Outcome of phacoemulsification and intraocular lens implantion in eyes with pseudoexfoliation and weak zonules.

PURPOSE: To evaluate the results of phacoemulsification and intraocular lens (IOL) implantation in eyes with pseudoexfoliation (PEX) and zonular weakness. METHODS: Two hundred and ninety-five patients (295 eyes) were recruited. This study is a retrospective case review of 143 PEX eyes with preoperative (Group 1) and intraoperative (Group 2) signs of zonular weakness, 76 PEX eyes (Group 3) and 76 non-PEX eyes without zonular weakness (Group 4) undergoing phacoemulsification and IOL implantation performed by single surgeon from year 1988 to 2010. Outcome measures included frequency of postoperative pseudophakodonesis, anterior capsule contraction and IOL decentration/dislocation. Postoperative vision, intraocular pressure (IOP) and glaucoma medication requirements were also assessed. A subanalysis on identical postoperative outcomes of capsular tension ring (CTR) implantation was performed. Comparisons were made for 52 PEX eyes with zonular weakness receiving nonsutured CTR implantation (Group A), 91 PEX eyes with zonular weakness not receiving CTR implantation (Group B) and 142 PEX eyes without zonular weakness (Group C). RESULTS: Mean follow-up was 4.08 ± 0.48 years and maximum was 8.3 years. Both Groups 1 and 2 showed higher incidence of complications than Groups 3 and 4 (p < 0.01). Vision, IOP and glaucoma medication requirements were similar postoperatively for all four groups. Groups A and B had a significantly higher proportion of postoperative complications than Group C (p < 0.01). There was no significant difference in risk of developing these complications between Groups A and B (p = 0.64). CONCLUSION: Postoperative complication rates are higher in PEX eyes with preoperative and/or intraoperative signs of zonular weakness undergoing phacoemulsification. Nonsutured CTR implantation does not prevent IOL and capsular complications postoperatively.

Management and outcomes of intraocular lens dislocation in patients with pseudoexfoliation.

PURPOSE: To analyze the outcomes of surgery for dislocated intraocular lenses (IOLs) in patients with pseudoexfoliation (PXF). SETTING: Private practice, Boston, Massachusetts, USA. DESIGN: Retrospective case study. METHODS: Eyes with PXF and IOL dislocations that had IOL exchange or repositioning were reviewed. An outcomes analysis compared the surgical techniques with regard to corrected distance visual acuity (CDVA), intraocular pressure (IOP), and glaucoma medication requirements. RESULTS: The IOL exchange was performed in 64 eyes (79%) and IOL repositioning in 17 eyes (21%). The CDVA improved in all eyes, from a preoperative mean of 0.78 logMAR ± 0.50 (SD) to a mean of 0.35 ± 0.31 logMAR at the final follow-up (mean 2.5 ± 2.6 years) (P<.0001). The mean IOP was reduced by 4.2 mm Hg at the final follow-up (P<.0001). The mean glaucoma medication requirement remained stable at the final follow-up compared with the preoperative levels (P>.05). There were no significant differences in the mean CDVA, IOP, or glaucoma medication requirement between eyes that had IOL exchange and eyes that had IOL repositioning. There were no significant intraoperative complications. The most common postoperative complication was a transient decrease in IOP to 5 mm Hg or lower or an increase in IOP to 30 mm Hg or higher. CONCLUSIONS: Patients with PXF having surgical treatment of IOL dislocation have the potential for excellent visual outcomes with minimal intraoperative and postoperative complications. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Combined cataract and trabeculectomy surgery in eyes with pseudoexfoliation glaucoma.

