Combined phacoemulsification, goniosynechialysis and ab interno trabeculectomy in primary angle-closure glaucoma: three-year results

Combined phacoemulsification, goniosynechialysis and ab interno trabeculectomy in primary angle-closure glaucoma: three-year results | 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 Article Combined phacoemulsification, goniosynechialysis and ab interno trabeculectomy in primary angle-closure glaucoma: three-year results Fengrui Yang, Yao Ma, Zhiqiao Liang, Kun Lv, Kangyi Yang, Huijuan Wu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4589914/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This research was designed to evaluate the efficacy and safety of ab-interno trabeculectomy (Trabectome and Kahook Dual Blade) combined with phacoemulsification, intraocular lens implantation, and goniosynechialysis in eyes with primary angle-closure glaucoma. A total of 51 patients were included in the study and all the patients received the combined surgery. Intraocular pressure, anti-glaucoma medications, best-corrected visual acuity, and the number of peripheral anterior synechiae quadrants were recorded at baseline and at various time points after surgery. Intraocular pressure decreased significantly from 21.19 ± 6.38 mmHg preoperatively to 16.00 ± 4.84 mmHg ( P = 0.01) at 36 months. The number of glaucoma medications was significantly reduced from 2.33 ± 1.29 preoperatively to 1.42 ± 1.78 ( P = 0.045) at 36 months. The success rate of the combined surgery was 87.5% at 36 months. The decrease of intraocular pressure exhibited a positive correlation with the baseline intraocular pressure ( P < 0.01), while the reduction in the number of glaucoma medications was positively correlated with the baseline number of glaucoma medications ( P < 0.001). Best-corrected visual acuity improved from 0.40 ± 0.29 to 0.50 ± 0.33 at 1 month ( P = 0.001). There were no vision‑threatening complications intraoperatively or postoperatively. The combined surgery has been proven to be effective and safe for patients with primary angle-closure glaucoma in the long term, suggesting that combined surgery may be beneficial for patients with primary angle-closure glaucoma, especially those with long-term and extensive peripheral anterior synechiae. Health sciences/Diseases/Eye diseases/Ocular hypertension Health sciences/Diseases/Eye diseases/Lens diseases primary angle-closure glaucoma ab-interno trabeculectomy Trabectome Kahook Dual Blade Figures Figure 1 Figure 2 Figure 3 Introduction Primary angle-closure glaucoma (PACG) is a condition characterized by elevated intraocular pressure (IOP) caused by angle closure, which can lead to irreversible damage to the optic nerve. The main risk factors for PACG include small cornea, shallow anterior chamber, thick lens, anterior lens position, and short axial length. 1 The global prevalence of PACG is 0.6%, 2 while the prevalence in China is 1.40–1.41%. 3 PACG has become an important cause of blindness in Asia and worldwide. 4 With the population rapidly aging, the glaucoma burden caused by PACG in China is expected to increase significantly. Minimally invasive or microinvasive glaucoma surgery (MIGS) is increasingly used for the treatment of PACG. 5 Ab-interno trabeculectomy (AIT) using Trabectome or Kahook Dual Blade (KDB) is an important surgical procedure that improves aqueous outflow through the Schlemm canal (SC). 6,7 However, potential complications such as shallow anterior chamber, choroidal detachment, hypotonous maculopathy, bleb leak, cataract development, and blebitis should not be overlooked. 8 Although cataract surgery alone can reduce IOP by deepening the crowded anterior chamber, its success rate is not satisfactory. 9–11 The combination of cataract surgery with goniosynechialysis (GSL) has been proven to effectively reduce IOP and the need for antiglaucoma medications. 12 AIT offers several advantages over traditional filtering procedures as it selectively removes the trabecular meshwork (TM) and SC without damaging the remaining components of the outflow system, thus avoiding the complications associated with filtering blebs. Trabectome is a specific type of AIT that effectively removes the TM and inner wall of the SC to reduce IOP, with a low risk of shallow anterior chamber, choroidal detachment, and hypotony maculopathy. 13 A previous study by Wang Y et al. demonstrated the efficacy and safety of phacoemulsification, intraocular lens (IOL) implantation, GSL and Trabectome in patients with PACG. 14 KDB is another specialized instrument used in AIT. AIT with KDB combined with phacoemulsification leads to statistically and clinically significant reductions in both IOP and the use of antiglaucoma medications in eyes with PACG, 15–18 while also enhancing best-corrected visual acuity (BCVA). 19 This report presents long-term follow-up data of patients with PACG who were treated with phacoemulsification, IOL implantation, GSL, and AIT (Trabectome or KDB). The aim of this study was to evaluate the efficacy and safety of AIT using KDB and Trabectome when combined with phacoemulsification, IOL implantation, and GSL in patients with PACG. The study also aimed to provide a more comprehensive and long-term assessment of the surgical outcomes while investigating the factors that may influence the success of these procedures. Results From September 2017 to July 2023, patients with PACG and visually significant cataracts were recruited from the ophthalmology department at a university-affiliated hospital. All patients required surgical intervention to control IOP. Baseline characteristics of all patients are presented in Table 1 . A total of 51 Chinese patients, with a mean age of 69.04 ± 9.75 years, were included in the study. The mean follow-up time for all the patients was 38.67 ± 22.88 months. Out of the 51 patients, 23 (45.1%) were male, and 28 (54.9%) were female. All patients underwent phacoemulsification, IOL implantation, GSL, and AIT. Forty-four patients underwent Trabectome surgery, while seven received trabeculectomy with KDB. Table 1 Demographic and Glaucoma Status Data at Baseline. Variables Results Gender, Male:Female 23:28 Age, mean years ± SD 69.04 ± 9.75 Follow-up time, mean months ± SD 38.67 ± 22.88 Preoperative BCVA, mean ± SD 0.44 ± 0.27 Preoperative IOP, mean mmHg ± SD 21.19 ± 6.38 Number of preoperative antiglaucoma drugs, mean ± SD 2.33 ± 1.29 Number of preoperative PAS quadrant, mean ± SD 3.14 ± 1.24 Combined surgery, Trabectome:trabeculectomy with KDB 44:7 Note: BCVA, best corrected visual acuity; IOP, intraocular pressure; PAS, peripheral anterior synechiae; KDB, Kahook dual blade; SD, standard deviation. The mean IOP at baseline and each follow-up visit is presented in Fig. 1 and Table 2 . The mean IOP decreased significantly from 21.19 ± 6.38 mmHg preoperatively to 15.57 ± 2.86 mmHg at 2 years ( P = 0.002) and 16.00 ± 4.84 mmHg at 3 years ( P = 0.01) postoperatively. Significant decreases in IOP were observed at 1, 3, 6, and 12 months ( P < 0.001). Table 2 IOP and number of antiglaucoma medications at baseline and at each follow up visit. Follow-up time point n IOP, mean mmHg ± SD P Number of medications, mean ± SD P Baseline 51 21.19 ± 6.38 2.33 ± 1.29 1 month 51 14.45 ± 3.87 < 0.001 1.06 ± 1.03 < 0.001 3 months 44 13.63 ± 3.13 < 0.001 0.95 ± 1.03 < 0.001 6 months 36 14.19 ± 3.04 < 0.001 0.97 ± 1.08 < 0.001 12 months 32 14.88 ± 3.32 < 0.001 1.25 ± 1.22 < 0.001 24 months 20 15.57 ± 2.86 0.002 1.10 ± 1.02 0.001 36 months 12 16.00 ± 4.84 0.010 1.42 ± 1.78 0.045 48 months 7 14.46 ± 3.35 0.097 1.29 ± 1.25 0.103 60 months 1 8.60 - 3.00 - Note: IOP, intraocular pressure; n, number; SD, standard deviation. The mean number of antiglaucoma medications significantly decreased from 2.33 ± 1.29 at baseline to 1.10 ± 1.02 at 2 years ( P = 0.001) and 1.42 ± 1.78 at 3 years ( P = 0.045) postoperatively (Fig. 2 and Table 2 ). BCVA of all patients before surgery and at 1 month postoperatively is presented in Table 3 . There was a significant improvement in the average BCVA at 1 month after surgery (from 0.40 ± 0.20 to 0.50 ± 0.33) ( P = 0.001). Table 3 Best corrected visual acuity before surgery and 1 month after surgery. Follow-up time point Number BCVA P -< 0.1 -< 0.3 -< 0.5 -< 1.0 ≥ 1.0 Baseline 10 9 7 23 2 0.40 ± 0.20 1 month 8 6 7 22 8 0.50 ± 0.33 0.001 Note: BCVA, best correct visual acuity. The number of PAS