Surgical management of coincident cataract and glaucoma

Current Opinion in Ophthalmology

Volumn 8, Issue 1, 1997, Pages 39-45

  Samuelson, Thomas W ^a,b  

^a Phillips Eye Institute   (United States)

^b UNIVERSITY OF MINNESOTA MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CATARACT; CATARACT EXTRACTION; GLAUCOMA; GLAUCOMA SURGERY; HUMAN; PHACOEMULSIFICATION; PRIORITY JOURNAL; REVIEW; SUTURE; TRABECULECTOMY;

EID: 0030914723     PISSN: 10408738     EISSN: None     Source Type: Journal    
DOI: 10.1097/00055735-199702000-00009     Document Type: Review

References (30)

1. Stewart W, Crinkley C, Carlson A: Results of combined phacoemulsification and trabeculectomy in patients with elevated preoperative intraocular pressures. J Glaucoma 1995, 4:164-169.
2. Broadway DC, Sturmer J, Grierson I, Hitchings RA. Reversal of the adverse effect of topical anti-glaucoma medication on the conjunctiva prior to trabeculectomy. Invest Ophthalmol Vis Sci 1994, 35:1914.
3. Carlson D, Barad J, Parsons M: Reduced vision secondary to pigmented cellular membranes on silicone intraocular lenses. Am J Ophthalmol 1995, 120:462-470. This is an interesting paper that describes nine patients who developed significant intraocular lens (IOL) precipitates following IOL implantation. Eight of the nine patients had combined cataract and glaucoma surgery. Seven of the nine patients had been on miotics preoperatively. All patients had a relatively early generation silicone IOL implanted. The authors do not indicate the denominator in their series. That is. we do not know how many patients were exposed to surgery that resulted in nine individuals with cellular membranes on their IOLs.
4. Shah S, Spalton D: Natural history of cellular deposits on the anterior intraocular lens surface. J Cataract Refract Surg 1995, 21:466-471. The authors utilized high-resolution specular microscopy to evaluate the intraocular lens (IOL) surface of 27 eyes following implantation of a polymethyl-methacrylate IOL. All eyes were otherwise normal. Postoperatively, IOLs were assessed for the presence of inflammatory cells. Two inflammatory cell types were seen: small cells and giant cells. Small cells were found on 81.5% of IOLs at 1 month and generally declined over the subsequent year. The second cell type, giant cells, were found on 73.1% of IOLs at 3 months. Again, the frequency of giant cell precipitates declined over the next year. The authors do not correlate clinical findings such as visual acuity with the presence of these inflammatory cells. However, they provide an excellent service to those of us who perform combined glaucoma surgery. The fact that the giant cells peaked at 3 months in this study suggests the need for long-term postoperative steroid use following combined glaucoma surgery.
5. Samuelson T, Lindstrom R: Combined glaucoma filtration surgery and phacoemulsification. Semin Ophthalmol 1992, 7:279-285.
6. Samuelson T: Management of coincident glaucoma and cataract Curr Opin Ophthalmol 1994, 5:85-92.
7. Samuelson T: Management of coincident glaucoma and cataract. Curr Opin Ophthalmol 1995, 6:14-21.
8. Samuelson T Evolving techniques and changing indications for combined cataract extraction and trabeculectomy. Curr Opin Ophthalmol 1995, 6:1-2.
9. Samuelson T: Management of coincident glaucoma and cataract. Curr Opin Ophthalmol 1996, 7:53-58.
10. Samuelson T: Management of coincident glaucoma and cataract Curr Opin Ophthalmol 1993, 4:90-96.
11. Shingleton B, Kalina P: Combined phacoemulsification, intraocular lens implantation, and trabeculectomy with a modified scierai tunnel and single-stitch closure. J Cataract Refract Surg 1995, 21:528-532. The authors present a novel approach to combined phacoemulsification and trabeculectomy. They utilize a formx-based conjunclival flap and a modification of the scleral tunnel incision. They attempt to preserve the standard scleral tunnel architecture to minimize astigmatism, A center T relaxing incision is made at the midpoint of the scleral tunnel in conjunction with a punch sclerostomy. This modification of the incision provides the necessary filtration, which is then titrated with a single horizontal mattress suture. The authors achieve good pressure control during the follow-up period which is relatively short at 7 months. The mean post-operative intraocular pressure was 16.0, which was a reduction of 5.0 + 2.4 mm Hg. There is no discussion in this paper regarding evaluation of astigmatism. The advantages of this technique are that it is more likely to be more tamiliar to most cataract surgeons.
12. Arnold P: No-stitch phacotrabeculectomy. J Cataract Refract Surg 1996, 22:253-260. The author describes his technique of "no-stitch phacotrabeculectomy". The results in this paper are excellent with both a no-stitch approach and a sutured approach No antimetabolites are utilized, and the eyes were generally not high risk. However, the author achieves good results with a posterior lip sclerectomy technique. My concern regarding this technique would be the reduced ability to titrate filtration afforded by current techniques involving argon laser suture lysis. However, it should be noted that the author did not experience significant postoperative complications despite the sutureless approach. The author did have a relatively high incidence of hyphema and attributed this to the reffux of blood into the anterior chamber due to relatively low pressure in the early perioperative period. Impressively, 92% of patients had a detectable bleb and 88% of patients were off of glaucoma medications a mean of 13.2 months postoperatively.
