Efficacy and safety evaluation of phacoemulsification with intraocular lens implantation combined with goniotomy versus combined with trabeculectomy in advanced pseudoexfoliative glaucoma with cataract

Abstract

Objective

To evaluate the efficacy and safety of phacoemulsification with intraocular lens implantation (PEI) combined with 120° goniotomy (GT) versus PEI combined with trabeculectomy (Trab) in advanced Pseudoexfoliative glaucoma (PXG) with cataracts.

Methods

A retrospective study included 68 advanced PXG with cataract patients (68 eyes): 32 underwent PEI + GT and 36 underwent PEI + Trab. The visual acuity, intraocular pressure(IOP), the number of glaucoma medications, surgical success rate, complications, postoperative interventions, surgery duration, and quality of life (EQ-5D-5L) were recorded preoperatively and at 1, 3, 6, and 12 months postoperatively.

Results

The PEI + GT group had a higher 1-month IOP than PEI + Trab (15.7 ± 1.7 vs. 13.9 ± 2.3 mmHg; P<0.05). Both groups experienced a significant reduction in the IOP and the number of medications used postoperatively (all P<0.05).The cumulative success rate and early complication incidence were comparable between the groups (P>0.05).PEI + GT demonstrated significantly lower rates of late complications and postoperative interventions, shorter operative time (16.8 ± 3.1 vs. 34.5 ± 5.5 min), and higher postoperative quality of life (EQ-5D-5L) compared to PEI + Trab (all P < 0.05).

Conclusion

Both PEI + GT and PEI + Trab effectively reduced IOP and glaucoma medication use in PXG patients with cataract. However, PEI + GT demonstrated shorter surgery duration, fewer late complications, reduced need for postoperative interventions, better surgery safety, and higher postoperative quality of life than PEI + Trab.

Introduction

Pseudoexfoliative glaucoma (PXG) is a secondary glaucoma caused by pseudoexfoliative syndrome(PEX), accounting for about 25% of all open-angle glaucoma.Compared with primary open angle glaucoma (POAG), PXG has higher average IOP(IOP), wider IOP fluctuation range and more severe visual field damage [1, 2]. PXG has poor response to anti-glaucoma medication [3], and anti-glaucoma surgery is often needed. Trabeculectomy combined with phacoemulsification and intraocular lens implantation (PEI + Trab) is still the most popular and effective method to reduce IOP [4, 5]. Trab is limited in application due to risks such as malignant glaucoma, shallow anterior chamber, persistent low strabismus and blister-related complications [6–9].

Goniotomy (GT) is an important type of MIGS surgery, which can perform incisions of different ranges (120°, 180°, 240° and 360°), and can also be combined with cataract surgery through the same corneal incision without damaging the conjunctiva [10]. Previous studies [11, 12] have shown that GT surgery can effectively lowers IOP and medication use in open-angle glaucoma (PXG and POAG). The 360° incision shows a significantly higher rate of anterior chamber hemorrhage than the 180° incision, while the 120° and 180° incisions have considerable safety.

Here, the investigator reported the 1-year outcome of PEI + GT and PEI + Trab in patients with advanced PXG with cataract.

Materials and methods

Study design and participants

In this study, 68 cases (68 eyes) with advanced PXG diagnosed in Shijiazhuang People’s Hospital from July 2021 to December 2023 were selected by retrospective cohort study. This study follows the Helsinki Declaration, and the research plan was approved by the Ethics Committee of Shijiazhuang People’s Hospital (No.2024KYPJ167). All patients understand the purpose and method of this study and voluntarily sign the informed consent form of the subjects.

Diagnostic criteria for advanced PXG: [13] Under slit lamp microscope, the characteristic manifestations of PEX in the eye can be seen: for example, there are gray-white exfoliating materials on the pupil margin, iris surface and anterior lens capsule; IOP >21 mmHg (1 mmHg = 0.133 kPa) whether or not medication are used; Glaucomatous optic nerve damage and visual field defect (cup-disk ratio >0.8); Glaucomatous visual field defects diagnosed by Humphrey perimetry (SITA-standard 24 − 2 or 30 − 2 mode), such as nasal step, arcuate scotoma, paracentral scotoma, MD value ≤ -6dB.

