Phacoemulsification with Goniosynechialysis for Nanophthalmos with Secondary Angle-Closure or Secondary Angle-Closure Glaucoma: A 20-Case Series and Stepwise Management Strategy

Phacoemulsification with Goniosynechialysis for Nanophthalmos with Secondary Angle-Closure or Secondary Angle-Closure Glaucoma: A 20-Case Series and Stepwise Management Strategy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Phacoemulsification with Goniosynechialysis for Nanophthalmos with Secondary Angle-Closure or Secondary Angle-Closure Glaucoma: A 20-Case Series and Stepwise Management Strategy Hongyan Zhu, Zuohong Wu, Yong Wang, Xun Zhan, Jin Lv, Li Ye This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9395122/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Nanophthalmos is a rare congenital ocular disorder characterized by a short axial length (AL), which predisposes to secondary angle-closure and secondary angle-closure glaucoma. Surgical management is challenging due to high complication risks. This study aimed to evaluate the feasibility and efficacy of phacoemulsification with intraocular lens implantation and goniosynechialysis (Phaco+IOL+GSL) in nanophthalmos with secondary angle-closure or secondary angle-closure glaucoma, and to propose a stepwise complication management strategy. Methods This retrospective case series included 20 eyes of 20 patients diagnosed with nanophthalmos (AL < 20 mm) and PAC (2 eyes) or ACG (18 eyes) who underwent Phaco+IOL+GSL between January 2022 and Jun 2025. Patients were divided into three groups based on AL: Group A (14 mm ≤ AL < 16 mm, 9 eyes), Group B (16 mm ≤ AL < 18 mm, 4 eyes), and Group C (18 mm ≤ AL < 20 mm, 7 eyes). Preoperative and postoperative uncorrected visual acuity (UCVA, logMAR) and best-corrected visual acuity (BCVA, logMAR) were recorded, intraocular pressure (IOP), number of antiglaucoma medications, and intraoperative and postoperative complications were analyzed. Results At the final follow-up (6-12 months postoperatively), the median IOP significantly decreased from 25.5 [16.0, 35.0] mmHg to 16.0 [14.0, 19.0] mmHg (P < 0.05). The median number of antiglaucoma medications decreased from 2.5 [0.0, 4.0] to 0.0 [0.0, 0.0] (P < 0.05). UCVA improved from 1.30 [1.00, 1.70] to 0.40 [0.12, 1.10] (P < 0.05), and BCVA improved from 0.82 [0.40, 1.30] to 0.70 [0.30, 1.30] (P = 0.035). The qualified success rate was 95.0% (19/20), and the complete success rate was 80.0% (16/20). The intraoperative complication rate was 25.0% (5/20), primarily shallow anterior chamber. The postoperative complication rate was 40.0% (8/20), primarily shallow anterior chamber with elevated IOP. Complications were concentrated in Groups A and B. Multivariate logistic regression analysis revealed that shorter AL was significantly associated with a higher risk of surgical complications (OR = 0.439, P < 0.05). A stepwise management strategy—initiating with medical/laser therapy, escalating to cyclophotocoagulation, and reserving pars plana vitrectomy for refractory cases—achieved successful complication management. Conclusion Phaco+IOL+GSL is a feasible and effective procedure for nanophthalmos with secondary angle-closure glaucoma, reducing IOP, medication dependence, and improving visual acuity. Compared with more complex combined procedures(e.g., with prophylactic vitrectomy or sclerectomy) , this technique is simpler and less invasive. A stepwise management strategy effectively addresses complications. Shorter AL, particularly <16 mm, is associated with higher surgical risk. Nanophthalmos Secondary Angle-Closure Glaucoma Goniosynechialysis Phacoemulsification Stepwise Management Axial Length Background Nanophthalmos is a rare congenital ocular maldevelopment characterized by a significantly shortened axial length (AL), thickened sclera, high hyperopia, and a shallow anterior chamber [1]. Primary angle closure (PAC) and secondary angle-closure glaucoma (ACG) are among its most serious complications, and its management is challenging [2, 3]. Due to crowded anterior segments and unique scleral properties, patients with nanophthalmos are at high risk for serious complications such as choroidal effusion, malignant glaucoma, and expulsive suprachoroidal hemorrhage during traditional filtering surgeries [4]. Yalvac et al. [5] reported that the incidence of choroidal detachment after filtering surgery was 25%, and uveal effusion occurred in 50% of cases. These findings were further corroborated by Rajendrababu et al. [3]. Given the anatomical peculiarities and risks, many surgeons have explored cyclophotocoagulation as an alternative [6, 7]. Abdelrahman et al. [6] demonstrated that transscleral cyclophotocoagulation (TSCPC) significantly reduced IOP over 6 months without severe complications like hypotony or choroidal effusion. However, as a destructive procedure, the long-term efficacy and potential complications of cyclophotocoagulation warrant cautious evaluation. Recently, phacoemulsification with intraocular lens implantation (Phaco+IOL) has been increasingly used in nanophthalmic eyes, and its safety profile has been preliminarily recognized [8]. For cases complicated by PAC or ACG, most surgeons adopt combined procedures, often incorporating anterior vitrectomy and/or sclerectomy. Studies by Wei et al. [9] and Fan et al. [10] indicated that combined surgeries yielded better IOP control, fewer complications, and higher success rates compared to filtering surgery alone. Anterior vitrectomy has been shown to reduce the risk of postoperative malignant glaucoma [10, 11], while prophylactic sclerectomy helps prevent uveal effusion [10, 11]. However, both vitrectomy and sclerectomy increase surgical trauma and operating time, presenting additional challenges for patients. Phacoemulsification combined with IOL implantation and goniosynechialysis (Phaco+IOL+GSL) has gained widespread use in managing PAC and ACG, particularly with coexisting cataract, and its efficacy and safety have been supported by numerous studies [12, 13]. The mechanism primarily involves removing the relatively thick lens to deepen the anterior chamber, thereby alleviating pupillary block and peripheral anterior synechiae (PAS), while gonioscopic separation of synechiae aims to reopen the physiological aqueous outflow pathway via the trabecular meshwork [14]. Compared to complex combined surgeries, Phaco+IOL+GSL offers the advantages of a simpler technique and shorter operative time. Therefore, this retrospective study aims to evaluate the feasibility and efficacy of Phaco+IOL+GSL for nanophthalmos with secondary angle-closure or secondary angle-closure glaucoma, and to explore influencing factors. Compared with more complex combined procedures (e.g., with prophylactic vitrectomy or sclerectomy) reported in the literature [9,10], this technique is simpler and less invasive. We also propose a stepwise management strategy for postoperative complications as a clinical highlight. Methods Study Population This retrospective case series consecutively enrolled 20 eyes of 20 patients diagnosed with nanophthalmos (axial length <20 mm) and secondary angle-closure who underwent Phaco+IOL+GSL at Aier Eye Hospital of Wuhan University between January 2022 and June 2025. Of these, 18 eyes had glaucomatous optic neuropathy (secondary angle-closure glaucoma) and 2 eyes had angle closure without glaucomatous damage (secondary angle-closure). The study adhered to the tenets of the Declaration of Helsinki and was approved by the hospital's Ethics Committee. Informed consent was obtained from all patients. 1. Inclusion Criteria: (1) AL < 20 mm measured by IOLMaster-700; (2) Gonioscopy confirming synechial angle closure ≥180°; (3) Postoperative follow-up ≥6 months. 2. Exclusion Criteria : (1) Previous intraocular surgery; (2) Coexisting ocular diseases such as uveitis, ocular trauma, or retinal detachment; (3) Incomplete clinical data. Grouping and Methods Patients were divided into three groups based on AL: Group A (14 mm ≤ AL < 16 mm, 9 eyes); Group B (16 mm ≤ AL < 18 mm, 4 eyes); Group C (18 mm ≤ AL < 20 mm, 7 eyes). Baseline characteristics were collected and compared among the groups. Surgical Technique All surgeries were performed by two experienced glaucoma and cataract surgeons. 1. Preoperative Preparation : Topical IOP-lowering medications (excluding prostaglandin analogs) were administered 1-3 days preoperatively. Intravenous 20% mannitol (250 ml) was administered 30 minutes before surgery. 2. Surgical Equipment : Two Alcon phacoemulsification systems (Centurion and Infinity) were used alternately. 3. Surgical Procedure : Retrobulbar or general anesthesia was administered. A 2.2 mm main incision and a side port were created at the limbus. Continuous curvilinear capsulorhexis was performed, followed by hydrodissection and phacoemulsification of the nucleus and aspiration of the residual cortex. Single IOL was implanted in 16 eyes (single-piece, hydrophobic acrylic IOL). Two eyes aiming for emmetropia underwent piggyback IOL implantation (one three-piece IOL in the ciliary sulcus and one single-piece IOL in the bag). Two eyes with preoperative vision of light perception or no light perception did not receive an IOL. Subsequently, under direct gonioscopic view, extensive blunt separation of PAS was performed using an iris repositor, aiming to maximally re-expose the functional trabecular meshwork and ciliary body band, targeting a separation extent of ≥270°. Six eyes with poorly controlled preoperative IOP (≥30 mmHg on medications) or a recent acute attack underwent combined prophylactic peripheral iridectomy (PI), ensuring IOL haptics were positioned away from the PI. Four eyes developed intraoperative shallow anterior chamber/aqueous misdirection. In 2 eyes, anterior chamber depth was restored via pars plana vitreous cavity tap (23G needle, aspirating 0-0.1 ml fluid), allowing surgery to proceed. The other 2 eyes with persistent shallow anterior chamber underwent anterior vitrectomy via the pars plana; one of these also had posterior capsular rupture requiring IOL scleral fixation. Significant hemorrhage during synechialysis in one eye was managed by injecting a small air bubble into the anterior chamber. Postoperative Management and Follow-up Postoperative topical antibiotics, corticosteroids, and nonsteroidal anti-inflammatory drugs were routinely administered and tapered. IOP, anterior chamber depth, inflammation, and fundus were closely monitored. If shallow anterior chamber or elevated IOP occurred, intravenous mannitol and intensified anti-inflammatory therapy were initiated. If ineffective within 24-48 hours, Nd:YAG laser anterior capsulotomy, posterior capsulotomy, and anterior hyaloidotomy were performed via the existing PI site or at the IOL edge. If laser access was unavailable or ineffective, cyclophotocoagulation or secondary surgery (anterior vitrectomy + goniosynechialysis ± IOL explantation) was considered. Observation Indicators Preoperative and postoperative UCVA (logMAR), BCVA (logMAR), IOP, number of antiglaucoma medications, and intraoperative and postoperative complications were recorded. Surgical Success Criteria: Complete success: IOP ≤21 mmHg without antiglaucoma medications; Qualified success: IOP ≤21 mmHg with medications. Statistical Analysis SPSS 26.0 was used for analysis. Visual acuities were converted to logMAR (counting fingers, hand motions, light perception, and no light perception were assigned values of 2.0, 2.3, 2.7, and 3.0, respectively [15]). Normally distributed continuous data are presented as mean ± standard deviation, and non-normally distributed data as median [Q1, Q₃]. The Wilcoxon signed-rank test or Kruskal-Wallis H test was used for comparisons. Categorical data are presented as n (%), compared using Fisher's exact test. Multiple comparisons employed Bonferroni correction. Multivariate logistic regression analyzed risk factors for postoperative complications. P < 0.05 was considered statistically significant. Results Patient Baseline Characteristics Twenty eyes of 20 patients were included (8 males [40.0%], 12 females [60.0%]). No significant differences were found among the three groups regarding age, gender, preoperative IOP, number of preoperative medications, or preoperative visual acuity (P > 0.05), indicating comparability (Table 1). Table 1. Comparison of Baseline Characteristics Among the Three Groups Indicator Group A (14-16mm, n=9) Group B (16-18mm, n=4) Group C (18-20mm, n=7) P-value Statistical Test Age (years), M [Q1, Q3] 55.0 [48.0, 59.0] 56.5 [44.3, 68.0] 59.0 [51.5, 73.0] 0.770 Kruskal-Wallis Gender (Male), n (%) 4 (44.4%) 2 (50.0%) 2 (28.6%) 0.804 Fisher's Exact Preop IOP (mmHg), M [Q1, Q3] 21.0 [16.5, 33.5] 29.5 [18.8, 40.5] 34.0 [17.0, 54.0] 0.233 Kruskal-Wallis Preop Meds (n), M [Q1, Q3] 3.0 [0.0, 4.0] 3.0 [3.0, 3.0] 1.0 [0.0, 3.0] 0.056 Kruskal-Wallis Preop UCVA (logMAR), M [Q1, Q3] 1.40 [ 1.22, 1.70 ] 1.40 [ 1.03, 1.78 ] 1.10 [ 0.96, 2.20 ] 0.924 Kruskal-Wallis Preop BCVA (logMAR), M [Q1, Q3] 1.00 [ 0.82, 1.55 ] 1.20 [ 0.88, 1.48 ] 0.70 [ 0.40, 2.00 ] 0.660 Kruskal-Wallis Note: M [Q1, Q3]: Median [First Quartile, Third Quartile]. Surgical Efficacy Evaluation The median preoperative IOP was 25.5 [16.0, 35.0] mmHg, which decreased to 16.0 [14.0, 20.0] mmHg at 3 months postoperatively (P < 0.05) and at the 6-12 month follow-up ,it was 16.0 [12.0, 19.0] mmHg , indicating a significant and sustained IOP reduction (Table 2). The median number of antiglaucoma medications decreased from 2.5 [0.0, 4.0] preoperatively to 0.0 [0.0, 0.0] at 3 months postoperatively (P = 0.003) and remained at 0.0 [0.0, 0.0] at the 6-12 month follow-up, with no statistically significant difference compared to the 3-month postoperative visit (P = 1.000), demonstrating that the surgery significantly reduces medication dependence, and this effect is sustained over time ( Table 2). UCVA (logMAR) improved from 1.30 [1.00, 1.70] preoperatively to 0.40 [0.12, 1.10] postoperatively (P < 0.001). BCVA (logMAR) improved from 0.82 [0.40, 1.30] to 0.70 [0.30, 1.30] (P = 0.035) (Table 3). At the final follow-up (6-12 months), the qualified success rate was 95.0% (19/20), the complete success rate was 80.0% (16/20), and the failure rate was 5.0% (1/20). Table 2. Changes in IOP and Number of Antiglaucoma Medications Indicator Preoperative Postop 3 Months Postop 6-12 Months P 1 -value (Pre vs postop 3 M) P 1 -value (Pre vs 6-12M) P 2 -value (3M vs 6-12M ） IOP (mmHg), M [Q1, Q3] 25.5[16.0,35.0] 16.0 [14.0,20.0] 16.0[14.0,19.0] 0.004 0.008 1.000 Meds (n), M [Q1, Q3] 2.5[0.0,4.0] 0.0[0.0,0.0] 0.0[0.0,0.0] 0.003 0.002 1.000 Note: Wilcoxon signed-rank test with Bonferroni correction.（For the P 1 values, a total of three comparisons were made, and the corrected significance level was set at 0.05/3 = 0.017. A corrected P-value 0.025 indicated no statistically significant difference.） Table 3. Changes in UCVA and BCVA (logMAR) Visual Acuity (logMAR) Preoperative Postoperative P-value UCVA (n=20) 1.30 [1.00, 1.70] 0.40 [0.12, 1.10] <0.001 BCVA (n=20) 0.82[0.40, 1.30] 0.70 [0.30, 1.30] 0.035 Note: Wilcoxon signed-rank test. Intergroup comparison of surgical outcomes (Table 4) showed that : In Group A, both postoperative intraocular pressure (IOP) and the number of medications decreased significantly compared to preoperative levels (P < 0.05). In Group C, there was no statistically significant difference in the number of medications, but postoperative IOP was significantly lower than preoperative IOP (P < 0.05). Group B exhibited the largest magnitude of change in both IOP and medication number; however, none of the P values reached statistical significance, suggesting that a larger sample size may be needed to confirm the statistical significance of this effect. Table 4. Preoperative and Postoperative Changes in IOP and Medications by Group Group Preop IOP (mmHg), M [Q1,Q3] Final IOP (mmHg), M [Q1,Q3] P-value (IOP) Preop Meds (n), M [Q1,Q3] Final Meds (n), M [Q1,Q3] P-value (Meds) A 21.0 [16.5, 33.5] 18.0 [17.0, 19.0] 0.012 3.0 [0.0, 4.0] 0.0 [0.0, 1.0] 0.020 B 29.5 [18.8, 40.5] 14.5 [12.0, 15.0] 0.250 3.0 [3.0, 3.0] 0.0 [0.0, 2.0] 0.250 C 34.0 [17.0,54.0] 13.0[12.0,16.0] 0.031 1.0 [0.0, 3.0] 0.0 [0.0, 0.0] 0.125 Note: Wilcoxon signed-rank test for within-group changes. Safety Evaluation: Complications and Management 1. Intraoperative Complications : The overall intraoperative complication rate was 25.0% (5/20). Shallow anterior chamber/aqueous misdirection was the most common complication (4 eyes, 20.0%), with one eye concurrently experiencing posterior capsular rupture (PCR rate 5.0%). No expulsive suprachoroidal hemorrhage occurred. Complications were concentrated in Groups A and B, with no complications in Group C (Table 5). The difference in the incidence of any intraoperative complication among groups (Group A 33.3% vs Group B 50.0% vs Group C 0.0%) was statistically significant (P = 0.044, Fisher's exact test). Management : All 4 eyes with intraoperative aqueous misdirection/shallow anterior chamber underwent pars plana vitreous tap (23G needle, aspirating approximately 0-0.1 ml). This restored anterior chamber depth in 2 eyes, allowing surgery to continue. The other 2 eyes required additional anterior vitrectomy; one of these also had PCR requiring IOL scleral fixation. One eye with significant hemorrhage during synechialysis was managed by anterior chamber air injection. Table 5. Intraoperative Complications by Axial Length Group [n(%)] Group Total Eyes Shallow AC PCR Hyphema Any Complication* Intergroup P-value A（14-16mm） 9 2 (22.2%) 0 (0.0%) 1 (11.1%） 3 (33.3%） B（16-18mm） 4 2 (50.0%) 1 (25.0%) 0 (0.0%) 2 (50.0%) C（18-20mm） 7 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Total 20 4 (20.0%) 1 (5.0% ） 1(5.0%) 5 (25.0%) 0.044 Note: PCR: Posterior Capsular Rupture. *"Any Complication" refers to independent eyes experiencing at least one complication. 2. Postoperative Complications: Seven complications occurred within the first week, and one at 4 weeks postoperatively, with a total rate of 40.0% (8/20). The main manifestation was shallow anterior chamber with elevated IOP (25.0%, 5/20), followed by isolated shallow anterior chamber (5.0%, 1 eye), isolated elevated IOP (5.0%, 1 eye), and choroidal detachment (5.0%, 1 eye). All complications occurred in Groups A and B. Group A had the highest incidence (66.7%). The intergroup difference was statistically significant (P = 0.008, Fisher's exact test) (Table 6). Pairwise comparisons showed Group A (shortest AL) had a significantly higher complication rate than Group C (longest AL) (P = 0.009). Group B also had a high rate (50.0%), but its comparison with Group C did not reach the Bonferroni-corrected significance level (P 18 mm, while AL <16 mm is a clear risk factor. Multivariate logistic regression confirmed that shorter AL was negatively correlated with both intraoperative (OR = 0.52, 95%CI[0.28, 0.95], P=0.034) and postoperative complications (OR = 0.42, 95%CI[0.22, 0.80], P=0.008), indicating higher complication risk with shorter eyes. AL <16 mm was an independent risk factor for postoperative shallow AC/elevated IOP. Table 6. Postoperative Complications by Axial Length Group [n(%)] Group Total Eyes Shallow AC High IOP Shallow AC + High IOP Choroidal Detachment Any Complication Intergroup P-value A（14-16mm） 9 1(11.1%) 1(11.1%) 4 (44.4%) 0 (0.0%) 6 (66.7%) B（16-18mm） 4 0 (0.0%) 0 (0.0%) 1 (25.0%) 1 (25.0%) 2 (50.0%) C（18-20mm） 7 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Total 20 1 (5.0%) 1 (5.0%) 5 (25.0%) 1 (5.0%) 8 (40.0%) 0.008 Note: Fisher's exact test 3. Management of Postoperative Complications: Among the 8 eyes with complications, 1 eye with choroidal detachment resolved with conservative medical treatment. The remaining 7 eyes (including 2 with piggyback IOLs) presented with shallow AC and/or elevated IOP. In these 7 eyes, initial intervention with Nd:YAG laser anterior capsulotomy, posterior capsulotomy, and anterior hyaloidotomy were performed in 3 eyes, successfully resolving shallow AC in 2 eyes; the other eye was unresponsive and subsequently underwent successful cyclophotocoagulation for IOP control. Management and outcomes for the other 4 eyes were as follows: Among 2 eyes with single IOL implantation, cyclophotocoagulation was ineffective in both. One eye underwent successful secondary surgery (anterior vitrectomy + goniosynechialysis) at 1 month, while the other declined further intervention and had uncontrolled IOP at final follow-up, with vision declining from hand motions to light perception. Among the 2 eyes with piggyback IOLs, one underwent secondary surgery (anterior vitrectomy + goniosynechialysis) 2 months after failed cyclophotocoagulation. The other eye developed early malignant glaucoma with severe exudation, requiring emergency secondary surgery (anterior vitrectomy + sulcus IOL removal + goniosynechialysis) on postoperative day 3, which successfully controlled IOP and exudation. As shown in Table 7, secondary surgery (vitrectomy combined with goniosynechialysis ± IOL removal) had a 100% success rate (3/3). Nd:YAG laser posterior capsulotomy was 66.7% effective (2/3). Conventional cyclophotocoagulation was 25.0% effective (1/4). Table 7. Efficacy of Different Complication Management Strategies Management Strategy Eyes Treated (n) Effective (n) New Complications (n) Success Rate Nd:YAG laser posterior capsulotomy with anterior hyaloidotomy 3 2 0 66.7% Cyclophotocoagulation 4 1 0 25.0% Secondary Surgery (PPV+GSL±IOL) 3 3 0 100% 4. Postoperative Refractive Status in Single IOL Implantation (Group A) : Analysis of 5 eyes in Group A (AL<16 mm) that received single IOL implantation showed persistent significant hyperopia postoperatively (mean SE +13.45 D). Comparison of the difference between preoperative and postoperative SE revealed minimal change in residual refractive error with single IOL implantation (mean difference +0.80 ± 1.48 D) (Table 8). Table 8. Refractive Status Changes in 5 Eyes with Single IOL Implantation in Group A (14-16mm) Case Preop SE (D) Postop SE (D) Difference (Postop-Preop) (D) Tan XX +12.75 +13.50 +0.75 Liao XX +14.00 +13.00 -1.00 Sun X +16.50 +16.50 0.00 Wang XX +11.00 +12.00 +1.00 Liu XX +9.00 +12.25 +3.25 Mean +12.65 +13.45 +0.80 ± 1.48 Discussion Surgical management of nanophthalmos with secondary angle-closure glaucoma is challenging due to the high risk of complications. This study reports a 20-case series of Phaco+IOL+GSL in this rare condition. The stepwise management strategy—initiating with medical/laser therapy, escalating to cyclophotocoagulation, and reserving pars plana vitrectomy for refractory cases—was used to manage postoperative complications. This series includes 9 eyes with axial length <16 mm, a subgroup infrequently described in the literature. It is well established that lens extraction (phacoemulsification) alone can deepen the anterior chamber, widen the angle, and reduce intraocular pressure (IOP) in nanophthalmic eyes with angle closure [4,9,10]. However, studies on primary angle-closure disease have shown that the IOP reduction after phacoemulsification alone is limited, particularly in eyes with extensive peripheral anterior synechiae (PAS) or higher baseline IOP [16]. A meta-analysis of nine randomized controlled trials reported that phacoemulsification combined with goniosynechialysis (GSL) achieved greater IOP reduction compared with phacoemulsification alone in patients with angle-closure disease (mean difference, 1.81 mmHg; p = 0.002) [16]. In the present series, the baseline IOP was relatively high (median 25.5 mmHg) and PAS was extensive (≥180°). Therefore, the additional IOP reduction associated with GSL may be relevant for this specific population. Our final follow-up showed a qualified success rate of 95.0% and a complete success rate of 80.0%. This efficacy is comparable to the 71.4% complete success rate reported by Zhang et al. [17] for 23G pars plana vitrectomy combined with lensectomy (without IOL implantation). Notably, Wei et al. [9] employed a more complex procedure (phacoemulsification combined with anterior vitrectomy and posterior capsulotomy), reporting an overall success rate of 88.9%, but a lower complete success rate (42.5%) than our study. This discrepancy may be attributed to the absence of gonioscopic synechialysis, potentially affecting the completeness of angle opening. However, their very low complication rate (4.4%) also underscores the value of anterior vitrectomy in relieving ciliary block and managing high-risk factors [9]. The crucial question is whether such prophylactic procedures should be routinely combined during initial surgery. The randomized controlled trial by Rajendrababu et al. [18] provides key insights. They found no statistical difference in complication risk between "phacoemulsification with prophylactic sclerostomy" and "phacoemulsification alone," with the combined procedure inducing significant inflammation. However, they observed a trend towards lower complication rates and suggested considering combined surgery. This reveals the clinical dilemma: the potential reduction in risk must be balanced against the greater trauma and inflammatory burden imposed on all patients by a more complex procedure[18]. In this context, our proposed stepwise treatment