Combined cataract and glaucoma surgery

Introduction
O Cataract and glaucoma both are leading
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causes of blindness world wide The prevelance of both is incresing with aging population The prevelance of significant cataract in 6574yrs-is 20% The prevelance of chronic glaucoma in >70yrs age is 4.5% The 5yrs incidence of nuclear cataract in patients with open angle glaucoma & aged >50yrs is 20%

Management
O cataract surgery ----> trabeculectomy
O Trabeculectomy ----- > cataract surgery O Combined cataract surgery and

trabeculectomy - ECCCE + Trabeculectomy - SICS + Trabeculectomy - phacotrabeculectomy

factors
O Visual need & visual potential of the
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patient Severity of glaucoma Target IOP Current IOP Health status of the patient

Cataract surgery alone

O Indication

-only mild glaucomatous damage with IOP well controlled with 1 or 2 medications - Better results are obtained in angle closure glaucoma

Advantages O Cataract surgery alone can lower IOP upto 5mmhg - thus avoiding need for trabeculectomy DisadvantagesO Early postoperative rise in IOP

Trabeculectomy -- > cataract

O Indications

-In a eye with incipient cataract where visual impairment is mild & glaucoma is uncontrolled AdvantagesO Better IOP control than combined procedure DisadvantagesO Increased cataractogenesis O Increased risk of bleb failure if cataract surgery is done within 6 months of trabeculectomy

Combined surgery
O

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Indications Adequate IOP control with medications but drug related side effects or cost or compilance problems Adequate IOP control but advanced glaucomatous optic atrophy IOP on only boderline control or uncontrolled with maximam medications Urgent need to restore vision and 2 surgeries is neither feasible nor in patients best interest

Surgical approach
O Smaller is the incision the better is the IOP control
O Decrease in the IOP when the incision size is

decreases from 11mm to 6mm is much pronounced than from 6mm to 3mm O One site versus two site appproach O One site approach- both procedures are done superiorly through one insicion O Two site approach trabeculectomy is done superiorly & catarct surgery done by temporal approach

One site surgery-technique

O Conjunctival flap is raised superiorly

limbal based flap or fornix based flap O Wound leaks & vitreous loss more & less maneuverability of instruments during cataract surgery limbal based flap O Bare sclera is exposed & cautery done if needed

O Partial thickness scleral flap is raised

using a V shaped incision ( with its base at limbus ) using a scleratome blade O Alternately scleral tunnel is made initially, with completion of flap after the cataract portion of the surgery using vanass scissors O Keratotome of 3.2mm is used to enter the anterior chamber O Phacoemulsification is performed as usual

O IOL is inserted
O Sclerectomy of about 2mm is performed

under the flap using kelleys descemets punch O Vanass scissors is used to perform a peripheral iridectomy O Any bleeders are cauterized & scleral flap closed with 10.0 nylon

Advantages of single site surgery over two site

O Saves time
O Only one wound made O No need to change surgeons position or

microscope DISADVANTAGES O More postoperative inflammation O Care needed to avoid spillage of antimetabolites into anterior chamber

Two site surgery

O Temporal clear corneal cataract surgery is

performed in usual manner O It is recommended to suture the incision site to prevent wound leak O Trabeculectomy performed superiorly ADVANTAGES OVER ONE SITE O Improved exposure for catarct extraction O Enhanced bleb survival due to less manipulation of conjunctiva

DISADVANTAGESO Longer time O Microscope requires adjustment O Surgeon needs to change position

O Patients convenience in terms of cost , risks

Advantages of combined surgery over cataract or trabeculectomy alone

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of anaesthesia, presence of medical conditions precluding multiple surgeries Avoids potential postoperative IOP spikes which can be seen after cataract surgery Long term control of IOP with trabeculectomy & quick visual recovery from cataract surgery Less chance of shallow anterior chamber Less chance of bleb infection or endophthalmitis

disadvantages
O More intraoperative & postoperative

complications -cataract surgery can be difficult due to poor pupil dilation or synechiae or weak zonules due to PXF syndrome e.t.c O IOP control is less with combined surgery than with trabeculectomy alone O Complex postoperative care & Longer visual recovery O More astigmatism or myopic shift O Long term bleb problems