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Editors Selection IGR 22-1

Surgical Treatment: Deep Sclerectomy

Comment by Philippe Denis on:

Mercieca et al. report the long-term outcomes of combined phacoemulsification and deep sclerectomy (DS). This retrospective review was comprised of 296 eyes from 282 consecutive glaucoma patients (mainly, with POAG) which were identified from a surgery database over a ten-year period and underwent a combined surgery with phaco-DS. Two levels of IOP success criteria were defined: (A) IOP < 19 mmHg and/or 20% decrease from baseline and, a more stringent level, (B) IOP < 16 mmHg and/or 30% decrease from baseline.

Mean age at time of surgery was 80.3 ± 6.6 years and mean follow-up was 63.5 ± 35.3 months. It is noteworthy that nearly half of the patients (45.7%) died during the observation period, and this result may simply reflect the increased population age of patients in this retrospective study. Kaplan-Meier success rates in all eyes for criteria A were 89.1% and 80% with glaucoma medications (qualified success) and 81.2% and 68.3% without medications (unqualified success) at two and five years, respectively. Qualified success for criteria B was 72.4 and 61.4% and unqualified rates were 67.2 and 55.2% for the same time periods. At last follow-up, 20% of eyes were on glaucoma medications.

Mitomycin C was applied in 49% of patients, but the decision of use MMC was not clearly investigated (similar age, similar number of drops at inclusion). Furthermore, univariate and multivariate actuarial analyses failed to demonstrate a significant effect of MMC application on long-term IOP control. Hypotony was observed in only 3% of the cohort, mainly in MMC-treated eyes. Laser goniopuncture, which was performed in nearly 55% of patients, was associated with a better clinical outcome. Conversely, the absence of implantation/injection of a spacer device (mainly SK-Gel and viscoleastics) during the procedure was negatively associated with longterm success.

In summary, with the limitations of a retrospective study, the authors have collected information on long-term IOP results of phaco-DS. Phacoemulsification with non-penetrating glaucoma surgery appears to be an effective and safe technique to lower IOP in patients with coexisting glaucoma and cataract, with few postoperative complications and significant IOP-lowering efficacy. The long-term outcomes also suggest that phaco-DS is a valid option when compared to trabeculectomy, or to combined phaco-trabeculectomy. It would be interesting to compare phaco-DS surgery with MIGS procedures, which can also offer IOP reduction, decrease in dependence on glaucoma medications and a good safety profile when combined to cataract surgery.

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