touchOPHTHALMOLOGY touchOPHTHALMOLOGY
Anterior Segment
Read Time: < 1 min

Combined Surgery in the Treatment of Patients with Cataract and Primary Open-angle Glaucoma

Copy Link
Published Online: Aug 5th 2012 European Ophthalmic Review, 2012;6(4):218-221 DOI: http://doi.org/10.17925/EOR.2012.06.04.218
Authors: Giovanni Taibbi, Gianmarco Vizzeri
Quick Links:
Abstract
Article
Article Information
Abstract:
Overview

Cataract and glaucoma are the two leading causes of blindness worldwide and frequently co-exist in the ageing population. No uniform recommendations can be proposed when the two conditions are associated. In the presence of a visually significant cataract and uncontrolled glaucoma, clinicians should consider performing combined cataract surgery and trabeculectomy. Numerous phacotrabeculectomy techniques have been proposed. However, in the absence of strong evidence in support of a specific technique, surgeons’ preference and experience may dictate the choice. Unless contraindicated, mitomycin-C should be considered in all combined procedures. In addition, novel and minimally invasive glaucoma surgical procedures, such as ab interno trabeculotomy, have recently emerged and gained in popularity. In general, these procedures have shown the potential to be combined with phacoemulsification to further lower intraocular pressure (IOP) with relatively few post-operative complications. However, available data suggest that these techniques seem unlikely to be able to achieve a degree of IOP reduction comparable with that of trabeculectomy. Rigorous studies are necessary to better understand the long-term efficacy and safety profile of these novel procedures, when performed alone or in combination with cataract surgery.

Keywords

Cataract, intraocular pressure, primary open angle glaucoma, phacoemulsification, surgery, trabeculectomy

Article:

Cataract and glaucoma are the two leading causes of blindness worldwide and frequently co-exist in the ageing population. Adequate management of these two conditions may require surgical intervention. In general, cataract extraction is necessary in case of visually significant lens opacity, while surgery for glaucoma is indicated when optimum medical therapy and/or laser surgery fails to sufficiently lower intraocular pressure (IOP) or a patient does not have access to or cannot comply with medical therapy.1

As a general rule, the management of glaucoma patients should be directed towards those treatments aimed at achieving an individualised target IOP safely and efficaciously. The presence of concomitant and visually significant cataracts can challenge the decision-making process, so that clinicians need to determine how cataract extraction would best fit the management of patients with glaucoma. In particular, when a combined surgical approach for cataract and glaucoma is desired, the timing of surgery and an accurate procedure selection are important aspects to consider. Phacotrabeculectomy techniques are not standardised and the way the procedure is performed is largely dictated by the surgeon’s preference and experience.1 Furthermore, novel and minimally invasive surgical approaches to lower IOP have been recently introduced and may be combined with phacoemulsification, representing a potential alternative to phacotrabeculectomy. This review is aimed at summarising current evidence on combined surgery in the treatment of patients with cataract and primary open angle glaucoma.

To view the full article in PDF or eBook formats, please click on the icons above.

Article Information:
Disclosure

The authors have no conflicts of interest to declare.

Correspondence

Gianmarco Vizzeri, Department of Ophthalmology and Visual Sciences, The University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555-1106, US. E: givizzer@utmb.edu

