Effect of technique on intraocular pressure after combined cataract and glaucoma surgery: An evidence-based review.
OBJECTIVE
To analyze the literature pertaining to the techniques used in combined cataract and glaucoma surgery, including the technique of cataract extraction, the timing of the surgery (staged procedure versus combined procedure), the anatomic location of the operation, and the use of antifibrosis agents.


CONCLUSIONS
Cataract and glaucoma are both common conditions and are often present in the same patient. There is no agreement concerning the optimal surgical management of these disorders when they coexist.


METHODS
Electronic searches of English language articles published since 1964 were conducted in Pub MED and CENTRAL, the Cochrane Collaboration's database. These were augmented by a hand search of six ophthalmology journals and the reference lists of a sample of studies included in the literature review. Evidence grades (A, strong; B, moderate; C, weak; I, insufficient) were assigned to the evidence that involved a direct comparison of alternative techniques.


RESULTS
The preponderance of evidence from the literature suggests a small (2-4 mmHg) benefit from the use of mitomycin-C (MMC), but not 5-fluorouracil (5-FU), in combined cataract and glaucoma surgery (evidence grade B). Two-site surgery provides slightly lower (1-3 mmHg) intraocular pressure (IOP) than one-site surgery (evidence grade C), and IOP is lowered more (1-3 mmHg) by phacoemulsification than by nuclear expression in combined procedures (evidence grade C). There is insufficient evidence to conclude either that staged or combined procedures give better results or that alternative glaucoma procedures are superior to trabeculectomy in combined procedures.


CONCLUSIONS
In the literature on surgical techniques and adjuvants used in the management of coexisting cataract and glaucoma, the strongest evidence of efficacy exists for using MMC, separating the incisions for cataract and glaucoma surgery, and removing the nucleus by phacoemulsification.
Jampel
Henry D
HD
Department of Ophthalmology, Johns Hopkins University, Baltimore, Maryland, USA.
Friedman
David S
DS
Lubomski
Lisa H
LH
Kempen
John H
JH
Quigley
Harry
H
Congdon
Nathan
N
Levkovitch-Verbin
Hani
H
Robinson
Karen A
KA
Bass
Eric B
EB
D000964:Antimetabolites, Antineoplastic / Q000627:therapeutic use; D002386:Cataract / Q000150:complications / Q000628:therapy*; D002387:Cataract Extraction / Q000379:methods*; D019317:Evidence-Based Medicine; D005472:Fluorouracil / Q000627:therapeutic use; D005901:Glaucoma / Q000150:complications / Q000601:surgery*; D006801:Humans; D007429:Intraocular Pressure; D016685:Mitomycin / Q000627:therapeutic use; D013997:Time Factors; D014130:Trabeculectomy / Q000379:methods*
D000964:Antimetabolites, Antineoplastic; D016685:Mitomycin; D005472:Fluorouracil