|Year : 2015 | Volume
| Issue : 1 | Page : 6-11
A Comparative Evaluation of Phacotrabeculectomy with Manual Phacofracture Trabeculectomy
Kirti Singh, Ankush Mutreja, Pooja Jain
Senior Resident, Department of Ophthalmology, Guru Nanak Eye Center, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||27-Jan-2015|
Dr. Kirti Singh
Department of Ophthalmology, Guru Nanak Eye Center, Maulana Azad Medical College, New Delhi
Source of Support: None, Conflict of Interest: None
Purpose: To compare the results of manual phacofracture trabeculectomy (manual small incision cataract surgery trabeculectomy) versus phacotrabeculectomy with respect to visual gain and intraocular pressure (IOP) control. Materials and Methods: Thirty consecutive patients who underwent combined surgery performed by the same surgeon were prospectively evaluated for a minimum period of 12 months. Fifteen patients underwent single site phacotrabeculectomy, and the remaining 15 patients underwent single site phacofracture trabeculectomy at Guru Nanak Eye Hospital, New Delhi. Results: Both surgeries resulted in a highly significant decrease in IOP, the final percentage reduction being 46% in phacotrabeculectomy group and 44% in phacofracture trabeculectomy group. The complete success rate (IOP < 21 mmHg) without additional antiglaucoma medications was 100% for both the groups till l2 months of follow-up. Improvement in visual acuity was similar in both the groups with 53% patients in phacotrabeculectomy and 60% in phacofracture trabeculectomy group attaining a final visual acuity of 20/40 or better. The mean surgically induced astigmatism was 1.33 D and 1.3 D in phacotrabeculectomy and phacofracture trabeculectomy group respectively, at the end of 12 months follow-up. Manual phacofracture trabeculectomy resulted in more early postoperative inflammation within the first 7 days. Conclusions: There was no statistically significant difference in the final visual acuity, IOP control and surgically induced astigmatism between phacofracture trabeculectomy and phacotrabeculectomy groups.
Keywords: Trabeculectomy, phacoemulsification, manual phacofracture, small incision cataract surgery
|How to cite this article:|
Singh K, Mutreja A, Jain P. A Comparative Evaluation of Phacotrabeculectomy with Manual Phacofracture Trabeculectomy. MAMC J Med Sci 2015;1:6-11
|How to cite this URL:|
Singh K, Mutreja A, Jain P. A Comparative Evaluation of Phacotrabeculectomy with Manual Phacofracture Trabeculectomy. MAMC J Med Sci [serial online] 2015 [cited 2020 Jan 20];1:6-11. Available from: http://www.mamcjms.in/text.asp?2015/1/1/6/150050
| Introduction|| |
The simultaneous presence of two ocular pathologies such as glaucoma and cataract often influences the ophthalmologist to use a combined surgical procedure, which simultaneously deals with both the diseases. ,,,, In glaucoma patients undergoing cataract extraction, concomitant trabeculectomy not only reduces the damaging effects of early postoperative spikes of intraocular pressure (IOP), but also provides a long term control of IOP. ,,,,,,,,,,,,,,,,,, It thus grants the patient independence from multiple glaucoma drugs and improves patient quality of life. The refinement in manual small incision cataract surgery (MSICS) and phacoemulsification has brought new options for combined procedures. Smaller scleral and conjunctival incisions come with the advantage of lesser surgical insult, thereby less subsequent inflammation and wound healing stimuli. Conjunctival fibrosis is consequently reduced, and longevity of the bleb filtration is enhanced. ,,,,,,,, Smaller scleral incisions also reduce postoperative astigmatism thereby enabling early visual rehabilitation. ,,,,,,,, In the present study, we compared the advantages offered by phacoemulsification over manual phacofracture in the combined operation for cataract and glaucoma.
| Materials and Methods|| |
A prospective study involving 30 eyes of 30 patients comprising of a cohort of 19 women and 11 men aged 40-85 years, undergoing combined surgery was conducted with a minimum follow-up of 1 year. Selection criteria included a visually disabling cataract along with poorly controlled glaucoma on more than two antiglaucoma drugs or very high IOP (>35 mm Hg) at presentation. Patients who had central corneal opacities, congenital/developmental glaucoma, and acute or chronic inflammatory eye disease were excluded from the study. The patients were divided into two groups. The study group underwent phacofracture with trabeculectomy and the control group underwent scleral tunnel phacoemulsification with trabeculectomy. The preoperative best corrected visual acuity, IOP, corneal thickness, keratometry, refraction, anterior chamber depth, axial length, gonioscopy, non-contact corneal endothelial cell counts and visual fields (24-2 humphrey fields) were recorded in both the groups. The mean values were compared with the postsurgical values in both the groups over a 1 year follow-up period. The complete success rate of surgery was defined as IOP < 21 mmHg without additional antiglaucoma medications. For statistical analysis, Student's t-test and paired t-test were performed using SPSS software version 17 ((SPSS ® , Inc., Chicago, IL, USA), for Windows ® ).
