CLINICAL SCIENCES

SURGEONS CORNER

Phacoemulsification vs Phacotrabeculectomy in Chronic Angle-closure Glaucoma With Cataract

Complications
Clement C. Y. Tham, FRCS; Yolanda Y. Y. Kwong, MRCS; Dexter Y. L. Leung, FRCS; Sze Wing Lam, MRCS; Felix C. H. Li, MRCS; Thomas Y. H. Chiu, FRCS; Jonathan C. H. Chan, FRCS; Dennis S. C. Lam, FRCS, FRCOphth; Jimmy S. M. Lai, MD, FRCOphth

Objective: To compare the complications of phacoemulsification alone vs combined phacotrabeculectomy in chronic angle-closure glaucoma (CACG) with coexisting cataract. Methods: Patients with CACG with coexisting cataract recruited into 2 randomized controlled trials comparing phacoemulsification alone vs combined phacotrabeculectomy were pooled for analysis. The first trial recruited patients with medically controlled intraocular pressure, while the second trial recruited patients with medically uncontrolled intraocular pressure. The 2 trials had otherwise identical study designs. All patients were reviewed every 3 months for 2 years after surgery. The main outcome measure was the surgical complications of phacoemulsification alone vs combined phacotrabeculectomy in CACG eyes with cataract. Results: One hundred twenty-three CACG eyes with cataract from 123 patients were included. Sixty-two CACG

eyes were randomized to receive phacoemulsification alone, and 61 eyes had combined phacotrabeculectomy. In the phacoemulsification group, 5 of the 62 CACG eyes (8.1%) had a total of 5 surgical complications. In the combined phacotrabeculectomy group, 16 of the 61 CACG eyes (26.2%) had a total of 19 surgical complications. The difference in the proportion of eyes with 1 or more surgical complications between the 2 treatment groups was statistically significant (P =.007, Pearson 2 test). There was no statistically significant difference in final visual acuity or glaucomatous progression during the 24month follow-up.
Conclusions : Combined phacotrabeculectomy resulted in significantly more surgical complications than phacoemulsification alone in CACG eyes with coexisting cataract. There was no difference in visual acuity or disease progression between the 2 treatment groups.

Arch Ophthalmol. 2010;128(3):303-311 mentary, so all patients fulfilling the other recruitment criteria would be eligible for recruitment into 1 of these 2 studies. There was no overlap of patients between the 2 studies. It was shown that irrespective of preoperative IOP control, phacoemulsification alone was effective in reducing IOP and the requirement for IOP-lowering drugs in CACG eyes with cataract. Combined phacotrabeculectomy was more effective than phacoemulsification in controlling IOP in these eyes, but the difference was mainly in a decreased requirement for IOP-lowering drugs. This article compares the surgical complications of the 2 surgical procedures in CACG eyes with cataract. To our knowledge, this is the first study directly comparing the surgical complications of phacoemulsification alone vs combined phacotrabeculectomy in CACG eyes with cataract.

Author Affiliations: Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong (Drs Tham, Kwong, Leung, S. W. Lam, Li, Chiu, Chan, and D. S. C. Lam) and Eye Institute, The University of Hong Kong, Queen Mary Hospital (Dr Lai), Hong Kong, China; Hong Kong Eye Hospital (Drs Tham, Kwong, Leung, Li, and D. S. C. Lam) and Department of Ophthalmology, United Christian Hospital (Dr Chan), Kowloon, China; and Prince of Wales Hospital (Drs S. W. Lam and Chiu), Shatin, China.

N EYES WITH CHRONIC ANGLE closure glaucoma (CACG) and coexisting cataract, combined phacotrabeculectomy treats both diseases in a single surgical setting. In recent years, evidence that cataract extraction alone results in significant lowering of intraocular pressure (IOP) in CACG eyes has accumulated.1-12 Cataract extraction alone may thus also treat both diseases at the same time. The 2 randomized controlled trials by our group compared the efficacy in IOP control using phacoemulsification alone vs combined phacotrabeculectomy with adjunctive mitomycin C chemotherapy in eyes with medically controlled11 and medically uncontrolled12 CACG with coexisting cataract. Except for IOP control, the 2 studies had identical recruitment criteria and study designs. The definitions of IOP control of the 2 studies were comple-

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Table 1. Recruitment Criteria

