Effect of trabeculectomy in the treatment of primary angle-closure glaucoma combined with cataract: A case control study

doi:10.21203/rs.3.rs-3424981/v1

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Effect of trabeculectomy in the treatment of primary angle-closure glaucoma combined with cataract: A case control study

https://doi.org/10.21203/rs.3.rs-3424981/v1

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Background

Elderly cataract patients usually accompany primary angle-closure glaucoma (PACG), leading to a series of pathophysiological changes in the patient’s eyes. While, the treatment of PACG combined with cataracts remains controversial.

Methods

A retrospective case control study was conducted. One hundred patients with PACG comorbid with cataract who were treated by phacoemulsification, intraocular lens implantation and trabeculectomy were selected as the study group. And another one hundred patients with PACG comorbid with cataract who were treated by phacoemulsification and intraocular lens implantation were selected as the control group. The intraocular pressure (IOP), best corrected visual acuity (BCVA), corneal endothelial cell density, average cell area, anterior chamber depth, anterior chamber angle width, and surgery complications before and after surgery were compared between the two groups.

Results

One month and three months after surgery, the IOP and BCVA of the study group were lower than those of the control group (P < 0.05). The corneal endothelial cell density of patients in the two groups at one and three months after operation was lower than that before the operation (P < 0.05), and the average cell area was larger than that before the operation (P < 0.05). There was no significant difference in the depth of the anterior chamber and the width of the anterior chamber angle between the two groups (P > 0.05). The depth and width of the anterior chamber angle in the study group were higher than those of the control at one month and three months after surgery (P < 0.05). The complication rate was lower in the study group than in the control group (P < 0.05).

Conclusions

Phacoemulsification, intraocular lens implantation and trabeculectomy for the treatment of PACG patients with cataract is effective and safe.

trabeculectomy

phacoemulsification

intraocular lens implantation

primary angle-closure glaucoma

cataract

Cataract is an ophthalmic disease in which lens clouding is the main pathological change. Primary angle-closure glaucoma (PACG) is a common irreversible blinding disease in ophthalmology and has a high incidence in the elderly population ^[1–2]. In elderly cataracts, which usually accompany PACG, the lens becomes larger during the distension phase due to excessive water absorption and the anterior and posterior diameters of the lens increase significantly, leading to pupillary blockage, resulting in forward movement of the lens iris septum and closure of the atrial angle, preventing atrial water flow and increasing intraocular pressure ^[3–4]. Studies have concluded ^[5] that cataract and PACG promote each other, leading to a series of pathophysiological changes in the patient’s eye. In the clinical management of patients with PACG and varying degrees of cataract, medications, surgery and laser are often used, resulting in a more ideal surgical treatment. Pupillary block is one of the pathogenesis of glaucoma, and the key idea in the treatment of this condition is lens extraction ^[6–7]. Currently, studies have confirmed that ultrasound emulsification and intraocular lens (IOL) implantation is more effective in reducing intraocular pressure (IOP) ^[8–9]. A disposable combined procedure can be used to treat PACG comorbid with cataract, but its efficacy is controversial ^[10]. However, the different episodes of PACG determine the choice of surgical approach.

There has been controversy regarding the surgical approach for patients with PACG and cataract, where trabeculectomy is performed by forming a new atrial drainage channel at the corneal limbus, which is absorbed by the tissue after draining into the subconjunctival space ^[11]. There are few studies on the combined treatment of cataract comorbid with PACG by phacoemulsification, IOL implantation and trabeculectomy, and the clinical results are unclear, based on which this study was conducted.

Patients

Inclusion criteria: (1) the diagnostic criteria of patients with PACG comorbid with cataract referred to those in Ophthalmology (2nd edition)^[12]; (2) age range from 50 to 79 years old; (3) all were monocular lesions with intraocular pressure < 40 mmHg; (4) lens nuclear hardness ≥ 2 grade, cataract post-removal changes in the field of vision score 1–11, presence of optic papillary damage or visual field visual deficit, anterior atrial angle microscopy showed anterior adhesions around the iris and atrial angle adhesions ≤ 270°^[13]; (5) the possible risks arising from the surgery were fully communicated with patients and their families before the surgery and an agreement was signed; (6) the study protocol was approved by the hospital ethics expert committee and implemented.

Exclusion criteria: (1) other types of glaucoma (neovascular type, high iris fold type, etc.); (2) ocular infection; (3) history of ocular trauma, keratopathy, and lens injury; (4) diabetic retinopathy, hypertensive retinopathy; (5) with other complications.

In the study group, the age range of 100 patients was 55 to 79 years, and the mean age of the patients was 67.4 ± 6.0 years, of which there were 54 male patients and 46 female patients. In the control group, the age range of 100 patients ranged from 53 to 79 years, and the average age of the patients was 66.6 ± 5.8 years, of which there were 47 male and 53 female patients. The above two indicators were balanced and comparable in the study and control groups (P > 0.05).

