EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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72 EW FEATURE February 2011 Combined glaucoma and cataract surgery October 2013 Combining iStent implantation with femto by Ellen Stodola EyeWorld Staff Writer AT A GLANCE • The iStent is used in combination with cataract surgery when a patient has mild to moderate glaucoma. • Both the iStent and femtosecond laser cataract surgery focus on safety and a quick recovery for patients. The iStent can be implanted at the end of a femto laser procedure because corneas are usually relatively clear after these surgeries. • The goals of limiting dependence on glasses and medications help make this a desirable combination for patients with both cataracts and glaucoma. Implantation of the iStent for glaucoma treatment after femtosecond laser cataract surgery is proving to be a beneficial combination B oth femtosecond laser technology in cataract surgery and the use of the iStent (Glaukos, Laguna Hills, Calif.) are relatively new procedures. But now, some surgeons are combining the two. John Berdahl, MD, Vance Thompson Vision, Sioux Falls, S.D.; William Wiley, MD, medical director, Cleveland Eye Clinic, Brecksville, Ohio; and Nathan Radcliffe, MD, assistant professor of ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, commented on the combination of the two technologies. Combining the femtosecond laser and iStent implantation "What we call femto in our practice is ReLACS, and that stands for refractive laser-assisted cataract surgery," Dr. Berdahl said. "We started off doing ReLACS and we found that we had excellent refractive outcomes using everything that goes into that package. Simultaneously we were starting to adopt the iStent and were having tremendous results with that, and results appeared to be refractively neutral." He said that the iStent is likely one of the few glaucoma procedures that is refractively neutral. This combination is ideal for someone with mild to moderate glaucoma who also has a cataract and is hoping to both avoid wearing glasses and limit the number of necessary glaucoma drops. "We've got a natural situation to make [patients] very happy because in one combined procedure, we can end up eliminating their glasses and eliminating their glaucoma medication," Dr. Berdahl said. "That's a big improvement in their quality of life in one elegant surgery." When considering this combination treatment for a patient, Dr. Berdahl said there are a couple factors. He said to first figure out if there is a cataract to be removed and to then determine what a patient's visual goals are following cataract surgery. For example, he said it's important to know if the patient will be content wearing glasses, if glasses are fine for reading but not for distance, or if the patient wants presbyopia correction for both distance and near vision. A lot of times for glaucoma patients, if they have some visual field loss, that means they likely have some decreased contrast sensitivity, Dr. Berdahl said. This might warn against using a multifocal IOL. After determining a patient's visual goals after surgery, Dr. Berdahl said it's important to evaluate the severity of the glaucoma. If it's mild or moderate, the iStent could be offered in addition to the cataract surgery. "Many people feel that if they're going to go through surgery, they'd like to be as least dependent on glasses as possible and as least dependent on medications as possible, so they readily see the value," he said. "Overall, I think the iStent with the femto is a great angle," Dr. Wiley said. He sees a lot of patients who are dependent on eye drops for glaucoma and have glasses, and these patients come in looking for options with their cataract surgery. Premium type procedures are often good op- Inserting the iStent into the trabecular meshwork tions, as is the iStent for treating glaucoma, and Dr. Wiley said he thinks this combination is a great addition to a premium procedure. Dr. Radcliffe said that although cataract/refractive surgery and glaucoma management may seem like two distinct fields, these specialties both center on improving a patient's quality of life. "Heavy dependence on eyeglasses and the existence of astigmatism can hamper patients' visual function, just as the need for constant eye drop application and the side effects of eye drops can decrease a patient's quality of life," Dr. Radcliffe said. He said currently the femtosecond laser helps optimize refractive outcomes in cataract procedures, and the iStent helps limit a patient's dependence on eye drops. "Additionally, right now the iStent can only be placed at the time of a cataract extraction, so you don't want a refractive cataract surgery patient who also happens to have glaucoma to miss out on the iStent," he said. The two technologies fit well together, Dr. Radcliffe said, because both focus on safety and provide for a quick visual recovery for the patient after the cataract procedure. This could be convenient for patients who have already become glasses independent from surgery but may still be looking to free themselves from the necessity of applying eye drops. "Of course, with either procedure, there are no guarantees," Dr. Radcliffe said. "But since they are both safe approaches, it seems worthwhile to try." Challenges of the combination Dr. Berdahl said the combination of iStent implantation with femtosecond laser cataract surgery does not create any additional challenges. "The only thing that could make it more challenging is if you put your incision on axis, on the steep meridian of the astigmatism," he said. "If that ends up not being temporal, then you may have to put the iStent in inferiorly or 180 degrees away from wherever you put your incision." The biggest challenge for this combination would be neutralizing astigmatism, he said, but femto and iStent implantation generally fit very well together. "If they have small amounts of astigmatism and I'm modulating my incision position, I pay attention to astigmatism correction," Dr. Berdahl said. The iStent implantation is generally done at the end of the surgery. "One thing to keep in mind when you're providing patients who have glaucoma with a spectacle independent result is that they may be