Eyeworld

EW FEATURE 90 For instance, in cases of corneal disease and cataract, removing the cataract alone may save 3-6 months of recovery time, but those patients are still going to need spectacles and "are obviously not candidates for multifocal technology because of their concurrent disease," Dr. Lane said. In Dr. Donnenfeld's practice, certain procedures are planned to be sequential, such as Descemet's strip- ping endothelial keratoplasty (DSEK) in patients with borderline corneas, when the procedures are not being performed in the same session as cataract surgery or LASIK after cataract surgery. (For more on elec- tive refractive procedures, see side- bar.) Since DSEK can result in hyperopia, he recommended aiming for –1.0 to –1.5 D of myopia and avoiding using multifocal technol- ogy because of the increased con- trast sensitivity loss. In contrast to sequential sur- gery, Dr. Terry said, "If we have de- termined pre-operatively that both the cataract and the cornea are con- tributing to visual loss, we always do the DSAEK and phaco/IOL together, reducing the time, expense, and risk of two surgeries." Cataract and glaucoma Dr. Devgan said he has a "specific al- gorithm for certain diagnoses, such as neovascular glaucoma." In those patients, if a drainage tube is recom- mended, Dr. Devgan performs both the glaucoma and cataract surgeries concurrently if the patient is over age 60. "If the patient is age 50 to 60 and has any significant cataractous changes, we also do the cataract/ IOL surgery at the same time as the glaucoma surgery. If under age 50, we only combine with a cataract/ IOL if there is clearly a visually sig- nificant cataract present. This is be- cause the patient is more likely to get a cataract after the glaucoma sur- gery, and it is difficult to do a con- trolled cataract/IOL surgery in an eye with a functioning drainage tube," he said. Dr. Donnenfeld said he is "very interested in and following longer- term outcomes with the micro-inva- sive glaucoma devices," even though he is not a glaucoma specialist. The results to date indicated these de- vices are safe and well tolerated over the long term, and that adds to his comfort as an anterior segment sur- geon to have them in his repertoire. "Quality of life is also impor- tant, and many glaucoma patients are not compliant with their med- ication; missing doses could result in subtle visual field loss. I strongly consider combined surgery in pa- tients with cataract and glaucoma even if the glaucoma is well con- trolled," he said. For some glaucoma patients, cataract surgery alone will lower pressures enough that a sec- ond procedure can be put on hold, Dr. Donnenfeld said. Conversely, he will likely increase the number of combined procedures he performs once the micro-invasive devices are approved in the U.S. "For patients with both primary open-angle glaucoma and cataract, I feel it is better to do a step-wise ap- proach—first fix the cataract and see what happens to the pressure," Dr. Devgan said. "Then you can go back and do the trabeculectomy if needed." Because trabeculectomy is a "very invasive procedure with less control of post-op results than other surgeries," Dr. Devgan believes the future holds more combined cataract and glaucoma device surger- ies, such as the iStent (Glaukos, Laguna Hills, Calif.), canaloplasties (iScience, Menlo Park, Calif.), and suprachoroidal shunts (CyPass, Transcend Medical, Menlo Park, Calif.). "Those three will change the game since they are easier to im- plant and offer a more predictable post-op response," he said. On occasion, Dr. Donnenfeld said patients with cataract and con- comitant glaucoma need even more—a triple procedure consisting of phaco, DSEK, and endolaser for ciliary body ablations. "In the future, I think the micro-invasive devices will be used more in these types of cases," he said. Corneal disease and the lens Visually debilitating corneal disease can present in the presence of a clear crystalline lens, a cataract lens, a posterior chamber IOL, an anterior chamber IOL, or even aphakia. In each setting the surgeon can be faced with a dilemma. When patients present with Fuchs' dystrophy or bullous ker- atopathy and a posterior chamber IOL is in place, Dr. Terry advised sur- geons to "go ahead with the DSAEK; there's no therapeutic dilemma." If the patient is phakic, however, and the cataract is visually disturbing, then he would proceed with a com- bined DSEK/phaco procedure. "Our published results with the new triple procedure in 225 consec- utive eyes yielded a low 1.8% dislo- cation rate and 0% primary graft failure rate, so doing this combined procedure is safe," he said. "Con- versely, if the patient only has mild Fuchs' and the visual loss is almost entirely from the cataract, there may be no need to perform a transplant at all, and a careful phaco/IOL should be done." Sometimes, patients present with endothelial dystrophy "and the corneal disease is accounting for a more significant decrease in visual acuity than the cataract," Dr. Lane said. Patients with Fuchs' and frank corneal edema are destined for a corneal transplant, but age should determine if it becomes a combined procedure with phaco, he said. Forty-year-olds will not have as visu- ally significant a cataract as 60-year- olds. "But if the surgery itself is likely to cause a cataract to develop, you have to weigh if it's worthwhile to remove the lens at the same time as the corneal procedure," he said. In general, his rule of thumb is when the endothelial disease is worse than the cataract, combining procedures makes sense, but when the cataract is worse and there is no frank corneal edema on clinical exam and no history of morning edema, "see if the corneal endothelium can with- stand the trauma of the surgery," he said. Certainly a thorough discus- sion of the potential for a second procedure must be had before se- quential surgery is entertained. He Co-morbidities continued from page 89 Elective procedures C ombining cataract and refractive procedures may not seem as difficult as treating multiple pathologies, but patients opting for elective surgery "want superior visual rehabilitation and are much more demanding," Dr. Donnenfeld said. Depending on the initial refractive error, patients may need cataract surgery followed by a LASIK procedure weeks later. "High myopes or hyperopes—especially with astigmatism—will not be helped by conventional cataract surgery to the level they want," he said. "They're going to need additional refractive correction, and LASIK can offer a rapid visual rehabilitation." Because high myopes are not candidates for LASIK but are for pha- kic lenses, "you need to provide them with good uncorrected vision, but you can't leave 2.5 D of astigmatism," Dr. Lane said. "You're not going to give them excellent visual results unless you perform a double proce- dure of phakic IOL implantation and LASIK." For patients with significant astigmatism (more than 1.00 D), Dr. Yoo's approach is "to cut the LASIK flap, but not lift it," she said. "Then I'll insert the phakic IOL in one eye, wait a week, and put the IOL in the other eye." About 4 weeks after the second surgery, she'll bring the pa- tient back and perform LASIK on both eyes. "That's been my approach for years," she said. "There are some pa- tients who get phakic IOLs who aren't candidates for LASIK because their corneas are too thin. They may fare better with astigmatic keratec- tomy or concomitant LRIs at the phakic IOL stage of the surgery." She said it's a surgeon's preference and comfort level in terms of per- forming combined or sequential surgery in those needing phakic IOLs. For Dr. Lane, the key is to prepare patients that the initial refractive error will warrant additional surgery. "You need to set their expectations," he said. "Before the advent of the femtosecond laser, we'd make the flaps ahead of time, lift both, and do LASIK after the lens implantation. It used to take a few months from start to finish." Dr. Donnenfeld now performs LASIK about 1 month after implant- ing premium IOLs. "One caveat to this is the Crystalens (Bausch & Lomb, Rochester, N.Y.)," he said. "Those need a posterior capsulotomy and about a 4- month wait." He advised aiming for a myopic residual error, as myopic LASIK corrections are more predictable and can heal more rapidly. February 2011 COMBINED SURGERY March 2011

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