Phacoemulsification Combined With High-Frequency Deep Sclerotomy In Borderline-Pressure Poag On Maximally Tolerated Therapy: Real-World 24-Month Outcomes

To evaluate the 24-month efficacy and safety of ab interno high-frequency deep sclerotomy (HFDS) combined with phacoemulsification in eyes with primary open-angle glaucoma (POAG), clinically significant cataract, borderline intraocular pressure (IOP; 18-22 mmHg) despite maximally tolerated medical therapy, and documented structural and/or functional progression. The aim was to determine whether the combined procedure could provide sustained additional IOP lowering while reducing treatment burden in a challenging real-world cohort with restricted therapeutic options.

Retrospective, single-center, real-world case series conducted at a tertiary ophthalmology referral center. Twenty-two eyes of 14 patients with POAG and visually significant cataract were included and followed for at least 24 months after combined cataract surgery and HFDS.

Eligible eyes had POAG on maximally tolerated therapy, borderline preoperative IOP, progressive damage on Humphrey 24-2 visual field and/or OCT, and clinically significant cataract. Exclusion criteria included angle-closure or secondary glaucoma, advanced disease, previous glaucoma surgery, or inadequate gonioscopic visualization. HFDS was performed ab interno immediately after phacoemulsification using a 19-gauge high-frequency bipolar probe to create six nasal deep sclerotomy pockets. Main outcomes were Goldmann IOP, number of IOP-lowering medications, visual acuity, visual field stability, and adverse events through 24 months.

Twenty-two eyes of 14 patients (mean age 78.6 years) were analyzed. Mean IOP decreased from 19.86 ± 1.49 mmHg preoperatively to 12.73 ± 2.88 mmHg at 24 months (mean change -7.14 mmHg; p<0.001). Mean medication burden decreased from 2.64 to 1.45 drugs per eye (mean change -1.18; p=0.024); 16 eyes reduced therapy by at least one medication. At 24 months, 6 eyes were medication-free, 6 required 1 drug, 4 required 2 drugs, and 6 required 3 drugs. Visual field indices remained stable, while visual acuity improved in keeping with cataract extraction. No intraoperative or postoperative clinically relevant complications were observed.

In eyes with POAG, cataract, and borderline IOP despite maximally tolerated medical therapy, combined phacoemulsification-HFDS provided significant and durable IOP reduction together with meaningful medication sparing over 24 months, with a favorable safety profile and stable functional outcomes. This conjunctiva-sparing strategy appears particularly attractive when the clinical goal is to simplify topical therapy and achieve additional pressure lowering in patients with limited tolerance for medications.