Introduction: To investigate the impact of cataract surgery on visual acuity and visual field (VF) in patients with end-stage glaucoma with tubular VF, and assess the risk of severe visual impairment. Methods: Retrospective analysis of the case data of patients with end-stage glaucoma with tubular VF who underwent cataract surgery in our hospital in the past 7 years. Results: A total of 59 patients with 63 eyes were enrolled, 62 eyes were primary angle-closure glaucoma (PACG) and 1 eye was primary open-angle glaucoma. The last follow-up time was an average of 9 months, and no cases of severe vision loss occurred. Best corrected visual acuity (BCVA) improved significantly after surgery (0.57 ± 0.46 vs. 0.45 ± 0.43 logarithm of the minimum angle of resolution, p < 0.01), and there was a significant drop in intraocular pressure (IOP; 22.85 ± 9.7 vs. 16.07 ± 3.38, p < 0.01), a reduced number of glaucoma medications (2 ± 1.32 vs. 0.5 ± 1, p < 0.01), statistical improvement in VF index (VFI) and mean defect (MD) (12.3% ± 7.65% vs. 16.1% ± 9.84%, p < 0.01; −29.09 ± 2.16 vs. −28.31 ± 3.01, p < 0.01) after surgery. The higher the preoperative VFI and MD were, the better the postoperative BCVA (r = −0.387, r = −0.347, respectively). The degree of postoperative VFI improvement was significantly correlated with preoperative MD (r = 0.372, p < 0.01). During the follow-up period, 5 eyes (8%) underwent anti-glaucoma surgery due to elevated IOP. Conclusion: Cataract surgery can significantly improve visual acuity and VF in patients with end-stage PACG with tubular VF, and no patients have severe visual impairment. The less preoperative VF damage there is, the greater the postoperative visual acuity and VF improvement. Poor IOP control is the main cause of further damage to postoperative visual acuity and VF.

Glaucoma and cataract are the two major causes of blindness and can seriously affect the vision and quality of life of patients. Age, antiglaucoma surgery, and drugs can all contribute to cataract formation [1‒3]. Therefore, glaucoma patients are more likely to develop cataracts.

For patients with early-stage glaucoma, visual acuity and visual field (VF) are significantly improved after cataract surgery [4]. However, for patients with end-stage glaucoma, there have been many reports of sudden loss of vision after surgery in the past, so many doctors are very hesitant to choose surgery when treating end-stage glaucoma. The optic nerve fibers in such patients are already severely damaged, the VF is lost in a large area, and any small increase in optic nerve damage may lead to loss of central vision. Many ophthalmologists have noted that an otherwise successful glaucoma surgery can immediately lead to permanent loss of central vision when the field of view is significantly narrow, so they believe that surgery is contraindicated in patients with chronic glaucoma with tubular fields [5‒8].

In 1949, Bloomfield’s research showed that the vision loss of end-stage glaucoma after surgery was as high as 58%. He believed that only drug treatment, even if the intraocular pressure (IOP) was not well controlled, could keep the patient’s central VF for a long time, while surgical treatment, although it can reduce IOP, greatly increases the risk of visual impairment [9]. In 1977, Kolker’s study found that the risk of sudden loss of vision after cataract surgery in end-stage glaucoma was as high as 8.7% [10]. Many researchers have expressed similar views [11, 12], suggesting that optic nerve or intraocular hemorrhage, intraoperative IOP fluctuations, toxicity to the optic nerve given retrobulbar anesthesia, or direct injury may all be the cause of vision loss [10, 13]. In recent years, many studies have also found that the probability of vision loss after surgery for end-stage glaucoma is small, and once the operation is successful, it can not only reduce IOP but also maintain the existing vision for a longer time, so they believe that patients with end-stage glaucoma should be treated with surgery [14‒17].

There are few reports on the observation of postoperative visual acuity and VF changes in end-stage glaucoma with a tubular VF. The purpose of this study was to evaluate the impact of cataract surgery on patients with end-stage glaucoma with tubular VF. Patients with a VF index (VFI) ≤22% [18] and a central VF diameter of less than 10° were defined as having end-stage glaucoma, and their visual acuity and VF changes before and after cataract surgery were compared.

