Caprioli J, Park H J, Weitzman M
Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut, USA.
Trans Am Ophthalmol Soc. 1996;94:451-63; discussion 463-8.
To determine the intraocular pressure (IOP)-lowering effects of combined temporal corneal phacoemulsification and separate incision superior trabeculectomy with those of trabeculectomy alone.
This is a retrospective case-control study of 40 consecutive patients who underwent combined temporal corneal phacoemulsification and superior trabeculectomy with low-dose 5-fluorouracil (5-FU) (cases), and 40 eyes matched with respect to age, race, preoperative medications, and preoperative IOP that had trabeculectomy alone with low dose 5-FU (controls). Survival analyses for IOP were performed for the cases and controls. We reviewed the charts of 40 consecutive patients who underwent combined temporal corneal phacoemulsification and superior trabeculectomy with low dose 5-FU to determine the effect on IOP, visual acuity, and requirement for glaucoma medications. For controls, we chose 40 eyes matched with respect to age, race, preoperative medications, and preoperative IOP who had trabeculectomy alone with low dose 5-FU. In both groups, trabeculectomy was performed with the same technique, was located superiorly, and employed a limbus-based conjunctival flap. In the combined surgery group, temporal corneal phacoemulsification immediately preceded trabeculectomy and employed a 3.5-mm incision and a one-piece silicone intraocular lens. All patients received 3 or 4 subconjunctival 5-FU injections of 5 mg each over the first 11 postoperative days. Patients were followed up for at least 1 year. Success of trabeculectomy was defined as an IOP less than 22 mmHg and 20% or more reduction from the preoperative level on 2 consecutive follow-up visits, regardless of the use of antiglaucoma medications.
The mean postoperative intraocular pressure was higher in the combined surgery group than in the control group at each follow-up interval (P < 0.05). The mean (+/- SD) IOP reduction was 6.8 (+/- 5.5) mmHg in the combined surgery group, and 10.3 (+/- 7.6) mmHg in the trabeculectomy group at 1 year. The reduction in the number of antiglaucoma medications was 1.6 (+/- 0.9) in the combined surgery group and 2.0 (+/- 1.0) in the control group at 1 year. In the combined surgery group, the mean visual acuity beyond the first postoperative month was significantly better than at baseline (P < 0.001). Kaplan-Meier survival analysis showed that the cumulative success rate at 2 years was 62% in the combined surgery group and 86% in the trabeculectomy group. The time to failure was significantly shorter (P = 0.04) in the combined surgery group.
Combined surgery for cataract and glaucoma is associated with less long-term IOP reduction compared with trabeculectomy alone, despite identical trabeculectomy techniques in both groups. Nevertheless, combined surgery effectively lowers IOP and reduces the long-term requirement for antiglaucoma medications without additional complications. This technique is appropriate in selected patients with coexisting cataract and glaucoma.
比较颞侧角膜超声乳化联合上方小梁切除术与单纯小梁切除术降低眼压（IOP）的效果。
这是一项回顾性病例对照研究，连续纳入40例行颞侧角膜超声乳化联合上方小梁切除术并使用低剂量5-氟尿嘧啶（5-FU）的患者（病例组），以及40例在年龄、种族、术前用药和术前眼压方面与之匹配且仅行单纯小梁切除术并使用低剂量5-FU的患者（对照组）。对病例组和对照组进行眼压的生存分析。我们回顾了40例行颞侧角膜超声乳化联合上方小梁切除术并使用低剂量5-FU的连续患者的病历，以确定其对眼压、视力和青光眼药物需求的影响。对于对照组，我们选择了40例在年龄、种族、术前用药和术前眼压方面与之匹配且仅行单纯小梁切除术并使用低剂量5-FU的患者。两组均采用相同技术在上方进行小梁切除术，并采用以角膜缘为基底的结膜瓣。在联合手术组中，颞侧角膜超声乳化紧接在小梁切除术之前进行，采用3.5mm切口和一体式硅胶人工晶状体。所有患者在术后的前11天内接受3或4次结膜下注射，每次注射5mg的5-FU。患者随访至少1年。小梁切除术成功的定义为眼压低于22mmHg，且在连续2次随访中较术前水平降低20%或更多，无论是否使用抗青光眼药物。
在每个随访间隔期，联合手术组的术后平均眼压均高于对照组（P<0.05）。联合手术组1年时平均（±标准差）眼压降低6.8（±5.5）mmHg，小梁切除术组为10.3（±7.6）mmHg。联合手术组1年时抗青光眼药物使用数量减少1.6（±0.9），对照组为2.0（±1.0）。在联合手术组中，术后第1个月后的平均视力明显优于基线水平（P<0.001）。Kaplan-Meier生存分析显示，联合手术组2年时的累积成功率为62%，小梁切除术组为86%。联合手术组的失败时间明显更短（P = 0.04）。
与单纯小梁切除术相比，白内障和青光眼联合手术的长期眼压降低效果较差，尽管两组的小梁切除术技术相同。然而联合手术能有效降低眼压并减少抗青光眼药物的长期需求，且无额外并发症。该技术适用于部分同时患有白内障和青光眼的患者。