| Results|| |
The mean age in phacotrabeculectomy group was 61 ± 9 (range-40-85) years and 56 ± 8 (range-40-85) years in phacofracture trabeculectomy group with no intergroup statistically significant difference. In the phacotrabeculectomy group, 11 (73%) patients were suffering from chronic angle closure glaucoma (CACG), rest 4 (27%) had open angle glaucoma (OAG) whereas in phacofracture group 10 (67%) patients had CACG and 5 (33%) had OAG.
Intraocular pressure control
The preoperative mean IOP in both phacotrabeculectomy and phacofracture trabeculectomy groups was 29 ± 3 mm Hg. The reduction in mean IOP at the end of 3 months was 46% in the phacotrab-eculectomy group and 44% in phacofracture trabeculectomy group. At the 12 months follow-up the percentage reduction was similar to that seen at 3 months. The intergroup difference was not statistically significant at any time. No case developed ocular hypotony (<4 mm Hg) at any time during the follow-up period. The complete success rate (IOP < 21 mm Hg) without additional antiglaucoma medications was 100% in both the groups at the interim follow-up of 3 months and at the last follow-up of 12 months. [Table 1] shows IOP levels at the specifi ed follow-up periods.
The percentage reduction in mean postoperative IOP from the preoperative values with time is detailed in the [Table 2] and [Figure 1].
|Figure 1: Comparison of percentage reduction in mean intraocular pressure|
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In the phacotrabeculectomy group, most of the patients had flat or absent bleb (Grade 1) except two patients who had elevated engorged conjunctiva (Grade II bleb), whereas in the phacofracture trabeculectomy group, all the patients had a Grade I bleb. The bleb classification followed was that of Migdal and Hitchings'. 
The range of preoperative visual acuity in log minimum angle of resolution equivalent varied from 0.5 to 3 in both the groups and the mean visual acuity was 2.14 in phacotrabeculectomy group and 2.21 in phacofracture group. Postoperatively 53% patients in phacotrabeculectomy group and 60% patients in phacofracture group had final corrected visual acuity of 0.3 or better.
[Table 3] depicts the mean postoperative visual acuity in the two groups. At no time in the follow-up period could any significant difference be detected between the two groups. The mean increase of visual acuity in the two groups was comparable on all postoperative days. At the 12 months follow-up the visual acuity was maintained in all except one case who developed posterior capsule opacification necessitating Nd: YAG capsulotomy in the manual phacofracture trabeculectomy group [Figure 2].
|Figure 2: Astigmatism change over time in the phacotrabeculectomy and phacofracture trabeculectomy groups|
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|Table 3: Mean postoperative visual acuity (logMAR equivalent) in both the groups|
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In the phacotrabeculectomy group, the surgery induced an astigmatism of 2.14 D on day 1, which was a 179% increase from preoperative value; mean increase of 1.22 ± 0.51 D. The astigmatism declined to 1.38 D on day 14 (postsuture removal) and stabilised at 1.33 D by the end of 3 months, an ultimate change of 61.66% from preoperative value. In phacofracture trabeculectomy group, the mean astigmatism on day 1 was 2.10 D, which translates into a 167.5% change from the preoperative value. This declined to 1.43 D on day 14 (after bleb forming suture removal) and stabilised at 1.3 D at the end of 3 months an ultimate change by 55.8% from the preoperative level. After this period, there was no further decline in the induced astigmatism. There was no statistically significant difference between the two groups at any time interval in the astigmatism induced (P = 0.888, P = 0.842 and P = 0.944 on day 1, day 14 and day 90 respectively). [Figure 3] depicts the astigmatism decline over time.
|Figure 3: Graph comparing mean increase of postoperative visual acuity (log minimum angle of resolution equivalent) in both the groups|
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Preoperatively central corneal thickness as measured by ultrasonic pachymetry was 0.53 mm in both phacotrabeculectomy group and phacofracture trabeculectomy group. On first postoperative day it increased to 0.556 mm (5.3% increase) in phacotrabeculectomy group and 0.560 mm (6.29% increase) in phacofracture trabeculectomy group, which was a statistically significant increase. The corneal edema subsided by day 7 in all cases.