Study Design

After screening patients who were diagnosed with end-stage glaucoma and tubular VF in our hospital in the past 7 years and who underwent cataract surgery or cataract combined with glaucoma surgery, relevant data were collected before and after surgery, including best corrected visual acuity (BCVA), IOP, VF(30-2), and the number of glaucoma medications. Postoperative data included in the analysis were selected from reliable values recorded at the first and last visits. For the convenience of statistics, BCVA was converted to logarithm of the minimum angle of resolution visual acuity during data analysis. Severe visual loss was defined as BCVA <0.1 in the affected eye, counting fingers or less when the preoperative BCVA was <0.1, or logarithmic visual acuity loss of more than 3 lines [10]. Our research was approved by the Medical Ethics Committee of Tongji Hospital, affiliated with Tongji Medical College of Huazhong University of Science and Technology and conforms to the purpose of the Declaration of Helsinki.

Object of Study

Inclusion criteria: (1) diagnosed with end-stage glaucoma with tubular VF due to meeting the following three conditions: (i) central VF less than 10° with or without residual island; (ii) VFI ≤22%; (iii) the optic disc and optic nerve fibers have obvious glaucoma damage; and (2) cataract or glaucoma-cataract combined surgery was performed. Exclusion criteria: (1) acute exacerbation of glaucoma; (2) combined with eye diseases such as corneal disease, uveitis, macular disease, and retinopathy; (3) incomplete case data.

Statistical Analysis

All data are expressed as the mean ± SD and were analyzed using SPSS (version 26.0; SPSS, Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test was used to determine whether the data conformed to a normal distribution. The changes in various parameters before and after surgery were compared using a paired sample t test or Wilcoxon paired signed-rank test. The relationship between postoperative visual acuity and related preoperative parameters was analyzed by Pearson correlation analysis or univariate linear regression analysis. p values <0.05 indicated statistically significant differences.

A total of 63 eyes of 59 people were eligible for inclusion, only one of the eyes was primary open-angle glaucoma (POAG), and cataract surgery was performed. The remaining 62 eyes were all primary angle-closure glaucoma (PACG), of which 24 eyes underwent cataract surgery alone, 31 eyes underwent cataract surgery and goniosynechialysis, 2 eyes underwent cataract surgery combined with trabeculectomy, and 5 eyes underwent cataract surgery combined with cyclophotocoagulation. During the phacoemulsification procedure, the maximum energy did not exceed 40% and the maximum vacuum was 380 mm Hg. No surgical complications were observed during the operation. Table 1 shows the basic parameters of the patients before surgery.

Table 1.

Basic parameters

Parametern or mean±SD
Total people 59 
Total eyes 63 
Gender, male/female 25/34 
Age, years 57.46±11.67 
Axial length, mm 22.51±1.06 
Corneal endothelial cell density, cell/mm2 2,509±404.31 
Central corneal thickness, μm 538.40±33.99 
ACD, mm 1.93±0.28 
Vertical cup disc ratio 0.96±0.06 
Peripapillary RNFL thickness, μm 
 Average thickness 41.70±8.38 
 Superior thickness 49.38±12.98 
 Nasal thickness 26.72±14.29 
 Inferior thickness 47.72±12.97 
 Temporal thickness 42.42±14.99 
Preoperative BCVA, logMAR 0.57±0.46 
Preoperative IOP, mm Hg 22.85±9.70 
 IOP >21 mm Hg (n, mean±SD) 28, 31.36±7.24 
 IOP ≤21 mm Hg (n, mean±SD) 35, 16.39±2.10 
Preoperative medication 2±1.32 
VFI, % 12.30±7.65 
MD, dB −29.09±2.16 
PSD, dB 6.60±2.54 
Parametern or mean±SD
Total people 59 
Total eyes 63 
Gender, male/female 25/34 
Age, years 57.46±11.67 
Axial length, mm 22.51±1.06 
Corneal endothelial cell density, cell/mm2 2,509±404.31 
Central corneal thickness, μm 538.40±33.99 
ACD, mm 1.93±0.28 
Vertical cup disc ratio 0.96±0.06 
Peripapillary RNFL thickness, μm 
 Average thickness 41.70±8.38 
 Superior thickness 49.38±12.98 
 Nasal thickness 26.72±14.29 
 Inferior thickness 47.72±12.97 
 Temporal thickness 42.42±14.99 
Preoperative BCVA, logMAR 0.57±0.46 
Preoperative IOP, mm Hg 22.85±9.70 
 IOP >21 mm Hg (n, mean±SD) 28, 31.36±7.24 
 IOP ≤21 mm Hg (n, mean±SD) 35, 16.39±2.10 
Preoperative medication 2±1.32 
VFI, % 12.30±7.65 
MD, dB −29.09±2.16 
PSD, dB 6.60±2.54 

SD, standard deviation; ACD, central anterior chamber depth; RNFL, retinal nerve fiber layer, logMAR, logarithm of the minimum angle of resolution; dB, decibel; PSD, pattern standard deviation.

