ArticleLiterature Review

The Effects of Phacoemulsification on Intra-Ocular Pressure and Topical Medication Use in Patients with Glaucoma: A Systematic Review and Meta-Analysis

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Abstract

PURPOSE. For patients with co-morbid cataract and primary open angle glaucoma (POAG), guidance is lacking as to whether cataract extraction and traditional filtering surgery should be performed as a staged or combined procedure. Achieving this guidance requires an evidence-based understanding of the effects of phacoemulsification alone on intraocular pressure (IOP) in patients with POAG. For this reason, a systematic review and meta-analysis was undertaken to synthesize evidence quantifying the effect of phacoemulsification on IOP and the required number of topical glaucoma medications in patients with cataract and POAG. METHODS. Database searches were last run on August 15, 2016 to identify potentially relevant studies. Identified articles were screened for relevance and meta-analysis was used to compute post-operative mean and percentage reduction in IOP (IOPR%) as well as mean difference in topical glaucoma medications. RESULTS. The search strategy identified 1613 records. Thirty-two studies (1826 subjects) were included in quantitative synthesis. A 12%, 14%, 15% and 9% reduction in IOP from baseline occurred six, 12, 24 and 36 months after phacoemulsification. A mean reduction of 0.57, 0.47, 0.38 and 0.16 medications per patient of glaucoma medication occurred 6, 12, 24 and 36 months after phacoemulsification. CONCLUSIONS. Phacoemulsification as a solo procedure does lower IOP in patients with POAG, and reduces dependency on topical glaucoma medications. These effects appear to last at least 36 months with gradual loss of the initial effect noted after two years. Certain populations appear to experience much greater reductions in IOP than others and future work to identify these high responding patients is needed.

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... In healthy people undergoing cataract surgery, the average reduction in IOP was 1.0-4.0 mmHg [12][13][14]; in individual studies the effect was slightly higher [15]. The degree of IOP reduction has been shown to be proportional to the baseline value [13,15,16]. ...
... In patients with POAG, similar analyses of long-term effects showed a slightly different IOP reduction one year after the procedure: by 1.15 ±3 mmHg (6.8 ±18.1%) [17], by 1.0 ±5.5 [12], or by 13% [18]. A large metaanalysis found that the mean reduction in IOP noted at 6, 12, 24 and 36 months after the surgery was 12%, 14%, 15% and 9% from the baseline, respectively [14]. Similarly to healthy subjects, the reduction of IOP in patients with POAG was proportionally greater in patients with higher baseline IOP. ...
... A total of 7.2% patients required additional glaucoma medications, and in 75.7% of patients with POAG the number of medications remained unchanged [17]. Reducing the dependence on glaucoma medications limits their adverse effects on the ocular surface [14], leading to improved patient comfort and potentially increasing therapeutic compliance. ...
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Aim of the study Evaluation of ab interno goniotomy using a Kahook Dual Blade in combination with phacoemulsification in patients with primary open angle glaucoma during a 6-month follow-up. Material and methods 75 patients with mild and moderately advanced primary open angle glaucoma, who had phacoemulsification combined with ab interno goniotomy using a Kahook Dual Blade (New World Medical, USA), were included in this analysis. The average age was 68.4 ±8.9 years. Mean pre- and postoperative intraocular pressure, number of antiglaucoma medications, complications of the surgery and need for another procedure were analysed in the 6-month follow-up. Results Before the surgery, mean intraocular pressure was 21.9 ±3.9 mmHg and the number of antiglaucoma medications was 2.2 ±1.2. A reduction in intraocular pressure of 17.53% and a decrease in number of antiglaucoma medications of 60% (p < 0.001) were observed in the 6-month follow-up. There was slight intra-operative bleeding into the anterior chamber from the incision in all cases. On the first days after surgery there were diffuse blood cells or a clot in the anterior chamber in 38% of eyes. Increase in intraocular pressure above 25 mmHg on the first day after surgery was observed in 30.6% of eyes. In one eye there was no postoperative intraocular pressure stabilisation and laser cyclodestruction was performed. Conclusions Ab interno goniotomy performed simultaneously with phacoemulsification results in a significant reduction in intraocular pressure and a decrease in the number of anti-glaucoma drugs used. The treatment is characterized by a good safety profile and does not require intensive postoperative management.
... [6,9] Although not as much as in ACG eyes, phacoemulsification has also been shown to provide a decrease in IOP in eyes with open-angle glaucoma (OAG). [10,11] Higher preoperative IOP level, smaller anterior chamber depth (ACD) and greater ratio of preoperative IOP/ACD (PD ratio) were found to be predictors of greater IOP drop after surgery. [12,13] In addition to these biometric parameters, recent studies found axial length (AL), lens thickness (LT), lens vault, and lens position (LP) to be associated with the IOP change following cataract surgery. ...
... Recent years saw an increase in publications over the efficacy of phacoemulsification surgery in eyes with OAG. [5,7,11,[14][15][16] There seem to be 2 major reasons accounting for such growing interest in this issue. First, the proven efficacy of phacoemulsification as a surgical treatment for angle-closure glaucoma generated clinical interest in its potential efficacy in other types of glaucoma. ...
... [6,9] Although small in its magnitude, most studies have demonstrated that phacoemulsification effectively reduces IOP in eyes with POAG. [10,11] Another reason is a growing popularity of Table 2 Association of various predictors of intraocular pressure (IOP) change (using % IOP change at 3 months as the dependent variable). The estimated coefficients in the univariate results were obtained after adjusting for the only effect of laterality in the general linear mixed models. ...
Article
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To investigate the relationship between glaucoma severity and intraocular pressure (IOP) reduction after cataract surgery in patients with medically controlled primary open-angle glaucoma (POAG).Retrospective case series.This study included glaucoma suspects (GS) and POAG patients who underwent cataract surgery and continued to use the same glaucoma medications during the postoperative period of 4 months. The main outcomes were percent and absolute IOP changes calculated using the preoperative IOP and the postoperative IOP at 3 months. Preoperative glaucoma medications, preoperative IOP, demographic information, biometric parameters and variables for glaucoma severity were evaluated as potential predictors of IOP change.The average IOP reduction was 3.3 ± 2.4 mmHg (20.0%) and 2.2 ± 2.5 mmHg (13.1%) from the preoperative mean of 16.0 ± 2.9 mmHg and 15.2 ± 3.3 mmHg in the GS and POAG groups, respectively. Preoperative IOP, preoperative IOP/anterior chamber depth (preoperative IOP/ACD [PD ratio]) and preoperative IOP/retinal nerve fiber layer (RNFL) thickness (preoperative IOP/RNFL [PNFL ratio]) and preoperative IOP score x MD score x number of glaucoma medications (glaucoma index) predicted absolute IOP change in the POAG group, whereas preoperative IOP, PD ratio, PNFL ratio, and axial length (AL) did in the GS group. Preoperative IOP, PD ratio, and PNFL ratio predicted %IOP change in the POAG group, whereas only AL did in the GS group.In medically controlled POAG eyes, structural or functional parameters for glaucoma severity did not independently predict IOP change following phacoemulsification. However, novel severity indices obtained by addition of preoperative IOP and/or glaucoma medications to the structural or functional parameter predicted IOP changes.
... S everal studies reported a change in intraocular pressure (IOP) after intraocular surgery. Most of them focused on cataract extraction (CE), the most performed type of surgery in the world [1][2][3][4][5] . Trans pars plana vitrectomy (TPPV) is another type of intraocular surgery that is performed regularly in the ophthalmic practice. ...
... Although less is known about the change in IOP after TPPV than after CE, studies have shown that vitrectomy causes an elevation of 5%-35% of the IOP postoperatively [6][7][8] . In patients who underwent CE the IOP decreased significantly, ranging from 14.2% to 21.1% at one month follow-up [2][3][4][5] . Also, after CE the number of IOPlowering medications was decreased in glaucoma patients [4,9] . ...
... In patients who underwent CE the IOP decreased significantly, ranging from 14.2% to 21.1% at one month follow-up [2][3][4][5] . Also, after CE the number of IOPlowering medications was decreased in glaucoma patients [4,9] . Patients with a high preoperative IOP or patient who develop a deep anterior chamber postoperatively tend to have a greater reduction in postoperative IOP, respectively 3.7±2.5 mm Hg and 2.3±1.0 mm Hg [10][11][12][13][14] . ...
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Aim: To investigate the changes in intraocular pressure (IOP) before and after intraocular surgery measured with Goldmann applanation tonometry (GAT) and pascal dynamic contour tonometry (PDCT), and assessed their agreement. Methods: Patients who underwent trans pars plana vitrectomy (TPPV) with or without cataract extraction (CE) were included. The IOP was measured in both eyes with GAT and PDCT pre- and postoperatively, where the non-operated eyes functioned as control. Results: Preoperatively, mean IOP measurements were 16.3±6.0 mm Hg for GAT and 12.0±2.8 mm Hg for PDCT for the operated eyes. Postoperatively, the mean IOP dropped to 14.3±5.6 mm Hg for GAT (P=0.011) and rose up to 12.7±2.6 mm Hg for PDCT (P=0.257). Bland-Altman analysis showed a poor agreement between GAT and PDCT with a mean difference of 2.9 mm Hg preoperatively and 95% limits of agreement ranging from -3.2 to 9.0 mm Hg. Postoperatively, the mean difference was 1.2 mm Hg with 95% limits of agreement ranging from -8.3 to 10.7 mm Hg. There were no significant differences between the TPPV and TPPV+CE group, except when measured with PDCT postoperatively (P=0.012). Conclusion: The IOP is reduced after surgery when measured with GAT and remained stable when measured with PDCT. However, the agreement between GAT and PDCT is poor. Although PDCT may be a more accurate predictor of the true IOP, it seems less suitable for daily use in the clinical practice.
... Segundo a revisão sistemática desenvolvida por Armstrong et al. (2017), a cirurgia de catarata apresenta uma redução temporária na PIO, mas ela volta a subir após três anos. Os resultados demonstraram que a redução da PIO em relação à PIO inicial foi de 12%, 14%, 15% e 9%, depois de 6, 12, 24 e 36 meses após a cirurgia de catarata (Armstrong et al., 2017). ...
... Segundo a revisão sistemática desenvolvida por Armstrong et al. (2017), a cirurgia de catarata apresenta uma redução temporária na PIO, mas ela volta a subir após três anos. Os resultados demonstraram que a redução da PIO em relação à PIO inicial foi de 12%, 14%, 15% e 9%, depois de 6, 12, 24 e 36 meses após a cirurgia de catarata (Armstrong et al., 2017). ...
... A retrospective analysis of iStent implantation in pseudophakic eyes found mean IOP reductions of 19% and medication reductions of 13% at 12 months, although this device is not approved for stand-alone implantation in the USA [19]. Other angle-based procedures have been reported in combination with cataract surgery, but their results are not comparable to this stand-alone study in which all observed IOP and medication reductions are directly attributable to the procedure itself and not to the known effects of cataract surgery on IOP and medication reduction [20]. Goniotomy with the KDB addresses the primary cause of elevated IOP and removes the obstruction to aqueous outflow at the level of the diseased TM, thus re-establishing the normal flow of aqueous into Schlemm's canal and the distal outflow pathway. ...
... Cataract surgery alone is known to reduce both IOP and the need for IOPlowering medications in eyes with glaucoma. In a recent meta-analysis, the mean IOP reduction seen in eyes with glaucoma 6 months after cataract surgery was 12% and the reduction in mean number of IOP-lowering medications used was 0.6 [20]. Thus, in studies of glaucoma procedures combined with cataract surgery, it is difficult to assess the relative contribution of each procedure on the final outcome. ...
Article
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Introduction To characterize the reduction in intraocular pressure (IOP) and IOP-lowering medication use following goniotomy via trabecular meshwork excision performed using the Kahook Dual Blade as a stand-alone procedure in adult eyes with glaucoma uncontrolled on a regimen of 1–3 topical IOP-lowering medications. Methods In this retrospective analysis, data from consecutive patients undergoing goniotomy with the Kahook Dual Blade by 11 surgeons were analyzed. Preoperative, intraoperative, and postoperative follow-up data through 6 months of follow-up were collected. The primary efficacy endpoint was IOP reduction from preoperative baseline; reduction in IOP-lowering medication use was a secondary endpoint. Results Data were collected from 53 eyes of 42 subjects. Mean (± SE) preoperative IOP was 23.5 ± 1.1 mmHg, and from day 1 through 6 months of postoperative follow-up mean IOP reductions of 7.0–10.3 mmHg (29.8–43.8%; p < 0.001 at each time point) were observed. Mean preoperative medication use was 2.5 ± 0.2 medications per eye and was reduced by month 6 to 1.5 ± 0.2 (a 40.0% reduction; p < 0.05). Eyes with higher baseline IOP experienced mean IOP reductions of 13.7 mmHg (− 46.4%) at month 6, while eyes with lower baseline IOP experienced mean IOP reductions of 3.8 mmHg (− 21.0%) at month 6. Mean medications were reduced by 1.3 medications in high-IOP eyes and by 0.9 in low-IOP eyes at month 6. No significant sight-threatening adverse events were observed. Conclusions Goniotomy via trabecular meshwork excision performed using the Kahook Dual Blade effectively and safely lowered IOP when performed as a stand-alone procedure in eyes with glaucoma. The significant drop in IOP met or exceeded the recommended targets for these glaucoma patients. Funding New World Medical, Inc.
... Finally, cataract surgery alone is known to transiently reduce both IOP and the need for IOP-lowering medications in medically treated glaucoma patients. A recent meta-analysis revealed that the average magnitude of these reductions expected at 12 months from cataract surgery alone is 14% for IOP and 0.47 for IOP-lowering medications [18]. In our series, mean reductions of 26.2% and 0.8%, respectively, were observed. ...
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Introduction: To describe the 12-month efficacy and safety of goniotomy performed using the Kahook Dual Blade (KDB) in combination with cataract surgery in eyes with medically treated open-angle glaucoma (OAG). Methods: This was a prospective, interventional case series conducted at seven centers in North America. Consecutive patients with medically treated OAG and visually significant cataract underwent phacoemulsification combined with goniotomy (PE + goniotomy) using KDB. Indications for glaucoma surgery included reduction of intraocular pressure (IOP) and reduction of IOP-lowering medications. De-identified data were collected and included pre-, intra-, and postoperative data on IOP, the use of IOP-lowering medications, and adverse events through 12 months of follow-up. Results: Among 52 eyes undergoing surgery, mean IOP was reduced from 16.8 ± 0.6 mmHg at baseline to 12.4 ± 0.3 mmHg at month 12 (P < 0.001), a 26.2% reduction. Mean IOP across time points ranged from 12.4-13.3 mmHg during follow-up. The mean number of topical IOP-lowering medications was reduced from 1.6 ± 0.2 at baseline to 0.8 ± 0.1 at month 12 (P < 0.05), a 50.0% reduction. At month 12, 57.7% of eyes had IOP reduction ≥ 20% from baseline, and 63.5% were on ≥ 1 fewer IOP-lowering medications. In subgroup analysis, 84.6% of eyes with lower mean baseline IOP were using ≥ 1 fewer medications at month 12, and 100% of eyes with higher mean baseline IOP had IOP reductions ≥ 20%. The most common postoperative adverse events were pain/irritation (n = 4, 7.7%), opacification of the posterior lens capsule (n = 2, 3.8%), and IOP spike > 10 mmHg (n = 2, 3.8%). Conclusion: PE + goniotomy using the KDB significantly lowers both IOP and dependence on IOP-lowering medications in eyes with OAG. Adverse events were not sight-threatening and typically resolved spontaneously. Funding: New World Medical, Inc.
