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107 EW INTERNATIONAL October 2017 by Maxine Lipner EyeWorld Senior Contributing Writer a cataract that isn't bad, but they have glaucoma as well, there could be an argument for just taking out the cataract," he said. "They benefit from the better vision, and it brings their pressure down." Dr. Murdoch added that de- pending on patients' overall health, you may not want to subject them to an extra glaucoma surgery when phacoemulsification alone may be enough to keep them seeing for the remainder of their lives. Dr. Murdoch hopes that when people are thinking about manage- ment of glaucoma, they recognize the use of phacoemulsification as an appropriate option. "The pressure dropping this much surprised us all," he said. "But if it does, let's use it." Going forward, he hopes to see the work replicated by others and a discussion on this brought to the fore to find a rational approach to glaucoma in Africa and beyond. EW Reference 1. Dhalla K, et al. Phacoemulsification com- pared with phacotrabeculectomy surgery: a within-person observational cohort study. Br J Ophthalmol. 2017 Apr 17. Epub ahead of print. Editors' note: Dr. Murdoch has no financial interests related to his comments. Contact information Murdoch: i.murdoch@ucl.ac.uk Dr. Murdoch was encouraged by the results. "The phaco wasn't quite as good as the phacotrabeculecto- my, but it was very good," he said. "There was a hint of its effect wear- ing off after a few years, but it did seem to last for quite a long time." Real world implications From a clinical perspective, the effectiveness of phacoemulsifica- tion alone is important for many reasons, Dr. Murdoch said. Many patients are unaware that they even have glaucoma. "First, they're unaware of the disease at the time it should be discovered and treated," he said. "Second, the treatment is a preventative treatment." It doesn't make the patient's vision better, he explained. Cataract, on the other hand, is symptomatic. With glauco- ma, people don't necessarily know what it is and the treatment is a cost to them for no clear immediate benefit. This can make cataract removal all the more important. "If you have an elderly patient who has a com- bination of cataract and glaucoma, and you take out the cataract, that has a big sell value because it makes their vision better," Dr. Murdoch said. In Africa, generally only the worst cataracts tend to get treated. If the patient also has glaucoma, however, doing this sooner could be- come more important. "If they have eye per individual, which leaves the other eye in these glaucoma pa- tients that they were going to have to treat, Dr. Murdoch pointed out. "We came up with the idea of just doing phaco in the other eye," he said, adding this made for a stronger study because of the propensity for scarring and other individual aspects that were the same in both of the patients' eyes. Considering phaco alone While the larger study included 300 Tanzanian patients, this nest- ed study considered the effect of phacoemulsification and included 52 open angle glaucoma patients. In the study, one eye underwent phacotrabeculectomy and the other phacoemulsification alone, Dr. Murdoch explained. Investigators found both phacotrabeculectomy and phacoemulsification alone significantly improved visual acuity and lowered IOP. For those who underwent phacotrabeculectomy, with 250 days or more of follow-up, IOP dropped on average by 50%; for phacoemulsification alone, this went down by 41%, he reported. In nine patients who underwent extended follow-up at around 1,482 days, a mean rise in IOP of 1.8 mm Hg was seen in phacotrabeculectomy eyes, while in eyes that underwent phaco alone, this rose by an average of 4.2 mm Hg. Study conducted in Tanzania looks at how phacoemulsification stacks up to phacotrabeculectomy P hacoemulsification alone may offer a good pres- sure-lowering effect in primary open angle cases, results from a recent study conducted in Tanzania show. In the study, investigators found that the average pressure lowering was more than 40% for eyes undergoing phacoemulsification alone. 1 The study was spurred by the observation of Kazim Dhalla, MD, Kinondoni, Tanzania, that phacoemulsification seemed to have a profound effect on some glaucoma patients. "It was an observation by Dr. Dhalla that doing phaco alone seemed to produce a lowering of pressure in the eyes that he was working with," said Ian Murdoch, MD, senior lecturer, University College London. Dr. Murdoch saw the need to empower people locally in Africa, noting that if Dr. Dhal- la hadn't made the observation, the study would not have been launched. This was part of a larger ran- domized trial on glaucoma and cataract surgery involving two types of anti-scarring treatments. In such studies, investigators randomize one When the pressure is on Research highlight sutures to prevent the lens from dislocating. For this purpose, he will often use a 9-0 Prolene; how- ever, if he is suturing a one-piece PMMA IOL in the absence of capsule support, he, like Dr. Ouano, uses Go- re-Tex sutures. When using Prolene for suturing, Dr. Safran prefers to tie the suture directly to the eyelet in the haptic rather than pass the suture through the eyelet, which can lead to the material being abraded and cut over time. This is because the haptic eyelets on PMMA lenses are not polished as smoothly as the rest of the lens and may be abrasive to the suture. With Gore-Tex, this is not an issue as the suture is strong and can be passed through the eye- let without concern. To avoid external erosion when using Gore-Tex, Dr. Safran recom- mended making a scleral groove, situating the Gore-Tex at the base of the groove, and rotating the knot so it's inside the eye. Advantages of a sutured IOL ISHF technique, Dr. Ouano said, include its prevention of hypotony and wound leak, no exposure of in- traocular lens material, longevity of fixation, and stability in secondary surgeries like endothelial keratoplas- ty. While the glued IOL technique and the double-needle flanged tech- nique pioneered by Dr. Agarwal and Dr. Yamane, respectively, are "very much in vogue," Dr. Ouano said, he has concerns about the stability of such an intrascleral haptic-fixated lens during a DSEK case. What's more, he finds the externalized haptic concerning from a potential fistula standpoint and wonders if lens tilt and decentration could be an issue. "Maintain a healthy skepticism with new techniques and make sure that the technique adheres to basic ocular surgery concepts," he said. "Techniques will come and go. Sometimes [techniques] will disap- pear silently, and there's a reason for that because many of them fail." In the end, however, Dr. Ouano said he is "cautiously optimistic" about the glued and flanged intras- cleral haptic fixation techniques. EW Editors' note: Dr. Jacob has a patent pending for modified versions of the glued capsular hook. The physicians have no financial interests related to their comments. Contact information Agarwal: aehl19c@gmail.com Garg: gargs@uci.edu Jacob: dr_soosanj@hotmail.com Ouano: ouanod@suddenlink.net Safran: safran12@comcast.net Yamane: shinyama@yokohama-cu.ac.jp Intrascleral continued from page 106

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