Combined cataract and glaucoma surgery can provide benefits of reduced costs, stress, and risks compared to staged surgeries. However, it also carries risks like increased inflammation and complications affecting the success of both procedures. The choice depends on factors like glaucoma severity and damage, medications, prior surgeries, and surgeon expertise. Successful outcomes require minimizing these risks through techniques like two-site surgeries and addressing challenges like poor dilation.

1. INDICATION OF
COMBINED
CATARACT &
GLAUCOMA SURGERY
CHAIRMAN- PROF DR IFTEKHAR MD
MUNIR, PROF & HEAD OF THE DEPT, GLAUCOMA
DEPT, NIOH
MODERATOR- DR SAMORENDRA NATH
ADHIKARI, ASSISTANT PROF, GLAUCOMA DEPT,
NIOH
Presented by DR MD SHAHJAHAN SIRAJ, FELLOW
GLAUCOMA

2. Introduction
 Cataract and glaucoma are the leading causes of blindness
worldwide.
 The surgeon has to decide best suited for a particular
patient, combined surgery or staged (sequential) surgeries,
depending on the patient’s severity of glaucoma and visual
compromise from a cataract.
 The ultimate goal to enable the optic nerve to withstand an
IOP spike & maintaining post-operative IOP control without
further surgical intervention.

3. Cataract on evaluation of glaucoma
 Worsen all tests of visual field.
 Affect visual field index/
glaucoma progression as well as
the characterization of scotomas.
 Underestimation of the thickness
of RNFL.

4. Mechanism of IOP reduce???
 In POAG---
Reduction of glycos-aminoglycan deposition in trabecular
meshwork due to higher fluid flow rates, stimulate metalo-
proteinase production & TM remodeling, facilitate AH
drainage.
 In CACG—
Removal of the lens would relieve the risk of pupillary block
& the posterior forces crowding the angle.
……

5. Mechanism of IOP reduce???....
….
 Inflammation induced morphologic changes after effect of
laser trabeculoplasty.
 Remodeling of trabecular endothelium secondary to
ultrasonic vibrations.
 Alterations in the blood-aqueous barrier.
 Increased posterior zonular traction due to cataract surgery-
-- improve patency of trabecular meshwork & result in lower
IOP.

6. Options can be chosen...
 Cataract surgery
alone.
 Combined cataract
and glaucoma
surgery.
 Or two-phased
surgery
( glaucoma surgery
followed by
cataract surgery or
vice versa).

7. Choice depends on…
 The extent of glaucomatous damage
 The type of patient
 The surgeon’s individual expertise
 The number of topical medicines was taking
 The corneal endothelium, pupilary & zonular
integrity.
 The target pressure

8. Combined Cataract and Glaucoma
Surgery
 Potential Advantages
Patient Convenience:
beneficial in terms of cost, easiar & less stressful
Less risks of anesthesia,
stress of multiple surgeries, drugs and social issues.
Avoid potential post-operative IOP spike .
Long term control of IOP and quick visual
recovery.

9. Combined Cataract and Glaucoma
Surgery
Potential Disadvantages
weak/fragile zonules, which may lead to zonular
dehiscence and vitreous loss.
Vitreous loss may lead to failure of glaucoma surgery.
may be less effective for eyes with advanced
glaucomatous damage
Longer visual recovery.

10. Impact of cataract surgery
on intraocular pressure
 Depending on various factors such as --
disease stage,
preoperative IOP,
number of medications,
gonioscopy appearance,
age and the experience and skills of the surgeon.

11. Impact of cataract surgery
on intraocular pressure…..
 The effect of cataract surgery IOP reduction related to --
 angle anatomy,
 preoperative IOP and
 anterior chamber depth.
 Significant & sustained reduction of IOP of individuals.
 Phaco-emulsification lowers long term IOP by 2-4 mmHg.
 Improve interpretation of perimetric testing & optic nerve imaging.

12. Pre-operative Evaluation
 Complete ocular examination, careful history and clinical
exam includings:
Glaucoma Medications--How many medications ? Is
compliance an issue? Is cost an issue?
Visual acuity—best corrected visual acuity? Is glare an
issue? How much of decline in vision is due to cataract
versus glaucoma?
Intraocular pressure—Is the IOP controlled?
Gonioscopy - Is the angle open or closed? Is there subtle
angle recession?

