1. COMBINED PHACOEMULSIFICATION AND TRANS-SCLERAL CYCLOPHOTOCOAGULATION
IN TREATMENT OF GLAUCOMA
MINISTRY OF HEALTH
MALAYSIA
J MOHAMED-NOOR, LAU SC, YONG GY, DHANIAH AS, REBECCA JL
HOSPITAL KUALA LUMPUR
Introduction
Cataract extraction by phacoemulsification (Phaco) is often performed in glaucoma patients. Combined surgeries have been tried as it provides the opportunity to lower IOP in a single operation. Recent studies have shown that trans-scleral cyclophotocoagulation (TSCP) may be performed in eyes with good vision1,2. However, little is known of the outcome and complications of combined phacoemulsification with TSCP (Phaco TSCP). Hence, we hope to compare Phaco TSCP to Phaco in glaucoma patients in our study.
Methods
Glaucoma cases that underwent Phaco TSCP or Phaco from January 2013 to December 2015 were studied. We excluded eyes which had significant scleral thinning, where TSCP could not be performed; previous filtering surgery or TSCP; previous ocular surgery; or incomplete data.
TSCP was done inferiorly with settings of shots at mW and msec in a single session to avoid hypotony. TSCP was not repeated postoperatively in the study cases.
The patient’s demographics, visual acuity (VA), refractive status, intraocular pressure (IOP) and number of medication were analyzed. Worsening of VA is defined as a one or more Snellen line reduction from baseline or reduction in VA to no light perception (NLP).
Results
A total of 115 eyes of 100 patients were included. There were 30 eyes that underwent Phaco TSCP (study group) and 85 eyes had Phaco (control group). Demographic characteristic of the study subjects is summarized in Table 1.
There was worsening of vision in 33.3% of eyes in the study group compared to 10.6% in the control group at 3 months (p<0.001). A similar trend was seen at 6 months after surgery (p<0.001)(Table 2).
  There was a reduction in intraocular pressure (IOP) in both groups but the study group had a greater reduction (median IOP reduction = 7 mmHg at 3 months and 6 mmHg at 6 months) compared to the control group (median IOP reduction = 0 mmHg at 3 and 1 mmHg at 6 months)(p<0.001)(Table 3). The number of medications decreased from 3.6 to 2.9 at 6 months in the study group (p=0.04) as compared to 2 to 1.98 at 6 months in the control group (p=0.57)(Table 4).
  There was fibrinous exudation (FE) in the anterior chamber (6), temporary rise in IOP from steroid use (1), cystoid macular oedema (1) and conjunctival burn (2) in the study group. There was no other complications in the control group except FE (5).
Discussion
In cases that require Phaco and trabeculectomy the surgery may be performed as a staged procedure to reduce the risk of trabeculectomy failure. In our practice Phaco is done ahead of filtering surgery. However, in a few cases IOP is not satisfactorily controlled after Phaco.
Based on our results Phaco TSCP may be considered to temporarily lower IOP. There was significant reduction after a single application of TSCP to a confined area. The number of medication could also be decreased. However, a few patients had worsening of vision and complications. Fortunately these complications resolved with treatment.
Conclusion
TSCP may be performed together with Phaco to reduce IOP in the short term. This would allow the staging of filtering surgery, trabeculectomy or glaucoma drainage device, to a later date and thus, increase its success.
Reference
1. Ghosh S, Manvikar S, Ray-Chaudhuri N, Birch M. Efficacy of transscleral diode laser cyclo- photocoagulation in patients with good visual acuity. Eur J Ophthalmol May-Jun;24(3):
2. Zhekov I, Janjua R, Shahid N, Martin KR, White AJ. A retrospective analysis of long-term outcomes following a single episode of transscleral cyclodiode laser treatment in patients with glaucoma. BMJ Open.2013 Jul 6;3(7).
Table 1: Demographic features of the study population
Phaco TSCP
n = 30
Phaco
n = 85
p value
Subgroup (%)
26.09
73.91 -
Mean age (years)
(SD)
54.70
±16.85
69.82
±9.44
Pɑ<0.001
Ethnicity(%)
Malay
Chinese
Indian
18 (60.0)
8 (26.7)
4(13.3)
22 (25.9)
49 (57.6)
14 (16.5)
Pɓ=0.003
Gender
Male (%)
Female (%)
16 (53.3)
14 (46.7)
45 (52.9)
40 (47.1)
pɓ=0.001
ɑ Independent T test, ɓ Pearson Chi Square
Table 2: Postoperative vision
Postoperativevision
Phaco
TSCP
3 months
n = 30
n = 85
p value*
6 months
Worsen (%)
10 (33.3)
9 (10.6)
<0.001
14 (46.6)
5 (5.9)
No change (%)
14 (46.7)
16 (18.8)
8 (26.7)
18 (21.2)
Improve (%)
6 (20.0)
60 (70.6)
62 (72.9)
* Pearson Chi Square
Table 3: Comparison of postoperative intraocular pressure change between groups
Type of surgery
IOP
Postoperative period
3 months
6 months
 Phaco TSCP
 Median IOP change
(mmHg)
Range
-7.00
( to 13.00)
-6.00
( to 8.00)
 Phaco
 Median change  0
( to 6.00)
-1.00
(-9.00 to 6.00)
p value**
<0.001
** Mann Whitney test, (-) denotes reduction of IOP
Table 4: Number of medication
Type of surgery
Number of medications
(Mean)
Pre treatment
3 months
P value*
> 6 months
Phaco
TSCP
n = 30 eyes
3.6
3.0
0.007
2.9
0.04
n = 85 eyes
2.0
1.96
0.320
1.98
0.567
* Paired t test