Eyeworld

8 World view Embracing cataract surgery in glaucoma patients A mazing improvements in cataract surgery have helped all patients, but none more than those with glaucoma. Historically, surgeons had lower expectations when approaching cataract surgery in glaucoma pa- tients: If pressure didn't increase, the surgery was considered a success, but astigmatism was not treated and the ocular surface was ignored. Now these attitudes—and the goals—have radically changed. In addition to great vision, we expect cataract surgery to lower pressure and reduce the number of glaucoma medications. Meanwhile, we are treating the ocular surface much more ef- fectively. These advances are particularly important since studies have shown that up to 20% of patients undergoing cataract surgery have a coexisting diagnosis of glaucoma. Any patient with mild to moderate open angle glaucoma about to undergo cataract surgery would be a candidate for MIGS. The ideal MIGS patient is discussed by Malik Kahook, MD, Shakeel Shareef, MD, and Brian Francis, MD. If we estimate 3.5 million patients have cataract surgery annu- ally in the U.S. and 20% have glaucoma, that suggests up to 700,000 would be MIGS candidates. The two devices approved for this indication are the iStent (Glaukos, San Clemente, California) and the CyPass (Alcon, Fort Worth, Texas). When implanted along with cataract surgery, both lower pressure more than cataract surgery alone. These MIGS devices give us the opportunity to make cataract surgery a glaucoma operation. Medication questions arise during cataract surgery regarding the use of prostaglandin analogues as well as postoperative steroids. We are fortunate to have the perspectives of Scott Fudemberg, MD, Husam Ansari, MD, and Parag Parekh, MD, to guide us through these issues. The ocular surface in glaucoma patients is only now getting the atten- tion it deserves. Most glaucoma medications have some degree of surface toxicity. But we often are so focused on lowering pressure that we ignore the redness and irritation. An impaired ocular surface also may distort IOL measurements and make toric lens calculations inaccurate. The context where ocular toxicity becomes most obvious is when a patient has had suc- cessful surgery in one eye and still uses multiple medications in the fellow eye. Heather Weissman, MD, Dana Wallace, MD, Tony Realini, MD, and Jeffrey Kammer, MD, give us a current update on treating the ocular surface. No one benefits more from cataract surgery than those with angle clo- sure glaucoma. It appears that cataract surgery at any stage of angle closure is effective in lowering pressure and usually prevents the need for riskier glau- coma surgery. This raises the question of doing clear lens extraction in angle closure, which I have done in highly selected cases and have found to be very effective. We are fortunate to have the observations of Robert Feldman, MD, and Joseph Panarelli, MD, on their experiences with cataract surgery in angle closure. The prospective EAGLE study gives us strong support for using cataract surgery as a true treatment modality for angle closure that is usually superior to a trabeculectomy or tube. Every glaucoma patient eventually develops cataract. In the past, we were taught to put off cataract surgery in the glaucoma patient because of increased risks and uncertain results. Now we welcome it. Cataract surgery is one of the best things that can happen to a glaucoma patient. EW Reay Brown, MD, Glaucoma editor The official publication of the American Society of Cataract & Refractive Surgery A S C R S February 2017 Volume 22 • No. 2 Publisher Donald Long don@eyeworld.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Staff Writer Liz Hillman liz@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Berlin, Germany Vanessa Caceres Bradenton, Florida Michelle Dalton Reading, Pennsylvania Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. 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