... The success rate was also similar if we excluded the phaco-Xen cases, with 33 and 71% of cases meeting the most strict (IOP ≤ 15 mmHg and ≥ 6 mmHg and ≥ 20% reduction from baseline with no drops) and least strict (IOP ≤ 21 mmHg and ≥ 6 mmHg and ≥ 20% reduction from baseline with or without drops), respectively. In addition a recent review and metaanalysis examining the effect of phaco alone on IOP in glaucoma patients concluded that at 1 year post phacoemulsification the mean percentage drop in IOP in glaucoma patients was only 14.4% [17]. Further research is needed to the relative effectiveness of phaco-Xen and Xen without phaco. ...
Article
To describe the 12-month outcomes of the Xen45 glaucoma stent. Non-comparative retrospective study of all cases who underwent Xen glaucoma surgery in April 2017 or earlier and completed 12 months of follow-up. The primary outcome measures were intraocular pressure (IOP) reduction and number of glaucoma medications at 12 months postoperatively. The secondary outcome measures were surgical complications and the success rate of surgery at 1 year. Success rate was defined according to the multiple IOP thresholds of 15 mmHg, 18 mmHg, and 21 mmHg with all requiring a drop of 20% and no additional glaucoma surgery. Revision or needling of the Xen conjunctival bleb was not considered to constitute a surgical failure. Sixty-eight eyes were included in the study. Mean IOP dropped from 22.1 mmHg preoperatively to 14.8 mmHg at 12 months, a 33% drop (p < 0.0001). Mean number of glaucoma medications reduced from 2.9 preoperatively to 1.1 at 12 months (p < 0.0001). In total, 54.4% of cases were back on glaucoma medications by 12 months. Success rate varied from 32.4% when defined as IOP ≤ 15 mmHg and ≥ 6 mmHg and ≥ 20% reduction without medications to 70.6% when defined as IOP ≤ 21 mmHg and ≥ 6 mmHg and ≥ 20% reduction with or without medications. Thirty cases (44.1%) required bleb needling or surgical revision. The Xen45 is effective at reducing IOP and glaucoma medication use at 12 months postoperatively. Patients considering this procedure should be warned that by 12 months postoperatively there is a significant chance of requiring postoperative bleb intervention and glaucoma drops.
... Several studies have shown that cataract extraction plays a crucial role in the controlling intraocular pressure (IOP) in comorbid glaucoma. [1][2][3][4] A recent large clinical trial showed that clear lens extraction was more efficacious in IOP control and more cost-effective than laser peripheral iridotomy, and it has been suggested as a first-line treatment for primary angle-closure glaucoma (PACG). [5] However, the role of phacoemulsification in treating primary open-angle glaucoma (POAG) remains controversial. ...
Article
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To determine whether cataract or glaucoma and combined cataract and glaucoma surgery (CGS) affect glaucoma medication usage.We recruited patients who received new diagnoses of glaucoma, either primary open-angle glaucoma (POAG) (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 365.1) or primary angle-closure glaucoma (PACG) (ICD-9-CM code 365.2), between 1998 and 2011 and had undergone cataract surgery alone (CS), glaucoma surgery alone (GS), or CGS under the National Health Insurance program in Taiwan. CS, GS, and CGS in all the patients were performed after the glaucoma diagnosis date. The patients were subdivided into CS, CGS, and GS groups. The number of glaucoma medications, including prostaglandin analogs, β-blockers, carbonic anhydrase inhibitors, α-agonists, pilocarpine, and a combination of drugs, in each prescription, were compared before and after surgery.The mean number of glaucoma medications in each prescription before the surgery increased from approximately 0.5/1 (CS/CGS + GS) to a peak of 1.75/3 within 3 months before the index date. The mean number of glaucoma medications in each prescription reduced to 0 (CS group) and to approximately 0.5 (CGS and GS) at the end of the 3-year follow-up period. The mean number of glaucoma medications in each prescription significantly reduced at the time points within 6 months, between 6 months and 2 years, and during 2 to 3 years after surgery in each group. At the end of the 3-year period, the reduction effect was most evident in the CS group. Similar trends were also observed in the POAG and PACG group.CS, GS, and CGS significantly reduced the number of glaucoma medications used by the glaucoma patients.
... IOP is a well-recognized risk factor for the development and progression of glaucoma and remains the only modifiable risk factor in glaucoma treatment. 3,[29][30][31] In agreement with previous studies, [32][33][34][35] all IOP parameters had a significant and sustained improvement after cataract surgery; however, the measured rate of glaucoma progression surprisingly did not slow. In the present study, postoperative peak IOP was significantly associated with postoperative rates and the change in rates compared with the preoperative period. ...
Article
PURPOSE: To test the hypothesis that cataract surgery slows the apparent rate of visual field (VF) decay in primary open-angle glaucoma patients compared with rates measured during cataract progression. DESIGN: Retrospective cohort study. METHODS: Consecutive open-angle glaucoma patients who underwent cataract surgery and who had ≥4 VFs and ≥3 years of follow-up before and after surgery were retrospectively reviewed. Mean deviation (MD) rate, visual field index (VFI) rate, pointwise linear regression (PLR), pointwise rate of change (PRC), and the Glaucoma Rate Index (GRI) were compared before and after cataract surgery. RESULTS: 134 eyes of 99 patients were included. Median (interquartile range) follow-up was 6.5 (4.7-8.1) and 5.3 (4.0-7.3) years before and after cataract surgery, respectively. All intraocular pressure (IOP) parameters (mean IOP, SD of IOP, and peak IOP) significantly improved (p<0.001) after cataract surgery. All VF indices indicated an accelerated VF decay rate after cataract surgery: MD rate (-0.18±0.40 dB/year vs. -0.40±0.62 dB/year, p<0.001), VFI rate (-0.44±1.09%/year vs. -1.19±1.85%/year, p<0.001), GRI (-5.5±10.8 vs. -13.5±21.5; p<0.001), and PRC (-0.62±2.47%/year before and -1.35±3.71%/year after surgery; p<0.001) and PLR (-0.20±0.82 dB/year before and -0.42±1.16 dB/year after surgery; p<0.001) for all VF locations. Worse baseline MD and postoperative peak IOP were significantly associated with the postoperative VF decay rate and the change in the decay rate after cataract surgery. CONCLUSION: Although all IOP parameters improved after cataract surgery, VFs continued to progress. Cataract surgery does not slow the apparent rate of glaucomatous VF decay as compared to rates measured during the progression of the cataract.
... 33,34 Comparisons with outcomes of devices implanted in conjunction with cataract surgery are not applicable, because cataract surgery alone can reduce both IOP and the need for IOP-lowering medications in glaucomatous eyes. 35 In the current study, the MINIject was implanted in a standalone procedure; thus, all IOP reduction and reduction of medication use is attributable to the device alone. ...
Article
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Purpose To describe the safety and efficacy of a novel, supraciliary, microinvasive glaucoma surgery drainage system, MINIject (iSTAR Medical, Wavre, Belgium), in the study. Design Prospective, multicenter, interventional, single-arm trial. Participants Twenty-six patients with primary open-angle glaucoma uncontrolled with 1 or more intraocular pressure (IOP)-lowering medications. Methods Using an ab interno approach, 25 eyes were implanted successfully in a stand-alone procedure with a 5-mm long device made of biocompatible STAR material, which is soft and flexible silicone in a microporous, network design. Intraocular pressure, medication use, and other ocular parameters were evaluated before surgery, 1 day, 1 and 2 weeks, and 1, 3, and 6 months after surgery. Main Outcome Measures Intraocular pressure reduction at 6 months compared with baseline analyzed using a paired t test. Safety evaluation entailed tabulation of the nature and frequency of adverse events. Results Mean baseline diurnal IOP was 23.2 mmHg (standard error, 0.6 mmHg) using a mean ± standard deviation of 2.0±1.1 IOP-lowering medication classes. During the 6-month follow-up period, mean IOP ranged from 10.0–16.3 mmHg (mean reductions, 6.9–13.2 mmHg or 31.0%–56.8%). Six months after surgery, mean diurnal IOP was 14.2 mmHg (standard error, 0.9 mmHg), equivalent to a reduction of 9.0 mmHg or 39.1% (P < 0.0001). The mean ± standard deviation number of IOP-lowering medications was 0.3±0.7. Of 24 patients seen at 6-month follow-up, 21 (87.5%) were medication-free and 23 (95.8%) achieved a minimum 20% IOP reduction from baseline. There were no serious adverse events related to the device or procedure, and no additional glaucoma surgery was required. Frequently reported events included anterior chamber inflammation (n = 8), IOP elevation (n = 6), of which 1 event was an IOP spike per protocol, visual acuity reduction (n = 3), and hyphema (n = 3), all of which resolved. There was no change to mean central or peripheral corneal endothelial cell density. No device-related adverse events were reported. Conclusions The MINIject glaucoma drainage system significantly lowered IOP and eliminated the need for medication in most patients 6 months after surgery when implanted in a standalone procedure. There were no serious ocular adverse events.
... One possible explanation for this lack of studies is the achievement of sufficient reduction of IOP reduction or the number of medications needed is considered to be difficult in the absence of phacoemulsification. It is widely known that cataract surgery itself has a lowering effect on IOP and the number of medications needed in glaucoma patients [24][25][26][27][28][29][30]. However, a consensus has not been reached regarding the indications for this type of surgery. ...
Article
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The purpose of the study was to evaluate the 12-month surgical outcome and prognostic factors of stand-alone ab interno trabeculotomy. The changes in the intraocular pressure (IOP) and medication score and the success rate of the surgery were analyzed. Thirty-four eyes of 29 patients with primary open-angle glaucoma (POAG; n = 16) or pseudoexfoliation glaucoma (PEG; n = 18) with a 12-month follow-up period were included in the study. The decreases in IOP and medication score from the baseline to the all-time-point were statistically significant ( P < 0.001). The surgical success rates were 97.1%, 76.5%, and 44.0% at 3 months (90 days), 6 months (180 days), and 12 months (365 days), respectively. A mixed effect Cox model revealed that the type of glaucoma (POAG) was significantly associated with surgical failure ( P = 0.044). Furthermore, the surgical success rate was significantly higher in eyes with PEG than it was in those with POAG ( P = 0.019). Stand-alone ab interno trabeculotomy significantly lowered both the IOP and the medication score in patients with glaucoma, although almost one quarter of the cases needed additional glaucoma surgeries. The surgical success rate was significantly higher in eyes with PEG than it was in those with POAG.
... A review of recent literature reveals that cataract surgery in glaucoma patients (not involving washout of IOP-lowering medications) was associated with a reduction in IOP ranging between 0.6-2.5 mmHg at 1 year. [22][23][24] The 360° ab-interno canal viscodilation efficiently meets all the cardinal features of MIGS3 it is a safe, abinterno, micro-incisional approach to lowering IOP and medication use with minimal anatomical and physiological disruption. In this case series, ab-interno canal viscodilation demonstrated reliable IOP lowering and medication reduction with a good safety profile. ...
Article
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Purpose: To evaluate the safety and effectiveness of ab-interno microcatheterization and 360° viscodilation of Schlemm's canal (SC) using the VISCO360® Viscosurgical System in treatment of primary open angle glaucoma (POAG). Setting: Surgical center (Augencentrum Köln, Köln, Germany). Design: Retrospective analysis of 106 eyes from 71 consecutive patients. Methods: Ab-interno canal viscodilation (VISCO360®) with or without cataract extraction was performed in two groups of patients with mild-moderate POAG: Group 1 had a baseline intraocular pressure (IOP) ≥18 mmHg (n=72 eyes) and Group 2 had a baseline IOP <18 mmHg (n=34 eyes). IOP without washout was measured and number of IOP-lowering medications were documented at all visits. Effectiveness was determined by reduction in IOP and reduction in the number of IOP-lowering medications at 12±3 months from baseline. Safety was determined by the rate of adverse events (AEs) and secondary surgical interventions (SSI). Results: In Group 1, all eyes available at 12±3 months (n=72), had a 41.0% reduction in mean IOP (from 24.6±7.1 mmHg to 14.6±2.8 mmHg), 87% (n=62) of which showed an IOP reduction of ≥20% with no increase in IOP-lowering medications. In Group 2, all eyes (n=34) maintained their baseline IOP at all postoperative visits. In both groups, a significant decrease (>89%) in mean number of IOP-lowering medications was seen at 12 months with 86% of eyes completely off medication with no increase in IOP. The most common AE seen was hyphema (13%) and no eye required SSI during the study period. Conclusion: Ab-interno SC viscodilation (VISCO360) is safe and effective in lowering IOP and reducing hypotensive medications in patients with OAG.
... Also, we limited cases to those undergoing combined phacoemulsification and glaucoma surgery in both treatment groups for standardization, as phacoemulsification alone is known to lower IOP for up to several years postoperatively. 25 Outcome measuresspecifically IOP-were measured as per routine clinical practice and not under strict trial protocols. However, our results are meant to complement the existing robust body of literature by providing a description of these procedures' efficacy and safety when deployed in real-world use. ...
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Purpose: To compare 6-month surgical outcomes of patients who underwent phacoemulsification (Phaco) combined with iStent implantation (iStent) versus excisional goniotomy using Kahook Dual Blade (KDB). Methods: Retrospective comparative case series of 58 iStent-Phaco eyes and 44 KDB-Phaco eyes operated upon by a single surgeon between 2016 and 2018. Preoperative, intraoperative, and postoperative intraocular pressure (IOP) and IOP-lowering medication data were collected. The primary outcome was the proportion of eyes using ≥1 fewer IOP-lowering medication at Month 6 while maintaining IOP ≤ 18 mmHg. Results: Baseline IOP was 17.2 (standard error 0.7) in the KDB-Phaco group using a mean of 1.9 (0.2) medications; at Month 6, mean IOP was 14.8 mmHg P=0.002) on 1.0 (0.2) medications (P<0.002). Baseline IOP was 16.7 (0.4) in the iStent-Phaco group using a mean of 1.4 (0.1) medications; at Month 6, mean IOP was 14.2 mmHg (P<0.002) on 1.4 (0.1) medications P=0.374). Changes in IOP and medications were not significantly different between groups (P>0.05). Significantly more KDB-Phaco eyes than iStent-Phaco eyes (43.2% vs 17.2%, P=0.004) were using ≥1 fewer medications while maintaining IOP ≤18 mmHg at Month 6. Adverse events were uncommon and similar in nature and frequency between groups with the exception that more KDB-Phaco eyes than iStent-Phaco eyes (8 [18.2%] versus 1 [1.7%]) experienced an IOP elevation presumed to be related to steroid use. Conclusion: KDB-Phaco and iStent-Phaco provided comparable IOP and medication reductions. The proportion of eyes able to discontinue 1 or more medications while maintaining IOP ≤ 18 mmHg was significantly greater in eyes undergoing KDB-Phaco.
... Chen et al. found a postoperative IOP drop by -2.3 mmHg (range -1.1 mmHg to -4.0 mmHg), that is, -13% (range -7% to -22%) [9]. The study by Armstrong et al. found postoperative IOP drops by 12%, 14%, 15% and 9% after 6, 12, 24 and 36 months of follow-up, respectively [22]. ...