strategy offers a more targeted solution. We do not negate the role of vitrectomy/sclerostomy but reserve them as "backup plans." We primarily selected the minimally invasive Phaco+IOL+GSL, enabling 90.0% (18/20) of patients to complete surgery safely. Anterior vitrectomy was added only for the minority of high-risk patients (10.0%, 2/20) with persistent intraoperative shallow AC/aqueous misdirection. Another subset (15.0%, 3/20) developed postoperative malignant glaucoma refractory to medical and laser therapy, ultimately requiring secondary pars plana vitrectomy (PPV) to resolve the shallow anterior chamber and control IOP. It should be noted that one of these three cases requiring secondary surgery was the patient who had already received intraoperative vitrectomy. Therefore, overall, 4 out of 20 patients (20.0%) eventually required vitrectomy (either during initial surgery or postoperatively) for complication management. This outcome supports the rationale for the stepwise strategy on two levels: First, it allowed 80.0% (16/20) of patients to avoid vitrectomy during initial surgery, with no cases of severe complications like expulsive suprachoroidal hemorrhage, thereby upholding the principle of minimal invasiveness. Second, by prioritizing Phaco+IOL+GSL, combining anterior vitrectomy intraoperatively as needed (10% in this study), and aggressively performing pars plana vitrectomy for refractory complications unresponsive to laser and cyclophotocoagulation, a high final success rate (95.0% in this study) was achieved. IOP control in this study was achieved through thorough goniosynechialysis performed under direct gonioscopic view. While the contribution of GSL versus lens extraction alone cannot be fully isolated, the meta-analysis evidence [ 16 ] supports the incremental benefit of adding GSL, especially in eyes with high baseline IOP and extensive PAS. This aligns with the concept of internal drainage procedures centered on Phaco+GSL, which has been increasingly adopted in the general ACG population [19]. Tang Yihua et al. [12] emphasized that gonioscopy-guided synechialysis with confirmation of angle opening is crucial for achieving better IOP-lowering outcomes. All cases in our study achieved synechialysis over ≥270°, aiming to expose the functional trabecular meshwork, which establishes a solid anatomical foundation for long-term IOP control [12, 13,20]. Visual improvement primarily stemmed from clearing the optical media and addressing the pre-existing hyperopia. Surgery significantly improved both UCVA (median logMAR from 1.30 to 0.40, p<0.001) and BCVA (median logMAR from 0.82 to 0.70, p=0.035), indicating that the procedure not only improved vision through refractive correction but also potentially enhanced visual system function by resolving factors like concomitant cataract. This study further validates AL as a key determinant of surgical risk. Grouping revealed that Group A (AL<16 mm) had high intraoperative and postoperative complication rates (33.3% and 66.7%, respectively), while Group C (AL 18-20 mm) had no complications, consistent with findings from larger studies by Day et al. [8] and Hammer et al. [21], confirming short AL as an independent risk factor. The most common intraoperative complication was shallow AC/aqueous misdirection (20.0%), primarily occurring in eyes with AL<18 mm. The mechanism involves the extremely small vitreous cavity volume in nanophthalmos, where anterior chamber opening can lead to forward movement of the anterior hyaloid face and lens-iris diaphragm, disrupting aqueous dynamics [14]. Therefore, advanced phaco platforms (e.g.2.2mm micro-incision) and skilled phacoemulsification techniques are crucial for maintaining intraoperative anterior chamber stability [22]. The early postoperative complication rate was 40.0% (8/20), mainly shallow AC with elevated IOP (i.e., malignant glaucoma), accounting for 25.0% (5/20). The pathogenesis is considered a "vicious cycle" involving ciliary block, anterior hyaloid face block, and other factors [14]. Our experience suggests that traditional medical and laser therapies have limited efficacy for such cases, whereas aggressive intervention with pars plana vitrectomy (performed in 3 eyes in this study) achieved 100% success. This aligns with conclusions from Zhang et al. [17] in nanophthalmos, and is supported by recent evidence from Lincke et al. [23] showing that pars plana vitrectomy is effective for refractory aqueous misdirection. This study also explored the impact of other surgical details on safety: 1. Clinical Significance of Prophylactic Peripheral Iridectomy (PI): In this study, prophylactic PI was selectively performed only in cases with poorly controlled preoperative IOP or recent acute attack. However, based on our observations and analysis, we recommend routinely combining prophylactic PI in all nanophthalmic eyes with glaucoma undergoing Phaco+IOL+GSL. The rationale is as follows: First, nanophthalmic eyes often exhibit significant postoperative inflammation, and a dhesions between the iris and the implanted intraocular lens (IOL) were observed in a subset of patients. The literature widely attributes this to fragile blood-aqueous barrier function due to unique anatomy, leading to postoperative fibrin exudation and related synechiae [11], which is reported as a typical postoperative feature in nanophthalmos [4]. Notably, the newly created peripheral iridectomy (PI) itself carries a risk of inflammatory synechial or membranous closure (observed in one case), which can precipitate pupillary block and malignant glaucoma. Thus, the primary clinical value of the PI is to serve as a pre-established conduit for intervention in the event of postoperative shallow anterior chamber or malignant glaucoma. When ciliary block or IOL optic-posterior capsule adherence happens, the pupil often dilates poorly. Performing Nd:YAG laser posterior capsulotomy directly in the visual axis is not only technically challenging and risks IOL damage but also cannot ensure the newly created aqueous pathway effectively drains to the anterior chamber. In contrast, the PI area, even if membranous, is relatively easier to penetrate with Nd:YAG laser. This safely re-establishes communication between the posterior and anterior chambers, creating an aqueous drainage path that effectively bypasses the IOL haptics [23, 24]. This approach aligns with standard management principles for malignant glaucoma [24, 25]. In this study, 2 out of 3 eyes with postoperative shallow AC were successfully managed via laser treatment at this site, confirming the strategy's effectiveness (66.7%). Furthermore, a patent PI can also mechanistically prevent secondary pupillary block due to complete pupillary seclusion. Therefore, based on its dual role as both an "intervention pathway” for postoperative complications and a "preventive measure” against pupillary block, we advocate for routine prophylactic PI as a reasonable and necessary step in such high-risk surgery. 2. IOL Selection for Extremely Short Eyes (≤16 mm): Nanophthalmic patients often require high-power IOLs (+45 D to +75 D), posing challenges in IOL selection and implantation technique [26]. To achieve emmetropia, piggyback IOL implantation (one in the bag, one in the sulcus) has been reported to provide sufficient refractive power [27]. However, caution is warranted as sulcus-placed IOLs can cause a range of anterior segment complications, such as iris pigment dispersion, iritis, peripheral anterior synechiae, and posterior synechiae [28]. In this study, both patients receiving piggyback IOLs for emmetropia developed severe fibrinous exudation, shallow AC, and elevated IOP. One required emergency removal of the sulcus IOL on postoperative day 3 due to a very shallow AC with severe exudation, retaining the bag IOL, combined with anterior vitrectomy and repeat goniosynechialysis. The other, with uncontrolled IOP despite medical and cyclophotocoagulation therapy ,accompanied by severe exudation and corneal edema, underwent secondary surgery (anterior vitrectomy + repeat goniosynechialysis) at 2 months. Fortunately, neither suffered irreversible optic nerve damage from persistent high IOP. These adverse events are consistent with documented complications of sulcus implantation [28]. Based on our experience and literature evidence, we believe the primary surgical goal for extremely short eyes should be relieving anatomical obstruction and controlling IOP, placing refractive emmetropization as a secondary objective [3, 8]. Furthermore, studies indicate that existing IOL power calculation formulas are inaccurate in nanophthalmos, further reducing the reliability of achieving precise refractive targets [29]. Therefore, implanting a single IOL and correcting residual hyperopia with spectacles postoperatively is a safer, more reasonable, and practical choice [8]. Our analysis of 5 eyes with AL <16 mm receiving single IOL implantation supports this strategy, showing little change in residual hyperopia compared to preoperative status (mean difference +0.80 ± 1.48 D), which is usually well-tolerated by most long-term spectacle-wearing hyperopic patients. 3. Gonioscopic Synechialysis is Key to Successful IOP Control: This concept originates from the pioneering description of goniosynechialysis by Campbell and Vela [20], who emphasized that it must be performed under direct gonioscopic view to accurately separate synechiae and confirm successful re-exposure of the functional trabecular meshwork. Without this direct visualization, surgeons cannot judge whether true anatomical opening of the angle has been achieved, potentially leading to surgery only relieving pupillary block without re-establishing effective aqueous outflow, resulting in IOP control failure. Recent studies have repeatedly confirmed the correlation between thorough, gonioscopy-guided synechialysis and superior IOP reduction [12, 13, 30]. Therefore, meticulous and extensive synechialysis, maximizing exposure of the functional trabecular meshwork, is the anatomical foundation for breaking aqueous outflow obstruction and achieving long-term stable IOP control. This study clearly reaffirms that short AL (especially <16 mm) is the primary risk factor for surgical complications, consistent with the large-sample study by Hammer et al. [21]. Limitations of this study include its retrospective design and relatively small sample size, inherent to the rarity of the disease. Future larger, multicenter prospective studies are needed to further validate our conclusions. Conclusion In conclusion, for nanophthalmos with secondary angle-closure glaucoma, Phaco+IOL+GSL is recommended as a first-line surgical option , rather than initially combining more invasive procedures such as vitrectomy. The proposed stepwise management strategy (laser → cyclophotocoagulation → vitrectomy) is reserved for managing postoperative complications when they occur, allowing most patients to avoid upfront vitrectomy. Shorter axial length (<16 mm) is a key risk factor warranting heightened vigilance. This 20-case series, including 9 eyes with AL<16 mm, provides valuable evidence for this rare condition. List of Abbreviations AC: Anterior Chamber ACG: Angle-Closure Glaucoma AL: Axial Length BCVA: Best-Corrected Visual Acuity IOL: Intraocular Lens IOP: Intraocular Pressure GSL: Goniosynechialysis logMAR: Logarithm of the Minimum Angle of Resolution PAC: Primary Angle Closure PAS: Peripheral Anterior Synechiae Phaco: Phacoemulsification PI: Peripheral Iridectomy PCR: Posterior Capsular Rupture PPV: Pars Plana Vitrectomy SE: Spherical Equivalent UCVA: Uncorrected Visual Acuity Declarations Ethics approval and consent to participate: This study was approved by the Ethics Committee of Aier Eye Hospital of Wuhan University and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all participants. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: HZ and ZW conceived the study. ZW, YW, performed surgeries. HZ,XZ, JL, LY collected data. HZ analyzed the data and drafted the manuscript. ZW critically revised the manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable. References Singh OS, Simmons RJ, Brockhurst RJ, Trempe CL. Nanophthalmos: a perspective on identification and therapy. Ophthalmology. 1982;89(9):1006-12. PMID: 7177565. Luo NC, Zuo CG, Liu X. Research status and progress of nanophthalmos.Zhong hua Yan Ke Za Zhi. 2025;61(5):391-6. DOI: 10.3760/cma.j.cn112142-20240702-00289. Rajendrababu S, Shroff S, Uduman MS, Babu N. Clinical spectrum and treatment outcomes of patients with nanophthalmos. Eye (Lond). 