Special considerations needed for patients with glaucoma undergoing cataract surgery
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When planning surgery for patients with cataracts and glaucoma, Douglas J. Rhee, MD, has several “rules of thumb” to consider when deciding whether to add a minimally invasive glaucoma procedure to phacoemulsification.
“If the patient preoperatively has an uncontrolled intraocular pressure [or] if the patient has a controlled intraocular pressure but requires three or more medications to keep it under control, you might want to consider adding a MIGS procedure,” Rhee said at the virtual American Academy of Ophthalmology annual meeting.
Rhee also considers MIGS in patients at high risk for an IOP spike, for example, those with pseudoexfoliation syndrome, or when there is a high risk for loss of central fixation.
Other pearls for performing cataract surgery in patients with glaucoma include using iris hooks or a Malyugin ring (MicroSurgical Technology) as deemed necessary to maintain the pupil.
“An extra pearl is, if you do utilize a capsular tension ring in an eye with pseudoexfoliation syndrome, there can be up to about a 0.8 D difference in the final spherical equivalent. Specifically, you would have a hyperopic change,” Rhee said.
Rhee suggested adjusting IOL calculations when using trabeculectomy and tube shunts, which may cause surgically induced astigmatism and hyperopic shift. For MIGS, there is no change in surgically induced astigmatism when the main cataract wound or paracentesis is used for the MIGS procedure, he said.
Rhee further cautioned against the use of a multifocal IOL in a patient with glaucoma.
“We know that multifocal intraocular lens implants can degrade contrast sensitivity in normal patients. We also know that glaucoma itself degrades contrast sensitivity,” Rhee said.
Finally, Rhee suggested using topical NSAIDs if the patient is on a prostaglandin analogue. Even though topical prostaglandin analogue use can increase the risk for postoperative cystoid macular edema after cataract surgery, “Anecdotally, it’s been my experience that the use of topical NSAIDs can decrease the rate of postoperative cystoid macular edema,” Rhee said.
Rhee said he does not stop use of the preoperative prostaglandin because the NSAIDs can mitigate or prevent cystoid macular edema.
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Rhee DJ. Phaco with glaucoma. Presented at: American Academy of Ophthalmology annual meeting; Nov. 13-15, 2020 (virtual meeting).
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