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Introduction. It has been recognized that cataract surgery leads to a reduction of intraocular pressure, both in healthy and in glaucoma patients. This prospective interventional clinical study aimed to investigate the effects of cataract surgery on intraocular pressure and its short- and long-term fluctuations in medically controlled primary open-angle glaucoma patients and non-glaucomatous patients. Material and Methods. Two groups of 31 patients (31 eyes) were studied. The observed group included patients with glaucoma and cataract, and the control group included patients with senile cataract only. The intraocular pressure was measured three times daily pre- and at 1, 3 and 6 months postoperatively. Results. In both groups, a significant postoperative reduction in both mean and maximum intraocular pressure. Six months after surgery, in the observed group the average and maximum intraocular pressure reduction levels were -2.73 ? 1.91 mmHg and -3.16 ? 2.19 mmHg, and -2.26 ? 1.71 mmHg and -2.53 ? 1.70 mmHg in the control group. In the observed group, at 3 and 6 months after surgery, a significant reduction in short-term fluctuations was observed. Six months after surgery, short-term fluctuations decreased by -1.04 ? 2.20 mmHg compared to preoperative. Postoperatively, in the observed group, long-term fluctuations of average and maximum intraocular pressure were 2.69 ? 2.15 mmHg and 2.88 ? 2.22 mmHg, respectively, and in the controls they were 2.02 ? 1.28 mmHg and 2.42 ? 1.47 mmHg, showing no significant differences between groups. Conclusion. In patients with primary open-angle glaucoma, cataract surgery results in a statistically significant reduction in both average and maximum intraocular pressure as well as of short-term fluctuations.
... The CRS may influence the disease burden of glaucoma due to the following reasons: First, both glaucoma and the medications to control intraocular pressure could accelerate the development of cataracts, and the vision loss of glaucoma patients may be due to the combined influence of glaucoma and cataracts. Second, recent studies revealed that cataract surgery can reduce intraocular pressure in patients with glaucoma [43][44][45][46]. This finding suggested that higher CRS may help reduce the disease burden of glaucoma. ...
Article
Background: To evaluate the disease burden of glaucoma in terms of disability-adjusted life years (DALY) and assess the contribution of risk factors to DALY due to glaucoma. Methods: Global, regional, and country DALY number, rate, and age-standardized rates of glaucoma were obtained from the Global Burden of Disease Study 2017 database. The Human Development Index (HDI), Inequality-Adjusted HDI, Socio-Demographic Index (SDI), and other country-level data were derived from international open databases. Regression analysis was used to assess the correlations between the age-standardized DALY rate and the variables. Results: The global DALY due to glaucoma increased by 81% from 1990 to 2017 and decreased by 10% over the last two decades after adjusting for age and population size. Males had higher age-standardized DALY rates (P < 0.001). The age-standardized DALY rate was higher in countries with lower income or lower SDI (P < 0.001). The country-level age-standardized DALY rates in 2017 were negatively associated with HDI, SDI, country-level age-standardized prevalence rates of cataracts, cataract surgery rates (CRS), physician rates, and Inequality-Adjusted HDI. Stepwise multiple regressions showed that HDI, CRS, and Inequality-Adjusted HDI were significantly negatively associated with the country-level age-standardized DALY rate in 2017 after adjusting for other confounding factors (P < 0.001). Conclusions: Higher education, higher CRS, and diminishing the inequality in resource distribution may help reduce the disease burden of glaucoma. These findings can provide information for policymakers and could serve as an impetus for efforts toward alleviating the disease burden of glaucoma.
... The standalone nature of the procedure is a strength of this analysis, as there are few studies evaluating the effects of new glaucoma procedures performed on their own, without the confounding effect that cataract surgery has on both IOP and medication use in glaucomatous eyes. 42 Extending follow-up through 12 months builds on a prior report of 6-month outcomes in this data set 23 and provides longer-term data to guide surgical decision-making for this chronic disease. Also, this data set was derived from multiple surgeons; while this can be considered a limitation in that procedures may not have been robustly standardized, there is also value in assessing the outcome of the procedure in a multi-surgeon, real-world setting where such standardization would be artificial. ...
Article
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Purpose: To describe 12-month intraocular pressure (IOP) and medication use outcomes following excisional goniotomy (EG) as a stand-alone procedure in eyes with medically uncontrolled glaucoma. Methods: This was a retrospective analysis of data from surgeons at 8 centers (6 US, 2 Mexico). Eyes with glaucoma undergoing standalone EG with a specialized instrument (Kahook Dual Blade, New World Medical, Rancho Cucamonga, CA) for IOP reduction and followed for 12 months postoperatively were included. Data were collected preoperatively, intraoperatively, and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. The primary outcome was reduction from baseline in IOP, and key secondary outcomes included IOP-lowering medication reduction as well as adverse events. Results: A total of 42 eyes were analyzed, of which 36 (85.7%) had mild to severe primary open-angle glaucoma (POAG). Mean (standard error) IOP at baseline was 21.6 (0.8) mmHg, and mean number of medications used at baseline was 2.6 (0.2). At 3, 6, and 12 months postoperatively, mean IOP reductions from baseline were 4.6 mmHg (22.3%), 5.6 mmHg (27.7%), and 3.9 mmHg (19.3%) (p≤0.001 at each time point). At the same time points, mean medications reductions of 0.7 (25.8%), 0.9 (32.6%), and 0.3 (12.5%) medications were seen (p<0.05 at months 3 and 6, not significant at month 12). Six eyes (14.3%) underwent additional glaucoma surgery during the 12-month follow-up period. Discussion: Standalone EG with KDB can reduce IOP, and in many cases reduce medication use, through up to 12 months in eyes with mild to severe glaucoma. Statistically significant and clinically relevant reductions in IOP were seen at every time point. While the goal of surgery was not to reduce medication burden, mean medication use was significantly reduced at all but the last time point. In the majority of eyes, the need for a bleb-based glaucoma procedure was delayed or prevented for at least 12 months.
... There is evidence in the literature that cataract surgery alone can reduce IOP in open-angle glaucoma cases; however, the reduction tends to be limited and temporary. [18][19][20] Armstrong et al 18 provided some pooled results from 32 studies, where phacoemulsification alone can induce a reduction of the baseline IOP on average 12% to 15% up to 24 months, reducing the effect to 9% at 36 months. There is also sufficient evidence that the combined procedure (cataract and trabecular by-pass procedures) is more efficacious, both in terms of IOP reduction and a reduction in medication burden, while maintaining similar safety profiles, compared with cataract surgery alone. ...
Article
PRéCIS:: An older age, a low number of baseline glaucoma medications, an early glaucoma stage, lower intraocular pressure values during the first post-operative month, and combined surgery are possible predictors of unqualified success after a trabecular by-pass MIGS procedure. Purpose: To identify the potential predictors of unqualified success (intraocular pressure [IOP] <18▒mmHg with no glaucoma medication) after trabecular by-pass micro-invasive glaucoma surgery (MIGS). Methods: We designed a case-control study using logistic regression modelling that included all trabecular by-pass surgeries with at least 3 months of follow up, performed at a single center from June 2017 to December 2019. Eyes that achieved an end-point of unqualified success (dependent variable) were considered cases. All other eyes were used as the controls. Cases and controls were paired by sex and postoperative time. We tested the following independent variables: age, race, laterality (OD or OS), glaucoma stage, type of surgery (combined or stand-alone), type of trabecular bypass, intraoperative complications, baseline number of medications, baseline IOP, and post-operative IOP on days 1, 15, and 30. Additional analysis using IOP <15▒mmHg as a threshold and including eyes with at least 12 months of follow up were performed. Results: One-hundred and ninety-four eyes were included in the analysis. We observed complete success in 56.7% of eyes. The mean follow-up time for the entire population was 12.3±6.8 months. All variables were considered in the first step of the modeling process; however, only age, day-15 IOP, day-30 IOP, baseline number of medications, glaucoma stage, and type of surgery remained until the completion of our model, with adequate significance (P<0.05). The additional analysis confirmed our results. Conclusions: We identified that an older age, a low number of baseline glaucoma medications, an early glaucoma stage, lower IOP values during the first post-operative month, and combined surgery were associated with a higher chance of unqualified success at 12 months after a trabecular by-pass MIGS procedure.
... A meta-analysis reported a 12% reduction of IOP and 0.57 medication per patient after phaco alone surgery. [28] The short duration of follow up was another limitation. Albeit, this study is continuing and more eyes with a longer follow up will be recruited. ...
Article
Purpose: Angle-based surgeries for the treatment of open-angle glaucoma have gained popularity in recent years. This study aimed to evaluate the efficacy of combined phacoemulsification and goniotomy in primary open-angle and pseudoexfoliation glaucoma (POAG and PXG) and ocular hypertension (OHTN). Methods: In this interventional case series in the setting of the Glaucoma Service at the Farabi Eye Hospital, 32 eyes of 30 patients with early-to-moderate POAG and PXG and OHTN were enrolled. All eyes underwent combined phacoemulsification and needle goniotomy. Intraocular pressure (IOP) and the number of antiglaucoma medications as well as demographic data were recorded at baseline and one day, one week, one month, three months, and six months after the surgery. Generalized Estimating Equation (GEE) was used to compare the values of IOP and the number of medications at different time points. Kaplan-Meier graph was used to demonstrate the survival status of the eyes. Results: Mean IOP at baseline was 21.8 ± 4.6 mmHg on mean 1.2 ± 1.5 topical medications. There was a 25.2% (16.3 ± 4.5 mmHg) and 32.1% (14.8 ± 3.9 mmHg) reduction in IOP at three and six months after procedure, respectively (P < 0.001). Meanwhile, the decline in medications was 66.7% (0.4 ± 0.9) and 50.0% (0.6 ± 1.1) at the same time points (P = 0.002 and P = 0.048, respectively). Post-operative complications were clot hyphema (n = 1, 3.1%), fibrinous inflammation (n = 1, 3.1%) and distorted pupil (n = 2, 6.3%). Conclusion: Combined phacoemulsification and needle goniotomy as a procedure for mild and moderate POAG and PXG and OHTN is as effective as other modified goniotomies in the setting of minimally invasive glaucoma surgeries (MIGS).
... The authors have warranted further follow-up where the latter is concerned, but in the context of a control group, they have cited several reports of clinically insignificant reduction of IOP after cataract surgery alone in POAG eyes. This argument does hold true as multiple authors over the years, [7,8] as well as several systematic reviews and meta-analysis [9,10] of the same, have validated that there is a very small reduction of IOP in POAG eyes; therefore, cataract surgery alone is unlikely to replace IOP-lowering surgery. ...
... Bien que la chirurgie de la cataracte par phacoémulsification ne soit pas une modalité de traitement du GPAO en soi, plusieurs études, dont une méta-analyse [Armstrong et al., 2017], démontrent une baisse non négligeable de la PIO à la suite de cette procédure. ...
Technical Report
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Le glaucome est une maladie de l’œil qui engendre une perte irréversible du champ visuel et qui peut, dans certains cas, mener à la cécité. Présentement, la stratégie thérapeutique utilisée vise principalement à réduire la pression intraoculaire (PIO) causée par la production de l’humeur aqueuse de l’œil et de son élimination. Il existe des dispositifs implantables qui visent à améliorer l’écoulement physiologique de l’humeur aqueuse afin de réduire la pression. Ces dispositifs, les ponts trabéculaires iStent® et iStent inject® sont actuellement offerts aux patients atteints de glaucome, mais leur accès demeure limité. L’INESSS a évalué la pertinence d’accroitre l’accessibilité à ce dispositif et conclu que, malgré la reconnaissance de la valeur thérapeutique des produits iStent® et iStent inject®, le rapport entre les coûts et les bénéfices, lequel est assorti d’une grande incertitude a été jugé trop élevé et ne constitue pas une allocation équitable des ressources du système de santé québécois. Cependant, elle pourrait constituer une décision juste et raisonnable si des mesures importantes d’atténuation du fardeau économique sont mises en œuvre, et que leur utilisation est encadrée par les critères suivants : patient non-répondant à deux médications hypotonisantes ou plus ou présentant une condition médicale documentée empêchant l’administration optimale des gouttes; mauvais candidat à une chirurgie de filtration.
... In the current study, where G1 implantation was combined with cataract surgery, a contribution to the overall IOP reduction from the cataract surgery alone would be expected. In a meta-analysis of studies of cataract surgery alone in POAG, a drop in IOP of 9% is seen by 3 years [22]. Since the drop in mean IOP in the current study was 20% at 5 years, it suggests that G1 augments the IOP reduction observed with phacoemulsification alone, which is consistent with prior studies demonstrating the IOP-lowering ability of the iStent alone [23,24]. ...
Article
Full-text available
Purpose To evaluate the safety and efficacy of combined phacoemulsification and single iStent (G1) (iStent, Glaukos Corp. San Clemente, USA), implantation in moderately advanced primary open angle glaucoma (POAG) with 5-years follow-up. Methods Retrospective, interventional case series. All subjects had POAG and underwent single iStent implantation+ phaco+IOL by a single surgeon, with 5 years follow-up. Primary outcome measures: reduction in intraocular pressure (IOP) and proportion of eyes achieving at least 20% reduction of IOP at 5 years. Secondary outcome measures: number of glaucoma drops at 1 through to 5 years; change in visual field mean deviation (MD) at year 5 compared to baseline. Results 35 eyes of 26 patients were included. Mean (sd) medicated pre-op IOP was 18.5 (3.2) mm Hg on mean (sd) 2.3 (1.0) medications. Mean IOP was reduced to 15.9 (4.5) mm Hg on 2.2 (0.9) drops, 15.0mm (4.5) mm Hg on 2.3 (0.9) drops, 15.6 (3.6) mm Hg on 2.5 (1.0) drops, 15.7 (4.43) mmHg on 2.6 (1.0) drops and 14.7 (3.02) mmHg (P<0.001) on 2.7 (1.14) drops (P = 0.06) from 1 through to 5 years. At year 5, 62% of eyes had achieved at least 20% reduction in IOP. MD reduced from -8 (8.1) dB to -10.7 (13.4) dB over 5 years (p = 0.8) at 0.54dB/ annum. One eye required filtering surgery. There were no sight-threatening complications. Conclusion This study showed sustained IOP reduction and excellent safety profile for single iStent implantation. Uniquely it provides data for a more severe stage of glaucoma, and also visual field data, which indicated no significant change through 5 years.
... Heterogeneity was tested by computing I 2 value and for low-heterogeneity studies (I 2 value <50%), the fixed-effect model was used, while for highheterogeneity studies (I 2 value ≥50%), the random-effect model was used. 35 Sensitivity analyses were performed for large studies (>1000 participants/person-years) and for studies with pediatric populations (<18 years of age) versus adult population. ...
Article
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Purpose: Starting in 2019, the Global Initiative for Asthma recommended the use of inhaled corticosteroids (ICS) as part of reliever combination therapy in patients 12 years of age and older, thus dramatically increasing the population exposure to ICS. ICS and intranasal corticosteroids (INS) are commonly used for a variety of respiratory diseases. Chronic steroid use is a well-known risk factor for elevated intraocular pressure (IOP) and glaucoma regardless of route of administration. This study aimed to determine the reported risk of glaucoma, ocular hypertension (OHT) and IOP elevation associated with ICS and INS use. Materials and methods: Systematic literature search in MEDLINE, EMBASE, Cochrane, CINAHL, BIOSIS, and Web of Science databases from the date of inception identified studies that assess ocular outcomes related to glaucoma in ICS and INS users. Study selection, risk of bias assessment and data extraction were done independently in duplicate. Meta-analysis assessed glaucoma incidence, OHT incidence and IOP changes in patients using ICS and INS. Study adhered to PRISMA guidelines. Study protocol was registered with PROSPERO: CRD42020190241. Results: Qualitative and quantitative analyses included 65 and 41 studies, respectively. Incidence of glaucoma was not significantly different in either ICS or INS users compared to control over 45,457 person-years of follow-up. Similarly, no significant difference in OHT incidence over 4431 person-years was detected. In studies reporting IOP, a significantly higher IOP was observed (0.69 mmHg) in 857 ICS or INS users compared to 615 controls. However, no significant increase in IOP was observed within ICS or INS users when compared to pre-treatment baseline. Conclusion: Overall, use of ICS or INS does not significantly increase the incidence of glaucoma or OHT. However, ICS and INS patients had significantly higher IOPs compared to untreated patients. Awareness of these findings is significant in care of patients with additional risk factors for glaucoma.
