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Editors Selection IGR 18-3

Surgical Treatment: One-site fornix based versus two-site limbus based phacotrab

Comment by Ronald Fellman on:

21719 Prospective randomized comparison of one- versus two-site Phacotrabeculectomy two-year results, Buys YM; Chipman ML; Zack B et al., Ophthalmology, 2008; 115: 1130-1133

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Phacotrabeculectomy is a highly effective procedure, but controversy continues over whether it is better to separate the cataract from the glaucoma incision as in a two-site approach or perform surgery through one site. As cataract surgery evolved towards a temporal approach, the logical question was could you achieve a better filter by separating the incisions. Buys et al. (1266) prospectively compared two-site limbus-based versus one-site fornix-based phacotrabeculectomy with IOP as the primary outcome measure and found no statistical difference; however, there was a trend towards more endothelial cell loss with two-site surgery as well as longer intraoperative time. Can a pure fornix-based filtration surgeon extrapolate these results to their technique? No. The topic continues to be difficult to study because there are four phacotrabeculectomy possibilities; one-site limbus, two-site limbus, one-site fornix, or two-site fornix-based. In addition, studies reveal surgeon experience, diabetes, superior rectus traction suture, subconjunctival anesthetic, suture lysis timing, marked postoperative inflammation and undetected wound leaks are all associated with variable outcomes. In this study, the method of fornix-based wound closure or postop- erative leaks is not known nor its potential impact on bleb formation. The investigators favor one-site phacotrabeculectomy. In this two-year follow-up, additional data concerning long-term bleb morphology, blebitis rates, bleb dysesthesia, bleb leaks, and symptomatic blebs would be a welcome addition.

Two-site surgeons should revisit a one-site approach in patients with a marginal endothelial reserve or in circumstances that require reduced operating room time

These are all well known problems that plague filtration patients. Are patients more or less likely to develop these bleb-related problems with limbus-based or fornix-based surgery? Until we have more information including visual field and bleb data for all four phacotrabeculectomy approaches, the bias of the surgeon regarding their best technique granted patient physiognomy, conjunctival scarring, enophthalmos-related surgeon access and incision familiarity will probably yield the least complications along with the best results. In light of the investigators findings, two-site surgeons should revisit a one-site approach in patients with a marginal endothelial reserve or in circumstances that require reduced operating room time. Surgeons adept at maximizing techniques to preserve the endothelium such as improved visoelastics, viscoelastic exchange, phacochop and improved phaco technology may mitigate temporal cataract extraction related endothelial cell loss.

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