Options for patients with cataract with glaucoma: phaco alone phaco-trabec trabec alone indications and guides

1. Glaucoma Patients with Cataract:
To Phaco or to Phaco-Trabec?
Cesar A. Perez Jr MD DPBO

2. Disclaimer
•No financial interest on products
mentioned

3. Intro
• Cataract and Glaucoma
• Coexist
• Seen frequently in elderly
patients
• Surgical intervention
• Goals: visual rehab and
IOP control

4. Cataract
• Surgery indications:
• Deterioration of vision
• Affecting daily living
• Co-existing glaucoma
• Small cataract – large effect on
compromised visual field
• Difficult to assess optic nerve

5. Glaucoma
• Surgery indications:
• IOP control
• Severity of optic nerve
damage
• Glaucoma subtype
• Current effects of meds

6. Cataract and Glaucoma
Surgery Considerations:
• Only 1 or 2 procedures?
• If 2 procedures, which will be first? Combined?
Goals:
• Short term plan: visual rehab and IOP control
• Long term plan: prevent disease progression

7. Co-existing
Cataract
and
Glaucoma
Cataract surgery alone
Combined cataract and
glaucoma surgery
Two-staged glaucoma
and cataract surgery

8. Cataract surgery alone

9. Lens extraction can reduce IOP
One of the safer surgical procedures to control glaucoma
Can be performed to many types of glaucoma
Different glaucoma procedures can be combined to lens extraction
Can change visual field sensitivity and improve retinal nerve fiber analysis

10. Cataract surgery alone
• Advantages
• Restores vision promptly
• Technically easiest (shortest)
• Facilitates post-operative assessment
of optic nerve and visual field
• Safe to do later glaucoma surgery if
needed
• Can lower down IOP long-term

11. Cataract surgery alone
• Disadvantages
• Early post-op IOP elevation
• Reduced long-term IOP
control compared to
combined
• If conjunctiva is violated,
future glaucoma surgery
success is compromised

12. Cataract surgery alone
No significant
field loss /
cupping
Acceptable IOP
control on < 2
meds
Older age
Narrow angles
and/or ocular
hypertension

13. Special situations in cataract surgery in
glaucoma patients
Small pupil
Pseudoexfoliation
Crowded anterior chamber

14. Combined Cataract and
Trabeculectomy Surgery

15. • Combined surgery has better IOP long-term control than cataract
surgery alone
• Faster visual rehabilitation

16. IOP decreased on both groups
Combined procedure has fewer IOP spikes and with less medications
Visual acuity improved in both groups

17. 123 eyes studied for 2 years – 62 underwent phaco, 61 phaco-trabec
Phaco-trabec yielded more complications
Both groups had decreased IOP and better visual recovery

18. Combined Cataract and
Trabeculectomy Surgery
• Advantages
• Restores vision promptly
• Single procedure – more convenient
• Facilitates post-operative assessment
of optic nerve and visual field
• Decreased glaucoma medications
• Can lower down IOP early post-op
• Better long-term IOP control than
phaco alone
• Many glaucoma surgical options

19. Combined Cataract and
Trabeculectomy Surgery
• Disadvantages
• Increased intra-op and post-op
complications
• Longer surgical time
• More intensive post-op care
• Glaucoma meds often needed
post-operatively
• Longer visual recovery

20. Combined Cataract &
Glaucoma Surgery
>2 medications
for IOP control
significant cupping
or field loss
younger age
unable to tolerate 2
separate surgeries
high risk / difficult
glaucomas
drop allergies /
contraindications
monocular

21. Special considerations for combined surgery
Glaucoma
drainage device
MIGS
Laser
Two-site
incision
One-site
incision
MSICS
ECCE

22. Two-staged Glaucoma and
Cataract Surgery

23. 141 patients with open angle, exfoliation and uveitic glaucoma
Phaco-trabec have lower success than trabec alone

24. Two-staged Glaucoma
and Cataract Surgery
• Advantages
• Best for immediate IOP control
• Possibly best long-term IOP
control
• Opportunities for glaucoma
enhancement at time of
glaucoma surgery