PURPOSE: To assess the short- and long-term effect of uneventful phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and trabeculectomy on intraocular pressure (IOP) and glaucoma medication requirements in eyes with pseudoexfoliation glaucoma (PXG) and compare the results with those in eyes that had uneventful phacoemulsification only (reported in a previous study of the same cohort of pseudoexfoliation eyes). SETTING: Private practice, Boston, Massachusetts, USA. DESIGN: Comparative case series. METHODS: A retrospective analysis was performed of consecutive PXG eyes that had uneventful combined phacoemulsification and trabeculectomy by the same surgeon. The change in IOP, glaucoma medication requirements, and logMAR corrected distance visual acuity was compared between the combined surgery group and the phaco-alone group. RESULTS: The combined-surgery group (n = 138) had statistically significant reduced mean IOP and glaucoma medication requirements through 10 years postoperatively (P<.018). The change in IOP and glaucoma medication requirements was greater in the combined-surgery group than in the phaco-alone group (n = 240); this was statistically significant up to 7 years postoperatively (P<.022). The reduction in mean postoperative IOP was greater in eyes with a higher mean preoperative IOP. In the combined-surgery group, 13.8% of eyes required subsequent laser trabeculoplasty, glaucoma surgery, or both. CONCLUSIONS: Uneventful phacoemulsification, IOL implantation, and trabeculectomy resulted in significant long-term reduction in IOP and glaucoma medication requirements in eyes with PXG. Combined procedures resulted in greater and more longstanding reductions in IOP and glaucoma medication requirements and fewer 1-day postoperative IOP spikes than phacoemulsification alone. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Pseudoexfoliation: High risk factors for zonule weakness and concurrent vitrectomy during phacoemulsification.

PURPOSE: To assess the frequency and results of cataract surgery with concurrent vitrectomy due to zonule weakness in eyes with pseudoexfoliation (PXF). SETTING: Private practice, Boston, Massachusetts, USA. METHODS: This retrospective nonrandomized study assessed consecutive eyes with PXF having cataract surgery. High risk was defined as preoperative phacodonesis, iridodonesis, or lens subluxation (subgroup 1); preoperative anterior chamber depth or angle-depth asymmetry between eyes confirmed by slitlamp biomicroscopy or gonioscopy, respectively (subgroup 2); or complicated cataract extraction related to zonule weakness in the fellow eye (subgroup 3). Exclusion criteria were previous vitrectomy, scleral buckle, or trabeculectomy surgery and combined cataract-glaucoma surgery. A comparative analysis of outcome parameters was performed. RESULTS: Of the 1059 eyes evaluated, 38 had vitrectomy. Concurrent vitrectomy was required in 19 (15.6%) of 122 high-risk eyes and 19 (2.0%) of 937 non-high-risk eyes (P<.00001). The need for concurrent vitrectomy was greatest in subgroup 3 (72.7%) and subgroup 1 (42.9%). There was no statistically significant difference between the vitrectomy group and the no-vitrectomy group in the mean improvement in logMAR corrected distance visual acuity (CDVA) (P = .38) or mean change in intraocular pressure (IOP) (mean decrease 2.6 mm Hg +/- 1.5 [SD] and 1.6 +/- 0.5 mm Hg, respectively) (P = .47). CONCLUSION: Despite the need for vitrectomy and the attendant increased demands in postoperative care, both the vitrectomy group and no-vitrectomy group had improved logMAR CDVA and IOP. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Outcomes of phacoemulsification in fellow eyes of patients with unilateral pseudoexfoliation: single-surgeon series.

PURPOSE: To compare intraoperative and postoperative complications, best corrected visual acuity, intraocular pressure (IOP), and glaucoma medication requirements between eyes with clinically apparent pseudoexfoliation (PEX) and fellow eyes without PEX in patients having bilateral cataract surgery. SETTING: Private practice, Boston, Massachusetts, USA. METHODS: This retrospective study comprised 1000 consecutive patients who had cataract surgery performed by the same surgeon. Of the 1000 patients, 137 had unilateral PEX and bilateral cataract surgery. Patients with previous or concurrent glaucoma surgery were eliminated from the study. Two-way analysis of variance and Tukey post hoc tests were used for statistical analysis. RESULTS: Complications were few, with no significant differences between the 2 groups intraoperatively (zonule instability) or postoperatively (corneal edema, cystoid macular edema, intraocular lens decentration). Both groups had improved visual acuity, with no statistically significant between- group difference in acuity at 1 year. Both groups had decreased IOP postoperatively, although the eyes with PEX had a significantly greater mean Delta IOP than the fellow eyes without PEX (P<.016). The PEX group required more glaucoma medications overall (P<.003) and needed more glaucoma medications at 3 to 5 years than preoperatively; the medication requirement in the fellow-eye group remained stable. CONCLUSIONS: The presence of clinically apparent PEX had an impact on IOP reduction and glaucoma medication requirements. There were no differences in intraoperative or postoperative complications between eyes with PEX and fellow eyes without PEX.

Evaluation of intraocular pressure in the immediate postoperative period after phacoemulsification.

