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Editors Selection IGR 20-4

Surgical Treatment: Timing of cataract extraction and impaired trab function

Comment by Nathan Radcliffe on:

48125 Cataract Surgery After Trabeculectomy: The Effect on Trabeculectomy Function, Husain R; Liang S; Foster PJ et al., Archives of Ophthalmology, 2011;

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Husain et al. (2146) retrospectively evaluated data from a prospective trial in which 235 patients with glaucoma underwent trabeculectomy and were randomized to receive either intraoperative 5-fluorouracil or placebo to determine whether the timing of cataract extraction is associated with impaired trabeculectomy function. The authors defined failure as IOP > 21 on two consecutive visits three to four months apart. Over a mean follow-up period of only 60 months, 124 (52.7%) patients underwent cataract extraction. A shorter time from trabeculectomy to cataract surgery was significantly associated with a shorter time to trabeculectomy failure (hazard ratio, 1.73 [95% CI, 1.05-2.85]; P=.03). Patients with open-angle glaucoma were about 75% more likely to experience trabeculectomy failure than those with chronic angle-closure glaucoma. While the analysis is sound and the results represent the most robust assessment of this subject to date, a few caveats should be considered. The use of IOP as a surrogate endpoint for trabeculectomy failure has a few limitations.

Early cataract extraction following trabeculectomy is associated with a shorter time to failure of IOP control

Eyes with failed blebs may experience IOP lowering due to the benefits of lens extraction on trabecular meshwork function, and some eyes with functioning blebs may experience elevated IOP due to steroid response or damage to the trabecular meshwork aquired during lens extraction. Finally, the present findings could be expected if cataract formation and trabeculectomy failure had a common (unknown) etiology, and if this is the case then one would be mistaken to assume that delaying cataract extraction after trabeculectomy would be beneficial for bleb longevity.

To formally answer this question, one would have to randomize patients to early versus delayed lens extraction following trabeculectomy. Until that study is performed, this large and well-executed investigation by Husain et al. represents the most compelling evidence that early cataract extraction following trabeculectomy is associated with a shorter time to failure of IOP control.

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