SURGICAL MANAGEMENT OF COEXISTING GLAUCOMA AND CATARACT

Abstract

As longevity increases among the elderly, the challenge of managing coexisting glaucoma and cataract is becoming ever more frequent. Modern surgical techniques for cataract removal (e.g., small incision phacoemulsification and temporal clear corneal incision) spare conjunctiva and minimize disruption of the anterior chamber angle. Postoperative bleb titration with releasable scleral flap sutures and antifibrotic medications increases the chance for successful aqueous filtration. These advances have made us reconsider the choice for performing cataract extraction and trabeculectomy together or in sequential steps (staged surgery) for eyes with coexisting cataract and glaucoma. There are many issues (Table 1) to consider in the surgical treatment of coexisting glaucoma and cataract including medication compliance, side effects, and cost. The severity of glaucomatous visual field loss and optic nerve damage and the level of intraocular pressure (IOP) influence the surgical decision. The possibility of further optic nerve damage from a postoperative IOP spike must be addressed. The type of glaucoma and the preoperative state of the conjunctiva and anterior segment also influence the decision-making process. Cataract extraction presents extra hazards in the glaucomatous eye relating to poor pupillary dilation caused by miotic use and diminished zonular integrity in eyes with exfoliation syndrome. The surgical approach for cataract extraction is also important. Large incision extracapsular cataract extraction (ECCE) or scleral tunnel phacoemulsification cause limbal and conjunctival scarring that may have an impact on the success of future glaucoma surgery. This can be avoided by using a clear corneal incision for removal of the cataract. In previous years, combined cataract and filtration surgery has gained favor over procedures. Combined surgery is convenient for the patient because two procedures are done during a single operation. It also diminishes the likelihood of a postoperative IOP spike, which is common when cataract surgery is performed alone. 18 This trend has resulted in more eyes with glaucoma who are destined for cataract extraction having a trabeculectomy added secondarily. Nevertheless, combined surgery risks more intraoperative and postoperative complications than either operation separately, slower visual recovery than cataract surgery alone, and lower chance of developing a filtration bleb. In this article we review the available information on the surgical management of eyes with coexisting cataract and glaucoma and present a rationale for a return to sequential or staged surgery. We approach each patient with glaucoma and cataract by considering the status of the patient's glaucoma and the patient's need for improved vision. Whatever procedures are selected, the ultimate goals should be an adequate IOP and improved quality of life by improving vision and decreasing the need for antiglaucoma medications.