Received

2012-08-01T00:00:00

References

  1. Weinreb RN, Crowston JG (eds), Glaucoma Surgery: Open Angle Glaucoma. World Glaucoma Association Consensus Series – 2, Amsterdam, The Netherlands: Kugler Publications, 2005.
  2. Kim KS, Kim JM, Park KH, et al., The effect of cataract surgery on diurnal intraocular pressure fluctuation, J Glaucoma, 2009;18(5):399–402.
  3. Shingleton BJ, Pasternack JJ, Hung JW, O’Donoghue MW, Three and five year changes in intraocular pressures after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients, J Glaucoma, 2006;15(6):494–8.
  4. Thirumalai B, Baranyovits PR, Intraocular pressure changes and the implications on patient review after phacoemulsification, J Cataract Refract Surg, 2003;29(3):504–7.
  5. Tennen DG, Masket S, Short-and long-term effect of clear corneal incisions on intraocular pressure, J Cataract Refract Surg, 1996;22(5):568–70.
  6. Law SK, Riddle J, Management of cataracts in patients with glaucoma, Int Ophthalmol Clin, 2011;51(3):1–18.
  7. Berdahl JP, Cataract surgery to lower intraocular pressure, Middle East Afr J Ophthalmol, 2009;16(3):119–22.
  8. Meyer MA, Savitt ML, Kopitas E, The effect of phacoemulsification on aqueous outflow facility, Ophthalmology, 1997;104(8):1221–7.
  9. Poley BJ, Lindstrom RL, Samuelson TW, Schulze R Jr, Intraocular pressure reduction after phacoemulsification with intraocular lens implantation in glaucomatous and nonglaucomatous eyes: evaluation of a causal relationship between the natural lens and open-angle glaucoma, J Cataract Refract Surg, 2009;35(11):1946–55.
  10. Poley BJ, Lindstrom RL, Samuelson TW, Long-term effects of phacoemulsification with intraocular lens implantation in normotensive and ocular hypertensive eyes, J Cataract Refract Surg, 2008;34(5):735–42.
  11. Vizzeri G, Weinreb RN, Cataract surgery and glaucoma, Curr Opin Ophthalmol, 2010;21(1):20–4.
  12. Issa SA, Pacheco J, Mahmood U, et al., A novel index for predicting intraocular pressure reduction following cataract surgery, Br J Ophthalmol, 2005;89(5):543–6.
  13. Mathalone N, Hyams M, Neiman S, et al., Long-term intraocular pressure control after clear corneal phacoemulsification in glaucoma patients, J Cataract Refract Surg, 2005;31(3):479–83.
  14. Shingleton BJ, Gamell LS, O’Donoghue MW, et al., Long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspect and glaucoma patients, J Cataract Refract Surg, 1999;25(7):885–90.
  15. Kim DD, Doyle JW, Smith MF, Intraocular pressure reduction phacoemulsification cataract extraction with posterior chamber lens implantation in glaucoma patients, Ophthalmic Surg Lasers, 1999;30(1):37–40.
  16. Cinotti DJ, Fiore PM, Maltzman BA, et al., Control of intraocular pressure in glaucomatous eyes after extracapsular cataract extraction with intraocular lens implantation, J Cataract Refract Surg, 1988;14(6):650–3.
  17. Handa J, Henry JC, Krupin T, Keates E, Extracapsular cataract extraction with posterior chamber lens implantation in patients with glaucoma, Arch Ophthalmol, 1987;105(6):765–9.
  18. Altan-Yaycioglu R, Canan H, Pelit A, Akova YA, Intraocular pressure after phacoemulsification in eyes with pseudoexfoliation, J Cataract Refract Surg, 2009;35(5):952–4.
  19. Shingleton BJ, Crandall AS, Ahmed II, Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses, J Cataract Refract Surg, 2009;35(6):1101–20.