Type Diagnostic criteria for medically controlled CACG Criteria At least 180 of angle closure obliterating pigmented part of trabecular meshwork, whether synechial or appositional, segmented or continuous, in the presence of a patent peripheral iridotomy Requiring IOP-lowering medications, or IOP 21 mm Hg without IOP-lowering medications Visual field loss compatible with glaucoma and/or glaucomatous optic disc changes a Definition of medically controlled in first randomized controlled trial11: IOP 21 mm Hg, with 3 topical drugs (combination drugs counted as 2 drugs) Definition of medically uncontrolled in second randomized controlled trial12: IOP 21 mm Hg despite maximally tolerated medications, or requiring 3 topical drugs for IOP control (combination drugs counted as 2 drugs) By pooling all of the patients from both randomized trials, all CACG eyes with coexisting cataract as defined in this Table, irrespective of the preoperative level of IOP control, were included in this report Presence of nucleus sclerosis, cortical cataract, or subcapsular cataract VA 20/50 and affecting activities of daily living Eyes with CACG and coexisting cataract as defined above Patient able and willing to give informed consent to phacoemulsification or combined phacotrabeculectomy prior to randomization Single functional eye Patients refusing either cataract extraction or trabeculectomy Previous intraocular surgery, with the exception of laser peripheral iridotomy and ALPI

Diagnostic criteria for cataract Inclusion criteria

Exclusion criteria

Abbreviations: ALPI, argon laser peripheral iridoplasty; CACG, chronic angle-closure glaucoma; IOP, intraocular pressure; VA, visual acuity. a Minimal criteria for glaucomatous visual field defect as per the published standard13 are the following: glaucoma hemifield test result outside normal limits, pattern standard deviation with P .05, or a cluster of 3 or more points in the pattern deviation plot in a single hemifield (superior or inferior) with P .05, one of which must have P .01. Any one of the preceding criteria, if repeatable, was considered sufficient evidence of a glaucomatous visual field defect.

METHODS From the randomized controlled trials comparing phacoemulsification alone vs combined phacotrabeculectomy with adjunctive mitomycin C chemotherapy, the 72 cases of medically controlled CACG with cataract11 and the 51 cases of medically uncontrolled CACG with cataract12 were pooled for analysis and reporting of the surgical complications of the 2 procedures during a 2-year follow-up period. We obtained prior approval of the study protocols by the ethics committees of The Chinese University of Hong Kong, Hong Kong Eye Hospital, Prince of Wales Hospital, and United Christian Hospital. The research protocols adhered to the tenets of the Declaration of Helsinki. The studies were registered with the Centre for Clinical Trials of The Chinese University of Hong Kong, which had been recognized by the International Committee of Medical Journal Editors for clinical trial registration (date of access and registration: September 7, 2005 [http://www.cct.cuhk .edu.hk/registry/publictrialrecord.aspx?trialid=CUHK _CCT00043]). Informed consent was obtained from all patients prior to recruitment. The recruitment criteria and methods were as previously described.11,12 The recruitment criteria are summarized in Table 1, and the surgical techniques are described in Table 2. The study designs for the 2 randomized controlled trials were identical except for the inclusion of the definitions of medically controlled and medically uncontrolled in the recruitment criteria (Table 1).

sual field loss. Progression based on changes in glaucomatous optic nerve head morphology was confirmed if 1 or more of the following criteria were fulfilled: (1) increase in vertical cupdisc ratio of 0.1 or more observed at 2 or more separate follow-up visits; (2) appearance of new splinter hemorrhage; (3) appearance of new or extension of old neuroretinal rim notching observed at 2 or more separate clinic visits; and (4) appearance of new or extension of old nerve fiber layer defects observed at 2 or more separate clinic visits. The vertical cup-disc ratio was taken to be the longest vertical cup diameter divided by the longest vertical disc diameter. Progression based on changes in Humphrey automated perimetry was as per the published standard13: the defect was deepened or enlarged if 2 or more points within or adjacent to an existing scotoma had worsened by at least 10 dB; all progression required confirmation on at least 1 subsequent field and clinical correlation with no other explanation for deterioration. Progressions of glaucomatous optic nerve head morphology and glaucomatous visual field loss were not counted as surgical complications in this study.

STATISTICAL ANALYSIS
All statistics were calculated using SPSS version 15.0 statistical software for Windows (SPSS Inc, Chicago, Illinois). Continuous data were expressed as mean (SD) and compared using t test or Mann-Whitney U test as appropriate. Categorical data were expressed in percentages and compared using the Pearson 2 test. P .05 was considered statistically significant. RESULTS

OUTCOME MEASURES
The primary outcome measure was surgical complication. The surgical complications are subdivided into intraoperative complications and postoperative complications for further analysis. Secondary outcome measures included best-corrected visual acuity (BCVA), any progression of glaucomatous optic nerve head morphology, and any progression of glaucomatous vi-

One hundred twenty-three CACG eyes with coexisting cataract from 123 patients were included in this analysis. Seventy-two eyes were medically controlled before surgery11 and 51 eyes were medically uncontrolled.12 Of these 123 eyes, 62 were randomized into the phacoemulWWW.ARCHOPHTHALMOL.COM