The preoperatively mean corneal endothelial cell count was 2691 cells/mm 2 in phacotrabeculectomy group whereas in phacofracture trabeculectomy group it was 2733 cells/mm 2 , the difference being, not statistically significant. At the final follow-up of 12 months, specular microscopy revealed an endothelial cell loss of 11.7% in the phacotrabeculectomy group, which was statistically significant (P = 0.006) while in phacofracture trabeculectomy group the corresponding figure was 13% at 12 months, which was again statistically significant (P = 0.000). However, no statistically significant intergroup difference was noted [Table 4].
| Complications|| |
There was no anterior chamber inflammation in 67% patients of phacotrabeculectomy group, whereas in the phacofracture trabeculectomy group only 33% cases were free from the inflammatory reaction. The reaction resolved completely by day 14 in both the groups. The grade of anterior chamber inflammation is depicted in [Figure 4].
|Figure 4: Comparison of anterior chamber inflammation on day 1 in phacotrabeculectomy and phacofracture trabeculectomy groups|
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Anterior chamber deepened by 24% in phacotrabeculectomy group and 23% in phacofracture trabeculectomy group, with no statistically significant intergroup difference. At no time was any anterior chamber shallowing noted. The axial length decreased by 0.8% in the phacotrabeculectomy group and 0.4% in phacofracture trabeculectomy group by the end of 12 months.
| Discussion|| |
Trabeculectomy combined with cataract surgery is considered a safe, effective and economical strategy in the management of cataract associated with glaucoma. ,,,,, It prevents early IOP spikes responsible for visual field wipeout in advanced glaucoma and provides visual rehabilitation with long-term IOP control. ,,,,,,,,,,,,, Also, both the diseases are controlled in a single sitting, thus it eliminates the need for glaucoma medications and frequent follow-ups. ,,,,,,, The advent of small incision cataract surgery both by phacoemulsification or manual small incision along with trabeculectomy has improved the IOP control outcome, ,,,,,,,,,,,,,,,, reduced complications and has made combined surgery technically faster and superior. Other advantages include less induced astigmatism, early visual rehabilitation, reduced stimuli to wound healing, inflammation and postoperative bleb scarring and thus improving long-term filtration. ,,,,,,,,,,,,,,,, Thus, the credo of today is small incision cataract surgery whether it be the sophisticated instrument dependent phacoemulsification or the phacofracture technique.
Our results suggest that there is no significant difference in visual acuity and IOP control between phacotrabeculectomy and phacofracture trabeculectomy. The final percentage reduction in mean IOP was 46% in phacoemulsification with trabeculectomy group and 44% in the phacofracture trabeculectomy group. No postoperative hypotony (IOP < 6 mm Hg) or IOP spikes were noted.
The complete success rate (IOP < 21 mmHg) without additional antiglaucoma medications was 100% for both the groups. Most of the studies clearly indicate the superiority of phacoemulsification with trabeculectomy over conventional extracapsular cataract extraction (ECCE) trabeculectomy. ,,,, Tezel et al. in 1997 noted that qualified IOP control was achieved in 97% of phacotrabeculectomy group as compared with 88% in ECCE trabeculectomy group, at mean follow-up of 23 months.  Shingleton et al. and Kosmin et al. in 1998 published their retrospective comparative studies on ECCE trabeculectomy versus phacotrabeculectomy and reported a better IOP control in the phacotrabeculectomy group. , Wishart et al. in 1993 analysed the same prospectively in 34 eyes undergoing phacotrabeculectomy and ECCE trabeculectomy each for around 13 months and again documented a better IOP control in phacotrabeculectomy group compared to ECCE trabeculectomy eyes at 79% versus 53% respectively.  similar results were found by Tous et al. when they compared phacotrabeculectomy versus ECCE-trabeculectomy. There was no significant difference (P = 1.000) between the groups in terms of visual acuity improvement rate, 66% (ECCE) versus 59% (Phaco). No significant difference (55% ECCE vs. 63% Phacoemulsification, P = 0.1674) between the two groups in terms of glaucoma medication reduction was found. The total number of postoperative complications (89% vs. 68.5%) were significantly higher in the ECCE-group, as well as the total number of eyes, which required further interventions (86% vs. 64%). 
In the few studies comparing phacofracture surgery with trabeculectomy versus phacoemulsification with trabeculectomy the results are similar and our experience also has been the same. Thomas et al. in their retrospective study in 2002 comparing phacotriple in 78 eyes and blumenthal triple in 86 eyes found mean IOP of 17.7 ± 9.3 mm Hg in phacotriple group and 17.1 ± 10 mm Hg in blumenthal triple group at 6 months follow-up, which is similar to our findings of 15.9 mm Hg and 16.6 mm Hg in phacotrabeculectomy and phacofracture trabeculectomy at 12 months. 
