EyeWorld India December 2013 Issue

20 EWAP CAtArACt/IOL December 2013 The comprehensive cataract surgeon and glaucoma by Kerry D. Solomon, MD With 20% of cataract cases having concomitant glaucoma or ocular hypertension, cataract surgeons are now also treating glaucoma W ith the rapid introduction of advanced technologies and techniques, the role of the comprehensive cataract surgeon continues to expand. Progressive clinical refinements, including small incision surgery and foldable lenses, have ushered in astigmatically neutral incisions. The use of limbal relaxing incisions to treat preexisting astigmatism and the introduction of multifocal, accommodating, toric, and aspheric IOLs have greatly improved visual outcomes for millions of patients. As new technologies are brought to market, comprehensive cataract surgeons continue to improve quality of life for a broadening range of patients. Glaucoma is the second leading cause of blindness, affecting more than 60 million people worldwide. 1 With approximately 20% of cataract cases having concomitant glaucoma and/or ocular hypertension (OHT), 2 it is logical that cataract surgeons are now also treating glaucoma. While severe glaucoma remains the purview of a glaucoma specialist, comprehensive cataract surgeons often take on the task of managing mild to moderate cases. Severe glaucoma or uncontrolled IOP, requiring the attention of a glaucoma specialist, is often treated with surgeries such as trabeculectomy or shunts. While these are the standard of care in extreme cases, the procedures are fraught with risks and side effects including hypotony and the Dr. Solomon presents at the 2013 ASCRS•ASOA Symposium & Congress. Source: EyeWorld continued on page 22 Edgar U. LEUENBERGER, MD Associate Professor, Asian Eye Institute and University of the East RM College of Medicine 9F Phinma Plaza, Rockwell Center, Makati City, Philippines Tel. no. +632-8982020 Fax no. +632-8982002 EUL@asianeyeinstitute.com G laucoma is a lifetime disease. Treatment should be accessible and effective for the long term. In patients with visually significant cataracts with coexisting mild to moderate open angle glaucoma, eye drops and/or laser surgery are acceptable treatment options. However, if the accompanying glaucoma is severe, a combined phacotrabeculectomy or staged procedure is indicated. Medical intervention via eye drops has its pitfalls. Side effects due to the active ingredient and preservatives lead to poor compliance. Prolonged use of eye drops has been shown to affect the outcome of future trabeculectomies. Lasers, on the other hand, have limited applications and efficacy. Patients with mild to moderate glaucoma who develop cataracts present an opportunity for the comprehensive cataract surgeon to combine cataract surgery with a glaucoma procedure. The goal is to make this approach effective and safe to significantly reduce the burden of eye drops. Furthermore, the impact of this goal would put glaucoma care directly in the hands of the physician and not the patient’s. There are four U.S. FDA-approved new treatment modalities which could be adopted into the combined approach. These are the Trabectome (NeoMedix Corporation, Tustin, Calif., USA), Canaloplasty (iScience Surgical, Menlo Park, Calif., USA), Endoscopic cyclophotocoagulation (Endo Optiks, Little Silver, NJ, USA), and iStent (Glaukos). All show marked IOP lowering as opposed to cataract surgery alone. However, more prospective, long-term trials are needed to establish their reliability in reproducing good clinical outcomes in all patient groups. In the current scenario, about 5 to 10% of patients requiring cataract surgery are on anti-glaucoma medications. This translates to a significant number of patients who will require combined phaco-minimally invasive glaucoma surgery. Lastly, the comprehensive cataract surgeon should be aware of the following limitations of the combined approach: a) access to training and capital investment, b) cost to the patient, c) IOP lowering to mid to high teens as the best possible outcome, and d) eye drops and trabeculectomy may still be needed if the intraocular pressure remains uncontrolled. Therefore, individualization of treatment and detailed discussion of realistic expectations for both physician and patient are keys to success. Editors’ note: Dr. Leuenberger has no financial interests related to his comments. Views from Asia-Pacific