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Would you consider early phacoemulsification to manage IOP in a patient with modestly uncontrolled glaucoma?
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Yes, phaco should be considered, with caveats
 Thomas W. Samuelson |
Cataract surgery is one of the most consistently reproducible procedures in all of medicine. Recipients of cataract surgery typically benefit from improved visual acuity, a more favorable refractive error, the potential for presbyopic correction and, based on mounting evidence, lower IOP. I am an advocate for earlier rather than later cataract surgery in patients with glaucoma. This is especially true when IOP control is suboptimal on one or two medications. If I were a patient with modestly uncontrolled early to moderate glaucoma, I would much prefer early cataract surgery over a filtration procedure. Most of the time, IOP is easier to control following phacoemulsification, and if not, all other management options remain available.
I am becoming more reluctant to perform incisional glaucoma surgery in phakic eyes. While there are exceptions, I consider cataract surgery an incremental step in the management of glaucoma. I would rarely perform glaucoma surgery without first trying a prostaglandin analogue. Likewise, it is uncommon for me to recommend an incisional, primary glaucoma procedure without first trying cataract surgery.
With that being said, I do not advocate phacoemulsification in visually asymptomatic eyes. I use minimally invasive methods as much as possible to control IOP to buy time until a patient has symptoms from the cataract. Notable exceptions include patients with unusually aggressive glaucoma, extremely high IOP and very advanced disease. For such patients, we need our complete armamentarium, including traditional approaches such as trabeculectomy and aqueous drainage devices. For patients with less severe disease, I prefer to augment physiological outflow and avoid transscleral filtration. Based on research at our center as well as the recent Glaukos trial demonstrating the favorable effects of cataract surgery on IOP, I am increasingly reluctant to give up the trabecular meshwork in phakic eyes. I am confident that ability to surgically enhance conventional outflow will continue to improve, further advancing this strategy.
Thomas W. Samuelson, MD, is the OSN Glaucoma Section Editor.
Generally, no, because of the limitations and possible risks
 Douglas J. Rhee |
Although there may be individual circumstances in which this approach is the preferred management option, there are important considerations that urge an alternate approach. The range of IOP-lowering obtained following phacoemulsification is rather modest — generally between 1 mm Hg to 4 mm Hg. Thus, the degree of desired IOP-lowering to attain the target range must be within this modest extent.
The risk of a high IOP elevation (ie, an IOP spike) is significant and could result in further damage or necessitate an urgent filtration procedure under less controlled circumstances. Furthermore, the risk of complications with phacoemulsification, albeit low, is a possibility.
There is no evidence that pre-existing pseudophakia results in lower IOPs from any of our filtration procedures. Visual deficits from cataracts are reversible and can be dealt with after the glaucoma is stabilized.
Douglas J. Rhee, MD, is an OSN Glaucoma Editorial Board Member.