... An additional limitation is the lack of a phacoemulsificationonly control group, as phacoemulsification alone is known to reduce both IOP and the need for IOP-lowering medications in glaucomatous eyes. 30 However, the magnitude of both IOP reduction and medication reduction in this study is significantly greater than would be expected from phacoemulsification alone, supporting the efficacy of the incisional goniotomy procedure. Also, the IOP outcomes presented in this interim analysis were not assessed after drug washout. ...
Article
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Purpose: To characterize the clinical outcomes of a novel ab interno minimally invasive procedure with the STREAMLINE® Surgical System for creation of incisional goniotomies and canal of Schlemm viscodilation in eyes with mild to severe primary open-angle glaucoma (POAG). Methods: In a prospective, single-arm, first-in-human case series, 20 eyes of 20 subjects with mild to severe POAG underwent creation of incisional goniotomies and canal of Schlemm viscodilation following phacoemulsification cataract extraction after washout of all intraocular pressure (IOP)-lowering medications. The angle surgery portion was performed with a single-use handpiece tipped with a microcannula that creates precise goniotomies through the trabecular meshwork into the canal of Schlemm and delivers a small volume of ophthalmic viscosurgical device directly into the canal via precise catheterization. Outcomes in this interim analysis included mean reduction in IOP and medications through 6 months of follow-up, as well as the proportion of eyes achieving IOP reduction ≥20% from baseline. Results: At month 6, mean IOP reduction of ≥20% from baseline was achieved in 89.5% of eyes (17/19). Mean (standard deviation) medicated IOP at screening was 16.3 (3.6) mmHg and unmedicated baseline IOP (after washout) was 23.5 (2.5) mmHg. Mean IOP was significantly reduced from baseline through 6 months of follow-up to 14.7 (2.4) mmHg (p<0.001), representing an IOP reduction of 8.8 mmHg (36.9%). Overall, 57.9% (11/19) of eyes decreased dependence on IOP-lowering medications by at least one medication, and 42.1% (8/19) were medication free. Mean medication use was reduced from 2.0 (0.8) at screening to 1.1 (1.1) at 6 months (p<0.001). Three eyes had transient IOP spikes treated with topical medications. Conclusion: The creation of incisional goniotomies and canal of Schlemm viscodilation safely and effectively reduced IOP and the need for IOP-lowering medications by both clinically and statistically significant magnitudes in eyes with mild to severe POAG undergoing concomitant phacoemulsification cataract extraction through the first 6 months of follow-up.
... A study done by Armstrong et al. (2017) found that a 12%, 14%, 15%, and 9% reduction in IOP from baseline occurred 6, 12, 24, and 36 months respectively after phacoemulsification. ...
... Recent studies have reported significant IOP reduction after cataract surgery in patients with ocular hypertension (OHT), glaucoma and also in non-glaucomatous patients [5][6][7][8][9][10][11][12][13]. Damji et al. reported that using higher volumes of irrigation fluid during phacoemulsification was significantly associated with a greater IOP reduction in PXF subjects [14]. ...
Article
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Background: Pseudoexfoliation (PXF) syndrome is the most common cause of secondary glaucoma worldwide. This systemic disorder causes further damage to the optic nerve and ultimately increases the need for surgical interventions. Therefore, intraocular pressure (IOP) control is very important in these patients. The aim of this study was to compare IOP changes after phacoemulsification in subjects with PXF syndrome compared to those without this syndrome. Methods: 61 patients were enrolled in this prospective clinical study. Subjects were assigned into two groups based on presence or absence of PXF syndrome. IOP and anterior chamber angle parameters including: angle opening distance (AOD) and trabecular-iris surface area (TISA) measured one day preoperatively and 3 months postoperatively. Intraoperative metrics factors including: infusion fluid usage (IFU), cumulative dissipated energy (CDE) and aspiration time (AT) were obtained from the phacoemulsification machine at the end of each surgery. IOP changes, anterior chamber angle parameters and intraoperative metrics factors were compared between groups. Results: Mean IOP before surgery was significantly higher in the PXF group (14.70 mm Hg) compared to controls (12.87 mm Hg) (P-value < 0.01). Phacoemulsification decreased IOP in both, but to greater extent in the PXF group (p-value < 0.01). AOD and TISA also increased significantly following surgery in both groups. The results showed that postoperative IOP was negatively correlated with preoperative IOP in both groups (p-value < 0.01). Also, IOP after phacoemulsification was negatively correlated with IFU in the PXF group (p-value = 0.03). Conclusions: Patients with PXF syndrome exhibited a reduction in IOP and increase in anterior chamber angle parameters after phacoemulsification. We observed a greater IOP reduction in PXF subjects when it was compared to controls. Higher preoperative IOP and intraoperative IFU were associated with more IOP reduction in the PXF group.
... Phacoemulsification alone is known to lower IOP and the need for IOP lowering medications in glaucomatous eyes. 41 We have attempted to mitigate this limitation by designing the statistical analysis plan around the relevant outcomes of phacoemulsification-only groups (which have been remarkably consistent albeit greater than what has been typically reported in other publications) in recent pivotal MIGS trials, 17,18 specifically powering the study to detect an effect size in excess of that expected by phacoemulsification alone in eyes with mild-moderate OAG. The decision to design this study without a cataract surgery only control group was not made lightly. ...
Article
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Purpose: To report 12-month efficacy outcomes of 360° canaloplasty and 180° trabeculotomy using the OMNI surgical system in combination with phacoemulsification in patients with mild-moderate open-angle glaucoma (OAG) and visually significant cataract. Setting: Fifteen multi-subspecialty ophthalmology practices and surgery centers located in 14 US states. Design: Prospective, multicenter, IRB approved study of patients treated with canaloplasty (360°) and trabeculotomy (180°). Eligible patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤33 mmHg on 1 to 4 hypotensive medications. Unmedicated post-washout mean diurnal IOP (DIOP) ≥21 and ≤36 mmHg. Methods: Medication washout preoperatively and prior to month 12 DIOP. Effectiveness outcomes were IOP and IOP lowering medication use. Safety outcomes included adverse events and secondary surgical interventions (SSIs). Evaluations at 1, 3, 6, and 12 months. Results: A total of 149 subjects underwent surgery and 120 were included in the final effectiveness analysis. Mean (standard deviation) unmedicated diurnal IOP was reduced from 23.8 (3.1) mmHg at baseline to 15.6 (4.0) at month 12 (-35%) and medications (before washout) were reduced from 1.8 (0.9) at baseline to 0.4 (0.9) at month 12 (-80%). At month 12, 84.2% of eyes achieved IOP reductions >20% from baseline, 80% of eyes were medication-free, and 76% of eyes achieved IOP between 6-18 mmHg inclusive. Adverse events were uncommon. Most were mild and self-limited including transient hyphema (9 of 149; 6%) and transient IOP elevations (3 of 149; 2.0%). No eyes required SSIs or experienced loss of VA that was attributable to the device or procedure. Conclusion: Canaloplasty and trabeculotomy performed with the OMNI surgical system at the time of phacoemulsification significantly reduces unmedicated mean diurnal IOP and medication use 12 months postoperatively, with an excellent safety profile. This procedure should be considered for eyes with mild-moderate OAG to reduce IOP, medication burden, or both.
... Phacoemulsification alone can transiently lower both IOP and the need for medications in eyes with glaucoma. In a recent meta-analysis, mean IOP reductions of 15% and mean medication reductions of 0.38 were reported at 24 months 27 . In a separate report, the endurance of IOP reduction following phacoemulsification in eyes with PXFG was reported to be no more than 1 year 28 . ...
Article
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To characterize changes in intraocular pressure (IOP) and IOP-lowering medications through up to 2 years of follow-up in patients undergoing combined phacoemulsification and excisional goniotomy with the Kahook Dual Blade (phaco-KDB), with simultaneous goniosynechialysis in cases of angle-closure glaucoma. Prospective, non-comparative, interventional case series. Consecutive patients with medically-treated glaucoma and visually-significant cataract underwent combined surgery. Analysis was conducted on open-angle (OAG) and angle-closure (ACG) glaucoma groups separately. Thirty-seven patients with OAG (24 with primary OAG and 13 with pseudoexfoliation glaucoma) and 11 with ACG were enrolled. In OAG eyes, mean (standard error) baseline IOP was 21.1 (0.9) mmHg and through 24 months of follow-up was reduced by 6.4–7.7 mmHg (24.6–32.1%; p ≤ 0.0001 at all time points). In ACG eyes, mean baseline IOP was 20.8 (1.6) mmHg and was reduced by 6.1–8.77 mmHg (23.4–39.0%; p ≤ 0.0353). Mean medications were reduced by 61.9–89.1% (p ≤ 0.0001) in OAG eyes and by 56.3–87.3% (p ≤ 0.0004) in ACG eyes. Phaco-KDB significantly lowered IOP ~ 30% and medications by > 50% through 24 months. This combined procedure provides meaningful long-term reductions in IOP and need for IOP-lowering medication and does not adversely affect visual rehabilitation in eyes with cataract and glaucoma.
... However, a recent systematic review and meta-analysis of 32 studies including 1826 patients found that cataract surgery alone could provide a 14% reduction in IOP at 12 months postsurgery in contrast to the 35% reduction observed in the present study. 9 The OMNI device is a safe, implant-free MIGS combining trabeculotomy and canaloplasty. The present analysis indicates that the favorable safety and effectiveness for OMNI reported in the broader population 5 is also observed in Hispanic patients. ...
Article
Purpose: To describe the 3-year outcomes of combined cataract surgery and 360-degree endocyclophotocoagulation (ECP) in eyes with uncontrolled glaucoma and no previous glaucoma drainage surgery. Setting: University Hospital Eye Department, Exeter, United Kingdom. Design: Retrospective case series. Methods: The study included patients who had combined cataract surgery and 360-degree ECP. The primary outcome measure was intraocular pressure (IOP) reduction at 3 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 3 years and the complications of surgery. Failure was defined by 1 of 2 criteria: (1) IOP higher than 21 mm Hg or lower than 6 mm Hg or not reduced by 20% from baseline at the 1-, 2-, or 3-year timepoint and (2) further laser or other surgery to reduce IOP at any timepoint. Results: The study comprised 84 patients (84 eyes). The mean IOP dropped from 18.7 mm Hg preoperatively to 13.3 mm Hg, 13.8 mm Hg, and 14.0 mm Hg at 1, 2, and 3 years postoperatively, respectively. By the 3-year timepoint, 58.3% had met the criteria for failure. The mean number of glaucoma medications was similar at 2.5 at 3 years postoperatively compared with 2.6 preoperatively. Nine patients (10.7%) had a significant complication, but all resolved without long-term sequelae. Conclusions: At 3 years postoperatively, combined cataract surgery and 360-degree ECP achieved a modest but significant drop in IOP in phakic patients with uncontrolled glaucoma and no previous drainage surgery. There was a low incidence of serious side effects but nearly 60% were classified as failures by 3 years.
Article
After a long period of little change, glaucoma surgery has experienced a dramatic rise in the number of possible procedures in the last two decades. Glaucoma filtering surgeries with mitomycin C and glaucoma drainage devices remain the standard of surgical care. Other newer surgeries, some of which are minimally or microinvasive glaucoma surgeries, target existing trabecular outflow, enhance suprachoroidal outflow, create subconjunctival blebs, or reduce aqueous production. Some require the implantation of a device such as the iStent, Hydrus, Ex-PRESS, XEN and PRESERFLO, whilst others do not—Trabectome, Kahook dual blade, Ab interno canaloplasty, gonioscopy-assisted transluminal trabeculotomy, OMNI and excimer laser trabeculotomy. Others are a less destructive variation of an established procedure, such as micropulse transscleral cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cycloplasty. Cataract surgery alone can be a significant glaucoma operation. These older and newer glaucoma surgeries, their mechanism of action, efficacy and complications are the subject of this review.
Article
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The senile cataract represents the blurring of the crystalline lens after the age of 65. It occurs due to metabolic changes in the crystalline lens which occur over the years. The only effective way to treat cataract is the surgical one. Pseudoexfoliation is an age related systemic disorder. PEX represents the accumulation fibrillar material in the extracellular matrix of the tissue. The most known ocular manifestation of the PEX are the collection at iris pupillary margin and anterior lens capsule. This accumulation is associated with many intraoperative and postoperative complications in patients scheduled for cataract surgery. The aim of the study was to investigate the prevalence of the surgical complications during phacoemulsfication in patients with PEX. The study included 91 patients scheduled for cataract surgery divided into two groups (PEX group 46, control group 45 patients). Poor intraoperative midryasis, zonular dehiscence, postoperative corneal edema, anterior chamber inflammation, elevated intraocular pressure and tear film instability had particularly higher rate of occurring in PEX group comparing to the control group (p<0.001). The highest mean value of intraocular pressure was observed in PEX group on the first postoperative day 25.6 ± 1.1 mmHg, while the best corrected visual acuity was measured in control group 0.71 ± 1.2 one month after phacoemulsification. Cataract surgery in patients with PEX carries great risk, but with adequate preoperative planning, the awareness of the potential complications, can provide safe and routine phacoemulification in these patients.
Article
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Background We investigated how cataract surgery might influence long-term intraocular pressure (IOP) change in both healthy subjects and glaucoma patients. Methods A retrospective analysis of patients who had had clear corneal phacoemulsification with a minimum of 12 months of follow up was performed. Glaucoma patients with medically controlled open-angle glaucoma and healthy subjects with no glaucoma were included in the analysis. The change of IOP after phacoemulsification and factors associated with postoperative IOP change were investigated. Results In total, 754 eyes of 754 patients, specifically 106 patients with glaucoma and 648 patients with no glaucoma (i.e., healthy subjects) were enrolled. The phacoemulsification effected a reduction of IOP: 1.03 ± 3.72 mmHg in healthy subjects and 1.08 ± 3.79 mmHg in glaucoma patients at postoperative 1 year (P = 0.656). There were negative coefficients of IOP until 1 year of follow up (all P < 0.001), but the IOP change gradually showed a less steeply decreasing slope (correlation coefficient: −0.993), compared with those for 1 week and 1 month of follow up (correlation coefficients: −1.893 and −1.540, respectively). In the multivariate analysis, age and preoperative IOP showed significant associations with postoperative IOP change (regression coefficients: −0.034 and 0.419 respectively, all P < 0.001). Conclusion Phacoemulsification resulted in IOP reduction, which effect regressed in healthy subjects and glaucoma patients over the course of long-term follow up. Therefore, long-term monitoring of IOP change is needed. In cases of higher preoperative IOP and young patients, phacoemulsification alone is a reliable option for IOP control.