2021;35(3):825-30. DOI: 10.1038/s41433-020-0971-4. Wu W, Dawson DG, Sugar A, Elner SG, Meyer KA, McKey JB, Moroi SE. Cataract surgery in patients with nanophthalmos: results and complications. J Cataract Refract Surg. 2004 Mar;30(3):584-90. doi: 10.1016/j.jcrs.2003.07.009. PMID: 15050253. Yalvac IS, Satana B, Ozkan G, Eksioglu U, Duman S. Management of glaucoma in patients with nanophthalmos. Eye (Lond). 2008;22(6):838-43. DOI: 10.1038/sj.eye.6702742. Abdelrahman AM, Ismail YM. Primary Transscleral Diode Laser Cyclophotocoagulation for Management of Glaucoma in Nanophthalmic Eyes. J Glaucoma. 2024;33(4):e15-e18. DOI: 10.1097/IJG.0000000000002284. Aquino MC, Barton K, Tan AM, Sng C, Li X, Loon SC, Chew PT. Micropulse versus continuous wave transscleral diode cyclophotocoagulation in refractory glaucoma: a randomized exploratory study. Clin Exp Ophthalmol. 2015;43(1):40-6. DOI: 10.1111/ceo.12360. Day AC, MacLaren RE, Bunce C, Stevens JD, Foster PJ. Outcomes of phacoemulsification and intraocular lens implantation in microphthalmos and nanophthalmos. J Cataract Refract Surg. 2013;39(1):87-96. DOI: 10.1016/j.jcrs.2012.08.057. Wei Y, Su Y, Fang L, Guo X, Chen S, Han Y, Zhu Y, Cheng B, Lin S, Zhong Y, Liu X. Effect of Combined Surgery in Patients with Complex Nanophthalmos. J Clin Med. 2022;11(19):5909. DOI: 10.3390/jcm11195909. Fan X, Wang J, Sheng Q, Zhai R, Kong X. Outcomes of combined phacoemulsification, anterior vitrectomy, and sclerectomy in nanophthalmic eyes with glaucoma. Eye (Lond). 2023 Mar;37(4):751-759. doi: 10.1038/s41433-022-02039-w. Epub 2022 Apr 5. PMID: 35383309; PMCID: PMC9998427. He MY, Feng JR, Zhang L. Treatment of Nanophthalmos Cataracts: Surgery and Complications. Semin Ophthalmol. 2022;37(7-8):849-55. DOI: 10.1080/08820538.2022.2102929. Tang YH, Li YY, Xie YQ, Zhang SD, Xu SX, Le RR, Chu XZ, Hu CJ, Wang XJ, Pan WH, Liang YB. Phacoemulsification combined with goniosynechialysis under a gonioscope in the treatment of angle-closure glaucoma: the effect of reopening the synechial anterior chamber angle. Zhonghua Yan Ke Za Zhi. 2022;58(9):701-705. DOI: 10.3760/cma.j.cn112142-20211127-00565. Zhao J, Zhang C, Pazo EE, Dai G, Li Y, Chen Y, Li M, Che H. Phaco-goniosynechialysis versus phaco-trabeculectomy in patients with refractory primary angle-closure glaucoma: a comparative study. BMC Ophthalmol. 2023;23(1):144. DOI: 10.1186/s12886-023-02885-6. Quigley HA, Friedman DS, Congdon NG. Possible mechanisms of primary angle-closure and malignant glaucoma. J Glaucoma. 2003;12(2):167-80. DOI: 10.1097/00061198-200304000-00013. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg. 1997;13(4):388-91. DOI: 10.3928/1081-597X-19970701-16. Yao L, Wang H, Wang Y, Zhao P, Bai H. Phacoemulsification combined with goniosynechialysis versus phacoemulsification alone for patients with primary angle‑closure disease: A meta-analysis. PLoS One. 2024 Feb 2;19(2):e0296849. doi: 10.1371/journal.pone.0296849. PMID: 38306318; PMCID: PMC10836673. Zhang Z, Zhang S, Jiang X, Wei Y. Combined 23-G Pars Plana Vitrectomy and Lensectomy in the Management of Glaucoma Associated with Nanophthalmos. Ophthalmic Res. 2018;59(1):37-44. DOI: 10.1159/000477620. Rajendrababu S, Babu N, Sinha S, Balakrishnan V, Vardhan A, Puthuran GV, Ramulu PY. A Randomized Controlled Trial Comparing Outcomes of Cataract Surgery in Nanophthalmos With and Without Prophylactic Sclerostomy. Am J Ophthalmol. 2017;183:125-133. DOI: 10.1016/j.ajo.2017.09.008. Wang XJ, Tian AJ, Zhang SD, et al. Multicenter retrospective analysis of treatment methods for acute primary angle-closure glaucoma in hospitalized patients. Zhonghua Yan Ke Za Zhi. 2025;61(09):667-676. DOI: 10.3760/cma.j.cn112142-20241031-00490. Campbell DG, Vela A. Modern goniosynechialysis for the treatment of synechial angle-closure glaucoma. Ophthalmology. 1984 Sep;91(9):1052-60. doi: 10.1016/s0161-6420(84)34195-1. PMID: 6493714. Hammer M, Teich L, Friedrich M, Reitemeyer E, Britz L, Khoramnia R, Yildirim TM, Auffarth GU. Cataract surgery in the extremely small eye: morphology, comorbidities and outcomes in 300 eyes. Br J Ophthalmol. 2025;109(8):917-924. DOI: 10.1136/bjo-2024-326998. Kim JY, Kim H, Jun I, Kim TI, Seo KY. Effect and Safety of Pressure Sensor-equipped Handpiece in Phacoemulsification System. Korean J Ophthalmol. 2023;37(5):387-394. DOI: 10.3341/kjo.2022.0157. Lincke JB, Häner N, Schawkat M, Zinkernagel MS, Unterlauft JD. Treatment of pseudophakic aqueous misdirection syndrome. Sci Rep. 2025 Jan 9;15(1):1415. doi: 10.1038/s41598-024-83659-y. PMID: 39788995; PMCID: PMC11718072. Safir M, Hecht I, Sharon T, Einan-Lifshitz A, Belkin A. Application of Nd:YAG laser to the anterior vitreous in malignant glaucoma - a systemic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2022 Sep;260(9):2981-2990. doi: 10.1007/s00417-022-05640-7. Epub 2022 Mar 29. PMID: 35348842. Schmidt DC, Kessel L, Pedersen KB, Villumsen JE, Bach-Holm D. Pars plana vitrectomy combined with hyaloido-zonula-iridectomy in treatment of patients with chronic aqueous misdirection: A systematic literature review and case series. Acta Ophthalmol. 2021 May;99(3):251-259.DOI: 10.1111/aos.14580. Epub 2020 Aug 25. PMID: 32840056. Yosar JC, Zagora SL, Grigg JR. Cataract Surgery in Short Eyes, Including Nanophthalmos: Visual Outcomes, Complications and Refractive Results. Clin Ophthalmol. 2021;15:4543-4551. DOI: 10.2147/OPTH.S344465. Cao KY, Sit M, Braga-Mele R. Primary piggyback implantation of 3 intraocular lenses in nanophthalmos. J Cataract Refract Surg. 2007;33(4):727-30. DOI: 10.1016/j.jcrs.2006.11.028. LeBoyer RM, Werner L, Snyder ME, Mamalis N, Riemann CD, Augsberger JJ. Acute haptic-induced ciliary sulcus irritation associated with single-piece AcrySof intraocular lenses. J Cataract Refract Surg. 2005;31(7):1421-7. DOI: 10.1016/j.jcrs.2004.12.056. Moore JE, McNeely RN, Moutari S. Cataract Surgery in the Small Adult Eye: A Review. Clin Exp Ophthalmol. 2025 Jul;53(5):558-569. doi: 10.1111/ceo.14510. Epub 2025 Mar 4. PMID: 40035171. Lai JS, Tham CC, Lam DS. The efficacy and safety of combined phacoemulsification, intraocular lens implantation, and limited goniosynechialysis, followed by diode laser peripheral iridoplasty, in the treatment of cataract and chronic angle-closure glaucoma. J Glaucoma. 2001 Aug;10(4):309-15. doi: 10.1097/00061198-200108000-00011. PMID: 11558816. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9395122","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625784875,"identity":"7e79ad4e-81e3-4b30-a11c-b2701791e114","order_by":0,"name":"Hongyan Zhu","email":"","orcid":"","institution":"Aier Eye Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Hongyan","middleName":"","lastName":"Zhu","suffix":""},{"id":625784876,"identity":"3053f301-407f-4297-8ea6-a6b09f64ff8a","order_by":1,"name":"Zuohong Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYLACxgYgwd7AcABIJbARr4XnAMlaJBLA7ASCqg1upD+T+LjDJk8+8vHDAx/32OXxSTc/YPhRsQ2PloQ0yZln0ooNb6cZHJzxLLmYTeaYAWPPmds4tZjdSDgmzdt2OHHj7ASDwzwHDiS2SSQYMDO24dOS2AbRMvP4h8N/wFrSPxDQkswG1jJfgsfgMANYSw5+W+zPPGO2nNmWlriBJ6fgYM+BZJAWIAOPXyTb0x/e+Nhmkzi//fjmDz8O2CXOn5G+8cGPCtxa4MDgABLnAA5FqEC+gShlo2AUjIJRMBIBAOnbYb7y++GGAAAAAElFTkSuQmCC","orcid":"","institution":"Aier Eye Hospital of Wuhan University","correspondingAuthor":true,"prefix":"","firstName":"Zuohong","middleName":"","lastName":"Wu","suffix":""},{"id":625784878,"identity":"e5a79fba-c705-45bb-89b0-b6369dfdf2fc","order_by":2,"name":"Yong Wang","email":"","orcid":"","institution":"Aier Eye Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Wang","suffix":""},{"id":625784879,"identity":"c07f0770-7d45-44ce-9684-48eb1dbc1828","order_by":3,"name":"Xun Zhan","email":"","orcid":"","institution":"Aier Eye Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Xun","middleName":"","lastName":"Zhan","suffix":""},{"id":625784880,"identity":"a4ca42d3-2b2a-4e07-b3d9-eeba85e8853d","order_by":4,"name":"Jin Lv","email":"","orcid":"","institution":"Aier Eye Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Lv","suffix":""},{"id":625784881,"identity":"c14278c0-8fc9-47fd-b633-32dec502cfd3","order_by":5,"name":"Li Ye","email":"","orcid":"","institution":"Aier Eye Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Ye","suffix":""}],"badges":[],"createdAt":"2026-04-12 14:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9395122/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9395122/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107509493,"identity":"b230e86c-d958-4fd3-aaab-b0e1feb9ac2f","added_by":"auto","created_at":"2026-04-22 07:28:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":820869,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9395122/v1/05efbb99-2637-433b-baf4-7046302e3963.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Phacoemulsification with Goniosynechialysis for Nanophthalmos with Secondary Angle-Closure or Secondary Angle-Closure Glaucoma: A 20-Case Series and Stepwise Management Strategy","fulltext":[{"header":"Background","content":"\u003cp\u003eNanophthalmos is a rare congenital ocular maldevelopment characterized by a significantly shortened axial length (AL), thickened sclera, high hyperopia, and a shallow anterior chamber [1]. Primary angle closure (PAC) and secondary angle-closure glaucoma (ACG)\u0026nbsp;\u0026nbsp;\u003cstrong\u003eare\u003c/strong\u003e among\u0026nbsp;its most serious complications, and its management is challenging [2, 3]. Due to crowded anterior segments and unique scleral properties, patients with nanophthalmos are at high risk for serious complications such as choroidal effusion, malignant glaucoma, and expulsive suprachoroidal hemorrhage during traditional filtering surgeries [4].\u0026nbsp;Yalvac et al. [5] reported that the incidence of choroidal detachment after filtering surgery was 25%, and uveal effusion occurred in 50% of cases. These findings were further corroborated by Rajendrababu et al. [3].\u003c/p\u003e\n\u003cp\u003eGiven the anatomical peculiarities and risks, many surgeons have explored cyclophotocoagulation as an alternative [6, 7]. Abdelrahman et al. [6] demonstrated that transscleral cyclophotocoagulation (TSCPC) significantly reduced IOP over 6 months without severe complications like hypotony or choroidal effusion. However, as a destructive procedure, the long-term efficacy and potential complications of cyclophotocoagulation warrant cautious evaluation.\u003c/p\u003e\n\u003cp\u003eRecently, phacoemulsification with intraocular lens implantation (Phaco+IOL) has been increasingly used in nanophthalmic eyes, and its safety profile has been preliminarily recognized [8]. For cases complicated by PAC or ACG, most surgeons adopt combined procedures, often incorporating anterior vitrectomy and/or sclerectomy. Studies by Wei et al. [9] and Fan et al. [10] indicated that combined surgeries yielded better IOP control, fewer complications, and higher success rates compared to filtering surgery alone. Anterior vitrectomy has been shown to reduce the risk of postoperative malignant glaucoma [10, 11], while prophylactic sclerectomy helps prevent uveal effusion [10, 11]. However, both vitrectomy and sclerectomy increase surgical trauma and operating time, presenting additional challenges for patients.\u003c/p\u003e\n\u003cp\u003ePhacoemulsification combined with IOL implantation and goniosynechialysis (Phaco+IOL+GSL) has gained widespread use in managing PAC and ACG, particularly with coexisting cataract, and its efficacy and safety have been supported by numerous studies [12, 13]. The mechanism primarily involves removing the relatively thick lens to deepen the anterior chamber, thereby alleviating pupillary block and peripheral anterior synechiae (PAS), while gonioscopic separation of synechiae aims to reopen the physiological aqueous outflow pathway via the trabecular meshwork [14]. Compared to complex combined surgeries, Phaco+IOL+GSL offers the advantages of a simpler technique and shorter operative time.\u003c/p\u003e\n\u003cp\u003eTherefore, this retrospective study aims to evaluate the \u003cstrong\u003efeasibility and efficacy\u003c/strong\u003e of Phaco+IOL+GSL for nanophthalmos with secondary angle-closure or secondary angle-closure glaucoma, and to explore influencing factors. Compared with more complex combined procedures (e.g., with prophylactic vitrectomy or sclerectomy) reported in the literature [9,10], this technique is simpler and less invasive. We also propose a \u003cstrong\u003estepwise management strategy\u003c/strong\u003e for postoperative complications as a clinical highlight.