Surgical strategies for coexisting glaucoma and cataract: An evidence-based update

doi:10.1016/S0161-6420(02)01267-8

Ophthalmology

Volume 109, Issue 10, October 2002, Pages 1902-1913

https://doi.org/10.1016/S0161-6420(02)01267-8 Get rights and content

Abstract

Objective

To assess short- and long-term control of intraocular pressure (IOP) with different surgical treatment strategies for coexisting cataract and glaucoma.

Design

Systematic literature review and analysis.

Method

We performed a search of the published literature to identify all eligible articles pertaining to the surgical management of coexisting cataract and glaucoma in adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting different approaches was graded by consensus as good, fair, weak, or insufficient.

Main outcome measures

Short-term (24 hours or fewer) and long-term (more than 24 hours) IOP control.

Results

The evidence was good that long-term IOP is lowered more by combined glaucoma and cataract operations than by cataract operations alone. On average, the IOP was 3 to 4 mmHg lower in the combined groups with fewer medications required. The evidence was weak that extracapsular cataract extraction (ECCE) alone results in short-term increase in IOP and was insufficient to determine the short-term impact of phacoemulsification cataract extraction (PECE) on IOP in glaucoma patients. The evidence was weak that short-term IOP control was better with ECCE or PECE combined with an incisional glaucoma procedure compared with ECCE or PECE alone. The evidence was also weak (but consistent) that long-term IOP is lowered by 2 to 4 mmHg after ECCE or PECE. Finally, there was weak evidence that combined PECE and trabeculectomy produces slightly worse long-term IOP control than trabeculectomy alone, and there was fair evidence that the same is true for ECCE combined with trabeculectomy.

Conclusions

There is strong evidence for better long-term control of IOP with combined glaucoma and cataract operations compared with cataract surgery alone. For other issues regarding surgical treatment strategies for cataract and glaucoma, the available evidence is limited or conflicting.

Section snippets

Methods

We searched the literature to identify articles addressing the management of glaucoma patients with coexisting cataract. The methods used to identify and select the studies to be included in this report are described in detail elsewhere.1 Briefly, the search was restricted to studies published from 1964 through March 2000 on adult patients with glaucoma and cataract. Several literature sources were used to identify all studies that potentially were relevant to the surgical treatment of patients

Results

The initial search identified 919 citations possibly addressing the study topic, of which 131 citations were deemed eligible for full article review. Abstracts were ineligible for full article review if they were not applicable to the study questions (1.8% of excluded abstracts), if the citation met an exclusion criterion (98% of excluded abstracts), or for a combination of the above. Twenty-one of the 131 citations deemed eligible for full review based on the abstracts were later found to be

Discussion

Our systematic review of the literature regarding the short- and long-term control of IOP after surgical management of patients with coexisting cataract and glaucoma offers important insights into the state of knowledge regarding the optimal treatment of these individuals. Table 4 summarizes the evidence in support of the major findings.

The current report has potential limitations. Although effort was made to include multiple sources in the literature search, including electronic databases and