The mean duration of the first follow-up was 2 months, and the mean duration of the last follow-up was 9 months. Compared with the preoperative BCVA, the postoperative BCVA was significantly improved, which was 0.57 ± 0.46 logarithm of the minimum angle of resolution before the operation, 0.39 ± 0.37 at 2 months after the operation (p < 0.001), and 0.45 ± 0.43 at 9 months after the operation (p < 0.01) (Fig. 1a). The IOP decreased significantly, the preoperative IOP was 22.85 ± 9.7 mm Hg, and 2 months and 9 months after the operation, the values were 16.71 ± 4.34 mm Hg (p < 0.001) and 16.07 ± 3.38 mm Hg (p < 0.001), respectively (Fig. 1b). The number of preoperative medications was 2 ± 1.32, and 2 months and 9 months after the operation was 0.5 ± 0.9 (p < 0.001) and 0.5 ± 1 (p < 0.001), respectively (Fig. 1c). The postoperative VF was significantly improved, and the preoperative VFI was 12.3% ± 7.65%; 2 months and 9 months after the operation was 16.2% ± 11% (p < 0.001) and 16.1% ± 9.84% (p < 0.001), respectively (Fig. 1d). The preoperative mean defect (MD) was −29.09 ± 2.16, and it was −28.5 ± 2.95 (p < 0.01) and −28.31 ± 3.01 (p < 0.001) at 2 and 9 months after operation, respectively (Fig. 1e). The pattern standard deviation was higher than that before the operation, which was 6.6 ± 2.54 before the operation and 7.2 ± 2.72 (p < 0.01) and 7.3 ± 2.92 (p < 0.01) after the operation, respectively (Fig. 1f). There were no statistically significant differences in the parameters at 2 and 9 months after surgery.

Fig. 1.

BCVA (a), IOP (b), number of glaucoma medications (c), VFI (d), MD (e), and PSD (f) before surgery, 2 months after surgery, and 9 months after surgery. PSD, pattern standard deviation.

Fig. 1.

BCVA (a), IOP (b), number of glaucoma medications (c), VFI (d), MD (e), and PSD (f) before surgery, 2 months after surgery, and 9 months after surgery. PSD, pattern standard deviation.

Close modal

The BCVA at 2 months after surgery was related to preoperative VFI and MD. The higher the preoperative VFI and MD, the better the postoperative visual acuity (Fig. 2a, b). The higher the preoperative MD was, the greater the difference between VFI at 2 months postoperatively and preoperative VFI (Fig. 2c).

Fig. 2.

Relationship between postoperative BCVA and preoperative VFI (a), preoperative MD (b); relationship between postoperative VFI improvement (ΔVFI = Postoperative VFI - Preoperative VFI) and preoperative MD (c).

Fig. 2.

Relationship between postoperative BCVA and preoperative VFI (a), preoperative MD (b); relationship between postoperative VFI improvement (ΔVFI = Postoperative VFI - Preoperative VFI) and preoperative MD (c).

Close modal

Before surgery, 19 eyes (30%) had a history of anti-glaucoma surgery. Eleven eyes had a history of trabeculectomy, 3 of which had high IOP that was controlled after cataract surgery. In addition, 1 of the 8 eyes with normal preoperative IOP control had elevated IOP 1 year after cataract surgery. There was no significant change in the morphology of the filtering bleb compared to pre-cataract surgery. Eight eyes had a history of peripheral iridotomy, 2 of which had normal IOP before and after cataract surgery. In addition, 1 of the 6 eyes with poorly controlled preoperative IOP still had high IOP after cataract surgery.

A total of 28 eyes (44%) had IOP above 21 mm Hg prior to cataract surgery, and 52 eyes (83%) were on antiglaucoma medications. At 2 months after surgery, 1 eye (2%) underwent anti-glaucoma surgery during follow-up, 7 eyes (11%) had high IOP, and 19 eyes (30%) were using anti-glaucoma drugs. As of the last follow-up, a total of 5 eyes (8%) had undergone anti-glaucoma surgery again, and all had postoperative IOP control. All 5 eyes were PACG, one of which had normal preoperative IOP control but developed uncontrolled IOP 1 year after cataract surgery. The remaining 4 eyes had poor IOP control before cataract surgery. At the last follow-up, 13 eyes (21%) required anti-glaucoma medication to control IOP, and 3 eyes (5%) with PACG had abnormal IOP, 2 of which had high prior IOP and still had poor IOP control after cataract surgery. The other eye had normal preoperative IOP and developed elevated IOP 1 year after cataract surgery. Ultimately, a total of 7 eyes (11%) had worse BCVA than before the operation, 12 eyes (19%) had lower VFI than before the operation, and no one had severe visual loss. One eye (2%) developed macular edema after surgery, 4 eyes (6%) developed posterior capsule opacification, and 2 eyes received YAG laser treatment (Table 2).