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective case series consecutively enrolled 20 eyes of 20 patients diagnosed with nanophthalmos (axial length \u0026lt;20 mm) and secondary angle-closure who underwent Phaco+IOL+GSL at Aier Eye Hospital of Wuhan University between January 2022 and June 2025. Of these, 18 eyes had glaucomatous optic neuropathy (secondary angle-closure glaucoma) and 2 eyes had angle closure without glaucomatous damage (secondary angle-closure).\u0026nbsp;The study adhered to the tenets of the Declaration of Helsinki and was approved by the hospital's Ethics Committee. Informed consent was obtained from all patients.\u003c/p\u003e\n\u003cp\u003e1. Inclusion Criteria: (1) AL \u0026lt; 20 mm measured by IOLMaster-700; (2) Gonioscopy confirming synechial angle closure ≥180°; (3) Postoperative follow-up ≥6 months.\u003c/p\u003e\n\u003cp\u003e2. Exclusion Criteria : (1) Previous intraocular surgery; (2) Coexisting ocular diseases such as uveitis, ocular trauma, or retinal detachment; (3) Incomplete clinical data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGrouping and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were divided into three groups based on AL: Group A (14 mm ≤ AL \u0026lt; 16 mm, 9 eyes); Group B (16 mm ≤ AL \u0026lt; 18 mm, 4 eyes); Group C (18 mm ≤ AL \u0026lt; 20 mm, 7 eyes). Baseline characteristics were collected and compared among the groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed by two experienced glaucoma and cataract surgeons.\u003c/p\u003e\n\u003cp\u003e1. Preoperative Preparation : Topical IOP-lowering medications (excluding prostaglandin analogs) were administered 1-3 days preoperatively. Intravenous 20% mannitol (250 ml) was administered 30 minutes before surgery.\u003c/p\u003e\n\u003cp\u003e2. Surgical Equipment : Two Alcon phacoemulsification systems (Centurion and Infinity) were used alternately.\u003c/p\u003e\n\u003cp\u003e3. Surgical Procedure : Retrobulbar or general anesthesia was administered. A 2.2 mm main incision and a side port were created at the limbus. Continuous curvilinear capsulorhexis was performed, followed by hydrodissection and phacoemulsification of the nucleus and aspiration of the residual cortex. Single IOL was implanted in 16 eyes (single-piece, hydrophobic acrylic IOL). Two eyes aiming for emmetropia underwent piggyback IOL implantation (one three-piece IOL in the ciliary sulcus and one single-piece IOL in the bag). Two eyes with preoperative vision of light perception or no light perception did not receive an IOL. Subsequently, under direct gonioscopic view, extensive blunt separation of PAS was performed using an iris repositor, aiming to maximally re-expose the functional trabecular meshwork and ciliary body band, targeting a separation extent of ≥270°. Six eyes with poorly controlled preoperative IOP (≥30 mmHg on medications) or a recent acute attack underwent combined prophylactic peripheral iridectomy (PI), ensuring IOL haptics were positioned away from the PI. Four eyes developed intraoperative shallow anterior chamber/aqueous misdirection. In 2 eyes, anterior chamber depth was restored via pars plana vitreous cavity tap (23G needle, aspirating 0-0.1 ml fluid), allowing surgery to proceed. The other 2 eyes with persistent shallow anterior chamber underwent anterior vitrectomy via the pars plana; one of these also had posterior capsular rupture requiring IOL scleral fixation. Significant hemorrhage during synechialysis in one eye was managed by injecting a small air bubble into the anterior chamber.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Management and Follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative topical antibiotics, corticosteroids, and nonsteroidal anti-inflammatory drugs were routinely administered and tapered. IOP, anterior chamber depth, inflammation, and fundus were closely monitored. If shallow anterior chamber or elevated IOP occurred, intravenous mannitol and intensified anti-inflammatory therapy were initiated. If ineffective within 24-48 hours,\u0026nbsp;\u003cstrong\u003eNd:YAG laser anterior capsulotomy, posterior capsulotomy, and anterior hyaloidotomy\u003c/strong\u003e were performed via the existing PI site or at the IOL edge. If laser access was unavailable or ineffective, cyclophotocoagulation or secondary surgery (anterior vitrectomy + goniosynechialysis ± IOL explantation) was considered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObservation Indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative and postoperative UCVA (logMAR), BCVA (logMAR), IOP, number of antiglaucoma medications, and intraoperative and postoperative complications were recorded.\u003c/p\u003e\n\u003cp\u003eSurgical Success Criteria: Complete success: IOP ≤21 mmHg without antiglaucoma medications; Qualified success: IOP ≤21 mmHg with medications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS 26.0 was used for analysis. Visual acuities were converted to logMAR (counting fingers, hand motions, light perception, and no light perception were assigned values of 2.0, 2.3, 2.7, and 3.0, respectively [15]). Normally distributed continuous data are presented as mean ± standard deviation, and non-normally distributed data as median [Q1, Q₃]. The Wilcoxon signed-rank test or Kruskal-Wallis H test was used for comparisons. Categorical data are presented as n (%), compared using Fisher's exact test. Multiple comparisons employed Bonferroni correction. Multivariate logistic regression analyzed risk factors for postoperative complications. P \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Baseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty eyes of 20 patients were included (8 males [40.0%], 12 females [60.0%]). No significant differences were found among the three groups regarding age, gender, preoperative IOP, number of preoperative medications, or preoperative visual acuity (P \u0026gt; 0.05), indicating comparability (Table 1).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\n \u003cp\u003eTable 1. Comparison of Baseline Characteristics Among the Three Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIndicator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup A (14-16mm, n=9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup B (16-18mm, n=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup C (18-20mm, n=7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;P-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Statistical Test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years), M [Q1, Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.0 [48.0, 59.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.5 [44.3, 68.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.0 [51.5, 73.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.770\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Kruskal-Wallis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (Male), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.804\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFisher\u0026apos;s Exact\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreop IOP (mmHg), M [Q1, Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.0 [16.5, 33.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.5 [18.8, 40.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.0 [17.0, 54.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eKruskal-Wallis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreop Meds (n), M [Q1, Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.0 [0.0, 4.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.0 [3.0, 3.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.0 [0.0, 3.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eKruskal-Wallis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreop UCVA (logMAR), M [Q1, Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1.40\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003cstrong\u003e1.22, 1.70\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1.40\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003cstrong\u003e1.03, 1.78\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1.10\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003cstrong\u003e0.96, 2.20\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eKruskal-Wallis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePreop BCVA (logMAR), M [Q1, Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1.00\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003cstrong\u003e0.82, 1.55\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1.20\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003cstrong\u003e0.88, 1.48\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.70\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003cstrong\u003e0.40, 2.00\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.660\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eKruskal-Wallis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: M [Q1, Q3]: Median [First Quartile, Third Quartile].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Efficacy Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe median preoperative IOP was 25.5 [16.0, 35.0] mmHg, which decreased to 16.0 [14.0, 20.0] mmHg at 3 months postoperatively (P \u0026lt; 0.05) and at the 6-12 month follow-up ,it was 16.0 [12.0, 19.0] mmHg , indicating a significant and sustained IOP reduction (Table 2).\u003c/p\u003e\n\u003cp\u003eThe median number of antiglaucoma medications decreased from 2.5 [0.0, 4.0] preoperatively to 0.0 \u0026nbsp;[0.0, 0.0] \u0026nbsp;at 3 months postoperatively (P = 0.003) and remained at 0.0 [0.0, 0.0] at the 6-12 month follow-up,\u0026nbsp;with no statistically significant difference compared to the 3-month postoperative visit (P = 1.000), demonstrating that the surgery significantly reduces medication dependence, and this effect is sustained over time ( Table 2).\u003c/p\u003e\n\u003cp\u003eUCVA (logMAR) improved from 1.30 [1.00, 1.70] preoperatively to 0.40 [0.12, 1.10] postoperatively (P \u0026lt; 0.001). BCVA (logMAR) improved from 0.82 [0.40, 1.30] to 0.70 [0.30, 1.30] (P = 0.035) (Table 3).\u003c/p\u003e\n\u003cp\u003eAt the final follow-up (6-12 months), the qualified success rate was 95.0% (19/20), the complete success rate was 80.0% (16/20), and the failure rate was 5.0% (1/20).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003eTable 2. Changes in IOP and Number of Antiglaucoma Medications\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Indicator\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePostop 3 Months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePostop 6-12 Months \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP\u003csup\u003e1\u003c/sup\u003e-value (Pre vs postop 3 M)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;P\u003csup\u003e1\u003c/sup\u003e-value (Pre vs 6-12M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP\u003csup\u003e2\u003c/sup\u003e-value (3M vs 6-12M\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;IOP (mmHg), M [Q1, Q3]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.5[16.0,35.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.0 [14.0,20.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.0[14.0,19.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMeds (n), M [Q1, Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.5[0.0,4.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0[0.0,0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0[0.0,0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Wilcoxon signed-rank test with Bonferroni correction.（For the P\u003csup\u003e1\u0026nbsp;\u003c/sup\u003evalues, a total of three comparisons were made, and the corrected significance level was set at 0.05/3 = 0.017. A corrected P-value \u0026lt; 0.017 was considered statistically significant. For the P\u003csup\u003e2\u003c/sup\u003e values, two comparisons were made, with a corrected significance level of 0.05/2 = 0.025. A P-value \u0026gt; 0.025 indicated no statistically significant difference.）\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003eTable 3. Changes in UCVA and BCVA (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVisual Acuity (logMAR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Preoperative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;P-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUCVA (n=20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.30 [1.00, 1.70]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.40 [0.12, 1.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBCVA (n=20)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.82[0.40, 1.30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.70 [0.30, 1.30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Wilcoxon signed-rank test.