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Refractive Outcomes of Phacoemulsification Cataract Surgery in Glaucoma Patients

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348 ARTICLE Refractive outcomes of phacoemulsification cataract surgery in glaucoma patients Niranjan Manoharan, MD, Jennifer L. Patnaik, PhD, Levi N. Bonnell, MPH, Jeffrey R. SooHoo, MD, Mina B. Pantcheva, MD, Malik Y. Kahook, MD, Brandie D. Wagner, PhD, Anne M. Lynch, MD, Leonard K. Seibold, MD Purpose: To evaluate refractive outcomes after phacoemulsifica- (P Z .0061) and 11.2% (P Z .0011) in the glaucoma group. Primary tion cataract surgery in patients with glaucoma. open-angle glaucoma (POAG) (n Z 154 eyes), chronic angle-closure glaucoma (n Z 18 eyes), and pseudoexfoliation glaucoma (n Z 23 Setting: University of Colorado Health Eye Center, Aurora, Colo- eyes) had odds ratios of 1.90 (P Z .1760), 14.54 (P Z .0006), and rado, USA. 7.27 (P Z .0138), respectively, of refractive surprise greater than G1.0 D compared with patients without glaucoma. Refractive Design: Retrospective case series. surprise was noted more often in POAG eyes with axial lengths longer than 25.0 mm (P Z .0298). Glaucoma eyes had worse Methods: The incidence of refractive surprise was evaluated in mean postoperative corrected distance visual acuity than control patients with and without glaucoma after phacoemulsification cata- eyes (glaucoma: 0.1088 logarithm of the minimum angle of ract surgery. Refractive surprise was defined as the difference in resolution [logMAR]; controls: 0.0358 logMAR; P Z .01). spherical equivalent of the refractive target and postoperative refraction in diopters (D). Conclusion: Patients with a diagnosis of glaucoma were more likely to have a refractive surprise and/or worse visual outcome after Results: The study comprised 206 eyes in the glaucoma group phacoemulsification cataract surgery. and 1162 control eyes. The refractive surprise greater than G0.5 D and G1.0 D was 29.9% and 4.9% in the control group and 40.3% J Cataract Refract Surg 2018; 44:348–354 Q 2018 ASCRS and ESCRS he leading causes of blindness worldwide are glau- Although these anatomic changes might be beneficial to- coma and cataracts.1 In the United States, the inci- ward aqueous outflow and IOP, it is unclear how they might T dences of glaucoma and cataracts are estimated to affect refractive outcomes, especially in patients with glau- increase over the coming decades because of the rapidly aging coma. As demand for precise refractive outcomes has population.2 Given that glaucoma and cataracts are both age- increased, there has been continuing research into opti- related diseases, studies have shown up to 20% of patients mizing refractive outcomes with newer formulas for intra- have concomitant disease3 and a significant proportion of ocular lens (IOL) power calculation.7 It remains unclear phacoemulsification cataract surgery is performed in patients what contribution a previous diagnosis of glaucoma has with glaucoma. The growing numbers of glaucoma patients on ocular biometry and refractive outcomes. In addition, having cataract surgery has led to many recent studies there is limited research on the effect of different types of – regarding a variety of outcome measures.4 6 glaucoma on cataract surgery refractive outcomes. Recent studies have shown phacoemulsification and The purpose of our study was to address these gaps in the manual small-incision cataract surgery can lead to signifi- literature by evaluating the refractive outcomes of patients cant intraocular pressure (IOP) reductions after surgery.4 with glaucoma compared with patients without glaucoma Moreover, anterior chamber and angle anatomy have also in a cohort of patients from Colorado who had phacoemul- been shown to change after modern cataract surgery.4 sification cataract surgery. Submitted: June 7, 2017 | Final revision submitted: December 2, 2017 | Accepted: December 19, 2017 From the Department of Ophthalmology (Manoharan, Patnaik, Bonnell, SooHoo, Pantcheva, Kahook, Wagner, Lynch, Seibold), University of Colorado School of Medicine and the Department of Biostatistics and Informatics (Wagner), University of Colorado School of Public Health, Aurora, Colorado, USA. Presented at ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016. Corresponding author: Leonard K. Seibold, MD, Department of Ophthalmology, University of Colorado School of Medicine, 1675 Aurora Court, Mailstop F731, Aurora, Colorado 80045, USA. E-mail: [email protected]. Q 2018 ASCRS and ESCRS 0886-3350/$ - see frontmatter Published by Elsevier Inc. https://doi.org/10.1016/j.jcrs.2017.12.024 CATARACT OUTCOMES IN GLAUCOMA PATIENTS 349 PATIENTS AND METHODS no previous diagnosis of glaucoma. The mean age of pa- This retrospective cohort study was approved by the Colorado tients with and without glaucoma was 71.2 