PURPOSE: To determine the incidence of hypotony and intraocular pressure (IOP) elevation in the immediate and early postoperative period after temporal posterior limbal phacoemulsification and intraocular lens (IOL) implantation. SETTING: Ambulatory surgical center. METHODS: This prospective analysis comprised 310 eyes that had temporal posterior limbal phacoemulsification with IOL implantation. Surgical parameters included keratome incision of 2.85 mm, incision length of 2.5 mm, peribulbar anesthesia, case-completion IOP of 20 mm Hg, and postoperative lid taping. The IOP measurements were collected preoperatively and 30 minutes and 1 day after surgery. RESULTS: Nineteen eyes (6.1%) had an IOP lower than 5 mm Hg 30 minutes postoperatively in the absence of incision leakage at the paracentesis or keratome sites. Eighteen of the 19 eyes with postoperative hypotony received hydroxypropyl methylcellulose 2% (OcuCoat) and 1 received hypromellose 2% (Cellugel). None of the 23 eyes with an acrylic IOL implanted via a cylindrical lens inserter had an IOP lower than 5 mm Hg postoperatively. Suturing did not significantly affect the incidence of hypotony, and there were no postoperative complications related to hypotony. The mean IOP at 30 minutes was lower than at 1 day in the normal, glaucoma, and glaucoma-suspect groups. Twenty-one normal eyes (8.1%), 5 glaucoma eyes (15.6%), and 1 glaucoma-suspect eye (5%) had an IOP greater than 30 mm Hg 1 day postoperatively. CONCLUSIONS: Postoperative hypotony (IOP <5 mm Hg) occurred in 19 (6.1%) of 310 eyes. At 1 day, IOP higher than 30 mm Hg was more frequent in glaucoma eyes than in normal eyes. Although there were no direct problems related to hypotony at 30 minutes or to elevated IOP (>30 mm Hg) at 1 day, surgeons should be aware of and check for IOP variability (low and high) that can occur in normal, glaucoma, and glaucoma-suspect eyes within the first 24 hours after surgery.

Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients.

PURPOSE: This study evaluates the change in intraocular pressure (IOP) and glaucoma medication requirements after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients at 3 years and last follow-up (mean 5 y). PATIENTS AND METHODS: This study represents a retrospective analysis of patients who had clear corneal phacoemulsification and at least 3 years of follow-up. The patients were classified into 3 groups: glaucoma (G), glaucoma suspects (GS), and no glaucoma (NG). No patient had a history of previous intraocular surgery. Single factor analysis of variance, Fisher exact tests, 2-tailed paired Student t tests and Kaplan-Meier analysis were applied. RESULTS: Forty-eight patients (55 eyes) in the glaucoma group, 41 patients (44 eyes) in the GS group, and 59 patients (59 eyes) in the NG group met the above criteria. At 3 years follow-up IOP was significantly decreased in all groups; (G) group decreased 1.4+/-3.3 mm Hg (P = 0.0025), GS 1.4+/-4.2 mm Hg (P = 0.004), and NG 1.7+/-3.1 mm Hg (P = 0.0005). At the final follow-up visit (mean near 5 y for all groups) the IOP was significantly decreased in all groups, (G) group 1.8+/-3.5 mm Hg (P = 0.005), GS 1.3+/-3.7 mm Hg (P = 0.025), and NG 1.5+/-2.5 mm Hg (P < 0.0001). The number of preoperative and postoperative glaucoma medications in the (G) group did not show any significant change at 3 and 5 years (P = 0.36, P = 0.87). Kaplan-Meier analysis shows that at 3 years, 85% of the (G) group, 81% of GS, and 90% of the NG had IOPs less than or equal to their preoperative IOP, with the same number of glaucoma medications or less. At 5 years the percentages were 76%, 79%, and 85%, respectively. CONCLUSIONS: This study demonstrates that cataract removal by clear cornea phacoemulsification in glaucoma patients, glaucoma suspects, and normal patients results in a small but significant decrease in IOP that is sustained at 3 years and a mean of 5 years in all groups. This study does not imply that cataract removal by phacoemulsification is a substitute for a combined procedure but may be an appropriate procedure for certain patients based on medication requirements and extent of optic nerve damage.

Effects of pupil stretch technique during phacoemulsification on postoperative vision, intraocular pressure, and inflammation.

