1. Copyright restrictions may apply JAMA Ophthalmology Journal Club Slides: Trabeculectomy for Open-Angle Glaucoma Takihara Y, Inatani M, Ogata-Iwao M, et al. Trabeculectomy for open-angle glaucoma in phakic eyes vs pseudophakic eyes after phacoemulsification: a prospective clinical cohort study. JAMA Ophthalmol. Published online November 14, 2013. doi:10.1001/jamaophthalmol.2013.5605.

2. Copyright restrictions may apply Introduction Whether pseudophakic eyes are resistant to trabeculectomy remains unproven. Objective –To determine the effect of previous phacoemulsification on surgical success of trabeculectomy with mitomycin C for open-angle glaucoma.

3. Copyright restrictions may apply Prospective cohort study. Patients with open-angle glaucoma aged ≥55 years with intraocular pressure (IOP) ≥22 mm Hg were included. There were 39 phakic eyes (phakic group) and 25 pseudophakic eyes after phacoemulsification (pseudophakic group). Main Outcome Measure: Probability of success at 1 year after trabeculectomy. Surgical failure was defined according to the following criteria: (A) IOP ≥21 mm Hg. (B) IOP ≥18 mm Hg. (C) IOP ≥15 mm Hg. The extent of surgical scarring in the conjunctiva due to prior phacoemulsification was not evaluated. Methods

4. Copyright restrictions may apply The probabilities of success at 1 year in the phakic and pseudophakic groups were 95% vs 74% for criterion A (P =.02), 84% vs 62% for criterion B (P =.04), and 67% vs 53% for criterion C (P =.10). Only pseudophakia was significantly associated with outcome in the multivariate analysis for criterion A (relative risk = 9.37) and criterion B (RR = 5.52) (P =.01 for both). Postoperative IOP in the pseudophakic group was significantly higher than that in the phakic group at 6 months (P =.03) and 9 months (P =.047) after trabeculectomy. No significant difference was noted in the number of postoperative antiglaucoma medications, laser suture lysis procedures, or surgical complications between both groups. Results

5. Copyright restrictions may apply Results

6. Copyright restrictions may apply Results Multivariable Analysis to Identify Prognostic Factors for Failure of Trabeculectomy Using Cox Proportional Hazards Regression Models

7. Copyright restrictions may apply This study is unique in its prospective comparison between phakic eyes and pseudophakic eyes after phacoemulsification. In addition, the surgical procedure of trabeculectomy with mitomycin C was identical for all patients in this prospective study. The rate of surgical failure of trabeculectomy with mitomycin C in pseudophakic patients after phacoemulsification with open-angle glaucoma was higher than that in phakic patients with open-angle glaucoma. Also, patients in the pseudophakic group had a significantly lower cumulative probability of success for criterion A (P =.02) and criterion B (P =.04). For criterion C, no significant difference was found, although poorer surgical outcomes were observed in the pseudophakic group. The lack of statistical significance of the results for criterion C may be attributable to the small number of patients in this study. A larger study would determine the significance of this criterion. Comment

8. Copyright restrictions may apply The pathomechanism for failure of trabeculectomy in pseudophakic eyes is not fully understood. Alterations in the nature of the aqueous humor may contribute to surgical failure of trabeculectomy. Intraocular surgery causes ocular inflammation and breakdown of the blood-aqueous barrier, which may cause bleb failure after trabeculectomy. A higher concentration of inflammatory cytokines has been shown in aqueous humor in pseudophakic eyes with glaucoma. A recent prospective clinical study compared concentrations of monocyte chemoattractant protein 1 in the aqueous humor of patients with no eye diseases other than cataract before and after phacoemulsification. Monocyte chemoattractant protein 1 was upregulated in aqueous humor collected between 1 and 2 years after phacoemulsification; it recruits leukocytes in the anterior ocular segments, which may promote subconjunctival fibrosis and bleb scarring after trabeculectomy in pseudophakic eyes. Comment

9. Copyright restrictions may apply If you have questions, please contact the corresponding author: –Masaru Inatani, MD, PhD, Department of Ophthalmology, Faculty of Medical Science, University of Fukui, 23-3 Shimoaizuki, Eiheiji, Yoshida, Fukui 910-1193, Japan (inatani@u-fukui.ac.jp). Funding/Support This study was supported in part by Grants-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science, and Technology, Tokyo, Japan. Conflict of Interest Disclosures None reported. Contact Information