Cataract-Glaucoma Preoperative considerations. Dimitrios Mikropoulos

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1 Cataract-Glaucoma Preoperative considerations Dimitrios Mikropoulos

2 Cataract surgery alone Trabeculectomy alone Combined surgery

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4 The cataract is visually significant, and the glaucoma is well controlled on drops that the patient tolerates and is willing to continue Other reasons for performing cataract surgery alone Clear corneal incision, thus preserving the conjunctiva for a future trabeculectomy Studies indicate cataract surgery alone can lower IOP

5 For a person who has a small cataract that is not visually significant Nothing gets the pressure as consistently low as trabeculectomy

6 The choice is clear when a patient has an absolutely visually significant cataract and has progressive glaucoma despite the best-tolerated medical treatment that we can offer

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8 First, does the patient really need both surgeries? Second, if both surgeries are called for, does it make sense to do them at the same time?

9 If it's driven by the cataract and the patient is only on one glaucoma medicine and doing well, I'm probably going to perform cataract surgery Do the cataract surgery, monitor the patient carefully for pressure spikes and see if the cataract surgery lowers the pressure enough to get the patient off of medication

10 If the glaucoma is driving the surgery (e.g., the eye has markedly elevated IOP and nerve damage), you may choose a staged approach, performing the glaucoma surgery first

11 If the patient is on maximum glaucoma meds and needs cataract surgery, then my inclination is to proceed with the combined surgery

12 With a two-site approach things are certainly easier because we are performing surgery we are used to there is less risk of antimetabolites entering the anterior chamber

13 One-site phacotrabeculectomy is a completely different procedure when compared with standard phacoemulsification or standard trabeculectomy the only advantage of one-site techniques is that they are faster

14 A recent study exploring the timing of cataract surgery after trabeculectomy suggests that the closer in time the two procedures are performed especially within the first six months the more likely it is that the trabeculectomy will fail Husain R et al. Arch Ophthalmol. 2012;130(2):

15 trabeculectomy combined procedure cataract extraction

16 Cataract surgery decreases IOP in ocular hypertensive patients over a long period of time (at least 36 months) The average decrease in postoperative IOP from preoperative IOP was 16.5%, and 39.7% of eyes had postoperative IOP 20% below preoperative IOP Steven L Mansberger et al. Ophthalmology. 2012

17 Trabectome (NeoMedix) Canaloplasty (iscience Surgical) Endoscopic cyclophotocoagulation (Endo Optiks) istent (Glaukos) CyPass (Transcend) Hydrus (Ivantis)

18 There is limited evidence regarding the efficacy of these newer glaucoma procedures, and each procedure poses some additional risk It argues for increased non industry-sponsored funding for trials to look at some of the newer things going on in glaucoma surgery

19 Despite the improved results of small incision phacoemulsification and of filtration surgery with anti-metabolites there is no evidence to support a generalized switch from sequential to combined surgery

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