quadrants reported by gonioscopy and UBM before and after surgery is presented in Table 4 . A significant reduction in the number of PAS quadrants was observed through a paired t-test in patients who underwent both gonioscopy and UBM examinations. Table 4 Number of PAS quadrant in patients before and after surgery. Follow-up time point Number of PAS quadrant P 0 1 2 3 4 Baseline 2 6 4 8 29 1 month 3 7 7 5 3 < 0.001 3 months 4 7 4 3 1 < 0.001 6 months 3 8 3 0 1 < 0.001 12 months 4 8 1 1 0 < 0.001 24 months 2 2 1 0 1 0.007 36 months 1 1 0 0 0 0.090 Note: PAS, peripheral anterior synechiae. Besides, the variables associated with the decrease in IOP and the reduction of antiglaucoma medications were analyzed. As indicated in Table 5 , preoperative IOP was positively correlated with the reduction in IOP at 1, 3, 6, 12, 24, 36, and 48 months postoperatively. Moreover, the number of preoperative antiglaucoma medications used was positively correlated with the reduction in antiglaucoma medications required at 1, 3, 6, 12, and 24 months postoperatively. Table 5 Correlation between preoperative IOP and the decrease of IOP in each follow-up visit. Correlation between preoperative antiglaucoma medications used and antiglaucoma medications required in each follow-up visit. Follow-up time point n IOP Number of medications PCC P PCC P 1 month 51 0.826 < 0.001 0.745 < 0.001 3 months 44 0.889 < 0.001 0.737 < 0.001 6 months 36 0.898 < 0.001 0.697 < 0.001 12 months 32 0.893 < 0.001 0.689 < 0.001 24 months 20 0.928 < 0.001 0.741 < 0.001 36 months 12 0.770 0.003 0.412 0.184 48 months 7 0.944 0.001 0.650 0.114 Note: IOP, intraocular pressure; PCC, Pearson correlation coefficient. To evaluate the long-term success rate of AIT when combined with phacoemulsification, IOL implantation, and GSL in patients with PACG, we selected the patients who had completed 36 months of follow-up after surgery (n = 24). All these patients underwent GSL, Trabctome, phacoemulsification, and IOL implantation. The Kaplan-Meier curve is shown in Fig. 3 . The success rate of the surgery was 91.7% and 87.5% for patients with PACG at 2 years and 3 years postoperatively, respectively. One patient experienced surgical failure at 6 months postoperatively and subsequently underwent XEN45 Gel Stent® (Xen) implantation 2 years after the initial surgery. Preoperatively, the patient's IOP was 18.00 mmHg while using two antiglaucoma medications (Brinzolamide and Brimonidine), and 360° PAS were observed. No serious complications were reported, and the patient's IOP remained below 15 mmHg without the use of antiglaucoma medication after surgery. At the six-month follow-up, his IOP was 18 mmHg with three antiglaucoma medications and the IOP increased to 22.6 mmHg at the 1-year follow-up visit despite absence PAS, which lead to XEN45 Gel Stent® (Xen) implantation two years after the surgery. The other two patients experienced surgical failure at 18 months and 36 months postoperatively, respectively, and no secondary surgery was conducted. In all cases, anterior chamber blood reflux was observed from SC, which resolved without additional treatment. Discussion In this study, we demonstrated the long-term efficacy and safety of AIT combined with phacoemulsification, IOL implantation, and GSL in patients with PACG. Building upon our previous research, we believe this is the first study to investigate the 3-year outcomes of combined cataract surgery, GSL, and AIT procedures. Over the 3-year follow-up period, a consistent reduction in IOP and the number of required antiglaucoma medications was observed. BCVA improved significantly one month postoperatively compared to baseline. Additionally, PAS was effectively relieved over the long term after surgery. The central feature of PACG is the closure of anterior chamber angle, which can lead to increased IOP and irreversible damage to the optic nerve. To prevent optic nerve damage, various treatment strategies for PACG have been developed to reduce IOP. Antiglaucoma medications, such as pilocarpine and brimonidine, can lower IOP and reopen the drainage angle. 1 However, as the disease progresses, surgical intervention is often necessary. There is no single surgical approach that is universally accepted as the most effective. Cataract surgery, trabeculectomy, GSL, glaucoma implant, and cyclodestructive procedures have shown effectiveness in lowering IOP and preventing damage to the optic nerve. 20 Phacoemulsification combined with IOL implantation is the standard surgical procedure for cataract treatment. Previous studies have demonstrated that cataract surgery can reduce IOP and improve the visual field (VF) in patients with PACG. 21,22 However, it is more effective in the early stages of PACG. 23 The need for additional glaucoma treatment is also a concern. 24 Phaco-trabeculectomy, a combination of phacoemulsification with IOL implantation and trabeculectomy, has been evaluated as a treatment option for PACG. However, it is associated with more postoperative interventions, complications, and longer recovery times. 10,11,25,26 Phaco-GSL (phacoemulsification and IOL implantation combined with GSL) is another combined surgery that is increasingly used in PACG. It has the potential to reduce IOP and the number of required antiglaucoma medications. 27 However, some studies have reported that phaco-GSL does not significantly differ from cataract surgery in terms of IOP, requirements for antiglaucoma medication, or complication rates. 9,12,25 Furthermore, Tian et al. compared the outcomes of phaco-GSL in patients with acute or chronic primary angle closure (PAC) /PACG and found a higher success rate in acute patients (100% versus 64.3%). 28 White et al. reported similar results. 29 AIT aims to remove the TM and the inner wall of SC through a minimally invasive internal approach. In Trabectome surgery, a strip of TM and the connected inner wall of SC are vaporized using high-frequency electrocautery energy. The KDB is a disposable gonioscopic ophthalmic knife designed to create parallel incisions in the TM, producing a strip of free tissue that can be removed using a gonioscopic approach. 30 Both surgeries aim to enhance physiological outflow, thereby reducing IOP, and were initially used in primary open-angle glaucoma (POAG) and secondary glaucoma. A previous study reported one-year follow-up outcomes of Trabectome surgery. 14 Dorairaj et al. combined cataract surgery, GSL, and KDB-assisted trabeculectomy in patients with PACG and reported a reduction in IOP of 12.0 mmHg and a decrease in the number of medications by 1.7 per eye. 16–18 However, the effectiveness of this surgery in Chinese patients of PACG has not been studied. The microhook ab interno trabeculotomy (µLOT) is an emerging MIGS procedure that uses a small metal hook to incise TM, facilitating the outflow of aqueous humor. 31 Despite its small incisional cross‑sectional area, µLOT was reported to be as effective as KDB in controlling IOP and reducing medication usage. 32 A multicenter study in China reported one-year outcomes of combined cataract surgery, GSL, and µLOT in PACG patients, observing an IOP reduction of 13.2 mmHg and a medication reduction of 1.7 medications. 33 µLOT has the potential to offer a minimally invasive, effective alternative for reducing IOP and managing glaucoma in patients with PACG. Suture trabeculotomy (SLOT) ab interno is another potential MIGS technique, but it is currently primarily utilized in POAG and secondary glaucoma. 34,35 In a previous study, the effectiveness and safety of phacoemulsification and IOL implantation combined with GSL and AIT were demonstrated during a one-year follow-up. [ 14 ] In the current study, our results showed a sustained reduction in IOP and a decrease in the use of antiglaucoma medication for up to 48 months postoperatively. Among the 51 patients who completed the 3-year follow-up, the success rate was 87.5% (21/24), with only 1 (2.0%) patient requiring a second surgery. The reduction of IOP (5.19 mmHg versus 4.6 mmHg) and antiglaucoma medications (0.91 versus no significant reduction) was much greater than those reported for cataract surgery alone, 24 supporting the effectiveness of angle opening and TM manipulation in treating patients with PACG. However, the effectiveness of phaco-GSL was limited in chronic and advanced PACG cases, suggesting that the temporary re-opening of the angle achieved by GSL poses a risk of PAS recurrence in the long term. Moreover, significant changes in the architecture and arrangement of trabecular fibres, which are considered a basic pathological change in PACG, 36 indicate that phaco-GSL alone is insufficient for reconstructing aqueous humor drainage. To identify a combined surgery that can sustainably reduce IOP and PAS in patients with chronic PACG, both the anterior chamber angle and TM should be considered. Trabeculectomy can effectively address TM blockage but is associated with a high incidence of complications, including shallow anterior chamber, choroidal detachment, hypotony maculopathy and blebitis. 