PURPOSE: To determine whether pupil stretch during phacoemulsification affects postoperative best corrected visual acuity (BCVA), intraocular pressure (IOP), and inflammation compared with results in patients without pupil stretch. METHODS: A retrospective analysis of 115 eyes that had pupil stretch during phacoemulsification (study group) and 125 eyes without pupil stretch (control group) was performed with a minimum of 12 months follow-up. Single-factor analysis of variance and 2-tailed homoscedastic t tests were used for statistical analysis. RESULTS: The mean preoperative logMAR equivalent BCVA was 0.5 +/- 0.3 (SD) in the study group and 0.6 +/- 0.4 in the control group. The mean preoperative IOP was 16.2 +/- 4.1 mm Hg in the study group and 16.0 +/- 3.5 mm Hg (control group). There was no statistically significant difference at postoperative follow-up of 1 year in BCVA or IOP between the 2 groups (1 year BCVA 0.2 +/- 0.2 [study group], 0.2 +/- 0.2 [control group] [P<.1]; IOP 14.5 +/- 3.5 mm Hg and 14.7 +/- 3.3 mm Hg, respectively [P<.7]). There was no significant difference in the number of glaucoma medications required for glaucoma patients preoperatively and postoperatively between the 2 groups (P<.5). Complications were rare, and there was no significant difference in the complications (ie, iritis, hyphema, cystoid macular edema, epiretinal membrane formation) between the 2 groups at 1 year. CONCLUSION: Pupil stretch during phacoemulsification was not associated with a statistically significant difference in BCVA, IOP, inflammation, or other complications postoperatively compared with results in the control group without pupil stretch.

Comparison of 1-site versus 2-site phacotrabeculectomy.

PURPOSE: To compare the results of 1-site versus 2-site combination glaucoma filtration and phacoemulsification surgery with respect to visual acuity, intraocular pressure (IOP), and glaucoma medication requirements via a case control study. METHODS: Results of 2-site phacotrabeculectomy surgery in 64 eyes of 59 patients were retrospectively reviewed with a minimum follow-up of 1 year. The 2-site procedures were compared with a randomly chosen control group of 71 1-site phacotrabeculectomies performed by the same surgeon. RESULTS: The presurgical visual acuity, IOP, and glaucoma medication requirements did not differ significantly between the 2 groups. Mean final postoperative results at 1 year for 2-site versus 1-site eyes, respectively, were visual acuity 0.32 +/- 0.353 (SD) and 0.32 +/- 0.37 (P = .99), IOP 15.0 +/- 3.7 mm Hg and 15.1 +/- 6.3 mm Hg (P = .97), and glaucoma medication requirements 0.43 +/- 0.90 and 0.61 +/- 1.1 (P = .52). CONCLUSION: There was no statistically significant difference in the final visual acuity, IOP, or glaucoma medication requirements between the 2-site and 1-site groups.

Efficacy of glaucoma filtration surgery in pseudophakic patients with or without conjunctival scarring.

PURPOSE: To analyze the intraocular pressure (IOP), glaucoma medication requirements, and visual acuity after glaucoma filtration surgery in pseudophakic eyes. SETTING: Private practice, Boston, Massachusetts, USA. METHODS: The results of glaucoma filtration surgery in 47 eyes of 40 pseudophakic patients with a minimum follow-up of 1 year were retrospectively reviewed. Eyes with previously surgically manipulated conjunctiva in the area of filtration were compared to eyes without previous manipulation. RESULTS: Preoperatively, the mean IOP was 25 mm Hg +/- 7.3 (SD); mean number of glaucoma medications, 3.3 +/- 1.0; and mean logMAR visual acuity, 0.41 +/- 0.38. At the final follow-up visit (mean 36.5 +/- 31.5 months), the respective means were 13.6 +/- 6.6 mm Hg (P<.001), 0.9 +/- 1.4 (P<.001), and 0.46 +/- 0.43 (P=.53). The mean postoperative IOP, glaucoma medication requirements, and visual acuity at the final follow-up in eyes with virgin conjunctiva and eyes with previously manipulated conjunctiva were, respectively, as follows: IOP, 12.5 +/- 3.2 mm Hg and 14.1 +/- 7.6 mm Hg (P=.52); medications, 1.1 +/- 1.3 and 0.9 +/- 1.4 (P=.66); and logMAR acuity, 0.6 +/- 0.52 and 0.4 +/- 0.39 (P=.23). CONCLUSIONS: Glaucoma filtration surgery in pseudophakic eyes significantly improved IOP and reduced glaucoma medication requirements while maintaining stability of vision. There were no statistically significant differences in final IOP, glaucoma medication requirements, or visual acuity between eyes with virgin conjunctiva and eyes with previously surgically manipulated conjunctiva.

