A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Glaucoma Panel: Philip P. Chen, MD,1 Shan C. Lin, MD,2 Anna K. Junk, MD,3 Sunita Radhakrishnan, MD,4 Kuldev Singh, MD, MPH,5 Teresa C. Chen, MD6
Ophthalmology, July 2015, Vol 122, 1294-1307 © 2015 by the American Academy of Ophthalmology. Click here for free access to the OTA.
Objective: To examine effects of phacoemulsification on longer-term intraocular pressure (IOP) in patients with medically treated primary open-angle glaucoma (POAG; including normal-tension glaucoma), pseudoexfoliation glaucoma (PXG), or primary angle-closure glaucoma (PACG), without prior or concurrent incisional glaucoma surgery.
Methods: PubMed and Cochrane database searches, last conducted in December 2014, yielded 541 unique citations. Panel members reviewed titles and abstracts and selected 86 for further review. The panel reviewed these articles and identified 32 studies meeting the inclusion criteria, for which the panel methodologist assigned a level of evidence based on standardized grading adopted by the American Academy of Ophthalmology. One, 15, and 16 studies were rated as providing level I, II, and III evidence, respectively.
Results: All follow-up, IOP, and medication data listed are weighted means. In general, the studies reported on patients using few glaucoma medications (1.5–1.9 before surgery among the different diagnoses). For POAG, 9 studies (total 461 patients; follow-up, 17 months) showed that phacoemulsification reduced IOP by 13% and glaucoma medications by 12%. For PXG, 5 studies (total, 132 patients; follow-up, 34 months) showed phacoemulsification reduced IOP by 20% and glaucoma medications by 35%. For chronic PACG, 12 studies (total, 495 patients; follow-up, 16 months) showed phacoemulsification reduced IOP by 30% and glaucoma medications by 58%. Patients with acute PACG (4 studies; total, 119 patients, follow-up, 24 months) had a 71% reduction from presenting IOP and rarely required long-term glaucoma medications when phacoemulsification was performed soon after medical reduction of IOP. Trabeculectomy after phacoemulsification was uncommon; the median rate reported within 6 to 24 months of follow-up in patients with controlled POAG, PXG, or PACG was 0% and was 7% in patients with uncontrolled chronic PACG.
Conclusions: Phacoemulsification typically results in small, moderate, and marked reductions of IOP and medications for patients with POAG, PXG, and PACG, respectively, and using 1 to 2 medications before surgery. Trabeculectomy within 6 to 24 months after phacoemulsification is rare in such patients. However, reports on its effects in eyes with advanced disease or poor IOP control before surgery are few, particularly for POAG and PXG.
1Department of Ophthalmology, University of Washington, Seattle, Washington
2Department of Ophthalmology, University of California, San Francisco, San Francisco, California
3Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami; Miami Veterans Affairs Medical Center, Miami, Florida
4Glaucoma Center of San Francisco; Glaucoma Research and Education Group, San Francisco, California
5Stanford University School of Medicine, Stanford, California
6Harvard Medical School, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary, Glaucoma Service, Boston, Massachusetts