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Klin Monbl Augenheilkd 2017; 234(04): 457-463
DOI: 10.1055/s-0043-100291
Klinische Studie
Georg Thieme Verlag KG Stuttgart · New York

Long-term efficacy of combined phacoemulsification plus trabeculectomy versus phacoemulsification plus excimer laser trabeculotomy

Langzeiterfolg von kombinierter Phakoemulsifikation plus Trabekulektomie im Vergleich zu Phakoemulsifikation plus Excimer-Laser-Trabekulotomie
M. Töteberg-Harms   *
1   UniversityHospital Zurich, Department of Ophthalmology, Zurich, Switzerland
,
J. Wachtl   *
1   UniversityHospital Zurich, Department of Ophthalmology, Zurich, Switzerland
2   Talacker Eye Center Zurich, TAZZ, Zürich, Switzerland
,
C. Schweier
3   Augenklinik, Klinikum Chemnitz
,
J. Funk
1   UniversityHospital Zurich, Department of Ophthalmology, Zurich, Switzerland
,
C. Kniestedt
1   UniversityHospital Zurich, Department of Ophthalmology, Zurich, Switzerland
2   Talacker Eye Center Zurich, TAZZ, Zürich, Switzerland
› Author Affiliations
Further Information

Publication History

Publication Date:
06 March 2017 (online)

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Abstract

Background Combined cataract and glaucoma procedures, and minimally-invasive glaucoma surgery in particular, have gained increasing interest over the past few years. The aim of this study was to compare the long-term efficacy of combined phaco-trabeculectomy (Phaco-Trab) and combined phacoemulsification plus excimer laser trabeculotomy (Phaco-ELT).

Patients and Methods Retrospective, non-randomised, comparative, interventional case series of consecutive patients after Phaco-Trab and Phaco-ELT at the University Hospital of Zurich and the Talacker Eye Center Zurich in Switzerland. Inclusion criteria were diagnosis of glaucoma plus vision-impairing coexisting cataract. Primary outcome measures were change in intraocular pressure (IOP), number of anti-glaucoma drugs (AGDs), and best-corrected visual acuity (BCVA) 1 year and 4 years after the procedure. Secondary outcome measures were surgical complications and requirement of postoperative interventions. Success was defined based on the criteria of the Tube-versus-Trabeculectomy study.

Results Mean age was 76.1 ± 8.6 years (29.2 % males; 47.8 % right eyes). Phaco-Trab (n = 62) decreased median IOP from 22.8 to 13.0 at 1 year and to 14.0 mmHg at 4 years. AGDs were reduced from 2 drugs to 0 AGDs at 1 year and 4 years. Median BCVA improved from 0.2 logMAR to 0.0 logMAR at 1 year and 4 years. Phaco-ELT (n = 51) lowered median IOP from 19.0 to 15.0 at 1 year and to 14.0 mmHg (p = 0.002) at 4 years. AGDs were reduced from 2 drugs to 1 AGD at 1 year and 4 years (p = 0.002). BCVA improved from 0.4 logMAR to 0.1 logMAR after 1 year and 4 years. If not stated otherwise, all changes compared to baseline were highly significant (p < 0.001). No perioperative complications occurred; postoperative interventions were performed in 74 % of Phaco-Trab patients.

Conclusion Both surgical procedures reduced IOP and AGDs and improved BCVA significantly and persistently during the entire follow-up period of 4 years with a good safety profile. This study validates Phaco-ELT as an option when post-operative target pressure in the mid-teens would be adequate, whereas Phaco-Trab would be the treatment of choice when IOP in the low teens is desired.

Zusammenfassung

Hintergrund Kombinierte Katarakt- und Glaukomverfahren, insbesondere die minimalinvasive Glaukomchirurgie (MIGS), gewinnen zunehmend an Bedeutung. Ziel dieser Studie war der Vergleich der Phakotrabekulektomie (Phako-Trab) als gegenwärtiger Goldstandard, mit einem MIGS-Verfahren, der Phakoemulsifikation plus Excimer-Laser-Trabekulotomie (Phako-ELT).

Patienten und Methoden Retrospektive Vergleichsstudie. Einschluss konsekutiver Glaukompatienten nach Phako-Trab oder Phako-ELT zwischen 01/2008 und 11/2009 am UniversitätsSpital Zürich und Talacker Augen Zentrum Zürich. Intraokulardruck (IOD), Anzahl Medikamente (AGD) und Visus (BCVA) wurden 1 und 4 Jahre postoperativ gemessen. Sekundäre Studienendpunkte: perioperative Komplikationen und postoperative Interventionen. Erfolg wurde in Anlehnung an die Tube- vs. Trabekulektomie-Studie definiert.