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Effectiveness of Trabeculectomy and Tube Shunt with versus without Concurrent Phacoemulsification: Intelligent Research in Sight Registry Longitudinal Analysis
2023, Ophthalmology Glaucoma
To determine the effectiveness of trabeculectomy and glaucoma drainage device (GDD) surgery performed with concurrent phacoemulsification compared with stand-alone procedures.
Multicenter retrospective cohort study.
Patients in the Intelligent Research in Sight Registry who underwent trabeculectomy or GDD from 2013 through 2019.
The Kaplan-Meier survival analysis was used to determine reoperation rates. Reoperation was defined as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine reoperation risk factors.
Reoperation rate, intraocular pressure (IOP), visual acuity, reoperation procedure type, postoperative complications, and predictors of surgical failure.
A total of 117 697 eyes undergoing glaucoma surgery alone and 35 657 eyes undergoing surgery with phacoemulsification were included. The cumulative reoperation rates at postoperative years 1 and 3 were 4.9% and 11.5%, respectively, for trabeculectomy alone and 3.0% and 7.3%, respectively, for trabeculectomy combined with phacoemulsification (P < 0.001). The reoperation rates at postoperative 1 and 3 years were 3.8% and 7.8%, respectively, for GDD alone and 2.1% and 5.4%, respectively, for GDD with phacoemulsification (P < 0.001). Stand-alone procedures achieved greater IOP reduction by percentage change from baseline (trabeculectomy alone, 35.3% vs. trabeculectomy with phacoemulsification, 23.1%, P < 0.001; and GDD alone, 36.0% vs. GDD with phacoemulsification, 29.3%; P < 0.001). Visual acuity improved by 0.12 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI], 0.11–0.12) and 0.10 logMAR (95% CI, 0.08–0.11) after trabeculectomy and GDD with phacoemulsification and declined by 0.15 logMAR (95% CI, 0.14–0.15) and 0.12 logMAR (95% CI, 0.11–0.12) after stand-alone trabeculectomy and GDD. The overall documented complication rate was 2.9% for GDD and 1.4% for trabeculectomy. Age, sex, race, ethnicity, baseline IOP, and glaucoma diagnosis and severity were associated with surgical failure risk. The most common reoperation procedure was GDD.
Reoperation rates within the first 3 years after trabeculectomy and GDD with and without phacoemulsification were low. Trabeculectomy and GDD with phacoemulsification had lower reoperation rates than those with stand-alone procedures. However, stand-alone procedures resulted in greater IOP reduction compared with combined procedures. Postoperative complications were uncommon overall. Patient age, sex, race, ethnicity, baseline IOP, and glaucoma diagnosis and severity were associated with surgical success.
Cataract surgery and Hydrus stent implantation in juvenile open-angle glaucoma: A case report
2022, Journal of the National Medical Association
To report a case of a patient with juvenile-onset open-angle glaucoma (JOAG) who was successfully treated with combination cataract extraction and Hydrus stent implantation.
An interventional case report.
The patient underwent cataract surgery and Hydrus stent implantation in the right eye. Preoperative intraocular pressure (IOP) was 25 mmHg in the right eye (OD) and 21 mmHg in the left eye (OS). Best-corrected visual acuities (BCVA) were 20/80 in the right eye and 20/200 in the left eye. Postoperatively, vision improved to 20/40 in the right eye with an IOP of 14 mmHg after 21 months follow up. No device-related complications were observed.
Cataract surgery in combination with the Hydrus stent implant effectively lowers intraocular pressures and can be used to surgically manage patients with JOAG. This intervention is a probable adjunct or substitute to first line treatments such as trabeculotomy.
Intraocular Pressure Reduction after Phacoemulsification: A Matched Cohort Study
2021, Ophthalmology Glaucoma
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.
Retrospective cohort study.
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.
Electronic medical record information was used to compare the matched surgical and nonsurgical groups.
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.
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).
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.
Comparison of bleb morphologies between phacoemulsification combined with Ex-PRESS mini shunt implantation, phacotrabeculectomy and trabeculectomy alone: a two-year retrospective in vivo confocal microscopy study
2024, BMC Ophthalmology
Combined versus standalone XEN45 Gel Stent implantation in either phakic or pseudophakic patients: a case-matched study
2024, Graefe's Archive for Clinical and Experimental Ophthalmology
Comparison of the safety and efficacy of Mitomycin C 0.02% used intra-operatively by subconjunctival injection versus direct scleral application using sponges in phacotrabeculectomy: A prospective randomized controlled trial
2024, Indian Journal of Ophthalmology

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^☆: Supported by the National Eye Institute, Bethesda, Maryland (grant nos.: K23-EY00358 [DSF], K23-EY00386 [JHK], K23-EY00388 [NC]); and Research to Prevent Blindness, Inc., New York, New York (Robert E. McCormick Award [DSF] and Career Development Award [NC]).

¹: This article is based on research conducted by the Johns Hopkins University Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (formerly, Agency for Health Care Policy and Research), contract no. 290-97-0006, Rockville, Maryland. The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the United States Department of Health and Human Services.

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Article for CME creditSurgical strategies for coexisting glaucoma and cataract: An evidence-based update1 ☆,

Abstract

Objective

Design

Method

Main outcome measures

Results

Conclusions

Section snippets

Methods

Results

Discussion

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