Article
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Purpose/objective: To evaluate the effectiveness of combined phacoemulsification, viscogoniosynechialysis (VGSL), and endocyclophotocoagulation (ECP) in patients with moderate chronic angle-closure glaucoma (CACG) with peripheral anterior synechia (PAS) ≥90 not controlled with glaucoma medications and previous iridotomy yag laser. Materials and methods: We retrospectively reviewed records from patients with cataract and uncontrolled chronic angle-closure glaucoma despite maximal tolerated medical therapy and iridotomy yag laser who received combined treatment with phacoemulsification with posterior capsular lens implantation, VGSL, and ECP 360°. We evaluated intraocular pressure (IOP), glaucoma medications, and best corrected visual acuity (BCVA) preoperatively and during follow-up. Results: A total of 29 eyes from 22 patients received surgical intervention. Mean follow-up was 6 months. Mean preoperative IOP was 18.2 mmHg, and postoperatively, IOP was 13.5, 12.2, and 12.8 mmHg at 1, 3, and 6 months, respectively. Complete success was 37.9%, and relative success was 72.4%. Mean BCVA was 0.4 logMAR preoperative and 0.3 logMAR 6 months after surgery. Glaucoma medication fell significantly from 2.34 ± 1.66 preoperatively to 1.31 ± 2.6 postoperatively (p < 0.001). Overall, 44.8% of the patients did not require glaucoma medications at 6 months. There were no visual significant complications. Conclusion: Combined treatment with phacoemulsification with posterior capsular lens implantation, VGSL, and ECP is effective and safe in reducing IOP and number of glaucoma medications with stable BCVA at 6 months.
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Purpose: To assess the 10-year effects of early phacoemulsification with intraocular lens (IOL) implantation in primary angle closure glaucoma (PACG) patients with cataract. Patients and methods: This prospective cohort study included 102 eyes of 102 patients with PACG. All patients had coexisting cataracts compromising vision. Patients underwent phacoemulsification and foldable IOL implantation. The main outcome measures were anterior chamber depth (ACD), angle width, value of intraocular pressure (IOP), and number of medications needed postoperatively and during follow-up. Results: Half (53%) of the patients were female, with ages ranging from 55 to 73 with a mean of 59.82±5.19 years. Mean IOP decreased significantly from 22.15±2.08 mmHg at baseline to 14.08±2.13 mmHg postoperatively (p˂ 0.05). The ACD increased from 2.2±0.21 preoperatively to 3.73±0.25 postoperatively (p˂0.001). Nasal angle width increased postoperatively to 40.05±2.09 compared to the preoperative value of 16.02±2.08 (p˂0.001). Temporal angle width increased from 13.05±2.07 to 41.9600±1.94 (p˂0.001). Anti-glaucoma treatment significantly decreased postoperatively (p˂0.001). A significant positive correlation was detected between ACD and angle width, while a negative correlation was detected between IOP and both ACD and angle width (p˂0.001). There was also a significant negative correlation between postoperative angle width and IOP (p˂0.001). Preoperative lens thickness was positively correlated with preoperative IOP and number of medications, while it was negatively correlated with preoperative AC depth and angle width. Preoperative lens thickness positively correlated with postoperative IOP and medications. Complete and qualified success was achieved in 69.65% and 30.4% of cases, respectively, while 2.9% failed to be controlled. Visual acuity significantly improved from 0.17±0.1 to 0.9±0.08 (p˂0.001). All parameters showed high stability throughout the follow-up period. Conclusion: Phacoemulsification with IOL implantation is a safe and effective early modality for long-term control of IOP in PACG patients with coexisting cataract. The effects can persist for at least 10 years.
Article
Purpose Cataract and glaucoma are among the leading causes of blindness worldwide in older people, and they are often concomitant. To assess topical intraocular (IOP)-lowering agents delivery changes after cataract extraction. Material and methods Longitudinal matched exposed–unexposed study from the French national healthcare database from January 1, 2005 to January 1, 2017. We compared individuals using topical IOP-lowering agents who underwent bilateral cataract extraction with individuals matched on IOP-lowering agents load, age, and sex who did not undergo cataract extraction. IOP-lowering agents number of drops was assessed 12 months before the first cataract extraction and compared with number of drops 12 months after the second cataract extraction. Results About 1194 individuals treated with IOP-lowering agents were included, 597 exposed to bilateral cataract extraction and 597 unexposed to any surgery (total mean age 74.8 ± 8.3 years; 69.0% women). Mean IOP-lowering agents delivery at baseline was 1.4 daily drops in both groups. The mean number of drops decreased greater in the exposed than unexposed group (−25.5% vs −3.5%; p < 0.0001). Overall, 159 (26.6%) and 48 (8.0%) individuals in the exposed and unexposed groups interrupted medication ( p < 0.0001). Conclusions A decrease of around one quarter of IOP-lowering agents delivery was observed after cataract extraction in the present real-life study with a longstanding interruption observed in one quarter of patients. Phacoemulsification as a standalone procedure reduces IOP-lowering agents delivery in ocular hypertension and glaucoma.
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Purpose: Intraocular pressure (IOP), medication outcomes at 24 months following trabeculotomy/viscodilation using the OMNI® surgical system as a standalone procedure in medically uncontrolled mild-moderate open-angle glaucoma (OAG). Setting: Surgical center (Duesseldorf, Germany). Design: Retrospective analysis. IOP and medication data were collected before surgery and through 24 months. Safety data included adverse events and the need for additional surgery. Methods: Pre-op medication washout. Goldmann tonometry. Number of medications and adverse events (AE) at each time point. Primary outcomes: changes in IOP and medications. Two-sided paired t-tests compare values at each follow-up with baseline, significance p = 0.05. Secondary outcomes: proportion of eyes with IOP reduction of ≥20%, on fewer medications, and medication-free at each time point. Results: This analysis included data from 38 eyes of 27 subjects. Mean (standard deviation) baseline IOP was 24.6 (3.0) mmHg and through 24 months ranged from 12.6 to 14.9 mmHg (p < 0.0001), representing reductions of 10.0-12.0 mmHg. Mean medications were 1.9 (baseline) and through 24 months ranged from 0.0 to 0.5 (70.6-100% reduction) (p < 0.0001). At Month 24, mean IOP was 14.9 mmHg (-10.0 mmHg), and 100% of eyes achieved IOP reduction >20% from baseline; mean medication use was 0.5 (-1.4 medications, p < 0.0001), 84.6% of eyes using >1 fewer medication, and 57.7% were medication-free. The most common adverse event was intraoperative hyphema (44.7%); all resolved spontaneously. There were two secondary procedures for IOP control. Conclusion: The OMNI surgical system provides clinically relevant and statistically significant reductions in both IOP and medications with an excellent safety profile and should be considered in phakic or pseudophakic eyes with mild-moderate OAG requiring IOP or medication reduction, or both.
Article
Purpose: To assess the safety and effectiveness of Schlemm canal stenting for reducing intraocular pressure (IOP) in combination with cataract surgery in the United States cohort of the HORIZON study. Setting: Twenty-six clinical sites in the U.S. Design: Prospective clinical trial. Methods: Eyes with mild to moderate primary open-angle glaucoma (POAG) on 1 to 4 medications, significant cataract, and an unmedicated diurnal IOP between 22 mm Hg and 34 mm Hg after medication washout were randomized 2:1 to receive the Hydrus microstent or no further treatment after successful cataract surgery. Patients were followed for 24 months. Medication washout and diurnal IOP measurements were repeated at 12 months and 24 months. Results: Two hundred nineteen eyes were randomized to microstent implantation and 112 patients to phacoemulsification only. At 24 months, the diurnal IOP was reduced by 20.0% or more in a greater proportion of eyes in the microstent group (78.5% versus 54.5%; P < .001). The mean change in the number of medications was -1.2 ± 0.9 (SD) in the microstent group and -0.8 ± 1.1 in the phaco-only group (P < .001), and 78.5% of eyes and 39.2% of eyes, respectively, were medication free (difference 38.8%; P < .001). Conclusions: Implantation of a Schlemm canal microstent after phacoemulsification significantly reduced diurnal IOP and medication use compared with phacoemulsification only in patients with mild to moderately severe POAG. The combination procedure was equivalent to cataract surgery alone in terms of visual acuity outcomes and the rate of adverse ocular events.
Article
Purpose: To evaluate the incidence of adverse events (AEs) in patients who underwent refractive lens exchange. Design: Retrospective case series. Methods: Setting: Private refractive surgery clinics. Patients/Study Population: Patients who underwent refractive lens exchange between July 1, 2014, and June 30, 2016. Intervention/Observation Procedures: All AEs recorded in the electronic medical record were extracted and retrospectively reviewed. The total incidence of AEs and serious AEs was calculated. Loss of 2 or more lines of corrected distance visual acuity (CDVA) was calculated for the entire cohort of patients that attended a minimum of 3 months follow-up. Main outcome measures: AEs. Results: The total number of patients included was 10,206 (18,689 eyes). A multifocal intraocular lens (IOL) was implanted in 84.3% of eyes; 15.7% of eyes received a monofocal IOL. A total of 1164 AEs were recorded (1112 eyes of 1039 patients, incidence 6.0% of eyes, 1:17 eyes). The most common AE was posterior capsular opacification (PCO; 748 eyes, incidence 4.0%). Of all AEs, 171 events (occurring in 165 eyes of 151 patients, incidence 0.9%, 1:113 eyes) were classified as serious, potentially sight threatening. Loss of 2 or more lines of CDVA was 0.56% when excluding eyes where the loss of CDVA was due to PCO; the majority of these were due to macular causes. Conclusion: The incidence of sight-threatening AEs and significant loss of CDVA in elective refractive lens exchange surgery was low. Other than PCO, postoperative macular issues were the most common cause of vision loss in this cohort.
Purpose: To evaluate the efficacy and complication profile of excimer laser trabeculostomy (ELT), an emerging laser-based trabecular minimally invasive glaucoma surgery (MIGS), combined with cataract surgery in routine clinical practice. Patients and methods: Single-site, retrospective, interventional study. Preoperative and postoperative clinical data of patients with cataract and open-angle glaucoma (OAG) who underwent combined phacoemulsification and ELT were collected and analyzed at preoperative day, one week postoperatively, and after one, two, three, six, nine and 12 months. Main outcome measure was intraocular pressure (IOP). Qualified and complete success were defined as an IOP less than 21 mmHg and an IOP reduction ≥ 20% from preoperative medicated IOP with or without adjuvant medical treatment, respectively. Results: Thirty-four eyes of 29 patients were included; 29 eyes completed 1-year follow-up. The mean preoperative IOP under medications was 20.9 ± 2.6 mmHg (± standard deviation, SD) and decreased significantly at one year (16.3 ± 1.9; p < 0.0001). The mean number of IOP-lowering medications decreased from 1.7 ± 0.7 to 0.3 ± 0.8 (p < 0.0001) at the 12-month follow-up. At one year, 81% of eyes were medication free. Qualified and complete success was obtained in 62% and 58% of eyes, respectively. Two eyes had postoperative hyphema, three eyes had transient IOP spikes and one patient underwent a subsequent filtering surgery at three months. Conclusion: Combining ELT with phacoemulsification in eyes with cataract and mild to moderate OAG significantly reduced IOP and medication use without meaningful complications after one-year follow-up in a real world clinical practice setting.
Article
Purpose of review: To review the current literature on the relationship between cataract extraction and intraocular pressure (IOP). Recent findings: Cataract extraction can be an effective IOP lowering treatment for open and closed angle glaucoma as well as ocular hypertension. In comparative trials studying novel micro-invasive glaucoma surgeries in open angle glaucoma, the control group undergoing cataract extraction alone routinely achieved significant reductions in IOP and medication use postoperatively. Data from the Effectiveness in Angle Closure Glaucoma of Lens Extraction (EAGLE) trials have demonstrated that lens extraction is more effective at lowering IOP than peripheral iridotomy in patients with angle closure and should be considered as first line therapy. Additionally, patients in the ocular hypertension treatment study who underwent cataract extraction over the course of follow-up demonstrated significant IOP lowering sustained over 3 years. Summary: Cataract extraction is an effective method to lower IOP in patients with glaucoma. Pressure lowering is more significant in eyes with narrow angles and those with higher baseline IOP levels. In eyes with angle closure, phacoemulsification alone can lower IOP, but when combined with GSL it may be even more effective. Recent large multicenter randomized trials have further elucidated the benefit of standalone cataract extraction to treat mild to moderate primary open angle glaucoma. Prospective and longitudinal studies that systematically investigate the variables that may influence degree and duration of IOP lowering post cataract extraction are lacking.
Article
PURPOSE To evaluate whether cataract surgery is associated with decreased risks of developing a central retinal vein occlusion (CRVO) or a branch retinal vein occlusion (BRVO) using the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight). DESIGN Retrospective database study of the IRIS Registry data. SUBJECTS Patients in the IRIS Registry who underwent cataract surgery and 1:1 matched controls from the IRIS Registry using a decision tree classifier as a propensity model. METHODS Control and treatment groups were initially selected using CPT codes for uncomplicated cataract surgery and other straightforward criteria. To accomplish treatment-control matching, a decision tree classifier was trained to classify patients as treatment versus control based on a set of chosen predictors for treatment, where best corrected visual acuity and age were the most important predictors. Treatments and controls were subsequently matched using the classifier, the visit dates, and the IDs of the practice. Cox regression was performed on the matched groups to measure the hazard ratio (HR) of developing retinal vein occlusion adjusted for age, sex, race, primary insurance type, and previous diagnosis of diabetic retinopathy (DR), glaucoma, and narrow angles. MAIN OUTCOME MEASURE The HR of developing retinal vein occlusion in patients who underwent cataract surgery compared to matched controls. RESULTS The HRs for developing CRVO and BRVO in patients who underwent cataract surgery compared to matched controls who did not during the first year following either cataract surgery or baseline visit were 1.20 [95%CI, 1.08, 1.34; P < 0.001] and 1.08 [1.00, 1.17; P = 0.05] respectively, after controlling for age, sex, race, insurance, and history of DR, glaucoma and narrow angles. DR was the strongest predictor associated with developing CRVO (2.79 [2.37,3.29; P < 0.001]) and BRVO (1.97 [1.70,2.28; P < 0.001]) after cataract surgery. CONCLUSION Cataract surgery is associated with a small increase in risk of RVOs within the first year; however the incidence is low, and is not likely clinically significant.
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Background/Objectives To describe intraocular pressure (IOP) and ocular hypotensive medication outcomes of combined phacoemulsification and ab interno trabeculectomy with the Kahook Dual Blade (KDB; New World Medical, Inc, Rancho Cucamonga, CA) in adults with cataract and open-angle glaucoma (OAG). Subjects/Methods Retrospective chart review of existing medical records. Data collected included intraocular pressure (IOP) and IOP-lowering medication use preoperatively and through up to 24 months postoperatively. Paired t-tests were utilized to compare preoperative to postoperative mean IOP and mean medications used. Results Data from 32 eyes of 26 subjects were analyzed. Subjects were predominantly Caucasian (25/26) had mean (standard error) age of 79.3 (1.2) years, and eyes had moderate-advanced OAG (mean visual field mean deviation -8.3 [1.3] dB). Mean IOP was 19.8 (0.8) mmHg at baseline and 15.5 (0.6) mmHg (p<0.0001) after mean follow-up of 11.5 (1.0) months; IOP reductions of ≥20% were achieved in 20/32 eyes (62.5%). Mean medication use declined from 2.4 (0.2) medications per eye at baseline to 0.5 (0.2) at last follow-up (p<0.0001); 23/32 eyes (71.9%) were medication-free at last follow-up. No vision-threatening complications were observed. Conclusions Combined phacoemulsification and ab interno trabeculectomy with the KDB safely provided mean IOP reductions of 21.7% and mean IOP medication reductions of 83% after mean follow-up of 12 months in eyes with moderate to advanced OAG. This procedure provides medication-independence in most eyes with statistically and clinically significant IOP reductions.
