Eyeworld

81 EW GLAUCOMA February 2015 by Ellen Stodola EyeWorld Staff Writer Tips for cataract surgery in glaucomatous eyes J uan Mura, MD, University of Chile, Santiago, offered pearls for cataract surgery in difficult eyes at a sympo- sium at the 2014 European Society of Cataract & Refractive Surgeons (ESCRS) meeting in London. He suggested 7 helpful tips for surgeons dealing with glaucoma cases. "Cataract surgery in glaucoma patients is more difficult than cata- ract surgery in healthy patients," he said. Many of these glaucomatous eyes have a whole host of issues that surgeons would not otherwise encounter. These issues can cause a higher risk of complications. 7 tips Dr. Mura's first tip was that cataract surgery in eyes with functioning filtration blebs increases the risk of bleb failure. He suggested talking with these patients before surgery and explaining that they have a 50% chance of having a significant cataract in the next 5 years after the trabeculectomy, and if they have a functioning bleb, there is a high risk of failure after cataract surgery. His second tip was that perform- ing cataract surgery in eyes with a tube shunt does not affect IOP con- trol. This is a good thing, Dr. Mura said, but you have to be sure that the tube is working properly. His third tip was that the risk of failure increases if there is a shorter time between trabeculectomy and cataract surgery. "We have to try to delay the cataract surgery as much as we can," he said. A fourth pearl offered by Dr. Mura was that higher IOP prior to cataract surgery causes an increased risk of bleb failure. Blebs with bor- derline function should be identi- fied, he said, because these are more susceptible to scarring. However, it can be difficult to determine if a bleb is working. Adding to this point, Dr. Mura suggested using an ultrasound biomicroscopy (UBM) or anterior segment OCT if possible. His fifth pearl was the more atraumatic the cataract surgery, the lower the risk of bleb failure. Use minimal intraoperative iris manipulation to decrease the in- flammation and risk of bleb scarring, Dr. Mura said. Also related, he said to try to get away from the bleb and use a temporal clear corneal ap- proach at least 3 clock hours apart. The sixth pearl was to under- stand the need for aggressive anti- inflammatory treatment in the post- operative period. This could include steroids, NSAIDs, and 5-fluorouracil (5-FU) injections. The seventh and final pearl was for surgeons to improve their gonioscopy skills. "The new tech- nology is here to stay," he said, and its role will evolve in the next few years. Additional advice In an email interview with EyeWorld, Dr. Mura elaborated on his advice for surgeons when dealing with cata- ract surgery in glaucoma patients. "The coincidence of cataract and glaucoma is a rather frequent situation, and it is increasing due to population development," he said. In the Caucasian population over the age of 40 years, cataract incidence is estimated between 15% and 20%, he said, while for the glaucoma population over the age of 70, the prevalence is about 6% in the Caucasian population and 16% in the black population. He added that when performing a trabeculec- tomy, "you have to know that the patient has a 50% risk of developing significant visual impairment from cataract in the next 5 years." Related to his first tip that cata- ract surgery in eyes with functioning filtration blebs increases the risk of bleb failure, Dr. Mura said that results in the literature indicate that a range of 10% to 61% of trabeculec- tomies fail between 12 to 36 months after cataract surgery. "The majority of recent studies suggest that phacoemulsification in the presence of a functioning filtra- tion bleb leads to an increased risk of bleb failure of somewhere around 33%," he said. This also includes changes in bleb morphology that are consistent with failure and corre- sponding elevation in IOP of 2 to 3 mm Hg, he said, although this can also be associated with additional medical or surgical treatment. Dr. Mura said that these patients are more likely to require additional glaucoma medication and possible further surgical treatment. When delaying cataract surgery to decrease the risk of bleb failure, Dr. Mura said the optimal timing between performing trabeculec- tomy and cataract surgery is not known. 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