25. Two-staged Glaucoma
and Cataract Surgery
• Disadvantages
• Two-stages: long delay in recovery
• Loss of IOP control after cataract
surgery
• Cataract surgery in presence of
bleb is more challenging

26. 2 staged: glaucoma surgery
followed by cataract surgery
IOP is immediate
threat to vision
need for lowest
IOP post-op
difficult
glaucoma (active
uveitis, NVG)

27. Some considerations in doing cataract surgery
after glaucoma surgery

28. Factors that may affect results of cataract
surgery success
• Low corneal endothelial count
• Poor pupillary dilatation; floppy iris
• Shallow anterior chamber
• Hypotony
• Pre-existing zonular weakness
• Posterior capsule rupture and vitreous loss
• Postoperative uveitis
• Postoperative bleb failure
• Postoperative enhanced need for antiglaucoma medications

29. Loss of IOP control after cataract surgery
• Eyes with higher IOP before phacoemulsification
• Younger patient (aged 50 or below)
• Intraoperative iris manipulation.
• Early IOP spikes more than 25 mm Hg.
• Posterior capsule rupture with vitreous loss.
• Interval between trabeculectomy and cataract surgery of less than 6 months.

30. 419 patients with either PAC or PACG with NO CATARACTS were studied – 208 underwent phaco and 211
with standard care
IOP was lower with the clear lens extraction group than the standard care
Reduced need for further glaucoma surgery in clear-lens extraction group

31. 2 Staged
procedure
Combined
cataract &
glaucoma sx
Phaco alone
Control of intra-ocular pressure

32. Phaco alone
Combined
cataract &
glaucoma sx
2 Staged
procedure
Faster visual rehabilitation

33. Visually Significant Cataract
Well-controlled
IOP
Uncontrolled
IOP
Controlled on
less than 2
meds
Controlled on
more than 2
meds
Mild to moderate
field loss / disc
change
Moderate-severe
field loss / disc
change
Little - moderate
field loss / disc
change
Urgent need to
restore vision /
2 stage not feasible
Phaco
Combined
phaco-trabec
Combined
phaco-trabec
Combined
phaco-trabec
2 stage
procedure

34. Summary
Glaucoma
and cataract
often coexist
Different
options may
be performed
Be guided by
the goals for
the patient

37. References
• Chandler and Grant’s glaucoma. -- 5th ed. / Malik Y. Kahook, Joel S. Schuman, editors ; David L. Epstein,
contributing editor.
• https://eyewiki.aao.org/Techniques_for_Combined_Cataract_and_Filtering_Glaucoma_Surgery
• The Role of Lens Extraction in Glaucoma Management – Tsui, Tham, Chan, Ann Transl Med. 2020 Nov; 8(22):
1550.
• Surgical strategies for coexisting glaucoma and cataract: an evidence-based update - David S
Friedman 1, et al, Ophthalmology. 2002 Oct;109(10):1902-13.
• Cataract Surgery in Eyes with Previous Glaucoma Surgery: Pearls and Pitfalls. - Tanuj Dada, Shibal Bhartiya,
Nafees Begum Baig Journal of Current Glaucoma Practice, September-December 2013;7(3):99-105
• Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a
randomised controlled trial - Azuara-Blanco, et al., Lancet 2016; 388: 1389–97
• A prospective study of combined phacoemulsification-trabeculectomy versus conventional
phacoemulsification in cataract patients with coexisting open angle glaucoma - Allan Storr-Paulsen, Jørn
Holger Pedersen and Caroline Laugesen Acta Ophthalmologica Scandinavica Volume 76, Issue 6 Dec 1998
Pages 643-759
• Comparison of 5-year outcomes between trabeculectomy combined with phacoemulsification and
trabeculectomy followed by phacoemulsification: a retrospective cohort study - Arimura et al BMC
Ophthalmology (2021) 21:188
• Phacoemulsification vs Phacotrabeculectomy in Chronic Angle-closure Glaucoma With Cataract – Tham et
al., Arch Ophthalmol. 2010;128(3):303-311