Table 2.

Postoperative follow-up

Preoperative, n (%)First follow-up (2 months), n (%)Last follow-up (9 months), n (%)
Number of eyes using glaucoma medications 52 (83) 19 (30) 13 (21) 
IOP >21 mm Hg 28 (44) 7 (11) 3 (5) 
Had anti-glaucoma surgery 19 (30) 19+1 (2) 19+5 (8) 
BCVA ≥ Preoperative BCVA 56 (89) 56 (89) 
BCVA < Preoperative BCVA 7 (11) 7 (11) 
VFI ≥ Preoperative VFI 54 (86) 51 (81) 
VFI < Preoperative VFI 9 (14) 12 (19) 
Severe visual loss 
PCO 4 (6) 
Macular edema 1 (2) 
Preoperative, n (%)First follow-up (2 months), n (%)Last follow-up (9 months), n (%)
Number of eyes using glaucoma medications 52 (83) 19 (30) 13 (21) 
IOP >21 mm Hg 28 (44) 7 (11) 3 (5) 
Had anti-glaucoma surgery 19 (30) 19+1 (2) 19+5 (8) 
BCVA ≥ Preoperative BCVA 56 (89) 56 (89) 
BCVA < Preoperative BCVA 7 (11) 7 (11) 
VFI ≥ Preoperative VFI 54 (86) 51 (81) 
VFI < Preoperative VFI 9 (14) 12 (19) 
Severe visual loss 
PCO 4 (6) 
Macular edema 1 (2) 

PCO, posterior capsule opacification.

There is no uniform definition of end-stage glaucoma. The Advanced Glaucoma Intervention Study (AGIS) classifies patients with a score of 18–20 as end-stage glaucoma based on 24-2 VFs [19], and scoring is complex. MD <−22 dB can be defined as end-stage glaucoma in the GSS2 chart [20], but MD is more susceptible to cataracts than VFI [21]. Therefore, in this study, a VFI ≤22% [18] and a central VF less than 10° were defined as end-stage glaucoma with a tubular VF.

In this study, changes in visual acuity and VF before and after surgery in 63 eyes with end-stage glaucoma with tubular VF were observed, and no one had severe visual impairment. Gradle reported that when the VF defect is within 10°, making a surgical incision will disrupt the balance of the intraocular environment, resulting in severe central vision impairment [22]. Lawrence and Langerhors each reported a case of advanced glaucoma with immediate visual loss after cataract surgery [23, 24]. Kolker reported two, one with intracapsular cataract extraction and the other with extracapsular extraction [10]. More reports about sudden loss of vision after surgery appeared before the 1990s. In the past, cataract surgery also included intracapsular or extracapsular cataract extraction, both of which had large surgical incisions, long postoperative recovery periods, and many complications. With the continuous improvement of phacoemulsification, cataract surgery can be performed under topical anesthesia, with a small limbal incision and a relatively closed and stable anterior chamber environment, which is safer and less complicated [25, 26].

Fu followed 19 patients with end-stage angle-closure glaucoma with normal IOP after cataract surgery. During the follow-up period of nearly 2 years, none of the patients had severe visual impairment, and final vision deterioration accounted for 15.8% [27]. To reflect the impact of surgery on patients more comprehensively, this study did not exclude patients with poor IOP control. At the last follow-up, 7 eyes (13%) had worse visual acuity than before surgery, 1 eye developed macular edema after surgery, 3 eyes had higher IOP after surgery, 2 of them underwent anti-glaucoma surgery again, and 2 eyes developed posterior capsule opacification without laser treatment.

During the process of phacoemulsification, the IOP increases sharply, and the retinal perfusion pressure decreases. Some researchers believe that this will cause further damage to the optic nerve fibers and VF [28‒30]. Kreutzer reported that in the phacoemulsification process, the maximum energy was set to 55–60%, the maximum vacuum was 450 mm Hg, the pressure in the vitreous cavity was greater than 80 mm Hg for approximately 1.8 s and greater than 60 mm Hg for approximately 1 min [31], and the time was very short. In this study, the maximum energy of phacoemulsification was 40%, the maximum vacuum was 380 mm Hg, and the time of intraoperative ultrahigh IOP may be shorter. At the last follow-up, 12 eyes (19%) had a decrease in VFI, of which 6 eyes decreased by 1–2%, which may have fluctuated because of the subjectivity of the measurement. Six eyes decreased by 3–7%, 1 eye developed macular edema after surgery, and 4 eyes had poor control of IOP during follow-up, which may be the reason for the decrease in VFI.

