Intraocular Pressure After Phacoemulsification in Patients With Uncontrolled Primary Open Angle Glaucoma
Intraocular Pressure After Phacoemulsification in Patients With Uncontrolled Primary Open Angle Glaucoma
Intraocular Pressure After Phacoemulsification in Patients With Uncontrolled Primary Open Angle Glaucoma
11-16
Abstract
Rationale (hypothesis). Although cataract and glaucoma represent an increasingly common situation encountered concomitantly,
the management of this association is still debatable.
Objective (aim). We aimed to assess intraocular pressure dynamics after phacoemulsification in patients with uncontrolled primary
open angle glaucoma (POAG).
Methods and Results. The present study was designed as a prospective, non-randomized, cohort study. The study population
comprised of 38 patients with medically uncontrolled POAG who underwent cataract surgery by phacoemulsification between 2011
and 2012. Most of the patients (32/38, 84.2%) needed glaucoma surgery after a variable time (mean time between surgeries was
11.6 +/- 4.18 months). Mean preoperative IOP decreased with 2,1 +/- 3,7 mmHg at 6 months (CI 95% 1.96 to 3.56) and with 1,9 +/3,9 mmHg at 12 months compared with the baseline IOP. Postoperative IOP was statistically significant lower compared with its
preoperative value at 6 months (p=9.11 x 10-8) and at one year (p=9.2 x 10-5). The difference between mean IOP at 6 months and 1
year after cataract surgery was not statistically significant (p>0.05). Preoperatively, all the patients received topical antiglaucoma
therapy. After phacoemulsification, their number did not change statistically significant, but it showed a slight increase. Average
number of topical glaucoma medications used preoperatively was 2.66 + / -0.66, while at 6 months after surgery it was 2.71 + / - 0,75
and at 12 months postoperatively, 2.9 +/- 0.53.
Discussion. IOP decreased statistically significant after phacoemulsification in patients with uncontrolled POAG, but the decrease
was not sufficient for optimal glaucoma management; therefore, many patients needed subsequent glaucoma surgery.
Keywords: intraocular pressure, uncontrolled glaucoma, phacoemulsification
Introduction
Glaucoma and cataract are frequently encountered
in the same patient, their prevalence increasing with age
[1]. An increasing number of patients who present to the
ophthalmologist with symptoms of cataract or glaucoma
are diagnosed with both conditions [2]. Although it is an
increasingly common situation, the management of
combined cataract and glaucoma is still a subject of
debate.
Primary open angle glaucoma (POAG) is one of the
most common forms of glaucoma in adults. Nowadays,
phacoemulsification represents the gold standard for
cataract surgery. The surgical technique assumes small
clear corneal incisions and foldable intraocular lenses,
which greatly reduce the operating time [3]. Several
studies report that cataract surgery lowers intraocular
pressure (IOP) in normal and glaucomatous eyes [4-6]
and some authors consider it a part of glaucoma
management as well.
endpoints
were
average
time
from
the
phacoemulsification to the glaucoma surgery, visual
function after cataract surgery, complications rate, and the
need for antiglaucomatous medication after cataract
surgery.
Study design
The clinical study was designed as a prospective,
non-randomized, cohort study. This study comprised of
eyes with uncontrolled POAG and cataract surgically
treated with phacoemulsification with IOL implantation,
between 2011 and 2012.
Patients selection
The inclusion criteria are listed in Table 1. Only one
eye was considered for each patient. For patients with
POAG affecting both eyes, the eye with higher IOP was
selected, even if the cataract was more advanced in the
other eye.
All the patients presented the diagnostic criteria for
POAG, IOP 21 mmHg, but 28 mmHg, with at least
three topical glaucoma medication (POAG medically
uncontrolled) and clinically significant lens opacities.
Patients selection met the criteria in Table 1.
Exclusion criteria
IOP evaluation
The IOP was measured by using Goldmann
tonometry, the gold standard for IOP assessment.
12
Postoperative follow-up
Postoperative reexaminations were performed after
surgery with the following periodicity: one day, one week,
one month, 3 months, 6 months, 9 months and 12 months
after surgery. Postoperatively, the following parameters
were assessed:
- PIO
- Number of topical antiglaucomatous medication
Target IOP
After glaucoma was diagnosed, we calculated target
IOP for each patient. Target IOP represents the value of
IOP at which it is least likely that glaucoma will progress.
Target IOP should be estimated according to glaucoma
severity; for more severe glaucoma, we should consider
smaller values for target IOP. Studies like Early Manifest
Glaucoma Trial and Collaborative Initial Glaucoma
Treatment Study conclude that target IOP should be with
25%-30% less than the baseline IOP [13-15]. We
calculated target IOP value extracting 30% from baseline
IOP in each patient, but we also considered that this value
should not be greater than 18 mmHg.
