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BLOG: The view is everything for both cataract and glaucoma surgery
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The use of cataract surgery in the management of glaucoma, especially as first-line surgical intervention, is gaining rapid momentum for several reasons.
Not only do we see a few points of IOP reduction by removing the cataractous lens, but also it is more commonly being done in conjunction with MIGS. This will further be magnified given the wide range of MIGS procedures that are now available for use, including the iStent (Glaukos), CyPass (Alcon), Xen (Allergan), Trabectome (NeoMedix) and various forms of trabeculotomy. The other factor compounding this trend is the use of cataract surgery in almost all forms of glaucoma from open to closed angle. This shift in paradigm, however, is dependent on achieving and maintaining good surgical outcomes from cataract removal and IOL replacement.
Just like in angle surgery for glaucoma, the view of the lens during cataract surgery is critical. We all can attest to the fact that obtaining and maintaining proper dilation of the iris during cataract surgery can make a significant difference in patient outcomes. Multiple studies have shown that every millimeter of additional dilation counts toward success. Good visualization of the lens leads to decreased surgical time, lower complication rates and a reduction in the use of additional tools like expansion rings.
However, issues for normal patients always seem to become more complicated in those with glaucoma. In patients with glaucoma, the ability to achieve good surgical results is especially important. These patients are already deficient in their visual field, and there can be an anticipation of this worsening over time. Difficulty with cataract surgery can compound the underlying problem and further decrease their quality of vision. A decrease in surgical time that can be achieved from proper dilation ultimately leads to better IOP control because there are fewer complicating factors. These include less tissue manipulation and trauma as fewer tools, like pupillary dilation rings, are involved, a decrease in the amount of viscoelastic used, which means less being left behind postoperatively, and lower rates of capsular tear with vitreous loss and CME.
Take, for example, the unique challenges in this patient subset as exemplified by those with pseudoexfoliation glaucoma. Typical issues that add complexity to cataract surgery include poor dilation, weak or loose zonules, and a denser lens. In these and similar patients, I have found the use of Omidria (Omeros) to be especially useful. Omidria is a combination mixture of phenylephrine 1% and ketorolac 0.3% that is diluted in the irrigating solution used in cataract surgery. From my own experience, I have noted the following in patients when one eye had the addition of Omidria while the other did not:
1. Peak iris dilation was larger in the eye with Omidria.
2. The length of pupillary dilation was longer with Omidria.
3. Factors No. 1 and 2 led to fewer complications, including tissue manipulation and the need to use expansion rings.
4. Factors No. 1, 2 and 3 resulted in surgical times, including phaco, that were shorter.
5. The above led to fewer IOP spikes.
6. Also, the ability to perform MIGS was not negatively affected with the dilation from the use of Omidria.
In patients with glaucoma, the ability to perform cataract surgery with the addition of MIGS while maintaining adequate IOP is critical. The use of Omidria in this patient subset better allows surgeons to have success. Ultimately, this leads to better functional vision and improves quality of life for our patients.
Disclosure: Teymoorian reports he is a consultant for Alcon, Allergan and Glaukos and does research for Allergan.