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

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

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