This document discusses cataract surgery in glaucoma patients. It notes that cataract and glaucoma commonly occur together, requiring management of both conditions. Cataract surgery can significantly lower IOP for up to 4 mmHg by improving outflow, and also aids in glaucoma evaluation. Options for surgical management include cataract surgery alone, combined cataract and glaucoma surgery, or staged surgeries. Factors like glaucoma severity, number of medications, and target IOP determine the best approach. Cataract surgery alone provides quick recovery but less IOP control than combined procedures.

1. Cataract surgery in glaucoma
patients
Presenter:
Dr.Jahidur Rahman
FCPS II Student
NIO&H
Moderator
Dr.Mezbahul Alom
Chairman
Prof. Dr. Iftekhar Md. Munir

2. INTRODUCTION:
• The coexistence of glaucoma and cataract is a
common occurrence that requires insight into
the diagnosis and management of both
conditions
• The main goal is to enable the optic nerve
to withstand an IOP spike & the
likelihood of maintaining postoperative IOP
control without further surgical intervention

3. THE IMPACT OF CATARACT ON THE
EVALUATION OF GLAUCOMA
• Worsens the mean deviation across all
tests of the visual field
• Affect the visual field index/ glaucoma
progression index as well as the
characterization of scotomas
• Underestimation of the thickness of the
RNFL

4. ROLE OF CATARACT SURGERY
ON GLAUCOMA
• produce a significant and sustained IOP
reduction in individuals with open-angle
glaucoma, ocular hypertension, and angle-
closure glaucoma
• Phaco lowers long term IOP by 2-4 mmHg
• improve the practitioner's ability to interpret
perimetric testing & optic nerve imaging

5. HOW DOES IOP REDUCE?
In patients with CACG:
Removal of the lens would relieve the risk of
pupillary block and posterior forces crowding
the angle
In patients with POAG:
• Reduction of glycosaminoglycan deposition in
the trabecular meshwork due to higher fluid
flow rates

6. • Inflammation induced morphologic changes in
the trabecular meshwork akin to the effects of
laser trabeculoplasty
• Remodeling of the trabecular endothelium
secondary to ultrasonic vibrations
• Alterations in the blood-aqueous barrier
• Increased posterior zonular traction due to
cataract surgery has been postulated to improve
patency of the trabecular meshwork and result in
lower IOP

7. SURICAL OPTION:
• The management of coexistent glaucoma and
cataract is a complex issue with several
therapeutic options
• A lack of consensus regarding the best
surgical management still remains

8. G3 OPTIONS :
• Cataract surgery alone
• Combined cataract and glaucoma surgery
• Or two-phased surgery (glaucoma surgery
followed by cataract surgery, or vice versa)

9. CHOICE DEPENDS ON -
• The extent of glaucomatous damage
• The type of patient
• The surgeon's individual expertise
• The number of topical medicines the patient
is taking
• The target pressure
• The corneal endothelium, pupillary
& zonular integrity

10. Challenges
• Small pupils,
• Posterior synechiae,
• Abnormally shallow or deep anterior
chambers, and
• Weakened zonules (especially in patients with
PXF syndrome/glaucoma).

11. PHACOEMULSIFICATION ALONE
Advantages:
• Quick procedure with rapid visual recovery
• Improved vision which benefits QOL
• Sustained IOP lowering efect

12. DISADVANTAGES
• IOP lowering effect is less than combined
surgery
• IOP should be watched closely in both the
early postoperative period & later
• Pharmaceutical control of the IOP may be
needed postoperatively

13. Candidate:
• Mild to moderate glaucoma
• Requiring few medications

14. Approach:
• 1.Clear corneal:
a.Temporal
b.Superior
• 2.Superior scleral tunnel

15. Mangement of the pupil
Glaucoma patients have pupil that dilate
poorly due to –
• Sphincter fibrosis from miotic therapy
• Posterior synechia
• Primary condition eg.PXF
• IFIS