  20. Shingleton BJ, Nguyen BK, Eagan EF, et al., Outcomes of phacoemulsification in fellow eyes of patients with unilateral pseudoexfoliation: single-surgeon series, J Cataract Refract Surg, 2008;34(2):274–9.
  21. Weinreb RN, Management of coexistent glaucoma and cataract. In: Mills RP, Weinreb RN (eds), Glaucoma Surgery: Principles and Techniques (Ophthalmology Monographs, 4), San Francisco, US: Oxford University Press, 1998;66–9.
  22. AGIS (Advanced Glaucoma Intervention Study) Investigators, The Advanced Glaucoma Intervention Study. 8: Risk of cataract formation after trabeculectomy, Arch Ophthalmol, 2001;119(12):1771–9.
  23. Mathew RG, Murdoch IE, The silent enemy: a review of cataract in relation to glaucoma and trabeculectomy surgery, Br J Ophthalmol, 2011;95(10):1350–4.
  24. Hylton C, Congdon N, Friedman D, et al., Cataract after glaucoma filtration surgery, Am J Ophthalmol, 2003;135(2):231–2.
  25. Lichter PR, Musch DC, Gillespie BW, et al., Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery, Ophthalmology, 2001;108(11):1943–53.
  26. Klink J, Schmitz B, Lieb WE, et al., Filtering bleb function after clear cornea phacoemulsification: a prospective study, Br J Ophthalmol, 2005;89(5):597–601.
  27. Manoj B, Chako D, Khan MY, Effect of extracapsular cataract extraction and phacoemulsification performed after trabeculectomy on intraocular pressure, J Cataract Refract Surg, 2000;26(1):75–8.
  28. Seah SK, Jap A, Prata JA Jr, et al., Cataract surgery after trabeculectomy, Ophthalmic Surg Lasers, 1996;27(7):587–94.
  29. Cioffi GA, Friedman DS, Pfeiffer N, Combined cataract/trabeculectomy. In: Weinreb RN, Crowston JG (eds), Consensus Series – 2. Glaucoma Surgery: Open Angle Glaucoma, The Hague, The Nederlands: Kugler Publications, 2005;65–72.
  30. Levkovitch-Verbin H, Habot-Wilner Z, Burla N, et al., Intraocular pressure elevation within the first 24 hours after cataract surgery in patients with glaucoma or exfoliation syndrome, Ophthalmology, 2008;115(1):104–8.
  31. Shingleton BJ, Rosenberg RB, Teixeira R, et al., Evaluation of intraocular pressure in the immediate postoperative period after phacoemulsification, J Cataract Refract Surg, 2007;33(11):1953–7.
  32. Vass C, Menapace R, Surgical strategies in patients with combined cataract and glaucoma, Curr Opin Ophthalmol, 2004;15(1):61–6.
  33. Buys YM, Chipman ML, Zack B, et al., Prospective randomized comparison of one- versus two-site Phacotrabeculectomy two-year results, Ophthalmology, 2008;115(7):1130–3.e1.
  34. Nassiri N, Nassiri N, Rahnavardi M, et al., A comparison of corneal endothelial cell changes after 1-site and 2-site phacotrabeculectomy, Cornea, 2008;27(8):889–94.
  35. Gdih GA, Yuen D, Yan P, et al., Meta-analysis of 1- versus 2-Site Phacotrabeculectomy, Ophthalmology, 2011;118(1):71–6.
  36. Zhao LQ, Zhu H, Phacotrabeculectomy meta-analysis, Ophthalmology, 2011;118(6):1216.e1–2.
  37. Nassiri N, Nassiri N, Mohammadi B, et al., Comparison of 2 surgical techniques in phacotrabeculectomy: 1 site versus 2 sites, Eur J Ophthalmol, 2010;20(2):316–26.
  38. Cotran PR, Roh S, McGwin G, Randomized comparison of 1-Site and 2-Site phacotrabeculectomy with 3-year follow-up, Ophthalmology, 2008;115(3):447–54.e1.
  39. Shingleton BJ, Price RS, O’Donoghue MW, et al., Comparison of 1-site versus 2-site phacotrabeculectomy, J Cataract Refract Surg, 2006;32(5):799–802.
