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Questions remain in preferred treatment for chronic angle-closure glaucoma with cataract
Ophthalmology. 2008:115(12):2167-2173.
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Combined phacotrabeculectomy may be only marginally better than phacoemulsification alone for chronic angle-closure glaucoma with concomitant cataract, and the combined surgery may be associated with increased complications and a need for additional surgeries.
IOP was lower among patients treated with phacotrabeculectomy and adjunctive mitomycin C compared with phaco alone at each 3-month interval after surgery up to 2 years. The difference was only statistically significant at 1 month and 3 months after surgery.
Moreover, seven eyes among the 37 treated with combined surgery were diagnosed with hypotony; when these seven eyes were excluded from the analysis, the difference in IOP when compared with the 35 eyes treated with phaco alone was only significant at 1 month after surgery.
Combined surgery resulted in 0.8 less topical glaucoma drugs, but there was no difference in best corrected visual acuity between the two groups.
Additional study is needed to determine if the benefits of combined phacotrabeculectomy outweigh the potential risks in this intervention to chronic angle closure with coexisting cataract.
In this study, the medium-term (2- year) data indicate that IOP control with combined phaco-trab is only marginally better than with phaco surgery alone for chronic angle-closure glaucoma with controlled IOP at baseline, and that the additional trabeculectomy surgery does have a cost in terms of added complications. The data, and other studies with similar findings, confirm my personal preference to consider straight phaco in stable cases of chronic angle-closure glaucoma. There is a clear interest in knowing whether the modest gains in IOP obtainable through additional trabeculectomy surgery are associated with better protection of the visual field in the long run; however, this would take a larger study with longer-term follow-up to answer.
– Nathan G. Congdon, MD
OSN Glaucoma Section Member
The authors present an analysis of something many clinicians have suspected and discussed for years. In our attempt to assist and improve the quality of life for our patients, combination surgery always seemed very attractive. This carefully controlled study has great clinical significance and will allow surgeons to separate these procedures in good faith to improve the outcomes for their patients. In my practice, I have abandoned combined phacotrabeculetomy because of the complication rate, and this study assures me that I am going in the right direction. Treating glaucoma earlier and more aggressively with new treatment modalities might limit the damage this terrible disease can inflict on the lives of our patients.
– Steven B. Siepser, MD
OSN Cataract Surgery Section Member