Treatment Methods

Patients in the control group were given phacoemulsification and IOL implantation. They were placed in a supine position, the pupil was dilated using compound tolbenclamide drops, the surface of the eye and the periocular area were anesthetized with proparacaine hydrochloride and lidocaine, respectively, and an incision of approximately 3 mm in length was made on the temporal side of the corneal limbus, the conjunctiva was cut and peeled backward, the sclera was exposed, a scleral lamellar incision was made, and the size of the incision was determined according to the size of the lens, and then perform peeling until the clear cornea is reached and a scleral tunnel is constructed. The anterior chamber was torn circumferentially, the lens capsule was aqueously separated and layered, the ultrasonic emulsification head was placed, the lens capsule was aspirated, an IOL was implanted, and the scleral incision was sutured. The study group utilized trabeculectomy on the basis of the control group. The trabecular tissue under the scleral flap was removed in an area of about 1.5 cm×2.5 cm, the residual local iris tissue was excised, and the incision was sutured and bandaged.

Observation indicators and evaluation methods

Follow-up was conducted before surgery, one month after surgery, and three months after surgery to detect the following indicators:

Anterior chamber depth measurement: Ultrasound biomicroscopy was used to measure anterior chamber depth, setting the probe frequency at 50 MHz, resolution at 50 µm, penetration depth at 5 mm, display range at 5 mm×5 mm, and scan speed at 10 images/sec. It was performed by the same technician with the same equipment, anterior chamber depth is the linear distance between the inner surface of the cornea in the center of the anterior chamber and the anterior surface of the lens. Corneal endothelial cell density and mean cell area measurement: The central zone of the cornea was selected as the measurement area, and the density of corneal endothelial cells was measured before and after the procedure. Three corneal images were collected, and the highest resolution and contrast images were retained and quantified using a corneal endothelial morphology computer.

Best corrected visual acuity (BCVA) was measured by the International Standard Logarithmic Visual Acuity Scale. IOP was measured by a Goldmann pressure leveling tonometer, and the average of three measurements was taken.

The Oculyser anterior segment analysis system was used to examine the anterior chamber angle width and the change in anterior chamber angle width. No corneal touching was required during the examination, and the patient’s lower jaw needed to be placed on the mandibular pad for the examination, looking at the blue light band. The examiner aims and focuses the joystick in an orderly manner according to the measurement protocol and keeps the eyes as wide open and unmoving as possible during the measurement. The collection was performed in a dark room in the natural light pupil state to avoid interference from external light sources, and three consecutive measurements were taken and averaged ^[14]. All examinations were performed by the same operator.

Telephone follow-up and outpatient follow-up were used, and strict attention was paid to the occurrence of adverse events during patient follow-up.

Statistical Processing

The collation and statistical analysis of all the measured and counted data collected in this study were performed by the professional statistical software SPSS 21.0, in which the collected measures of corneal endothelial cell density and average cell area were expressed by (_x±s) to complete the statistical description; the comparative analysis of the data between the two groups was performed by t-test; the complication rate and the grading of lens nuclear hardness in the two groups were compared between the two groups by χ² test; the statistical judgment standard for this study was α = 0.05.

Comparison of general data between the two groups

The baseline data of age, gender, body mass index (BMI), intraocular pressure and BCVA were compared between the two groups (P > 0.05). Table 1.

Table 1

Comparison of general information between two groups of patients
General data	Study group(n = 100)	Control group(n = 100)	t/χ²	P
Age(years)	67.4 ± 6.0	66.6 ± 5.8	0.959	0.339
BMI(kg/m2)	23.2 ± 2.1	23.0 ± 2.4	0.627	0.531
Systolic pressure(mmHg)	126.8 ± 8.6	127.1 ± 9.0	-0.241	0.810
Diastolic pressure(mmHg)	72.0 ± 7.3	74.1 ± 6.6	-2.134	0.034
Corrected vision(LogMAR)	0.78 ± 0.14	0.80 ± 0.11	-1.123	0.263
Intraocular pressure(mmHg)	29.8 ± 4.0	30.6 ± 4.5	-1.329	0.185
Gender(%)			0.980	0.322
Male	54(54.00)	47(47.00)
Female	46(46.00)	53(53.00)
Lens nucleus hardness(%)			1.828	0.401
Ⅱstage	24(24.00)	18(18.00)
Ⅲstage	45(45.00)	54(54.00)
Ⅳstage	31(31.00)	28(28.00)
Note: BMI, body mass index

Comparison of IOP and BCVA before and after operation between the two groups

Before surgery, there were no significant differences in IOP and BCVA between the study group and the control group (P > 0.05). Reexamination one month and three months after surgery showed that the IOP and BCVA in the study group were lower than those in the control group (P < 0.05). Table 2.

