Phaco-UCP Versus Phaco Alone for OAG and Cataract

Phaco-UCP; Combined Phacoemulsification and Ultrasound Ciliary Plasty Versus Phacoemulsification Alone for Management of Coexisting Cataract and Open Angle Glaucoma

This study was carried out to evaluate the safety and efficacy of combined phacoemulsification and Ultrasound ciliary plasty (Phaco-UCP) as a first-line surgical treatment of coexisting cataract and op /en angle glaucoma compared to phacoemulsification alone. To our knowledge, this is the first report of results of combined Phaco-UCP

the study involved 61 eyes of 61 patients with coexisting cataract and open angle glaucoma, 31 eyes were managed with Phaco-UCP and 30 eyes of age and sex matched patients were managed with phacoemulsification alone. Patients were randomized for either combined phacoemulsification and ultrasound ciliary plasty (Phaco-UCP) (the study group) or phacoemulsification alone (the control group). All surgeries were performed by one experienced surgeon (Y EZ). Preoperative evaluation included manifest refraction, BCVA measurement, slit-lamp biomicroscopy, gonioscopy, indirect ophthalmoscopy, measurement of IOP with Goldmann applanation tonometry (average of 3 readings taken). Corneal diameter (White-to-white) and axial length measurement were done using IOL Master 500 (Carl Zeiss Meditec AG., Germany). Ultrasound pachymetry with Tomey SP-100 (Tomey Corp. Nagoya, Japan) and visual fields using Humphrey Field Analyzer (24-2, SITA, standard program Carl Zeiss Meditec AG., Germany) were also performed.

Under peribulbar anesthesia, UCP was performed first, followed by phacoemulsification. UCP was performed using the same technique described before [18]. For all treatments, 2nd generation probe was used (EyeOP1, Eye Tech care; France) with the same parameters; Operating frequency was 21 MHz. Number of sectors activated was 6. Acoustic power was 2.45 W; duration of each shot was 8s; and the time between shots was 20s. The probe diameter (11, 12 or 13 mm) was determined according to the eye's biometric readings. The coupling cone was centered on the eye and kept in place with low vacuum suction, followed by introduction of the treatment probe inside the cone, then activation of the transducers by constantly pressing the foot switch. Once UCP treatment was finished, phacoemulsification was commenced

A standard phacoemulsification was performed with 2.2 mm clear corneal incision, continuous curvilinear capsulorhexis, phacoemulsification and intrabagal implantation of foldable acrylic intraocular lens (AcrySof® IQ SN60WF monofocal; Alcon Laboratories Inc, Fort Worth, TX, USA) for all patients. Irrigation-aspiration was performed for at least 30 seconds to remove any viscoelastic from the anterior chamber. Reformation of the anterior chamber was done with balanced saline solution (BSS), followed by hydration of the corneal wound and side port.

Qualified Success was defined as an IOP reduction of at least 20 % from baseline value, with an IOP that is between 6 - 21 mm Hg, without the need for additional antiglaucoma medications or glaucoma surgery

hyphema or vitreous hemorrhage necessitating surgical intervention, choroidal hemorrhage, chronic uveitis, endophthalmitis, hypotony (IOP ≤ 5 mm Hg), phthisis, IOL dislocation, and retinal detachment.

Inclusion Criteria: patients diagnosed with POAG or pseudoexfoliation glaucoma with coexisting visually significant cataract that required phacoemulsification Exclusion Criteria: patients with any other type of glaucoma, including narrow angle glaucoma, neovascular, uveitic or angle recession glaucoma, patients with advanced glaucoma characterized by advanced optic disc cupping or visual field damage, history of glaucoma or intraocular surgery and other ocular diseases that would affect safety or interfere with the procedure. We also excluded patients with incomplete follow-up or missing data

Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2012 May;96(5):614-8. doi: 10.1136/bjophthalmol-2011-300539. Epub 2011 Dec 1.

Chen DZ, Koh V, Sng C, Aquino MC, Chew P. Complications and outcomes of primary phacotrabeculectomy with mitomycin C in a multi-ethnic asian population. PLoS One. 2015 Mar 16;10(3):e0118852. doi: 10.1371/journal.pone.0118852. eCollection 2015.

Kung JS, Choi DY, Cheema AS, Singh K. Cataract surgery in the glaucoma patient. Middle East Afr J Ophthalmol. 2015 Jan-Mar;22(1):10-7. doi: 10.4103/0974-9233.148343.

Parikh HA, Bussel II, Schuman JS, Brown EN, Loewen NA. Coarsened Exact Matching of Phaco-Trabectome to Trabectome in Phakic Patients: Lack of Additional Pressure Reduction from Phacoemulsification. PLoS One. 2016 Feb 19;11(2):e0149384. doi: 10.1371/journal.pone.0149384. eCollection 2016.

