Risk Factors for Early Postoperative Intraocular Pressure Elevation after Phacoemulsification in Trabeculectomized Eyes

Won Mo Gu; Su Ho Lim; Soon Cheol Cha

doi:10.3341/jkos.2014.55.11.1659

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Gu, Lim, and Cha: Risk Factors for Early Postoperative Intraocular Pressure Elevation after Phacoemulsification in Trabeculectomized Eyes

Original Article

J Korean Ophthalmol Soc 2014;55(11):1659-1668.

Published online: 2 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.11.1659

Risk Factors for Early Postoperative Intraocular Pressure Elevation after Phacoemulsification in Trabeculectomized Eyes

Won Mo Gu, MD¹, Su Ho Lim, MD², Soon Cheol Cha, MD, PhD¹

¹Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea

²Department of Ophthalmology, Daegu Veterans Health Service Medical Center, Daegu, Korea

Address reprint requests to Soon Cheol Cha, MD, PhD, Department of Ophthalmology, Yeungnam University Medical Center, #170 Hyeonchung-ro, Nam-gu, Daegu 705-802, Korea, Tel: 82-53-620-3442, Fax: 82-53-626-5936, E-mail: sccha@yumail.ac.kr

Received 1 May 2014 Revised 8 July 2014 Accepted 27 October 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

In this study, we investigated the frequency and risk factors for early postoperative intraocular pressure (IOP) elevation after phacoemulsification in patients with a prior trabeculectomy.

Methods

We performed a retrospective chart review of 200 eyes (172 patients, study group) with filtering bleb after previous trabeculectomy and 207 eyes (144 patients, control group) without previous trabeculectomy, who underwent temporal clear corneal phacoemulsification with posterior chamber lens implantation. Twelve possible risk factors including age, gender, glaucoma type, interval from trabeculectomy to phacoemulsification, axial length, preoperative IOP, preoperative bleb morphology (height, vascularity), glaucoma medication, and concomitant intraoperative procedures (iris manipulation, anterior vitrectomy, subconjunctival mitomycin C injection) were analyzed to identify independent risk factors using a multivariate logistic regression method. Early postoperative IOP elevation was defined as IOP value ≥ 25 mm Hg or an IOP increase ≥ 10 mm Hg the morning after surgery compared to the preoperative IOP.

Results

There was a significant difference in the frequency of IOP elevation between the study group (25 eyes, 12.5%) and control group (6 eyes, 2.9%; p < 0.001). The mean early postoperative IOP (15.2 ± 6.7 mm Hg) was significantly higher than pre-operative IOP (12.5 ± 4.4 mm Hg) in the study group (p < 0.001). Risk factors for early postoperative IOP elevation were low bleb height (odds ratio; OR = 9.995, p = 0.003) and iris manipulation (OR = 4.831, p = 0.026) in the study group while risk factors were pre-operative use of glaucoma medication (OR = 3.492, p = 0.004) and iris manipulation (OR = 34.249, p = 0.009) in the control group.

Conclusions

Phacoemulsification increases the risk of IOP spike in prior trabeculectomized eyes, especially those with low bleb height and intraoperative iris manipulation. We suggest intraoperative and postoperative efforts to minimize intraocular inflammation and earlier follow-up examination in these patients.

Keywords: Glaucoma, Intraocular pressure, Phacoemulsification, Risk factor, Trabeculectomy

References

1. Kim YH, Moon IA, Park CK, Baek NH. Results of phacoemulsificatin with PCL implantation in post-trabeculectomy eyes. J Korean Ophthalmol Soc. 1998; 39:1755–61.

2. Shields MB. Another reevaluation of combined cataract and glaucoma surgery. Am J Ophthalmol. 1993; 115:806–11.

3. Lamping KA, Bellows AR, Hutchinson BT, Afran SI. Long-term evaluation of initial filtration surgery. Ophthalmology. 1986; 93:91–101.

4. Mills KB. Trabeculectomy: a retrospective long-term follow-up of 444 cases. Br J Ophthalmol. 1981; 65:790–5.

5. Clarke MP, Vernon SA, Sheldrick JH. The development of cataract following trabeculectomy. Eye (Lond). 1990; 4(Pt 4):577–83.

6. Vesti E. Development of cataract after trabeculectomy. Acta Ophthalmol (Copenh). 1993; 71:777–81.

7. Popovic V, Sjöstrand J. Long-term outcome following trabeculectomy: I Retrospective analysis of intraocular pressure regulation and cataract formation. Acta Ophthalmol (Copenh). 1991; 69:299–304.

8. Bonomi L, Marchini G, de Franco I, Perfetti S. Prospective study of the lens changes after trabeculectomy. Dev Ophthalmol. 1989; 17:97–100.