  40. Jampel HD, Friedman DS, Lubomski LH, et al., Effect of technique on intraocular pressure after combined cataract and glaucoma surgery: An evidence-based review, Ophthalmology, 2002;109(12):2215–24.
  41. Borggrefe J, Lieb W, Grehn F, A prospective randomized comparison of two techniques of combined cataractglaucoma surgery, Graefes Arch Clin Exp Ophthalmol, 1999;237(11):887–92.
  42. el Sayyad F, Helal M, el-Maghraby A, et al., One-site versus 2-site phacotrabeculectomy: a randomized study, J Cataract Refract Surg, 1999;25(1):77–82.
  43. Wyse T, Meyer M, Ruderman JM, et al., Combined trabeculectomy and phacoemulsification: a one-site vs a two-site approach, Am J Ophthalmol, 1998;125(3):334–9.
  44. Kozobolis VP, Siganos CS, Christodoulakis EV, et al., Two-site phacotrabeculectomy with intraoperative mitomycin-C: fornix- versus limbus-based conjunctival opening in fellow eyes, J Cataract Refract Surg, 2002;28(10):1758–62.
  45. Shingleton BJ, Chaudhry IM, O’Donoghue MW, et al., Phacotrabeculectomy: limbus-based versus fornix-based conjunctival flaps in fellow eyes, Ophthalmology, 1999;106(6):1152–5.
  46. Berestka JS, Brown SV, Limbus- versus fornix-based conjunctival flaps in combined phacoemulsification and mitomycin C trabeculectomy surgery, Ophthalmology, 1997;104(2):187–96.
  47. Tezel G, Kolker AE, Kass MA, et al., Comparative results of combined procedures for glaucoma and cataract: II. Limbusbased versus fornix-based conjunctival flaps, Ophthalmic Surg Lasers, 1997;28(7):551–7.
  48. Stewart WC, Crinkley CM, Carlson AN, Fornix- vs. limbus-based flaps in combined phacoemulsification and trabeculectomy, Doc Ophthalmol, 1994;88(2):141–51.
  49. de Barros DS, Da Silva RS, Siam GA, et al. Should an iridectomy be routinely performed as a part of trabeculectomy? Two surgeons’ clinical experience, Eye (Lond), 2009;23(2):362–7.
  50. Kaplan-Messas A, Cohen Y, Blumenthal E, et al., Trabeculectomy and phaco-trabeculectomy with and without peripheral iridectomy, Eur J Ophthalmol, 2009;19(2):231–4.
  51. Shingleton BJ, Chaudhry IM, O’Donoghue MW, Phacotrabeculectomy: peripheral iridectomy or no peripheral iridectomy?, J Cataract Refract Surg, 2002;28(6):998–1002.
  52. WilkinsM, Indar A,Wormald R, Intra-operative Mitomycin C for glaucoma surgery, Cochrane Database Syst Rev, 2005;(4):CD002897.
  53. Shin DH, Ren J, Juzych MS, et al., Primary glaucoma triple procedure in patients with primary open-angle glaucoma: the effect of mitomycin C in patients with and without prognostic factors for filtration failure, Am J Ophthalmol, 1998;125(3):346–52.
  54. Carlson DW, Alward WL, Barad JP, et al., A randomized study of mitomycin augmentation in combined phacoemulsification and trabeculectomy, Ophthalmology, 1997;104(4):719–24.
  55. Cohen JS, Greff LJ, Novack GD, et al., A placebo-controlled, double masked evaluation of mitomycin C in combined glaucoma and cataract procedures, Ophthalmology, 1996;103(11):1934–42.
  56. Desai MA, Gedde SJ, Feuer WJ, et al., Practice preferences for glaucoma surgery: a survey of the American Glaucoma Society in 2008, Ophthalmic Surg Lasers Imaging, 2011;42(3):202–8.
  57. Nassiri N, Nassiri N, Sadeghi Yarandi S, et al., Combined phacoemulsification and Ahmed valve glaucoma drainage implant: a retrospective case series, Eur J Ophthalmol, 2008;18(2):191–8.
  58. Chung AN, Aung T, Wang JC, et al., Surgical outcomes of combined phacoemulsification and glaucoma drainage implant surgery for Asian patients with refractory glaucoma with cataract, Am J Ophthalmol, 2004;137(2):294–300.
