Eyeworld

March 2011 A "combined procedure" has many different meanings to the ophthalmic surgeon depend- ing on the specialty. For the glaucoma-anterior segment surgeon, the most common combined surgery is coincident phacoemulsification and trabeculectomy. In the 1990s the combined "phaco-trab" was my most common operation. This strategy was not unique to me among glaucoma specialists. In fact, from 1995-1999, two-thirds of glaucoma filtering procedures were performed coincident with cataract surgery 1 . Two thirds—that figure is astonishing! Things have changed quite dramatically for four very important reasons. First, modern clear corneal cataract surgery is conjunc- tival and scleral sparing, thus phacoemulsification does not hinder subsequent glaucoma surgery. Indeed, a pseudopha- kic eye with untouched conjunctiva is ideal for trabeculec- tomy. Second, evidence is mounting that cataract surgery lowers IOP more than previously realized in a large percent- age of patients. Many glaucoma surgeons now consider cataract removal an incremental step in the management of glaucoma. Thus it is tempting to perform cataract surgery alone and reassess the IOP post-op. Third, improved medications and lasers control IOP in more patients than previously possible without the risk of incisional surgery. Fourth, the an- timetabolite era of filtration surgery has exposed the Achilles' heel of trabeculec- tomy, specifically, bleb-related infections. That a procedure (trabeculectomy) can render the eye vulnerable to devastating infection (endophthalmitis) for the rest of the patient's life is an unacceptable risk for all but the worst glaucoma cases. Even more unsettling to the glaucoma surgeon, this infection risk is iatrogenic, unrelated to the primary disease process. I have stopped subjecting my patients with mild to moderate glaucoma to this risk. Apparently I am not alone given that the number of trabeculectomies performed in the U.S. each year has steadily declined for the past decade. The decoupling of cataract and glaucoma surgery has undoubtedly con- tributed to this decline. Don't be surprised, however, to see another significant trend in the next decade. I expect to see a resurgence of combined surgery over the next several years. Yet it won't be an increase in phaco-trabeculectomy procedures. It will be combined phaco-MIGS (minimally invasive glaucoma surgery). Such procedures have signifi- cantly less risk and include ab interno-trabeculectomy (Trabectome, NeoMedix, Tustin, Calif.) and iStent (Glaukos, Laguna Hills, Calif.), which is under FDA review. Canaloplasty also falls into this category of less-invasive, less-risky glaucoma surgery. Likewise, endoscopic cyclophotocoagulation (ECP) can be combined with cataract surgery to enhance the IOP-lowering effect of phacoemulsification. It will be incum- bent on each of these technologies to prove added efficacy over phacoemulsification alone. While the IOP-lowering effect of MIGS is less than trabeculectomy, the risk is considerably less and more appropriate for early to moderate glaucoma. For patients with advanced glaucoma, combined phaco-trab remains an excellent option to im- prove vision, improve pressure control, and reduce medications. Advances such as the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas) have made trans-scleral, guarded filtration surgery more reproducible and precise. Meanwhile, as you will read in several excellent articles in this edition of EyeWorld, many additional iterations of "combined surgery" in cornea (DSEK and phacoemulsification) and refractive surgery (LRIs and phacoemulsification) continue to flourish. Reference 1. Coleman et al, Ophthalmology 2005; 112:401-406. Thomas W. Samuelson, M.D. Attending surgeon, Minnesota Eye Consultants, Minneapolis, and adjunct associate professor, University of Minnesota Publisher Donald R. 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POSTMASTER: Send change of address to EYEWORLD, 4000 Legato Road, Suite 700, Fairfax, VA 22033. Periodical postage paid at Fairfax, VA 22033 and at additional mailing offices. The ideas and opinions expressed in EYEWORLDdo not necessarily reflect those of the editors, publisher, or its advertisers. P U B L I S H I N G   S T A F F March 2011 Volume 16 • No. 3 EW NEWS & OPINION 10 A S C R S The official publication of the American Society of Cataract & Refractive Surgery World View The fall and rise of combined surgery?

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