13. Shepard D: Consultation section. Ann Ophthatmol 1995, 27:236-238. This paper is a discussion regarding the preferred technique of combined cataract and glaucoma surgery for several prominent anterior segment surgeons, There are several pearls regarding this procedure, although no specific data are presented.
14. Shingleton B, Jacobson L, Kuperwaser M: Comparison of combined cataract and glaucoma surgery using planned extracapsular and phacoemulsification techniques. Ophthalmic Surgery Lasers 1995, 26:414. The authors compare 35 patients who underwent planned extracapsular cataract extraction, intraocular lens (IOL) implantation, and trabeculectomy with 37 eyes that underwent phacoemulsification, IOL implantation, and trabeculectomy. The minimum follow-up for both groups was 1 year, with a mean of 16 months. There was no significant difference between groups in terms of visual acuity. However, the intraocular pressure was significantly lower in eyes undergoing phacoemulsification. The authors conclude that combined glaucoma surgery and phacoemulsification result in a greater reduction of intraocular pressure than in similar surgery utilizing extracapsular cataract extraction.
15. Metz D, Ackerman S, Lish A, Kanarek I, Kosowsky K, Ackerman J: Phacotrabeculectomy with posterior chamber lens insertion in early glaucoma. Ann Ophthalmol J 1995, 27:231-235. The authors describe 35 eyes from 27 patients with early open-angle glaucoma and clinically significant cataract that underwent combined phacotrabeculectomy. The technique involved a fornix-based conjunctival flap and insertion of an all polymethyl-methacrylate posterior chamber lens. Eighty-nine percent of patients did not require medications postoperatively, with 1 year follow-up, whereas 11% of patients required only a β-blocker to control intraocular pressure. The authors conclude that phacotrabeculectomy with posterior chamber lens implantation is a safe and effective procedure in patients with visually significant cataract and early glaucoma.
16. Gimbel H, Meyer D, DeBroff B, Roux C, Feronsowicz M: Intraocular pressure response to combined phacoemulsification and trabeculotomy ab externo versus phacoemulsification alone in primary open-angle glaucoma. J Cataract Refract Surg 1995, 21:653-660. This paper compares combined phacoemulsification and trabeculotomy with phacoemulsification alone in patients with mild glaucoma and ocular hypertension. The patients undergoing the combined approach achieved lower intraocular pressures and were more likely able to eliminate glaucoma medications. Interestingly, the group undergoing phacoemulsification alone did not have a significant incidence of perioperative pressure spikes and in general did reasonably well. Also, patients with advanced glaucoma were excluded from this study. This author has been a pioneer in developing this procedure, which has found renewed interest, especially in the Japanese literature.
17. Bloomberg L: Modified trabeculectomy/trabeculotomy with no-stitch cataract surgery. J Cataract Refract Surg 1996, 22:14-22. The author describes a technique of combined no-stitch cataract extraction utilizing a scierai tunnel approach and trabeculotomy combined with modified trabeculectomy. The postoperative results are excellent, with 96% of patients achieving a reduction in their glaucoma medications and 86% requiring no medications posloperatively. Pressure control was independent of bleb formation, There was no control group in this report.
18. Saito Y, Oo A, Okamoto S, Kuwayama Y, Nakatani H: Glaucoma triple procedure comprising trabeculotomy with a fornix-based scierai flap. Doc Ophthalmol 1995, 89:393-400. This report describes a unique procedure ol extracapsular cataract extraction and intraocular lens implantation combined with trabeculotomy utilizing a fornix-based scierai flap. The procedures were performed between 1988 and 1989 and techniques have changed since that time. It should be noted that 65% of patients were back on medications at 6 months. This does not compare favorably with more contemporary techniques. However, this paper provides additional support that trabeculotomy may be a viable procedure for the management of adult glaucomas. The mam advantage of this technique is the ability to control pressure without dependence on a filtration bleb.
19. Tanihara H, Negi A, Akimoto M, Nagata M: Long-term surgical results of combined trabeculotomy ab externo and cataract extraction. Ophthalmic Surg 1995, 26:316-324. This paper discusses relatively long-term data on combined trabeculectomy and cataract extraction. It is difficult to evaluate the results of this paper as one third of patients underwent intracapsular cataract extraction. This technique is generally not utilized at this time. However, the paper provides interesting long-term data regarding techniques that exceed the more contemporary phacoemulsification or extracapsular technique.
20. Smith R: A new technique for opening the canal of Schlemm. Br J Ophthalmol 1960, 44:370-375.
