Cataract surgery cases, coexisting ocular conditions need thorough assessment

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Issue: April 2011

ByH. Burkhard Dick, MD

H. Burkhard Dick

Today’s cataract surgical patients have high expectations because they know that cataract surgery is associated with excellent postoperative visual outcomes. Therefore, it is of particular importance to be thorough in terms of the preoperative evaluation of all patients.

Cataract coexisting with other eye diseases is a common problem in the aging population and a trend that is likely to increase as the population ages worldwide, according to experts. Physicians should carefully evaluate cases preoperatively, considering factors such as the ocular surface, corneal surface and endothelium, optic nerve head and optical coherence tomography of the macula. They must consider a variety of factors, including interdisciplinary approaches, before making surgical decisions. Relevant factors include patients’ characteristics, such as age, disease severity, anatomic situation and ability to tolerate medications, along with the desired IOP control.

Research has shown that in some comorbid eye disease cases, visual function is enhanced after phacoemulsification. Systemic and ocular comorbidities, age-related macular degeneration especially, should be seriously considered when discussing prognosis and expectations with patients.

Results after cataract surgery in elderly patients can be favorable, studies have found. According to results published by Pham and colleagues regarding age-related maculopathy and cataract surgery, after cataract surgery, comorbid patients had “improvement in postural stability and reduction of fall-related injuries and risk of fractures.”

The same study found that preventing zonulolysis and posterior capsular tear was vital, as those complications can occur more commonly in these eyes.

Performing combined cataract and glaucoma surgery can create specific problems. In recent years, more physicians have been considering performing cataract surgery alone to reduce IOP in some cases, such as angle-closure glaucoma.

Many of the newer glaucoma procedures, especially with ab interno approaches, such as the Aquesys implant (subconjunctival bypass), Transcend CyPass implant (suprachoroidal bypass), trabecular aspiration or canaloplasty (iScience), offer promising and safe alternatives to trabeculectomy.

Authors have reported that intravitreal injection of drugs such as Avastin (bevacizumab, Genentech) and triamcinolone in conjunction with cataract surgery in eyes with clinically significant macular edema actually minimized diabetic macular edema and diabetic retinopathy progression in certain diabetic patient populations.

Cataract surgery in eyes with comorbidities presents challenges in the preoperative, intraoperative and postoperative settings. New advances in surgical techniques and instrumentation as well as careful planning, surgery and postoperative care will help to minimize complication risks, increase the benefit to achieve target IOP and achieve vision results for a greater proportion of this special group of patients.

In this issue, four respected physicians will share with you their various approaches in this regard.

References:

Belovay GW, Varma DK, Ahmed II. Cataract surgery in pseudoexfoliation syndrome. Curr Opin Ophthalmol. 2010;21(1):25-34.

Buys YM, Chipman ML, Zack B, Rootman DS, Slomovic AR, Trope GE. Prospective randomized comparison of one- versus two-site Phacotrabeculectomy two-year results. Ophthalmology. 2008;115(7):1130-1133.

Crichton A. Management of coexisting cataract and glaucoma. Curr Opin Ophthalmol. 2010;21(2):129-134.

Davis D, Brubaker J, Espandar L, et al. Late in-the-bag spontaneous intraocular lens dislocation: evaluation of 86 consecutive cases. Ophthalmology. 2009;116(4):664-670.

Eghrari AO, Daoud YJ, Gottsch JD. Cataract surgery in Fuchs corneal dystrophy. Curr Opin Ophthalmol. 2010;21(1):15-19.

Lundström M, Stenevi U, Thorburn W. Cataract surgery in the very elderly. J Cataract Refract Surg. 2000;26(3):408-414.

Murtha T, Cavallerano J. The management of diabetic eye disease in the setting of cataract surgery. Curr Opin Ophthalmol. 2007;18(1):13-18.

Pham TQ, Cugati S, Rochtchina E, Mitchell P, Maloof A, Wang JJ. Age-related maculopathy and cataract surgery outcomes: visual acuity and health-related quality of life. Eye (Lond). 2007;21(3):324-330.

Pham TQ, Wang JJ, Rochtchina E, Maloof A, Mitchell P. Systemic and ocular comorbidity of cataract surgical patients in a western Sydney public hospital. Clin Experiment Ophthalmol. 2004;32(4):383-387.

Poley BJ, Lindstrom RL, Samuelson TW. Long-term effects of phacoemulsification with intraocular lens implantation in normotensive and ocular hypertensive eyes. J Cataract Refract Surg. 2008;34(5):735-742.

Rosen E, Rubowitz A, Assia EI. Visual outcome following cataract extraction in patients aged 90 years and older. Eye (Lond). 2009;23(5):1120-1124.

Shah AS, Chen SH. Cataract surgery and diabetes. Curr Opin Ophthalmol. 2010;21(1):4-9.

Shingleton B, Tetz M, Korber N. Circumferential viscodilation and tensioning of Schlemm canal (canaloplasty) with temporal clear corneal phacoemulsification cataract surgery for open-angle glaucoma and visually significant cataract: one-year results. J Cataract Refract Surg. 2008;34(3):433-440.

Tennant MT, Connolly BP. Cataract surgery in patients with retinal disease. Curr Opin Ophthalmol. 2002;13(1):19-23.

Tham CCY, Kwong YYY, Leung DYL, et al. Phacoemulsification versus combined phacotrabeculectomy in medically controlled chronic angle closure glaucoma with cataract. Ophthalmology. 2008;115(12):2167-2173.

Van Gelder RN, Leveque TK. Cataract surgery in the setting of uveitis. Curr Opin Ophthalmol. 2009;20(1):42-45.

Vizzeri G, Weinreb RN. Cataract surgery and glaucoma. Curr Opin Ophthalmol. 2010;21(1):20-24.

H. Burkhard Dick, MD, can be reached at Universität-Augenklinik, Bochum, In der Schornau 23-25, 44892 Bochum, Germany; +49-234-299-3100; fax +49-234-299-3109; email: burkhard.dick@kk-bochum.de.

Disclosure: Dr. Dick has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.