Cataract Surgery in the Glaucoma Patient

When this occurs, performing a cataract surgery with a lens replacement may open the drainage angle and improve the eye pressure. The decision of whether or not combined cataract-glaucoma surgery should be performed, and the choice of glaucoma surgery, depends on various factors including the type of glaucoma and its severity.

Your doctor will take all these important factors into consideration when advising what is best for your eye. Cataract surgery in a patient with glaucoma may give rise to unique concerns. For example, in patients with exfoliation glaucoma there is a higher risk of complications due to inherent weakness in the supportive structure of the natural lens the zonules.

Some newer types of intraocular lenses may not be suitable for patients with advanced glaucoma because they affect contrast sensitivity the ability to distinguish between an object and its background or may cause additional sensitivity to glare. Eye pressure spikes after cataract surgery may be more common in patients with underlying glaucoma and importantly, glaucoma patients are more likely to be susceptible to damage from a transient increase in eye pressure.

Glaucoma Today - Cataract Surgery in High-Risk Glaucoma Patients (May/June )

To conclude, in patients with coexisting cataract and glaucoma, surgical treatment poses unique challenges. There are several treatment options and many variables factor into the decision to choose a particular procedure. A detailed discussion with your doctor is important in order to determine the best option for you. Article by Davinder S. He specializes in the medical and surgical management of complex glaucoma as well as cataract surgery.

The goal of all glaucoma surgery is to lower eye pressure to prevent or reduce damage to the optic nerve. Where the Money Goes. Like Us on Facebook.

INTRODUCTION

We appreciate support from corporations who believe in our mission to educate glaucoma patients and speed a cure. Intraocular pressure was very carefully monitored in the Ocular Hypertension Treatment Study, making it a reliable source for data. Sixty-three patients in the medically untreated hypertensive group underwent cataract surgery during the study; this chart compares their IOPs to control subjects who did not undergo cataract surgery.

Following cataract surgery IOPs dropped about 4 mmHg, and the effect persisted for several years. Adapted from Mansberger, et al. The IOPs of the untreated OHTS subjects hovered around 24 mmHg before surgery; the group that underwent phaco had a pressure drop of about 4 mmHg, which persisted for several years. Also of note, the data from the OHTS study, as well as the others already mentioned, showed that the strongest predictor of a significant IOP drop after cataract surgery was a higher starting IOP. One study, for example, found that patients with starting IOPs in the upper 20s experienced a six-point drop in IOP, on average; patients with a starting IOP in the upper teens only showed a 2.

Of course, most patients coming into cataract surgery with a known diagnosis of glaucoma are already on treatment, so using that data to guide clinical practice with a glaucoma patient is fraught with peril. After we did phaco, I gave them a drug holiday before reintroducing their glaucoma medications to see how much pressure-lowering the phaco provided.

My purely anecdotal experience was that their pressures did tend to drop a little; the majority of ocular hypertensive patients on treatment were able to stay off medications and still achieve the OHTS-specified percent IOP lowering for about a year. But after a year, most of them had to go back on medication to reach the OHTS-defined target. This supports the conclusion that pressure-lowering after cataract surgery is not a long-term effect in glaucoma patients on medications.

Again, this is anecdotal; there is no solid clinical data to confirm my experience. Assuming a pressure drop does occur in a glaucoma patient following cataract surgery, what kind of pressure drop should you expect? Of course, a glaucoma patient could simply be returned to his preoperative medication regimen after cataract surgery. How quickly I restart medications depends on the severity of the disease; in some cases the patient may go back on drugs relatively quickly.

Generally, pressure spikes and other concerns are relatively manageable in the early postoperative period in this type of patient. If a patient is on multiple glaucoma medications before cataract surgery, my decision regarding whether or not to give the patient a drug holiday would be based on the indication for the multiple medications. A cataract surgery patient who already has a trabeculectomy or a tube shunt in place raises totally different concerns. In this study, mean intraocular pressure rose by 0.

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Adapted from Figure 1 in Swamynathan, et al. My perception, at least, is that a glaucoma drainage device is less likely to fail because of subsequent surgery than is a trabeculectomy.

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When performing phacoemulsification on a glaucoma patient with a tube or trabeculectomy, the following strategies can help ensure a good outcome: Is it a priority to have visual rehabilitation as quickly as possible? Or does the patient have a fellow eye that he can get along with just fine?

In terms of logistics, you have to consider what the patient wants and what he can manage. The postoperative care of such patients should not be delegated to others.

Can I Have Cataract Surgery If I Have Glaucoma?

I find it helpful to use the following preoperative checklist when making a decision about how to proceed with a glaucoma patient who needs cataract surgery: Before proceeding with the cataract surgery, you need to know how bad the glaucoma is. Knowing the pressure is not sufficient; you need to evaluate the optic nerve and visual fields. Perhaps gonioscopy has never been done on a patient; sometimes it was done years ago, and you need to reevaluate the condition of the angle. The presence of PAS might indicate that the pressure will not decrease following the cataract surgery, and you might need to perform goniosynechialysis or another type of procedure to deal with the angle closure.

It seems reasonable to consider using phaco alone as a means to reduce IOP in some glaucoma patients with mild disease; it may delay or avoid the need for a future trabeculectomy. Not every patient who is on one medication is the same. As noted earlier, factors such as how easy it is for the patient to come in for follow-up and the condition of the fellow eye must be considered when you decide how and when to proceed with the cataract surgery.

Make sure everyone is on the same page in terms of expectations.