Article
Aim Comparing outcomes after combined phacoemulsification, two iStents insertion and endocyclophotocoagulation (ECP) versus phacoemulsification-iStents alone. Methods This is a longitudinal retrospective 12 months study in eyes with ocular hypertension or early-to-moderate open angle glaucoma. Level of disease, intraocular pressure (IOP) and tolerance of glaucoma medication were considered before planning surgery. Best-corrected visual acuity (BCVA-logMAR), IOP (mm Hg), number of medications were assessed at baseline, week 1, week 5, month 3, 6, 12 postop. Main outcome: percentage (%) in IOP reduction at 12 months vs medicated baseline. Secondary outcomes: absolute values of IOP/medication reduction, BCVA and postop complications. Results The ICE2 (two iStents-cataract extraction-ECP) group included 63 eyes and Phaco-iStent group included 46 eyes. Baseline IOP was higher in the ICE2 than phaco-iStent group (19.97±4.31 mm Hg vs 17.63±3.86 mm Hg, p=0.004) and mean deviation was lower (−7.20±2.58 dB vs −4.94±4.51 dB, p=0.037). Number of medications were comparable at baseline: 2.22±1.06 (ICE2) vs 2.07±1.02 (phaco-iStent), p=0.442. At month 12 postop, IOP in the ICE2 group decreased 35% from baseline vs 21% in the phaco-iStent group (p=0.03); absolute IOP reduction was significantly lower than baseline in each group (p<0.001), yet final IOP was lower in the ICE2 group than phaco-iStent group (13.05±2.18 mm Hg vs 14.09±1.86 mm Hg, p=0.01). Similar results were found for glaucoma medication (1.24±1.05 in ICE2 group vs 1.39±1.03 in phaco-iStent group, p=0.01). Final BCVA was 0.11±0.18 (phaco-iStent group) vs 0.08±0.08 (ICE2 group), p=0.309. Safety outcomes were comparable between groups. Conclusion ICE2 procedure offers better results in IOP/medication reduction at 12 months than phacoemulsification-iStents alone.
Article
PurposeTo compare the short-term surgical effectiveness and safety profile of ab interno trabeculotomy using 2 types of trabecular hooks.Study designRetrospective comparative study.Patients and methodsA retrospective chart review was performed on Japanese open-angle glaucoma patients who underwent ab interno trabeculotomy with phacoemulsification and who had a 6-month follow-up. Trabeculotomy was performed using 2 kinds of trabecular hooks, the Tanito ab interno Trabeculotomy Micro-hook (TMH) or the Kahook Dual Blade (KDB). The patients’ demographics, preoperative and postoperative intraocular pressures (IOPs), medication scores, and occurrence of complications were analyzed and compared.ResultsFifty-nine eyes with open-angle glaucoma were included in the final analysis. Trabeculotomy was performed using the TMH in 30 eyes (50.8%) and the KDB in 29 eyes (49.2%). Significant decreases in IOP from the baseline (P < 0.001, except for the 1-month time-point in the KDB group, when P < 0.01) after the 1-month time-point and the medication scores (P < 0.001) at all time-points were noted in both groups. However, the percentage changes in the IOP and medication scores from the baseline at each time-point did not differ significantly between the 2 groups, with the exception of the medication score at the 1-month time-point (P < 0.0283). The occurrence of postoperative complications was similar in the 2 groups.Conclusions The present study demonstrates the absence of significant differences in IOP and medication score reductions at almost all time-points between the TMH and KDB groups.
Article
Surgical treatments for glaucoma have relied for decades on traditional filtering surgery such as trabeculectomy and, in more challenging cases, tubes. Antifibrotics were introduced to improve surgical success in patients at increased risk of failure but have been shown to be linked to a greater incidence of complications, some being potentially vision-threatening. As our understanding of glaucoma and its early diagnosis have improved, a more individualised management has been suggested. Recently the term “precision medicine” has emerged as a new concept of an individualised approach to disease management incorporating a wide range of individual data in the choice of therapeutic modalities. For glaucoma surgery, this involves evaluation of the right timing, individual risk factors, targeting the correct anatomical and functional outflow pathways and appropriate prevention of scarring. As a consequence, there is an obvious need for better knowledge of anatomical and functional pathways and for more individualised surgical approaches with new, less invasive and safer techniques allowing for earlier intervention. With the recent advent of minimally invasive glaucoma surgery (MIGS) a large number of novel devices have been introduced targeting potential new sites of the outflow pathway for lowering intraocular pressure (IOP). Their popularity is growing in view of the relative surgical simplicity and apparent lack of serious side effects. However, these new surgical techniques are still in an era of early experiences, short follow-up and lack of evidence of their superiority in safety and cost-effectiveness over the traditional methods. Each year several new devices are introduced while others are withdrawn from the market. Glaucoma continues to be the primary cause of irreversible blindness worldwide and access to safe and efficacious treatment is a serious problem, particularly in the emerging world where the burden of glaucoma-related blindness is important and concerning. Early diagnosis, individualised treatment and, very importantly, safe surgical management should be the hallmarks of glaucoma treatment. However, there is still need for a better understanding of the disease, its onset and progression, the functional and structural elements of the outflow pathways in relation to the new devices as well as their long-term IOP-lowering efficacy and safety. This review discusses current knowledge and the future need for personalised glaucoma surgery.
Article
Purpose To evaluate the efficacy and complication profile of excimer laser trabeculostomy (ELT), an emerging laser-based trabecular minimally invasive glaucoma surgery (MIGS), combined with cataract surgery in routine clinical practice. Patients and methods Single-site, retrospective, interventional study. Preoperative and postoperative clinical data of patients with cataract and open-angle glaucoma (OAG) who underwent combined phacoemulsification and ELT were collected and analyzed at preoperative day, one week postoperatively, and after one, two, three, six, nine and 12 months. Main outcome measure was intraocular pressure (IOP). Qualified and complete success were defined as an IOP less than 21 mmHg and an IOP reduction ≥20% from preoperative medicated IOP with or without adjuvant medical treatment, respectively. Results Thirty-four eyes of 29 patients were included; 29 eyes completed 1-year follow-up. The mean preoperative IOP under medications was 20.9 ± 2.6 mmHg (±standard deviation, SD) and decreased significantly at one year (16.3 ± 1.9; p < 0.0001). The mean number of IOP-lowering medications decreased from 1.7 ± 0.7 to 0.3 ± 0.8 (p < 0.0001) at the 12-month follow-up. At one year, 81% of eyes were medication free. Qualified and complete success was obtained in 62% and 58% of eyes, respectively. Two eyes had postoperative hyphema, three eyes had transient IOP spikes and one patient underwent a subsequent filtering surgery at three months. Conclusion Combining ELT with phacoemulsification in eyes with cataract and mild to moderate OAG significantly reduced IOP and medication use without meaningful complications after one-year follow-up in a real world clinical practice setting.
Article
Purpose Phacoemulsification has been linked to lowered intraocular pressure (IOP) in patients with glaucoma, ocular hypertension, anatomic narrow angles, and in glaucoma suspects, but the magnitude of change has varied. Design Retrospective cohort study. Participants Patients with glaucoma treated from June 2010 through May 2015 who underwent phacoemulsification (surgical group) were matched to patients who did not (nonsurgical group) for age, gender, type of glaucoma, baseline IOP, and number and type of glaucoma medications. Methods Electronic medical record information was used to compare the matched surgical and nonsurgical groups. Main Outcome Measures Change in IOP, change in number of glaucoma medications, and likelihood of a glaucoma procedure within 36 months after phacoemulsification. Intraocular pressure measures were obtained from Goldmann applanation tonometry when available (45%), and otherwise with the iCare tonometer (iCare USA, Raleigh, NC), the Tono-Pen (Reichert Technologies, Depew, NY), noncontact tonometry, and pneumotonometry. Results Among 16 169 matched pairs, average IOP after the index date was lower in the surgical than nonsurgical group throughout follow-up to 36 months. The difference was greatest during months 1 through 18, during which IOP increased by 0.22 mmHg from 16.49 mmHg in the average nonsurgical patient and decreased by 0.99 mmHg from 16.50 mmHg in the average surgical patient (difference in difference, 1.21 mmHg; 95% confidence interval [CI], 1.12–1.30 mmHg). The difference in difference was greatest for patients with ocular hypertension (2.00 mmHg) and for patients with preoperative IOP of 20 mmHg or more (2.46 mmHg). By 30 to 36 months, 5% (95% CI, 4%–6%) fewer surgical patients used an ophthalmic medication. In the surgical group, the odds of selective laser trabeculoplasty were reduced in patients with ocular hypertension (odds ratio [OR], 0.27; 95% CI, 0.10–0.74) or glaucoma suspects (OR, 0.31; 95% CI, 0.20–0.47), whereas the odds of glaucoma surgery were elevated in surgical patients with primary open-angle glaucoma (OR, 1.48; 95% CI, 1.08–2.01). Conclusions The association of phacoemulsification for cataract with IOP reduction was lower than in past referral-based studies. Surgeons should expect to reduce IOP approximately 1 to 2 mmHg with phacoemulsification in patients with preoperative IOP of less than 20 mmHg.
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Purpose: The present study aimed to compare the outcomes of combined phacoemulsification and 360-degree endocyclophotocoagulation with and without goniotomy using a Kahook Dual Blade in patients with glaucoma. Patients and methods: We enrolled 37 patients, 21 of whom underwent combined phacoemulsification with 360-degree endocyclophotocoagulation and goniotomy using a Kahook Dual Blade (tri-modal therapy (T-MT) group). The remaining 16 patients underwent phacoemulsification with endocyclophotocoagulation (bi-modal therapy (B-MT) group). Visual acuity, intraocular pressure, and number of glaucoma medications were recorded before the study and postoperatively on the first day, at week 1, and at 1, 3, 6, 9, and 12 months. Surgical success was defined as an IOP ≤12 mmHg and ≥6 mmHg or an at least 20% reduction in IOP from baseline with (qualified success) or without medications (complete success). Results: Forty-nine eyes were included. Baseline mean IOP was 16.96±3.66 mmHg and 15.64±4.88 mmHg in the T-MT and B-MT groups (p=0.122), respectively. At the 12-month follow-up, mean IOP values were 11.44±2.15 mmHg and 12.45±1.90 mmHg (p=0.031) in the T-MT and B-MT groups, respectively. Complete success rates were 37% in the T-MT group and 31% in the B-MT group, while qualified success rates were 74% and 50%, respectively. Glaucoma medications decreased from 2.0±1.4 to 0.8±1.0 (p<0.001) in the T-MT group and from 1.5±1.3 to 1.0±1.5 in the B-MT group (p=0.032). Similar improvements in visual acuity were observed in both groups. Complications were mild and resolved without intervention. Conclusion: The tri-modal treatment is safe and may be more effective in reducing IOP and glaucoma medication requirements than bi-modal treatment.
Article
Purpose: Elevated intraocular pressure (IOP) is a well-known risk factor in glaucoma development and progression. As most glaucoma risk factors are not modifiable, IOP remains the sole focus of medical and surgical therapy. Identifying modifiable factors and their effects on IOP, such as systemic diseases, is therefore of interest. The objective is to assess the long-term, longitudinal relationship between systemic diseases and IOP mean, peak and variability, including diabetes, hypertension, body mass index (BMI) and smoking status. Design: Secondary analysis of randomized clinical trial data. Methods: Longitudinal IOP and systemic disease data from the Age-Related Eye Disease Study (AREDS), a randomized clinical trial of high-dose antioxidants, was analyzed. Study population: 3909 older participants without a reported diagnosis of glaucoma or glaucoma treatment during AREDS with up to 12-years of annual IOP and systemic disease data. Main outcome measures: Independent systemic disease risk factors associated with IOP. Results: Univariate analysis identified numerous systemic disease factors associated with IOP mean, peak and variability. Longitudinal adjusted models identified diabetes, obesity, and systolic hypertension as significantly associated with increased IOP, while systemic beta-blocker use was inversely associated. Conclusion: Results demonstrate a relationship between multiple systemic diseases and IOP; moreover, they demonstrate systemic diseases influence additional parameters beyond mean IOP, such as IOP peak and variability. Although only to be taken within the context of IOP, these population-level trends reveal potentially modifiable factors in IOP control, and are particularly important in the context of increasing obesity and diabetes prevalence rates in American adults.
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Pur po se: To evaluate the effects of phacoemulsification surgery with primary intraocular lens (IOL) implantation on intraocular pressure (IOP) in various types of glaucoma patients with visually significant cataract and to compare these results with cataract patients without glaucoma. Ma te ri al and Met hod: This retrospective study included consecutive cases of 21 primary open-angle glaucoma patients, 13 primary angle-closure glaucoma (PACG) patients, 11 pseudoexfoliation glaucoma patients, and 21 control eyes without any type of glaucoma; all patients had co-existing cataract. Visual acuities, IOP, number of glaucoma medications used, anterior chamber depth (ACD), and gonioscopic evaluations were noted both pre- and postoperatively. Phacoemulsification and IOL implantations were performed via clear corneal incisions in the whole study group. Study group was followed-up for six months. Re sults: Postoperative visits at the 1st, 3rd, and 6th months were noted. After surgery, visual acuities improved significantly (p=0.001) in all groups. Intraocular pressures decreased in all groups postoperatively, but the change was statistically significant in the PACG group (p=0.013). Increase in ACD was significant in PACG group (p=0.001). Widening of iridocorneal angle and decrease in the number of antiglaucoma drugs were observed in all groups, but these were significant in the PACG group (p=0.001 and p
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Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7]. In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA Completing a Systematic Review Is an Iterative Process The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
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Purpose: To compare the efficacy of different surgical strategies for intraocular pressure (IOP) control in Hispanic glaucoma patients with and without visually significant cataracts. Design: Comparative retrospective consecutive case series. Methods: The charts of 153 consecutive patients with primary open angle glaucoma who underwent either trabeculectomy alone (n = 51), phacotrabeculectomy (n = 51), or phacoemulsification alone (n = 51) were reviewed to compare IOP control, the number of glaucoma medications required postoperatively, and the inci dence of surgical complications. Results: Preoperative IOP was 17.5 ± 5.2 mm Hg in the trabe-culectomy group, 15.4 ± 4.5 mm Hg in the phacotrabeculectomy group and 13.9 ± 2.9 mm Hg in the phacoemulsification group (p < 0.001 for all comparisons). Mean IOP reduction from baseline was 4.2 ± 6.9 (24.6%) for the trabeculectomy group, 2.9 ± 5.0 (20.8%) for the phacotrabeculectomy group, and 0.9 ± 3.4 (6.5%) for the phacoemulsification group (p = 0.009). The number of IOP-lowering medications required postoperatively decreased significantly in all three groups (p = 0.001). The rate of early and late postoperative complications was similar between the trabeculectomy and phacotrabeculectomy groups and less for the phacoemulsification group. Conclusion: Trabeculectomy and phacotrabeculectomy are both viable surgical options for managing open angle glau coma. Both resulted in similar rates of success, IOP reduction, decrease in use of IOP-lowering medications and post operative complication rates. Phacoemulsification alone had a lower success rate and greater need for postoperative IOP-lowering medications compared to trabeculectomy alone or phacotrabeculectomy. Phacoemulsification alone may be a reasonable option for patients with visually significant cataract and lower baseline IOP. How to cite this article: Jung JL, Isida-Llerandi CG, Lazcano-Gomez G, SooHoo JR, Kahook MY. Intraocular Pressure Control after Trabeculectomy, Phacotrabeculectomy and Phaco-emulsification in a Hispanic Population. J Curr Glaucoma Pract 2014;8(2):67-74.
