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Three reasons to take out the cataract early when treating glaucoma
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In the cover story of this issue of OSN, we review a myriad of topics from the Corneal Health Round Table at OSN New York. This is one of my very favorite sessions at this great meeting because of the lively discussion that always takes place. Part of the discussion at the meeting was the importance of cataract surgery sooner rather than later in patients with glaucoma. Here are three reasons I encourage everyone to think about an earlier approach to cataract surgery in these patients:
1. Earlier surgery does a favor to the ocular surface. Virtually all topical glaucoma medications contain BAK, a dilute soap-like preservative that slowly destroys the ocular surface. Also, some medications additionally have a non-neutral pH, further causing toxicity. This chronic assault on the eye causes severe surface problems in many older glaucoma patients and can be put to a stop if cataract surgery (plus MIGS) can adequately lower pressure and eliminate drops. Furthermore, eliminating this surface toxicity improves vision in these patients who have reduced contrast not just from cataract but also from some optic nerve damage that reduces visual resolution. These combined effects have a very real impact on perception far before visual field defects are measurable. Anything we can do to improve contrast is a great favor to these patients.
2. Cataract surgery by itself reduces pressure. Many studies have now demonstrated that most cataract patients with open-angle glaucoma have at least some phacomorphic component of their disease. Removing the cataract increases the anterior chamber depth and facilitates aqueous outflow, lowering pressure consistently by at least a few points in most individuals. There is little point in delaying cataract surgery, even in patients who have relatively early visual complaints. (Naturally, an appropriate discussion with the patient about balancing risks and benefits should always be undertaken.)
3. All MIGS procedures are approved in combination with cataract surgery. The patient receives two benefits in one sitting, whether you choose the iStent (Glaukos), Trabectome (NeoMedix), Visco360 (Sight Sciences), Kahook dual blade (New World Medical), ab interno canaloplasty (Ellex), the newly cleared CyPass (Alcon) or Xen (Allergan) device, or the soon-to-be approved Hydrus (Ivantis). The success of these procedures is the reason glaucoma specialists are doing fewer and fewer tube shunts and trabeculectomy procedures. Why shouldn’t every capable cataract surgeon avail his or her patients of these procedures?
In the interest of public health, I am hopeful we will see standards shift not just in surgical decision making but also among payment rules. Clinical experience dictates that cataract surgery should be performed earlier in these patients. We know that MIGS should be offered at all stages of glaucoma, not just advanced disease, and we have increasing evidence that combining multiple MIGS procedures in the same patient may also be appropriate. As always, the payment system should follow good clinical sense, although it may take some time for the folks at CMS to catch up with those of us who treat patients “in the trenches.”
Disclosure: Hovanesian reports he is a consultant for or on the medical advisory board to Alcon, Allergan, Glaukos, Ivantis and Sight Sciences.