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Clinical Study A Comparison of Endothelial Cell Loss inCombined Cataract and MIGS (Hydrus) Procedure toPhacoemulsification Alone: 6-Month Results

Antonio M. Fea, Giulia Consolandi, Giulia Pignata, Paola Maria Loredana Cannizzo,

Carlo Lavia, Filippo Billia, Teresa Rolle, and Federico M. Grignolo

Department of Surgical Sciences, Eye Clinic, University of Turin, Turin, Italy

Correspondence should be addressed to Carlo Lavia; [email protected]

Received July ; Accepted October

Academic Editor: Suphi aneri

Copyright © Antonio M. Fea et al. Tis is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. o compare the corneal endothelial cell loss afer phacoemulsication, alone or combined with microinvasive glaucomasurgery (MIGS), in nonglaucomatous versus primary open angle glaucoma (POAG) eyes affected by age-related cataract. Methods.eyes o patientsweredividedinto group ( = 25, affected by age-relatedcataract) and group ( = 37, affected by age-relatedcataract and POAG). All patients underwent cataract surgery. Group was divided into subgroups A ( = 19, cataract surgery alone) and B ( = 18, cataract surgery and MIGS). Prior to and months afer surgery the patients’ endothelium was studied. Main

outcomes wereCD (celldensity),SD (standard deviation), CV (coefficient o variation), and A (hexagonality coefficient) variationsafer surgeries. Results. Tere were no signicant differences among the groups concerning preoperative endothelial parameters.Te differences in CD beore and afer surgery were signicant in all groups: .% in group , .% in group A, and .% ingroup B. All endothelial parameters did not signicantly change afer surgery. Conclusions. Phacoemulsication determined a losso endothelial cells in all groups. Afer surgery the change in endothelial parameters afer MIGS was comparable to the ones o patients who underwent cataract surgery alone.

1. Introduction

Te high rate o complications o traditional glaucomasurgery (trabeculectomy) has prompted the glaucoma com-munity to search or alternative surgeries to treat primary open angle glaucoma (POAG) []. Recently, the interest or

less invasive glaucoma surgeries has signicantly increased.Tese new techniques have been collectively dened asmicroinvasive glaucoma surgery (MIGS). While tube surgery is generally reserved to cases where trabeculectomy is con-sidered ineffective or has previously ailed [, ], MIGS isrecommended or initial to moderate glaucoma.

Most o the MIGS imply the insertion o a drainingstent in the anterior chamber angle. Te Hydrus microstent(Hydrus, Ivantis, Irvine, CA) is inserted into Schlemm’s canal,bypassing the trabecular meshwork and providing directaqueous access to Schlemm’s canal.

It is known that the corneal endothelial cell density (EDC) progressively decreases over time [, ] and that any

implant within the anterior chamber can result in progressiveendothelial cell loss [, –]. Anterior chamber IOLs [,] and tube surgery can determine endothelial damage:although the exact mechanism causing the damage afertube surgery is mostly unknown, the requency o corneal

complications afer Ahmed Glaucoma Valve (AGV) implantsurgery has been reported to be % afer long-term ollow-up [].

Due to the ofen coexisting age-related cataract and tothe easiness o a combined procedure, MIGS are best used inconjunction with cataract surgery, which can cause by itsel damage to the corneal endothelium [].

Te effect o cataract surgery and MIGS implant on thecorneal endothelium has not been previously investigated.

Tis prospective study compares the corneal endothelialcell loss afer phacoemulsication in nonglaucomatous eyesto phacoemulsication in POAG eyes with and withoutcombined MIGS implant over a six-month period.

Hindawi Publishing CorporationJournal of Ophthalmology Volume 2015, Article ID 769289, 5 pageshttp://dx.doi.org/10.1155/2015/769289

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Journal o Ophthalmology

: Preoperative demographic and operative data o the patients (mean ± standard deviation; LOCS: lens opacity classication system;CD: cell density; SD: standard deviation; CV: coefficient o variation; A: hexagonality coefficient; US: ultrasound; : value; N/A: notapplicable).

