Phacoemulsification versus Combined Phacotrabeculectomy in Medically Uncontrolled Chronic Angle Closure Glaucoma with Cataracts

doi:10.1016/j.ophtha.2008.12.054

Ophthalmology

Volume 116, Issue 4, April 2009, Pages 725-731.e3

https://doi.org/10.1016/j.ophtha.2008.12.054 Get rights and content

Objective

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

Design

Prospective randomized clinical trial.

Participants

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

Intervention

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

Main Outcome Measures

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

Results

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

Conclusions

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

Financial Disclosure(s)

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

Section snippets

Materials and Methods

The authors obtained prior approval of the study protocol by the Ethics Committees of the Chinese University of Hong Kong, Hong Kong Eye Hospital, United Christian Hospital, and Prince of Wales Hospital. The research protocol adheres to the tenets of the Declaration of Helsinki. The study protocol was registered with the Centre for Clinical Trials of the Chinese University of Hong Kong, which has been recognized by the International Committee of Medical Journal Editors for clinical trial

Patient Demographics and Preoperative Clinical Status

During the study recruitment period from March 2002 to October 2007, 51 medically uncontrolled CACG eyes with coexisting cataract of 51 patients were recruited. Of these 51 eyes, 27 were randomized into the “phaco alone” treatment group and 24 were randomized into the “combined phacotrabeculectomy with adjunctive mitomycin C chemotherapy” treatment group.

Table 3 summarizes the patient demographics. There were more female than male patients in both treatment groups, but the difference between

Discussion

Two sister randomized controlled clinic trials were undertaken in Hong Kong to compare the efficacy in IOP control of cataract extraction alone by phacoemulsification versus combined phacotrabeculectomy with adjunctive mitomycin C chemotherapy in CACG eyes with coexisting cataract. The other study²⁴ focused on the subgroup of CACG eyes with medically controlled IOP before surgery, whereas this study focused on those CACG eyes with medically uncontrolled IOP before surgery. Table 9 (available at

References (25)

R.F. Lowe
Causes of shallow anterior chamber in primary angle-closure glaucoma: ultrasonic biometry of normal and angle-closure glaucoma eyes
Am J Ophthalmol
(1969)
R. Wojciechowski et al.
Age, gender, biometry, refractive error, and the anterior chamber angle among Alaskan Eskimos
Ophthalmology
(2003)
K. Hayashi et al.
Changes in anterior chamber angle width and depth after intraocular lens implantation in eyes with glaucoma
Ophthalmology
(2000)
C.H. Yang et al.
Intraocular lens position and anterior chamber angle changes after cataract extraction in eyes with primary angle-closure glaucoma
J Cataract Refract Surg
(1997)
J. Acton et al.
Extracapsular cataract extraction with posterior chamber lens implantation in primary angle-closure glaucoma
J Cataract Refract Surg
(1997)
F.P. Gunning et al.
Lens extraction for uncontrolled angle-closure glaucoma: long-term follow-up
J Cataract Refract Surg
(1998)
K. Hayashi et al.
Effect of cataract surgery on intraocular pressure control in glaucoma patients
J Cataract Refract Surg
(2001)
D.R. Anderson et al.
Criteria for progression of glaucoma in clinical management and in outcome studies
Am J Ophthalmol
(2000)
J.S. Lai et al.
Incisional surgery for angle closure glaucoma
Semin Ophthalmol
(2002)
R. Bellucci et al.
Filtration and complications after trabeculectomy and after phaco-trabeculectomy
Acta Ophthalmol Scand Suppl
(1997)

C.C. Tham et al.

Results of trabeculectomy with adjunctive intraoperative mitomycin C in Chinese patients with glaucoma

Ophthalmic Surg Lasers Imaging

(2006)

P.J. Foster

The epidemiology of primary angle closure and associated glaucomatous optic neuropathy

Semin Ophthalmol

(2002)

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: Manuscript no. 2008-965.

: Supported by a Direct Grant for Research from the Chinese University of Hong Kong 2004–2005. The funding organization had no role in the design or conduct of this research.

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

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Original articlePhacoemulsification versus Combined Phacotrabeculectomy in Medically Uncontrolled Chronic Angle Closure Glaucoma with Cataracts

Objective

Design

Participants

Intervention

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Materials and Methods

Patient Demographics and Preoperative Clinical Status

Discussion

Am J Ophthalmol

Ophthalmology

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

J Cataract Refract Surg

J Cataract Refract Surg

Am J Ophthalmol

Incisional surgery for angle closure glaucoma

Semin Ophthalmol

Filtration and complications after trabeculectomy and after phaco-trabeculectomy

Acta Ophthalmol Scand Suppl

Results of trabeculectomy with adjunctive intraoperative mitomycin C in Chinese patients with glaucoma

Ophthalmic Surg Lasers Imaging

The epidemiology of primary angle closure and associated glaucomatous optic neuropathy

Semin Ophthalmol

Original article
Phacoemulsification versus Combined Phacotrabeculectomy in Medically Uncontrolled Chronic Angle Closure Glaucoma with Cataracts