 months of follow-up, BCVA improvements were
noted in 30 eyes (91%) and 29 eyes (90%) in the treatment
group and control group, respectively. Best-corrected visual
acuity less than 0.1 was noted in 2 patients, among which 1 was
diagnosed with branch retinal vein occlusion, the other was
found to have glaucomatous optic neuropathy (with vertical
cup-to-disc ratio equal to 1.0; Table 6).
Anterior Chamber Depth
Significant difference was noted between the preoperative
and postoperative central ACD in the treatment group (mean
[SD], 1.94 [0.22] vs 3.61 [0.27] mm; P G 0.001) and control
group (mean [SD], 1.92 [0.20] vs 3.65 [0.33] mm; P G 0.001),
respectively. The preoperative peripheral ACD was 1/4 corneal
thickness or less in 65 eyes. The postoperative iris bulge
disappeared in all eyes with peripheral ACD of 1 corneal
thickness or greater.
Chamber Angle
Gonioscope and UBM showed that the anterior chamber
angle was completely opened up in 14 eyes (42.4%) in the
TABLE 2. Comparison of Averaged IOP in Both Groups
Group
Preoperative Postoperative T Value
Treatment
20.63 (5.41)
group, mean
(SD), mm Hg
Control group,
20.58 (5.25)
mean (SD),
mm Hg
P
13.51 (2.96)
7.8119
G0.001
12.73 (2.48)
6.9269
G0.001
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Zhao et al
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Volume 2, Number 5, September/October 2013
TABLE 3. Changes of Postoperative IOP
Group
Treatment group, mean (SD), mm Hg
Control group, mean (SD), mm Hg
1d
1 wk
1 mo
3 mo
6 mo
12 mo
14.77 (2.23)
15.56 (2.25)
15.34 (3.00)
14.54 (3.55)
15.65 (3.30)
15.74 (4.38)
13.95 (3.75)
15.28 (4.61)
14.30 (3.51)
15.38 (4.11)
13.51 (2.96)
12.73 (2.48)
treatment group and in 9 eyes (28.1%) in the control group.
Significant difference was observed in the chamber angle
opening after intergroup analysis (P G 0.05). The condition
of anterior chamber angle before and after operation is listed
in Tables 7 and 8.
Primary angle-closure glaucoma, a major cause for blindness worldwide, is a disorder of ocular anatomy featured by
drainage angle closure. Treatment is aimed at opening the anterior drainage angle and lowering the IOP with medical and/or
surgical treatment. Various surgery procedures have been advocated for the treatment. Trabeculectomy is conventionally
used to reduce IOP in patients with PACG. Recent evidence
indicates that combined trabeculectomy and cataract extraction
has the same IOP-lowering effect and surgical complication but
incurred fewer subsequent surgical intervention when compared with trabeculectomy alone.5 Cataract extraction alone (by
phacoemulsification) also has been proven to significantly reduce both IOP and the requirement for glaucoma medications in
patients with PACG with coexisting cataract.6
For the patients with PACG with coexisting cataract and
goniosynechia (Q180 degrees), combined phacoemulsification,
IOL implantation, and trabeculectomy was preferred in clinical practices because it can release the drainage angle and reduce IOP simultaneously. Its theoretical advantages included
high-quality visual rehabilitation, prevention of IOP spikes, and
widening of the angles after lens removal. However, the surgery
procedure is complex and may be associated with more risk
of postoperative complications. To our knowledge, phacoemulsification and IOL implantation change the anterior chamber
angle width and depth, whereas the anterior chamber angle
remains closed. Goniosynechialysis strips the PAS from the
angle wall so as to open the angle and restore trabecular function and can be an effective supplementary procedure for
phacoemulsification. So phacoemulsification, IOL implantation, and goniosynechialysis can also be a better option for
the treatment of patients with PACG with coexisting cataract
and goniosynechia (Q180 degrees). Lai et al6 reported that
phacoemulsification with IOL implantation combined with inferior 180-degree goniosynechialysis followed by diode laser
peripheral iridoplasty is an effective and safe procedure for
the treatment of CACG with total synechial angle closure
and cataract.4 In the study, 7 eyes with a mean (SD) IOP of
33.0 (4.8) mm Hg were included. The mean follow-up was
8.9 months (range, 2Y16 months). The mean (SD) postoperative
IOP reduced to 13.3 (2.9) mm Hg with an absolute successful
rate of 100%. The visual acuity of all 7 eyes improved by more
than 2 Snellen lines. Postoperative UBM showed that the superior angle, where no goniosychialysis was performed, remained
closed. In contrast, the inferior angle in all patients was opened
up by the goniosynechialysis. This confirms the necessity of
goniosynechialysis in patients with angle-closure glaucoma during cataract surgery. In 2010, Fang et al7 reported a new surgical
technique for optimized visualization of the chamber angle
using ophthalmic microendoscope in goniosynechialysis. In the
study, 12 eyes were included and underwent the aforementioned
procedure with a mean (SD) follow-up of 7.4 (1.38) months.