From the research results, we also found that postoperative visual acuity and VFI improvement were closely related to preoperative VF damage, which is consistent with the results of Fu’s and Koucheki’s study [4]. The greater the preoperative VFI and MD, the greater the postoperative visual acuity. In addition, the better the preoperative MD, the greater the improvement of postoperative VFI, which suggests that early surgery can bring greater benefits to patients.

In this study, there were 28 eyes with high preoperative IOP, with an average of 31.36 ± 7.24 mm Hg, and 16.29 ± 4.21 mm Hg 2 months after operation, a decrease of 48%. The preoperative IOP of 35 eyes was normal, and there was no significant difference between postoperative and preoperative IOP. Eighty-three percent of patients were using glaucoma medications before surgery, and only 21% were using it at the last visit. The thin intraocular lens replaces the thick native lens, and the anterior chamber angle is widened, which is the main mechanism of postoperative IOP reduction in angle-closure glaucoma. The angle of the chamber in open-angle glaucoma is not narrow, but many studies have shown that phacoemulsification can also significantly reduce the IOP of open-angle glaucoma and reduce the use of glaucoma medications [32, 33]. The exact mechanism is unclear, but the flushing of the outflow system and the stretching of the trabecular meshwork caused by fibrosis of the capsular bag may play a role in lowering IOP [33, 34]. One eye in our study had open-angle glaucoma, and the IOP did not decrease significantly after surgery, but the glaucoma drugs were significantly reduced. Although cataract surgery had a significant effect in lowering IOP, during the follow-up period, 5 eyes (8%) still underwent anti-glaucoma surgery due to poor IOP control. In 3 eyes (5%), the IOP was higher than 21 mm Hg at the last visits. Therefore, IOP may remain poorly controlled after cataract surgery or may rise again during follow-up, and it is very important to monitor the IOP regularly after surgery.

Although conservative treatment avoids the possible risks of surgery, it also ignores the visual quality of patients. Patients with end-stage glaucoma have severe peripheral VF impairment, which can be defined as blindness by visual impairment criteria, but these patients may retain good central vision. They can perform simple daily tasks relying on residual central vision. However, the remaining central vision is more susceptible to cataracts, so it is very important to protect the remaining central vision. In this study, visual acuity and VF improved in more than 80% of patients. Improvement of vision can enhance patients’ self-care ability and independence and reduce the disease burden on individuals and society [24, 35]. Seventy-nine percent of patients do not need glaucoma medications after surgery, thereby avoiding the side effects of drugs.

This retrospective study has some limitations. First, there was only one case of POAG in this study, so the effect of cataract surgery on POAG in the end stage needs to be evaluated by collecting more cases in the future. Further, those patients who underwent combined cataract and glaucoma surgery had postoperative eye conditions that were the result of a combination of both. In addition, many patients do not come to our hospital for regular review, so the follow-up time was not uniform. We have not strictly graded the severity of cataracts before surgery, so it is impossible to compare the relationship between the severity of cataracts and the recovery of vision after surgery.

In conclusion, cataract surgery did not result in severe visual acuity and VF impairment in patients with end-stage PACG with tubular VFs in this study. The surgery improves the patient’s vision and field of vision and reduces the use of glaucoma medications. Postoperative visual acuity and VF improvement were related to the degree of preoperative VF damage. Poor control of postoperative IOP is the main cause of visual impairment and further damage to the VF.

The authors thank Linhao Wang and Qianyue Cheng for their help in case collection.

This study is a retrospective study, and all patients signed informed consent before surgery. Our research was approved by the Medical Ethics Committee of Tongji Hospital, affiliated with Tongji Medical College of Huazhong University of Science and Technology (TJ-IRB20210527). Trial registration ID: ChiCTR2100051653.

The authors have no conflicts of interest to declare.

This study was supported by the National Natural Science Foundation of China (Grant No. 82070965).

Tian Hu organized medical records and wrote the article. Lingjuan Xu, Xuhui Chen, and Binbin Liu were involved in case screening and collection. Hong Zhang contributed to research content, direction, and provided funding.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

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