8 Our study found a lower reduction in IOP (5.19 mmHg) and a decrease in the number of antiglaucoma medications (0.91 medications) at 3 years compared to phaco-trabeculectomy at 5 years (5.69 mmHg and 1.9 medications), 26 but without any serious complications, unlike the 25 complications observed in 44 patients who underwent phaco-trabeculectomy. AIT removes a portion of the TM and SC via an internal approach, allowing aqueous humor to directly enter the SC, bypassing the blocked TM. GSL releases adhesions between the iris and the angle. The combination of AIT and GSL may effectively restore aqueous humor drainage in both the anterior chamber angle and the TM. Furthermore, the minimally invasive internal approach used in AIT causes less damage to the ocular structure than the external approach used in trabeculectomy, resulting in fewer complications. Univariate linear regression analysis was conducted to assess the association between various variables and the reductions in IOP and the use of antiglaucoma medication. Similar to the results of our previous study, patients with higher preoperative IOP experienced greater IOP reduction, and those using more antiglaucoma medications before surgery experienced greater medication reduction. A possible explanation for these results is that some patients with higher IOP and more antiglaucoma medications may typically have a shorter disease duration and a lower likelihood of developing acute, severe PAS. Conversely, patients with a longer disease course, end-stage PAS, and severe TM disease may still benefit from combined phacoemulsification, IOL implantation, GSL, and AIT. Several study limitations should be considered. First, all patients included in our study underwent phacoemulsification, IOL implantation, GSL, and AIT, and there was no control group. A randomized controlled trial comparing patients with PACG who underwent phacoemulsification, IOL implantation, and GSL with or without AIT would further demonstrate the efficacy of the procedure. Secondly, our center has only recently started using KDB surgery. As a result, there is no compelling comparison between KDB trabeculectomy and Trabectome. Additional data will be reported after a longer follow-up period. In conclusion, the combination of phacoemulsification, IOL implantation, GSL, and AIT is a highly effective and safe surgical approach for reducing IOP and the number of required anti-glaucoma medications in patients with PACG during long-term follow-up. This approach may offer a less invasive option for patients with chronic and severe PAS. Methods This prospective study was approved by the ethics committee of Peking University People’s Hospital and adhered to the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants. Patients were enrolled in the study if they met the following baseline criteria: 1) Synechial angle closure greater than 2 quadrants, as demonstrated on gonioscopy and ultrasound biomicroscopy (UBM); 2) IOP greater than 21 mmHg or normal IOP with the use of at least one anti-glaucoma medication; 3) The presence of visually significant cataract. Patients were excluded from the study based on the following criteria: 1) A history of prior intraocular surgery, except for laser peripheral iridotomy, laser iridoplasty, and anterior chamber paracentesis; 2) Presence of ocular diseases that could potentially affect the anatomy or function of the TM, such as a history of ocular trauma, uveitis, and proliferative diabetic retinopathy. All patients underwent a comprehensive ophthalmologic examination before surgery, which included the following assessments: BCVA (Snellen visual chart), IOP (Goldmann applanation tonometry), slit-lamp examination, and visual field perimetry (Swedish Interactive Threshold Algorithm [SITA] 24 − 2 test of the Humphrey visual field analyzer 750i, Carl Zeiss Meditec, Dublin, CA). Gonioscopy and UBM (Aviso, Quantel Medical, Inc., Bozeman, MT, USA) were performed to determine the extent of peripheral anterior synechiae (PAS). PAS was defined as a region of irido-trabecular contact that could not be opened by indentation gonioscopy. The UBM examination divided the peripheral iris into four 90-degree quadrants and reported the condition of the anterior chamber angle in each quadrant. The type of surgery and any intraoperative complications were documented. The following data were collected at 1 day, 1 week, and 1, 3, 6, 12, 24, and 36 months postoperatively: BCVA, IOP, postoperative complications, and the number of IOP-lowering medications used by each patient. In this study, a successful surgery was defined as a reduction in IOP by more than 20% or maintenance of IOP under 21 mmHg, along with a decrease in the number of antiglaucoma medications required. Patients with unsuccessful results in two or more consecutive follow-up visits were considered to have had a failed surgery, while an isolated unsuccessful visit was regarded as a normal fluctuation in IOP. Patients who underwent a second anti-glaucoma operation (excluding laser peripheral iridotomy and laser iridoplasty) were immediately classified as unsuccessful. All surgeries were performed by the same skilled surgeon under topical anesthesia. Standard phacoemulsification and IOL implantation were performed through clear corneal incisions. GSL was performed with a circumferential application of viscoelastic (1ml, Bausch & Lomb, Shandong, CN). With the assistance of an intraoperative surgical gonioscope (Ocular Instrument, Inc., US), a blunt cyclodialysis spatula was gently pressed against the peripheral iris to apply retrograde pressure on the iris and visualize the TM as clearly as possible, facilitating the AIT portion of the procedure. For Trabectome surgery, the temporal clear corneal incision was enlarged to 1.7 mm, and the Trabectome single-use handpiece with the irrigation-aspiration (I/A) system (Neomedix Inc., Tustin, USA) was inserted into the nasal anterior chamber. The TM and inner wall of the SC were removed over a 90°–120° range using a power of 0.8 W. In trabeculectomy with KDB, the KDB instrument was introduced through the temporal incision. For the right eye, a new temporal clear corneal incision was made in addition to the primary two, guiding the instrument to the nasal angle under direct gonioscopy. The tip of the instrument was inserted through the TM into the SC and advanced for several clock hours, excising a narrow strip of the TM. During a second pass in the opposite direction, more clock hours of TM were removed, leading to a total TM excision range of approximately 120 degrees per eye. Reflux hemorrhage from SC upon withdrawal of the handpiece served as a marker of success for both methods. The viscoelastic substance was then removed using the I/A system. Postoperative care included a standard course of antimicrobial prophylaxis for 1 week and anti-inflammatory therapy tapered over 4 weeks. Patients typically received Tobradex eye drops (5 ml, produced by ALCON-COUVREUR N.V., Rijksweg 14, B-2870 Puurs, Belgium) four times a day after surgery, gradually reducing the frequency over several weeks. The use of IOP-lowering medications was determined based on postoperative IOP levels, with postoperative inflammation and intraocular hemorrhage also considered in medication application. Data were analyzed using SPSS 26.0 software (Chicago, USA). Arithmetic means and changes from the baseline are presented as ± standard error (SE). The distribution of the data was validated using the Kolmogorov–Smirnov test. A Student’s t-test (parametric test) was conducted to compare pre- and post-surgical findings. The success of the procedure was analyzed using Kaplan-Meier analysis. Variables hypothesized to be associated with a reduction in IOP or a decrease in the number of glaucoma medications were analyzed through univariate linear regression. These variables included age, baseline IOP, the number of preoperative glaucoma medications, and the number of PAS quadrants. A P -value of less than 0.05 was deemed statistically significant. Declarations Competing Interests Statement The authors declare no competing interests. Author Contribution Y.M., F.R.Y and H.J.W designed the study. Y.M. and F.R.Y collected data and performed the statistical analysis. K.L., K.Y.Y, Z.Q.L and H.J.W interpreted the results. Y.M. and F.R.Y wrote the manuscript. All authors commented on and approved the manuscript. Y.M. and F.R.Y contributed equally to this study, and should be considered as co-first authors. Acknowledgement This work was supported by Capital's Funds for Health Improvement and Research (2024-2-4087) and Central guidance for local scientific and technological development funding projects (2022ZY0026). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Data Availability Datasets from the current study are not publicly available due to compliance with patient privacy. Summary statistics are available from the corresponding author on reasonable request. References Sun, X. et al. Primary angle closure glaucoma: What we know and what we don't know. Prog Retin Eye Res 57, 26–45, doi: 10.1016/j.preteyeres.2016.12.003 (2017). Zhang, N., Wang, J., Chen, B., Li, Y. & Jiang, B. Prevalence of Primary Angle Closure Glaucoma in the Last 20 Years: A Meta-Analysis and Systematic Review. Front Med (Lausanne) 7, 624179, doi: 10.3389/fmed.2020.624179 (2020). Song, P. et al. National and subnational prevalence and burden of glaucoma in China: A systematic analysis. 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Management of Primary Angle-Closure Glaucoma. Asia Pac J Ophthalmol (Phila) 5, 59–62, doi: 10.1097/apo.0000000000000180 (2016). Hu, T., Xu, L., Chen, X., Liu, B. & Zhang, H. Visual Acuity and Visual Field Changes in Patients with End-Stage PACG with Tubular Visual Field after Cataract Surgery. Ophthalmic Res 66, 620–626, doi: 10.1159/000529778 (2023). Tojo, N., Otsuka, M., Miyakoshi, A., Fujita, K. & Hayashi, A. Improvement of fluctuations of intraocular pressure after cataract surgery in primary angle closure glaucoma patients. Graefes Arch Clin Exp Ophthalmol 252, 1463–1468, doi: 10.1007/s00417-014-2666-7 (2014). He, Y. et al. Clinical outcome of phacoemulsification combined with intraocular lens implantation for primary angle closure/glaucoma (PAC/PACG) with cataract. Am J Transl Res 13, 13498–13507 (2021). Sakai, D. et al. Ten-year outcomes of cataract surgery for glaucoma management in patients with primary angle-closure disease. Jpn J Ophthalmol 67, 129–137, doi: 10.1007/s10384-022-00971-8 (2023). Ong, A. Y., Ng, S. M., Vedula, S. S. & Friedman, D. S. Lens extraction for chronic angle-closure glaucoma. Cochrane Database Syst Rev 3, Cd005555, doi: 10.1002/14651858.CD005555.pub3 (2021). Hansapinyo, L., Choy, B. N. K., Lai, J. S. M. & Tham, C. C. Phacoemulsification Versus Phacotrabeculectomy in Primary Angle-closure Glaucoma With Cataract: Long-Term Clinical Outcomes. J Glaucoma 29, 15–23, doi: 10.1097/ijg.0000000000001397 (2020). Qian, Z. et al. Cataract Surgery (Phacoemulsification with Intraocular Lens Implantation) Combined with Endoscopic Goniosynechialysis for Advanced Primary Angle-Closure Glaucoma. Ophthalmol Glaucoma 4, 365–372, doi: 10.1016/j.ogla.2020.11.003 (2021). Tian, T., Li, M., Pan, Y., Cai, Y. & Fang, Y. The effect of phacoemulsification plus goniosynechialysis in acute and chronic angle closure patients with extensive goniosynechiae. BMC Ophthalmology 19, 65, doi: 10.1186/s12886-019-1070-9 (2019). White, A. J. R., Orros, J. M. A. & Healey, P. R. Outcomes of combined lens extraction and goniosynechialysis in angle closure. Clinical & Experimental Ophthalmology 41, 746–752, doi: https://doi.org/10.1111/ceo.12121 (2013). Francis, B. A., Akil, H. & Bert, B. B. Ab interno Schlemm's Canal Surgery. Dev Ophthalmol 59, 127–146, doi: 10.1159/000458492 (2017). Tanito, M., Tsutsui, A., Manabe, K. & Mochiji, M. Comparison of outflow facility before and after the microhook ab interno trabeculotomy. Eye (Lond) 36, 760–765, doi: 10.1038/s41433-021-01524-y (2022). Arimura, S. et al. Randomised clinical trial for morphological changes of trabecular meshwork between Kahook dual-blade goniotomy and ab interno trabeculotomy with a microhook. Sci Rep 13, 20783, doi: 10.1038/s41598-023-48121-5 (2023). Song, Y. et al. One-Year Results of a Multicenter Study: Intraocular Pressure-Lowering Effect of Combined Phacoemulsification, Goniosynechialysis, and Goniotomy for Cases of Advanced Primary Angle-Closure Glaucoma With Cataract. Asia Pac J Ophthalmol (Phila) 11, 529–535, doi: 10.1097/apo.0000000000000579 (2022). Kawaji, T. & Sato, T. Suture trabeculotomy ab interno for secondary glaucoma in Japanese patients with Val30Met hereditary transthyretin amyloidosis. Sci Rep 12, 19330, doi: 10.1038/s41598-022-23150-8 (2022). Sato, T., Kawaji, T., Hirata, A. & Mizoguchi, T. 360-degree suture trabeculotomy ab interno to treat open-angle glaucoma: 2-year outcomes. Clin Ophthalmol 12, 915–923, doi: 10.2147/opth.S161238 (2018). Matos, A. G., Asrani, S. G. & Paula, J. S. Feasibility of laser trabeculoplasty in angle closure glaucoma: a review of favourable histopathological findings in narrow angles. Clin Exp Ophthalmol 45, 632–639, doi: 10.1111/ceo.12938 (2017). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4589914","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":325304500,"identity":"5121e490-eab0-48cf-97d2-f2879aac4bb7","order_by":0,"name":"Fengrui Yang","email":"","orcid":"","institution":"Peking University People’s Hospital, Peking University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Fengrui","middleName":"","lastName":"Yang","suffix":""},{"id":325304501,"identity":"2337c5e3-486b-4e96-aa76-d283c0ed1bab","order_by":1,"name":"Yao Ma","email":"","orcid":"","institution":"Peking University People’s Hospital, Peking University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Yao","middleName":"","lastName":"Ma","suffix":""},{"id":325304502,"identity":"6f659d0c-86ad-498f-b0b5-8e4ce608a63b","order_by":2,"name":"Zhiqiao Liang","email":"","orcid":"","institution":"Peking University People’s Hospital, Peking University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Zhiqiao","middleName":"","lastName":"Liang","suffix":""},{"id":325304506,"identity":"62a82139-51f8-47be-a34c-87d5a034188b","order_by":3,"name":"Kun Lv","email":"","orcid":"","institution":"Peking University People’s Hospital, Peking University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Kun","middleName":"","lastName":"Lv","suffix":""},{"id":325304508,"identity":"01c7c490-8e1e-4c6f-bddc-879a50d67a57","order_by":4,"name":"Kangyi Yang","email":"","orcid":"","institution":"Peking University People’s Hospital, Peking University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Kangyi","middleName":"","lastName":"Yang","suffix":""},{"id":325304511,"identity":"a088ee21-79a5-4f1a-8ee5-345f6fe77797","order_by":5,"name":"Huijuan Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYDCCA0DM2MDAA8QMDB8MbORI08I4oyDNmGgtYMDM8+FwIkEdfLcPsEnz7jgswzwj+dljGwPmBAb2w0c34NMieS4BqOXMYR7GGWnmxjkGbHkMPGlpN/BpMTjDwHabtw2kJcFMOseAp5hBgseMWC3p36QtDCQSG0jQkmMmzWBgQFiL5BkG9p9z29J5GHvelEn2GCQYsxHyC98ZBmaDt23W9obt6dskfvz5L8fPfvgYXi0MDPwfwJRhA5TPhl85EpAnWuUoGAWjYBSMOAAA+YFFJvkBKKkAAAAASUVORK5CYII=","orcid":"","institution":"Peking University People’s Hospital, Peking University Health Science Center","correspondingAuthor":true,"prefix":"","firstName":"Huijuan","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2024-06-16 13:40:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4589914/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4589914/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60615347,"identity":"6fc60af9-0576-48ed-bfc5-eacbc078add4","added_by":"auto","created_at":"2024-07-18 20:11:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19208,"visible":true,"origin":"","legend":"\u003cp\u003eIOP before surgery and at each follow up visit. The IOP significantly decreased at each follow-up visit before 36 months. IOP, intraocular pressure. *** P \u0026lt; 0.001, ** P \u0026lt; 0.01, * P \u0026lt; 