Outcomes of phacoemulsification in patients with and without pseudoexfoliation syndrome.

UNLABELLED: To characterize the differences in technique, complications, and outcomes in a large series of cataract extractions in patients with and without pseudoexfoliation (PEX) syndrome. SETTING: Ophthalmic Consultants of Boston, Boston, Massachusetts, USA. METHODS: A retrospective analysis was performed of 297 cases of cataract extraction in patients with PEX and 427 cases of cataract extraction in patients without PEX. This study examined and quantified the intraoperative and postoperative complications, performed a comparative outcomes analysis of intraocular pressure (IOP) change, and determined the prevalence of systemic vascular diseases in these patients. RESULTS: The overall rate of vitreous loss was 4% (7/297) in the PEX population and 0% (0/427) in the non-PEX group. There were no overall differences in the rate of postoperative complications. At 2 years, IOP had declined from a mean of 16.8 to 13.9 mm Hg in the PEX group and from 16.3 to 14.4 mm Hg in the non-PEX group. The decline was significantly greater in the PEX group. The prevalence of hypertension and diabetes was significantly greater in the non-PEX group (50% and 11%, respectively) than in the PEX group (38% and 5%, respectively). CONCLUSIONS: The increased frequency of intraoperative complications during cataract extraction in PEX patients stemmed from zonular weakness rather than capsule tears. Postoperative IOP declines were greater in the PEX group even 2 years after cataract extraction, suggesting the potential for long-term improvement in outflow facility in patients with coexisting cataract and glaucoma.

Results of phacoemulsification in eyes with preexisting glaucoma filters.

PURPOSE: To evaluate the intraocular pressure (IOP), best corrected visual acuity (BCVA), and glaucoma medication requirements in patients having phacoemulsification after preexisting glaucoma filters. SETTING: Ophthalmic Consultants of Boston, Boston, Massachusetts, USA. METHODS: A retrospective analysis of 58 eyes that had temporal phacoemulsification via a clear corneal (32 eyes) or a scleral tunnel (26 eyes) approach after filtration surgery was performed with a minimum follow-up of 12 months. Two-tailed homoscedastic t tests were used for statistical analysis. RESULTS: The mean preoperative IOP in all eyes was 11.8 mm Hg +/- 4.2 (SD), and the mean final postoperative IOP was 13.7 +/- 4.6 mm Hg (P<.022). The mean preoperative logMAR equivalent BCVA was 0.8 +/- 0.4, which improved to a mean of 0.4 +/- 0.4 postoperatively (P<.0000002). There was no statistically significant change in glaucoma medication requirements postoperatively. The differences in IOP, BCVA, and postoperative glaucoma medication requirements were not statistically significant between the clear corneal group and the scleral tunnel group or between patients who received mitomycin at the time of filtration surgery and those who did not. There were no intraoperative complications; 1 patient required additional glaucoma surgery. CONCLUSION: Clear corneal or scleral tunnel phacoemulsification in the setting of a preexisting glaucoma filter was associated with improved BCVA, a small but statistically significant increase in IOP, and stability in the number of glaucoma medicines required for IOP control over a minimum follow-up of 1 year.

Phacotrabeculectomy: peripheral iridectomy or no peripheral iridectomy?

PURPOSE: To study the effect of peripheral iridectomy (PI) in phacotrabeculectomy. SETTING: Academic private glaucoma practice with a primarily white patient population. METHODS: This retrospective study comprised 126 eyes of 117 patients randomized for PI or no PI during phacotrabeculectomy who were followed for 12 months. Postoperative parameters in both groups included intraocular pressure (IOP), bleb development, visual acuity, and complications. RESULTS: There were no statistically significant differences between the 2 groups in visual acuity or IOP. Bleb development required significantly more 5-fluorouracil therapy in the no-PI group than in the PI group; however, bleb failure and the need for laser suture lysis were not significantly different between groups. Complications were rare in both groups. CONCLUSION: Phacotrabeculectomy without PI may be an acceptable alternative to the surgical management of co-existing cataract and glaucoma.