years G 12.5 Multiple Institutional Review Board. The University of Colorado (SD) and 68.9 G 10.1 years, respectively (P Z .0329). ’ Department of Ophthalmology s Cataract Outcomes Registry Table 1 and Table 2 show comparisons of the periopera- was used to identify patients for inclusion in this study. The Uni- versity of Colorado Eye Center is a tertiary care academic medical tive characteristics and refractive outcomes, respectively, center. In brief, every patient who has cataract surgery has a between patients with and without glaucoma. There was a comprehensive review of their medical record. The registry in- significantly higher frequency of both small and large cludes data on demographic information, medical history, preop- magnitude refractive surprise (OG0.5 diopter [D] and erative medication history, intraoperative and postoperative G1.0 D) and myopic surprise (OÀ1.0 D) in glaucoma pa- complications, and preoperative and postoperative eye examina- tients compared with patients without glaucoma. The pro- tions. The data are collected for up to 12 months postoperatively. OC Between January 2014 and June 2015, 1732 patients (2559 eyes) portion of patients with a hyperopic surprise ( 1.0 D) had phacoemulsification cataract surgery with IOL implantation. was also higher in the glaucoma group compared with pa- Intraocular power was calculated using partial coherence interfer- tients without glaucoma; however, this association did not ometry (IOLMaster 500, Carl Zeiss Meditec AG) supplemented reach statistical significance. with ultrasound immersion as needed. The formulas used were per surgeon preference and generally as follows: Hoffer Q8 was Table 3A and Table 3B show the odds ratio (OR) of the used for axial lengths (ALs) shorter than 23.0 mm, Holladay 19 subtypes of glaucoma for refractive surprise. In patients for ALs between 23.0 mm and 26.0 mm, and SRK/T10 for having phacoemulsification cataract surgery alone 26.0 mm and longer. A total of 1191 (46.5%) eyes were excluded (Table 3A), patients with a preoperative diagnosis of glau- for the following reasons: preexisting comorbid conditions (ie, coma had greater odds for refractive surprise than patients traumatic cataract, history of retinal detachment, severe age- ! related macular degeneration) (n Z 369); previous refractive sur- without glaucoma (P .01). Patients with POAG, ACG, gery (n Z 110); cataract surgery combined with non-glaucoma and PXG had higher ORs of refractive surprise than pa- related surgeries (ie, vitrectomy) (n Z 102); complications during tients without glaucoma. These trends were also noted surgery (capsule tear, vitreous loss, iris trauma, retained lens frag- when eyes that had cataract surgery combined with MIGS Z ments, zonular dialysis, and choroidal hemorrhage) (n 19); and were included in the glaucoma groups (Table 3B). records that did not contain target refractions or postoperative Z Table 4 shows the OR of combination glaucoma surgeries manifest refractions (n 591) (Figure 1). G Among records excluded because of missing target or follow-up for refractive surprises greater than 1.0 D. The relation- refractions, 20.8% had glaucoma versus 15.1% for records ship of any combination of MIGS and phacoemulsification included. Eyes with a diagnosis of glaucoma of any kind were cataract surgery with refractive surprises was not statisti- included in the glaucoma group and patients with no history of cally significant. glaucoma were included in the control group. In addition, patients with glaucoma were categorized in the following subgroups: pri- Table 5 shows a comparison of risk factors between pa- mary open-angle glaucoma (POAG), chronic angle-closure glau- tients who had a refractive surprise versus patients who coma (ACG), pseudoexfoliation glaucoma (PXG), and “other had no refractive surprise in POAG. In POAG, eyes with glaucoma.” Several glaucoma patients had microinvasive glau- a refractive surprise after cataract surgery had a statistically coma surgery (MIGS) performed at the time of their phacoemul- significant higher frequency of AL longer than 25.0 mm sification cataract surgery. These patients were marked specifically for subgroup analysis to determine the effect of these additional than patients who had no refractive surprise. In chronic glaucoma procedures on refractive outcomes. ACG and PXG, none of the risk factors assessed were signif- The primary outcome measure was refractive surprise, defined as a icantly related to refractive surprise. difference in the spherical equivalent (SE) refractive target and post- No statistically significant difference was noted in history of operative SE. Postoperative refractions were taken from the 1-month filtration surgery (n Z 22) or type of surgery (cataract surgery to 1-year postoperative visits. Other variables included
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