0.05\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4589914/v1/1de12ae40aba9e6f294c88f6.png"},{"id":60615348,"identity":"9e53afd3-dc94-4909-ac26-71bb4fde4d7e","added_by":"auto","created_at":"2024-07-18 20:11:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24019,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of antiglaucoma medications before surgery and at each follow-up visit. The number significantly decreased at each follow-up visit before 36 months. *** P\u0026lt; 0.001, ** P \u0026lt; 0.01, * P\u0026lt; 0.05\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4589914/v1/9a175222403c7be8a501e30d.png"},{"id":60615346,"identity":"4893d344-e54f-482f-a8c1-a2c7132ff45c","added_by":"auto","created_at":"2024-07-18 20:11:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":10592,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curve of patients reached 3 years after surgery\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4589914/v1/934437a240ea2261bedb032f.png"},{"id":62009629,"identity":"7b92f4d0-8d0f-4b74-9454-75340eaf6181","added_by":"auto","created_at":"2024-08-08 07:26:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":578632,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4589914/v1/25e8f70c-b996-4e73-b7b8-8acff2653b5c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Combined phacoemulsification, goniosynechialysis and ab interno trabeculectomy in primary angle-closure glaucoma: three-year results","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary angle-closure glaucoma (PACG) is a condition characterized by elevated intraocular pressure (IOP) caused by angle closure, which can lead to irreversible damage to the optic nerve. The main risk factors for PACG include small cornea, shallow anterior chamber, thick lens, anterior lens position, and short axial length.\u003csup\u003e1\u003c/sup\u003e The global prevalence of PACG is 0.6%,\u003csup\u003e2\u003c/sup\u003e while the prevalence in China is 1.40\u0026ndash;1.41%.\u003csup\u003e3\u003c/sup\u003e PACG has become an important cause of blindness in Asia and worldwide.\u003csup\u003e4\u003c/sup\u003e With the population rapidly aging, the glaucoma burden caused by PACG in China is expected to increase significantly.\u003c/p\u003e \u003cp\u003eMinimally invasive or microinvasive glaucoma surgery (MIGS) is increasingly used for the treatment of PACG.\u003csup\u003e5\u003c/sup\u003e Ab-interno trabeculectomy (AIT) using Trabectome or Kahook Dual Blade (KDB) is an important surgical procedure that improves aqueous outflow through the Schlemm canal (SC).\u003csup\u003e6,7\u003c/sup\u003e However, potential complications such as shallow anterior chamber, choroidal detachment, hypotonous maculopathy, bleb leak, cataract development, and blebitis should not be overlooked.\u003csup\u003e8\u003c/sup\u003e Although cataract surgery alone can reduce IOP by deepening the crowded anterior chamber, its success rate is not satisfactory.\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e The combination of cataract surgery with goniosynechialysis (GSL) has been proven to effectively reduce IOP and the need for antiglaucoma medications.\u003csup\u003e12\u003c/sup\u003e AIT offers several advantages over traditional filtering procedures as it selectively removes the trabecular meshwork (TM) and SC without damaging the remaining components of the outflow system, thus avoiding the complications associated with filtering blebs. Trabectome is a specific type of AIT that effectively removes the TM and inner wall of the SC to reduce IOP, with a low risk of shallow anterior chamber, choroidal detachment, and hypotony maculopathy.\u003csup\u003e13\u003c/sup\u003e A previous study by Wang Y et al. demonstrated the efficacy and safety of phacoemulsification, intraocular lens (IOL) implantation, GSL and Trabectome in patients with PACG.\u003csup\u003e14\u003c/sup\u003e KDB is another specialized instrument used in AIT. AIT with KDB combined with phacoemulsification leads to statistically and clinically significant reductions in both IOP and the use of antiglaucoma medications in eyes with PACG,\u003csup\u003e15\u0026ndash;18\u003c/sup\u003e while also enhancing best-corrected visual acuity (BCVA).\u003csup\u003e19\u003c/sup\u003e This report presents long-term follow-up data of patients with PACG who were treated with phacoemulsification, IOL implantation, GSL, and AIT (Trabectome or KDB). The aim of this study was to evaluate the efficacy and safety of AIT using KDB and Trabectome when combined with phacoemulsification, IOL implantation, and GSL in patients with PACG. The study also aimed to provide a more comprehensive and long-term assessment of the surgical outcomes while investigating the factors that may influence the success of these procedures.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom September 2017 to July 2023, patients with PACG and visually significant cataracts were recruited from the ophthalmology department at a university-affiliated hospital. All patients required surgical intervention to control IOP. Baseline characteristics of all patients are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 51 Chinese patients, with a mean age of 69.04\u0026thinsp;\u0026plusmn;\u0026thinsp;9.75 years, were included in the study. The mean follow-up time for all the patients was 38.67\u0026thinsp;\u0026plusmn;\u0026thinsp;22.88 months. Out of the 51 patients, 23 (45.1%) were male, and 28 (54.9%) were female. All patients underwent phacoemulsification, IOL implantation, GSL, and AIT. Forty-four patients underwent Trabectome surgery, while seven received trabeculectomy with KDB.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Glaucoma Status Data at Baseline.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, Male:Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23:28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.04\u0026thinsp;\u0026plusmn;\u0026thinsp;9.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up time, mean months\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.67\u0026thinsp;\u0026plusmn;\u0026thinsp;22.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative BCVA, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative IOP, mean mmHg\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.19\u0026thinsp;\u0026plusmn;\u0026thinsp;6.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of preoperative antiglaucoma drugs, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of preoperative PAS quadrant, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined surgery, Trabectome:trabeculectomy with KDB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44:7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNote: BCVA, best corrected visual acuity; IOP, intraocular pressure; PAS, peripheral anterior synechiae; KDB, Kahook dual blade; SD, standard deviation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean IOP at baseline and each follow-up visit is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The mean IOP decreased significantly from 21.19\u0026thinsp;\u0026plusmn;\u0026thinsp;6.38 mmHg preoperatively to 15.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86 mmHg at 2 years (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) and 16.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.84 mmHg at 3 years (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) postoperatively. Significant decreases in IOP were observed at 1, 3, 6, and 12 months (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIOP and number of antiglaucoma medications at baseline and at each follow up visit.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up time point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIOP, mean mmHg\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber of medications, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.19\u0026thinsp;\u0026plusmn;\u0026thinsp;6.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.45\u0026thinsp;\u0026plusmn;\u0026thinsp;3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.045\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e48 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNote: IOP, intraocular pressure; n, number; SD, standard deviation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe mean number of antiglaucoma medications significantly decreased from 2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29 at baseline to 1.