¡¡¡¡Table 2Adverse events between oneª²site and twoª²site phacotrabeculectomy

¡¡¡¡Adverse eventsStudies

¡¡¡¡(n)Crude event rate,n/nOneª²siteTwoª²site

¡¡¡¡RR (95%CI)HeterogeneityQPI2significant differences comparing between oneª²site and twoª²site 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

¡¡¡¡Twoª²site 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 oneª²site phacotrabeculectomy in the treatment of coexisting cataract and glaucoma[6ª²16]. Previous studies have prospectively evaluated the efficacy and tolerability of oneª²site phacotrabeculectomy compared with twoª²site procedure[6ª²9,14,15]. The overwhelming majority of studies presented that twoª²site procedure was associated with a numerically lower but nonsignificant reduction in IOP efficaciously compared with oneª²site approach[6ª²8,14]. Variations of sample sizes and followª²up 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 oneª²site and twoª²site 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 metaª²analysis imply that, with available evidence from controlled clinical trials, the efficacy of twoª²site phacotrabeculectomy appears to be superior to oneª²site for the management of coexisting cataract and glaucoma, and there is nonsignificant difference in tolerability between two surgical procedures. Twoª²site phacotrabeculectomy was associated with numerically greater, and significant, efficacy than oneª²site in lowering IOP, numerically greater, but nonsignificant, proportions of twoª²site patients than oneª²site patients had a BCVA of 0.5 or better,and numerically greater,but nonsignificant, proportions of twoª²site patients than oneª²site patients achieved the target end point IOP. Twoª²site procedure was comparable with oneª²site in lowering adverse events. However, the greater IOPR effect and slightly greater BCVA increase effect of twoª²site procedure over oneª²site that we have shown does not necessarily indicate a greater surgical effect with twoª²site 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 oneª²site procedure are faster surgical time, less corneal endothelial cell loss, and surgeon experience with a superior approach. Factors that may favor a twoª²site approach are surgeon familiarity with temporal phacoemulsification, orbital physiognomy, reduced the surgicallyª²induced 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 antiª²metabolite effect.

¡¡¡¡The results of our metaª²analysis should be interpreted with caution because there may be some limitations in this metaª²analysis. One limitation of our metaª²analysis is that the analysis of clinically relevant outcome measures that were based on data pooled from trials and followª²up 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 ¡Ü18, ¡Ü20, and ¡Ü21mmHg. 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 metaª²analysis 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 metaª²analysis, we conclude that the efficacy of twoª²site phacotrabeculectomy appears to be superior to oneª²site 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 twoª²site and oneª²site procedure were well tolerated. Pragmatic randomized controlled trials are needed to further evaluate the efficacy and tolerability of twoª²site phacotrabeculectomy in the treatment of patients with coexisting cataract and glaucoma. In particular, multicenter, longª²term, large sample size, randomized, controlled trials are warranted.

¡¡¡¡¡¾²Î¿¼ÎÄÏס¿

¡¡¡¡1 Shingleton BJ, Pasternack JJ, Hung JW, O¬ðDonoghue MW. Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients. J Glaucoma 2006;15(6):494ª²498

¡¡¡¡2 Tham CC, Li FC, Leung DY, Kwong YY, Yick DW, Lam DS. Microincision bimanual phacotrabeculectomy in eyes with coexisting glaucoma and cataract. J Cataract Refract Surg 2006;32(11):1917ª²1920

¡¡¡¡3 Bayer A, Erdem U, Mumcuoglu T, Akyol M. Twoª²site phacotrabeculectomy versus bimanual microincision cataract surgery combined with trabeculectomy. Eur J Ophthalmol 2009;19(1):46ª²54

¡¡¡¡4 Tham CC, Kwong YY, Leung DY, Lam SW, Li FC, Chiu TY, Chan JC, Lam DS, Lai JS. Phacoemulsification versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts. Ophthalmology 2009;116(4):725ª²731

¡¡¡¡5 Kobayashi H, Kobayashi K. Randomized comparison of the intraocular pressureª²lowering effect of phacoviscocanalostomy and phacotrabeculectomy. Ophthalmology 2007;114(5):909ª²914

¡¡¡¡6 Wyse T, Meyer M, Ruderman JM, Krupin T, Talluto D, Hernandez R, Rosenberg LF. Combined trabeculectomy and phacoemulsification: a oneª²site vs a twoª²site approach. Am J Ophthalmol 1998;125(3):334ª²339

¡¡¡¡7 el Sayyad F, Helal M, elª²Maghraby A, Khalil M, elª²Hamzawey H. Oneª²site vs 2ª²site phacotrabeculectomy: a randomized study. J Cataract

¡¡¡¡Refract Surg 1999;25(1):77ª²82

¡¡¡¡8 Borggrefe J, Lieb W, Grehn F. A prospective randomized comparison of two techniques of combined cataractª²glaucoma surgery. Graefes Arch

¡¡¡¡Clin Exp Ophthalmol 1999;237(11):887ª²892

¡¡¡¡9 Mandic Z, Ivekovic R, Petric I, Zoricª²Geber M. Glaucoma triple procedure: a oneª²site vs a twoª²site approach. Coll Antropol 2000;24(2):367ª²371

¡¡¡¡10 Zou Y, Lin Z, Zhou J. Comparison between oneª²site and twoª²site incision in phacotrabeculectomy. Chin J Ophthalmol 2001;37(5): 335ª²337

¡¡¡¡11 Isasiª²Saseta MB, Urcelayª²Segura JL, Zamoraª²Barrios J, Ortegaª²Usobiaga J, Moreno Garc¨ªaª²Rubio B, Cort¨¦sª²Vald¨¦s C. Trabeculectomy and phacoemulsification. One site vs two site approach. A comparative study. Arch Soc Esp Oftalmol 2002;77(12):677ª²680

¡¡¡¡12 Dong DQ, Chen G, Hou XW. Clinical observation of the combination of phacoemulsification and trabeculectomy. Chin J Ophthalmol 2004;40(5):295ª²298

¡¡¡¡13 Shingleton BJ, Price RS, O¬ðDonoghue MW, Goyal S. Comparison of 1ª²site vs 2ª²site phacotrabeculectomy. J Cataract Refract Surg 2006;32(5):799ª²802

¡¡¡¡14 Cotran PR, Roh S, McGwin G. Randomized comparison of 1ª²site and 2ª²site phacotrabeculectomy with 3ª²year followª²up. Ophthalmology 2008;115(3):447ª²454

¡¡¡¡15 Buys YM, Chipman ML, Zack B, Rootman DS, Slomovic AR, Trope GE. Prospective randomized comparison of oneª² vs twoª²site Phacotrabeculectomy twoª²year results. Ophthalmology 2008;115(7):1130ª²1133

¡¡¡¡16 Nassiri N, Nassiri N, Rahnavardi M, Rahmani L. A comparison of corneal endothelial cell changes after 1ª²site and 2ª²site phacotrabeculectomy. Cornea 2008;27(8):889ª²894

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