Yang HS, Lee J, Choi S. Ocular biometric parameters associated with intraocular pressure reduction after cataract surgery in normal eyes. Am J Ophthalmol. 2013 Jul;156(1):89-94.e1. doi: 10.1016/j.ajo.2013.02.003. Epub 2013 Apr 28.

Lin SC, Masis M, Porco TC, Pasquale LR. Erratum: Predictors of Intraocular Pressure After Phacoemulsification in Primary Open-Angle Glaucoma Eyes with Wide Versus Narrower Angles (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc. 2018 Jan 1;115:T6C1. eCollection 2017 Aug.

Baek SU, Kwon S, Park IW, Suh W. Effect of Phacoemulsification on Intraocular Pressure in Healthy Subjects and Glaucoma Patients. J Korean Med Sci. 2019 Jan 30;34(6):e47. doi: 10.3346/jkms.2019.34.e47. eCollection 2019 Feb 18.

O'Brien PD, Ho SL, Fitzpatrick P, Power W. Risk factors for a postoperative intraocular pressure spike after phacoemulsification. Can J Ophthalmol. 2007 Feb;42(1):51-5.

Potop V, Corbu C. The role of clear lens extraction in angle closure glaucoma. Rom J Ophthalmol. 2017 Oct-Dec;61(4):244-248.

Chen HY, Lin CL, Kao CH. Changes in glaucoma medication numbers after cataract and glaucoma surgery: A nationwide population-based study. Medicine (Baltimore). 2019 Jan;98(4):e14128. doi: 10.1097/MD.0000000000014128.

Vass C, Menapace R. Surgical strategies in patients with combined cataract and glaucoma. Curr Opin Ophthalmol. 2004 Feb;15(1):61-6. doi: 10.1097/00055735-200402000-00012.

Mercieca K, Shevade B, Anand N. Outcomes of combined phacoemulsification and deep sclerectomy: a 10-year UK single-centre study. Eye (Lond). 2015 Nov;29(11):1495-503. doi: 10.1038/eye.2015.163. Epub 2015 Sep 4.

Francis BA, Sarkisian SR, Tan JC (2017). Minimally invasive glaucoma surgery: A practical guide. 1st ed. New York: Thieme.

Melamed S, Goldenfeld M, Cotlear D, Skaat A, Moroz I. High-intensity focused ultrasound treatment in refractory glaucoma patients: results at 1 year of prospective clinical study. Eur J Ophthalmol. 2015 Nov-Dec;25(6):483-9. doi: 10.5301/ejo.5000620. Epub 2015 May 13.

Mastropasqua R, Fasanella V, Mastropasqua A, Ciancaglini M, Agnifili L. High-Intensity Focused Ultrasound Circular Cyclocoagulation in Glaucoma: A Step Forward for Cyclodestruction? J Ophthalmol. 2017;2017:7136275. doi: 10.1155/2017/7136275. Epub 2017 Apr 22.

Giannaccare G, Vagge A, Sebastiani S, Urbini LE, Corazza P, Pellegrini M, Carmassi L, Bergamini F, Traverso CE, Campos EC. Ultrasound Cyclo-Plasty in Patients with Glaucoma: 1-Year Results from a Multicentre Prospective Study. Ophthalmic Res. 2019;61(3):137-142. doi: 10.1159/000487953. Epub 2018 May 16.

Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL; Tube Versus Trabeculectomy Study Group. Three-year follow-up of the tube versus trabeculectomy study. Am J Ophthalmol. 2009 Nov;148(5):670-84. doi: 10.1016/j.ajo.2009.06.018. Epub 2009 Aug 11.

Francis BA, Berke SJ, Dustin L, Noecker R. Endoscopic cyclophotocoagulation combined with phacoemulsification versus phacoemulsification alone in medically controlled glaucoma. J Cataract Refract Surg. 2014 Aug;40(8):1313-21. doi: 10.1016/j.jcrs.2014.06.021.

Coleman DJ, Lizzi FL, Driller J, Rosado AL, Chang S, Iwamoto T, Rosenthal D. Therapeutic ultrasound in the treatment of glaucoma. I. Experimental model. Ophthalmology. 1985 Mar;92(3):339-46. doi: 10.1016/s0161-6420(85)34029-0.

De Gregorio A, Pedrotti E, Stevan G, Montali M, Morselli S. Safety and efficacy of multiple cyclocoagulation of ciliary bodies by high-intensity focused ultrasound in patients with glaucoma. Graefes Arch Clin Exp Ophthalmol. 2017 Dec;255(12):2429-2435. doi: 10.1007/s00417-017-3817-4. Epub 2017 Oct 17.

