NOV 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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44 EW FEATURE February 2011 Cataract/glaucoma combined surgeries November 2012 Weighing combinations by Maxine Lipner Senior EyeWorld Contributing Writer AT A GLANCE • Minimally invasive glaucoma procedures can easily be added to phacoemulsification • Performing ECP together with phacoemulsification can lower pressure long term • Ab interno trabeculectomy with cataract removal is very fast with few complications Phacoemulsification with ab interno trabeculectomy or ECP F or many glaucoma patients, cataract removal may also be common, ac- cording to Douglas J. Rhee, M.D., associate professor, Harvard Medical School, and associate chief of operations, Massachusetts Eye and Ear Infir- mary, Boston. Today, more mini- mally invasive glaucoma approaches for controlling IOP, such as use of endoscopic cyclophotocoagulation (ECP) or ab interno trabeculectomy with the Trabectome (Neomedix, Tustin, Calif.), are being done in- stead of traditional trabeculectomy. Practitioners may find that with such approaches they can easily add value on the glaucoma side for patients undergoing cataract surgery anyway, Dr. Rhee pointed out. Eyeing ECP ECP seeks to curtail the amount of Considering continued from page 42 added. "With the binocular patient, you have to talk about double vision," he said. However, if you take a com- bined approach, you have the ad- vantage of only one trip to the OR. "The combined cataract/tube proce- dure could potentially save the pa- tient time, money, inconvenience, and a second trip to the OR," Dr. Fechter said. Dr. Fechter usually performs two separate procedures and noted that he schedules the cataract surgery in eyes with tubes once they are quiet and have a stable IOP. "I avoid mul- tifocal lenses in glaucomatous eyes due to the possibility of exacerbat- ing already reduced contrast sensi- tivity. There is a role, however, for toric intraocular lenses to correct astigmatism," he said. This is espe- cially the case when the tube enters the eye through a long scleral tun- nel. Moving forward As the indications for this specific surgical approach are limited, Dr. Reynolds doesn't see its use increas- ing or decreasing soon. "I think in most people's hands, it's an unusual indication anyway," he said. Although Dr. Rhee agreed that the number of procedures of this type performed will remain unchanged, he still encourages surgeons to consider it more if the patient meets the selection criteria. "I love it in the properly selected patient," he said. Dr. Gedde sees a trend toward the increased use of shunts. He cites Medicare claims data that shows a steady decline in the number of trabeculectomies performed in the recent past decades and a simultane- ous increase in the number of aque- ous shunts placed. Surveys from the American Glaucoma Society are showing a similar trend, he added. However, he also observes a trend in glaucoma away from combined procedures and a move toward staged procedures. EW Editors' note: Dr. Gedde has financial interests with Alcon, Allergan (Irvine, Calif.), and Merck (Whitehouse Station, N.J.). The other physicians have no financial interests related to this article. Contact information Fechter: 706-651-2020, fechter@pol.net Gedde: 305-326-6435, sgedde@med.miami.edu Reynolds: 208-373-1200, aqueous fluid produced by the eye. "It uses a laser to thermally destroy or to cauterize the ciliary body and that will inhibit aqueous secretion," Dr. Rhee explained. Stanley J. Berke, M.D., associ- ate clinical professor of ophthalmol- ogy, Hofstra North Shore LIJ School of Medicine, and chief, Glaucoma Service, Nassau University Medical Center, Lynbrook, N.Y., reserves the less invasive ECP technique for mod- erate glaucoma patients. "I probably use ECP in 50% of my cataract and glaucoma patients who I do phaco on," he said. "That 50% fall into the moderate range." Dr. Berke discusses the possibil- ity of adding ECP to the treatment protocol with such patients who have been flagged for cataract re- moval. "I have pretty much a 100% acceptance rate because it's almost a no-brainer," Dr. Berke said. "We use this as an opportunity to do some- thing to treat the glaucoma as well." Using ECP phacoemulsification, cataract removal and IOL implanta- tion is performed in the usual man- ner. "What I tell them is after I do the regular phaco and put in the posterior chamber lens then I spend an additional 2 minutes doing ECP." With the ECP probe, he added, it is possible to see the ciliary processes lined up like stalactites and stalagmites. "There are about 80 of them in the circumference of the eye," he said. Using a red aiming beam, the practitioner then targets each of the ciliary processes. Once treated, this shrinks and turns white. "When you have completely treated used, IOP went back up to pre-op levels. "Whatever pressure-lowering effect that may have occurred from the phaco alone has worn off en- tirely, but in the phaco ECP group the pressure-lowering effect is main- tained long term," Dr. Berke said. He pointed out that glaucoma is With the ab interno technique using the Trabectome, the practitioner selectively ablates the trabecular meshwork and the inner wall of Schlemm's canal to open up access to natural ocular drainage, which can improve outflow one ciliary process then you move on to the next," Dr. Berke said. "It's like spray painting a fence." Dr. Berke finds that adding this relatively simple step can have an important long-term impact on IOP. While surprisingly some IOP reduc- tion can be attained by using pha- coemulsification alone, Dr. Berke stressed that for long-term control this is not enough. He cited a study of his that indi- cated that while phaco alone might reduce IOP for the first year, com- bined surgery could control this for several years. The study, presented at the March 2006 American Glaucoma Society annual meeting, involved 626 eyes undergoing phacoemulsifi- cation combined with ECP, as well as 81 eyes treated with phacoemulsifi- cation alone. "At 1 year, both groups showed the same pressure-lowering effect," Dr. Berke said. By year 2 and 3, however, when phaco alone was a long-term chronic disease. "We're not looking for a short honeymoon period; we're looking for long-term control, and that's the benefit of combining ECP with phaco," Dr. Berke said. Dr. Rhee, however, prefers enhancing outflow in glaucoma patients instead of inhibiting inflow. "The problem with glaucoma is the drain, not that we are producing too much aqueous," he said. "Compared to people of a similar age, those with glaucoma produce the exact same amount of aqueous as those who don't have glaucoma." While ECP is relatively safe, it does destroy tissue, and there have been instances of pressure dropping too low, Dr. Rhee cautioned. Adding ab interno trabeculectomy To enhance outflow he prefers using ab interno trabeculectomy with the Trabectome. "The advantage of ab interno trabeculectomy is that it does not disturb the conjunctiva," Dr. Rhee said. "If you later need to do a trabeculectomy, you have not hurt yourself." The ab interno technique is far less likely to result in complications than traditional trabeculectomy, he finds. "An advantage is that it's safer

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