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02 at 2 years (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) and 1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78 at 3 years (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045) postoperatively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBCVA of all patients before surgery and at 1 month postoperatively is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There was a significant improvement in the average BCVA at 1 month after surgery (from 0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20 to 0.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBest corrected visual acuity before surgery and 1 month after surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFollow-up time point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBCVA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e-\u0026lt; 0.1\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-\u0026lt; 0.3\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e-\u0026lt; 0.5\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-\u0026lt; 1.0\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;1.0\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eNote: BCVA, best correct visual acuity.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe number of PAS quadrants reported by gonioscopy and UBM before and after surgery is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. A significant reduction in the number of PAS quadrants was observed through a paired t-test in patients who underwent both gonioscopy and UBM examinations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of PAS quadrant in patients before and after surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFollow-up time point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eNumber of PAS quadrant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eNote: PAS, peripheral anterior synechiae.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBesides, the variables associated with the decrease in IOP and the reduction of antiglaucoma medications were analyzed. As indicated in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, preoperative IOP was positively correlated with the reduction in IOP at 1, 3, 6, 12, 24, 36, and 48 months postoperatively. Moreover, the number of preoperative antiglaucoma medications used was positively correlated with the reduction in antiglaucoma medications required at 1, 3, 6, 12, and 24 months postoperatively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between preoperative IOP and the decrease of IOP in each follow-up visit. Correlation between preoperative antiglaucoma medications used and antiglaucoma medications required in each follow-up visit.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFollow-up time point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIOP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eNumber of medications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePCC\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ePCC\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.928\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.770\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e48 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.944\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.650\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNote: IOP, intraocular pressure; PCC, Pearson correlation coefficient.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo evaluate the long-term success rate of AIT when combined with phacoemulsification, IOL implantation, and GSL in patients with PACG, we selected the patients who had completed 36 months of follow-up after surgery (n\u0026thinsp;=\u0026thinsp;24). All these patients underwent GSL, Trabctome, phacoemulsification, and IOL implantation. The Kaplan-Meier curve is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The success rate of the surgery was 91.7% and 87.5% for patients with PACG at 2 years and 3 years postoperatively, respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOne patient experienced surgical failure at 6 months postoperatively and subsequently underwent XEN45 Gel Stent\u0026reg; (Xen) implantation 2 years after the initial surgery. Preoperatively, the patient's IOP was 18.00 mmHg while using two antiglaucoma medications (Brinzolamide and Brimonidine), and 360\u0026deg; PAS were observed. No serious complications were reported, and the patient's IOP remained below 15 mmHg without the use of antiglaucoma medication after surgery. At the six-month follow-up, his IOP was 18 mmHg with three antiglaucoma medications and the IOP increased to 22.6 mmHg at the 1-year follow-up visit despite absence PAS, which lead to XEN45 Gel Stent\u0026reg; (Xen) implantation two years after the surgery.\u003c/p\u003e \u003cp\u003eThe other two patients experienced surgical failure at 18 months and 36 months postoperatively, respectively, and no secondary surgery was conducted. In all cases, anterior chamber blood reflux was observed from SC, which resolved without additional treatment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we demonstrated the long-term efficacy and safety of AIT combined with phacoemulsification, IOL implantation, and GSL in patients with PACG. Building upon our previous research, we believe this is the first study to investigate the 3-year outcomes of combined cataract surgery, GSL, and AIT procedures. Over the 3-year follow-up period, a consistent reduction in IOP and the number of required antiglaucoma medications was observed. BCVA improved significantly one month postoperatively compared to baseline. Additionally, PAS was effectively relieved over the long term after surgery.\u003c/p\u003e \u003cp\u003eThe central feature of PACG is the closure of anterior chamber angle, which can lead to increased IOP and irreversible damage to the optic nerve. To prevent optic nerve damage, various treatment strategies for PACG have been developed to reduce IOP. Antiglaucoma medications, such as pilocarpine and brimonidine, can lower IOP and reopen the drainage angle.\u003csup\u003e1\u003c/sup\u003e However, as the disease progresses, surgical intervention is often necessary. There is no single surgical approach that is universally accepted as the most effective. Cataract surgery, trabeculectomy, GSL, glaucoma implant, and cyclodestructive procedures have shown effectiveness in lowering IOP and preventing damage to the optic nerve.\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePhacoemulsification combined with IOL implantation is the standard surgical procedure for cataract treatment. Previous studies have demonstrated that cataract surgery can reduce IOP and improve the visual field (VF) in patients with PACG.\u003csup\u003e21,22\u003c/sup\u003e However, it is more effective in the early stages of PACG.\u003csup\u003e23\u003c/sup\u003e The need for additional glaucoma treatment is also a concern.\u003csup\u003e24\u003c/sup\u003e Phaco-trabeculectomy, a combination of phacoemulsification with IOL implantation and trabeculectomy, has been evaluated as a treatment option for PACG. However, it is associated with more postoperative interventions, complications, and longer recovery times.\u003csup\u003e10,11,25,26\u003c/sup\u003e Phaco-GSL (phacoemulsification and IOL implantation combined with GSL) is another combined surgery that is increasingly used in PACG. It has the potential to reduce IOP and the number of required antiglaucoma medications.\u003csup\u003e27\u003c/sup\u003e However, some studies have reported that phaco-GSL does not significantly differ from cataract surgery in terms of IOP, requirements for antiglaucoma medication, or complication rates.\u003csup\u003e9,12,25\u003c/sup\u003e Furthermore, Tian et al. compared the outcomes of phaco-GSL in patients with acute or chronic primary angle closure (PAC) /PACG and found a higher success rate in acute patients (100% versus 64.3%).\u003csup\u003e28\u003c/sup\u003e White et al. reported similar results.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAIT aims to remove the TM and the inner wall of SC through a minimally invasive internal approach. In Trabectome surgery, a strip of TM and the connected inner wall of SC are vaporized using high-frequency electrocautery energy. The KDB is a disposable gonioscopic ophthalmic knife designed to create parallel incisions in the TM, producing a strip of free tissue that can be removed using a gonioscopic approach.