Inclusion criteria: (1) Age > 50 years old; (2) It meets the diagnosis criteria of PXG in the advanced; (3) There are obvious cataracts, and the uncorrected visual acuity is less than 0.4 (logarithmic visual acuity chart) and 0.63 (ETDRS visual acuity chart) or the lens needs to be removed after evaluation by doctors; (4) The patient’s compliance was good, and he agreed to follow up according to the research plan, and the follow-up time was ≥ 1 year.

Exclusion criteria: (1) Suffering from ophthalmic diseases and having a history of internal surgery or ocular trauma (except for selective laser trabeculoplasty); (2) Other types of glaucoma; (3) Patients receiving warfarin or anticoagulants should have routine preoperative examination with an International Normalized Ratio (INR) of > 3.0, for patients on anticoagulant therapy, medication should be discontinued 2 weeks prior to surgery; (4) There are various types of fundus diseases that affect the collection of eye parameters or interfere with visual field examination; (5) Long-term local or systemic use of glucocorticoid; (6) One eye (corrected visual acuity of non-research eye is less than 0.05); (7) Complicated with serious systemic diseases; (8) Pregnant or lactating women; (9) Have a history of intraocular surgery.

Methods

Preoperative examination data

Before the patients entered the group, we collected the general situation, medical history and medication in detail. All patients underwent systematic ophthalmological examination, including Sine Correctionb (SC), best corrected vision (BCVA), intraocular pressure (IOP), slit lamp, gonioscope, axial length (AL), OCT and visual field. Patient demographics and baseline characteristics are shown in (Table 1).

Table 1.

Baseline demographics and baseline characteristics

Groups	PEI + GT	PEI + Trab	χ2/F	P value
Eyes(n)	32	36
Gender(n) M/F	15/17	17/19	0.001	0.977*
Age(years), mean (SD)	73.5 ± 6.4	74.8 ± 7.2	0.731	0.396†
AL, mean (SD)	24.8 ± 1.7	24.5 ± 1.6	0.933	0.354*
MD(dB), mean (SD)	-23.1 ± 5.9	-23.5 ± 5.7	0.235	0.797*
logMAR SC	1.4 ± 0.5	1.3 ± 0.5	0.461	0.646
BCVA, logMAR, mean (SD)	1.1 ± 0.5	1.2 ± 0.5	-0.218	0.828*
IOP(mmHg), mean (SD)	28.6 ± 4.1	27.6 ± 4.1	1.003	0.320*
Glaucoma medications, median (IQR)	2.2(2.0,3.0)	2.2(2.0,3.0)	-0.229	0.819*
Scores on the EQ-5D-5L questionnaire, mean (SD)	80.0(71.3,85.0)	81.0(75.0,88.8)	-0.656	0.512*

Abbreviations: GT = goniotomy; PEI = phacoemulsification with intraocular lens implantation; Trab = trabeculectomy

AL = Axial Length; MD = mean deviation; SC = Sine Correction; BCVA = best-corrected visual acuity; IOP = intraocular pressure; SD = standard deviation;

IQR = interquartile range; EQ-5D-5L = five-level version of European quality of life-5 dimensions questionnaire;

*Two-sample t test

† Pearson chi-squared test

Surgical procedures

All surgeries were performed under topical anesthesia, by senior ophthalmic surgeons (GX Tang).

