OCT 2013

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

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Page 16 of 134

A S C R S World view Combined surgery: Still challenging after all these years T here 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 glaucoma—the goal was to assess the risk of hip fractures following cataract surgery. The detecReay H. Brown, MD, tion of the high rate of glaucoma among cataract glaucoma editor 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 IOLs—or 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 cornea—more 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 Reference 1. Tseng VL, Yu F, Lum F, Coleman, AL, JAMA 2012;308(5): 493-501. The official publication of the American Society of Cataract & Refractive Surgery October 2013 Volume 18 • No. 10 P U B L I S H I N G   S TA F F Publisher Matt Young don@eyeworld.org Enette Ngoei Donald R. Long Editorial Editor Jena Passut jena@eyeworld.org Managing Editor Stacy Majewicz stacy@eyeworld.org Senior Staff Writer Erin Boyle erin@eyeworld.org Malaysia Dublin Rich Daly Arlington, Virginia Senior Contributing Writer Maxine Lipner Nyack, New York Advertising Sales ASCRSMedia 4000 Legato Road Suite 700 Fairfax, VA 22033 ellen@eyeworld.org 703-591-2220 fax: 703-591-0614 eyeworld@eyeworld.org www.eyeworld.org Production Advertising Sales Graphic Designer Jeff Brownstein Julio Guerrero jeff@eyeworld.org julio@eyeworld.org 703-788-5745 Production Manager Paul Zelin Staff Writer Ellen Stodola Cathy Stern cathy@eyeworld.org 703-383-5702 Production Assistant Daniela Galeano daniela@eyeworld.org Contributing Writers Vanessa Caceres Lakeland, Florida Michelle Dalton Reading, Pennsylvania paul@eyeworld.org 703-383-5729 Classified Sales Cathy Stern cathy@eyeworld.org 703-383-5702 EyeWorld Special Projects and Events Jessica Donohoe jessica@eyeworld.org 703-591-2220 ASCRS Publisher: EYEWORLD (ISSN 1089-0084) is published monthly by ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; telephone: 703-591-2220; fax: 703-591-0614. 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