July 2008

 

CATARACT/ IOL

 

In the trenches: one-eyed, cataract glaucoma patient with a coloboma


by Maxine Lipner Senior EyeWorld Contributing Editor

 

Dick Lindstrom is the most talented person I have ever met. He has been a spectacular voice for all of ophthalmology, in addition to being uniquely effective as a clinician, researcher, teacher, author, surgeon, consultant, business, and a friend to many people all over the world. In this month’s column, he describes a cataract patient who would be memorable in anybody’s experience, and so it is of interest, not only specifically, but also generally because of the lesson it teaches us about the combination of cataract and glaucoma in our patients. I think everybody will benefit from reading his column.

I. Howard Fine, MD, Column Editor

 

Sometimes a simple cataract approach can prevail in even a complex case

While not every cataract case is memorable, occasionally there is one that stands out. For Richard L. Lindstrom, M.D., Adjunct Professor Emeritus, University of Minnesota, Minneapolis, one such case that he remembers vividly involved a cataract patient who also had glaucoma and an iris, lens, and retinal coloboma. Such a case would likely be a bit more challenging than most under any circumstances but this patient had only one eye as result of problems with previous surgery. “She had undergone a combined cataract surgery trabeculectomy in her first eye about ten years earlier,” Dr. Lindstrom said. During this initial procedure the patient was plagued by one complication after another. “She developed hypotony, had a large hyphema and some blood got into the vitreous,” Dr. Lindstrom said. “Then that finally cleared and she developed a very thin bleb, she had a bleb leak, and then she developed an infectious blebitis secondary ophthalmitis and she lost the eye.”

As a result, when it came to the second eye she had resisted undergoing the combined surgery for many years. “Her doctors had been saying, ‘You need a combined cataract surgery with implantation trabeculectomy,” Dr. Lindstrom said. “Based upon her experience the first time around she was not very enthusiastic about that and kept saying, ‘No, no, no.’” As a result the patient’s vision decreased to 20/200 and she developed a very dense brunescent cataract. Her pressure was also only marginally controlled, hovering in the low 20’s, on three medications. She also had some glaucomatous damage. “She had a large field defect,” Dr. Lindstrom said. “Because of her retinal coloboma it was also a somewhat difficult field to follow although when I saw her she still had a pretty good residual field.”

Cataracts pressure link

At this point Dr. Lindstrom and his associates began to consider another option and started to look into the impact of cataract surgery alone on IOP. “What we found was that eye pressure is lowered following cataract surgery alone preoperative eye pressure,” Dr. Lindstrom said. “We discovered that in patients that have elevated pressure in the 23 to 30 mm Hg range that you can have a significant drop in pressure in the range of 6 to 7 mm Hg.” This was much higher than had previously been reported by others who had lumped patients with high and relatively low pressures together and determined that there was only a 2 to 3 mm Hg drop. The cataract itself can cause the pressure to significantly increase. “What we found is that those with higher pressures get a greater drop because the cataract as it grows does so anterior to posterior,” Dr. Lindstrom said. “It shallows the anterior chamber and basically crowds the trabecular meshwork, reducing the facility of the outflow.”

Armed with this information Dr. Lindstrom approached the patient about performing a simple cataract procedure. “I was able to say to her that, ‘Probably besides improving your vision by simply removing your cataract that we don’t have to do a glaucoma filtration procedure and you will probably have better pressure control and may be able to take less drops,” he said.

Complex maneuvers

Actually performing the procedure was a bit of a challenge. “Besides simply taking out the cataract we had to deal with the absence of the zonules so we needed to use a capsular tension ring,” Dr. Lindstrom said. “Also, she had a small pupil that didn’t dilate well so we had to use iris retractors.” This required doing phacoemulsification on the dense brunescent lens in a careful way. “We had to stop and put in viscoelastic a couple of extra times,” Dr. Lindstrom said. He also needed to repair her iris so that she would have a well-centered pupil after the lens was removed and the implant put in place. For this he used a couple of polypropylene sutures on a PC7 needle (Alcon, Fort Worth, Texas).

Despite the complexity of the procedure the patient ultimately fared very well with a significant reduction in her pressure, even while taking fewer medications.

”We did not get her off her medicines altogether and she simply takes one drop a day—Xalatan (latanoprost, Pfizer, New York),” Dr. Lindstrom said. “But she doesn’t have to take Timoptic (timolol maleate ophthalmic solution, Whitehouse Station, N.J.) or Alphagan (brimonidine tartrate ophthalmic solution, Allergan, Irvine, Calif.) anymore and now her pressure is measuring between 15 and 18 mm Hg on a single drop.” The patient’s vision improved to a best corrected result of 20/20 and an uncorrected one of approximately 20/30. Overall, Dr. Lindstrom sees the case as memorable for two reasons. Firstly, the case drove home what a large impact a cataract can have on pressure. “It really reaffirmed for me that probably one of the best glaucoma operations available to today is simply to remove the patient’s cataract,” Dr. Lindstrom said. “With modern cataract surgery and clear corneal incisions if you do need a filtration procedure later you can do it as a separate procedure with a high success rate because you haven’t damaged any conjunctiva.”

Secondly, the case reaffirmed for Dr. Lindstrom how the core skills available to today’s surgeon can usually be enough for managing even complex cases. “Here we needed some method of enlarging the pupil, a method to manage weak or absent zonules and the ability to reconstruct a pupil with a couple of polypropylene sutures,” he said.

Editors’ note: Dr. Lindstrom has financial interests with Advanced Medical Optics (Sana Ana, Calif.), Alcon (Fort Worth, Texas), and Bausch & Lomb (Rochester, N.Y.).

Contact

Lindstrom: 612-813-3633, rllindstrom@mneye.com

In the trenches: one-eyed, cataract glaucoma patient with a coloboma In the trenches: one-eyed, cataract glaucoma patient with a coloboma
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