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sification treatment group (35 eyes medically controlled before surgery and 27 eyes medically uncontrolled), while 61 eyes were randomized into the combined phacotrabeculectomy treatment group (37 eyes medically controlled and 24 eyes medically uncontrolled). Demographic characteristics of the patients in the 2 treatment groups are summarized in Table 3. There were no statistically significant differences between the 2 treatment groups in age, sex ratio, or laterality of recruited eyes (P .05). The preoperative clinical status of the patients is summarized in Table 4. There were no statistically significant differences between the 2 treatment groups in the preoperative IOP, number of preoperative topical IOPlowering drugs used, preoperative BCVA, preoperative vertical cup-disc ratio, mean deviation or pattern standard deviation in automated perimetry, and proportion of eyes with previous acute angle-closure attack (P .05). All included patients had clinical reviews every 3 months for a minimum of 24 months. In this article, the outcome measures up to 24 months are reported. PRIMARY OUTCOME MEASURES In the phacoemulsification group, 5 of the 62 CACG eyes (8.1%) had a total of 5 surgical complications (including both intraoperative and postoperative complications). In the combined phacotrabeculectomy group, 16 of the 61 CACG eyes (26.2%) had a total of 19 surgical complications (including both intraoperative and postoperative complications). The difference in the proportion of eyes with 1 or more surgical complications between the 2 treatment groups was statistically significant (P =.007, Pearson 2 test). Intraoperative Complications
Table 5 presents the intraoperative complications in the

Table 2. Surgical Techniques

Group Phacoemulsification Technique

2 treatment groups. Four of the 62 eyes in the phacoemulsification group (6.5%) had a total of 4 intraoperative complications, while 3 of the 61 eyes in the combined phacotrabeculectomy group (4.9%) had a total of 3 intraoperative complications (P = .71, Pearson 2 test). Table 6 and Table 7 summarize the clinical outcomes in the eyes with intraoperative complications in the phacoemulsification group and the combined phacotrabeculectomy group, respectively. Table 8 compares the eyes with and without intraoperative complications in the phacoemulsification group. There were no statistically significant differences in preoperative (P =.33, t test) and postoperative (P =.54, t test) BCVA between eyes with and eyes without intraoperative complications. Intraoperative complications were not associated with progression in glaucomatous optic neuropathy (P =.59, Pearson 2 test) or with progression in glaucomatous visual field loss (P = .97, Pearson 2 test). Table 9 compares the eyes with and without intraoperativecomplicationsinthecombinedphacotrabeculectomy group. There were no statistically significant differences in preoperative (P =.23, t test) and postoperative (P =.50, t test) BCVA between eyes with and eyes without intraoperative complications. Intraoperative complications were not as-

Any topical pilocarpine hydrochloride was stopped for 1 wk prior to phacoemulsification (other eye medications were continued up to and beyond phacoemulsification) Corneal incision was used to preserve conjunctiva for future filtration surgery Topical prednisolone acetate, 1%, and topical chloramphenicol were given postoperatively; frequency and duration were dictated by clinical needs Postoperatively, 1 immediate dose of 250 mg of oral acetazolamide was given as prophylaxis against an IOP spike; additional oral acetazolamide could be given to treat an IOP spike as indicated Postoperatively, any glaucoma eyedrops were tapered if the mean IOP at 2 consecutive visits was 21 mm Hg; the order of stopping drugs was the reverse of the order of resuming drugs, ie, adrenergic agonists first, followed by pilocarpine hydrochloride, carbonic anhydrase inhibitors, prostaglandin analogues, and finally -blockers Combined Any topical pilocarpine hydrochloride was phacotrabeculectomy stopped for 1 wk prior to phacotrabeculectomy (other eye medications were continued up to the day of phacotrabeculectomy) Either 1- or 2-site phacotrabeculectomy could be performed depending on the surgeons preference Adjunctive mitomycin C (0.4 mg/mL) was applied to the scleral surface before scleral incision; the standard application duration was 2 minutes, which was increased to 3 minutes if any of the following criteria were present: (1) extensive uveal manipulation anticipated, eg, significant posterior synechiae present, (2) young patient (aged 40 y), (3) previous failed trabeculectomy or phacotrabeculectomy in the fellow eye, or (4) prolonged use of topical IOP-lowering drugs, with conjunctival changes on slitlamp examination Topical prednisolone acetate, 1%, and topical chloramphenicol were given postoperatively; Frequency and duration were dictated by clinical needs Postoperatively, laser suture lysis was performed if there was no bleb and IOP increased to 21 mm Hg Abbreviation: IOP, intraocular pressure.

sociated with progression in glaucomatous optic neuropathy (P =.29, Pearson 2 test) or with progression in glaucomatous visual field loss (P =.72, Pearson 2 test). Postoperative Complications
Table 10 presents the postoperative complications in the 2 treatment groups. One of the 62 eyes in the phacoemulsification group (1.6%) had 1 postoperative complication, while 15 of the 61 eyes in the combined phaco-