\u003csup\u003e30\u003c/sup\u003e Both surgeries aim to enhance physiological outflow, thereby reducing IOP, and were initially used in primary open-angle glaucoma (POAG) and secondary glaucoma. A previous study reported one-year follow-up outcomes of Trabectome surgery.\u003csup\u003e14\u003c/sup\u003e Dorairaj et al. combined cataract surgery, GSL, and KDB-assisted trabeculectomy in patients with PACG and reported a reduction in IOP of 12.0 mmHg and a decrease in the number of medications by 1.7 per eye.\u003csup\u003e16\u0026ndash;18\u003c/sup\u003e However, the effectiveness of this surgery in Chinese patients of PACG has not been studied. The microhook ab interno trabeculotomy (\u0026micro;LOT) is an emerging MIGS procedure that uses a small metal hook to incise TM, facilitating the outflow of aqueous humor.\u003csup\u003e31\u003c/sup\u003e Despite its small incisional cross‑sectional area, \u0026micro;LOT was reported to be as effective as KDB in controlling IOP and reducing medication usage.\u003csup\u003e32\u003c/sup\u003e A multicenter study in China reported one-year outcomes of combined cataract surgery, GSL, and \u0026micro;LOT in PACG patients, observing an IOP reduction of 13.2 mmHg and a medication reduction of 1.7 medications.\u003csup\u003e33\u003c/sup\u003e \u0026micro;LOT has the potential to offer a minimally invasive, effective alternative for reducing IOP and managing glaucoma in patients with PACG. Suture trabeculotomy (SLOT) ab interno is another potential MIGS technique, but it is currently primarily utilized in POAG and secondary glaucoma.\u003csup\u003e34,35\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn a previous study, the effectiveness and safety of phacoemulsification and IOL implantation combined with GSL and AIT were demonstrated during a one-year follow-up.\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e In the current study, our results showed a sustained reduction in IOP and a decrease in the use of antiglaucoma medication for up to 48 months postoperatively. Among the 51 patients who completed the 3-year follow-up, the success rate was 87.5% (21/24), with only 1 (2.0%) patient requiring a second surgery. The reduction of IOP (5.19 mmHg versus 4.6 mmHg) and antiglaucoma medications (0.91 versus no significant reduction) was much greater than those reported for cataract surgery alone,\u003csup\u003e24\u003c/sup\u003e supporting the effectiveness of angle opening and TM manipulation in treating patients with PACG.\u003c/p\u003e \u003cp\u003eHowever, the effectiveness of phaco-GSL was limited in chronic and advanced PACG cases, suggesting that the temporary re-opening of the angle achieved by GSL poses a risk of PAS recurrence in the long term. Moreover, significant changes in the architecture and arrangement of trabecular fibres, which are considered a basic pathological change in PACG,\u003csup\u003e36\u003c/sup\u003e indicate that phaco-GSL alone is insufficient for reconstructing aqueous humor drainage. To identify a combined surgery that can sustainably reduce IOP and PAS in patients with chronic PACG, both the anterior chamber angle and TM should be considered.\u003c/p\u003e \u003cp\u003eTrabeculectomy can effectively address TM blockage but is associated with a high incidence of complications, including shallow anterior chamber, choroidal detachment, hypotony maculopathy and blebitis.\u003csup\u003e8\u003c/sup\u003e Our study found a lower reduction in IOP (5.19 mmHg) and a decrease in the number of antiglaucoma medications (0.91 medications) at 3 years compared to phaco-trabeculectomy at 5 years (5.69 mmHg and 1.9 medications),\u003csup\u003e26\u003c/sup\u003e but without any serious complications, unlike the 25 complications observed in 44 patients who underwent phaco-trabeculectomy. AIT removes a portion of the TM and SC via an internal approach, allowing aqueous humor to directly enter the SC, bypassing the blocked TM. GSL releases adhesions between the iris and the angle. The combination of AIT and GSL may effectively restore aqueous humor drainage in both the anterior chamber angle and the TM. Furthermore, the minimally invasive internal approach used in AIT causes less damage to the ocular structure than the external approach used in trabeculectomy, resulting in fewer complications.\u003c/p\u003e \u003cp\u003eUnivariate linear regression analysis was conducted to assess the association between various variables and the reductions in IOP and the use of antiglaucoma medication. Similar to the results of our previous study, patients with higher preoperative IOP experienced greater IOP reduction, and those using more antiglaucoma medications before surgery experienced greater medication reduction. A possible explanation for these results is that some patients with higher IOP and more antiglaucoma medications may typically have a shorter disease duration and a lower likelihood of developing acute, severe PAS. Conversely, patients with a longer disease course, end-stage PAS, and severe TM disease may still benefit from combined phacoemulsification, IOL implantation, GSL, and AIT.\u003c/p\u003e \u003cp\u003eSeveral study limitations should be considered. First, all patients included in our study underwent phacoemulsification, IOL implantation, GSL, and AIT, and there was no control group. A randomized controlled trial comparing patients with PACG who underwent phacoemulsification, IOL implantation, and GSL with or without AIT would further demonstrate the efficacy of the procedure. Secondly, our center has only recently started using KDB surgery. As a result, there is no compelling comparison between KDB trabeculectomy and Trabectome. Additional data will be reported after a longer follow-up period.\u003c/p\u003e \u003cp\u003eIn conclusion, the combination of phacoemulsification, IOL implantation, GSL, and AIT is a highly effective and safe surgical approach for reducing IOP and the number of required anti-glaucoma medications in patients with PACG during long-term follow-up. This approach may offer a less invasive option for patients with chronic and severe PAS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This prospective study was approved by the ethics committee of Peking University People\u0026rsquo;s Hospital and adhered to the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants. Patients were enrolled in the study if they met the following baseline criteria: 1) Synechial angle closure greater than 2 quadrants, as demonstrated on gonioscopy and ultrasound biomicroscopy (UBM); 2) IOP greater than 21 mmHg or normal IOP with the use of at least one anti-glaucoma medication; 3) The presence of visually significant cataract. Patients were excluded from the study based on the following criteria: 1) A history of prior intraocular surgery, except for laser peripheral iridotomy, laser iridoplasty, and anterior chamber paracentesis; 2) Presence of ocular diseases that could potentially affect the anatomy or function of the TM, such as a history of ocular trauma, uveitis, and proliferative diabetic retinopathy.\u003c/p\u003e \u003cp\u003eAll patients underwent a comprehensive ophthalmologic examination before surgery, which included the following assessments: BCVA (Snellen visual chart), IOP (Goldmann applanation tonometry), slit-lamp examination, and visual field perimetry (Swedish Interactive Threshold Algorithm [SITA] 24\u0026thinsp;\u0026minus;\u0026thinsp;2 test of the Humphrey visual field analyzer 750i, Carl Zeiss Meditec, Dublin, CA). Gonioscopy and UBM (Aviso, Quantel Medical, Inc., Bozeman, MT, USA) were performed to determine the extent of peripheral anterior synechiae (PAS). PAS was defined as a region of irido-trabecular contact that could not be opened by indentation gonioscopy. The UBM examination divided the peripheral iris into four 90-degree quadrants and reported the condition of the anterior chamber angle in each quadrant.\u003c/p\u003e \u003cp\u003eThe type of surgery and any intraoperative complications were documented. The following data were collected at 1 day, 1 week, and 1, 3, 6, 12, 24, and 36 months postoperatively: BCVA, IOP, postoperative complications, and the number of IOP-lowering medications used by each patient.