Three-year outcomes of phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma with cataract: A randomized controlled trial

PURPOSE: To evaluate the 3-year efficacy and safety of phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma (PACG) with cataract. DESIGN: Multicenter, randomized controlled, open-label, non-inferiority trial. METHODS: Patients were randomized 1:1 to undergo either phacogoniotomy (65 eyes) or phacotrabeculectomy (59 eyes). Three years retention was 92.3% (60/65) and 83.1% (49/59) for each group, respectively. Primary outcome was 3-year intraocular pressure (IOP) reduction (noninferiority margin: 4 mmHg). Secondary outcomes included surgical success, complications, hypotensive medications used; additional outcomes were changes in visual acuity (BCVA), visual field (VF), and corneal endothelial cell density (ECD). RESULTS: At 3 years, phacogoniotomy reduced mean IOP from 40.2 (10.3) to 14.1 (2.4) mmHg (-26.1 [10.4] mmHg reduction); phacotrabeculectomy, from 39.7 (9.3) to 14.4 (2.5) mmHg (-25.3 [9.2] mmHg reduction). Adjusted between-group difference in IOP change was -0.37 mmHg (95% CI, -1.32-0.58 mmHg; P = 0.44), meeting noninferiority. Complete (78.3% vs 89.8%; P = 0.13) and qualified (90.0% vs 91.8%; P > 0.999) success rates were comparable. Hypotensive medications declined in both groups (phacogoniotomy: 2.1 [1.2] to 0.2 [0.6]; phacotrabeculectomy: 2.1 [1.3] to 0.0 [0.2]; P = 0.06 for 3-year difference). BCVA improvements (0.1 vs 0.0 logMAR; P = 0.49), VF stability (MD difference:1.42 dB, P = 0.26; PSD difference: 0.22 dB, P = 0.75), and ECD loss (difference: 2%; P = 0.53) were similar. No new complications occurred in extended follow-up. CONCLUSIONS: At 3 years, phacogoniotomy remained non-inferior to phacotrabeculectomy in IOP reduction for advanced PACG with cataract.