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Phaco effective in reducing IOP for PACG patients
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Phacoemulsification resulted in small and moderate intraocular pressure reductions in primary open-angle glaucoma and pseudoexfoliation glaucoma patients, respectively, according to a study recently published in Ophthalmology.
Chen and colleagues also reported that the procedure resulted in a marked IOP reduction for primary angle-closure glaucoma (PACG) patients.
Researchers identified 32 studies from PubMed and Cochrane that met their inclusion criteria and rated them by American Academy of Ophthalmology standards. The studies were used to determine how phacoemulsification affected glaucoma medication use as well as IOP in PACG, primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG) patients.
Results showed that acute PACG patients saw a 71% reduction in IOP after phacoemulsification and rarely needed long-term glaucoma medications. Comparatively, chronic PACG patients saw a 30% drop in IOP and 58% reduction in glaucoma medications, PXG patients saw a 20% drop in IOP and 35% reduction in glaucoma medications, and POAG patients saw a 13% drop in IOP and 12% reduction in glaucoma medications.
"For patients with acute PACG, phacoemulsification performed soon after initial medical reduction of IOP seems to be highly effective in maintaining reduction of IOP, and most patients did not require medication for IOP control afterward," the authors concluded. “However, the number of studies and patients on this topic is small, and this is the principal limitation of this assessment.
“Given the uniformly positive results reported and the relative strength of the evidence (three of four studies were prospective), patients who have had an acute PACG attack and whose IOP has been decreased with medications to a normal level, and who have had improvement in acute inflammation, could be offered phacoemulsification with the possible benefit of reducing the likelihood that chronic PACG would develop in the affected eye,” they continued. “Consideration should be given to complications after surgery commonly seen in eyes with short axial length, shallow anterior chamber depth and, often, relatively dense cataracts. Although these complications, including corneal edema and decompensation, can be vision threatening, for most patients they are not persistent." – by Chelsea Frajerman
Disclosures: Chen is a consultant/advisor for Allergan. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Derek MacDonald, OD, FAAO
Whereas lens-based glaucoma surgery has gained acceptance in the treatment of primary angle-closure glaucoma, its role in medically managed open-angle glaucoma remains uncertain and controversial, according to Walland and Thomas. Although there are a few randomized controlled trials to inform our decision-making regarding cataract extraction to lower IOP, several trends seem to be emerging.
Patients with higher pre-cataract extraction IOPs, including those with exfoliation, experience greater postoperative IOP decreases, equivalent to an additional topical medication or selective laser trabeculoplasty.
Conversely, patients with lower pre-cataract extraction IOPs, including those with normal-tension glaucoma, demonstrate less IOP reduction. In fact, a significant minority experience a post-cataract extraction IOP increase.
While not part of this review, cataract extraction combined with minimally invasive glaucoma surgery (MIGS) may reduce IOP and the need for medications in early to moderate glaucoma more than cataract extraction alone, with minimal increase in risk and no impact on future filtration surgery.
Although many questions have yet to be answered, we may be witnessing another shift in the traditional glaucoma treatment paradigm, from “medicine before laser before surgery” to “medicine and/or laser and/or cataract extraction with/without MIGS before incisional surgery.” Stay tuned.
Reference:
Walland MJ, Thomas R. J Cataract Refract Surg. 2015;41(1):247-248.
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