13. Pre-operative Evaluation
 Slit Lamp Exam-
 Evaluate type and extent of cataract, How is pupil dilation?
 iridodenesis or phacodenesis ? pseudoexfoliation, or posterior
synechiae?
 Optic nerve exam and retina evaluation-
 How damaged is the optic nerve? coexisting macular or retinal
pathology ?
 Visual Field Testing—
 extent of glaucoma,
 central island from severe glaucoma,
 After careful evaluation and discussion with the patient, the decision

14. Challenges….
 Small pupils
 Posterior synechiae
 Abnormally shallow or deep anterior chambers
 Weakened zonules ( especially in patients with PXF
syndrome /glaucoma)

15. Special Considerations
 Poor-Pupil Dilation
 Due to
 chronic use of miotics, synechiae formation,
 chronic angle closure,
 prior trauma, or prior laser procedures.
 Patients with
 diabetes,
 or those on alpha-adrenergic receptor blockers .
 If the patient is on any miotics, should be stopped before cataract
surgery. The use of intracameral preservative-free epinephrine 1:10,000
may aid in pupillary dilation.

16. Special Considerations…
 Synechiae and pupillary membranes may often be broken by following
steps may be used:
 Sphincterotomies
 Pupil Stretching using Kuglen or Sinsky
 Mechanical dilation using iris hooks, Morcher dilating ring, or
Malyugan ring
 Inadequate Anterior Capsule Visualization
 corneal opacities or edema
 vitreous hemorrhage.
--In such cases the use of trypan blue can greatly aid in safely
completing the capsulorhexis.

17. Anaesthesia
 Under topical anesthesia using 2% Xylocaine
jelly.
 Trabeculectomies done with supplemental
intracameral or subtenon injections
with lidocaine or marcaine.
 Combined can be performed using
retrobulbar, peribulbar, or topical anesthesia
depending on the surgeons experience and

18. Single-Site vs. Two-Site Surgery
(Cataract Extraction with Trabeculectomy)
 It is up to the surgeon to decide whether to
perform a single-site or a two-site surgery.
 Single-site surgery is done using the scleral
tunnel technique.
 With the increasing popularity of temporal
clear corneal approach for cataract surgery,
two-site surgery has gained more popularity.

19. Single-Site Surgery Technique
 Single-Site Surgery is done with the surgeon sitting superiorly.
 Both surgery are performed using the same conjunctival and
scleral incisions.
 Superior peritomy is performed to expose bare sclera. Gentle
cautery is performed as needed. Paracentesis is made either
before or after the peritomy.
 5-flourouracil (5-FU) or mitomycin-C (MMC), these may be
applied using the surgeon's preferred technique.
 A partial-thickness scleral flap, hinged at the limbus is made.
Alernatively, a scleral tunnel incision can be made initially.

20. Single-Site Surgery Technique….
 A keratome is used to enter the anterior chamber
 Phacoemulsification is performed in the usual manner
 Intraocular lens is inserted
 Viscoelastic is removed
 Sclerectomy is performed using a Kelley descsment’s punch or
wedge sclerectomy using a sharp point blade .
 A peripheral iridectomy to be made.
 The scleral flap is closed using interrupted or releasable 10-0
mylon sutures & be adjusted to ensure adequate flow.
 Tenons and conjunctiva are closed.

21. Video(Single-Site Surgery)

22. Single-Site Surgery
 Advantages
Saves Time
One wound is made
No need for the surgeon to change position and the
microscope.
 Disadvantages
More post-operative inflammation
Excessive conjunctival manipulation
Longer visual recovery.

23. Two-Site Surgery Technique
 The surgeon first completes --
 the cataract extraction sitting temporally and
 then moves superiorly to complete the trabeculectomy.
 Temporal clear corneal is performed.
 The main incision be sutured (typically using 10-0 nylon) to prevent
wound leak.
 Surgeon moves superiorly and performs trabeculectomy using his or
her preferred technique.
 Antimetabolite used—
 Mitomycin-C

24. Conjunctival flap…
 Fornix based-
Allows better visualization during surgery
Difficult to achieve water-tight closure but may be
overcome by-
A continuous vertical mattress suture
Interrupted suture technique in which the knots are buried into
partial thickness corneal incision.