1. PEI + GT: Made a 3 mm tunnel incision at the upper or temporal transparent cornea, all surgical procedures employed standardized phacoemulsification techniques for lens nucleus removal. All intraocular lenses (IOLs) were implanted in the capsular bag [14]. The same IOL model (Qiangsheng ICB00) was used in all cases. GT procedure was subsequently performed.The patient´s head was rotated 35–40°away from the surgeon, and the surgical microscope was tilted 30–40° toward the surgeon. Coat viscoelastic agent on the corneal surface, so as to look directly at the angle structure under the gonioscope. GT were performed in the nasal or inferior quadrant from the temporal or superior clear corneal incision after the anterior segment was refilled with viscoelastic. GT was performed using the tip of a microhook inserted into Schlemm’s canal and moved to incise the inner wall of Schlemm’s canal and trabecular meshwork over 120°. After aspiration of the viscoelastic agent, the corneal incision was closed using corneal stromal hydration [15, 16].

2. PEI + Trab: 6 − 0 silk suture needle was used to fix the transparent cornea above, a fornix-based conjunctival flap was created from 11 o’clock to 1 o’clock, and the subconjunctival tissue was separated, and the blood vessels on the sclera surface were electrocoagulated to stop bleeding. At 12 o’clock, a rectangular scleral flap with the size of about 3 mm×4 mm was made based on the corneal limbus, and the thickness of the sclera was about 1/2 or 2/3. The 0.04%(0.4 mg/mL) mitomycin cotton piece was placed under the scleral flap for 4–5 min, balanced salt solution (60 ml) was used for flushing.After a temporal clear corneal incision was made, a viscoelastic agent was used to maintain the anterior chamber. PEI following the aforementioned method. The trabecular tissue of 1 mm×2 mm was removed under the scleral flap at 12 o’clock followed by peripheral iridectomy. The scleral flap and conjunctiva were tightly sutured using 10–0 nylon sutures (with or without adjustable sutures), and the upper bulbar conjunctiva tissue was sutured intermittently with 10 − 0 suture, A balanced salt solution was injected through a paracentesis track to deepen the anterior chamber and elevate the bleb. The wounds were examined to ensure no leakage was present.

Postoperative medication

Topical tobramycin dexamethasone eye drops and non - steroidal anti - inflammatory eye drops were applied after surgery, and tobramycin dexamethasone eye ointment was topically applied every night before going to bed. This treatment lasted for 4 weeks, and glucocorticoid medication were stopped if IOP increased briefly after surgery. PEI + GT group was treated with 1% pilocarpine eye drops for 8 weeks. If there was shallow anterior chamber during follow-up, stop using it.

Follow-up inspection data and evaluation indicators

After 1 month, 3 months, 6 months and 12 months, the visual acuity (1 month), IOP, the amount of medications used to reduce IOP, the success rate of surgery, surgical complications and postoperative intervention measures were examined. Other results included the surgery duration and postoperative quality of life (EQ-5D-5 L) [17]. Criteria for success of surgery: The complete success is defined as postoperative IOP control of 6-18mmHg, and a 20% reduction from baseline without antiglaucoma medications without the use of medications.The qualified success is defined as the IOP reaches the above standard with the use of medications (≤ 3 kinds).

Statistical analysis

Spss 27.0 was used for statistical analysis. Two-factor analysis of variance was used to compare the measurement data of normal distribution at different time points after surgery between the two groups, and Bonferroni test was used for multiple comparison. Wilcoxon signed rank sum test and chi-square test were used for counting data. Kaplan-Meier survival curve analysis was used to evaluate the success rate of surgery. P < 0.05 was statistically significant.

Result

Comparison of visual acuity and IOP at different time

In PEI + GT group, the logMAR BCVA was increased from (1.1 ± 0.5) at baseline to (0.8 ± 0.6) at 12 months postoperatively (t = 9.338 p < 0.01), the logMAR SC was increased from (1.4 ± 0.5) at baseline to (1.0 ± 0.4) at 12 months postoperatively (t = 6.872 p < 0.01). In PEI + Trab group, the logMAR BCVA was increased from (1.2 ± 0.5) at baseline to (0.7 ± 0.6) at 12 months postoperatively (t = 9.238 p < 0.01), the logMAR SC was increased from (1.3 ± 0.5) at baseline to (1.1 ± 0.5) at 12 months postoperatively (t = 5.265 p < 0.01).

