The authors of this study (including the reviewer of this article) describe a surgical technique for phacoemulsification in the presence of shallow choroidal detachment owing to hypotony following trabeculectomy. In their case series, four eyes of four patients with advanced primary open-angle glaucoma underwent trabeculectomy with intraoperative application of mitomycin-C. Ages of the patients ranged from 67 to 75 years. They all developed early postoperative hypotony with intraocular pressure between 3 and 5mmHg recorded with Goldmann applanation tonometry. The blebs in all cases were relatively avascular and diffuse, whereas details about bleb morphology for each patient was documented, using the Indiana Bleb Appearance Grading Scale. Within three months from initial surgery they developed a manifest cilio-choroidal detachment which was documented utilising b-scan ultrasonography (BUS) and ultrasound biomicroscopy (UBM). They were all managed with cycloplegia and tapering dose of corticosteroids. No other postoperative complications of trabeculectomy were evident, such as flat anterior chamber or bleb leakage. All patients were examined on a monthly basis. Twelve months later, all eyes had a corrected distance visual acuity of worse than 1.0 Log-MAR (ranging counting fingers to 1.3 LogMAR). None of the patients demonstrated clinical or spectral domain optical coherence tomography (Spectralis V.5.0, Heidelberg Engineering) findings indicating presence of hypotonous maculopathy. Poor VA in all cases was mainly attributed to cataract progression. At that point decision for cataract surgery was made, despite the presence of cilio-choroidal detachment. IOLMaster V.5.4 (Carl Zeiss Meditec) was used for preoperative biometry taking into account axial length adjustments. All patients underwent uncomplicated torsional phacoemulsification using a stop-and-chop technique.
The procedure was performed under topical anaesthesia through a 2.4mm incision with the aid of a dispersive ophthalmic viscosurgical device (OVD). The 2.4mm incision was on purpose made slightly longer in order to ensure it was watertight. During phacoemulsification and irrigation / aspiration, the bottle height was set at 105cm. Thorough care was taken to ensure no cortical remnants were left before intraocular lens insertion. At all times during the surgery, hypotony was avoided by adding either OVD or balanced salt solution through the paracentesis simultaneously with removal of instruments and / or handpieces from the eye. A three piece soft hydrophobic acrylic intraocular lens (PreciSAL, Millenium Biomedical Inc., Pomona, CA) was implanted in the capsular bag at the end of each case. Surgery was uncomplicated in all cases, despite the fact that it was performed with almost complete absence of red reflex and fundus visualisation because of choroidal detachments obstructing retro-illumination. Postoperatively, patients were given topical steroids with fast tapering regimen. All patients had improvement of corrected distance visual acuity (CDVA) which ranged from 0.1 to 0 LogMAR in the first postoperative month. Intraocular pressure in all patients demonstrated an increase of 6-8mmHg which was maintained up to one year postoperatively. Regarding the choroidal detachment, BUS and UBM were repeated in the first postoperative month of follow-up and revealed a complete resolution of choroidal detachment in all cases.
The authors conclude that phacoemulsification is a justifiable intervention for visual improvement in eyes with underlying chronic choroidal detachment. Taking into consideration that cataract development in patients after trabeculectomy is a common scenario, they suggest that proceeding to cataract extraction under precautions is safe and in some cases, should be considered as a possible intervention that could lead to both choroidal resolution and visual acuity restoration. Appropriate preoperative assessment, intraoperative precautions, and meticulous postoperative care are of paramount importance in delivering optimal results.