GLAUCOMA EWAP MARCH 2024 33 W hen performing cataract surgery on patients who have a functioning trabeculectomy, there may be an increased risk of trabeculectomy failure. Michael Boland, MD, PhD, and Erin Boese, MD, discussed this risk and how to approach patients. Dr. Boland said it’s important to be sure patients are aware that there is an increased risk that the trabeculectomy will fail if you do surgery, including cataract surgery. In some cases, the trabeculectomy may not be working optimally preop, and cataract surgery may be a good opportunity to revive it. Dr. Boland would consider some sort of bleb needling procedure at the time of cataract surgery. He said that since MIGS procedures generally don’t get the pressure as low as trabeculectomy, he usually wouldn’t choose to do cataract surgery plus MIGS if the trabeculectomy failed. He usually tries the needling procedure first because if the patient needed lower pressures to begin with, you’re much less likely to get that with a MIGS procedure. However, the caveat that Dr. Boland mentioned was patients who may have had trabeculectomy a long time ago when fewer surgical options were available. If you decide that the pressure doesn’t need by Ellen Stodola Editorial Co - Director Contact information Boese: erin-boese@uiowa.edu Boland: michael_boland@meei.harvard.edu to be that low, Dr. Boland suggested that the surgeon try a less invasive procedure if that trabeculectomy fails. “If your target is not 12 but maybe 18, I would potentially consider some other kind of procedure at the same time,” he said. “I tend to think of MIGS as important for certain targets, but they’re not currently interchangeable with trabeculectomy.” Erin Boese, MD, said that cataract surgery with a wellfunctioning trabeculectomy can be particularly tricky for a couple of reasons: the risk of bleb failure and errors/variability in the IOL calculations. In both cases, a good preoperative conversation is necessary to manage expectations appropriately. “What I worry about the most is that the cataract surgery may cause the trabeculectomy to not work as well or to fail entirely,” she said. “There are things that can be done to minimize this, but it can still happen even when all precautions are taken.” Another important preoperative consideration has to do with IOL calculations. If the IOP is on the low side from a well - functioning bleb, Dr. Boese said two things may cause the IOL calculations to be off. One is that a softer eye is often a bit shorter. “If the IOP increases following the surgery and the axial length increased, you may have a myopic surprise, sometimes by a significant amount,” she said. The other aspect that can be off is the astigmatism. “A soft eye will often have regular with - the - rule astigmatism, something that resolves when the IOP is Complications in cataract surgery with a functioning trabeculectomy This article originally appeared in the December 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Needling of a focal trabeculectomy bleb at the time of cataract surgery. The anterior chamber infusion helps the surgeon identify a successful needling by producing a fluid wave into the bleb as adheasions are lysed. Source: Michael Boland, MD, PhD
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