\u003c/p\u003e\n\u003cp\u003eIntergroup comparison of surgical outcomes (Table 4) showed that :\u0026nbsp;In Group A, both postoperative intraocular pressure (IOP) and the number of medications decreased significantly compared to preoperative levels (P \u0026lt; 0.05). In Group C, there was no statistically significant difference in the number of medications, but postoperative IOP was significantly lower than preoperative IOP (P \u0026lt; 0.05). Group B exhibited the largest magnitude of change in both IOP and medication number; however, none of the P values reached statistical significance, suggesting that a larger sample size may be needed to confirm the statistical significance of this effect.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eTable 4. Preoperative and Postoperative Changes in IOP and Medications by Group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreop IOP (mmHg), M [Q1,Q3]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Final IOP (mmHg), M [Q1,Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value (IOP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Preop Meds (n), M [Q1,Q3]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Final Meds (n), M [Q1,Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;P-value (Meds)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.0 [16.5, 33.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.0 [17.0, 19.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.0 [0.0, 4.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.0 [0.0, 1.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.5 [18.8, 40.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.5 [12.0, 15.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.0 [3.0, 3.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.0 [0.0, 2.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34.0 [17.0,54.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.0[12.0,16.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.0 [0.0, 3.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.0 [0.0, 0.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Wilcoxon signed-rank test for within-group changes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSafety Evaluation: Complications and Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003e\u0026nbsp;Intraoperative Complications\u003c/strong\u003e: The overall intraoperative complication rate was 25.0% (5/20). Shallow anterior chamber/aqueous misdirection was the most common complication (4 eyes, 20.0%), with one eye concurrently experiencing posterior capsular rupture (PCR rate 5.0%). No expulsive suprachoroidal hemorrhage occurred. Complications were concentrated in Groups A and B, with no complications in Group C (Table 5). The difference in the incidence of any intraoperative complication among groups (Group A 33.3% vs Group B 50.0% vs Group C 0.0%) was statistically significant (P = 0.044, Fisher\u0026apos;s exact test).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u003cstrong\u003e\u0026nbsp;Management\u003c/strong\u003e: All 4 eyes with intraoperative aqueous misdirection/shallow anterior chamber underwent pars plana vitreous tap (23G needle, aspirating approximately 0-0.1 ml). This restored anterior chamber depth in 2 eyes, allowing surgery to continue. The other 2 eyes required additional anterior vitrectomy; one of these also had PCR requiring IOL scleral fixation. One eye with significant hemorrhage during synechialysis was managed by anterior chamber air injection.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"566\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\n \u003cp\u003eTable 5. Intraoperative Complications by Axial Length Group [n(%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Total Eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eShallow AC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePCR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHyphema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Any Complication*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntergroup P-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eA（14-16mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (11.1%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (33.3%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eB（16-18mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC（18-20mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e4 (20.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1 (5.0%\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1(5.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e5 (25.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.044\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: PCR: Posterior Capsular Rupture. *\u0026quot;Any Complication\u0026quot; refers to independent eyes experiencing at least one complication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Postoperative Complications:\u003c/strong\u003e Seven complications occurred within the first week, and one at 4 weeks postoperatively, with a total rate of 40.0% (8/20). The main manifestation was shallow anterior chamber with elevated IOP (25.0%, 5/20), followed by isolated shallow anterior chamber (5.0%, 1 eye), isolated elevated IOP (5.0%, 1 eye), and choroidal detachment (5.0%, 1 eye). All complications occurred in Groups A and B. Group A had the highest incidence (66.7%). The intergroup difference was statistically significant (P = 0.008, Fisher\u0026apos;s exact test) (Table 6). Pairwise comparisons showed Group A (shortest AL) had a significantly higher complication rate than Group C (longest AL) (P = 0.009). Group B also had a high rate (50.0%), but its comparison with Group C did not reach the Bonferroni-corrected significance level (P \u0026lt; 0.017, \u0026alpha;=0.05/3\u0026asymp;0.017), possibly due to its small sample size (n=4). No complications occurred in Group C, indicating lower risk for patients with AL \u0026gt;18 mm, while AL \u0026lt;16 mm is a clear risk factor.\u003c/p\u003e\n\u003cp\u003eMultivariate logistic regression confirmed that shorter AL was negatively correlated with both intraoperative (OR = 0.52, 95%CI[0.28, 0.95], P=0.034) and postoperative complications (OR = 0.42, 95%CI[0.22, 0.80], P=0.008), indicating higher complication risk with shorter eyes. AL \u0026lt;16 mm was an independent risk factor for postoperative shallow AC/elevated IOP.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003eTable 6. Postoperative Complications by Axial Length Group [n(%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Total Eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eShallow AC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh IOP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eShallow AC + High IOP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eChoroidal Detachment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAny Complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntergroup P-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eA（14-16mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1(11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1(11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eB（16-18mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC（18-20mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1 (5.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1 (5.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e5 (25.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1 (5.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e8 (40.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e\u003cem\u003e\u0026nbsp;Fisher\u0026apos;s exact test\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Management of Postoperative Complications:\u0026nbsp;\u003c/strong\u003eAmong the 8 eyes with complications, 1 eye with choroidal detachment resolved with conservative medical treatment. The remaining 7 eyes (including 2 with piggyback IOLs) presented with shallow AC and/or elevated IOP. In these 7 eyes, initial intervention with\u0026nbsp;\u003cstrong\u003eNd:YAG laser anterior capsulotomy, posterior capsulotomy, and anterior hyaloidotomy\u003c/strong\u003e \u0026nbsp;were performed in 3 eyes, successfully resolving shallow AC in 2 eyes; the other eye was unresponsive and subsequently underwent successful cyclophotocoagulation for IOP control. Management and outcomes for the other 4 eyes were as follows: Among 2 eyes with single IOL implantation, cyclophotocoagulation was ineffective in both. One eye underwent successful secondary surgery (anterior vitrectomy + goniosynechialysis) at 1 month, while the other declined further intervention and had uncontrolled IOP at final follow-up, with vision declining from hand motions to light perception. Among the 2 eyes with piggyback IOLs, one underwent secondary surgery (anterior vitrectomy + goniosynechialysis) 2 months after failed cyclophotocoagulation. The other eye developed early malignant glaucoma with severe exudation, requiring emergency secondary surgery (anterior vitrectomy + sulcus IOL removal + goniosynechialysis) on postoperative day 3, which successfully controlled IOP and exudation.\u003c/p\u003e\n\u003cp\u003eAs shown in Table 7, secondary surgery (vitrectomy combined with goniosynechialysis \u0026plusmn; IOL removal) had a 100% success rate (3/3). Nd:YAG laser posterior capsulotomy was 66.7% effective (2/3). Conventional cyclophotocoagulation was 25.0% effective (1/4).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eTable 7. Efficacy of Different Complication Management Strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eManagement Strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEyes Treated (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEffective (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNew Complications (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuccess Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNd:YAG laser posterior capsulotomy with anterior hyaloidotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Cyclophotocoagulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Secondary Surgery (PPV+GSL\u0026plusmn;IOL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e4. Postoperative Refractive Status in Single IOL Implantation (Group A)\u003c/strong\u003e: Analysis of 5 eyes in Group A (AL\u0026lt;16 mm) that received single IOL implantation showed persistent significant hyperopia postoperatively (mean SE +13.45 D). Comparison of the difference between preoperative and postoperative SE revealed minimal change in residual refractive error with single IOL implantation (mean difference +0.80 \u0026plusmn; 1.48 D) (Table 8).\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"564\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003eTable 8. Refractive Status Changes in 5 Eyes with Single IOL Implantation in Group A (14-16mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePreop SE (D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;Postop SE (D)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDifference (Postop-Preop) (D)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTan XX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+12.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+13.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLiao XX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+14.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+13.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSun X\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+16.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+16.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWang XX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+11.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+12.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLiu XX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+9.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+12.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+12.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+13.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+0.80 \u0026plusmn; 1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSurgical management of nanophthalmos with secondary angle-closure glaucoma is challenging due to the high risk of complications. This study reports a 20-case series of Phaco+IOL+GSL in this rare condition. The stepwise management strategy—initiating with medical/laser therapy, escalating to cyclophotocoagulation, and reserving pars plana vitrectomy for refractory cases—was used to manage postoperative complications. This series includes 9 eyes with axial length \u0026lt;16 mm, a subgroup infrequently described in the literature.