Table 2

Comparison of IOP and BCVA before and after operation between the two groups(x̄±s)
Group	n	Intraocular pressure(mmHg)			BCVA(LogMAR)
Group	n	Preoperative	1 month after surgery	3 month after surgery	Preoperative	1 month after surgery	3 month after surgery
Study group	100	29.8 ± 4.0	12.9 ± 3.0^*	13.4 ± 2.6^*	0.78 ± 0.14	0.41 ± 0.14^*	0.43 ± 0.12^*
Control group	100	30.6 ± 4.5	14.3 ± 3.5^*	14.8 ± 2.8^*	0.80 ± 0.11	0.53 ± 0.13^*	0.55 ± 0.15^*
t		-1.329	-3.037	-3.664	-1.123	-6.281	-6.247
P		0.185	0.003	0.000	0.263	0.000	0.000
Note: Compared with this group before operation *P < 0.05. BCVA, best corrected visual acuity.

Comparison of corneal endothelial cell density and average cell area before and after surgery between the two groups

There were no significant differences in corneal endothelial cell density and average cell area between the study group and the control group before surgery, one month and three months after surgery (P > 0.05). The density of corneal endothelial cells in the two groups at one month and three months after surgery was lower than that before surgery (P < 0.05), and the average cell area was higher than that before surgery (P < 0.05). Table 3.

Table 3

Comparison of corneal endothelial cell density and average cell area before and after surgery between the two groups(x̄±s)
Group	n	Endothelial cell density(number /mm²)			Average cell area(µm²)
Group	n	Preoperative	1 month after surgery	3 month after surgery	Preoperative	1 month after surgery	3 month after surgery
Study group	100	2341.8 ± 98.5	2183.7 ± 88.0^*	2155.0 ± 78.5^*	376.9 ± 44.5	414.0 ± 52.7^*	458.3 ± 55.0^*
Control group	100	2321.5 ± 103.2	2203.4 ± 95.5^*	2171.6 ± 85.6^*	383.2 ± 38.1	406.7 ± 48.3^*	451.6 ± 49.4^*
t		1.423	-1.517	-1.429	-1.075	1.021	0.906
P		0.156	0.131	0.155	0.283	0.308	0.366
Note: Compared with this group before operation *P < 0.05.

Comparison of anterior chamber depth and anterior chamber Angle width before and after surgery between the two groups

Before surgery, there was no significant difference in anterior chamber depth and angle width between the study group and the control group (P > 0.05). The anterior chamber depth and angle width of the study group were higher than those of the control group one month and three months after surgery (P < 0.05). Table 4.

Table 4

Comparison of anterior chamber depth and anterior chamber angle width between two groups of patients before and after surgery(x̄±s)
Group	n	Anterior chamber depth(mm)			Anterior chamber angle width(mm)
Group	n	Preoperative	1 month after surgery	3 month after surgery	Preoperative	1 month after surgery	3 month after surgery
Study group	100	1.65 ± 0.45	3.71 ± 0.76^*	3.66 ± 0.68^*	0.096 ± 0.041	0.271 ± 0.084^*	0.268 ± 0.075^*
Control group	100	1.74 ± 0.41	3.32 ± 0.62^*	3.28 ± 0.71^*	0.093 ± 0.043	0.240 ± 0.068^*	0.231 ± 0.068^*
t		-1.478	3.976	3.865	0.505	2.868	3.655
P		0.141	0.000	0.000	0.614	0.005	0.000
Note: Compared with this group before operation *P < 0.05.

Comparison of surgical complication rates between the two groups

The complication rate of the study group was 4.00% lower than that of the control group (12.00%), and the difference was statistically significant (P < 0.05). Table 5.

Table 5

Comparison of surgical complication rates between two groups of patients
Group	n	Transient elevated intraocular pressure	Edema	Incision bleeding	Hyphema of anterior chamber	Complication rate(%)
Study group	100	1	2	1	0	4(4.00)
Control group	100	3	4	3	2	12(12.00)
χ²						4.348
P						0.037

Both cataract and PACG are serious diseases of the eye with blinding properties, and they can be mutually influential factors. This is reflected in the fact that the treatment of the latter promotes the progression of the former, while the appearance of the former is often accompanied by the occurrence of PACG ^[15]. Pupillary block is one of the causative factors of PACG, and the key to the treatment of this condition is the removal of the lens. Phacoemulsification is a novel treatment method with the advantages of small surgical incisions, fewer surgical complications, and rapid visual recovery ^[16–17]. However, treatment alone can easily lead to macular keratopathy, and many people have demonstrated that ultrasonic emulsion aspiration and IOL implantation are more effective in lowering IOP. Studies have shown that phacoemulsification and IOL implantation combined with trabeculectomy has improved visual acuity. It improves the postoperative effect due to poor visual discomfort, because the procedure can simultaneously address the patient’s atrial aqueous circulation disorder and visual acuity loss, the efficacy is superior to that of phacoemulsification and IOL implantation ^[18–19].