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Purpose . To report the long-term follow-up results in patients with cataract and primary open-angle glaucoma (POAG) randomly assigned to cataract surgery combined with micro-bypass stent implantation or phacoemulsification alone. Methods . 36 subjects with cataract and POAG were randomized in a 1 : 2 ratio to either iStent implantation and cataract surgery (combined group) or cataract surgery alone (control group). 24 subjects agreed to be evaluated again 48 months after surgery. Patients returned one month later for unmedicated washout assessment. Results . At the long-term follow-up visit we reported a mean IOP of 15,9 ± 2,3 mmHg in the iStent group and 17 ± 2,5 mmHg in the control group ( p = N S ). After washout, a 14,2% between group difference in favour of the combined group was statistically significant ( p = 0,02 ) for mean IOP reduction. A significant reduction in the mean number of medications was observed in both groups compared to baseline values ( p = 0,005 in the combined group and p = 0,01 in the control group). Conclusion . Patients in the combined group maintained low IOP levels after long-term follow-up. Cataract surgery alone showed a loss of efficacy in controlling IOP over time. Both treatments reduced the number of ocular hypotensive medications prescribed. This trial is registered with: NCT00847158 .
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PURPOSE: To determine if intraocular pressure plays a part in the pathogenic process of normal tension glaucoma. METHODS: One eye of each eligible subject was randomized either to be untreated as a control or to have intraocular pressure lowered by 30% from baseline, Eyes were randomized if they met criteria for diagnosis of normal-tension glaucoma and showed documented progression or high-risk field defects that threatened fixation or the appearance of a new disk hemorrhage. The clinical course (visual field and optic disk) of the group with lowered intraocular pressure was compared with the clinical course when intraocular pressure remained at its spontaneous untreated level. RESULTS: One hundred-forty eyes of 140 patients were used in this study. Sixty-one were in the treatment group, and 79 were untreated controls. Twenty eight (35%) of the control eyes and 7 (12%) of the treated eyes reached end points (specifically defined criteria of glaucomatous optic disk progression or visual field loss). An overall survival analysis showed a statistically significant difference between the two groups (P < .0001), The mean survival time +/-SD of the treated group was 2,688 +/- 123 days and for the control group, 1,695 +/- 143 days. Of 34 cataracts developed during the study, 11 (14%) occurred in the control group and 23 (38%) in the treated group (P = .0075), with the highest incidence in those whose treatment included filtration surgery. CONCLUSIONS: Intraocular pressure is part of the pathogenic process in normal-tension glaucoma. Therapy that is effective in lowering intraocular pressure and free of adverse effects would be expected to be beneficial in patients who are at risk of disease progression. (Am J Ophthalmol 1998;126:487-497, (C) 1998 by Elsevier Science Tnc. All rights reserved.).
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Glaucoma is a leading cause of irreversible blindness. It is firmly entrenched in the traditional treatment paradigm to start with pharmacotherapy. However, pharmacotherapy is not benign and has been well documented to have a number of significant challenges. Minimally invasive glaucoma surgery (MIGS) that targets the outflow pathway with minimal to no scleral dissection has resulted in the need to reconsider the glaucoma treatment paradigm. To perform a systematic review and meta-analysis to evaluate and quantify the effect on post-operative intraocular pressure (IOP) and number of topical glaucoma medications, in patients receiving the iStent MIGS device as the solo procedure without concurrent cataract surgery. A systematic review was conducted by searching various databases between January 1, 2000, and June 30, 2014. Studies reporting up to a maximum follow-up period of 24 months were retrieved and screened using the EPPI-Reviewer 4 gateway. Percentage reduction in IOP (IOPR%), and mean reduction in topical glaucoma medications after surgery were computed. Meta-analysis was performed using STATA v. 13.0. The standardized mean difference (SMD) was calculated as the effect size for continuous scale outcomes. Heterogeneity was determined using the I2 statistics, Z-value, and χ2 statistics. Fixed-effect and random-effect models were developed based on heterogeneity. Sub-group analysis was performed based on the number of iStents implanted and the follow-up period. The outcome measures were changes in the IOP and number of glaucoma medications. The search strategy identified 105 records from published literature and 9 records from the grey literature. Five studies with 248 subjects were included for quantitative synthesis. A 22% IOP reduction (IOPR%) from baseline occurred at 18-months after one iStent implant, 30% at 6-months after two iStents implantations, and 40% at 6-months after implantation of three iStents. A mean reduction of 1.2 bottles per patient of topical glaucoma medications occurred at 18-months after one iStent implant, 1.45 bottles per patient at 6-months after two iStents, and one bottle of medication per patient was reduced at 6-months following placement of three iStents implants. Meta-analysis results showed a significant reduction in the IOP after one iStent (SMD = -1.68, 95% CI: [-2.7, -0.61]), two iStents (SMD = -1.88, 95% CI: [-2.2, -1.56]), and three iStents (SMD = -2, 95% CI: [-2.62, -1.38]) implantation. Results showed a significant drop in the topical glaucoma medications after one iStent (SMD = -2.11, CI: [-3.95, -0.27]), two iStent (SMD = -1.88, CI: [-2.20, -1.56]), and three iStents (SMD = -2.00, CI: [-2.62, -1.38]) implantation. The maximum reduction in IOP occurred at 12-months (SMD = -2.21, CI: [-2.53, -1.88]) and a significant reduction in post-operative topical glaucoma medications occurred even after 18-months of iStent implantation (SMD = -0.71, CI: [-1.15, -0.26]). iStent implantation as a solo procedure without concurrent cataract extraction does lower IOP, and reduces the dependency on glaucoma medications. This effect seems to last at least 18 months.
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Purpose: Glaucoma is the leading cause of global irreversible blindness. Present estimates of global glaucoma prevalence are not up-to-date and focused mainly on European ancestry populations. We systematically examined the global prevalence of primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG), and projected the number of affected people in 2020 and 2040. Design: Systematic review and meta-analysis. Participants: Data from 50 population-based studies (3770 POAG cases among 140,496 examined individuals and 786 PACG cases among 112 398 examined individuals). Methods: We searched PubMed, Medline, and Web of Science for population-based studies of glaucoma prevalence published up to March 25, 2013. Hierarchical Bayesian approach was used to estimate the pooled glaucoma prevalence of the population aged 40-80 years along with 95% credible intervals (CrIs). Projections of glaucoma were estimated based on the United Nations World Population Prospects. Bayesian meta-regression models were performed to assess the association between the prevalence of POAG and the relevant factors. Main outcome measures: Prevalence and projection numbers of glaucoma cases. Results: The global prevalence of glaucoma for population aged 40-80 years is 3.54% (95% CrI, 2.09-5.82). The prevalence of POAG is highest in Africa (4.20%; 95% CrI, 2.08-7.35), and the prevalence of PACG is highest in Asia (1.09%; 95% CrI, 0.43-2.32). In 2013, the number of people (aged 40-80 years) with glaucoma worldwide was estimated to be 64.3 million, increasing to 76.0 million in 2020 and 111.8 million in 2040. In the Bayesian meta-regression model, men were more likely to have POAG than women (odds ratio [OR], 1.36; 95% CrI, 1.23-1.52), and after adjusting for age, gender, habitation type, response rate, and year of study, people of African ancestry were more likely to have POAG than people of European ancestry (OR, 2.80; 95% CrI, 1.83-4.06), and people living in urban areas were more likely to have POAG than those in rural areas (OR, 1.58; 95% CrI, 1.19-2.04). Conclusions: The number of people with glaucoma worldwide will increase to 111.8 million in 2040, disproportionally affecting people residing in Asia and Africa. These estimates are important in guiding the designs of glaucoma screening, treatment, and related public health strategies.
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Data on causes of vision impairment and blindness are important for development of public health policies, but comprehensive analysis of change in prevalence over time is lacking.
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Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30
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To study the long-term effects of phacoemulsification with intraocular lens (IOL) implantation in nonglaucomatous and glaucomatous eyes. Phillips Eye Institute, Minneapolis, Minnesota, and private practice, Savannah, Georgia, USA. Intraocular pressure (IOP) after phacoemulsification with IOL implantation was retrospectively reviewed. Eyes were divided into 5 groups by preoperative IOP. Data were recorded preoperatively, 1 year postoperatively, and at the final check. Analysis included preoperative IOP versus IOP at 1 year and final IOP, percentage of eyes with elevated or reduced IOP postoperatively, patient age at surgery, and years of postoperative follow-up. The study comprised 124 eyes. The final mean IOP reduction was 8.5 mm Hg (34%) in the 29 to 23 mm Hg group, 4.6 mm Hg (22%) in the 22 to 20 mm Hg group, 3.4 mm Hg (18%) in the 19 to 18 mm Hg group, and 1.1 mm Hg (10%) in the 17 to 15 mm Hg group. In the 14 to 5 mm Hg group, IOP increased by 1.7 mm Hg (15%). Intraocular pressure reduction was proportional to preoperative IOP; the highest preoperative IOPs decreased the most and the lowest increased slightly. One-year IOP reductions were sustained for 10 years and were similar in patients of all ages. The IOP reductions were similar to previously reported reductions in nonglaucomatous eyes, indicating that the aging crystalline lens may be a major cause of ocular hypertension and glaucoma and that phacoemulsification with IOL implantation may help prevent and treat adult glaucoma.
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Poor compliance with medication is a major concern in the management of glaucoma. Improper administration technique can lead to contamination and inaccurate dosing. This study estimates the prevalence and predictors of noncompliance and improper administration technique among Canadian glaucoma patients. Data were collected using a standardized questionnaire. Noncompliance was defined as missing at least 1 drop of medication per week and (or) the inability to accurately describe the medication regimen. Patients were asked to indicate the most common reason for missing medication. Study personnel assessed drop administration technique as patients were applying eye drops. Physicians provided information, including measures of disease stability, regarding the patient's glaucoma. Predictors were assessed using odds ratios from a logistic regression model. 500 patients from 10 centers across Canada participated in the study. Of these, 25.6% reported missing at least 1 drop of medication per week, and 4.2% were unable to accurately describe their medication regimen. The overall proportion of noncompliance was 27.9%. With regard to drop administration, 6.8% missed their eye and 28.8% contaminated the bottle tip; overall, 33.8% demonstrated improper technique. The most common reasons given for missing eye drops were "forgetfulness" and "being away from drops." Formal education limited to elementary school and treatment duration of <5 years increased patient-reported noncompliance. Factors associated with improper administration technique were age 60 years and older and formal education limited to elementary school. Over 50% of the patients surveyed were either noncompliant or demonstrated improper administration technique. Glaucoma patients should be educated on the importance of compliance and instructed on proper drop administration.
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We investigated trabeculotomy ab externo as a means of optimizing intraocular pressure (IOP) control in glaucoma patients having phacoemulsification and implantation of an intraocular lens (IOL). A prospective, randomized, controlled study was performed to evaluate the effect on IOP and the incidence of complications associated with combined phacoemulsification and trabeculotomy ab externo. The study group had the combined procedure, while the control group had only phacoemulsification with IOL implantation. A total of 106 patients were randomized, and the IOP for each group was compared at 3, 6, 12, and 24 months. At two years, the mean IOP reduction was 6.1 mm Hg in the study group and 3.8 mm Hg in the control group (P = .001). There were no complications in the control group. Two complications (2/53 or 3.8%) occurred in the study group: a small tear in Descemet's membrane and a postoperative microhyphema. There was no increase in medication in either the study or control group. Combined phacoemulsification and trabeculotomy ab externo represents an option to lower IOP and potentially reduce the need for pressure-lowering medications in patients with primary open-angle glaucoma and visually significant cataracts.
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Background: Cataract and glaucoma are both common conditions and are often present in the same patient. The incidence of these diseases increases with age. Besides vision impairment, these diseases are associated with decrement in quality of life (QOL). Objective: To study the effect of phacoemulsification surgery on various parameters in patients with glaucoma. Materials and methods: We enrolled 50 eyes of 36 patients with glaucoma and concomitant cataract scheduled for phacoemulsification cataract surgery . A record was made which included number of anti-glaucoma medications, visual acuity (VA), intra-ocular pressure (IOP), anterior chamber depth (ACD), cataract category/grade, visual field (VF) analysis (mean deviation (MD) and pattern standard deviation (PSD) and responses to Indian visual function questionnaires (IND-VFQ). The patients were re-evaluated at one month after cataract extraction and the above parameters were again obtained to compare them with the firs values. Results: The mean age of the patients was 66.34 yrs ± 7.96; 10 eyes (20 %) had angle closure and 40 (80 %) had open angle glaucoma. Following cataract extraction, VA improved, IOP decreased, number of glaucoma medications decreased and AC depth increased. The VF analysis showed that the improvement in MD was significant while changes in PSD were not. The improvements seen in the visual function questionnaires (VFQ) were significant. When these parameters were analyzed based on the types of glaucoma, in the angle closure glaucoma (ACG) group, the decrease of IOP from 15.30 ± 6.18 to 12.70 ± 2.71 was not significant ( p = 0.24). In the open angle glaucoma (OAG) group, the changes in the number of anti-glaucoma medication were not significant. When the parameters were analyzed in subgroups, based on cataract category, nuclear sclerosis and posterior sub-capsular, the VA improved significantly in both and the MD improved in the posterior sub-capsular surgery. Improvement in VFQ's was observed in denser nuclear sclerotic and posterior subcapsular cataracts. Conclusion: Cataract extraction results in significant improvement in vision, IOP reduction, decrease in the number of medications, deepening of AC and in the quality of life in patients with co-existing glaucoma when the cataract is of significant density.
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Purpose of the study: The purpose of the study was to assess the role of significant risk factors and develop a risk-group category related to the trabeculectomy (Trab) failure. Materials and methods: A retrospective cohort study was developed between January 2009 and June 2014. In total, 120 eyes included in this study had a glaucoma diagnosis and undergone to Trab with mitomycin. The main outcome measures were surgical success and failure rate. Multivariate (Cox proportional hazards regression model) analyses were used to examine the predictive value of significant factors. A risk-group category was build based on the number of significant risk factors for patients. The risk group category was tested using the Kaplan-Meier method and log-rank test. Results: With a median follow-up of 33 months (3 to 72 mo), the complete surgical success in 1, 2, 3, and 4 years was 82%, 63.5%, 52%, and 27.6%, respectively. The probability of freedom from a complete surgical failure was 88%, 84.5%, 78%, and 70% in 1, 2, 3, and 4 years, respectively. Glaucoma type (P=0.008), previous ophthalmic surgery (P=0.04), glaucoma medication use ≥3 years (P=0.010) and 4 glaucoma medication use pre-Trab (P=0.038) were identified as risk factors for surgical failure. The probability of freedom of surgical failure in 3 years was 93%, 83%, and 37.6% (P=0.003), for low (no factors), intermediate (1 to 2 factors), and high-risk group (3 to 4 factors). Conclusions: Trab with mitomycin produces satisfactory intraocular pressure control over time. However, several risk factors influence the efficacy of the surgical procedure. Our data show that there seems to exist an additive effect among risk factors with similar pathophysiology.