Group A B versus A versus B A versus B

Mean age (yrs) . ± . . ± . . ± . . . .

Gender m/ (%) ()/ () (.)/ (.) (.)/ (.) N/A N/A N/A

Cataract grade (LOCS III) . ± . . ± . . ± . . . .

CD (cell/mm2) . ± . . ± . . ± . . . .

SD (m2) . ± . . ± . . ± . . . .

CV . ± . . ± . . ± . . . .

A (%) . ± . . ± . . ± . . . .

otal surgical time (mins) . ± . ± . . ± . .

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: Difference and statistical analysis between preoperative and postoperative parameters (mean ± standard deviation; CD: cell density;SD: standard deviation; CV: coefficient o variation; A = hexagonality coefficient).

Group Parameters CD SD CV A

Preoperative . ± . . ± . . ± . . ± .

Postoperative . ± . . ± . . ± . . ± .

Difference −. ± . . ± . . ± . −. ± .-test . . . .

value . . . .

A

Preoperative . ± . . ± . . ± . . ± .

Postoperative . ± . . ± . . ± . . ± .

Difference −. ± . ± . . ± . . ± .

-test . . . .

value

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: Reported mean endothelial cell loss afer cataract surgery (SICS: small incision cataract surgery; ECD: endothelial cell density)[–].

Author Year echnique Mean ECD

loss (%)

Gogate et al. []

Phacoemulsication .

SICS .

Reuschel et al. [] Phacoemulsication .

Mathew et al. [] Phacoemulsication .

suneoka et al. [] Phacoemulsication .

Walkow et al. [] Phacoemulsication .

Ataş et al. [] Phacoemulsication .

Present study Phacoemulsication .

Phacoemulsication + stent .

4. Discussion

Te new ab interno glaucoma surgeries through a clearcorneal incision (MIGS) aim at reducing the potentialcomplications o traditional glaucoma surgery. Tey presentseveral other advantages: the sparing o the conjunctiva,allowing uture glaucoma surgery i needed, direct visualiza-tion o anatomic landmarks, and maintenance o the anteriorchamber with negligible disruption o normal anatomy andphysiology [].

Tese new less invasive surgical approaches can easily becombined with cataract surgery and several studies provedtheir efficacy in reducing the IOP [–]. Nevertheless, all thenew trabecular shunting devices need to be inserted passingthrough the anterior chamber and lie in the chamber angle

very close to the corneal endothelium. Although all theseprocedures avoid the common complications o trabecularsurgery, they might determine a progressive loss o endothe-lial cells.

We analyzed the effect o the placement o the Hydrusstent in patients undergoing combined surgery and wecompared our results with a group o patients with andwithout glaucoma afer uncomplicated cataract surgery, toavoid the conounding actor o the damage induced by thephacoemulsication itsel. o our knowledge, there is noprevious report which analyzes corneal endothelial cell lossafer combined surgery with MIGS implant compared tophacoemulsication alone.

Phacoemulsication determined a loss o endothelial cellsin allgroups. Our results are in line with what was reported by other authors (able ). Te phacoemulsication parametersbetween the three groups were similar as was the degree o cataract. Although the total surgical time was longer in thecombo group, we did not observe any urther damage in thisgroup o patients. At six months the change in the endothe-lial parameters afer implantation o the Hydrus stent wascomparable to the ones o patients who underwent cataractsurgery. Tis is extremely important because it is well knownthat any device in the anterior chamber can cause somedegree o damage [, –]. MIGS have been developed toaddress patients with mild to moderate glaucoma and any

damage to the corneal endothelium would be considered aserious adverse event.

Our study presents some limitations: the number o patients is relatively small (but we must consider that this isa relatively new procedure), the ollow-up is relatively short,and there is just one postoperative ollow-up. Further data

need to be gathered in the uture.

Conflict of Interests

Te authors declare that there is no conict o interestsregarding the publication o this paper.

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