Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
Department of Ophthalmology, School of Medicine, University of Colorado, Aurora, CO, USA.
Cochrane Database Syst Rev. 2021 Mar 24;3(3):CD005555. doi: 10.1002/14651858.CD005555.pub3.
Primary angle-closure glaucoma (PACG) is characterized by a rise in intraocular pressure (IOP) secondary to aqueous outflow obstruction, with relative pupillary block being the most common underlying mechanism. There is increasing evidence that lens extraction may relieve pupillary block and thereby improve IOP control. As such, comparing the effectiveness of lens extraction against other commonly used treatment modalities can help inform the decision-making process.
To assess the effectiveness of lens extraction compared with other interventions in the treatment of chronic PACG in people without previous acute angle-closure attacks.
We searched CENTRAL, MEDLINE, Embase, one other database, and two trials registers (December 2019). We also screened the reference lists of included studies and the Science Citation Index database. We had no date or language restrictions.
We included randomized controlled trials (RCTs) comparing lens extraction with other treatment modalities for chronic PACG.
We followed standard Cochrane methodology.
We identified eight RCTs with 914 eyes. We obtained data for participants meeting our inclusion criteria for these studies (PACG only, no previous acute angle-closure attacks), resulting in 513 eyes included in this review. The participants were recruited from a diverse range of countries. We were unable to conduct meta-analyses due to different follow-up periods and insufficient data. One study compared phacoemulsification with laser peripheral iridotomy (LPI) as standard care. Participants in the phacoemulsification group were less likely to experience progression of visual field loss (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13 to 0.91; 216 eyes; moderate certainty evidence), and required fewer IOP-lowering medications (mean difference [MD] -0.70, 95% CI -0.89 to -0.51; 263 eyes; moderate certainty evidence) compared with standard care at 12 months. Moderate certainty evidence also suggested that phacoemulsification improved gonioscopic findings at 12 months or later (MD -84.93, 95% CI -131.25 to -38.61; 106 eyes). There was little to no difference in health-related quality of life measures (MD 0.04, 95% CI -0.16 to 0.24; 254 eyes; moderate certainty evidence), and visual acuity (VA) (MD 2.03 ETDRS letter, 95% CI -0.77 to 4.84; 242 eyes) at 12 months, and no observable difference in mean IOP (MD -0.03mmHg, 95% CI -2.34 to 2.32; 257 eyes; moderate certainty evidence) compared to standard care. Irreversible loss of vision was observed in one participant in the phacoemulsification group, and three participants in standard care at 36 months (moderate-certainty evidence). One study (91 eyes) compared phacoemulsification with phaco-viscogonioplasty (phaco-VGP). Low-certainty evidence suggested that fewer IOP-lowering medications were needed at 12 months with phacoemulsification (MD -0.30, 95% CI -0.55 to -0.05). Low-certainty evidence also suggested that phacoemulsification may have improved gonioscopic findings at 12 months or later compared to phaco-VGP (angle grading MD -0.60, 95% CI -0.91 to -0.29; TISA500 MD -0.03, 95% CI -0.06 to -0.01; TISA750 MD -0.03, 95% CI -0.06 to -0.01; 91 eyes). Phacoemulsification may result in little to no difference in best corrected VA at 12 months (MD -0.01 log MAR units, 95% CI -0.10 to 0.08; low certainty evidence), and the evidence is very uncertain about its effect on IOP at 12 months (MD 0.50 mmHg, 95% CI -2.64 to 3.64; very low certainty evidence). Postoperative fibrin reaction was observed in two participants in the phacoemulsification group and four in the phaco-VGP group. Three participants in the phaco-VGP group experienced hyphema. No data were available for progression of visual field loss and quality of life measurements at 12 months. Two studies compared phacoemulsification with phaco-goniosynechialysis (phaco-GSL). Low-certainty evidence suggested that there may be little to no difference in mean IOP at 12 months (MD -0.12 mmHg, 95% CI -4.72 to 4.48; 1 study, 32 eyes) between the interventions. Phacoemulsification did not reduce the number of IOP-lowering medications compared to phaco-GSL at 12 months (MD -0.38, 95% CI -1.23 to 0.47; 1 study, 32 eyes; moderate certainty evidence). Three eyes in the phaco-GSL group developed hyphemas. No data were available at 12 months for progression of visual field loss, gonioscopic findings, visual acuity, and quality of life measures. Three studies compared phacoemulsification with combined phaco-trabeculectomy, but the data were only available for one study (63 eyes). In this study, low-certainty evidence suggested that there was little to no difference between groups in mean change in IOP from baseline (MD -0.60 mmHg, 95% CI -1.99 to 0.79), number of IOP-lowering medications at 12 months (MD 0.00, 95% CI -0.42 to 0.42), and VA measured by the Snellen chart (MD -0.03, 95% CI -0.18 to 0.12). Participants in the phacoemulsification group had fewer complications (risk ratio [RR] 0.59, 95% CI 0.34 to 1.04), and the phaco-trabeculectomy group required more IOP-lowering procedures (RR 5.81, 95% CI 1.41 to 23.88), but the evidence was very uncertain. No data were available for other outcomes.
