Aim: Whether pupillary expansion during phacoemulsification causes a change in postoperative intraocular pressure (IOP) is currently unknown. However, a growing proportion of patients can present with concurrent glaucoma and cataracts, which poses an increased risk of having small pupils and makes finding the answer to this question imperative for treating physicians.
Materials and methods: This was a retrospective, observational cohort study which utilized data from 2008 to 2016 from the University Hospital, Newark, New Jersey, USA. All patients with primary open-angle glaucoma (POAG) who underwent phacoemulsification with pupillary expansion were considered for inclusion. Cases were subsequently excluded if they had prior incisional glaucoma surgery, if phacoemulsification was combined with another surgery, or if they had any incisional surgery in the eye 1 year preoperatively or postoperatively. The control group was made up of patients without POAG. The primary outcome was IOP.
Results: Thirty-seven eyes from 31 glaucoma patients and 29 eyes from 28 control patients met inclusion criteria. The mean IOP in the POAG group increased from 15.0 ± 4.6 mm Hg to 15.9 ± 3.5 mm Hg after 1 year, whereas the control group decreased from 14.1 ± 3.6 mm Hg to 11.9 ± 3.9 mm Hg. Multivariate analysis showed that glaucoma was associated with a 5.56 mm Hg increase in IOP at 12 months postoperatively. The average number of glaucoma medications decreased significantly from 1.7 ± 1.4 at the baseline to 1.3 ± 1.3 after 1 year.
Conclusion: In contrast with non-POAG patients, no significant drop in the mean IOP was noted after complex cataract surgery for this cohort of glaucoma patients, although medication burden significantly decreased and VA improved significantly.
Clinical significance: Phacoemulsification with intraoperative pupillary expansion in POAG patients may not decrease IOP after 12 months but it can decrease the number of anti-glaucoma medications they take.
Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012;96(5):614–618. DOI: 10.1136/bjophthalmol-2011-300539.
Obstbaum SA. Glaucoma and intraocular lens implantation. J Cataract Refract Surg 1986;12(3):257–261.
Perasalo R. Phaco-emulsification of cataract in eyes with glaucoma. Acta Ophthalmol Scand 1997;75(3):299–300.
Kim DD, Doyle JW, et al. Intraocular pressure reduction following phacoemulsification cataract extraction with posterior chamber lens implantation in glaucoma patients. Ophthalmic Surg Lasers 1999;30(1):37–40.
Shingleton BJ, Gamell LS, et al. Long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients vs glaucoma suspect and glaucoma patients. J Cataract Refract Surg 1999;25(7):885–890.
Mierzejewski A, Eliks I, et al. Cataract phacoemulsification and intraocular pressure in glaucoma patients. Klin Oczna 2008;110(1–3): 11–17.
Mathalone N, Hyams M, et al. Long-term intraocular pressure control after clear corneal phacoemulsification in glaucoma patients. J Cataract Refract Surg 2005;31(3):479–483. DOI: 10.1016/j.jcrs.2004.06.046.
Shrivastava A, Singh K. The effect of cataract extraction on intraocular pressure. Curr Opin Ophthalmol 2010;21(2):118–122. DOI: 10.1097/ICU.0b013e3283360ac3.
Hayashi K, Hayashi H, et al. Changes in anterior chamber angle width and depth after intraocular lens implantation in eyes with glaucoma. Ophthalmology 2000;107(4):698–703. DOI: 10.1016/s0161-6420(00)00007-5.
Dooley I, Charalampidou S, et al. Changes in intraocular pressure and anterior segment morphometry after uneventful phacoemulsification cataract surgery. Eye (Lond) 2010;24(4):519–526; quiz 527##10.1038/eye.2009.339.
Alaghband P, Beltran-Agullo L, et al. Effect of phacoemulsification on facility of outflow. Br J Ophthalmol 2018;102(11):1520–1526.
Meyer MA, Savitt ML, et al. The effect of phacoemulsification on aqueous outflow facility. Ophthalmology 1997;104(8):1221–1227. DOI: 10.1016/s0161-6420(97)30154-7.
Wang N, Chintala SK, et al. Activation of a tissue-specific stress response in the aqueous outflow pathway of the eye defines the glaucoma disease phenotype. Nat Med 2001;7(3):304–309. DOI: 10.1038/85446.
Park JW, Kang BH, et al. Analysis of various factors affecting pupil size in patients with glaucoma. BMC Ophthalmol 2017;17(1):168. DOI: 10.1186/s12886-017-0564-6.
Turalba A, Payal AR, et al. Cataract Surgery Outcomes in Glaucomatous Eyes: Results From the Veterans Affairs Ophthalmic Surgery Outcomes Data Project. Am J Ophthalmol 2015;160(4):693–701 e691. DOI: 10.1016/j.ajo.2015.07.020.
Malyugin B. Cataract surgery in small pupils. Indian J Ophthalmol 2017;65(12):1323–1328. DOI: 10.4103/ijo.IJO_800_17.
Katz LJ, Zangalli C, et al. Combined cataract and glaucoma surgery: the effect of pupil enlargement on surgical outcomes (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2013;111:155–168.
Huang J, Huang J, et al. Evaluation of Approaches to Analyzing Continuous Correlated Eye Data When Sample Size Is Small. Ophthalmic Epidemiol 2018;25(1):45–54. DOI: 10.1080/09286586.2017.1339809.
Chen PP, Lin SC, et al. The Effect of Phacoemulsification on Intraocular Pressure in Glaucoma Patients: A Report by the American Academy of Ophthalmology. Ophthalmology 2015;122(7):1294–1307. DOI: 10.1016/j.ophtha.2015.03.021.
Tan RKY, Wang X, et al. Numerical stress analysis of the iris tissue induced by pupil expansion: Comparison of commercial devices. PLoS One 2018;13(3):e0194141. DOI: 10.1371/journal.pone.0194141.
Doukas AG, McAuliffe DJ, et al. Physical factors involved in stress-wave-induced cell injury: the effect of stress gradient. Ultrasound Med Biol 1995;21(7):961–967.
Wang N, Chintala SK, et al. Ultrasound activates the TM ELAM-1/IL-1/NF-kappaB response: a potential mechanism for intraocular pressure reduction after phacoemulsification. Invest Ophthalmol Vis Sci 2003;44(5):1977–1981. DOI: 10.1167/iovs.02-0631.
Kee C, Seo K. The effect of interleukin-1alpha on outflow facility in rat eyes. J Glaucoma 1997;6(4):246–249.
Kung JS, Choi DY, et al. Cataract surgery in the glaucoma patient. Middle East Afr J Ophthalmol 2015;22(1):10–17. DOI: 10.4103/0974-9233.148343.
Chen PP, Musch DC, et al. The effect of early posttrabeculectomy intraocular pressure spike in the collaborative initial glaucoma treatment study. J Glaucoma 2011;20(4):211–214. DOI: 10.1097/IJG.0b013e3181e07947.
Aung T, Oen FT, et al. Randomised controlled trial comparing the effect of brimonidine and timolol on visual field loss after acute primary angle closure. Br J Ophthalmol 2004;88(1):88–94. DOI: 10.1136/bjo.88.1.88.
Tsai JC. A comprehensive perspective on patient adherence to topical glaucoma therapy. Ophthalmology 2009;116(11 Suppl):S30–S36. DOI: 10.1016/j.ophtha.2009.06.024.