Abstract
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Purpose: To compare long-term surgical outcomes of deep sclerectomy (DS) performed alone versus combined with phacoemulsification (DS+Phaco).
Patients and Methods: This retrospective cohort study included 154 eyes (DS alone, n = 95; DS+Phaco, n = 59) operated at King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia; 2018–2023). All procedures used a standardized, implant-free, mitomycin C-augmented technique performed by a single glaucoma surgeon or by fellows under his direct supervision. The primary endpoint was surgical success (intraocular pressure (IOP) <18 mmHg with ≥20% reduction from baseline). Complete success required medication-free IOP control; qualified success allowed adjunctive therapy. Cumulative surgical survival was compared using Kaplan–Meier analysis and log-rank testing, and logistic regression was used to identify predictors of failure.
Results: DS+Phaco patients were significantly older (60.8±11.1 vs. 45.9±18.0 years; P < .001) and had lower baseline IOP (21.8±7.7 vs. 25.3±8.2 mmHg; P = .008). Both groups achieved sustained IOP reduction throughout 48-month follow-up, with no significant intergroup differences from 3 months onward (all P > .05). Complete success was significantly higher in DS alone at 18 months (37% vs. 21%; P = .044) and 24 months (33% vs. 16%; P = .032), while overall success remained equivalent. Kaplan–Meier analysis showed no significant difference in cumulative overall success at IOP <18 mmHg (48-month estimates, 57.9% for DS alone vs. 60.5% for DS+Phaco; P = .636); under the <21 mmHg criterion, DS+Phaco demonstrated superior cumulative survival (P = .049). On multivariate analysis, older age (OR 1.04 per year; P = .009) and higher baseline IOP (OR 1.06 per mmHg; P = .013) independently predicted failure at 12 months, whereas the surgical group did not (P = .395).
Conclusions: Deep sclerectomy combined with phacoemulsification achieves comparable long-term overall success to DS alone, with a progressive shift toward medication-assisted IOP control. Combined surgery is not inferior under standard success criteria, supporting its use in patients with coexisting cataract, while highlighting greater long-term pharmacological dependency.
Keywords: deep sclerectomy; phacoemulsification; combined glaucoma surgery; non-penetrating glaucoma surgery; surgical survival
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