Background: Within the aging population, coexisting of glaucoma and cataract is frequent. The treatment of either condition can influence the course of the other. Cataract extraction, glaucoma filtration surgery or combined procedures are the management options. The choice of procedure depends on the level of visual impairment, severity of glaucoma, level of intraocular pressure and other factors.Objective: The study was aimed at assessing the outcome of combined manual small incision cataract surgery and trabeculectomy in lowering intraocular pressure and restoration of vision.Methods and Patients: A retrospective chart review of one year follow-up of patients who under went combined manual small incision cataract surgery and trabeculectomy at Menelik II Hospital.Results: Forty-nine eyes of 43 patients were included in the study. Pre-operative intraocular pressure decreased from mean 27.04 mmHg to 13.41 mmHg at 12 months postoperative follow-up, with mean reduction of 13.63 mmHg.  Hypotensive medication was not required in 71.4% of the operated eyes. Visual acuity, which was less than 6/18 in all eyes on Snellen chart improved to greater than 6/18 in 35 eyes, 71.4%.Conclusion: Combined manual small incision cataract surgery and trabeculectomy is effective in terms of IOP control and vision restoration in treating patients with coexisting cataract and glaucoma.Recommendation:  The procedure is doable and cost effective for eye care professionals who handle glaucoma patients and practicing manual small incision cataract surgery.Key words: Cataract, Glaucoma, Manual small incision cataract surgery and trabeculectomy.

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Outcomes of Combined Manual Small Incision Cataract Surgery and Trabeculectomy

Trabeculectomy is a gold standard filtration procedure in the management of glaucoma. However, small incision cataract surgery with trabeculectomy is the combined surgical procedure for the management of coexisting glaucoma and cataract. The final success rate related to minimizing intraocular pressure (IOP) depends on the follow-up duration and assessment criteria. This study was aimed to evaluate the long term control of intraocular pressure and morphology of bleb in cases undergoing small incision cataract surgery with trabeculectomy. One hundred cases diagnosed with moderate or severe glaucomatous damage with cataract above 32 years were recruited. Postoperative follow up was done from day 1 to 12 months, to evaluate the intraocular pressure (IOP), bleb morphology and postoperative complications. In PAOG, 61.3% cases had good control and 60% cases had poor control of postoperative IOP. In PACG, 32% cases had good control and 28% cases had poor postoperative IOP control. In the overall success, the qualified success rate was 63% and the complete success rate was 97%. Cases with early postoperative IOP of >10mmHg on 5th day or >13mmHg on 10th day is associated with poor control of intraocular IOP at the end of 12th month. Small incision cataract surgery with trabeculectomy is an effective procedure in reducing the intraocular pressure.

https://www.ophthalmoljournal.com/articles/54/3-1-3-635.pdf

Combined small incision cataract surgery and trabeculectomy on intra ocular pressure outcome

Precis We describe standardization and simplification of classic trabeculectomy combined with manual small incision cataract surgery (MSICS) to effectively manage the 2 leading and often coexisting causes of blindness and vision impairment in resource-constrained areas. Purpose The purpose of this study was to describe modifications to trabeculectomy combined with MSICS and report on the outcomes of this technique. The modifications consist of standardization and simplification of the surgical steps. Methods Data obtained from adult patients who underwent described surgical technique at rural eye care centers across 3 Indian states between January 2018 and May 2019 were analyzed retrospectively. Complete success was intraocular pressure between 6 and 18 mm Hg without supplementary medication. Qualified success allowed up to 3 topical medication(s). Data are presented as median (first and third quartiles). Results We analyzed data of 70 eyes of 70 patients. Ophthalmology fellows performed 27 (38.5%) surgeries, whereas an experienced glaucoma specialist performed 43 (61.4%) surgeries. Patients were 63 (56, 67) years old. The preoperative intraocular pressure was 20 (16, 26) mm Hg on treatment with 3 (2, 3) antiglaucoma medications. Glaucoma was advanced by optic disc structural criteria in 58 (82.8%) eyes. Intraoperative mitomycin C was used in 5 (7.1%) eyes. Follow-up was 12.5 (6, 18) months. At 1 year, complete success (95% confidence interval) achieved was 55% (41-67), whereas qualified success was 83% (68-92) with 0 (0, 1) topical medications. The complete and qualified success rates did not differ between ophthalmology fellows and the glaucoma specialist (P=0.75 and 0.44, respectively). Conclusions We present a straightforward, yet effective technique of combined cataract and glaucoma surgery. The technique has a potential for wider applicability, especially in the underserved regions of the world.