Glaucoma medication (number and type)
To perform the statistical analysis, the number of
topical antiglaucoma medication was numerically
quantified, considering the number 1 for each topical
pharmaceutical category. Thus, if patients used betablockers and topical prostaglandin analogs, it was coded
with 2. There were also cases where patients used
preoperatively systemic carbonic anhydrase inhibitors.
Each tablet of acetazolamide 250 mg was coded with 2.
Results
This study comprised 38 eyes with cataract and
medically uncontrolled POAG. The mean age of the
studied population was 71.7+/-8.27 years. The sex ratio
was 61.5% females and 38.5% males.
All the patients underwent cataract surgery
(phacoemulsification with IOL implantation). The vast
majority (32/38, 84.2%) also needed glaucoma surgery
after a variable time (mean time between surgeries was
11.6 +/- 4.18 months). Only 6 patients out of 38 (15.8%)
no longer required trabeculectomy after cataract surgery.
The follow-up period considered in the study was the time
between the cataract surgery and the glaucoma surgery
in 32 patients, and for the rest of 6 patients, the mean
follow up was 23 +/- 8,16 months. We evaluated all the
patients at 6 months and one year; if the glaucoma
surgery was performed, we considered as final IOP the
pressure measured before trabeculectomy.
Eyes were placed into 1 of 3 groups based on
preoperative IOP as it follows: 28 to 27 mmHg (6
patients), 26 to 24 mmHg (13 patients), 23 to 21 mmHg
(19 patients).
Preoperative IOP varied between 21 and 28 mmHg.
Mean preoperative IOP decreased with 2,1 +/- 3,7 mmHg
at 6 months (CI 95% 1.96 to 3.56) and with 1,9 +/- 3,9
mmHg at 12 months compared with the baseline IOP.
Postoperative IOP was statistically significant lower
compared with its preoperative value at 6 months and at
one year (Table 2). The difference between the mean IOP
at 6 months and 1 year after cataract surgery was not
statistically significant (Fig. 1).
Cataract surgery
The phacoemulsification surgery will be briefly
described. All the cataract surgeries were performed
through a small incision of 2.2 mm. The incisions were
made in clear cornea, after corneal incision capsulorhexis
being performed, followed by hydrodissection and
hydrodelineation. The crystalline nucleus was split and
removed by phacoemulsification. The irrigation-aspiration
was used to remove any cortical fragments remaining
after phacoemulsification. All the patients received a
Table 2. Mean IOP changes at 6 months and 1-year follow-up.
Eyes
(number)
Mean age
(years)
Mean
preoperative IOP
(mmHG)
Mean IOP 6
months post
phaco
Mean IOP 1
year post
phaco
P value preop/
6 months
P value
preop/1 year
38
71.7+/-8.27
23.8+/-2.32
21+/-2.1
21.6+/-2.4
9.11 x 10-8
9.2 x 10-5
13
Discussion
The small population size is the main drawback of
our study.
The mean postoperative IOP at 6 and 12 months
was statistically significant lower than the corresponding
preoperative values, and the mean percentage change
from baseline was clinically significant. Despite the
reduction in IOP values after phacoemulsification, the
number of glaucoma medication did not change
significantly, but it showed a slight increase. Our findings
concur with the findings of previous studies that document
improvement
in
glaucoma
control
after
phacoemulsification [16,17]. However, the majority of
studies enrolled patients with no glaucoma or with
medically controlled glaucoma. Therefore, a direct
comparison could not be made, the present study
enrolling only patients with medically uncontrolled
glaucoma.
Although reduction of IOP by a mean of 2.7 mmHg
after cataract surgery was statistically significant, this
small change is often not sufficient to treat the patient with
uncontrolled POAG only by cataract surgery.
Consequently, only 15.8% of the patients did not require
further glaucoma surgery for lowering IOP to the desired
target values.
Previous studies have shown that cataract lens
removal improve glaucoma control by reducing IOP.
Although a clear relationship between cause and effect
has been recorded and checked, the mechanisms by
which cataract surgery influences IOP are not fully
understood. Possible mechanisms can include the
following: reduced aqueous humor secretion, reduced
resistance to aqueous humor efflux, altered
biomechanical barrier or blood-aqueous humor barrier [3].
Other studies demonstrate IOP reduction after cataract
surgery in patients without associated ocular pathology
[18,19]. This may bring some information regarding
pressure reduction mechanisms. If IOP decrease would
be caused by the increase in trabecular outflow, we would
expect a greater decrease of IOP in eyes without
glaucoma compared to patients with POAG, because in
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