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Table 3. Demographic Characteristics of the 2 Treatment Groups

Combined Phacotrabeculectomy With Adjunctive Mitomycin C Chemotherapy 61 (61) 37 24 71.0 (7.6) [55-91] 25/36 27/34

Characteristic Eyes, No. (patients, No.) Eyes medically controlled before surgery, No. Eyes medically uncontrolled before surgery, No. Age, mean (SD) [range], y Male/female, No. Left eye/right eye, No.
a From t test. b From Pearson

Phacoemulsification 62 (62) 35 27 71.2 (7.0) [51-85] 22/40 33/29

P Value

.87 a .53 b .32 b

2 test.

Table 4. Preoperative Clinical Status of the 2 Treatment Groups a

Combined Phacotrabeculectomy With Adjunctive Mitomycin C Chemotherapy 19.3 (5.1) [10 to 32] 2.6 (0.9) [1 to 5] 0.72 (0.34) [0.40 to 2.00] 0.7 (0.2) [0.4 to 1.0] 14.8 (10.2) [2.2 to 32.1] 5.1 (3.2) [1.5 to 12.4] 16 of 61 (26.2)

Clinical Status Preoperative IOP, mm Hg Preoperative IOP-lowering drugs, No. Preoperative best-corrected visual acuity, logMAR Vertical cup-disc ratio Automated perimetry, dB Mean deviation Pattern standard deviation Eyes with previous acute angle-closure attack, No. (%)

Phacoemulsification 19.8 (6.1) [11 to 38] 2.7 (1.0) [1 to 5] 0.78 (0.51) [0.40 to 3.00] 0.7 (0.2) [0.3 to 0.9] 17.5 (11.0) [2.1 to 31.4] 5.2 (3.3) [1.2 to 14.7] 16 of 62 (25.8)

P Value .61 b .56 b .41 b .81 b .21 b .82 b .96 c

Abbreviation: IOP, intraocular pressure. a Values are expressed as mean (SD) [range] unless otherwise indicated. b From t test. c From Pearson 2 test.

Table 5. Intraoperative Complications in the Phacoemulsification Group vs Combined Phacotrabeculectomy Group in Eyes With Chronic Angle-Closure Glaucoma and Coexisting Cataract
No. (%) Phacoemulsification (n = 62) 2 (3.2) 1 (1.6) 1 (1.6) a 4 4 (6.5) Combined Phacotrabeculectomy With Adjunctive Mitomycin C Chemotherapy (n = 61) 2 (3.3) 0 1 (1.6) b 3 3 (4.9)

Intraoperative Complication Posterior capsular rupture Retrobulbar hemorrhage secondary to anesthetic injection Zonular dehiscence Intraoperative complications, total No. Eyes with 1 intraoperative complication c
a Does not require capsular tension ring implantation. b Requires capsular tension ring implantation. c P = .71, Pearson 2 test.

trabeculectomy group (24.6%) had a total of 16 postoperative complications (P .001, Pearson 2 test). Table 11 summarizes the clinical outcomes in eyes with postoperative complications in the combined phacotrabeculectomy group. Both the preoperative and postoperative BCVAs of the single case with postoperative complication in the phacoemulsification group were within 1 SD from the mean of the preoperative and postoperative BCVAs of the eyes without postoperative complications. Postoperative complications were not associated with progression in glaucomatous optic neuropathy (P = .79, Pearson 2 test) or with progression in glaucomatous visual field loss (P =.55, Pearson 2 test) in the phacoemulsification group.

There were no statistically significant differences in preoperative (P =.31, t test) and postoperative (P =.72, t test) BCVAs between eyes with and eyes without postoperative complications in the combined phacotrabeculectomy group. Postoperative complications were not associated with progression in glaucomatous optic neuropathy (P = .31, Pearson 2 test) or with progression in glaucomatous visual field loss (P =.35, Pearson 2 test) in the combined phacotrabeculectomy group. SECONDARY OUTCOME MEASURES At 24 months, the phacoemulsification group had a mean (SD) BCVA of 0.46 (0.49) logMAR (range, 0.00-3.00
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Table 6. Clinical Outcomes in Eyes With Intraoperative Complications in the Phacoemulsification Group a
Topical IOP-Lowering Drugs, No. Preoperative 3 Postoperative 0

BCVA, logMAR Eye No. 1 Complication Posterior capsular rupture Management of Complication Preoperative 1.00 Postoperative 0.70

IOP, mm Hg Preoperative 12 Postoperative 11

Progression GON No GVFL No

Anterior vitrectomy and sulcus implantation of intraocular lens 2 Posterior Anterior vitrectomy capsular and anterior rupture chamber implantation of intraocular lens 3 Retrobulbar Surgery rescheduled hemorrhage and performed with no further secondary to complications anesthetic injection under topical anesthesia 4 Zonular Capsular dehiscence implantation of intraocular lens achieved without capsular tension ring All 62 eyes in group receiving phacoemulsification alone, mean

0.70

0.20

14

13

No

No

1.10

0.54

30

27

No

Yes

1.30

1.00

27

18

No

No

0.80

0.50

19.8

15.2

2.7

1.4

4 of 62 (6.5%)

16 of 62 (25.8%)

Abbreviations: BCVA, best-corrected visual acuity; GON, glaucomatous optic neuropathy; GVFL, glaucomatous visual field loss; IOP, intraocular pressure. a Postoperative indicates 2 years after surgery.