Ergebnisse Durchschnittsalter 76,1 ± 8,6 Jahre (29,2 % Männer; 47,8 % rechte Augen). Phako-Trab (n = 62) senkte den IOD von 22,8 (Median) auf 13,0 (1 Jahr) und 14,0 mmHg (4 Jahre). AGD-Reduktion von 2 zu 0 AGD nach 1 Jahr und 4 Jahren. BCVA verbessert sich von 0,2 auf 0 logMAR nach 1 Jahr und 4 Jahren. Phako-ELT (n = 51) senkte den IOD von 19,0 auf 15,0 (1 Jahr) und 14,0 mmHg (4 Jahre) (p = 0,002). AGD-Reduktion von 2 zu 1 AGD nach 1 Jahr und 4 Jahren (p = 0,002). BCVA verbessert sich von 0,4 auf 0,1 logMAR nach 1 Jahr und 4 Jahren. Wenn nicht erwähnt, war die Änderung hoch signifikant (p < 0,001). Keine Komplikationen; 74 % der Phako-Trab-Patienten benötigten postoperative Interventionen.

Schlussfolgerungen Beide Verfahren senkten IOD und AGD bzw. verbesserten den Visus stabil und sicher über 4 Jahre. Die Studie validiert die Phako-ELT als Operationsmethode bei mittlerem Ziel-IOD, während die Phako-Trab bei Patienten mit tiefem Zieldruck Methode der Wahl ist.

Key words

glaucoma - intraocular pressure - phacoemulsification - trabeculectomy - micro-invasive glaucoma surgery

Schlüsselwörter

Glaukom - Intraokulardruck - Phakoemulsifikation - Phako-Trabekulektomie - minimal-invasive Glaukomchirurgie

* These authors contributed equally to this work.


 

