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Combined cataract-glaucoma procedures needed less frequently
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ROME — Advances in medical treatment for glaucoma have greatly reduced the need for combined cataract-glaucoma surgical procedures, according to a physician speaking here.
“In the past I used to perform a lot of combined procedures. Now I have reduced them to only one or two a year,” said Richard L. Lindstrom, MD, chief medical editor of Ocular Surgery News. Dr. Lindstrom gave the Benedetto Strampelli Medal Lecture here during the Italian Ophthalmology Society annual meeting. In his lecture, entitled “Cataract Surgery in the Glaucoma Patient,” Dr. Lindstrom outlined special considerations and cautions for cataract surgery in this population.
Most patients with glaucoma who are seen by a comprehensive ophthalmologist because of visual impairment from cataract can be treated with cataract surgery and lens implantation alone, Dr. Lindstrom said. Phacoemulsification with posterior chamber IOL implant lowers the IOP of a patient by an average of 2 mm Hg to 4 mm Hg, and “every millimeter of mercury reduction lowers the risk of visual field loss by 10%,” he said.
Combined phaco-trabeculectomy procedures “have only marginally better results” with IOP lowering, Dr. Lindstrom said.
“Intraocular tension might be lowered 3 to 6 mm Hg, but the risk of complications, short and long term, is much higher and visual recovery is significantly slower than after cataract surgery alone,” he said.
Cataract surgeons who operate on glaucoma patients must consider the negative effects the eye may have experienced from the disease itself, from chronic use of medications and, more important, from the preservatives contained in those medications.
Clear corneal cataract surgery spares the conjunctiva in case glaucoma surgery is required later, Dr. Lindstrom said. He recommended creating a small incision in clear cornea, “never invading the conjunctiva.” Endothelial abnormalities are likely to be present, and the endothelial reserve reduced, so specular microscopy and pachymetry should be performed preoperatively to assess the condition of the cornea.
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If the patient’s pupil is very small – another effect of chronic medication – “it can be enlarged by simply using iris retractors,” he said.
Extra care must be taken intraoperatively with the use of viscoelastics, which can block outflow channels if left in the eye.
Dr. Lindstrom said implantation of a capsular tension ring may be helpful in some patients. He said IOL placement is sometimes a challenge.
“I normally implant the lens in the bag, but if the capsule is very loose, I place the lens in the sulcus, with the optic captured in the bag,” he said.
To reduce the inflammation that can be seen due to drug preservatives, Dr. Lindstrom asks patients to discontinue use of any potentially inflammatory drug a few days before surgery. In some cases he prescribes nonsteroidal anti-inflammatory drugs and steroids preoperatively.
Inflammation can also complicate outcomes postoperatively, Dr. Lindstrom noted.
“Watch out for cystoid macular edema, which is also quite commonly caused by drug preservatives,” he said. Prophylactic treatment for postop pressure spikes is also advisable, he added.
A higher rate of Nd:YAG laser capsulotomy is to be expected in these patients, in whom capsular fibrosis and capsular phimosis are more frequent.
Dr. Lindstrom’s lecture was presented by Ocular Surgery News, the Italian Society of Ophthalmology, the Italian Association of Cataract and Refractive Surgeons and the International Society of Refractive Surgery/American Academy of Ophthalmology.