AUTHORS' CONCLUSIONS: Moderate certainty evidence showed that lens extraction has an advantage over LPI in treating chronic PACG with clear crystalline lenses over three years of follow-up; ultimately, the decision for intervention should be part of a shared decision-making process between the clinician and the patient. For people with chronic PACG and visually significant cataracts, low certainty evidence suggested that combining phacoemulsification with either viscogonioplasty or goniosynechialysis does not confer any additional benefit over phacoemulsification alone. There was insufficient evidence to draw any meaningful conclusions regarding phacoemulsification versus trabeculectomy. Low certainty evidence suggested that combining phacoemulsification with trabeculectomy does not confer any additional benefit over phacoemulsification alone, and may cause more complications instead. These conclusions only apply to short- to medium-term outcomes; studies with longer follow-up periods can help assess whether these effects persist in the long term.
原发性闭角型青光眼（PACG）的特征是眼内压（IOP）升高继发于房水流出受阻，其中相对瞳孔阻滞是最常见的潜在机制。越来越多的证据表明晶状体摘出可能缓解瞳孔阻滞并从而改善 IOP 控制。因此，比较晶状体摘出与其他常用治疗方法的有效性可以帮助做出决策过程。
评估晶状体摘出与慢性 PACG 无既往急性闭角型发作的人群中其他干预措施相比的疗效。
我们检索了 CENTRAL、MEDLINE、Embase、一个其他数据库和两个试验登记处（2019 年 12 月）。我们还筛选了纳入研究的参考文献列表和科学引文索引数据库。我们没有时间或语言限制。
我们纳入了比较晶状体摘出与其他治疗方法治疗慢性 PACG 的随机对照试验（RCT）。
我们遵循了标准的 Cochrane 方法。
我们确定了 8 项 RCT，涉及 914 只眼。我们获得了符合我们纳入标准的参与者的数据（仅 PACG，无既往急性闭角型发作），因此，有 513 只眼纳入了本综述。参与者来自不同的国家。由于不同的随访期和数据不足，我们无法进行荟萃分析。一项研究比较了晶状体超声乳化术与激光周边虹膜切开术（LPI）作为标准护理。晶状体超声乳化术组的参与者视野丧失进展的可能性较小（比值比[OR]0.35，95%置信区间[CI]0.13 至 0.91；216 只眼；中等确定性证据），并且在 12 个月时需要的降 IOP 药物较少（平均差异[MD]-0.70，95%CI-0.89 至-0.51；263 只眼；中等确定性证据）与标准护理相比。中度确定性证据还表明，晶状体超声乳化术在 12 个月或以后改善了房角镜检查结果（MD-84.93，95%CI-131.25 至-38.61；106 只眼）。