The IOP in the PEI + GT Group was (15.7 ± 1.7) mmHg at 1 month postoperatively, which was higher than that in the PEI + Trab Group (13.9 ± 2.3) mmHg, the difference was statistically significant (P < 0.05), there was no significant difference at preoperative, 3,6 and 12 months (P > 0.05). The IOP at 1 month, 3 months, 6 months and 12 months was lower than preoperative values in two groups, which was statistically significant (P < 0.05) (Table 2).

Table 2.

Change of vision and intraocular pressure (IOP) at 12 months

		PEI + GT	PEI + Trab	F	P
Preoperative	IOP	28.6 ± 4.1bcde	27.6 ± 4.1bcde	1.003	0.320
	logMAR SC	1.4 ± 0.5	1.3 ± 0.5	0.461	0.646
	logMAR BCVA	1.1 ± 0.5a	1.2 ± 0.5b	−0.218	0.828
1mo	IOP	15.7 ± 1.7a	13.9 ± 2.3acde	12.932	0.001
3mo	IOP	15.6 ± 1.8ae	15.7 ± 1.5abe	0.097	0.756
6mo	IOP	15.4 ± 1.9be	16.1 ± 1.2abe	3.776	0.056
12mo	IOP	16.4 ± 2.4ad	17.0 ± 1.6abcd	1.605	0.203
	logMAR SC	1.0 ± 0.4a	1.1 ± 0.5a	−0.735	0.465
	logMAR BCVA	0.8 ± 0.6a	0.7 ± 0.6a	0.165	0.869
	Scores on the EQ−5D−5 L questionnaire	89.0(82.5,95.0)	85.0(78.0,92.0)	−1.046	0.296
	Changes in scores on the EQ−5D−5 L questionnaire form baseline	8.0(7.0,9.0)	4.0(3.0,4.0)	−6.660	<0.001
F		87.813	90.189
P		<0.001	<0.001

GT = goniotomy; PEI = phacoemulsification with intraocular lens implantation; Trab = trabeculectomy༛ IOP = intraocular pressure;

SC = Sine Correction; BCVA = best-corrected visual acuity༛ LogMAR = logarithm of minimum angle of resolution

A means compared with preoperative, P < 0.05; B means compared with 1 month after operation, P < 0.05; C indicates that compared with 3 months after operation, P < 0.05; D means that compared with 6 months after operation, P < 0.05; E means compared with 12mo months after operation, P < 0.05

Postoperative glaucoma medications

In PEI + GT group, the number of glaucoma medications at 1 month, 3 months, 6 months and 12 months lower than preoperative, and the differences were statistically significant (Z= -4.984, P < 0.001; Z= -4.765, P<0.001; Z= -4.607, P<0.001; Z= -4.253, P<0.001), the number of glaucoma medications increased significantly at 12 months compared with 6 months (Z= -2.530, P = 0.011). There was no significant difference between 3 months and 1 month, 6 months and 3 months (Z= -1.633, P = 0.102; Z= -1.890, P = 0.059). In PEI + Trab group, the number of glaucoma medications decreased at 1 month, 3 months, 6 months and 12 months compared with preoperative, and the differences were statistically significant (Z= -5.348, P < 0.001; Z= -5.185, P<0.001; Z= -5.012, P<0.001; Z= -4.649, P<0.001). At 6 months after surgery, the number of glaucoma medications increased significantly compared with 3 months. And at 12 months after surgery, the number of glaucoma medications increased significantly compared with 6 months (Z= -2.271, P = 0.023;Z= -2.126, P = 0.033).(Table 3).

Table 3.

