4/24/2018. Management of Patients with Conjoint Cataract and Glaucoma. Prevalence of Glaucoma C: NEW WORLD MEDICAL

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1 Management of Patients with Conjoint Cataract and Glaucoma Bryan Lee, MD, JD 40 th Annual Dallas Spring Ophthalmology Symposium April 27, 2018 Consultant: Allergan, Katena, New World Medical Financial Disclosure C: NEW WORLD MEDICAL Prevalence of Glaucoma In 2011, 2.7 million Americans with POAG 31% in 70s, 53% women, 44% non-hispanic whites In 2050, 7.3 million Americans with POAG 32% in 70s, 50% women, 50% Hispanic Largest shift to Hispanic men Texas: 244,440 cases in 2011=>881,125 in 2050 Vajaranant TS, Wu S, Torres M, Varma R. The changing face of primary open-angle glaucoma: demographic and geographic changes from Am J Ophthalmol Aug; 154 (2):

2 Cataract Demographics Approximately million cataract surgeries/yr in the U.S. By 2050, projected 84 million >65yo, doubled from 2012 IOP Effect of Phaco IOP lowering effect depends on starting IOP (Poley, retrospective) mmhg baseline => mmhg => -4.8 Similar findings for eyes with glaucoma Swedish cataract registry: -1.5mmHg (p<0.001) 20,437 surgeries, preop v. mean POD38 More lowering in those with higher preop IOP, older, short eyes, glaucoma/pxf IOP Effect of Phaco istent trial: Control group -8.5 mmhg OHTS: -4.0 mmhg However, some of these studies relied on one-time pre-op measurements or didn t have pre-op gonio 2

3 IOP Effect of Phaco Medically controlled glaucoma patients (n=157, Slabaugh AJO 2014): -1.8mmHg: 16.3mmHg pre-op, 14.5mmHg POY1 (p<0.001) 38% required additional medications or laser More IOP lowering in eyes with higher preop IOP; older; larger ACD Possible IOP spike: 17% of patients without prior incisional glaucoma surgery had a spike >50% baseline post-phaco (Slabaugh JCRS 2014) Phaco for Angle Closure EAGLE: RCT for clear lens extraction v. LPI Lens extraction resulted in lower IOP (mean 16.6, -1.2 mmhg, p=0.004) European quality of life (EQ-5D) questionnaire score also was higher by 0.05 (p=0.005) Incremental cost effectiveness ratio also favorable Significantly less likely to need any glaucoma treatment after as well as fewer needed glaucoma medications Phaco for Angle Closure If there is PAS, perform goniosynechialysis during phaco Greater outflow, reduced meds, less PAS in goniosynechialysis group (Rodrigues BJO 2017) Case is very strong for angle closure Phaco alone may also be adequate for open angle glaucoma patients 3

4 Cochrane review 9 RCTs, 657 eyes, mo f/u Phaco v. phaco + glaucoma surgery (3 trab, 3 istent, 2 TM aspiration, 1trabeculotomy): -1.6 more IOP lowering in combined POY1 3 istent studies: 1.4mmHg more lowering combined, best results in the study with two istents per eye Concluded only low quality evidence & that combined surgery may provide a small benefit IOL Selection Toric IOL OK for all but end stage glaucoma Glaucoma causes loss of contrast sensitivity, often early on Happens before a decline in high contrast visual acuity Functionally significant Crystalens/Trulign: doesn t diminish contrast sensitivity, but would not use in someone with pseudoexfoliation; can patient really benefit? K IOL Selection MFIOL: also makes harder to monitor glaucoma Symfony: Modulation transfer function with 5mm pupil same as Tecnis monofocal, but at 3mm, loss of contrast sensitivity N 4

5 Discuss before using in someone who is a glaucoma suspect can t predict the future Worry about decentration issues in someone with pxf Possibly for a very motivated very early glaucoma patient with perfect control, but may not be able to do IOLX later on Microinvasive Glaucoma Surgery MIGS as defined by Ike Ahmed: ab interno procedure biocompatibility with minimal disruption of normal anatomy/physiology very high safety profile efficacy of IOP lowering quick recovery time Minimally Invasive Glaucoma Surgery? Drainage Anatomy 5

6 IOP lowering: Cochrane review of 3 RCTs: -1.4mmHg v. phaco POY1 Complications include hyphema, usually selflimited; DM detachment if too anterior; iris occlusion; intraop dialysis; and malposition istent Long Term IOP with istent IOP lowering usually maximal at POM3, probably because of the effect of steroids Tan, Eye phaco-istent patients, 36 with 3 yrs of f/u Pre-op 21 mmhg with 2.1 meds 15.9 mmhg on 0.5 gtts POY mmhg on 1.0 gtts POY mmhg on 1.3 gtts POY3 Tips for ab interno procedures Try different gonioprisms to see which one you prefer Vold Hill Swan Jacob 6