  • References

  • 1 Oliver JE, Hattenhauer MG, Herman D. et al. Blindness and glaucoma: a comparison of patients progressing to blindness from glaucoma with patients maintaining vision. Am J Ophthalmol 2002; 133: 764-772
    CrossrefPubMedGoogle Scholar
  • 2 Weinreb RN, Khaw PT. Primary open-angle glaucoma. Lancet 2004; 363: 1711-1720
    CrossrefPubMedGoogle Scholar
  • 3 Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol 1996; 80: 389-393
    CrossrefPubMedGoogle Scholar
  • 4 Grant WM, Burke jr. JF. Why do some people go blind from glaucoma?. Ophthalmology 1982; 89: 991-998
    CrossrefPubMedGoogle Scholar
  • 5 Heijl A, Leske MC, Bengtsson B. et al. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol 2002; 120: 1268-1279
    CrossrefPubMedGoogle Scholar
  • 6 Quigley HA. Glaucoma. Lancet 2011; 377: 1367-1377
    CrossrefPubMedGoogle Scholar
  • 7 Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006; 90: 262-267
    CrossrefPubMedGoogle Scholar
  • 8 Resnikoff S, Pascolini D, Etyaʼale D. et al. Global data on visual impairment in the year 2002. Bull World Health Organ 2004; 82: 844-851
    PubMedGoogle Scholar
  • 9 AGIS (Advanced Glaucoma Intervention Study) Investigators. The Advanced Glaucoma Intervention Study: 8. Risk of cataract formation after trabeculectomy. Arch Ophthalmol 2001; 119: 1771-1779
    CrossrefPubMedGoogle Scholar
  • 10 Krupin T, Feitl ME, Bishop KI. Postoperative intraocular pressure rise in open-angle glaucoma patients after cataract or combined cataract-filtration surgery. Ophthalmology 1989; 96: 579-584
    CrossrefPubMedGoogle Scholar
  • 11 Lochhead J, Casson RJ, Salmon JF. Long term effect on intraocular pressure of phacotrabeculectomy compared to trabeculectomy. Br J Ophthalmol 2003; 87: 850-852
    CrossrefPubMedGoogle Scholar
  • 12 Casson RJ, Salmon JF. Combined surgery in the treatment of patients with cataract and primary open-angle glaucoma. J Cataract Refract Surg 2001; 27: 1854-1863
    CrossrefPubMedGoogle Scholar
  • 13 Kuroda S, Mizoguchi T, Terauchi H. et al. Trabeculectomy combined with phacoemulsification and intraocular lens implantation. Semin Ophthalmol 2001; 16: 168-171
    CrossrefPubMedGoogle Scholar
  • 14 Saheb H, Ahmed II. Micro-invasive glaucoma surgery: current perspectives and future directions. Curr Opin Ophthalmol 2012; 23: 96-104
    CrossrefPubMedGoogle Scholar
  • 15 Brandão LM, Grieshaber MC. Update on minimally invasive glaucoma surgery (MIGS) and new implants. J Ophthalmol 2013; 2013: 705915
    PubMedGoogle Scholar
  • 16 Vogel EM, Chase EW, Jackel JL. et al. Fabrication of thin film nonlinear optical glasses using pulsed excimer laser deposition. Appl Opt 1989; 28: 649-651
    CrossrefPubMedGoogle Scholar
  • 17 Toteberg-Harms M, Hanson JV, Funk J. Cataract surgery combined with excimer laser trabeculotomy to lower intraocular pressure: effectiveness dependent on preoperative IOP. BMC Ophthalmol 2013; 13: 24
    CrossrefPubMedGoogle Scholar
  • 18 Toteberg-Harms M, Ciechanowski PP, Hirn C. et al. [One-year results after combined cataract surgery and excimer laser trabeculotomy for elevated intraocular pressure]. Ophthalmologe 2011; 108: 733-738
    CrossrefPubMedGoogle Scholar
  • 19 Pache M, Wilmsmeyer S, Funk J. [Laser surgery for glaucoma: excimer-laser trabeculotomy]. Klin Monatsbl Augenheilkd 2006; 223: 303-307
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Wilmsmeyer S, Philippin H, Funk J. Excimer laser trabeculotomy: a new, minimally invasive procedure for patients with glaucoma. Graefes Arch Clin Exp Ophthalmol 2006; 244: 670-676
    CrossrefPubMedGoogle Scholar
  • 21 Herdener S, Pache M. [Excimer laser trabeculotomy: minimally invasive glaucoma surgery]. Ophthalmologe 2007; 104: 730-732
    CrossrefPubMedGoogle Scholar
  • 22 Gedde SJ, Schiffman JC, Feuer WJ. et al. The tube versus trabeculectomy study: design and baseline characteristics of study patients. Am J Ophthalmol 2005; 140: 275-287
    PubMedGoogle Scholar
  • 23 Kobayashi H, Kobayashi K, Okinami S. A comparison of the intraocular pressure-lowering effect and safety of viscocanalostomy and trabeculectomy with mitomycin C in bilateral open-angle glaucoma. Graefes Arch Clin Exp Ophthalmol 2003; 241: 359-366
    CrossrefPubMedGoogle Scholar
  • 24 Budenz DL, Gedde SJ. New options for combined cataract and glaucoma surgery. Curr Opin Ophthalmol 2014; 25: 141-147
    CrossrefPubMedGoogle Scholar
  • 25 Augustinus CJ, Zeyen T. The effect of phacoemulsification and combined phaco/glaucoma procedures on the intraocular pressure in open-angle glaucoma. A review of the literature. Bull Soc Belge Ophtalmol 2012; (320) 51-66
    PubMedGoogle Scholar
  • 26 Chang L, Thiagarajan M, Moseley M. et al. Intraocular pressure outcome in primary 5FU phacotrabeculectomies compared with 5FU trabeculectomies. J Glaucoma 2006; 15: 475-481
    CrossrefPubMedGoogle Scholar
  • 27 Hudovernik M, Pahor D. Intraocular pressure after phacoemulsification with posterior chamber lens implantation in open-angle glaucoma. Klin Monatsbl Augenheilkd 2003; 220: 835-839
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Kim DD, Doyle JW, Smith MF. Intraocular pressure reduction following phacoemulsification cataract extraction with posterior chamber lens implantation in glaucoma patients. Ophthalmic Surg Lasers 1999; 30: 37-40
    PubMedGoogle Scholar
  • 29 Shingleton BJ, Gamell LS, OʼDonoghue MW. et al. Long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspect and glaucoma patients. J Cataract Refract Surg 1999; 25: 885-890
    CrossrefPubMedGoogle Scholar
  • 30 Shingleton BJ, Pasternack JJ, Hung JW. et al. Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients. J Glaucoma 2006; 15: 494-498
    CrossrefPubMedGoogle Scholar
  • 31 Francis BA, Hong B, Winarko J. et al. Vision loss and recovery after trabeculectomy: risk and associated risk factors. Arch Ophthalmol 2011; 129: 1011-1017
    CrossrefPubMedGoogle Scholar
  • 32 Law SK, Nguyen AM, Coleman AL. et al. Severe loss of central vision in patients with advanced glaucoma undergoing trabeculectomy. Arch Ophthalmol 2007; 125: 1044-1050
    CrossrefPubMedGoogle Scholar
  • 33 Tunc Y, Tetikoglu M, Kara N. et al. Management of hypotony and flat anterior chamber associated with glaucoma filtration surgery. Int J Ophthalmol 2015; 8: 950-953
    CrossrefPubMedGoogle Scholar
  • 34 Olayanju JA, Hassan MB, Hodge DO. et al. Trabeculectomy-related complications in Olmsted County, Minnesota, 1985 through 2010. JAMA Ophthalmol 2015; 133: 574-580
    CrossrefPubMedGoogle Scholar