9. Daugeliene L, Yamamoto T, Kitazawa Y. Cataract development after trabeculectomy with mitomycin C: a 1-year study. Jpn J Ophthalmol. 2000; 44:52–7.

10. Jahn CE. Reduced intraocular pressure after phacoemulsification and posterior chamber intraocular lens implantation. J Cataract Refract Surg. 1997; 23:1260–4.

11. Tanaka T, Inoue H, Kudo S, Ogawa T. Relationship between postoperative intraocular pressure elevation and residual sodium hyaluronate following phacoemulsification and aspiration. J Cataract Refract Surg. 1997; 23:284–8.

12. Meyer MA, Savitt ML, Kopitas E. The effect of phacoemulsification on aqueous outflow facility. Ophthalmology. 1997; 104:1221–7.

13. Bömer TG, Lagrèze WD, Funk J. Intraocular pressure rise after phacoemulsification with posterior chamber lens implantation: effect of prophylactic medication, wound closure, and surgeon's experience. Br J Ophthalmol. 1995; 79:809–13.

14. Park HJ, Kwon YH, Weitzman M, Caprioli J. Temporal corneal phacoemulsification in patients with filtered glaucoma. Arch Ophthalmol. 1997; 115:1375–80.

15. Shingleton BJ, Gamell LS, O'Donoghue MW, et al. Long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspect and glaucoma patients. J Cataract Refract Surg. 1999; 25:885–90.

16. Shingleton BJ, Pasternack JJ, Hung JW, O'Donoghue MW. Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients. J Glaucoma. 2006; 15:494–8.

17. Byun SW, Park CK, Ahn MD. Effect of cataract surgery through clear corneal incision in glaucomatous eyes with filtering blebs. J Korean Ophthalmol Soc. 1999; 40:1630–5.

18. Sałaga-Pylak M, Kowal M, Zarnowski T. Deterioration of filtering bleb morphology and function after phacoemulsification. BMC Ophthalmol. 2013; 13:17.

19. Cantor LB, Mantravadi A, WuDunn D, et al. Morphologic classification of filtering blebs after glaucoma filtration surgery: the Indiana Bleb Appearance Grading Scale. J Glaucoma. 2003; 12:266–71.

20. Murthy SK, Damji KF, Pan Y, Hodge WG. Trabeculectomy and phacotrabeculectomy, with mitomycin-C, show similar two-year target IOP outcomes. Can J Ophthalmol. 2006; 41:51–9.

21. Chen PP, Weaver YK, Budenz DL, et al. Trabeculectomy function after cataract extraction. Ophthalmology. 1998; 105:1928–35.

22. Crichton AC, Kirker AW. Intraocular pressure and medication control after clear corneal phacoemulsification and AcrySof posterior chamber intraocular lens implantation in patients with filtering blebs. J Glaucoma. 2001; 10:38–46.

23. Rebolleda G, Muñoz-Negrete FJ. Phacoemulsification in eyes with functioning filtering blebs: a prospective study. Ophthalmology. 2002; 109:2248–55.

24. Klink J, Schmitz B, Lieb WE, et al. Filtering bleb function after clear cornea phacoemulsification: a prospective study. Br J Ophthalmol. 2005; 89:597–601.

25. Swamynathan K, Capistrano AP, Cantor LB, WuDunn D. Effect of temporal corneal phacoemulsification on intraocular pressure in eyes with prior trabeculectomy with an antimetabolite. Ophthalmology. 2004; 111:674–8.

26. Bigger JF, Becker B. Cataracts and primary open-angle glaucoma: the effect of uncomplicated cataract extraction on glaucoma control. Trans Am Acad Ophthalmol Otolaryngol. 1971; 75:260–72.

27. Smith M, Chipman ML, Trope GE, Buys YM. Correlation between the indiana bleb appearance grading scale and intraocular pressure after phacotrabeculectomy. J Glaucoma. 2009; 18:217–9.

28. Ferguson VM, Spalton DJ. Continued breakdown of the blood aqueous barrier following cataract surgery. Br J Ophthalmol. 1992; 76:453–6.

29. Husain R, Liang S, Foster PJ, et al. Cataract surgery after trabeculectomy: the effect on trabeculectomy function. Arch Ophthalmol. 2012; 130:165–70.

30. Seah SK, Jap A, Prata JA Jr, et al. Cataract surgery after trabeculectomy. Ophthalmic Surg Lasers. 1996; 27:587–94.

31. Maumenee AE. External filtering operations for glaucoma: the mechanism of function and failure. Trans Am Ophthalmol Soc. 1960; 58:319–28.

32. Addicks EM, Quigley HA, Green WR, Robin AL. Histologic characteristics of filtering blebs in glaucomatous eyes. Arch Ophthalmol. 1983; 101:795–8.

