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Response: Mitomycin C-augmented Phacotrabeculectomy versus Phacoemulsification in Primary Angle Closure Glaucoma: A Randomized Controlled Study.

In Reply: We would like to thank Dr Borgohain and colleagues for their interest in our study and their insightful comments. We shall respond to the comments point/ counterpoint: We would like to congratulate and highly appreciate Yasmine et al1 for their study “Mitomycin C-augmented phacotrabeculectomy versus phacoemulsification in primary angle-closure glaucoma: a randomized controlled study.” However, we have a few queries. First: Although gonioscopy revealing >180 degrees of iridotrabecular contact were included in this present study, appositional or synechial angle closure was not mentioned. The influence of the extent of peripheral anterior synechiae (PAS) on the success of phacoemulsification alone in primary angle-closure glaucoma (PACG) is still unclear. Some studies have shown that the bigger the extent of PAS, the more the intraocular pressure (IOP)-lowering effect of phacoemulsification,1 while many others have shown that IOP reduction with phacoemulsification is unrelated to the extent of PAS.2–5 The extent of PAS, in addition to being difficult to determine exactly in eyes with large lenses and shallow anterior chambers,3,5 may also not reflect the extent of damage in the trabecular outflow pathway.2,6 Second: Synechiolysis was not performed in any cases as mentioned in the article. We are interested to know, whether all eyes included had appositional angle closure only? If not, then how can the IOP drop be explained in eyes with synechial angle closure in the phacoemulsification only group? We think it would have been better evaluated if both groups (appositional and synechial angle closure) were analyzed separately. There is little evidence to suggest that goniosynechiolysis offers additional benefits when combined with phaco in PACG, compared with phaco alone. Randomized controlled trials comparing both procedures have shown no additional benefit to performing goniosynechialysis.7,8 Phacoemulsification in PACG lowers the IOP through the deepening of the anterior chamber and improving the facility of outflow. The positive pressure of viscoelastic and fluids injected into the anterior chamber also helps lyse some of the PAS, even without having to tackle them directly.9 Third: The tight closure of the scleral flap aiming at no flow in immediate postoperative period could have led to exaggerated healing and a poorly functioning bleb requiring bleb revision in a greater number of eyes. This might be the reason why the complete success rate was insignificant between the 2 groups. Eyes that underwent phacotrabeculectomy might not be having a functioning bleb and hence behaved as phacoemulsification only group and the mechanism of IOP control might be the same in both groups with no added advantage of trabeculectomy in the former group. We agree that this was a possible reason and we have previously mentioned that in the discussion section. That being said, the tight closure of the flap had the benefit of reducing the risk of hypotony (9.6% compared with 18.9% in Tham et al’s10 study).