EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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22 EW CATARACT Is cataract continued from page 21 "We compared the IOP between the surgical and fellow eyes both before and at several points after the cataract surgery. We found no statis- tically significant differences in both the IOP and number of medications used between the surgical and fellow eye at any of these points up to 3 years post-op," Dr. Chang said. The EAGLE study For primary angle-closure glaucoma patients, there may soon be enough evidence to support whether or not cataract surgery alone decreases IOP significantly. The EAGLE study, a multicenter randomized trial to eval- uate whether early lens extraction improves patient-reported, clinical outcomes and cost-effectiveness, compared with standard care, is under way. While data won't be filed for several years, Dr. Friedman said there's enough preliminary evidence to support doing the study to look at whether just removing the lens early, even if the lens isn't catarac- tous, might prevent further worsen- ing of angle-closure glaucoma. Current recommendations Presently, Dr. Friedman recommends that if glaucoma is well controlled, even on medicines, it's probably reasonable to take out the lens and see where the pressure ends up. "I would be cautious in the first 24 hours to try to make sure that pressure control is ideal, and the way you can do this is to consider giving oral Diamox [acetazolamide, Duramed Pharmaceuticals, Pomona, N.Y.] at the end of surgery," he said. Using mannitol at the end of a case is another way to reduce pres- sure, he added. Dr. Friedman said he would not do a combined procedure for pa- tients with controlled glaucoma, even to get patients currently on glaucoma medications off them. "I much prefer internal procedures so I might try that with a trabectome," he said. The only time he does a com- bined surgery is when the cataract is really bothering the patient and creating a problem with glaucoma control, Dr. Friedman said. Dr. Chang has similar recom- mendations. For most ocular hyper- tensive or glaucoma patients with mild to moderate disease, he prefers to perform cataract surgery alone and to perform the glaucoma sur- gery, if necessary, once the eye has completely recovered from the cataract surgery, he said. "In my hands, this sequence yields better long-term success for the glaucoma surgery than a com- bined procedure. However, if a pa- tient has severe glaucoma and is likely to have significant progression due to post-operative pressure spikes after cataract surgery, then a com- bined procedure would be more appropriate," he added. Dr. Chang also said that minimally invasive glaucoma sur- gery may be a good temporizing procedure between medical therapy and traditional trabeculectomy in patients for whom the risk of tra- beculectomy complication is high and in whom a modest IOP-lowering effect would suffice in controlling their glaucoma. EW References 1. Chang TC, Budenz DL, Dang T, Iwach AG, Kim WI, Li C, Liu A, Radhakrishnan S, Singh K. Long-term effect of phacoemulsification on intraocular pressure using phakic fellow eye as control. Journal of Cataract & Refractive Surgery 2012; 38(5): 866-870. 2. Friedman DS, Bass EB, Congdon N, Jampel HD, Kempen JH, Levkovitch-Verbin H, Lubomski LH, Quigley H, Robinson KA. Surgical strategies for coexisting glaucoma and cataract; an evidence-based update. Ophthalmology 2002; 109:1902-191. Editors' note: Drs. Chang and Friedman have no financial interests related to this article. Contact information Chang: tachenchang@hotmail.com Friedman: 410-955-6052, david.friedman@jhu.edu July 2012