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Editors Selection IGR 17-4
Surgical treatment: Combined surgery with anti-fibrotics in uveitic glaucoma
Comment by Darrell WuDunn on:
67249 The Influence of Phacoemulsification on Surgical Outcomes of Trabeculectomy with Mitomycin-C for Uveitic Glaucoma, Nishizawa A; Inoue T; Ohira S et al., PLoS ONE, 2016; 11: e0151947
Nishizawa and colleagues studied the influence of phacoemulsification on trabeculectomy MMC survival in 80 patients with uveitic glaucoma. They defined surgical success as IOP < 21 mmHg, < 18 mmHg, or < 15 mmHg with or without topical hypotensive medications. In a Cox Proportional Hazards Model analysis using phacoemulsification as a time-dependent covariate, they found that phacoemulsification was a risk factor for failure of IOP control < 15 mmHg with or without medications. In addition, early phacoemulsification (within one year of trabeculectomy) was associated with early failure of IOP control < 15 mmHg with or without medications.
The authors acknowledge several limitations including the retrospective nature and the small sample size. With only 24 of the 80 uveitic glaucoma patients having undergone phacoemulsification after trabeculectomy, statistical significance was only found for the most stringent IOP success criteria. The detrimental effect of phacoemulsification on trabeculectomy survival has been well documented for primary open-angle glaucoma and this study does confirm the same effect in uveitic glaucoma.
Early phacoemulsification (within one year of trabeculectomy) was associated with early failure of IOP control < 15 mmHg with or without medications
However, a few additional analyses would have made this study even more useful for clinical practice. Comparing the IOP at six or 12 months post-phacoemulsification (rather than at last follow-up) to the IOP just before phacoemulsification would allow clinicians to see the direct influence of phacoemulsification on IOP. Furthermore, in the Kaplan-Meier survival analysis comparing the 16 patients who were treated with phacoemulsification more than one year after trabeculectomy with the eight patients who were treated with phacoemulsification within one year after trabeculectomy, the start time should have been the time of the phacoemulsification rather than the time of the trabeculectomy. This would have enabled clinicians to estimate how long IOP control would be maintained after phacoemulsification and to determine whether delaying cataract surgery would prolong IOP control after phacoemulsification.
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