Advanced Glaucoma and Cataract: Management Options

Regenbogen Michael – IchilovAmer Radgonde – HadassahRon Yonina – BeilinsonReyvitch Svetlana – Barsilai

Chetrit Noa – Assaf HarofBlumenfeld Oren - Wolfson

Kaplan Audrey

Definition

Cataract: Visually significant

Advanced glaucoma: Visual field loss Moderate-severe Inadequate lowering of target pressure

Cataract Glaucoma

Both are age –related

Increased cataract PXF antiglaucomatous medications

Prevalence of Visual Impairment in Older Americans

Goals of Treatment

Improve VA Reach target IOP Free from drugs Preserve VF

Surgical options

Glaucoma surgery

Cataract surgery

Combinedsurgery

Glaucoma Surgery

TrabeculectomyNon-penetrating filtering surgeryGoniosynechiolysisShunt deviceEndoscopic cyclophotocoagulation

Glaucoma Surgery

TrabeculectomyNon-penetrating filtering surgeryGoniosynechiolysisShunt deviceEndoscopic cyclophotocoagulation

Glaucoma Surgery

TrabeculectomyNon-penetrating filtering surgeryGoniosynechiolysisShunt deviceEndoscopic cyclophotocoagulation

Glaucoma Surgery

TrabeculectomyNon-penetrating filtering surgeryGoniosynechiolysisShunt deviceEndoscopic cyclophotocoagulation

Surgical options

Trabeculectomy

Cataract surgery

Combinedsurgery

Stand alone Trabeculectomy

Pros:Reduces IOP +++

phacotrabeculectomy or cataract extraction

Caprioli J et al.Trans Am Ophthalmol Soc

1996.

Cons:Cataractogeneous

Higher complication rate (hypotony, significant chamber shallowing…)

AGIS investigators Arch Oph 2001

Cataract extraction alone Pros:

• Cataract extraction decreases IOP per se (ACG>PXF>OAG)

• Dimitrov et al. Clin Exp Ophthal 2001• Friedman et al. Ophthalmology 2002

Cons:

• 10% IOP spike• By 2 yr. 30% IOP worse

than preoperative status

• Rainer et al. J Cat Ref Surg 1999• Hayashi et al. J Cat Ref Surg

2001

Lens extraction in PAC

• Pre-Phaco/IOL Post-Phaco/IOL

Combined Surgery: Best Choice

One procedure improves VA and reduces IOPQuality of lifeCataract surgery post trabeculectomy: more bleb failure

Combined surgery : techniques

ECCE / phaco ?One site vs. two sitesLimbal or fornix basedWith/without MMC

Phacotrabeculotomy 2 sites + MMC (Vass Curr Op. 2004)

Complications InfectionsHypotonyCataract formationTransient IOP elevationCMEChoroidal effusionSuprachoroidal hemorrhage

Leakage/failure of blebBlebitisEndophthalmitis

Cataract+ well controlled OAG

Only cataract

Cataract + CACG

CATARACT SURGERY ONLY

Cataract with uncontrolled OAG moderate damage

Phacotrabeculectomy +/- MMC

Cataract + advanced glaucoma (low target IOP)

Phacotrabeculectomy+MMC

trabeculectomy+MMC

Thank You