Issue: June 2009
June 01, 2009
1 min read
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In light of research showing adequate IOP-lowering effects of cataract surgery alone, do you think combined procedures are still viable? If so, why?

Issue: June 2009
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POINT

Combined surgery still viable treatment option

James C. Tsai, MD
James C. Tsai

While cataract surgery alone appears to lower IOP in a substantial number of cases, I believe that the combined cataract/glaucoma procedure is still a viable and useful treatment option in a significant number of patients with moderate to severe glaucoma. Specific situations include those patients with inadequate IOP control despite maximum tolerated medical and/or laser therapy. Moreover, the combined procedure should be considered in patients with mild to moderate glaucoma who have anticipated difficulty with postoperative IOP control. Other indications include a visually significant cataract in the presence of an existing inadequate or failed filtering bleb.

While trabeculectomy is often the glaucoma surgery combined with cataract surgery, other glaucoma procedures may be substituted, including aqueous shunt implants, the Ex-PRESS shunt (Optonol), the Trabectome (NeoMedix), endocyclophotocoagulation and canaloplasty. It is my usual preference to combine trabeculectomy surgery with mitomycin C (0.4 mg/mL for 2 minutes) with the phacoemulsification technique through a single-site superior location. Under local anesthesia (ie, topical, subconjunctival and intracameral), I employ a fornix-based conjunctival flap incision, leaving a 1-mm skirt of tissue that allows for easy closure with a running, intermittent locking stitch of 9-0 monofilament Vicryl suture on a BV (blood vascular) needle. A releasable 10-0 nylon corneal suture is instituted to facilitate ease of early postoperative IOP control.

James C. Tsai, MD, is an OSN U.S. Edition Glaucoma Board Member.

COUNTER

Combined procedures still controversial

Kensaku Miyake, MD
Kensaku Miyake

Generally, from 1 mm Hg to 3 mm Hg IOP-lowering effects of cataract/IOL surgery are accepted in peer-reviewed articles. Combined cataract/IOL/trabeculectomy is, however, still controversial because of postoperative complications of trabeculectomy, such as shallow anterior chamber, choroidal detachment and increased anterior chamber inflammatory reactions. Increase of these complications is recognized particularly in the procedure combined with mitomycin C application. These complications sometime threaten the merits of this type of combined procedure.

To increase the merits of the combined procedure, I recommend trabeculotomy or its modified procedures, such as viscocanalostomy or canaloplasty, as the operation for lowering IOP in cases with primary open-angle glaucoma or exfoliation syndrome and cataract.

These antiglaucoma procedures have a significantly low incidence of the postoperative complications cited above.

Kensaku Miyake, MD, is a physician at the Shohzankai Medical Foundation, Miyake Eye Hospital, Nagoya, Japan.