Table 2Adverse events between onesite and twosite phacotrabeculectomy
Adverse eventsStudies
(n)Crude event rate,n/nOnesiteTwosite
RR (95%CI)HeterogeneityQPI2significant differences comparing between onesite and twosite phacotrabeculectomy were found in the incidence of hyphema, choroidal detachment, hypotony, bleb leak, posterior capsule opacification and shallow anterior chamber, with the pooled RRs being 1.03 (95% CI 0.61 to 1.75), 0.80 (95% CI 0.36 to 1.80), 1.03 (95% CI 0.55 to 1.92), 1.74 (95% CI 0.87 to 3.48), 1.26 (95% CI 0.59 to 2.70) and 0.90 (95% CI 0.27 to 2.95), respectively.
DISCUSSION
Twosite phacotrabeculectomy now is used frequently as a primary intervention for the management of coexisting cataract and glaucoma[5]. However, it remains controversial as to whether it provides a better outcome than onesite phacotrabeculectomy in the treatment of coexisting cataract and glaucoma[616]. Previous studies have prospectively evaluated the efficacy and tolerability of onesite phacotrabeculectomy compared with twosite procedure[69,14,15]. The overwhelming majority of studies presented that twosite procedure was associated with a numerically lower but nonsignificant reduction in IOP efficaciously compared with onesite approach[68,14]. Variations of sample sizes and followup time within these studies prohibit attribution of treatment outcome to one type of intervention in these reports and make it difficult to draw a valid conclusion regarding the superiority of one procedure over another. We identified various studies that provided comparative treatment outcomes of onesite and twosite procedure and controlled for variations in study characteristics to identify a preferred intervention for the management of coexisting cataract and glaucoma.The results of this metaanalysis imply that, with available evidence from controlled clinical trials, the efficacy of twosite phacotrabeculectomy appears to be superior to onesite for the management of coexisting cataract and glaucoma, and there is nonsignificant difference in tolerability between two surgical procedures. Twosite phacotrabeculectomy was associated with numerically greater, and significant, efficacy than onesite in lowering IOP, numerically greater, but nonsignificant, proportions of twosite patients than onesite patients had a BCVA of 0.5 or better,and numerically greater,but nonsignificant, proportions of twosite patients than onesite patients achieved the target end point IOP. Twosite procedure was comparable with onesite in lowering adverse events. However, the greater IOPR effect and slightly greater BCVA increase effect of twosite procedure over onesite that we have shown does not necessarily indicate a greater surgical effect with twosite procedure. This is because IOP and BCVA merely are surrogate measures for phacotrabeculectomy, and the two surgical procedures may act through pathways independent of this mechanism. There are many preoperative and postoperative key factors to determine which surgical approach to carry out. Factors that may favor a onesite procedure are faster surgical time, less corneal endothelial cell loss, and surgeon experience with a superior approach. Factors that may favor a twosite approach are surgeon familiarity with temporal phacoemulsification, orbital physiognomy, reduced the surgicallyinduced astigmatism, conjunctival scar, limited superior access, ergonomic comfort for the surgeon, and absence of irrigation outflow underneath the conjunctival flap during phacoemulsification that might potentially affect intraoperative antimetabolite effect.
The results of our metaanalysis should be interpreted with caution because there may be some limitations in this metaanalysis. One limitation of our metaanalysis is that the analysis of clinically relevant outcome measures that were based on data pooled from trials and followup periods were not uniform. Another potential source of heterogeneity in the results is the assessment criteria of success. Success was defined as target end point IOP, and there were several different criteria of the normal IOP, such as IOP ≤18, ≤20, and ≤21mmHg. Although such assessments of success are widely used as outcome measures in clinical trials, further research is still needed to fully determine their validity, reliability, and sensitivity to choose the best one. A third limitation of this metaanalysis is that publication bias cannot be excluded fully, because with no sufficient studies, the Begg and Egger tests have a low power to detect publication bias. Finally, some of the controlled clinical trials included in the analysis are not prospective randomized controlled trials, but retrospective or prospective nonrandomized, which may fail to detect actual results. The likelihood of bias was minimized by developing a detailed protocol before initiating the study, by performing a meticulous search for published and unpublished studies, especially published in other languages, and by using explicit methods for study selection, data extraction, and statistical analysis.
In summary, based on the findings of this metaanalysis, we conclude that the efficacy of twosite phacotrabeculectomy appears to be superior to onesite in IOP control, and the proportions of patients in both surgical procedures achieving BCVA of 0.5 or better were comparable, as well as complete success rate. Both twosite and onesite procedure were well tolerated. Pragmatic randomized controlled trials are needed to further evaluate the efficacy and tolerability of twosite phacotrabeculectomy in the treatment of patients with coexisting cataract and glaucoma. In particular, multicenter, longterm, large sample size, randomized, controlled trials are warranted.
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