Combine Cataract – Glaucoma Surgery

Vassilios Kozobolis

✓Democritus University of Thrace

✓Glaucoma & Laser Eye Center Athens

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CATARACT & OAG

CATARACT & PACD (Primary Angle-Closure Disease)

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Combined cataract–glaucoma surgery

CAT – TRAB

CAT – NPGS

CAT – EXPRES

CAT – GDDs

CAT – MIGS

CLE / PACD

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Pros

•• Decreased risk of one surgical and

anaesthetic procedure compared to two different

•• Less cost to healthcare services

•• Less TOTAL operating time

•• Faster visual rehabilitation

•• Decreased incidence of postop pressure

spikes compared to cataract surgery alone

Cons

•• Lengthy procedure that requires experience

•• A complicated cataract surgery may compromise

the success of the antiglaucoma procedure

CAT – TRAB

PRONS & CONS

•The two-site surgery (incision: 60

– 90 away) offers slightly lower IOP

(1-3 mmHg) than the one-site

surgery

•The two-site technique causes

less damage to the area of filtration

and subsequently less fibrosis with

better chances for the survival of

the trabeculectomy over time

CAT/TRAB: One–Site vs Two–Site surgery

vs

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There is evidence that

limbus based flaps are

more prone to bleb infection

CAT – TRAB: Limbus vs Fornix conjunctival incision

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LIMBUS BASED:

•FASTER - Early bleb

leaks were more

common

•The limbus and fornix based

conjunctival flaps are equally

effective in lowering IOP

MMC has been used in varying

concentration (0.2-0.4mg/ml)

and application time (2-5

minutes) depending on the

severity of glaucoma and

presence of risk factors.

Intraoperative

Antifibrotic agents / Antimetabolites

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The intraoperative dose of

5-FU is 0.1 ml of a 50mg/ml

solution for 5 minutes.

•TOPICAL PREOP Corticosteroids in patients who were treated with antiglaucoma drops as these patients have lower success rate (Araujo, S. V, Lavin M)

•TOPICAL POSTOP Corticosteroidstopical drops is associated with better IOP control and less glaucoma medicines less needling (Higginbotham, E. J)

•INJIECTION OF TRIAMCILONE in the bleb or behind the globe seems beneficial in terms of IOP control (Tham, C. C, Kahook M)

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Corticosteroids and NSAIDs drugs

✓ Releasable Suture

✓ NEEDLING ***

✓ CORTICOSTEROIDS SC*

✓ MMC SC***

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POSTOPERATIVE F/U

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•Three (3) main aspects have

to be considered:

•Area

•Height and

•Vascularity

Describing a bleb: Moorfields Bleb Grading System

•There are six criteria to assess:

•2 describing area

•1 describing height and

•3 describing vascularity

Resistance at the level of sclerostomy

•● Blood. Management: topical steroids, ocular massage, intracameraltissue plasminogen activator, aspiration in theatre

•● Iris: retraction of iris tissue with argon laser, removal of iris in theatre.

•● Vitreous: YAG-laser to release vitreous, removal of vitreous in theatre.

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Resistance at the level of scleral flap

•Tight sutures / Management: ocular massage, argon laser suturolysis, removal of releasable sutures

•Blood / Management: topical steroids, ocular massage, intracameral tissue plasminogen activator, aspiration in theatre

Resistance at the level of Conjunctiva / Tenon’s layer

•Diffuse scar tissue formation or formation of encapsulated bleb (Tenon’s cyst).

•Management. Topical steroids, bleb needling with 5-FU or MMC injection, scar tissue removal in theatre.

Cat/DS: Aqueous in the subconjunctival

space

A: bleb wall B: bleb cavity

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BLEBS

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Cat/EX PRESS BLEB / AS-OCT

•Ex-PRESS device

• Aqueous subconjoctival

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✓Hypotony,

✓Choroidal Hemorrhage,

✓Bleb Problems

MIGSEvolved in order to avoid problems associated

with full-thickness filtering procedures:

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- Ab interno

(microstents, trabectome,

Cypass)

- Ab externo

(NPS)

• Increasing outflow

through trabeculum

(canaloplasty, XEN GEL)

• Increasing outflow

through collector channels

(trabectome, IStent)

• Increasing outflow

through suprachoroidal space

(CyPass, Solx Gold Shunt)

- Bleb related

(DS, XEN GEL)

- Blebless

(canaloplasty, microstents

Trabectome, CyPass)

MIGS: CLASSIFICATION

(MIGS)

THE NEXT FIGHT IN GLAUCOMA SURGERY

1/ Xen Gel Stent by Allergan

2/ Inn Focus Micro Shunt by Santen

3/ CyPass Micro-Stent by Alcon

4/ I Stent by Glaukos

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CY PASS

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I STENTGlaukos

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XEN GEL: gelatin-based

implant

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IN FOCUS: made of SIBS, biostable thermoplastic elastomeric material

Cat/GL Surgery

✓ Calculation formula

✓ IOL Positioning: Bag – Sulcus / ACh

✓ IOL technology: Material – Design –

Refraction

✓ Eye Pathology: PEX - Zonule

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IOL Calculations in Patients with OAG

•precise biometry

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SRK II vs SRK-T

• The SRK-T formula calculates the effective lens position (ELP), an important parameter in predicting postoperative SE, by considering AL and corneal height.

