Transcript JAMA Ophthalmology Journal Club Slides

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.
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.
Copyright restrictions may apply
Methods
•
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.
Copyright restrictions may apply
Results
•
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.
Copyright restrictions may apply
Results
Copyright restrictions may apply
Results
Multivariable Analysis to Identify Prognostic Factors for Failure of
Trabeculectomy Using Cox Proportional Hazards Regression Models
Copyright restrictions may apply
Comment
•
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.
Copyright restrictions may apply
Comment
•
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.
Copyright restrictions may apply
Contact Information
•
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 ([email protected]).
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.
Copyright restrictions may apply