  59. Hoffman KB, Feldman RM, Budenz DL, et al., Combined cataract extraction and Baerveldt glaucoma drainage implant: indications and outcomes, Ophthalmology, 2002;109(10):1916–20.
  60. Molteno AC, Whittaker KW, Bevin TH, et al., Otago Glaucoma Surgery Outcome Study: long term results of cataract extraction combined with Molteno implant insertion or trabeculectomy in primary glaucoma, Br J Ophthalmol, 2004;88(1):32–5.
  61. Francis BA, Singh K, Lin SC, et al., Novel glaucoma procedures: a report by the American Academy of Ophthalmology, Ophthalmology, 2011;118(7):1466–80.
  62. Godfrey DG, Fellman RL, Neelakantan A, Canal surgery in adult glaucomas, Curr Opin Ophthalmol, 2009;20(2):116–21.
  63. Grant WM, Experimental aqueous perfusion in enucleated human eyes, Arch Ophthalmol, 1963;69:783–801.
  64. Fluorouracil Filtering Surgery Study Group, Five-year follow-up of the Fluorouracil Filtering Surgery Study, Am J Ophthalmol, 1996;121(4):349–66.
  65. Francis BA, Minckler D, Dustin L, et al., Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma: initial results, J Cataract Refract Surg, 2008;34(7):1096–103.
  66. Fea AM, Phacoemulsification versus phacoemulsification with micro-bypass stent implantation in primary open-angle glaucoma: randomized double-masked clinical trial, J Cataract Refract Surg, 2010;36(3):407–12.
  67. Samuelson TW, Katz LJ, Wells JM, et al., Randomized evaluation of the trabecular micro-bypass stent with phacoemulsification in patients with glaucoma and cataract, Ophthalmology, 2011;118(3):459–67.
  68. Spiegel D, Wetzel W, Neuhann T, et al., Coexistent primary open-angle glaucoma and cataract: interim analysis of a trabecular micro-bypass stent and concurrent cataract surgery, Eur J Ophthalmol, 2009;19(3):393–9.
  69. Kanner EM, Netland PA, Sarkisian SR Jr, et al., Ex-PRESS miniature glaucoma device implanted under a scleral flap alone or combined with phacoemulsification cataract surgery, J Glaucoma, 2009;18(6):488–91.
  70. Rivier D, Roy S, Mermoud A, Ex-PRESS R-50 miniature glaucoma implant insertion under the conjunctiva combined with cataract extraction, J Cataract Refract Surg, 2007;33(11):1946–52.
  71. Traverso CE, De Feo F, Messas-Kaplan A, et al., Long term effect on IOP of a stainless steel glaucoma drainage implant (Ex-PRESS) in combined surgery with phacoemulsification, Br J Ophthalmol, 2005;89(4):425–9. Erratum in: Br J Ophthalmol, 2005;89(5):645.
  72. Shingleton B, Tetz M, Korber N, Circumferential viscodilation and tensioning of Schlemm canal (canaloplasty) with temporal clear corneal phacoemulsification cataract surgery for open-angle glaucoma and visually significant cataract: one-year results, J Cataract Refract Surg, 2008;34(3):433–40.
  73. Al Sabti K, Raizada S, Al Abduljalil T, Cataract surgery assisted by anterior endoscopy, Br J Ophthalmol, 2009;93(4):531–4.
  74. Barkana Y, Morad Y, Ben-nun J, Endoscopic photocoagulation of the ciliary body after repeated failure of trans-scleral diode-laser cyclophotocoagulation, Am J Ophthalmol, 2002;133(3):405–7.
  75. Shaarawy T, Grehn F, Sherwood M (eds), Guidelines on design and reporting of glaucoma surgical trials, 2009. Available at: www.worldglaucoma.org/Download/ dl_files.php?id=1 (accessed 9 January 2012).

Further Resources

Share this Article
Related Content In Anterior Segment
  • Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72