33. Yamagami S, Araie M, Mori M, Mishima K. Posterior chamber intraocular lens implantation in filtered or nonfiltered glaucoma eyes. Jpn J Ophthalmol. 1994; 38:71–9.

34. Yaldo MK, Stamper RL. Long-term effects of mitomycin on filtering blebs. Lack of fibrovascular proliferative response following severe inflammation. Arch Ophthalmol. 1993; 111:824–6.

35. Kim YB, Moon JI, Baek NH. Efficacy of 5-Fluorouracil and Mitomycin-C on Glaucoma Filtration Surgery in Rabbits. J Korean Ophthalmol Soc. 1995; 36:681–90.

36. Sharma TK, Arora S, Corridan PG. Phacoemulsification in patients with previous trabeculectomy: role of 5-fluorouracil. Eye (Lond). 2007; 21:780–3.

Figure 1.

Standard photos of bleb height (A-C) and vascularity (D-F) from modified Indiana Bleb Grading System. (A) Elevated bleb. (B) Moderate elevated bleb. (C) Low elevated bleb. (D) Avascular bleb. (E) Hypovascular bleb. (F) Vascular bleb.

Figure 2.

Mean intraocular pressure (IOP) in trabeculectomized group over a 12-month period. Group A (IOP spike group) tended to be worse than group B (no IOP spike group) in long-term IOP control. Values are presented as mean± SD. ^∗Repeated measures ANOVA and Bonferroni post hoc analysis for multiple comparisons.

Table 1.

Patients demographic data and type of glaucoma in trabeculectomized group

Characteristics	Group A (n = 25)	Group B (n = 175)	p-value
Age (years)	67.0 ± 9.2	64.9 ± 12.0	0.310^∗
Sex (%)			0.162^†
Male	17 (68.0)	93 (53.1)
Female	8 (32.0)	82 (46.9)
Laterality (%)			0.520^†
OD	13 (52.0)	79 (45.1)
OS	12 (48.0)	96 (54.9)
Systemic disease (%)
Diabetes	5 (20.0)	38 (21.7)	0.845^†
Hypertension	7 (28.0)	40 (22.9)	0.571^†
Cardiovascular disease	0 (0.0)	7 (4.0)	0.600^‡
Type of glaucoma (%)			0.642^‡
Primary open angle	11 (44.0)	86 (49.1)
Chronic angle closure	8 (32.0)	46 (26.3)
Pseudoexfoliation	2 (8.0)	14 (8.0)
Uveitic	1 (4.0)	15 (8.6)
Neovasular	2 (8.0)	6 (3.4)
Traumatic	1 (4.0)	3 (1.7)
Steroid-induced	0 (0.0)	3 (1.7)
Developmental	0 (0.0)	2 (1.1)

Values are presented as mean ± SD unless otherwise indicated; Group A: IOP spike group in trabeculetomized eyes; Group B: no IOP spike group in trabeculectomized eyes.

^∗ t-test;

^† Chi-square test;

^‡ Fisher's exact test.

Table 2.

Comparison between intraocular pressure spike group and no intraocular pressure spike group in trabeculectomized group by univariate analysis

Factors	Group A (n = 25)	Group B (n = 175)	p-value
Age (years, %)			0.322^∗
≤50	1 (4.0)	23 (13.1)
>50	24 (96.0)	152 (86.9)
Sex (%)			0.162^†
Male	17 (68.0)	93 (53.1)
Female	8 (32.0)	82 (46.9)
Uveitic glaucoma (%)	1 (4.0)	15 (8.6)	0.699^∗
Preoperative IOP (mm Hg)	12.2 ± 4.8	12.5 ± 4.4	0.731^‡
No. of glaucoma medication prior to PEA	0.0 ± 0.2	0.3 ± 0.8	0.093^§
Interval from trabeculectomy to PEA (months, %)			1.000^†
≤6	1 (4.0)	10 (5.7)
>6	24 (96.0)	165 (94.3)
Axial length (mm)	22.94 ± 0.80	23.22 ± 1.30	0.146^‡
Bleb height (%)			0.001^†
Elevated	6 (24.0)	100 (57.1)
Moderate elevated	11 (44.0)	57 (32.6)
Low elevated	8 (32.0)	18 (10.3)
Bleb vascularity (%)			0.129^∗
Avascular	10 (40.0)	88 (50.3)
Hypovascular	13 (52.0)	84 (48.0)
Vascular	2 (8.0)	3 (1.7)
Anterior vitrectomy (%)	1 (4.0)	4 (2.3)	0.491^∗
Iris manipulation (%)	6 (24.0)	8 (4.6)	<0.001^†
MMC injection (%)	16 (64.0)	88 (50.3)	0.199^†

Values are presented as mean ± SD unless otherwise indicated; Group A: IOP spike group in trabeculetomized eyes; Group B: no IOP spike group in trabeculectomized eyes.

