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BLOG: But doctor, why are we talking about cataracts when I have glaucoma?
No two glaucoma patients are identical. In one way or another, each is unique. They present at different stages of disease, IOPs, tolerability to medications or age, to name just a few things. The goal for providers of these patients, however, remains the same. We strive to provide them with care that will give good functional vision throughout their life with the least amount of risk or intervention. This philosophy requires that we see the care of glaucoma patients as a lifelong commitment. It is a marathon and not a sprint. Just like in long-distance running, planning ahead and executing at the right time are critical. The right (or wrong) move early can have a dramatic effect on the outcome of the race.
The introduction of technology such as OCT has moved the pendulum to early diagnosis and treatment of glaucoma patients. If we now diagnose patients in their 40s and expect them to live into their late 70s, the result is, on average, almost 40 years of glaucoma care. Treatment needs to be done at the right time with the correct intervention. Fortunately, our armamentarium continues to evolve, improve and grow. There are a plethora of options, from eye drops to lasers to surgery, including the evolution of microinvasive glaucoma surgery (MIGS).
Despite all of these options for glaucoma treatment, our goal as providers is still to intervene as little as possible in order to decrease risks to our patients. It is in this environment that cataract surgery has now begun to take center stage for glaucoma care. It has become an almost inevitable part of ophthalmic care for all patients, even those without glaucoma. Cataract surgery is less risky, IOL technology is better, and patients are living long enough to develop them.
One is only left to deduce that glaucoma patients will have cataract surgery at some point in their lives. If that is the case, then as providers we should use that information to our advantage and plan accordingly, much like making an expected move in our marathon. Glaucoma, though, is not a straightforward disease but rather a multifactorial process that we are still trying to completely understand. There are patients with primary open-angle glaucoma (POAG), secondary open-angle glaucoma (SOAG), acute angle-closure glaucoma (AACG) or chronic angle-closure glaucoma (CACG).
However, cataract surgery does play a role in all these subtypes despite their varying pathophysiology. It just so happens that cataract surgery for most patients results in some IOP reduction as a welcome side effect, including those with POAG. For patients who have pseudoexfoliation, there are additional advantages to earlier cataract surgery when zonules are not as weak and cataracts not as dense that decrease the risk of complications. In AACG, there is growing research to use cataract surgery as a treatment once IOPs are as best medically controlled (or even not) instead of performing a laser peripheral iridotomy. Even in patients with narrow angles before having an episode of AACG, the use of cataract surgery has been shown to deepen the anterior chamber and reduce IOP, possibly from a phacomorphic effect and the development of peripheral anterior synechiae.
If a patient with any of these subtypes does need gold-standard surgery with trabeculectomy or a tube shunt, the removal of a cataract beforehand is also advantageous. It makes performing these surgeries easier once the natural lens is removed because it deepens the angle for placement of an Ex-Press glaucoma filtration device (Alcon) during trabeculectomy or the tip of a tube in seton shunt surgery. It removes the risk of a traumatic cataract. Performing cataract surgery first also eliminates the inevitable need to address an advancing cataract as a result of prior intraocular surgery.
The introduction of MIGS with its concurrent use in cataract surgery has further positioned cataract surgery at the forefront of care for glaucoma patients. It is now up to us as providers to better understand its role in treatment and strategically incorporate it into our marathon running with patients. This comes with educating our glaucoma patients about the role of this intervention in their care.
Disclosure: Teymoorian reports he is a consultant for Glaukos.