\u003c/p\u003e\n\u003cp\u003eIt is well established that lens extraction (phacoemulsification) alone can deepen the anterior chamber, widen the angle, and reduce intraocular pressure (IOP) in nanophthalmic eyes with angle closure [4,9,10]. However, studies on primary angle-closure disease have shown that the IOP reduction after phacoemulsification alone is limited, particularly in eyes with extensive peripheral anterior synechiae (PAS) or higher baseline IOP [16]. A meta-analysis of nine randomized controlled trials reported that phacoemulsification combined with goniosynechialysis (GSL) achieved greater IOP reduction compared with phacoemulsification alone in patients with angle-closure disease (mean difference, 1.81 mmHg; p = 0.002) [16]. In the present series, the baseline IOP was relatively high (median 25.5 mmHg) and PAS was extensive (≥180°). Therefore, the additional IOP reduction associated with GSL may be relevant for this specific population.\u003c/p\u003e\n\u003cp\u003eOur final follow-up showed a qualified success rate of 95.0% and a complete success rate of 80.0%. This efficacy is comparable to the 71.4% complete success rate reported by Zhang et al. [17] for 23G pars plana vitrectomy combined with lensectomy (without IOL implantation). Notably, Wei et al. [9] employed a more complex procedure (phacoemulsification combined with anterior vitrectomy and posterior capsulotomy), reporting an overall success rate of 88.9%, but a lower complete success rate (42.5%) than our study. This discrepancy\u0026nbsp;may be attributed to the absence of\u0026nbsp;gonioscopic synechialysis, potentially affecting the\u0026nbsp;completeness\u0026nbsp;of angle opening. However, their very low complication rate (4.4%) also underscores the value of anterior vitrectomy in relieving ciliary block and managing high-risk factors [9].\u003c/p\u003e\n\u003cp\u003eThe crucial question is whether such prophylactic procedures should be routinely combined during initial surgery. The randomized controlled trial by Rajendrababu et al. [18] provides key insights. They found no statistical difference in complication risk between \"phacoemulsification with prophylactic sclerostomy\" and \"phacoemulsification alone,\" with the combined procedure inducing significant inflammation. However, they observed a trend towards lower complication rates and suggested considering combined surgery.\u0026nbsp;This reveals the clinical dilemma: \u003cstrong\u003ethe potential reduction in risk must be balanced against the greater trauma and inflammatory burden\u003c/strong\u003e imposed on all patients by a more complex procedure[18].\u003c/p\u003e\n\u003cp\u003eIn this context, our proposed stepwise treatment strategy offers a more targeted solution. We do not negate the role of vitrectomy/sclerostomy but reserve them as \"backup plans.\" We primarily selected the minimally invasive Phaco+IOL+GSL, enabling 90.0% (18/20) of patients to complete surgery safely. Anterior vitrectomy was added only for the minority of high-risk patients (10.0%, 2/20) with persistent intraoperative shallow AC/aqueous misdirection.\u0026nbsp;Another subset (15.0%, 3/20) developed postoperative malignant glaucoma refractory to medical and laser therapy, ultimately requiring secondary pars plana vitrectomy (PPV) to resolve the shallow anterior chamber and control IOP.\u0026nbsp;\u003cstrong\u003eIt should be noted that\u003c/strong\u003e one of these three cases requiring secondary surgery was the patient who had already received intraoperative vitrectomy. \u003cstrong\u003eTherefore, overall, 4 out of 20 patients (20.0%) eventually required vitrectomy\u003c/strong\u003e (either during initial surgery or postoperatively) for complication management.\u003c/p\u003e\n\u003cp\u003eThis outcome supports the rationale for the stepwise strategy on two levels: First, it \u0026nbsp;allowed 80.0% (16/20) of patients to avoid vitrectomy during initial surgery, with no cases of severe complications like expulsive suprachoroidal hemorrhage,\u0026nbsp;thereby upholding the principle of minimal invasiveness.\u0026nbsp;Second, by prioritizing Phaco+IOL+GSL, combining anterior vitrectomy intraoperatively as needed (10% in this study), and aggressively performing pars plana vitrectomy for refractory complications unresponsive to laser and cyclophotocoagulation, a high final success rate (95.0% in this study) was achieved.\u003c/p\u003e\n\u003cp\u003eIOP control in this study \u003cstrong\u003ewas achieved through\u003c/strong\u003e thorough goniosynechialysis performed under direct gonioscopic view. \u003cstrong\u003eWhile the contribution of GSL versus lens extraction alone cannot be fully isolated, the meta-analysis evidence [\u003c/strong\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003cstrong\u003e] supports the incremental benefit of adding GSL, especially in eyes with high baseline IOP and extensive PAS.\u003c/strong\u003e This aligns with the concept of internal drainage procedures centered on Phaco+GSL, which has been increasingly adopted in the general ACG population [19]. Tang Yihua et al. [12] emphasized that gonioscopy-guided synechialysis with confirmation of angle opening is crucial for achieving better IOP-lowering outcomes. All cases in our study achieved synechialysis over ≥270°, aiming to expose the functional trabecular meshwork, which establishes a solid anatomical foundation for long-term IOP control [12, 13,20].\u003c/p\u003e\n\u003cp\u003eVisual improvement primarily stemmed from clearing the optical media and addressing the pre-existing hyperopia. Surgery significantly improved both UCVA (median logMAR from 1.30 to 0.40, p\u0026lt;0.001) and BCVA (median logMAR from 0.82 to 0.70, p=0.035), indicating that the procedure not only improved vision through refractive correction but also potentially enhanced visual system function by resolving factors like concomitant cataract.\u003c/p\u003e\n\u003cp\u003eThis study further validates AL as a key determinant of surgical risk. Grouping revealed that Group A (AL\u0026lt;16 mm) had high intraoperative and postoperative complication rates (33.3% and 66.7%, respectively), while Group C (AL 18-20 mm) had no complications, consistent with findings from larger studies by Day et al. [8] and Hammer et al. [21], confirming short AL as an independent risk factor.\u003c/p\u003e\n\u003cp\u003eThe most common intraoperative complication was shallow AC/aqueous misdirection (20.0%), primarily occurring in eyes with AL\u0026lt;18 mm. The mechanism involves the extremely small vitreous cavity volume in nanophthalmos, where anterior chamber opening can lead to forward movement of the anterior hyaloid face and lens-iris diaphragm, disrupting aqueous dynamics [14]. Therefore, advanced phaco platforms (e.g.2.2mm micro-incision) and skilled phacoemulsification techniques are crucial for maintaining intraoperative anterior chamber stability [22].\u003c/p\u003e\n\u003cp\u003eThe early postoperative complication rate was 40.0% (8/20), mainly shallow AC with elevated IOP (i.e., malignant glaucoma), accounting for 25.0% (5/20). The pathogenesis is considered a \"vicious cycle\" involving ciliary block, anterior hyaloid face block, and other factors [14]. Our experience suggests that traditional medical and laser therapies have limited efficacy for such cases, whereas aggressive intervention with pars plana vitrectomy (performed in 3 eyes in this study) achieved 100% success. This aligns with conclusions from Zhang et al.\u0026nbsp;[17] in nanophthalmos, and is supported by recent evidence from Lincke et al. [23] showing that pars plana vitrectomy is effective for refractory aqueous misdirection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThis study also explored the impact of other surgical details on safety:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. \u0026nbsp; Clinical Significance of Prophylactic Peripheral Iridectomy (PI): In this study, prophylactic PI was selectively performed only in cases with poorly controlled preoperative IOP or recent acute attack. However, based on our observations and analysis, we recommend routinely combining prophylactic PI in all nanophthalmic eyes with glaucoma undergoing Phaco+IOL+GSL.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;The rationale is as follows: First, nanophthalmic eyes often exhibit significant postoperative inflammation, and a\u003cstrong\u003edhesions between the iris and the implanted intraocular lens (IOL) were observed in a subset of patients.\u003c/strong\u003eThe literature widely attributes this to fragile blood-aqueous barrier function due to unique anatomy, leading to postoperative fibrin exudation and related synechiae [11], which is reported as a typical postoperative feature in nanophthalmos [4].\u0026nbsp;Notably, the newly created peripheral iridectomy (PI) itself carries a risk of inflammatory synechial or membranous closure (observed in one case), which can precipitate pupillary block and malignant glaucoma. Thus, the primary clinical value of the PI is to serve as a pre-established \u003cstrong\u003econduit for intervention in the event of\u003c/strong\u003e postoperative shallow anterior chamber or malignant glaucoma.\u0026nbsp;When ciliary block or IOL optic-posterior capsule adherence happens, the pupil often dilates poorly. Performing Nd:YAG laser posterior capsulotomy directly in the visual axis is not only technically challenging and risks IOL damage but also cannot ensure the newly created aqueous pathway effectively drains to the anterior chamber. In contrast, the PI area, even if membranous, is relatively easier to penetrate with Nd:YAG laser. This safely re-establishes communication between the posterior and anterior chambers, creating an aqueous drainage path that effectively bypasses the IOL haptics [23, 24]. This approach aligns with standard management principles for malignant glaucoma [24, 25]. In this study, 2 out of 3 eyes with postoperative shallow AC were successfully managed via laser treatment at this site, confirming the strategy's effectiveness (66.7%). Furthermore, a patent PI can also mechanistically prevent secondary pupillary block due to complete pupillary seclusion. Therefore, based on its dual role as both an \"intervention pathway” for postoperative complications and a \"preventive measure” against pupillary block,\u0026nbsp;we advocate for routine prophylactic PI as a reasonable and necessary step in such high-risk surgery.\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; IOL Selection for Extremely Short Eyes (≤16 mm): Nanophthalmic patients often require high-power IOLs (+45 D to +75 D), posing challenges in IOL selection and implantation technique [26]. To achieve emmetropia, piggyback IOL implantation (one in the bag, one in the sulcus) has been reported to provide sufficient refractive power [27]. However, caution is warranted as sulcus-placed IOLs can cause a range of anterior segment complications, such as iris pigment dispersion, iritis, peripheral anterior synechiae, and posterior synechiae [28].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;In this study, both patients receiving piggyback IOLs for emmetropia developed severe fibrinous exudation, shallow AC, and elevated IOP. One required emergency removal of the sulcus IOL on postoperative day 3 due to a very shallow AC with severe exudation, retaining the bag IOL, combined with anterior vitrectomy and repeat goniosynechialysis. The other, with uncontrolled IOP despite medical and cyclophotocoagulation therapy ,accompanied by severe exudation and corneal edema, underwent secondary surgery (anterior vitrectomy + repeat goniosynechialysis) at 2 months. Fortunately, neither suffered irreversible optic nerve damage from persistent high IOP. These adverse events are consistent with documented complications of sulcus implantation [28].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Based on our experience and literature evidence, we believe the primary surgical goal for extremely short eyes should be relieving anatomical obstruction and controlling IOP, placing refractive emmetropization as a secondary objective [3, 8]. Furthermore, studies indicate that existing IOL power calculation formulas are inaccurate in nanophthalmos, further reducing the reliability of achieving precise refractive targets [29]. Therefore, implanting a single IOL and correcting residual hyperopia with spectacles postoperatively is a safer, more reasonable, and practical choice [8]. Our analysis of 5 eyes with AL \u0026lt;16 mm receiving single IOL implantation supports this strategy, showing little change in residual hyperopia compared to preoperative status (mean difference +0.80 ± 1.48 D), which is usually well-tolerated by most long-term spectacle-wearing hyperopic patients.