Pellegrini M, Sebastiani S, Giannaccare G, Campos EC. Intraocular inflammation after Ultrasound Cyclo Plasty for the treatment of glaucoma. Int J Ophthalmol. 2019 Feb 18;12(2):338-341. doi: 10.18240/ijo.2019.02.23. eCollection 2019.

Torky MA, Al Zafiri YA, Hagras SM, Khattab AM, Bassiouny RM, Mokbel TH. Safety and efficacy of ultrasound ciliary plasty as a primary intervention in glaucoma patients. Int J Ophthalmol. 2019 Apr 18;12(4):597-602. doi: 10.18240/ijo.2019.04.12. eCollection 2019.

Sun W, Yu CY, Tong JP. A review of combined phacoemulsification and endoscopic cyclophotocoagulation: efficacy and safety. Int J Ophthalmol. 2018 Aug 18;11(8):1396-1402. doi: 10.18240/ijo.2018.08.23. eCollection 2018.

Perez Bartolome F, Rodrigues IA, Goyal S, Bloch E, Lim WS, Alaghband P, Guajardo J, Jones S, Lim KS. Phacoemulsification plus endoscopic cyclophotocoagulation versus phacoemulsification alone in primary open-angle glaucoma. Eur J Ophthalmol. 2018 Mar;28(2):168-174. doi: 10.5301/ejo.5001034.

Hugo J, Matonti F, Beylerian M, Zanin E, Aptel F, Denis D. Safety and efficacy of high-intensity focused ultrasound in severe or refractory glaucoma. Eur J Ophthalmol. 2021 Jan;31(1):130-137. doi: 10.1177/1120672119874594. Epub 2019 Sep 25.

Heinz C, Zurek-Imhoff B, Koch J, Rosel M, Heiligenhaus A. Long-term reduction of laser flare values after trabeculectomy but not after cyclodestructive procedures in uveitis patients. Int Ophthalmol. 2011 Jun;31(3):205-10. doi: 10.1007/s10792-011-9440-1. Epub 2011 Mar 25.

Tan AM, Chockalingam M, Aquino MC, Lim ZI, See JL, Chew PT. Micropulse transscleral diode laser cyclophotocoagulation in the treatment of refractory glaucoma. Clin Exp Ophthalmol. 2010 Apr;38(3):266-72. doi: 10.1111/j.1442-9071.2010.02238.x.

Aquino MC, Barton K, Tan AM, Sng C, Li X, Loon SC, Chew PT. Micropulse versus continuous wave transscleral diode cyclophotocoagulation in refractory glaucoma: a randomized exploratory study. Clin Exp Ophthalmol. 2015 Jan-Feb;43(1):40-6. doi: 10.1111/ceo.12360. Epub 2014 Jun 21.

Liu GJ, Mizukawa A, Okisaka S. Mechanism of intraocular pressure decrease after contact transscleral continuous-wave Nd:YAG laser cyclophotocoagulation. Ophthalmic Res. 1994;26(2):65-79. doi: 10.1159/000267395.

Sousa DC, Ferreira NP, Marques-Neves C, Somers A, Vandewalle E, Stalmans I, Pinto LA. High-intensity Focused Ultrasound Cycloplasty: Analysis of Pupil Dynamics. J Curr Glaucoma Pract. 2018 Sep-Dec;12(3):102-106. doi: 10.5005/jp-journals-10028-1253.

Rivero-Santana A, Perez-Silguero D, Perez-Silguero MA, Encinas-Pisa P. Pupil Ovalization and Accommodation Loss after High-intensity Focused Ultrasound Treatment for Glaucoma: A Case Report. J Curr Glaucoma Pract. 2019 May-Aug;13(2):77-78. doi: 10.5005/jp-journals-10078-1256.

Bolek, B., Wylegala, A., Mazur, R. and Wylegala, E. (2019), Pupil irregularity after ultrasound ciliary plasty in glaucoma treatment. Acta Ophthalmol, 97:. doi:10.1111/j.1755-3768.2019.5480

Deb-Joardar N, Reddy KP. Application of high intensity focused ultrasound for treatment of open-angle glaucoma in Indian patients. Indian J Ophthalmol. 2018 Apr;66(4):517-523. doi: 10.4103/ijo.IJO_1024_17.

Torky MA, Alzafiri YA, Abdelhameed AG, Awad EA. Phaco-UCP; combined phacoemulsification and ultrasound ciliary plasty versus phacoemulsification alone for management of coexisting cataract and open angle glaucoma: a randomized clinical trial. BMC Ophthalmol. 2021 Jan 21;21(1):53. doi: 10.1186/s12886-021-01818-5.