\u003c/p\u003e \u003cp\u003eIn this study, a successful surgery was defined as a reduction in IOP by more than 20% or maintenance of IOP under 21 mmHg, along with a decrease in the number of antiglaucoma medications required. Patients with unsuccessful results in two or more consecutive follow-up visits were considered to have had a failed surgery, while an isolated unsuccessful visit was regarded as a normal fluctuation in IOP. Patients who underwent a second anti-glaucoma operation (excluding laser peripheral iridotomy and laser iridoplasty) were immediately classified as unsuccessful.\u003c/p\u003e \u003cp\u003eAll surgeries were performed by the same skilled surgeon under topical anesthesia. Standard phacoemulsification and IOL implantation were performed through clear corneal incisions. GSL was performed with a circumferential application of viscoelastic (1ml, Bausch \u0026amp; Lomb, Shandong, CN). With the assistance of an intraoperative surgical gonioscope (Ocular Instrument, Inc., US), a blunt cyclodialysis spatula was gently pressed against the peripheral iris to apply retrograde pressure on the iris and visualize the TM as clearly as possible, facilitating the AIT portion of the procedure.\u003c/p\u003e \u003cp\u003eFor Trabectome surgery, the temporal clear corneal incision was enlarged to 1.7 mm, and the Trabectome single-use handpiece with the irrigation-aspiration (I/A) system (Neomedix Inc., Tustin, USA) was inserted into the nasal anterior chamber. The TM and inner wall of the SC were removed over a 90\u0026deg;\u0026ndash;120\u0026deg; range using a power of 0.8 W.\u003c/p\u003e \u003cp\u003eIn trabeculectomy with KDB, the KDB instrument was introduced through the temporal incision. For the right eye, a new temporal clear corneal incision was made in addition to the primary two, guiding the instrument to the nasal angle under direct gonioscopy. The tip of the instrument was inserted through the TM into the SC and advanced for several clock hours, excising a narrow strip of the TM. During a second pass in the opposite direction, more clock hours of TM were removed, leading to a total TM excision range of approximately 120 degrees per eye.\u003c/p\u003e \u003cp\u003eReflux hemorrhage from SC upon withdrawal of the handpiece served as a marker of success for both methods. The viscoelastic substance was then removed using the I/A system. Postoperative care included a standard course of antimicrobial prophylaxis for 1 week and anti-inflammatory therapy tapered over 4 weeks. Patients typically received Tobradex eye drops (5 ml, produced by ALCON-COUVREUR N.V., Rijksweg 14, B-2870 Puurs, Belgium) four times a day after surgery, gradually reducing the frequency over several weeks. The use of IOP-lowering medications was determined based on postoperative IOP levels, with postoperative inflammation and intraocular hemorrhage also considered in medication application.\u003c/p\u003e \u003cp\u003eData were analyzed using SPSS 26.0 software (Chicago, USA). Arithmetic means and changes from the baseline are presented as \u0026plusmn;\u0026thinsp;standard error (SE). The distribution of the data was validated using the Kolmogorov\u0026ndash;Smirnov test. A Student\u0026rsquo;s t-test (parametric test) was conducted to compare pre- and post-surgical findings. The success of the procedure was analyzed using Kaplan-Meier analysis. Variables hypothesized to be associated with a reduction in IOP or a decrease in the number of glaucoma medications were analyzed through univariate linear regression. These variables included age, baseline IOP, the number of preoperative glaucoma medications, and the number of PAS quadrants. A \u003cem\u003eP\u003c/em\u003e-value of less than 0.05 was deemed statistically significant.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eCompeting Interests Statement\u003c/b\u003e \u003cp\u003eThe authors declare no competing interests. \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.M., F.R.Y and H.J.W designed the study. Y.M. and F.R.Y collected data and performed the statistical analysis. K.L., K.Y.Y, Z.Q.L and H.J.W interpreted the results. Y.M. and F.R.Y wrote the manuscript. All authors commented on and approved the manuscript. Y.M. and F.R.Y contributed equally to this study, and should be considered as co-first authors.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e This work was supported by Capital's Funds for Health Improvement and Research (2024-2-4087) and Central guidance for local scientific and technological development funding projects (2022ZY0026). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDatasets from the current study are not publicly available due to compliance with patient privacy. Summary statistics are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSun, X. \u003cem\u003eet al.\u003c/em\u003e Primary angle closure glaucoma: What we know and what we don't know. 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Feasibility of laser trabeculoplasty in angle closure glaucoma: a review of favourable histopathological findings in narrow angles. Clin Exp Ophthalmol 45, 632\u0026ndash;639, doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ceo.12938\u003c/span\u003e\u003cspan address=\"10.1111/ceo.12938\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"primary angle-closure glaucoma, ab-interno trabeculectomy, Trabectome, Kahook Dual Blade","lastPublishedDoi":"10.21203/rs.3.rs-4589914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4589914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis research was designed to evaluate the efficacy and safety of ab-interno trabeculectomy (Trabectome and Kahook Dual Blade) combined with phacoemulsification, intraocular lens implantation, and goniosynechialysis in eyes with primary angle-closure glaucoma. A total of 51 patients were included in the study and all the patients received the combined surgery. Intraocular pressure, anti-glaucoma medications, best-corrected visual acuity, and the number of peripheral anterior synechiae quadrants were recorded at baseline and at various time points after surgery. Intraocular pressure decreased significantly from 21.19\u0026thinsp;\u0026plusmn;\u0026thinsp;6.38 mmHg preoperatively to 16.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.84 mmHg (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) at 36 months. The number of glaucoma medications was significantly reduced from 2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29 preoperatively to 1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045) at 36 months. The success rate of the combined surgery was 87.5% at 36 months. The decrease of intraocular pressure exhibited a positive correlation with the baseline intraocular pressure (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), while the reduction in the number of glaucoma medications was positively correlated with the baseline number of glaucoma medications (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Best-corrected visual acuity improved from 0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29 to 0.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33 at 1 month (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). There were no vision‑threatening complications intraoperatively or postoperatively. The combined surgery has been proven to be effective and safe for patients with primary angle-closure glaucoma in the long term, suggesting that combined surgery may be beneficial for patients with primary angle-closure glaucoma, especially those with long-term and extensive peripheral anterior synechiae.\u003c/p\u003e","manuscriptTitle":"Combined phacoemulsification, goniosynechialysis and ab interno trabeculectomy in primary angle-closure glaucoma: three-year results","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:11:42","doi":"10.21203/rs.3.rs-4589914/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d612d8b4-632d-4b71-b794-38ab023b2cf2","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":34413571,"name":"Health sciences/Diseases/Eye diseases/Ocular hypertension"},{"id":34413572,"name":"Health sciences/Diseases/Eye diseases/Lens diseases"}],"tags":[],"updatedAt":"2024-08-08T07:18:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:11:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4589914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4589914","identity":"rs-4589914","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}