IOP = intraocular pressure; No = number; PEA = phacoemulsification; MMC = mitomycin C.

^∗ Fisher's exact test;

^† Chi-square test;

^‡ t-test;

^§ Mann Whitney U-test.

Table 3.

Multivariate analysis for risk factors for intraocular pressure spike after phacoemulsification in trabeculectomized group (n = 200)

Factors	Odds ratio	95% CI	p-value^∗
Age (years)			0.211
≤50	1
>50	4.594	0.422-50.060
Sex			0.158
Male	1
Female	0.449	0.148-1.364
Uveitic glaucoma	0.471	0.041-5.419	0.546
Preoperative IOP	0.973	0.863-1.098	0.661
No. of glaucoma medication prior to PEA	0.192	0.027-1.378	0.101
Interval from trabeculectomy to PEA (months)			0.910
≤6	1
>6	0.851	0.052-13.844
Axial length	0.825	0.456-1.491	0.523
Bleb height			0.011
Elevated	1
Moderate elevated	2.796	0.869-8.995	0.085
Low elevated	9.995	2.205-45.306	0.003
Bleb vascularity			0.714
Avascular	1
Hypovascular	1.494	0.539-4.144	0.440
Vascular	1.744	0.144-21.086	0.662
Anterior vitrectomy	3.480	0.191-63.277	0.399
Iris manipulation	4.831	1.209-19.311	0.026
MMC injection	1.415	0.464-4.311	0.541

CI = confidence interval; IOP = intraocular pressure; No = number; PEA = phacoemulsification; MMC = mitomycin C.

^∗ Multivariate logistic regression analysis.

Table 4.

Patients demographic and baseline data in control group (n = 207)

Characteristics	Total
Age (years)	66.6 ± 10.7
Sex (%)
Male	66 (31.9)
Female	141 (68.1)
Laterality (%)
OD	106 (51.2)
OS	101 (48.8)
Systemic disease (%)
Diabetes	66 (31.9)
Hypertension	82 (39.6)
Cardiovascular disease	26 (12.6)
Preoperative IOP (mm Hg)	14.3 ± 2.7
No. of glaucoma medication prior to PEA	0.5 ± 0.9
Eyes with glaucoma medication (%)	48 (23.2)
Eyes with angle closure (%)	77 (37.2)
Axial length (mm)	23.26 ± 1.85

Values are presented as mean ± SD unless otherwise indicated. IOP = intraocular pressure; No = number; PEA = phacoemlusification.

Table 5.

Comparison between intraocular pressure spike group and no intraocular pressure spike group in control group by univariate analysis

Factors	Group C (n = 6)	Group D (n = 201)	p-value
Age (years, %)			1.000^∗
≤50	0 (0.0)	13 (6.5)
>50	6 (100.0)	188 (93.5)
Sex (%)			1.000^∗
Male	2 (33.3)	64 (31.8)
Female	4 (66.7)	137 (68.2)
Preoperative IOP (mm Hg)	14.7 ± 2.3	14.3 ± 2.7	0.733^†
No. of glaucoma medication prior to PEA	2.0 ± 1.7	0.4 ± 0.9	0.002^†
Eyes with glaucoma medication (%)	4 (66.7)	44 (21.9)	0.027^∗
Eyes with angle closure (%)	3 (50.0)	74 (36.8)	0.673^∗
Axial length (mm)	24.36 ± 2.64	23.23 ± 1.82	0.270^†
Anterior vitrectomy (%)	0 (0.0)	5 (2.5)	1.000^∗
Iris manipulation (%)	2 (33.3)	11 (5.5)	0.047^∗

Values are presented as mean ± SD unless otherwise indicated; Group C: IOP spike group in non-trabeculectomized eyes; Group D: no IOP spike group in non-trabeculectomized eyes.

IOP = intraocular pressure; No = number; PEA = phacoemulsification.

^∗ Fisher's exact test;

^† Mann Whitney U-test.

Table 6.

Multivariate analysis for risk factors for intraocular pressure spike after phacoemulsification in non-trabeculectomized group (n = 207)

Factors	Odds ratio	95% CI	p-value^∗
Age (>50 years)	NA	NA	NA
Sex			0.461
Male	1
Female	0.461	0.059-3.612
Eyes with angle closure	1.433	0.162-12.671	0.746
Preoperative IOP	1.293	0.840-1.992	0.243
No. of glaucoma medication prior to PEA	3.492	1.481-8.236	0.004
Axial length	1.413	0.905-2.208	0.128
Anterior vitrectomy	NA	NA	NA
Iris manipulation	34.249	2.390-490.731	0.009

CI = confidence interval; NA = not applicable; IOP = intraocular pressure; No = number; PEA = phacoemulsification.

^∗ Multivariate logistic regression analysis.

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