Changes in the quantity of glaucoma medications at 12 months M(Q1,Q3)

	PEI + GT	PEI + Trab	Z	P
Preoperative	2.2(2.0,3.0)	2.2(2.0,3.0)	-0.229	0.819
1mo	0.0(0.0,0.0)	0.0(0.0,0.0)	-0.598	0.550
3mo	0.0(0.0,0.0)	0.0(0.0,0.0)	-0.459	0.646
6mo	0.0(0.0,0.75)	0.0(0.0,0.0)	-0.116	0.908
12mo	0.0(0.0,1.0)	0.0(0.0,1.0)	-0.163	0.870

GT = goniotomy; PEI = phacoemulsification with intraocular lens implantation; Trab = trabeculectomy

Comparison of surgical success rate

The complete success rates at 12 months postoperatively in PEI + GT group and PEI + Trab group were 62.5% and 63.9% respectively. The qualified success rates of PEI + GT group and PEI + Trab group were 81.3% and 83.3% respectively. There was no significant difference between the two groups at 1, 3, 6 and 12 months postoperatively (χ² = 0.154 P>0.05;χ² = 0.068 P>0.05)(Fig. 1).

Fig. 1.

Kaplan–Meier survival analysis of complete (A) and qualified (B) success of PEI + GT group and PEI + Trab group. Complete and qualified success rates were no significantly different in the PEI+GT group and PEI+Trab group (P ＝ 0.98, P ＝ 0.68, Mantel–Cox log-rank test)

Surgical complications

Early complication rates showed no significant difference between PEI + GT (n = 8, 25.0%) and PEI + Trab groups (n = 10, 27.8%) (χ²=0.067, P = 0.796). However, PEI + GT demonstrated significantly fewer late complications (χ²=4.346, P = 0.037).In PEI + GT group, there were 2 cases of hyphema, 5 cases of IOP spike and 1 case of Descemet’s layer detachment, and most of them recovered within 2 weeks after surgery, In PEI + Trab group, there were 2 cases of choroidal detachment, 3 cases of shallow anterior chamber, 4 cases of wound leakage and 1 case of hypotony. Late complications in PEI + GT group and PEI + Trab group were 1 case (3.1%) and 7 cases (19.4%) respectively. Only 1 case of cyclodialysis cleft occurred in PEI + GT group. A total of 5 cases of filtering bleb-related complications (including 2 cases of filtering bleb leakage, 1 case of thin-walled filtering bleb scar, 2 cases of bleb fibrosis), 1 case of choroidal detachment and 1 case of hypotony maculopathy occurred in PEI + Trab group.(Table 4).

Table 4.

Postoperative complications and interventions of patients over 12 months of follow-up

Postoperative Complications	PEI + GT (32eyes)	PEI + Trab (36eyes)
Early complications(≤3mo)	8(25.0)	10 (27.8)
Hyphema(≥2weeks)	2 (6.3)	0 (0)
IOP spike(≥30mmHg)	5 (15.6)	0 (0)
Choroidal detachment	0 (0)	2 (5.6)
Wound leaks	0 (0)	4 (11.1)
Shallow anterior chamber	0 (0)	3 (8.3)
Descemet’s layer detachment	1(3.1)	0 (0)
Hypotony(≤6mmHg)	0 (0)	1 (2.8)
Long-term complications(>mo)	1 (3.1)	7 (19.4)
Filtering bleb leaking	0 (0)	2 (5.5)
Thin-walled filtration bubble	0 (0)	1 (2.8)
Bleb fibrosis/Filter bubble failure	0 (0)	2 (5.5)
Choroidal detachment	0 (0)	1 (2.8)
Hypotony maculopathy	0 (0)	1 (2.8)
cyclodialysis cleft	1 (3.1)	0 (0)
Total number of postoperative complications	9 (28.1)	17 (47.2)
Total number of patients with postoperative complication	7 (21.9)	12 (33.3)
Interventions
Paracentesis of anterior chamber	1 (3.1)	0 (0)
Laser suture lysis	0 (0)	2 (5.5)
Bleb massage	0 (0)	4 (11.1)
Bleb needling	0 (0)	3 (8.3)
Reoperation	1 (3.1)	2 (5.5)
Total number of postoperative interventions	2 (6.3)	11(30.6)
Total number of patients with postoperative interventionsed	2 (6.3)	10(27.8)