25. Conjunctival flap…
 Limbus based-
 It is closed with a 2 layer technique-
Tenon’s capsule closure followed by
Conjunctival closure.

26. Video(Two-Site Surgery)

27. Two-Site Surgery
 Advantages
Improved exposure
Deep set eyes
Narrow palpebral fissure
In shallow eyes, reduces the risk of touching or injuring
the iris
Less inflammation and less manipulation of the
conjunctiva superiorly
Enhances bleb survival

28. Two-Site Surgery
 Disadvantages
May take longer
Surgeon needs to change position
Microscope also requires adjustment

29. Cataract surgery before TRAB…
 Avoids development of cataract related adverse effect
of many glaucoma procedures.
 The violation of the conjunctival space, any superior
extracapsular cataract extraction made subsequent
glaucoma surgery more difficult.
 Expands the depth of the anterior chamber.
 Doesn’t reduce the success of the subsequent
trabeculectomy with MMC.

30. Cataract surgery after
TRAB…
May lead to poor outcomes particularly in
trabeculectomy failure.
Cause—
 Bleb fibrosis by inflammatory mediators.
 Reduction in both bleb size and elevation.
** Exception of the rule in --- ACG & Shunt
surgery

31. Toric IOL in glaucoma patients
 Toric IOLs might also not be successful in patients with
 an unstable capsular bag,
 or pseudoexfoliation and/or weak zonules, as the lens and bag
may rotate or tilt once implanted, altering the patients’ vision.
 Potential error if a toric IOL with glaucoma surgery might
induce keratometric changes--
 depending on sutures and their tension,
 and further changes may occur if those sutures are removed or
lysed, negating any benefit from the toric implant.

32. Multifocal IOLs in Combined
Surgery
 Multifocal IOL implants may be inadvisable in patients
 where central visual field reduction may not be tolerated,
 such as macular degeneration, retinal pigment epithelium
changes and glaucoma.
 Multifocal platforms can be safely used in
 glaucoma suspects and ocular hypertensive patients
 with no disc or visual field damage who have been stable.
 with early or mild visual field damage that has been controlled and
stable,
 in the fellow eye that is similar, and not severe, advanced or
progressive.

33. Post-Operative Management
 Should be seen on the first post-operative day
 and then weekly there after until the IOP has
stabilized.
 Sutures may by pulled or lysed as needed.
 In the presence of significant inflammation, more
frequent visits may be required.

34. Post-Operative Management….
 Post-operative medications
 Antibiotic drops every four hours for the first week.
 Steroid drops every 2 hours for the first month, followed by
taper.
 Cycloplegics may be used in cases of shallow anterior
chamber or hypotony & also beneficial in post-operative
cases of CACG to prevent malignant glaucoma.

35. Potential Complications
 Shallow or flat anterior chamber
 Persistent inflammation
 Choroidal effusion
 Bleb leaks, blebitis.
 Filtration failure
 Suprachoroidal hemorrhage
 Endophthalmitis
 Chronic hypotony
 Maculopathy

36. Success to combine surgeries and
minimize complications….
The success depends on several factors among which :
 Type of glaucoma
 Severity of damage
 Amount and time of use of topical medicine
 Previous surgery/s
 Type of surgery to be performed

37. Other Types of Combined Surgery
These include:
 Phacoemulsification with Glaucoma drainage devices
 Ex-PRESS Shunt Combined with Cataract Extraction
 Microinvasive Glaucoma Surgery (MIGS)
 Combined phacoemulsification and canaloplasty
 Combined phacoemulsification and iStent®
 Combined phacoemulsification and CyPass®
 Combined phacoemulsification and
endocyclophotocoagulation
 Phacotrabeculectomy
 Femtosecond-assisted cataract surgery in glaucoma

38. Conclusion
 In the glaucoma specialist’s race
against time, a simple cataract surgery
may buy several years of IOP control
& delay the morbidity of traditional
filtering surgeries.
 Desired outcome depends on figuring
out the best surgical maneuver on the
context of the presenting disease.