Table 7. Clinical Outcomes in Eyes With Intraoperative Complications in the Combined Phacotrabeculectomy Group a
Topical IOP-Lowering Drugs, No. Preoperative 3 Postoperative 0

BCVA, logMAR Eye No. 1 Complication Posterior capsular rupture Management of Complication Preoperative 1.60 Postoperative 1.00

IOP, mm Hg Preoperative 22 Postoperative 12

Progression GON No GVFL No

Anterior vitrectomy and sulcus implantation of intraocular lens 2 Posterior Anterior vitrectomy capsular and sulcus rupture implantation of intraocular lens 3 Zonular Capsular dehiscence implantation of intraocular lens achieved with capsular tension ring All 61 eyes in group receiving combined phacotrabeculectomy with adjunctive mitomycin C chemotherapy, mean

0.70

0.70

20

13

Yes

No

0.54

0.40

20

11

No

Yes

0.70

0.50

19.3

13.6

2.6

0.3

8 of 61 (13.1%)

15 of 61 (24.6%)

Abbreviations: BCVA, best-corrected visual acuity; GON, glaucomatous optic neuropathy; GVFL, glaucomatous visual field loss; IOP, intraocular pressure. a Postoperative indicates 2 years after surgery.

logMAR), while the combined phacotrabeculectomy group had a mean (SD) BCVA of 0.49 (0.56) logMAR (range, 0.00-3.00 logMAR) (P = .81, t test). Based on our definition of progression of glaucomatous optic neuropathy, 4 of the 62 eyes (6.5%) in the phacoemulsification group had progression of glauco-

matous optic neuropathy at 24 months as compared with 8 of the 61 eyes (13.1%) in the combined phacotrabeculectomy group (P =.21, Pearson 2 test). Based on our definition of progression of glaucomatous visual field loss, 16 of the 62 eyes (25.8%) in the phacoemulsification group had progression of glaucoWWW.ARCHOPHTHALMOL.COM

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Table 8. Comparison of Eyes With and Without Intraoperative Complications in the Phacoemulsification Group
Eyes With Intraoperative Complications (n=4) 1.03 (0.25) [0.70-1.30] 0.61 (0.33) [0.20-1.00] 0 1 (25.0) Eyes Without Intraoperative Complications (n = 58) 0.77 (0.52) [0.40-3.00] 0.45 (0.50) [0.00-3.00] 4 (6.9) 15 (25.9)

Characteristic BCVA, mean (SD) [range], logMAR Preoperative Postoperative at 24 mo Progression in glaucomatous optic neuropathy, No. (%) Progression in glaucomatous visual field loss, No. (%) Abbreviation: BCVA, best-corrected visual acuity. a From t test. b From Pearson 2 test.

P Value .33 a .54 a .59 b .97 b

Table 9. Comparison of Eyes With and Without Intraoperative Complications in the Combined Phacotrabeculectomy Group
Eyes With Intraoperative Complications (n=3) 0.95 (0.57) [0.54-1.60] 0.70 (0.30) [0.40-1.00] 1 (33.3) 1 (33.3) Eyes Without Intraoperative Complications (n = 58) 0.71 (0.32) [0.40-2.00] 0.47 (0.57) [0.00-3.00] 7 (12.1) 14 (24.1)

Characteristic BCVA, mean (SD) [range], logMAR Preoperative Postoperative at 24 mo Progression in glaucomatous optic neuropathy, No. (%) Progression in glaucomatous visual field loss, No. (%) Abbreviation: BCVA, best-corrected visual acuity. a From t test. b From Pearson 2 test.

