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Know indications for sequential cataract and glaucoma surgeries, surgeon says
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LISBON, Portugal — Phaco-trabeculectomy is not appropriate for all patients with concomitant cataract and glaucoma, so surgeons must understand the appropriate conditions for choosing a sequential approach to surgery instead, according to a presenter here.
Philippe Sourdille, MD, said it is critical to understand the special conditions of the eye that determine when to avoid a combined procedure, as well as how to decide upon the best approach for sequential surgery. He spoke on the topic at the European Society of Cataract and Refractive Surgeons meeting.
“Since more and more phaco-(trabeculectomies) are routinely performed with the application of mitomycin-C to enhance filtration, and since this is prone to complications such as hypotony, bleb leak, blebitis and even endophthalmitis with a final loss in visual acuity ... should we consider a more selective approach of a combined surgery and the use of MMC?” Dr. Sourdille asked.
He said sequential surgery should be considered in patients with coexisting open-angle glaucoma and incipient cataract, with the glaucoma surgery performed first.
In special anatomic conditions, such as closed- or narrow-angle glaucoma, phacoemulsification alone can resolve both the cataract and glaucoma at once, Dr. Sourdille said.
“We know this is more frequent in Asia than in Europe. Cataract surgery can open the angle and deepen the anterior chamber, which are both important for aqueous outflow and circulation,” he said.
In cases where both surgeries are needed, cataract surgery can be performed first when the patient has angle-closure glaucoma that has been successfully treated, or a previous iridectomy or iridotomy.
Other factors to be weighed include the condition of the optic nerve, whether the target IOP has changed since an earlier glaucoma surgery, whether medical therapy has been effective, and the presence of surface inflammation or a blood condition. The condition of an existing filtering bleb should also be evaluated.
“When considering glaucoma surgery and cataract extraction, we must also deal with the incidence of cataract, and compare between penetrating and nonpenetrating surgeries,” Dr. Sourdille said.
Furthermore, when performing cataract surgery after a previous glaucoma surgery, Dr. Sourdille recommended use of a clear corneal incision, meticulous removal of viscoelastic, and careful management of postop wound tightness to avoid hypotony or a spike in IOP.
Above all, he stressed the importance of reviewing the literature on the benefits of combined vs. sequential surgery as a foundation for any decision.