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Purpose: To determine if intraocular pressure plays a part in the pathogenic process of normal-tension glaucoma. Methods: One eye of each eligible subject was randomized either to be untreated as a control or to have intraocular pressure lowered by 30% from baseline. Eyes were randomized if they met criteria for diagnosis of normal-tension glaucoma and showed documented progression or high-risk field defects that threatened fixation or the appearance of a new disk hemorrhage. The clinical course (visual field and optic disk) of the group with lowered intraocular pressure was compared with the clinical course when intraocular pressure remained at its spontaneous untreated level. Results: One hundred-forty eyes of 140 patients were used in this study. Sixty-one were in the treatment group, and 79 were untreated controls. Twenty-eight (35%) of the control eyes and 7 (12%) of the treated eyes reached end points (specifically defined criteria of glaucomatous optic disk progression or visual field loss). An overall survival analysis showed a statistically significant difference between the two groups (P < .0001). The mean survival time +/-SD of the treated group was 2,688 +/- 123 days and for the control group, 1,695 +/- 143 days. Of 34 cataracts developed during the study, 11 (14%) occurred in the control group and 23 (38%) in the treated group (P = .0075), with the highest incidence in those whose treatment included filtration surgery. Conclusions: Intraocular pressure is part of the pathogenic process in normal-tension glaucoma. Therapy that is effective in lowering intraocular pressure and free of adverse effects would be expected to be beneficial in patients who are at risk of disease progression.
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To determine the difference between predicted and actual refractive outcomes after combined endoscopic cyclophotocoagulation and cataract surgery (phaco-ECP) in patients with open-angle glaucoma (OAG). Retrospective case-control study of patients with OAG who underwent phaco-ECP compared with cataract surgery alone. Eighty-three patients with OAG, aged 55 to 91 years, who underwent a combined phaco-ECP procedure and 58 biometry- and age-matched control patients with OAG who underwent cataract surgery alone. Patient records were retrospectively reviewed at the Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis (St. Louis, Mo.). The primary outcome was the difference in predicted and actual refractive outcomes in patients undergoing either phaco-ECP or standard cataract surgery. Compared with phaco alone, the difference in predicted versus actual postoperative results was more myopic in the phaco-ECP group (0.029, -0.110, and -0.095 vs -0.169, -0.325, and -0.312 [p < 0.05] for Sanders, Retzlaff, Kraff/Theoretical, Hoffer Q, and Holladay, respectively). Moreover, the F test for variability showed significantly more variability in refractive outcomes in the phaco-ECP group compared with standard cataract surgery. Patients undergoing phaco-ECP may have postoperative refractive errors that may vary from that predicted preoperatively more so than in cataract surgery alone. Surgeons may consider analyzing their results to determine whether any adjustment should be made to lens power selection when performing phaco-ECP. Copyright © 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.
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To assess the safety and effectiveness of the Hydrus Microstent (Ivantis, Inc, Irvine, CA) with concurrent cataract surgery (CS) for reducing intraocular pressure (IOP) in open-angle glaucoma (OAG). Prospective, multicenter, randomized, single-masked, controlled clinical trial. One hundred eyes from 100 patients 21 to 80 years of age with OAG and cataract with IOP of 24 mmHg or less with 4 or fewer hypotensive medications and a washed-out diurnal IOP (DIOP) of 21 to 36 mmHg. On the day of surgery, patients were randomized 1:1 to undergo CS with the microstent or CS alone. Postoperative follow-up was at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. Washout of hypotensive medications was repeated at 12 and 24 months. Response to treatment was defined as a 20% or more decrease in washed out DIOP at 12 and 24 months of follow-up compared with baseline. Mean DIOP at 12 and 24 months, the proportion of subjects requiring medications at follow-up, and the mean number of medications were analyzed. Safety measures included change in visual acuity, slit-lamp observations, and adverse events. The proportion of patients with a 20% reduction in washed out DIOP was significantly higher in the Hydrus plus CS group at 24 months compared with the CS group (80% vs. 46%; P = 0.0008). Washed out mean DIOP in the Hydrus plus CS group was significantly lower at 24 months compared with the CS group (16.9±3.3 mmHg vs. 19.2±4.7 mmHg; P = 0.0093), and the proportion of patients using no hypotensive medications was significantly higher at 24 months in the Hydrus plus CS group (73% vs. 38%; P = 0.0008). There were no differences in follow-up visual acuity between groups. The only notable device-related adverse event was focal peripheral anterior synechiae (1-2 mm in length). Otherwise, adverse event frequency was similar in the 2 groups. Intraocular pressure was clinically and statistically significantly lower at 2 years in the Hydrus plus CS group compared with the CS alone group, with no differences in safety. Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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To compare the angle and intraocular pressure (IOP) changes after phacoemulsification between eyes with closed-angle or open-angle glaucoma. Angle measurements using Visante AS-OCT imaging was performed for a prospective cohort of 24 subjects with closed-angle and 30 subjects with open-angle glaucoma before and 3 months after phacoemulsification. IOP measurement was measured at 6 and 12 months after surgery using Goldmann applanation tonometry as secondary outcome measures. Eyes with closed angles were smaller than those with open angles (mean axial length 22.88 vs. 24.11 mm, P<0.001). Mean anterior chamber depth, area, volume, AOD500, AOD750, ARA, TISA500, and TISA750 increased after phacoemulsification in all eyes regardless of preexisting angle status (all P<0.001). Increase in AOD500, AOD750, TISA500, and TISA750 were greater in eyes with open angles compared with closed angles (P=0.03, 0.04. 0.04, 0.04, respectively). Mean IOP decreased by 1.8 and 2.1 mm Hg at 6 and 12 months, respectively, after phacoemulsification for all eyes (P<0.001 for both timepoints compared with preoperative baseline). However, postoperative reduction in the mean IOP was not significantly different between eyes with closed and open angles (Mann-Whitney test P=0.32 at 6 mo and P=0.75 at 12 mo postsurgery compared with preoperative). Angle opening postphacoemulsification was considerable in all eyes. A similar IOP reduction after phacoemulsification was observed in all eyes regardless of angle status.
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Objective To provide the results of the Early Manifest Glaucoma Trial, which compared the effect of immediately lowering the intraocular pressure (IOP), vs no treatment or later treatment, on the progression of newly detected open-angle glaucoma. Design Randomized clinical trial. Participants Two hundred fifty-five patients aged 50 to 80 years (median, 68 years) with early glaucoma, visual field defects (median mean deviation, −4 dB), and a median IOP of 20 mm Hg, mainly identified through a population screening. Patients with an IOP greater than 30 mm Hg or advanced visual field loss were ineligible. Interventions Patients were randomized to either laser trabeculoplasty plus topical betaxolol hydrochloride (n = 129) or no initial treatment (n = 126). Study visits included Humphrey Full Threshold 30-2 visual field tests and tonometry every 3 months, and optic disc photography every 6 months. Decisions regarding treatment were made jointly with the patient when progression occurred and thereafter. Main Outcome Measures Glaucoma progression was defined by specific visual field and optic disc outcomes. Criteria for perimetric progression were computer based and defined as the same 3 or more test point locations showing significant deterioration from baseline in glaucoma change probability maps from 3 consecutive tests. Optic disc progression was determined by masked graders using flicker chronoscopy plus side-by-side photogradings. Results After a median follow-up period of 6 years (range, 51-102 months), retention was excellent, with only 6 patients lost to follow-up for reasons other than death. On average, treatment reduced the IOP by 5.1 mm Hg or 25%, a reduction maintained throughout follow-up. Progression was less frequent in the treatment group (58/129; 45%) than in controls (78/126; 62%) (P =.007) and occurred significantly later in treated patients. Treatment effects were also evident when stratifying patients by median IOP, mean deviation, and age as well as exfoliation status. Although patients reported few systemic or ocular conditions, increases in clinical nuclear lens opacity gradings were associated with treatment (P = .002). Conclusions The Early Manifest Glaucoma Trial is the first adequately powered randomized trial with an untreated control arm to evaluate the effects of IOP reduction in patients with open-angle glaucoma who have elevated and normal IOP. Its intent-to-treat analysis showed considerable beneficial effects of treatment that significantly delayed progression. Whereas progression varied across patient categories, treatment effects were present in both older and younger patients, high- and normal-tension glaucoma, and eyes with less and greater visual field loss.
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Background To evaluate the long-term effects of combined endoscopic cyclophotocoagulation (ECP) and phacoemulsification (phaco) vs. phacoemulsification alone on intraocular pressure (IOP) control and medication reliance in the treatment of mild to moderate glaucoma.DesignRetrospective chart review in private practice setting by glaucoma fellowship trained surgeons.Participants261 eyes in the combined phaco-ECP group with 52 eyes in the phaco alone group.Methods Comparison of phaco-ECP to phaco alone over 36 months.Main Outcome MeasuresFull and qualified success cumulative survival, IOP and medication reliance six to 36 months compared to baseline. Full success was defined as minimum 20% IOP reduction with a decrease of at least one ocular hypertensive medication. Qualified success was defined as IOP no higher than baseline with a decrease of at least one ocular hypertensive medication.ResultsAt 36 months, mean IOP in the combined phaco-ECP group was 14.6 mmHg while the phaco alone group was 15.5 mmHg (P = 0.34). Mean medication reliance in the combined phaco-ECP group was 0.2 medications while the phaco alone group was 1.2 (P <0.001). Full success in the phaco-ECP group was 61.4%; the phaco alone group was 23.3% (P<0.001). Qualified success survival was 72.6% in the phaco-ECP group and 23.3% in the phaco alone group (P <0.001).Conclusions Combined phaco-ECP effectively lowers or maintains IOP and results in ocular hypertensive medication reduction up to 36 months when compared to phaco alone. Therefore phaco-ECP may help to increase medication compliance and reduce glauocma progression in mild to moderate glaucoma.
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Purpose: To compare the outcomes of combined endoscopic cyclophotocoagulation (ECP) and phacoemulsification cataract extraction versus cataract extraction alone in eyes with medically controlled open-angle glaucoma (OAG) and visually significant cataract. Setting: Clinical practices of glaucoma specialists and comprehensive ophthalmologists. Design: Prospective nonrandomized matched-control study. Methods: Consecutive patients with medically controlled OAG and visually significant cataracts were treated with ECP and cataract extraction (study group) or cataract extraction alone (control group). The groups were matched in age and baseline intraocular pressure (IOP). The main outcome measures were the change in IOP and number of glaucoma medications. Secondary measures included visual acuity and postoperative complications. Results: In the study group (n = 80) the mean IOP decreased (baseline: 18.1 mm Hg ± 3.0 [SD]; 1 year: 16.0 ± 2.8 mm Hg; 2 years: 16.0 ± 3.3 mm Hg). The number of glaucoma medications decreased from 1.5 ± 0.8 to 0.4 ± 0.7 (1 year and 2 years). In the control group (n = 80), the mean IOP was 18.1 ± 3.0 mm Hg (baseline), 17.5 ± 3.6 mm Hg (1 year), and 17.3 ± 3.2 mm Hg (2 years). The mean number of glaucoma medications was 2.4 ± 1.0, 1.8 ± 1.2, and 2.0 ± 1.0, respectively. The difference in IOP and medication reduction between the 2 groups was statistically significant at all timepoints. Visual acuity outcomes and complication rates were similar between the 2 groups. Conclusion: Combined ECP and cataract extraction resulted in lower IOP and a greater reduction in glaucoma medications than cataract extraction alone in medically controlled OAG patients with visually significant cataract. Financial disclosures: Proprietary or commercial disclosures are listed after the references.
Article
Background: To examine the efficacy and safety of combined phaco-trabeculectomy in patients with cataract and controlled, open-angle advanced glaucoma and to identify preoperative predictive factors of postoperative glaucoma course. Setting: Departments of Ophthalmology, University of Athens, and General Hospital of Lamia, Greece. Methods: Prospective, interventional, parallel, cluster (units=examinations), randomized clinical study. 60 patients with visually significant cataract, visual field Mean Deviation (MD) worse than -15.0 dB, and preoperative intraocular pressure (IOP), controlled (consistently below 22 mmHg) on topical medications and with no previous ocular surgery, were randomly allocated (1:1) to phacoemulsification alone or phaco-trabeculectomy group. Intention-to-treat analysis was performed to compare the postoperative outcome and adjusted multivariate longitudinal linear regression analysis was performed to identify predictive factors of the main outcome measures, with postoperative visual field MD change up to two years postoperatively. Participant recruiters and data collectors were masked to group assignment. Results: 31 and 29 patients were randomized to phacoemulsification alone and phaco-trabeculectomy groups, respectively. Patients assigned to the phaco-trabeculectomy group experienced a 1.7 mmHg [95% CI:-3.1 to -0.23] reduction in IOP, a 1.4 dB [95% CI: -0.17 to 2.96] improvement in visual fields MD, a 0.6 [95% CI: -1.2 to -0.05] reduction in the number of glaucoma medications needed postoperatively, while the visual acuity improvement was similar between the two groups. Best predictors for visual field MD: degree of nuclear sclerosis, relative afferent pupilary defect (RAPD), preoperative MD deviation from -19.0 dB and preoperative cup-disc ratio deviation from 0.9. The phacoemulsification group experienced more IOP spikes (>25 mmHg) with Odds Ratio (OR) of 0.34 [95% CI: 0.11-1.02]. No patient lost light perception. Conclusion: Phaco-trabeculectomy in advanced, controlled, open-angle glaucoma patients with cataract results in better postoperative visual field MD with no major adverse events.
Article
To evaluate the risk factors for and frequency of an acute intraocular pressure (IOP) elevation (spike) after phacoemulsification in patients with glaucoma. Academic glaucoma clinics and operating rooms. Retrospective case series. Charts of consecutive glaucoma patients without previous incisional glaucoma surgery having phacoemulsification by the same surgeon between August 1996 and July 2012 were reviewed to obtain demographic information, preoperative glaucoma medications, severity and treatment measures, intraoperative course, and postoperative outcomes. A postoperative IOP spike was defined as IOP greater than 50% above baseline IOP. Main outcome measures were the number of eyes with a postoperative IOP spike and risk factors associated with an IOP spike after phacoemulsification. Of 271 eyes (271 patients) included in the study, 45 (17%) had an IOP spike. Risk factors for postoperative IOP spike by multivariate analysis included longer axial length (AL) or associated characteristics (wider angle grade on gonioscopy, deeper anterior chamber, and male sex), higher number of preoperative IOP-lowering medications, previous laser trabeculoplasty, and lack of postoperative oral acetazolamide. One eye (0.4%) required trabeculectomy during the 90-day postoperative period. A significant proportion of glaucoma patients having phacoemulsification had an IOP spike. Patients requiring a higher number of IOP-lowering medications or laser trabeculoplasty for IOP control preoperatively and those with a greater AL should be treated more aggressively with IOP-lowering medication in the immediate postoperative period. No author has a financial or proprietary interest in any material or method mentioned.
Article
This study was conducted to determine how phaco-emulsification and intraocular lens (IOL) implantation influenced intraocular pressure (IOP) in eyes with glaucoma, and glaucoma medication requirements postoperatively. A retrospective clinical analysis was undertaken of 226 eyes of 182 glaucoma patients who had undergone phacoemulsification and IOL implantation. IOP on the first day after operation increased from a preoperative mean of 17.1 mmHg (SD ± 3.9 mmHg) to a mean of 20.7 mmHg (SD ± 9.0 mmHg). One week after operation the average IOP was 17.4 mmHg (SD ± 5.5 mmHg). One year after operation the average IOP had declined to 15.3 mmHg (SD ± 3.1 mmHg). One year after operation 34% of the patients did not need glaucoma medication. If glaucoma is fairly well controlled (mean IOP preoperative 17.1 mmHg) phacoemulsification alone can result in satisfactory IOP control in eyes with capsular and primary open-angle glaucoma.