P Value .23 a .50 a .29 b .72 b

Table 10. Postoperative Complications in the Phacoemulsification Group vs Combined Phacotrabeculectomy Group in Eyes With Chronic Angle-Closure Glaucoma and Coexisting Cataract
No. (%) Combined Phacotrabeculectomy With Adjunctive Mitomycin C Chemotherapy (n = 61) 3 (4.9) 4 (6.6) 2 (3.3) 1 (1.6) 4 (6.6) 1 (1.6) 1 (1.6) 16 15 (24.6)

Postoperative Complication Anterior chamber shallowing requiring anterior chamber reformation Conjunctival wound leak healed with conservative measures Conjunctival wound leak requiring suturing Giant symptomatic bleb requiring surgery Hyphema Overdrainage with choroidal detachment Posterior capsular opacity requiring YAG capsulotomy Postoperative complications, total No. Eyes with 1 postoperative complication a
aP

Phacoemulsification (n = 62) 0 0 0 0 0 0 1 (1.6) 1 1 (1.6)

.001, Pearson 2 test.

matous visual field loss at 24 months as compared with 15 of the 61 eyes (24.6%) in the combined phacotrabeculectomy group (P = .88, Pearson 2 test).
COMMENT

Even though our 2 randomized controlled trials were individually powered to compare IOP control rather than complications, the 2 studies combined provided us with the largest prospective cohort of CACG eyes receiving either procedure as the primary surgical treatment, with follow-up every 3 months for at least 2 years. Our study

confirmed that combined phacotrabeculectomy resulted in significantly more surgical complications, particularly postoperative complications, than phacoemulsification alone in CACG eyes with coexisting cataract. Our study also demonstrated that phacoemulsification in CACG eyes was associated with a higher rate of surgical complications (8.1%) than we would normally expect for phacoemulsification in eyes with cataract alone. Furthermore, approximately 1 in 4 CACG eyes (26.2%) receiving combined phacotrabeculectomy may have 1 or more surgical complications. Even though our study did not demonstrate any statistically significant differences
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Table 11. Clinical Outcomes in Eyes With Postoperative Complications in the Combined Phacotrabeculectomy Group a
Topical IOP-Lowering Drugs, No. Preoperative 3 Postoperative 0

BCVA, logMAR Eye No. 1 Complication Management of Complication Anterior chamber reformation with viscoelastic agent Preoperative 0.54 Postoperative 0.30

IOP, mm Hg Preoperative 30 Postoperative 16

Progression GON No GVFL No

Anterior chamber shallowing requiring anterior chamber reformation 2 Anterior chamber shallowing requiring anterior chamber reformation 3 Conjunctival wound leak healed with conservative measures 4 Conjunctival wound leak healed with conservative measures 5 Conjunctival wound leak healed with conservative measures 6 Conjunctival wound leak healed with conservative measures Shallow anterior chamber requiring anterior chamber reformation 7 Conjunctival wound leak requiring suturing 8 Conjunctival wound leak requiring suturing 9 Giant symptomatic bleb requiring surgery 10 b Hyphema 11 12 13 14 Hyphema Hyphema Hyphema

Anterior chamber reformation with viscoelastic agent

0.70

0.30

14

No

No

Eye patching

0.70

0.18

20

19

No

Yes

Eye patching

0.70

0.40

16

13

No

No

Eye patching

1.00

0.30

18

14

No

No

Eye patching

0.70

0.18

19

15

No

No

Anterior chamber reformation with viscoelastic agent Suturing of conjunctival wound Suturing of conjunctival wound Suturing to reduce size of conjunctival bleb Intense topical steroid administration Intense topical steroid administration Intense topical steroid administration Intense topical steroid administration Resolved with pressure patching 1.60 1.00 22 12 3 0 No No

0.54

0.18

10

15

No

No

1.00

1.00

11

11

No

No

0.40 0.54 2.00 0.70 0.40

1.00 0.40 1.80 0.54 0.18

21 24 20 12 16

22 16 16 10 9

5 2 1 1 1

2 1 0 0 0

No No No No No

Yes No Yes No No

Overdrainage with choroidal detachment YAG capsulotomy 15 Posterior capsular opacity requiring YAG capsulotomy All 61 eyes in group receiving combined phacotrabeculectomy with adjunctive mitomycin C chemotherapy, mean

0.40

0.20

28

14

Yes

Yes

0.70

0.50

19.3

13.6

2.6

0.3

8 of 61 (13.1%)

15 of 61 (24.6%)

Abbreviations: BCVA, best-corrected visual acuity; GON, glaucomatous optic neuropathy; GVFL, glaucomatous visual field loss; IOP, intraocular pressure. a Postoperative indicates 2 years after surgery. b This patient subsequently had needling revision of trabeculectomy performed twice for IOP control.

in visual outcome or glaucomatous progression up to 2 years, surgical complications are no doubt associated with more clinic visits, more operative time, inconveniences,

financial costs to patients and society, and negative emotions for patients and health care professionals. All these should be taken into consideration in addition to the IOPWWW.ARCHOPHTHALMOL.COM

