Intraocular Pressure Following Phacoemulsification and Endoscopic Cyclophotocoagulation for Advanced Glaucoma

1-Year Outcomes

Jose Morales, MD; Masaoud Al Qahtani, MD; Rajiv Khandekar, MBBS, MS; Sami Al Shahwan, MD; Sami Al Odhayb, MD; Faisal Al Mobarak, MD; Deepak P. Edward, MD, FACS

Disclosures

J Glaucoma. 2015;24(6):e157-e162. 

In This Article

Abstract and Introduction

Abstract

Purpose: To evaluate changes in intraocular pressure (IOP), vision, and medications at least 1 year after phacoemulsification combined with endocyclophotocoagulation for advanced glaucoma and cataract.

Methods: A retrospective chart review was conducted on patients with advanced glaucoma who underwent phacoemulsification combined with endocyclophotocoagulation at King Khaled Eye Specialist Hospital between 2005 and 2012. Data were collected on patient demographics, type of glaucoma, IOP over time, best-corrected visual acuity, number of glaucoma medications, comorbidities, and previous surgeries. Absolute success was defined as IOP≤15 mm Hg without medication and qualified success was IOP≤15 mm Hg with medications. Statistical significance was indicated by P<0.05.

Results: The study sample comprised 104 eyes (104 patients). Mean follow-up was 17.3±1.8 months. Mean IOP decreased from 17±1.4 mm Hg preoperatively to 14.7±1.3 mm Hg at the last postoperative visit. Absolute success was achieved in 11.9% (95% confidence interval, 5.6–18.2) of the eyes. Qualified success was achieved in 72.3% (95% confidence interval, 63.5–81.0) of the eyes. Best-corrected visual acuity improved by ≥2 lines in 76 (73%) eyes. Eyes with primary open-angle glaucoma had the higher absolute and qualified success rates compared with primary angle-closure and pseudoexfoliation glaucoma (P>0.05). Only 48 (46%) patients required >3 medications for IOP control compared with 78 (75%) patients before surgery.

Conclusions: At ≥1 year postoperatively, the absolute success rate of treating advanced glaucoma by endocyclophotocoagulation and phacoemulsification was low. However, medication burden was reduced. Owing to the significant variation in the success rate based on the type of glaucoma, patients with advanced glaucoma should be carefully selected and counseled.

Introduction

In 1992, endoscopic cyclophotocoagulation (ECP) was introduced as a method to treat glaucoma by ablating the ciliary processes under direct visualization.[1] The safety and efficacy of ECP for lowering intraocular pressure (IOP) has been confirmed in several long-term studies.[2–4] ECP allows direct visualization and application of diode laser energy to the ciliary processes. Hence, it is less likely to produce the pain, inflammation, hypotony, and visual loss that can occur with transscleral cycloablation.[1] In addition, the intraocular approach with ECP allows surgeons to combine ECP with phacoemulsification, thus lowering IOP and reducing the need for medications in patients with cataracts and medically controlled glaucoma.

The advantages of ECP over transscleral cyclophotocoagulation include a more tangible treatment endpoint and the possibility of titrating treatment.[1] ECP has been commonly combined with cataract surgery because the ciliary processes are easily visualized and accessible for treatment during the procedure.[5–9] Other advantages include the lack of a filtration bleb and therefore less complex postoperative management than typically expected with combined cataract surgery and filtration surgery.

Cyclodestructive procedures were typically reserved for end-stage glaucoma cases and/or patients with minimal visual potential. However, the advantages of ECP documented above and less catastrophic complications increased the popularity of combined ECP and cataract surgery in patients with useful visual potential.[5–8] To the best of our knowledge, there are no publications in the peer-reviewed literature on the outcomes of combined phacoemulsification and endocyclophotocoagulation (Phaco/ECP) for advanced glaucomatous damage where lower postoperative IOPs are required and significant postoperative IOP spikes could result in further optic nerve damage or visual loss. Some consider that Phaco/ECP is best suited for mild to moderate glaucoma, as the likelihood of achieving lower IOP targets with this procedure were not possible.[8] However, there may be certain subsets of glaucoma where the risk of failure of glaucoma filtration surgery is high. In such cases, Phaco/ECP might be an alternative procedure for reducing IOP and potentially reducing the burden of medications. In addition, in patient populations with a traditionally high dropout rate postoperatively, Phaco/ECP might be safer.

In this study, we reviewed the changes in IOP, visual acuity, and number of medications after Phaco/ECP in patients with advanced glaucomatous damage and cataract.

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