Surgical strategies in patients with combined cataract and glaucoma.

Abstract

In the elderly population, the combined presence of cataract and glaucoma is a frequent condition. In this situation, several surgical options are possible: cataract surgery only and later maybe trabeculectomy, trabeculectomy only and later maybe cataract surgery, or combined cataract and glaucoma surgery. This review compares the different surgical options on the basis of their achievable postoperative intraocular pressure (IOP) level and success and complication rates. The impression of better IOP regulation with trabeculectomy than with phacotrabeculectomy has been recently confirmed by an evidence-based review. Contrary to this finding, the success of deep sclerectomy or trabeculotomy does not seem to be compromised by simultaneous phacoemulsification. In eyes with previous glaucoma-filtering surgery, cataract surgery with clear corneal incision has no effect on mean IOP but increases the 3-year failure probability. For phacotrabeculectomy, moderate evidence of a beneficial effect of MMC on IOP regulation and only weak evidence for separating the incisions has been recently reported by another evidence-based review. The choice of the preferred surgical method depends on the target pressure, the amount of glaucomatous damage, and the grade of visual disturbance caused by the cataract. Phacotrabeculectomy combined with mitomycin C achieves the best IOP lowering of all types of combined cataract and glaucoma surgery currently possible but is associated with potentially sight-threatening complications. In the absence of a low target pressure, phacotrabeculotomy or the combination of phacoemulsification with viscocanalostomy or deep sclerectomy may be the therapy of choice.