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lowering effects of the 2 procedures when deciding whether to perform combined phacotrabeculectomy or phacoemulsification alone for any patient with CACG. Eyes with CACG pose unique technical challenges to the cataract surgeon. These eyes have characteristically shallow anterior chambers,14-16 which may render anterior chamber surgical maneuvers more difficult and risky. Eyes with CACG, especially those with previous episodes of acute angle closure,17 often have lower corneal endothelial cell density and are therefore more prone to intraoperative and postoperative corneal edema. Previous acute angle closure and long-term use of topical pilocarpine hydrochloride may also have resulted in atrophic iris, smaller pupils, and posterior synechiae. All these characteristics of CACG eyes render cataract extraction technically more challenging and may increase the risk of surgical complications. A few previous studies have reported the apparent IOP-lowering effect of cataract extraction alone by phacoemulsification in CACG eyes,6,7,9,10,18 but to our knowledge only 2 studies have reported the rate and nature of complications of cataract extraction alone by phacoemulsification in a sufficiently large and homogeneous cohort of CACG eyes in detail.10,18 The proportion of eyes with surgical complications in the present study (8.1%) is broadly in line with the proportions in the 2 previously published studies (7.4% and 11.5%). The 2 previous studies did not analyze the effect of surgical complications on IOP control or glaucomatous progression. Earlier studies of cataract extraction in CACG eyes used extracapsular cataract extraction by manual expression of the complete nucleus through a large incision or even used intracapsular cataract extraction.1-5 As these earlier techniques were very different from modern small-incision phacoemulsification, direct comparison is not valid. The results from studies of cataract extraction in eyes with acute angleclosure glaucoma19,20 could also not be extrapolated to CACG eyes. There were 2 published studies reporting the surgical complications of combined phacotrabeculectomy in a sufficiently large cohort of CACG eyes.21,22 The proportion of eyes with 1 or more surgical complications in our study (26.2%) falls between the figures reported by the 2 earlier studies (34.8% and 14.0%). Tow et al22 reported a complication rate of 14.0%. However, the retrospective nature of this case series meant that the surgical complications were not well defined beforehand. There was a possibility of underreporting milder complications. Furthermore, only 23 of the 57 eyes (40.4%) in this series received perioperative antimetabolites, and some of these cases received 5-fluorouracil. In this case series, there was no direct comparison of the IOP and the requirement for IOP-lowering drugs before and after surgery, so the efficacy in improving IOP control of the procedure was uncertain. Other published studies reporting the surgical complications of combined phacotrabeculectomy included different types of glaucoma.23-27 These studies either did not report the complication rate in each glaucoma type separately24,25,27 or included only a very small number of CACG cases.26 The rate of surgical complications of combined phacotrabeculectomy in mixed glaucoma types ranged from 17.0%27 to 23.1%.24

