October 2013




Combined surgery: Still challenging after all these years


Reay H. Brown, MD, glaucoma editor


There are approximately 3.5 million cataract operations performed each year in the U.S. A recent review of 410,809 Medicare patients who had undergone cataract surgery found that 22.6% also had a diagnosis of glaucoma.1 This striking number came from a study that had nothing to do with glaucomathe goal was to assess the risk of hip fractures following cataract surgery. The detection of the high rate of glaucoma among cataract surgery patients was an incidental finding in a paper concerned with the epidemiology of hip fractures. If we apply the 22.6% rate to our 3.5 million cataract surgeries, we have up to 791,000 patients who may benefit from some type of glaucoma surgery combined with their cataract surgery.

The prospect of hundreds of thousands of cataract patients who would be grateful for a surgical solution to their glaucoma gives ophthalmologists a huge opportunity. This issue of EyeWorld addresses the range of available options for combining cataract surgery with a glaucoma intervention. Drs. Netland, Herndon, Panarelli, Rhee, and Condon review the use of the EX-PRESS device. This is probably the go-to device for patients with higher pressures and more advanced levels of visual field loss. Fortunately, this group is just the tip of the glaucoma iceberg. Most glaucoma patients are in the mild-to-moderate range where we can perform less invasive procedures with lower risk. With the FDA approval of the iStent, surgeons have access to a MIGS device for the first time. In the search for increasing efficacy, Drs. Parekh, Sarkisian, Radcliffe, and Mayer are combining implantation of the iStent with endocyclophotocoagulation (ECP). These innovative surgeons are very encouraged by their early results. The Trabectome, another MIGS procedure, also combines easily with cataract surgery. Drs. Fellman, Rhee, Loewen, and Condon review the current status of Trabectome surgery and how they use it in combined procedures.

It didn't take long for femtosecond cataract surgery to be combined with iStent implantation. Drs. Berdahl, Wiley, and Radcliffe describe their experience in combining these two breakthrough procedures. The safety of the iStent makes it very compatible with refractive cataract surgery. In patients with mild-to-moderate glaucoma we have the luxury of aiming to enhance their lives, whereas in patients with advanced disease our options may be much more limited. This permits us to have goals like getting patients off of a glaucoma medication or two and correcting vision without the need for glasses. The iStent works very well with toric IOLsor even presbyopia-correcting lenses if patients don't have significant glaucoma damage. Visualizing the angle anatomy is a key step to successful implantation of the iStent and other MIGS devices. Drs. Hill, Vold, and Radcliffe review pearls for using their intraoperative gonioscopy lenses, while Dr. Radcliffe shares how he uses endoscopy for iStent implantation. Dr. Hill was one of the inventors of the iStent, and the Hill lens has probably been the most popular for implanting the iStent. The TVG lens was developed by Dr. Vold and has some valuable new features. The main contact with the eye is through a modified Thornton ring that grips the sclera and allows the eye to be rotated by the surgeon. The TVG lens rests lightly on the corneamore with gravity than direct pressure. This may reduce the tendency for the chamber to shallow as the iStent is being implanted into the canal. The gonio lens and angle visualization components of MIGS will continue to be an area of exciting innovation.

Combined surgery has come a long way since the days of extracaps and taking a surgical bite out of the posterior lip of the cataract incision and hoping for the best. But challenges continue. The opportunity to help hundreds of thousands of glaucoma patients during their cataract surgery will hopefully provide the critical incentive for surgeons and industry to continue to develop better and better treatment options.

Reay H. Brown, MD, glaucoma editor


1. Tseng VL, Yu F, Lum F, Coleman, AL, JAMA 2012;308(5): 493-501.

Combined surgery: Still challenging after all these years Combined surgery: Still challenging after all these years
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