7 Tips for ab interno procedures Tilt the microscope away from you and tilt the patient s head away from you (about 70 degrees in total) Zoom in and increase brightness Have the patient look away also not at the light Practice this on several patients before an actual case Try using a hook in your dominant hand to get the feel for going through the incisions and reaching the opposite angle with an instrument Can use an intracameral miotic to improve your view Angle Anatomy 7

8 Courtesy John Berdahl, MD istent Tips Consider small goniotomy first if doing istent I always use a left istent; fine to do so if don t want to go backhand istent Tips Consider small goniotomy first if doing istent I always use a left istent; fine to do so if don t want to go backhand Aim for the top third of the trabecular meshwork (above scleral spur) Enter at 15 degree angle, drop the heel, then advance should glide in very easily Push injector in slightly then push button to release Push istent forward, flick to make sure seated well 8

9 Multiple istents work better than a single istent but are not reimbursed Sometimes a single istent isn t reimbursed Kahook Dual Blade (goniotomy) Single-use disposable blade Can use forehand or backhand or both Typically treat 3-4 clock hours with excision of the overlying TM Alternatives for Goniotomy Barkan knife MVR blade 9

10 Goniotomy with MVR Goniotomy with KDB Seibold, AJO 2013;155:524 KDB Tips Enter at 10 degree angle Engage tip then drop the heel Pressurize eye to 25 mmhg at the end of the case Can use pilocarpine post-op to control IOP and keep the cleft open, but I just have them use their regular glaucoma drops Typically takes 3-4 weeks after stopping steroids to know the post-op IOP 10

11 Outcomes: phaco + Kahook Dual Blade / / / /- 1.0 Complications: 39% blood reflux (28/71), 2.8% IOP spike, 1.4% corneal edema, 1.4% iridodialysis, 1.4% PAS Greenwood JCRS 2017; 43: Kahook Dual Blade Not structured to separate out IOP lowering from phaco alone compared to phaco-kdb, but based on Greenwood study, an additional 2.5mmHg with 1 fewer med Eyes NOT treated for glaucoma Poley JCRS 2008;34: Controlled OAG patients Slabaugh AJO 2014;157:26-31 KDB v. istent Mansouri, ESCRS 2017: 58 pts, 106 eyes retrospective review phaco-istent v. phaco-kdb IOP: istent 16.6 mmhg => 14.6 at 6 mos KDB 16.8 mmhg => 13.9 at 6 mos Medications: istent 1.8 (SD 1.0) -> 1.4 (1.2) KDB 1.9 (1.0) -> 1.1 (1.2) istent labeled for use in conjunction with cataract surgery 11

12 Kahook Dual Blade Complications include hyphema, which is almost always self-limiting Can do as a standalone procedure (goniotomy code) Cypass COMPASS: unmedicated starting IOP 23-31, randomized to phaco alone or phaco + Cypass -7.4 mmhg v. -5.4mmHg* in Cypass group at POY2 77% v. 60%* had IOP reduction 20% 12

13 Cypass Complications Can cause a cyclodialysis cleft Uncomfortable during insertion Has a risk of hypotony because is in the supraciliary space, so not backed up by episcleral venous pressure Delayed refractive recovery Trabectome Handpiece with irrigation and aspiration uses bipolar cautery to ablate TM Requires machine and handpiece Hyphema common complication, even months later; 8% IOP spike Cleft closure can diminish effectiveness 13

14 MIGS? Endocyclophotocoagulation? Gonioscopy Assisted Translaminar Trabeculotomy? Xen? ECP Ab interno procedure but destroys a natural structure istent + cataract extraction + ECP (ICE) -7.1 mmhg v mmhg* (Ferguson, JCRS 2017) 63% reduction in meds v. 38%* Complications: inflammation, IOP spikes, hyphema Less predictable post-op refraction, myopic shift (Wang, JCRS 2016) Gonioscopy-Assisted Transluminal Trabeculotomy Opens 360 degrees of the angle Preserves conjunctiva Learning curve? Complications: hyphema Courtesy Davinder Grover, MD, MPH 14

15 Ab interno but requires bleb management Lower potential IOP because goes subconjunctival Risks of hyphema, malposition, conj perforation/erosion, occlusion of the lumen 25% experienced at least transient hypotony (IOP <6 mmhg) Xen 15