在健康相关生活质量测量方面（MD0.04，95%CI-0.16 至 0.24；254 只眼；中等确定性证据）和视力（VA）（MD2.03 ETDRS 字母，95%CI-0.77 至 4.84；242 只眼）方面，在 12 个月时，晶状体超声乳化术与标准护理相比差异无统计学意义，而在平均 IOP（MD-0.03mmHg，95%CI-2.34 至 2.32；257 只眼；中等确定性证据）方面差异也无统计学意义。晶状体超声乳化术组有 1 名参与者和标准护理组有 3 名参与者在 36 个月时出现不可逆性失明（中等确定性证据）。一项研究（91 只眼）比较了晶状体超声乳化术与晶状体超声乳化联合前房角切开术（phaco-VGP）。低确定性证据表明，晶状体超声乳化术在 12 个月时需要的降 IOP 药物较少（MD-0.30，95%CI-0.55 至-0.05）。低确定性证据还表明，晶状体超声乳化术在 12 个月或以后可能改善了房角镜检查结果，与 phaco-VGP 相比（角度分级 MD-0.60，95%CI-0.91 至-0.29；TISA500 MD-0.03，95%CI-0.06 至-0.01；TISA750 MD-0.03，95%CI-0.06 至-0.01；91 只眼）。晶状体超声乳化术在 12 个月时可能对最佳矫正视力（VA）的影响差异无统计学意义（MD-0.01 对数 MAR 单位，95%CI-0.10 至 0.08；低确定性证据），并且证据非常不确定其对 12 个月时 IOP 的影响（MD0.50mmHg，95%CI-2.64 至 3.64；非常低确定性证据）。在晶状体超声乳化术组中观察到 2 名参与者和在 phaco-VGP 组中观察到 4 名参与者发生了术后纤维蛋白反应。phaco-VGP 组有 3 名参与者发生了前房积血。12 个月时进展的视野丧失和生活质量测量数据不可用。两项研究比较了晶状体超声乳化术与晶状体超声乳化联合小梁切开术（phaco-GSL）。低确定性证据表明，两组在 12 个月时平均 IOP 可能差异无统计学意义（MD-0.12mmHg，95%CI-4.72 至 4.48；1 项研究，32 只眼）。晶状体超声乳化术与 phaco-GSL 相比，12 个月时并没有减少 IOP 降低药物的使用（MD-0.38，95%CI-1.23 至 0.47；1 项研究，32 只眼；中等确定性证据）。phaco-GSL 组有 3 只眼发生了前房积血。12 个月时进展的视野丧失、房角镜检查结果、视力和生活质量测量数据不可用。三项研究比较了晶状体超声乳化术与联合小梁切除术，但只有一项研究（63 只眼）的数据可用。在这项研究中，低确定性证据表明，两组在从基线到眼压的平均变化（MD-0.60mmHg，95%CI-1.99 至 0.79）、12 个月时的 IOP 降低药物数量（MD0.00，95%CI-0.42 至 0.42）和 Snellen 图表测量的视力（MD-0.03，95%CI-0.18 至 0.12）方面差异无统计学意义。晶状体超声乳化术组的并发症较少（风险比[RR]0.59，95%CI 0.34 至 1.04），而小梁切除术组需要更多的 IOP 降低程序（RR5.81，95%CI 1.41 至 23.88），但证据非常不确定。其他结果的数据不可用。
中等确定性证据表明，在 3 年的随访中，晶状体摘出术在治疗具有清晰晶状体的慢性 PACG 方面优于 LPI；最终，干预措施的选择应该是临床医生和患者之间共同决策过程的一部分。对于患有慢性 PACG 和明显白内障的患者，低确定性证据表明，在晶状体超声乳化术联合粘性或小梁切开术治疗方面，与单独进行晶状体超声乳化术相比，不会带来任何额外的益处。没有足够的证据得出任何有意义的结论，比较晶状体超声乳化术与小梁切除术。低确定性证据表明，在晶状体超声乳化术联合小梁切除术方面，与单独进行晶状体超声乳化术相比，不会带来任何额外的益处，反而可能导致更多的并发症。这些结论仅适用于短期至中期结果；具有更长随访期的研究可以帮助评估这些影响是否会在长期内持续存在。
