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Editors Selection IGR 23-4
Surgical Treatment: Phaco-Endo-Cyclo-Photocoagulation
Comment by Lisandro Sakata on:
108094 The Effect of Combined Phacoemulsification and Endo-cyclophotocoagulation on Intraocular Pressure Fluctuation Assessed by The Water Drinking Test in patients with Primary Open Angle Glaucoma, Mohammad Razali A; Tang SF; Syed Zakaria SZ et al., Ophthalmic Research, 2023; 0:
Razali et al. performed a prospective, non-industry sponsored study to evaluate the effect of phacoemulsification and endo-cyclophotocoagulation (Phaco-ECP) on IOP as assessed by the water drinking test (WDT) at least six weeks after the procedure, in 20 eyes of 17 patients with primary open-angle glaucoma (POAG). When compared to the baseline WDT, there was no difference between the mean and peak IOP, albeit a significant reduction in IOP lowering medications after the intervention (2.2 ± 1.5 vs. 0.35 ± 0.9, p < 0.001). Interestingly, the IOP fluctuation was significantly greater postoperative (4 vs. 11 eyes showing IOP fluctuation > 6 mmHg), and the authors hypothesized that procedures aiming to reduce aqueous production may not blunt IOP fluctuation.
IOP fluctuation was significantly greater postoperative (4 vs. 11 eyes showing IOP fluctuation >6mmHg), and the authors hypothesized that procedures aiming to reduce aqueous production may not blunt IOP fluctuation
However, as mentioned by the authors, there are some relevant limitations, such as the relatively small sample size; varying glaucoma severity; non-standardized ECP technique; the reduction of glaucoma medications after the procedure ‒ which was guided according to a target IOP of < 18 mmHg, apparently in a non-standardized way; and the varying time of follow-up when WDT was repeated after the procedure (9.4 ± 3.8 weeks). It is unclear if the authors attempted to perform the WDTs at the same time of the day, which could impact IOP fluctuation assessment. Previous studies have observed that the 'IOP peak' showed a better reproducibility than 'IOP fluctuations', as assessed by the WDT.1 All these factors may influence the interpretation of the current paper's results and future studies should confirm its findings.
Although reducing the burden of multiple medications is desirable, there is a need to assess more clinically meaningful endpoints of the relatively new glaucoma surgical procedures to enable a better decision making process, particularly to properly allocate the limited resources for preventing glaucoma blindness worldwide
The authors are to be congratulated for contributing to the investigation of Phaco-ECP effect on IOP in a more comprehensive way than isolated IOP measurements. They observed that Phaco-ECP allowed the reduction of IOP lowering medications maintaining similar IOP mean and peak at the WDT. Although reducing the burden of multiple medications is desirable, there is a need to assess more clinically meaningful endpoints of the relatively new glaucoma surgical procedures to enable a better decision making process, particularly to properly allocate the limited resources for preventing glaucoma blindness worldwide.2,3
References
- He M, Jiang Y, Huang S, et al.Hatanaka M, Alencar LM, De Moraes CG, Susanna R Jr. Reproducibility of intraocular pressure peak and fluctuation of the water-drinking test. Clin Exp Ophthalmol. 2013;41(4):355-359. doi: 10.1111/j.1442-9071.2012.02882.x.
- Mathew DJ, Buys YM. Minimally Invasive Glaucoma Surgery: A Critical Appraisal of the Literature. Ann Rev Vis Sci. 2020;6:47-89. doi: 10.1146/ annurev-vision-121219-081737.
- Bicket AK, Le JT, Azuara-Blanco A, et al. Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma: An Overview of Cochrane Systematic Reviews and Network Meta-analysis. JAMA Ophthalmol. 2021;139(9):983-989. doi: 10.1001/jamaophthalmol.2021.2351.
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