EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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76 EW FEATURE February 2011 Combined glaucoma and cataract surgery October 2013 Combined continued from page 74 The EX-PRESS device being inserted into the anterior chamber at the level of the blue/gray line just anterior to the scleral spur filtration surgery, especially in conjunction with phacoemulsification. "It's a less traumatic, more refined approach [than primary trabeculectomy], and I think if you're going to do cataract surgery along with glaucoma surgery, less is more," he said. "If you can utilize techniques that involve creating lesser degrees of inflammation, particularly when you're also taking the cataract out, then it's a good thing. The EX-PRESS can be valuable in that regard." He said that in the past, when combined with cataract surgery, trabeculectomy may have failed more often due to increased postop inflammation and subsequent fibrosis. By incorporating the EX-PRESS, there is less intraop trauma and subsequently less stimulus for fibrosis, which may be a real advantage in using the device in combined cases. Dr. Herndon has published results of his experience using the device, including a retrospective study that looked at two groups of patients—one undergoing standard trabeculectomy alone and the other undergoing filtration surgery with the EX-PRESS. At one year, the pressures were the same between the two groups, at about 10 mm Hg, but the main differences were not in the long term: "Where the EX-PRESS really helps you is in the early postoperative period. There were fewer complications early on than what we saw with standard trabeculectomy, and lower rate of hypotony in the early period. So these eyes had quicker visual recovery," he said. Dr. Herndon said because of the progressive nature of cataracts and issues that can occur after filtration surgery even with use of the EXPRESS device, complications could arise for cataract surgery later on, so performing cataract surgery as a combined procedure could be an effective option in advanced cases. Dr. Netland has also examined this subject. He and colleagues looked at the EX-PRESS when combined with phaco in 345 eyes in a study published in the Journal of Glaucoma in 2009. "[That study] showed very similar IOP control in both groups, and it also showed that the EX-PRESS was effective alone or combined with cataract surgery," he said. He and his colleagues have found no unique complications from combining cataract surgery and EX-PRESS, and the combination can assist in lowering high pressures while keeping the added benefits of the device. EyeWorld @EWNews Follow EyeWorld on Twitter at twitter.com/EWNews Find us on social media Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine The EX-PRESS device being inserted; this illustrates proper positioning of the implant beneath the scleral flap. Source: Joseph Panarelli, MD Dr. Condon said patients with "advanced, precarious, unlikely to tolerate any dramatic, sustained, early postoperative pressure rise" disease are often good candidates for cataract surgery combined with the EX-PRESS device. He would not recommend cataract surgery alone in uncontrolled glaucoma cases. Those cases need a more aggressive approach, surgically, to prevent further damage. The EX-PRESS combined with cataract surgery can be a viable option in those cases instead of trabeculectomy and phaco, he said. "One of the problems in doing combined cataract and trabeculectomy surgery is getting a postoperative pressure spike," he said. "In my hands, I am much more likely to avoid postoperative pressure spikes with the EX-PRESS as opposed to a standard trabeculectomy, where we tend to hedge on the side of secure flap closure, particularly if it's done in conjunction with cataract surgery." Caution Drs. Rhee and Panarelli are cautious with their use of the EX-PRESS device combined with cataract surgery. Dr. Rhee said the EX-PRESS has not changed his personal use of filtration surgery combined with cataract surgery. He cited a study published in Ophthalmology in 2002, "Surgical strategies for coexisting glaucoma and cataract: an evidence-based update." "The main disadvantage of doing those two together is that when you combine phaco with trabeculectomy, there's excellent evidence from a meta analysis of more than 100 papers … [that found] you get a worse outcome, a decreased chance of success of trabeculectomy when you combine it with phacoemulsification," he said. The new microinvasive glaucoma surgeries (MIGS) have brought expanded possibilities to combined surgery and often lead to excellent postoperative results when combined with phaco in patients with less advanced disease, Dr. Rhee said. Dr. Panarelli said he performs combined surgery only in advanced cases when it is necessary. "For most glaucoma patients, I prefer to get the IOP controlled first and remove the cataract at a later date," Dr. Panarelli said. "I believe a staged procedure is often much safer for patients." EW References Kanner EM, Netland PA, Sarkisian SR Jr, Du H. EX-PRESS miniature glaucoma device implanted under a scleral flap alone or combined with phacoemulsification cataract surgery. J Glaucoma. 2009;18(6):488-491. Friedman DS, Jampel HD, Lubomski LH, Kempen JH, Quigley H, Congdon N, Levkovitch-Verbin H, Robinson KA, Bass EB. Surgical strategies for coexisting glaucoma and cataract: an evidence-based update. Ophthalmology. 2002;109(10):1902-1913. Marzette L, Herndon LW. A comparison of the EX-PRESS mini glaucoma shunt with standard trabeculectomy in the surgical treatment of glaucoma. Ophthalmic Surg Lasers Imaging. 2011;42(6):453-459. Editors' note: Dr. Panarelli has no financial interests related to this article. Drs. Condon, Herndon, Netland, and Rhee have financial interests with Alcon. Contact information Condon: garrycondon@gmail.com Herndon: leon.herndon@duke.edu Netland: dap2b@virginia.edu Panarelli: joepanarelli@gmail.com Rhee: DougRhee@aol.com