Both the groups in our study showed a significant gain in the best corrected Snellen's visual acuity postoperatively from the preoperative levels. At 12 months, 53% patients in the phacotrabeculectomy group and 60% patients in phacofracture trabeculectomy group attained a visual acuity of 20/40 or better. This is in concordance with the few studies comparing MSICS trabeculectomy with phacotrabeculectomy. Thomas et al. compared the phacotrabeculectomy technique with blumenthal technique of MSICS trabeculectomy and reported an equivalent visual gain in both groups of 88-89% achieving a visual acuity of 20/40 or better at 17 months. 
Tezel et al. who retrospectively analysed 127 eyes undergoing ECCE trabeculectomy and 270 eyes undergoing phacotrabeculectomy over a 2 years period, found postoperative visual acuity of 20/40 or better in 71% eyes of phacotrabeculectomy group whereas the corresponding figure for ECCE trabeculectomy group was a mere 52%.  Other studies have reported similar findings of better visual acuity results in phacotrabeculectomy versus ECCE trabeculectomy and the differences documented were highly significant. ,
In our study, we could not document any statistically significant difference amongst the two groups in terms of mean astigmatism on keratometry preoperatively (P = 0.653). Postoperatively there was a mean astigmatism of 2 D on day 1 (mean change of 1.2 ± 0.5), which reduced to 1.4 D on day 14 (after suture removal) and was 1.3 D at end of 12 months. For phacofracture trabeculectomy group, the mean astigmatism on day 1 was 2 D (a mean change of 1 ± 0.4), which reduced to 1.4 D on day 14 (after suture removal) and at end of 12 months it was 1.3 D (thus contributing to a permanent change of 0.3 ± 0.2 D. There was no statistically significant difference between the two groups. Suture removal contributed to a drastic decrease in astigmatism of 0.7 ± 0.3 D (34% change) in the phacotrabeculectomy group and 0.6 ± 0.3 D (31%) in the phacofracture trabeculectomy group, within 1 week, which was highly significant for both the groups (P = 0.000 in both).
Postoperative corneal edema, which had significantly increased on day 1, subsided by day 7 and stabilized thereafter, the corneal thickness returning to preoperative levels by end of 3 months. At 12 months, both the groups had no residual increase in corneal thickness. Prior studies by Ventura et al. and Amon et al. post phacoemulsification and SICS respectively have concluded that central corneal thickness increased significantly on day 1 but returned to baseline value by 3 and 1 month respectively, which is in concordance with our findings. ,
We documented a significant endothelial cell loss amounting to 12% in phacotrabeculectomy group and 13% in phacofracture trabeculectomy group. Prior studies, which have evaluated cell loss after phacoemulsification (by divide and conquer technique, similar to our technique), have concluded the cell loss to be between 8.5% and 16% and our findings corroborate the same. ,
Anterior chamber inflammation was relatively more in the 1 st week in phacofracture group, but this did not extend beyond day 10. The explanation elucidated for this is that the maintenance of a relatively controlled IOP during phacoemulsification incites less chamber reaction. Prior studies by Tezel et al.  and Wishart et al.  that have compared ECCE trabeculectomy with phacotrabeculectomy also documented lesser anterior chamber inflammatory reaction in phacotrabeculectomy group.
Postsurgery a highly significant increase in central anterior chamber depth of 24% in phacotrabeculectomy group and 23% in phacofracture trabeculectomy was noted at 3 months (P = 0.001). This concurs with previous studies where phacoemulsification alone causes a significant increase in central anterior chamber depth in both glaucomatous and nonglaucomatous eyes. , Axial length was reduced by 0.8% in phacotrabeculectomy and 0.4% in phacofracture trabeculectomy at the 3 month, and 12 months follow-up. This has been studied by previous researchers and the decrease in axial length post trabeculectomy has been documented to be 0.2%. 
The similar and excellent results achieved in our two groups imply that either technique might be used to handle the problem of concurrent cataract and glaucoma and encourages us to consider adopting the less infrastructure dependent, technically easier, more economical, MSICS trabeculectomy for combined cataract and glaucoma surgery, in developing countries.
| Synopsis|| |
Phacofracture trabeculectomy and phacotrabeculectomy are equally efficacious in terms of IOP control, visual acuity gain and surgically induced astigmatism. Thus, phacofracture trabeculectomy is a viable alternative to expensive and infrastructure dependent phacotrabeculectomy.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]