The data is expressed as the number of patients (percentage)

Some patients received more than one intervention

chi-square test

Postoperative intervention measures

During the follow-up period, the demand for postoperative interventions in PEI + GT group was lower than that in PEI + Trab group (χ² = 6.472, P = 0.011). There were 9 surgical complications in the PEI + GT group, and 2 patients (6.3%) underwent a total of 2 interventions, 1 was paracentesis of anterior chamber, and the other underwent a second surgery(tube shunt)due to uncontrolled IOP. In the PEI + Trab group,17 surgical complications occurred, and 10 patients (27.8%) received 11 interventions, including 2 laser suture - cutting procedures, 4 filtering bubble massages, 3 filtering bubble needle dissections and 2 reoperations (all underwent ube shunt).

Additional safety and effectiveness analyses

The average surgery duration for PEI + GT group (16.8 ± 3.1 min) was significantly shorter than that for PEI + Trab group (34.5 ± 5.5 min) (P = 0.012). The score of the EQ-5D-5L questionnaire in the PEI + GT group increased by 8.0(7.0,9.0) after surgery compared with baseline, which was higher than that in the PEI + Trab group 4.0(3.0,4.0) (P<0.001).

Discussion

At present, the research results confirm that the main resistance sites of aqueous humor outflow are trabecular meshwork and adjacent tubular tissue, and cutting or removing trabecular meshwork tissue is the main surgical target to increase aqueous humor outflow and reduce IOP [18, 19]. GT and Trab are both indications of PXG, but the surgical principles are different. GT enhances aqueous outflow by incising the trabecular meshwork, allowing direct access to Schlemm’s canal and collector channels [20–22]. In contrast, trabeculectomy (Trab) bypasses the trabecular outflow path, diverting aqueous humor subconjunctivally to form filtering blebs for IOP reduction [23, 24]. One of the advantages of MIGS surgery is that it can be combined with PEI enabling the treatment of glaucoma patients with concurrent cataracts, and PEI can reduce IOP by approximately 2 mmHg [10, 25]. Xiulan Zhang et al. [26] found that 120°, 240°or 360°GT with or without phacoemulsification can effectively reduce the IOP of POAG patients, but compared with 120°GT or 240°GT, the incidence of hyphema in 360°GT is higher, which proves that 120°GT with or without phacoemulsification is an effective treatment for patients with open angle glaucoma. Therefore, it is necessary to compare the efficacy and safety of two surgical methods combined with PEI in PXG patients, so as to further guide the effective selection of surgical methods in clinic.

At the 12-month follow-up of this study, it was confirmed that PEI + GT was non-inferior to PEI + Trab. Both groups showed similar complete and qualified success rates, though surgical success rates gradually decreased. The complete success rates at 12 months was 62.5% in PEI + GT group and 63.9% in PEI + Trab group, and qualified success rates were 81.3% and 83.3% respectively, which showed that both surgical methods had good treatment efficacy on PXG. Aktas et al. [27] showed that gonioscopy-assisted transluminal trabeculotomy (GATT) effectively lowers IOP and reduces glaucoma medications in PXG patients, with a 97.6% 12-month surgical success rate, which is higher than the qualified success rate of 81.3% in PEI + GT of this study. It is speculated that the difference of research results may be related to the setting standard of surgery success rate, the range of angle incision, the degree of diseases included in the operation eyes, the preoperative IOP and the different measuring instruments of follow-up indicators. The results of this study showed that the IOP of PEI + GT group and PEI + Trab group was lower than that before surgery at 12 months, IOP lowering was better in the PEI + Trab group at 1 month after surgery, but IOP gradually increased due to bleb fibrosis, and the effect was equivalent to that of PEI + GT group at 12 months after surgery. The number of glaucoma medications used within 12 months after surgery was significantly reduced compared with that before surgery, suggesting that both PEI + GT and PEI + Trab can effectively reduce IOP, and an ideal IOP control effect can be achieved with the postoperative application of a small number of glaucoma medication used after surgery. The number of glaucoma medication used to reduce IOP in PEI + GT group began to increase from 6 months after surgery, while that in PEI + Trab group began to increase from 3 months and continued until 12 months after surgery.

