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Editors Selection IGR 13-4

Surgical Treatment ACG: Phacogoniosynechiolysys versus phacotrabeculectomy

Comment by Clement Tham on:

24446 Clinical discussion on the phacoemulsification treating 49 cases of angle-closure glaucoma combined with goniosynechialysis, Chen B-R; Huang S-S, International Journal of Ophthalmology, 2009; 9: 1149-1150

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Chen and Huang (1324) reported a prospective randomized controlled trial comparing combined phaco-goniosynechialysis (phaco-GSL) against combined phaco-trabeculectomy in uncontrolled angle-closure glaucoma (ACG) patients with co-existing cataract. The type of angle closure (primary or secondary) was not indicated. In this study, 50 ACG eyes of 49 patients were randomized into receiving phaco-GSL, while 54 eyes of 49 patients were randomized into the phaco-trabeculectomy treatment group. Mean pre-operative intraocular pressure (IOP) was 46.45 mmHg in the phaco-GSL group, and 48.35 mmHg in the phaco-trabeculectomy group. The severity of the glaucomatous optic neuropathy before surgery was not reported. Patients were followed up for six months after surgery. The authors reported that despite no statistically significant difference in visual acuity between the two treatment groups before surgery, the phaco-GSL-treated eyes had significantly better visual acuity after surgery than the phaco-trabeculectomy-treated eyes (p < 0.01). Nevertheless, we cannot be sure if this could be related to a difference in the severity of the optic neuropathy between the two treatment groups. In the abstract, the authors reported that the IOP at two weeks after surgery was 'distinctly better' in the phaco-GSL group than in the phaco-trabeculectomy group. However, in the results section, there were actually no statistically significant differences in IOP between the two treatment groups before surgery, and at two weeks, one month, three months, and six months after surgery. The number of IOP-lowering medications used before or after surgery was not available. It was reported that the anterior chamber depth increased significantly after phaco-GSL, but not after phaco-trabeculectomy. Furthermore, the mean extent of synechial angle closure was significantly reduced from 290 degrees to 60 degrees after phaco-GSL (p < 0.01), compared to a reduction from 285 degrees to 280 degree after phaco-trabeculectomy (p > 0.05). The authors concluded that phaco-GSL 'has good clinical effect' in ACG. In my opinion, it is hard to draw conclusions from this study. The difference in visual outcomes could have been the result of a difference in the severity of glaucomatous optic neuropathy between the two treatment groups, or due to other causes, but these data were not available to the reader. I am not sure if one treatment group was receiving more IOP-lowering medications than the other group before or after surgery, despite no statistically significant differences in IOP at all time points. The reader would also be interested to know the complications arising from either procedure, and any required subsequent interventions. Last but not least, a follow up period of 6 months is rather short when comparing IOP-lowering surgical procedures.

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