21. Uram M: Combined phacoemulsification, endoscopic ciliary process photocoagulation, and intraocular lens implantation in glaucoma management. New Ideas 1995, 26:346-352. The author describes his postoperative results in 10 patients undergoing combined Kelman phacoemulsification and intraocular lens implantation with endoscopic photocoagulation. The results in this paper are excellent, with surprisingly little perioperative inflammation. There is no control group in this series. A potential advantage of this technique is pressure control without the presence of a filtration bleb. If perioperative inflammation is minimal and pressure control reasonably predictable and sustained, this technique, which has not been embraced by the glaucoma community at large, may deserve another look.
22. Watson NJ, Winder S, Green FD: Pupil dilatation in the pseudoexfoliation syndrome. R Coll Ophthatmolog 1995, 9:341-343. The authors present additional evidence that pharmacologic pupil dilatation is abnormal in the pseudoexfoliation syndrome. They speculate that a "stiffening of the iris" or posterior synechias are responsible for this observation.
23. Asano N, Schlotzer-Schrehardf U, Naumann G: A histopathologic study of iris changes in pseudoexfoliation syndrome. Ophthalmology 1995, 102:1279-1290. The authors provide extensive histopathologic observations involving the anterior segment structures in eyes with the pseudoexfoliation syndrome. They conclude that the poor dilatation of the pupil in exfoliative eyes may be the result of several factors, including atrophy of iris dilator muscle and lack of iris stromal elasticity due to accumulation of exfoliative material.
24. Fischel J, Wishart M: Spontaneous complete dislocation of the lens in pseudoexfoliation syndrome. Eut J Implant Ref Surg 1995, 7:31-33. This paper describes complete, spontaneous dislocation of the lens due to the exfoliation syndrome. This is a well-recognized occurrence. I have personally seen spontaneous and complete dislocation of the natural lens, as well as spontaneous, complete dislocation of an intraocular lens that was well positioned in the capsular bag. The latter case was referred with a presumptive diagnosis of aphakia. Careful inspection found the intraocular lens to be contained within the capsular bag that spontaneously dislocated 6 years after cataract surgery.
25. Puska P: Exfoliation syndrome: a risk factor for glaucoma and lens opacification. Acta Ophthalmol Scand 1996, 100. The author notes an increased tendency towards lens opacity associated with capsular glaucoma, as well as in eyes that have exfoliation, but no glaucoma.
26. Puska P: The amount of lens exfoliation and chamber-angle pigmentation in exfoliation syndrome with or without glaucoma. Acta Ophthalmol Scand 1995, 73:226-232. This paper compares 63 patients with unilateral exfoliation syndrome (without glaucoma) and 35 patients with unilateral capsular glaucoma. Angle pigmentation was more pronounced in eyes with capsular glaucoma than in nonglaucomatous exfoliation eyes, despite the fact that the amount of exfoliative material was not different between groups. The authors postulate that the main risk factor for glaucoma in exfoliative eyes is the amount of chamber-angle pigmentation rather than the amount of exfoliative material present.
27. Kuchle M, Vinores S, Mahlow J, Green WR: Blood-aqueous barrier in pseudoexfoliation syndrome: evaluation by immunohistochemical staining of endogenous albumin. Graefes Arch Clin Exp Ophthalmol 1996, 234:12-18. This study utilized immunohistochemical staining of albumin to analyze the blood-aqueous barrier in 10 eyes with exfoliation without intraocular surgery compared with 10 age-matched control subjects. Based on their findings, the authors conclude the impairment of the blood-aqueous barrier in exfoliation can be localized to the level of the iris and, to a lesser extent, the ciliary body.
28. Kuchle M, Nguyen N, Hannappel E, Naumann G: The blood-aqueous barrier in eyes with pseudoexfoliation syndrome. Ophthalmic Res 1995, 27(suppl):136-142. This paper utilized laser flare cell meter to quantitate postoperative inflammation in eyes with pseudoexfoliation following trabeculectomy or cataract surgery. The authors add evidence to the ophthalmic literature suggesting that eyes with pseudoexfoliation have an abnormal blood-aqueous barrier and are more prone to postoperative inflammation.
29. Dinsmore S: Modified stretch technique for small pupil phacoemulsification with topical anesthesia. J Cataract Refract Surg 1996, 22:27-30. This paper describes a technique of pupillary stretch in eyes undergoing phacoemulsification under topical anesthesia. Although most ophthalmic surgeons do not utilize topical anesthesia for combined glaucoma procedures, the successful management of the pupil in phacoemulsification in patients with glaucoma is extremely important, and this paper provides useful information regarding this important subject.
30. Storr-Paulsen A, Perriard A, Vangsted P: Indications and efficacy of combined trabeculectomy and ertracapsular cataract extraction with intraocular lens implantation in cataract patients with coexisting open angle glaucoma. Acta Ophthalmol Scand 1995, 73:273-276. The authors review the results of combined extracapsular cataract extraction and intraocular lens implantation with trabeculectomy in 19 eyes. The surgical technique in this series involves nucleus expression rather than phacoemulsification. However, the pressure results in these cases were favorable and the authors conclude that there is justification for broadening the indications for performing combined glaucoma surgery.