The mean (SD) preoperative and postoperative IOP were 42.89
(15.81) mm Hg and 12.72 (3.48) mm Hg, respectively. The
mean (SD) preoperative and postoperative PAS were 202.5
[111.61] and 92.15 [130.39], respectively. In another study,
56 eyes of 45 patients with CACG were divided into the controlled group (IOP G 21 mm Hg) and the uncontrolled group
(IOP 9 21 mm Hg). After phacoemulsification and goniosynechialysis,
TABLE 4. Comparison of Averaged IOP in AACG Groups
TABLE 5. Comparison of Averaged IOP in CACG Groups
Use of Hypotensive Agents
Before the surgery, hypotensive agents used included a
combination of topical A-blockers, brimonidine, carbonic anhydrase inhibitors and additional systemic hyperosmotic agent
(intravenous mannitol) and carbonic anhydrase inhibitors
(methazolamide 25 mg 3 times a day). After surgery, systemic
hypotensive agents were used only for IOP spike control. Topical
agents were significantly decreased in the treatment group and the
control group compared with their baseline levels (mean [SD],
0.64 [1.41] vs 3.70 [0.99]; 0.59 [1.24] vs 3.84 [0.88]; P G 0.001).
Complications
No complications occurred during the surgery in either
group. Seven patients in the treatment group had postoperative
complications, including 1 case of day 1 IOP spike, 4 cases of
severe fibrous exudates, and 3 cases of sever corneal edema.
Postoperative complications in the control group included
4 cases of day 1 IOP spike, 2 cases of hyphema, 1 case of fibrous exudates, 4 cases of corneal edema, and 1 case for IOL
decentration. Except for IOL decentration that required additional surgery, all other complications were resolved using
medication without surgical intervention.
DISCUSSION
Group
Preoperative Postoperative T Value
Treatment
21.64 (4.81)
group, mean
(SD), mm Hg
Control group,
20.89 (5.17)
mean (SD),
mm Hg
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P
14.16 (2.42)
7.6322
G0.001
13.41 (2.71)
7.0175
G0.001
Group
Preoperative Postoperative T Value
Treatment
19.96 (4.19)
group, mean
(SD), mm Hg
Control group,
20.13 (4.83)
mean (SD),
mm Hg
P
13.28 (2.69)
6.7614
G0.001
13.94 (2.39)
6.5486
G0.001
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TABLE 6. Distribution of Postoperative BCVA 12 Months
After Treatment
Treatment Group (n = 33)
BCVA Preoperative
G0.1
0.1Y0.2
0.3Y0.4
0.5Y0.6
0.7Y0.8
Q1.0
TABLE 8. Goniosynechia in the Control Group Before and
After Operation
Control Group (n = 32)
Postoperative
Postoperative
12 mo
Preoperative
12 mo
3
26
4
0
0
0
1
9
13
3
4
3
4
22
6
0
0
0
1
7
15
2
4
3
the mean (SD) IOP of the controlled group decreased from 16.7 (2.9)
to 14.4 (2.9) mm Hg, whereas that of the uncontrolled group
decreased from 27.95 (8.1) to 15.5 (2.8) mm Hg. The absolute
success rate for the controlled group was 40%, whereas that
of uncontrolled group was 38.1%.8 Except for the study of Lai
et al, all the previous studies had limited goniosynechialysis. In
our study, we specially analyzed patients with PAS more than
180 degrees of the angle, success rate for the phacoemulsification
and goniosynechialysis was 81.8% in all the eyes. We speculate
that this might be associated with the fact that goniosynechialysis
was effective for the treatment of AACG, whereas in our research,
we studied both CACG and AACG.