In this study, patients with PACG complicated with cataract were included and combined with trabeculectomy on the basis of phacoemulsification plus intraocular lens implantation, to explore the clinical efficacy of the combined protocol. The results of this study showed that IOP and BCVA were lower in the study group than in the control group after one and three months postoperatively. The reason analyzed was that phacoemulsification and IOL implantation could effectively improve pupillary block, relieve corneal stenosis, prevent further disease progression, and control the rise of intraocular pressure. And it can reduce patients’ dependence on IOP-lowering drugs. But it can not completely control the disease progression. After phacoemulsification and intraocular lens implantation, it can create a better anterior chamber and restore the patient’s visual ability in a shorter period of time ^[20]. The procedure is performed with a corneal incision, which facilitates the preservation of the intact bulbar conjunctiva so as to prepare for subsequent trabeculectomy ^[21]. Combined trabeculectomy reduces IOP and is also very effective in those with reduced trabecular function. Trabeculectomy enhances atrial drainage, reduces intraocular pressure and improves visual acuity by shifting the lens, deepening the anterior chamber and controlling intraocular pressure energy. The study also found that the rate of surgical complications was lower in the study group than in the control group.

The results showed that anterior chamber depth and anterior chamber angle width were higher in the study group than in the control group at one and three months postoperatively. Phacoemulsification and trabeculectomy complement each other by reducing the role of lens abnormalities in the disease process and opening the anterior chamber angle. Intraoperative viscoelastic material increases the anterior chamber pressure and also increases the anterior chamber angle ^[22]. Trabeculectomy is effective in improving atrial drainage and reducing IOP ^[23]. Intraocular perfusion treatment can cause rapid dissolution of glycosaminoglycans in the trabeculae of the anterior chamber angle, resulting in rapid expansion of the trabecular meshwork pores, increased permeability of the trabecular meshwork, improved division and phagocytosis of trabecular meshwork cells, further improvement in atrial drainage, and therefore some improvement in anterior chamber depth and anterior chamber angle width ^[24–25].

Corneal endothelial cells are monolayers that migrate together with the anterior iris endothelium, both have a stable structure and attach to the posterior elastic layer of the cornea, and corneal endothelial cells can maintain the level and state of corneal endothelial cells through their own Na-K-ATP enzyme active fluid pump function and their barrier function ^[26–27]. The corneal endothelium is unable to regenerate, and it is able to compensate for the loss of endothelial cells by migrating and expanding the cells of the elastic lamina ^[28]. Patients with PACG comorbid with cataract have higher intraocular pressure and narrow atrial angle, and the toxic side effects of the antiocular pressure drugs used during the treatment process can also have an effect on the anterior corneal endothelium, but it is the surgical factor that has the greatest impact on the anterior corneal endothelium ^{[ 29–30]}. The present results showed that the corneal endothelial cell density at one and three months after surgery was lower in both groups than before, and the average cell area was greater than before. Combined trabeculectomy is a traditional filtration operation for establishing atrial water outflow channels, which takes advantage of the release of peripheral angle of cataract surgery and the high perfusion pressure during surgery, thus increasing the density and area of corneal endothelial cells and effectively avoiding the possibility of later atrial angle re-adhesion.

Phacoemulsification, IOL implantation and trabeculectomy are effective and safe in treating patients with PACG comorbid with cataract.

BCVA, best corrected visual acuity

BMI, body mass index

IOL, intraocular lens

IOP, intraocular pressure

PACG, primary angle-closure glaucoma

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of The First Affiliated Hospital of Jinan University. Informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author Contributions

All authors contributed to the study conception and design. The study was designed by Qing Zhou. Material preparation, data collection and analysis were performed by Xianfen Cao, Yulun Ou, Xiaoping Zhou, Zhengwu Peng and Zelie Cao. The first draft of the manuscript was written by Xianfen Cao and Yulun Ou, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors sincerely thank all the study participants.

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No competing interests reported.

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Effect of trabeculectomy in the treatment of primary angle-closure glaucoma combined with cataract: A case control study

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Abstract

Background

Methods

Results

Conclusions

Background

Methods

Patients

Treatment Methods

Observation indicators and evaluation methods

Statistical Processing

Results

Comparison of general data between the two groups

Comparison of IOP and BCVA before and after operation between the two groups

Comparison of surgical complication rates between the two groups

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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