17. Techniques to overcome:
• Pupil stretching by two Kuglen hooks
• Dilatation by Greishaber disposable iris hooks
• Expansion by Malyugin ring
• Intracameral use of 1:1000 epinephrine

18. Management of the weak zonules:
• Careful thorough hydrodisection &
hydrodelineation
• Avoiding undue pushing of the nucleus with
the tip of the handpiece during sculpting
• A chopping or supra-capsular technique
• Peroperative use of CTR/Cionni ring/Ahmed
capsular tension segment

19. Completion of surgery
• Acrylic IOL is the best op tion
• A 3-piece acrylic foldable IOL for sulcus fixation
• Diffractive multifocal IOL is avoided as it reduces
contrast sensitivity
• Corneal incisions are checked for any leak

21. Combined surgery
Indications:
• The presence of cataract and medically
uncontrolled glaucoma
• The early treatment of glaucoma in cataract
patients
• Advanced glaucoma and cataract which is
likely to progress soon after an antiglaucoma
surgical procedure

22. SURGICAL OPTIONS
Many glaucoma procedures may be combined
with cataract surgery such as-
• Trabeculectomy
• deep sclerectomy, canaloplasty
• Trabectome surgery
• Endoscopic cyclophotocoagulation
• The placement of an Ex-Press mini glaucoma
shunt ,also iStent

23. ONE/TWO TWO SITE APPROACH
One site approach:
• Phaco by superior scleral incision firstly
• The tunnel is converted to a trabeculectomy
flap& a block of inner tissue is removed
either with a punch or freehand later

24. • Two site approach:
• Phaco is performed temporally first
• Then routine trabeculctomy superiorly
• It is slightly more successful with regard to
postoperative IOP control than the former

25. CONJUNCTIVAL FLAP
• Fornix based:
• Allows better visualization during surgery
• Difficult to achieve watertight closure but may
be overcome by –
• a)A continuous vertical mattress suture
described by Wise
• b)Interrupted suture technique in which the
knots are buried into partial thickness corneal
incision

27. • Limbus based:
• It is closed with a two layer technique:
a)Tenon’s capsule closure followed by
b)Conjunctiva closure
Antimetabolite Used:
a)Mitomycin- C
b)5- fluorouracil

29. ADVANTAGES
• Minimizes anesthetic risk by combining 2
procedures in 1
• Convenience to patient with 1 trip to operating
room rather than 2
• Cost saving
• May blunt potentially damaging postoperative
IOP spikes in patients with advanced VF loss
• Opportunity to improve vision & IOP at the
same time

30. DISADVANTAGES
• May not be as effective as long-term IOP
control as trabeculectomy alone
• Increased risk of complications of 2
procedures rather than 1
• Slower visual recovery than cataract alone

31. CATARACT SURGERY BEFORE TRAB
• Early cataract extraction avoids development of
cataract-a common adverse effect of many
glaucoma procedures
• Within 5 years of trabeculectomy or tube shunt
surgery, half of phakic patients develop a visually
significant cataract.(Jampel HD et al)
• The violation of the conjunctival space by
superior extracapsular cataract extraction in a
prior era made subsequent glaucoma surgery
more difficult

32. ADVANTAGES
• Phacoemulsification preserves the integrity of
the conjunctiva for future glaucoma procedures.
• Expands the depth of the anterior chamber
• Doesn’t reduce the success of the subsequent
initial trabeculectomy with MMC(Supawavej et
al)

33. CATARACT Sx AFTER TRAB
• May lead to poor outcomes particularly in
terms of the trabeculectomy failure.Causes -
 Bleb fibrosis by inflammatory mediators
 Reduction in both bleb size and elevation
“Exception to the rule”-1.ACG
2.Shunt surgery

34. Summary
• In the glaucoma specialist's race against time,
a simple cataract surgery may buy several
years of IOP control and delay the morbidity
of traditional filtering surgeries
• Desired outcome depends on figuring out the
best surgical maneuver on the context of the
presenting disease