Eyeworld

EW FEATURE 68 February 2011 GLAUCOMA February 2011 cataract surgery in patients who also have visual disturbances related to lens opacification." Another reason Dr. Singh considers performing cataract surgery as a means to both improve vision and better control IOP is that "temporal clear corneal phacoemulsification does not nega- tively interfere with future glaucoma surgery." A "significant proportion of pa- tients with mild glaucoma or ocular hypertension are able to reduce or eliminate the need for glaucoma medications following modern cataract surgery, and even when this does not occur, cataract surgery rarely makes glaucoma more diffi- cult to manage post-operatively in such patients with mild disease," Dr. Singh said. A good majority of patients "don't understand the implications of surgery," Dr. Cantor said. "It's cru- cial to have the conversation with them as early on as possible. We need to tell patients that although surgical procedures have improved, they're not perfect and there is no cure. With trabeculectomy, there's an 80–90% success rate at year one, but over subsequent years there's a 5% risk of failure. After 10 years or so, you've got a 50% chance that surgery is still working." Dr. Cantor advises surgeons to tell patients that "surgery is de- signed to stop vision loss from be- coming worse. You need to tell them they're not going to see 'better,' they're just not going to get worse as quickly as they would without the surgery." For those with pseudoexfoliative glaucoma and cataract, early pha- coemulsification can be supported for an additional reason; removing a moderately opacified lens "will re- quire less energy and is presumably safer than waiting for the lens to be- come very dense in this high-risk group," Dr. Singh said. He believes that trabeculectomy, with or with- out the EX-PRESS, will continue to be the predominant stand-alone pro- cedure for patients with severe and/or uncontrolled glaucoma in the coming years. He said the initial breakthrough in glaucoma surgery will be "a cataract plus glaucoma op- eration that is performed at the time of phacoemulsification in patients with mild-to-moderate glaucoma- tous disease who are undergoing sur- gery predominantly for visual impairment related to cataract and also happen to be under treatment for glaucoma. Phaco-trabeculectomy will be replaced by phaco-something else as the most frequently per- formed cataract-glaucoma combined procedure over the next 5 years," he said. "If a blebless combined cataract and glaucoma procedure can, on av- erage, safely lower IOP at least 2–3 mm Hg more than cataract surgery alone over the long term, such a breakthrough will have significant public health implications," Dr. Singh continued. "As cataract sur- gery continues to be performed sooner and life expectancy increases in successive generations, a safe, combined cataract-glaucoma proce- dure that allows patients to reduce their subsequent dependence on glaucoma medications and need for further surgical intervention will not only result in decreased morbidity but also significant cost savings for future generations of glaucoma pa- tients." For Dr. Noecker, the "big ques- tion" remains how effective non- penetrating surgery will be over the long term and how it will affect the number of trabeculectomy surgeries performed yearly. "There's a growing trend here— we're decreasing the gap between of- fice-based surgery and making the jump to the [operating room]," Dr. Noecker said. Newer procedures offer less risk for the patient, he said. Endolaser cyclophotocoagula- tion (ECP) has shown increased ac- ceptance, although the procedure has yet to be universally accepted, Dr. Samuelson said. Proponents of the procedure cite better titration of the laser energy when delivered en- doscopically as compared to transs- cleral laser procedures. "Surgery as a whole is moving toward more bleb- less procedures," he said. "ECP may be a good adjunct to modify the in- flow side of the equation to the ble- bless procedures that work on the outflow side." In his opinion, one of the benefits of the newer blebless procedures is retention of the physi- ologic pathway; these include the Trabectome (NeoMedix, Tustin, Calif.) and the iStent (Glaukos, La- guna Hills, Calif.). Dr. Cantor has been pleased with his outcomes with canaloplasty procedures. He, too, is awaiting the U.S. approval of the iStent. "I don't think either of those procedures will replace trab or tube shunts," he said. "Glaucoma surgery needs different procedures for differ- ent patients, and we're now at a point where we do have good op- tions beyond a one-size-fits-all men- tality." "Trab and tube shunts still play an important role in glaucoma man- agement," Dr. Samuelson said. "We see patients all the time who don't come in until late in the disease pro- gression who need aggressive IOP re- duction or who have failed medical strategies. If they're far enough along in their disease, those riskier procedures can be justified." When post-trab bleb failure oc- curs, Dr. Mundorf steals a page from the retinal specialists and performs a needle bleb revision with Avastin (bevacizumab, Genentech, South San Francisco, Calif.), using the same volume of Avastin as the reti- nal specialists do (about 1 mg). "Avastin is not as toxic as 5-flu- orouracil," he said. When to initiate laser/ surgical treatments Despite all of the advances in glau- coma care over the past two decades, the number of trabeculec- tomy procedures performed annu- ally has not changed substantially, remaining at approximately 100,000 a year by most estimates, Dr. Singh said. Although the decision to move toward surgery and away from med- ication is becoming more patient- centric, Dr. Noecker said most of the newer procedures work nicely as ad- juncts to cataract surgery. "On the other end of the spec- trum are patients who continue to progress. Despite our best efforts, we're going to hit this group of pa- tients much harder and accept more risk in the surgery," he said. Across the country, specialists are introducing laser procedures ear- lier in their management strategy, said Dr. Mundorf, sometimes as early as after the first topical drop stops being effective. Some surgeons have New continued from P. 65 Avascular, leaking area of bleb margin is incised and a posterior conjunctival flap is raised Source: Iqbal (Ike) K. Ahmed, M.D. After posterior conjunctival flap is undermined and bleb surface is cauterized, the flap is draped over the bleb and sutured to the limbus Source: Iqbal (Ike) K. Ahmed, M.D. 58-81 Feature_EW February 2011-DL2_Layout 1 2/4/11 2:29 PM Page 68

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