Abstract
There is no consensus on the surgical management of coexisting cataract in patients who undergo glaucoma surgery. In this study, we systematically reviewed the literature to compare the efficacy and safety of phacotrabeculectomy and trabeculectomy either alone or followed by later phacoemulsification. We systematically searched the literature databases PubMed/MEDLINE, EMBASE, and the Cochrane Central. Eligible studies were comparative trials of eyes with glaucoma that underwent either phacotrabeculectomy or trabeculectomy with or without later phacoemulsification. Our primary outcome measure was intraocular pressure (IOP) control closest to 12 months. Secondary outcome measures were efficacy closest to 12 months in terms of visual acuity, visual field, prevalence of complications, needling or revision, number of antiglaucomatous medications, and surgical success. We identified 25 studies with a total of 4,749 eyes. The IOP did not differ significantly between those who underwent phacotrabeculectomy versus trabeculectomy with (MD: 0.63, CI95%: −0.32, 1.59, p=0.19) or without later phacoemulsification (MD: −0.52, CI95%: −1.45, 0.40, p=0.27). However, phacotrabeculectomy was associated with lower risk of complications (RR: 0.80, CI95%: 0.67, 0.95, p=0.01) and better visual acuity corresponding to a 1.4-line difference (MD: −0.14, CI95%: −0.27, −0.95, p=0.03) compared to trabeculectomy. Other secondary outcome measures did not differ significantly (visual field, needling or revision, number of antiglaucomatous medications, and surgical success). In conclusion, postoperative IOP is comparable, and the number of complications is lower when phacotrabeculectomy is compared to trabeculectomy with or without later phacoemulsification in patients with coexisting glaucoma and cataract. However, our study also reveals that the level of evidence is low, and randomized clinical trials are warranted.
Highlights
Cataract and glaucoma are globally the most common causes of blindness and they frequently coexist [1,2,3]
Trabeculectomy is often performed prior to cataract surgery since the optic nerve head in these patients is at high risk of damage from postoperative intraocular pressure (IOP) spikes, which is a known phenomenon after cataract surgery [9], and because postponing the trabeculectomy may increase the risk of visual field loss
Secondary outcomes were evaluated closest to 12 months and included visual acuity, visual field, the prevalence of complications with an exception for worsening of cataract, needling or revision, number of antiglaucomatous medications, surgical success, and failure
Summary
Cataract and glaucoma are globally the most common causes of blindness and they frequently coexist [1,2,3]. Elevated intraocular pressure (IOP) is the only modifiable risk factor for the progression of visual field loss in patients with glaucoma. Among those who cannot achieve satisfactory target IOP and preservation of visual function, the current best practice is to consider filtration surgery. Trabeculectomy is often performed prior to cataract surgery since the optic nerve head in these patients is at high risk of damage from postoperative IOP spikes, which is a known phenomenon after cataract surgery [9], and because postponing the trabeculectomy may increase the risk of visual field loss. Trabeculectomy-induced cataract progression which necessitates cataract surgery may lead to a subsequent increase in IOP due to bleb failure [13, 14]. It is believed that bleb failure is related to postoperative inflammation and a change in the microenvironment, causing the closure of the filtration route of the aqueous humor, thereby making the filtering bleb dysfunctional [15, 16]
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