In addition to the surgical complications described earlier, there were also near complications in our study. These were mildly undesirable situations that resolved spontaneously and had no observable lasting effects. They were not counted as complications. These included 3 cases of intraoperative bleeding from the iris after posterior synechialysis and stretching of the pupil with iris hooks (1 case in the phacoemulsification group and 2 cases in the combined phacotrabeculectomy group). The bleeding stopped spontaneously during surgery in all 3 cases, and no gross hyphema or further complications arose from the bleeding during follow-up. In the combined phacotrabeculectomy group there were 4 cases (6.6%) of severe anterior chamber inflammation during the early postoperative period, but all 4 cases resolved with intensive topical steroid therapy with no further complications. In the combined phacotrabeculectomy group, there were also 7 cases of postoperative hypotony (IOP 6 mm Hg at 1 postoperative time point) as previously reported.11 In 2 of the 7 eyes, there was temporary anterior chamber shallowing that resolved spontaneously. As all 7 eyes had only temporary hypotony that resolved without further intervention and no hypotony maculopathy or other complications arose from the hypotony, these 7 cases were not counted as surgical complications. Failure to control IOP was not counted as a surgical complication. In our series, 4 of the 62 cataract extraction eyes (6.5%) required a subsequent trabeculectomy to control IOP. It would be interesting to compare the rates of surgical complications between trabeculectomy in pseudophakic eyes and combined phacotrabeculectomy. To our knowledge, no published studies in the literature directly compared these 2 surgical scenarios. Based on data from different case series, the risk of most filtration-related complications such as hypotony and hyphema appeared to be comparable between the 2 procedures.21,28-32 The ultimate goal for any glaucoma intervention is to halt progression of the disease. Glaucomatous progression was not counted as a surgical complication in this study. There was no statistically significant difference in the proportion of eyes with progression in glaucomatous optic neuropathy (P =.21, Pearson 2 test) or visual field loss (P =.88, Pearson 2 test) between the 2 treatment groups despite the difference in IOP control. Furthermore, intraoperative and postoperative complications were also shown to not be associated with glaucomatous optic neuropathy progression or visual field loss progression (P .05, Pearson 2 test) in either treatment group (Table 8 and Table 9). Nevertheless, the sample size may be too small to detect any small differences. The 24-month follow-up period may also be too short to reveal differences in progression. These are no doubt inherent weaknesses of this study in addition to those previously discussed.11,12 Phacoemulsification alone is associated with significantly fewer surgical complications, especially postoperative complications, than combined phacotrabeculectomy with adjunctive mitomycin C chemotherapy in CACG eyes with coexisting cataract. Submitted for Publication: June 26, 2009; final revision received September 9, 2009; accepted October 5, 2009.
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Correspondence: Clement C. Y. Tham, FRCS, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Eye Hospital, 147K Argyle St, Kowloon, Hong Kong, China (clemtham@hkstar.com). Financial Disclosure: None reported. Funding/Support: This work was supported by a direct grant for research from The Chinese University of Hong Kong, 2004-2005. Role of the Sponsor: The funding organization had no role in the design or conduct of this research.
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1. Acton J, Salmon JF, Scholtz R. Extracapsular cataract extraction with posterior chamber lens implantation in primary angle-closure glaucoma. J Cataract Refract Surg. 1997;23(6):930-934. 2. Greve EL. Primary angle closure glaucoma: extracapsular cataract extraction or filtering procedure? Int Ophthalmol. 1988;12(3):157-162. 3. Gunning FP, Greve EL. Uncontrolled primary angle closure glaucoma: results of early intercapsular cataract extraction and posterior chamber lens implantation. Int Ophthalmol. 1991;15(4):237-247. 4. Gunning FP, Greve EL. Lens extraction for uncontrolled angle-closure glaucoma: long-term follow-up. J Cataract Refract Surg. 1998;24(10):1347-1356. 5. Wishart PK, Atkinson PL. Extracapsular cataract extraction and posterior chamber lens implantation in patients with primary chronic angle-closure glaucoma: effect on intraocular pressure control. Eye (Lond). 1989;3(pt 6):706-712. 6. Di Staso S, Sabetti L, Taverniti L, Aiello A, Giuffre I, Balestrazzi E. Phacoemulsification and intraocular lens implant in eyes with primary angle-closure glaucoma: our experience. Acta Ophthalmol Scand Suppl. 2002;236:17-18. 7. Ge J, Guo Y, Liu Y, et al. New management of angle-closure glaucoma by phacoemulsification with foldable posterior chamber intraocular lens implantation. Yan Ke Xue Bao. 2000;16(1):22-28. 8. Hayashi K, Hayashi H, Nakao F, Hayashi F. Effect of cataract surgery on intraocular pressure control in glaucoma patients. J Cataract Refract Surg. 2001; 27(11):1779-1786. 9. Kubota T, Toguri I, Onizuka N, Matsuura T. Phacoemulsification and intraocular lens implantation for angle closure glaucoma after the relief of pupillary block. Ophthalmologica. 2003;217(5):325-328. 10. Lai JS, Tham CC, Chan JC. The clinical outcomes of cataract extraction by phacoemulsification in eyes with primary angle-closure glaucoma (PACG) and coexisting cataract: a prospective case series. J Glaucoma. 2006;15(1):47-52. 11. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification vs combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma with cataract. Ophthalmology. 2008;115(12):2167-2173, e2. 12. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification vs combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts. Ophthalmology. 2009;116(4):725-731, e3. 13. Anderson DR, Chauhan B, Johnson C, Katz J, Patella VM, Drance SM. Criteria for progression of glaucoma in clinical management and in outcome studies. Am J Ophthalmol. 2000;130(6):827-829. 14. Tham CC, Leung DY, Kwong YY, Li FC, Lai JS, Lam DS. Effects of phacoemul-

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Correction Errors in Byline and Text. In the Ophthalmic Molecular Genetics article titled Association Between Erythropoietin Gene Polymorphisms and Diabetic Retinopathy by Abhary et al, published in the January issue of the Archives (2010;128[1]:102-106), the first authors first name was misspelled. It should have been Sotoodeh Abhary, MBBS, not Scotoodeh Abhary, MBBS. Also, in the Comments section, the last sentence of the fourth paragraph on page 105 should have been deleted.

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Submitted for Publication: October 5, 2009; final revision received December 16, 2009; accepted January 7, 2010. Correspondence: Chan Yun Kim, MD, PhD, Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea (kcyeye@yuhs.ac). Financial Disclosure: None reported.
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Correction Error in Title. In the Clinical Sciences article titled Phacoemulsification vs Phacotrabeculectomy in Chronic Angle-closure Glaucoma With Cataract Complications by Tham et al, published in the March issue of the Archives (2010;128[3]:303-311), the title should have appeared as Phacoemulsification vs Phacotrabeculectomy in Chronic Angle-closure Glaucoma With Cataract: Complications. Online versions of this article on the Archives of Ophthalmology Web site were corrected on July 14, 2010.

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