BUT

• SRK II formula is preferable to other formulas when a trab has been performed or will be combined with cataract surgery due to significant difference between actual and estimated lens position in the presence of a well-functioning bleb

• AND

• when ACD is <3 mm and AL is within the normal RANGE.

• Miraftab M,. Effect of anterior chamber depth on the choice of intraocular lens calculation formula in patients with normal axial length.

Middle East Afr J Ophthalmol 2014

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V.A. & C.S.✓C.S. is an important visual function for day-to-day activities

✓C.S. is the visual function that allows one to differentiate the

•luminance between two appositional areas.

✓ Glaucoma patients may have excellent visual acuity, often

• as good as 20/20 but often

have decreased C.S.

✓ Decreased C.S. is correlated with visual field loss in patients with glaucoma

• (Hawkins AS et al. J Glaucoma 2003)

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Age - Wavefront Aberration - CS

✓ Decrease

✓ VA

✓ CS

✓ Increased wavefrontaberration

•Lens

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•Age

Spheric or Aspheric IOLs

✓ The more peripheral rays are refracted more

powerfully in spherical lenses: this creates

several problems (glare, halos, decreased CS)

✓ The spherical aberration is more

relevant in the patients with

larger pupils

✓ Pupillometry: Mesopic - Scotopic

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Aspheric IOLs in Patients with

Glaucoma

✓ Decrease the

•glare, halos, and other optical

phenomena

✓ Improve CS for both

•mesopic and scotopic

•Caporossi A et al, J Refract Surg 2007

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✓ An IOL that would correct for cornealspherical aberration

IOLs & PCO > VA & CS

✓Acrylic hydrophobic

✓Acrylic hydrophilic

✓Silicone

✓PMMA

•Buehl W, Findl O. Effect of intraocular lens design on posterior capsule opacification.

•J Cataract Refract Surg 2008

•Kugelberg M et al, Posterior capsule opacification after implantation of a hydrophilic or a hydrophobic acrylic intraocular lens: one-year follow-up.

•J Cataract Refract Surg 2006

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✓ PMMA (1.49)

✓ Silicone (1.43-1.46)

✓ Hydrophilic Acrylic (1.47)

✓ Hydrophobic Acrylic (1.47 to 1.55)

✓ Water (1.33)

•Effect of IOL design on

•posterior capsule opacification (PCO)

•Sharp-edged IOL

optics should be

preferred to round-

edged IOL optics

•Buehl W, Findl O, JCRS 2008

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Multifocal IOLs & OAG: Poor Literature

✓ Multifocal IOLs have focal

distances, usually one for

reading, and one for distance.

✓ Haloes and Glare

✓ Decentration problems

✓ Both glaucoma and multifocal

IOLs decrease CS

•(few small studies)

• Multifocal IOLs cause wavy artifacts on OCT images

•Inoue M et al, Wavy horizontal artifacts on OCT line-scanning images caused by diffractive multifocal

IOLs, JCRS 2009

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Astigmatic & Accommodating IOLs

✓These IOLs require an intact accommodative system

✓Without weak zonule

✓Capsular Contraction is more often in PEX eyes

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Rules for MF IOLs in GL Patients

✓ Ocular Hypertensive

patients

✓ Glaucoma Suspects

✓ Patients with Glaucoma

early or mild visual field

damage

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✓ Stable

✓ Not progressive

✓ Not severe,

✓ Not advanced

•Ahmed IK, Teichman JC.

•Multifocal IOLs and glaucoma: how much is to much?

•In: Chang D, editor. Transitioning to refractive IOLs: the art

and science. Thorofare, NJ: Slack Incorporated; 2008

Glistenings & Refractive Index

✓ PMMA (1.49)

✓ Silicone (1.43-1.46)

✓ Hydrophilic Acrylic (1.47)

✓ Hydrophobic Acrylic (1.47 to 1.55)

✓ Water (1.33)

✓ Glistenings, or microvacuoles, are reflections of light of 1 to 20 μm

✓ Difference of refractive properties of the IOL’s material

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• Altmann GE, JCRS 2005

• Wang L, Koch DD, Arch Ophthalmol 2005

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On the other hand: Decentration

The mechanism responsible for IOP decrease

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1/ Increase Trabecular Outflow

2/ Increase Uveoscleral Outflow

3/ Increase Ant Chamber Volume

4/ Hyposecretion of Aqueous

LENS extraction

Summary

•Phaco-trabeculectomy remains the standard procedure for the management of coexisting cataract and glaucoma

•Newer techniques have been developed in order to avoid usual complications of TRAB and provide a more controlled reduction of the IOP

• The use of antifibrotic agents have improved the survival of these procedures

•The postop F/U: crucial significance

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THANK YOU

Democritus Universityelkethop.alex.duth.gr

&Glaucoma & Laser Eye Center Athens

www.glaucoma-laser-eyecenter.gr

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“Οκοσα φάρμακα ουκ ιήται σίδηρος ιήται”

Ιπποκράτης