EyeWorld India December 2017 Issue

EWAP FEATURE 15 Managing cataract with advanced glaucoma by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer AT A GLANCE • Cataract surgery combined with MIGS is safe and offers rapid visual recovery and better IOL lowering and medical burden than cataract surgery alone. • Clinicians reach for the CyPass, iStent, and XEN for their advanced glaucoma cases at the time of cataract surgery. • Trabeculectomy still has its place in glaucoma treatment despite large pressure reductions by MIGS. Combining MIGS procedures can improve their ef cacy while maintaining the safety pro le. One such combination begins with the implantation of a CyPass Micro-Stent. After CyPass implanation, a left-going iStent is implanted in an area of Schlemm’s canal thought to be occupied by scleral collector channels identi ed beforehand by nding the location of aqueous veins in the conjunctiva. Finally, a right-going iStent is implanted in a similar targeted fashion to maximize trabecular out ow. After completion, two well-placed iStents can be seen with ap- propriate re ux bleeding from Schlemm’s canal on either side of the central CyPass implant. Source (all): Won Kim, MD continued on page 16 December 2017 Devising a treatment strategy to lower IOP in glaucoma that has progressed to moderate and advanced stages in eyes with cataract now includes MIGS as a standard option P atients on maximal medical glaucoma therapy need new solu- tions. Drop regimens are tedious, with efficacy only as good as the patient’s adherence to the drop protocol and their pressure-lowering effect in hard cases dwindling. When cataract enters the picture, clinicians are in a favorable position to maxi- mize IOP reduction by implanting microinvasive glaucoma surgery (MIGS) devices or performing tra- beculectomy, if needed. Attitudes on trabeculectomy as the gold standard treatment for advanced glaucoma cases are divided, owing to the relative surgical simplicity and high efficacy of different MIGS implants. Yes to MIGS with cataract According to Won Kim, MD, Walter Reed National Mili- tary Medical Center, Bethesda, Maryland, MIGS has an im- portant role in cataract cases with advanced glaucoma. “This idea that MIGS procedures are somehow off limits for patients with advanced glaucoma is misguided,” Dr. Kim said. “Be- fore the advent of MIGS proce- dures, many glaucoma surgeons often did cataract surgery alone in the setting of patients with advanced glaucoma who were well controlled on multiple medications. Why? Because we knew adding a trabeculectomy or glaucoma drainage implant to the cataract surgery in this setting would greatly elevate the risk for complications and delay the visual recovery. We would also reason to ourselves that cataract surgery itself has a small chance of modest pressure lowering and thus we could help with glaucoma control without a trab or tube. Then, if we desired further IOP lowering or greater medication burden reduction, we could do a trabeculectomy or drainage implant as a separate procedure months later. Taking this mentality, why wouldn’t you consider doing MIGS with cata- ract surgery in this setting? You will give patients a procedure that is comparable to cataract surgery alone in terms of safety and rapid visual recovery while giving them a much better chance at lowering IOP and/or medication burden. You can always go back and do