The incidence of early complications of 25% in the PEI + GT group was not statistically different from that of 27.8% in the PEI + Trab group. IOP spike was the most common complication in PEI + GT group, the incidence rate was 15.6%. The incidence of hyphema was 6.3%, which was self-limiting, required no additional medication therapy or intervention, and can be absorbed in a short period of time without any sequelae. IOP spike may be related to hyphema, transient inflammatory reaction and shallow detachment of ciliary body [27, 28]. In PEI + Trab group, the highest incidence rate was wound leakage in 4 eyes (11.1%), followed by shallow anterior chamber in 3 eyes (8.3%), choroidal detachment in 2 eyes (5.6%), and hypotony in 1 eye (2.8%), all of which were early complications of filtering surgery and did not occur in PEI + GT group. The incidence of late complications in PEI + GT group (3.1%) was significantly lower than that in PEI + Trab group (19.4%). 7 eyes had late complications in the PEI + Trab group, 5 of which were related to filtering blebs. Although trabeculectomy can reduce IOP well, trabeculectomy requires strict postoperative care to avoid late complications related to filtering blebs. The advantage of PEI + GT is to restore the natural outflow of aqueous humor without destroying the conjunctiva, which can overcome the shortcomings of related complications caused by filtering blebs. Only 1 patient in the PEI + GT group had effective IOP control after glaucoma drainage valve implantation due to uncontrolled IOP. In addition, PEI + GT surgery, which retains the physiological anatomy of the conjunctiva, sclera and most of the trabecular meshwork also provides more opportunities for the subsequent selection of filtration anti-glaucoma surgery. In terms of postoperative interventions, the most common interventions in PEI + Trab group were bleb massage, laser suture lysis and bleb needling, which can adjust the outflow of aqueous humor and reduce IOP, while PEI + GT surgery does not require the above interventions.

In addition, the EQ-5D-5L questionnaire score in PEI + GT group was significantly higher than that before surgery, indicating that the surgery had little negative impact on the quality of life of patients. The surgery duration of PEI + GT group was significantly shorter than that of PEI + Trab group, and the same incision of PEI can be used for goniotomy, which reduces the damage to the eyes.

There are some limitations in this study, such as relatively short follow-up time, relatively small sample size, and no grouping of the disease degree of the included patients. Therefore, further multicenter clinical randomized controlled trials are needed to provide higher-level evidence validation of the results of this study.

To sum up, the results of this study confirmed that PEI + GT and PEI + Trab can effectively reduce the IOP of advanced PXG patients with cataract, and reduce glaucoma medications. The early success rate of two groups was similar, and the PEI + GT group had a lower rate of late complications, a shorter surgery duration, a better surgical safety, fewer postoperative intervention measures, and had a better postoperative quality of life.

Author contributions

FL: manuscript drafting and result - interpretation; GXT: the search - conducting; TW: statistic analysis; XC: patient collection; LHM, WWT: data analysis; QLS: revision of the manuscript; studydesign, manuscript revising.

Funding

No funding was received.

Data availability

The data that support the findings of this study are available from the corresponding author, [QLS], upon reasonable request.

Declarations

Ethics approval and consent to participate

Approved by the Ethics Committee of Shijiazhuang People’s Hospital (No.2024KYPJ167). All patients understand the purpose and method of this study and voluntarily sign the informed consent form of the subjects.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.