Pupillary block was considered the main pathogenesis for
angle-closure glaucoma, among which the dimensions of irislens channel played an important role in the flow of aqueous
fluid from the posterior chamber to the anterior chamber.9 To
implant an IOL with thinner profile instead of a pathologic
thickened one is suitable for the elimination of papillary block
in theory. To date, several attempts have been made, among
which combined phacoemulsification, IOL implantation, and
trabeculectomy was not preferred because trabeculectomy was
associated with high risk of postoperative complications including shallow anterior chamber and malignant glaucoma. In
a retrospective study, Acton et al10 reported that cataract and
trabeculectomy surgery may not be necessary to achieve longterm IOP control because cataract extraction with IOL implantation resulted in good long-term IOP control with these
patients. With the development of micro-operative technique
and the application of viscoelastic agent, complete goniosynechialysis can be obtained through phacoemulsification plus
goniosynechialysis, based on which complete opening of the
chamber angle was possible.
In this study, we aimed to compare clinical efficiency and
safety of combined phacoemulsification, IOL implantation, and
goniosynechialysis with phacotrabeculectomy in the treatment
of PACG and cataract, especially in the treatment of those with
TABLE 7. Goniosynechia in Treatment Group Before and
After Operation
Open
e90
990 e 180 9180 e 270 9270
angle Degrees Degrees
Degrees
Degrees
Group
Before
operation
After
operation
0
0
0
15
18
14
12
4
3
0
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Comparative Study of 2 Ways to Treat PACG
Group
Before
operation
After
operation
Open
e90
990 e 180 9180 e 270 9270
Angle Degrees Degrees
Degrees Degrees
0
0
0
12
20
9
6
11
3
3
anterior chamber occluded more than 180 degrees. The use of
MMC in phacotrabeculectomy is controversial. Some studies
have shown lower IOPs with MMC use. Budenz et al11 found
similar IOP control with and without MMC. We have been
using MMC in cases of phacotrabeculectomy where patients are
young teenagers. In this study, the mean age of our patients is
69.7 years, so we chose to carry our phacotrabeculectomy
without MMC. A total of 7 of 33 eyes in the treatment group
and 12 of 32 eyes in the control group experienced postoperative complications. The high complication rate of our study is
perhaps caused by the high percentage of patients with AACG
(61.5%). In the treatment group, we had 4 cases of severe fibrous exudate; this may be because they all recently had acute
primary angle closure, which took high risk of operating in
these acutely inflamed eyes. To our knowledge, postoperative
IOP was strongly associated with the open angle and the function of trabecular meshwork. Compared with the phacotrabeculectomy group, no significant difference was noted between
the postoperative IOP, BCVA, and the use of antiglaucoma
medications in patients who underwent combined phacoemulsification, IOL implantation, and goniosynechialysis. However,
significant improvement of goniosynechia was noted in patients
who underwent combined phacoemulsification, IOL implantation, and goniosynechialysis.
In conclusion, for those patients with PACG with coexisting cataract and severe goniosynechia (9180 degrees),
phacoemulsification and goniosynechialysis are a safe and effective method for IOP control and can be considered a first
treatment option. Trabeculectomy can be an additional surgery
if unsatisfactory IOP control was occurred after phacoemulsification plus goniosynechialysis.
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"The soul, fortunately, has an interpreter - often an unconscious but still a faithful interpreter - in the eye."
V Charlotte Brontë, Jane Eyre
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