Modifications to Combined Trabeculectomy and Manual Small Incision Cataract Surgery: Outcomes and Adaptability in Resource-constrained Areas.

Context: Glaucoma is a optic neuropathy having multifactorial causes. Both cataract and glaucoma condition can influence management of the one another. Aims: To know the visual outcome and intraocular pressure control after combined trabeculectomy in patients with glaucoma and cataract. Settings and Design: It was a descriptive interventional study done for two years. All patients diagnosed to have significant cataract and diagnosed glaucoma were included in study. Methods and Material: After taking consent, combined surgery was performed and post-op follow up was done on 1st postoperative day and then on 1st week, 2weeks, 4weeks, 6weeks, 8weeks and 6 months. All parameters assessed and tabulated for statistical analysis. Results: Mean age of subjects was 59 years. 46.7% were males. Most of the patients (73.4%) were diagnosed as POAG. 26.7% were having PACG. Pre-operatively, 7 patients had vision better than 6/36. 13 patients had 6/36 and 10 patients had less than 6/36. At 6 weeks postoperatively, 76.7% had vision 6/9 or better, 16.7% had between 6/12 to 6/18, 6.7% less than 6/18. Mean IOP, Preoperatively among POAG and PACG was 19.90 and 33.25mmHg. Among POAG, Postoperatively at 6weeks, 8week, and 6months, IOP was 13.81, 13.91 and 12.72mmHg respectively. Postoperatively at 6weeks, 8week, and 6months, IOP was 19.75, 18.00 and 17.25mmHg in case of PACG. Conclusions: The study has showed the postoperative visual outcome and control of intraocular pressure is better with combined trabeculectomy with cataract surgery but still patients should be individualised according to their presentation.

A Descriptive Study on Visual Outcome and Intraocular Pressure Control after Trabeculectomy with Manual Small Incision Cataract Surgery in Patients with Glaucoma and Cataract

https://www.djo.org.in/filedownload.aspx?id=477

`Flying Eagle` Incision for Combined Manual Small Incision Cataract Surgery-Trabeculectomy

Both cataract and glaucoma are significant public health problems. Combined cataract operation and trabeculectomy is required for visual rehabilitation and control of intraocular pressure (IOP) thereby preventing progressive optic nerve damage, in patients with coexisting cataract and glaucoma. The aim of this study was to find out the visual rehabilitation and IOP control following combined manual small incision cataract surgery (SICS) and mitomycin-C (MMC) augmented trabeculectomy. In this study 45 consecutive eyes of 45 patients who had undergone combined procedures (manual SICS+ trabeculectomy with MMC) were reviewed between September 2011 and August 2012. Postoperative visual acuity and IOP were recorded at postoperative day 1, 2nd week and 6th week to see the short term outcome of surgery and any postoperative complications were recorded. Best corrected visual acuity (BCVA) at 6th week follow-up was noted. Out of 45 patients males were 31 (68.8%) and females were 14 (31.1%). Twenty nine (64.4%) patients were Primary open angle glaucoma (POAG), 11 (24.4%) Primary angle closure glaucoma (PACG), 5 (11.1%) Normal tension glaucoma (NTG) with visually significant cataract. The mean preoperative and postoperative IOP was 23.93 mmHg ± 0.75 mmHg and 11.2 mmHg ± 1.5 mmHg respectively. The mean reduction in IOP was 12.73 mmHg on the 6th week of follow up. There was statistically significant reduction in IOP on the 6th week follow up (p < 0.000 1). Twenty three patients (65.7%) achieved best corrected visual acuity between 6/6 to 6/18 and 6 patients (17.1%) had 6/24 to 6/60 on the 6th week follow up. Combined SICS with MMC augmented trabeculectomy is effective in terms of IOP control and visual rehabilitation in treating glaucoma patients with cataract.

P Singh

Papers

Visual rehabilitation and intraocular pressure control after combined manual small incision cataract surgery and mitomycin-C augmented trabeculectomy.