\u003c/p\u003e\n\u003cp\u003e3. \u0026nbsp; Gonioscopic Synechialysis is Key to Successful IOP Control: This concept originates from the pioneering description of goniosynechialysis by Campbell and Vela [20], who emphasized that it must be performed under direct gonioscopic view to accurately separate synechiae and confirm successful re-exposure of the functional trabecular meshwork. Without this direct visualization, surgeons cannot judge whether true anatomical opening of the angle has been achieved, potentially leading to surgery only relieving pupillary block without re-establishing effective aqueous outflow, resulting in IOP control failure. Recent studies have repeatedly confirmed the correlation between thorough, gonioscopy-guided synechialysis and superior IOP reduction [12, 13, 30]. Therefore, meticulous and extensive synechialysis, maximizing exposure of the functional trabecular meshwork, is the anatomical foundation for breaking aqueous outflow obstruction and achieving long-term stable IOP control.\u003c/p\u003e\n\u003cp\u003eThis study clearly reaffirms that short AL (especially \u0026lt;16 mm) is the primary risk factor for surgical complications, consistent with the large-sample study by Hammer et al. [21]. Limitations of this study include its retrospective design and relatively small sample size, inherent to the rarity of the disease. Future larger, multicenter prospective studies are needed to further validate our conclusions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, for nanophthalmos with secondary angle-closure glaucoma, Phaco+IOL+GSL is recommended as a \u003cstrong\u003efirst-line surgical option\u003c/strong\u003e, rather than initially combining more invasive procedures such as vitrectomy. The proposed stepwise management strategy (laser \u0026rarr; cyclophotocoagulation \u0026rarr; vitrectomy) is reserved for managing postoperative complications when they occur, allowing most patients to avoid upfront vitrectomy. Shorter axial length (\u0026lt;16 mm) is a key risk factor warranting heightened vigilance. This 20-case series, including 9 eyes with AL\u0026lt;16 mm, provides valuable evidence for this rare condition.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003eAC: Anterior Chamber\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; ACG: Angle-Closure Glaucoma\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; AL: Axial Length\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; BCVA: Best-Corrected Visual Acuity\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; IOL: Intraocular Lens\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; IOP: Intraocular Pressure\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; GSL: Goniosynechialysis\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; logMAR: Logarithm of the Minimum Angle of Resolution\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; PAC:\u0026nbsp;Primary Angle Closure\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; PAS: Peripheral Anterior Synechiae\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Phaco: Phacoemulsification\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; PI: Peripheral Iridectomy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; PCR: Posterior Capsular Rupture\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; PPV: Pars Plana Vitrectomy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; SE: Spherical Equivalent\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;UCVA: Uncorrected Visual Acuity\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u0026nbsp; \u0026nbsp; Ethics approval and consent to participate: This study was approved by the Ethics Committee of Aier Eye Hospital of Wuhan University and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Consent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Competing interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Authors\u0026apos; contributions: HZ and ZW conceived the study. ZW, YW, performed surgeries. HZ,XZ, JL, LY\u0026nbsp;collected data. HZ analyzed the data and drafted the manuscript. ZW critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Acknowledgements: Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSingh OS, Simmons RJ, Brockhurst RJ, Trempe CL. Nanophthalmos: a perspective on identification and therapy. Ophthalmology. 1982;89(9):1006-12. PMID: 7177565.\u003c/li\u003e\n\u003cli\u003eLuo NC, Zuo CG, Liu X. Research status and progress of nanophthalmos.Zhong hua Yan Ke Za Zhi. 2025;61(5):391-6. DOI: 10.3760/cma.j.cn112142-20240702-00289.\u003c/li\u003e\n\u003cli\u003eRajendrababu S, Shroff S, Uduman MS, Babu N. Clinical spectrum and treatment outcomes of patients with nanophthalmos. Eye (Lond). 2021;35(3):825-30. DOI: 10.1038/s41433-020-0971-4.\u003c/li\u003e\n\u003cli\u003eWu W, Dawson DG, Sugar A, Elner SG, Meyer KA, McKey JB, Moroi SE. Cataract surgery in patients with nanophthalmos: results and complications. 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Zhonghua Yan Ke Za Zhi. 2025;61(09):667-676. DOI: 10.3760/cma.j.cn112142-20241031-00490.\u003c/li\u003e\n\u003cli\u003eCampbell DG, Vela A. Modern goniosynechialysis for the treatment of synechial angle-closure glaucoma. Ophthalmology. 1984 Sep;91(9):1052-60. doi: 10.1016/s0161-6420(84)34195-1. PMID: 6493714.\u003c/li\u003e\n\u003cli\u003eHammer M, Teich L, Friedrich M, Reitemeyer E, Britz L, Khoramnia R, Yildirim TM, Auffarth GU. Cataract surgery in the extremely small eye: morphology, comorbidities and outcomes in 300 eyes. Br J Ophthalmol. 2025;109(8):917-924. DOI: 10.1136/bjo-2024-326998.\u003c/li\u003e\n\u003cli\u003eKim JY, Kim H, Jun I, Kim TI, Seo KY. Effect and Safety of Pressure Sensor-equipped Handpiece in Phacoemulsification System. Korean J Ophthalmol. 2023;37(5):387-394. DOI: 10.3341/kjo.2022.0157.\u003c/li\u003e\n\u003cli\u003eLincke JB, H\u0026auml;ner N, Schawkat M, Zinkernagel MS, Unterlauft JD. Treatment of pseudophakic aqueous misdirection syndrome. 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DOI: 10.2147/OPTH.S344465.\u003c/li\u003e\n\u003cli\u003eCao KY, Sit M, Braga-Mele R. Primary piggyback implantation of 3 intraocular lenses in nanophthalmos. J Cataract Refract Surg. 2007;33(4):727-30. DOI: 10.1016/j.jcrs.2006.11.028.\u003c/li\u003e\n\u003cli\u003eLeBoyer RM, Werner L, Snyder ME, Mamalis N, Riemann CD, Augsberger JJ. Acute haptic-induced ciliary sulcus irritation associated with single-piece AcrySof intraocular lenses. J Cataract Refract Surg. 2005;31(7):1421-7. DOI: 10.1016/j.jcrs.2004.12.056.\u003c/li\u003e\n\u003cli\u003eMoore JE, McNeely RN, Moutari S. Cataract Surgery in the Small Adult Eye: A Review. Clin Exp Ophthalmol. 2025 Jul;53(5):558-569. doi: 10.1111/ceo.14510. Epub 2025 Mar 4. PMID: 40035171.\u003c/li\u003e\n\u003cli\u003eLai JS, Tham CC, Lam DS. The efficacy and safety of combined phacoemulsification, intraocular lens implantation, and limited goniosynechialysis, followed by diode laser peripheral iridoplasty, in the treatment of cataract and chronic angle-closure glaucoma. J Glaucoma. 2001 Aug;10(4):309-15. doi: 10.1097/00061198-200108000-00011. PMID: 11558816.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nanophthalmos, Secondary Angle-Closure Glaucoma, Goniosynechialysis, Phacoemulsification, Stepwise Management, Axial Length","lastPublishedDoi":"10.21203/rs.3.rs-9395122/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9395122/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNanophthalmos is a rare congenital ocular disorder characterized by a short axial length (AL), which predisposes to secondary angle-closure and secondary angle-closure glaucoma. Surgical management is challenging due to high complication risks. This study aimed to evaluate the \u0026nbsp;feasibility and efficacy of phacoemulsification with intraocular lens implantation and goniosynechialysis (Phaco+IOL+GSL) in nanophthalmos with secondary angle-closure or secondary angle-closure glaucoma, and to propose a stepwise complication management strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective case series included 20 eyes of 20 patients diagnosed with nanophthalmos (AL \u0026lt; 20 mm) and PAC (2 eyes) or ACG (18 eyes) who underwent Phaco+IOL+GSL between January 2022 and Jun 2025. Patients were divided into three groups based on AL: Group A (14 mm ≤ AL \u0026lt; 16 mm, 9 eyes), Group B (16 mm ≤ AL \u0026lt; 18 mm, 4 eyes), and Group C (18 mm ≤ AL \u0026lt; 20 mm, 7 eyes). Preoperative and postoperative uncorrected visual acuity (UCVA, logMAR) and best-corrected visual acuity (BCVA, logMAR) were recorded, intraocular pressure (IOP), number of antiglaucoma medications, and intraoperative and postoperative complications were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the final follow-up (6-12 months postoperatively), the median IOP significantly decreased from 25.5 [16.0, 35.0] mmHg to 16.0 [14.0, 19.0] mmHg (P \u0026lt; 0.05). The median number of antiglaucoma medications decreased from 2.5 [0.0, 4.0] to 0.0 [0.0, 0.0] (P \u0026lt; 0.05). UCVA improved from 1.30 [1.00, 1.70] to 0.40 [0.12, 1.10] (P \u0026lt; 0.05), and BCVA improved from 0.82 [0.40, 1.30] to 0.70 [0.30, 1.30] (P = 0.035). The qualified success rate was 95.0% (19/20), and the complete success rate was 80.0% (16/20). The intraoperative complication rate was 25.0% (5/20), primarily shallow anterior chamber. The postoperative complication rate was 40.0% (8/20), primarily shallow anterior chamber with elevated IOP. Complications were concentrated in Groups A and B. Multivariate logistic regression analysis revealed that shorter AL was significantly associated with a higher risk of surgical complications (OR = 0.439, P \u0026lt; 0.05). A stepwise management strategy—initiating with medical/laser therapy, escalating to cyclophotocoagulation, and reserving pars plana vitrectomy for refractory cases—achieved successful complication management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhaco+IOL+GSL is a feasible and effective procedure for nanophthalmos with secondary angle-closure glaucoma, reducing IOP, medication dependence, and improving visual acuity. Compared with more complex combined procedures(e.g., with prophylactic vitrectomy or sclerectomy) , this technique is simpler and less invasive. A stepwise management strategy effectively addresses complications. Shorter AL, particularly \u0026lt;16 mm, is associated with higher surgical risk.\u003c/p\u003e","manuscriptTitle":"Phacoemulsification with Goniosynechialysis for Nanophthalmos with Secondary Angle-Closure or Secondary Angle-Closure Glaucoma: A 20-Case Series and Stepwise Management Strategy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 07:27:17","doi":"10.21203/rs.3.rs-9395122/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T06:49:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T11:11:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-26T16:30:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T04:48:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164794723439277295492794992883522397128","date":"2026-04-17T10:01:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197296232576820526149519672305439647325","date":"2026-04-16T18:58:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210615986620097153577389634242014592052","date":"2026-04-14T20:23:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299231576234112690278830143381763275899","date":"2026-04-14T15:58:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42875720066501143532181818327677981695","date":"2026-04-14T12:29:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173612397156512615774328630470610221309","date":"2026-04-14T12:16:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-14T11:24:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T12:32:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T12:32:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2026-04-12T14:47:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2681c4db-1b62-4657-9431-6304f9d9766d","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-29T06:49:24+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T06:55:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 07:27:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9395122","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9395122","identity":"rs-9395122","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}