Eyeworld

NOV 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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November 2012 Cataract/glaucoma combined surgeries February 2011 EW FEATURE 39 and will continue to prescribe medications as a first-line therapy. With an overall percentage reduction hovering around 16-17%, "the results were similar to what we find with carbonic anhydrase inhibitor or alpha agonist response rates as far as efficacy, so it's like adding one of the weaker glaucoma drugs without having to add it," Dr. Herndon said. Patients with higher IOPs tended to have the greatest lowering effect post-cataract surgery, and Dr. Mansberger told EyeWorld "these pa- tients may have a greater capacity to lower pressure after cataract surgery than those with normal tension glaucoma. For some reason, their trabecular meshwork isn't function- ing as well. After surgery, the mesh- work may provide more outflow facility for several reasons including opening the angle and stimulating the meshwork to work better." Fitting cataract surgery into treatment regimens By no means are the authors of the paper suggesting cataract surgery be a first-line treatment in all cases, but it should be considered, they said. Dr. Mundorf will continue to offer medications as a first-line treat- ment, but "if a person has border- line IOPs and the primary complaint is related to cataract, I might pro- ceed with the surgery and then re- evaluate the IOP to determine which Poll size: 376 path to take. I do believe I get more drop in IOP with a trabeculectomy than cataract surgery and more with the combination of cataract and trabeculectomy than cataract alone," he said. "I don't get any additional lowering, in the majority of my cases, by doing both the cataract and trab versus the trab alone." Dr. Samuelson will offer cataract surgery as one option, but only if the patient has visual symptoms from the cataract. Otherwise, "I suggest using conservative means until they do have symptoms. I think medications and selective laser trabeculoplasty (SLT) are perfect for that purpose. When there's asymp- tomatic lens opacity, I favor buying time with medications and laser." In advanced glaucoma, however, "patients have far less optic nerve reserve, and we must be careful that we don't delay definitive treatment too long. We don't have the luxury to spend too much time on these more conservative measures," he said, and continues to recommend trabeculectomy in those instances. If he's concerned about a con- version to primary open-angle glau- coma from ocular hypertension, Dr. Herndon said lasers—in particular, SLT—now get "more play in my practice." For patients with early glaucoma and who are treatment- naïve, "I'll immediately offer them the option of drops or SLT. Some studies have found SLT will be more cost effective in the long run for patients and for society. Now if the patient also has a little cataract, I won't hesitate to consider doing cataract surgery by itself," he said. If patients are only marginally controlled on medication and want cataract surgery, Dr. Mundorf suggested proceeding with the surgery, and re-evaluating the level of IOP control gained around 6-8 weeks post-op before adding another med- ication, laser, or incisional surgery. Cataract surgery can, indeed, be a means of "giving patients with oc- ular hypertension or early glaucoma a drug holiday for a few years," Dr. Brandt said, but said most patients will need to be back on meds after that timeframe. Discuss options with the pa- tient, Dr. Mansberger said—if the patient doesn't mind the glaucoma drops, cataract surgery alone is viable. "Patients will tell you what they prefer, especially if they dislike the thought of being on glaucoma medications," he said. "The key thing in our paper, however, is that we did not randomize patients to cataract surgery. We can't compare if cataract surgery is better than laser or better than starting a drop on someone. And we can't take out a lens simply hoping for lower pressures—all of our patients had visually significant cataracts." Once a patient has glaucoma, "that changes the indication for cataract surgery," Dr. Samuelson said. "I'm more likely to remove a cataract than perform trabeculec- tomy in patients with glaucoma and marginally or modestly uncontrolled intraocular pressure. This paper, and others like it, have caused us to play that cataract card earlier in the man- agement of patients with elevated pressures." EW Reference 1. Mansberger SL, Gordon MO, Jampel H, et al. for the Ocular Hypertension Treatment Study Group. Reduction in intraocular pressure after cataract extraction: the Ocular Hyperten- sion Treatment Study. Ophthalmology. 2012;119:1826-31. Editors' note: Dr. Brandt has financial interests with Alcon (Fort Worth, Texas) and MSD (Merck-Europe) and receives grant support from the National Eye Institute (NEI). Dr. Herndon has no financial interests re- lated to this article. Dr. Mansberger has financial interests with Allergan (Irvine, Calif.) and Merck (Whitehouse Station, N.J.), and receives grant support from the NEI. Dr. Mundorf has no financial interests related to this article. Dr. Samuelson has financial interests with companies involved in micro-incisional glaucoma surgery. Contact information Brandt: jdbrandt@ucdavis.edu Herndon: hernd012@duke.edu Mansberger: smansberger@deverseye.org Mundorf: tommundorf@aol.com Samuelson: twsamuelson@mneye.com EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email daniela@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2012

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