Take it slow when facing new challenges in cataract surgery

A surgeon's chances of success  in their first cataract cases involving glaucoma patients are  greatly enhanced through a slow and steady approach, said Thiemo Rudolph MD, FEBO, Sweden, at a Young Ophthalmologists Symposium at the 19th Winter Meeting of the ESCRS in Istanbul.

The first important decision is  whether to  perform first the cataract or the glaucoma procedure,or alternatively, the two combined. The current consensus supports the performance of the cataract procedure first on numerous grounds, Dr Rudolph said.

For example, cataract surgery using modern phaco with clear corneal incisions will not reduce the efficacy of subsequent filtration surgery, but cataract surgery following glaucoma filtration surgery can impair the functionality of the bleb. Moreover, in eyes with angle closure glaucoma, cataract surgery is often all that is necessary to bring IOP down to acceptable levels. In addition, combined procedures are generally less effective than trabeculectomy alone in lowering IOP.

However, when a patient who has already undergone  glaucoma surgery presents with a cataract, a  successful outcome is possible when appropriate precautions are taken, Dr Rudolph said. As an illustration, he described and demonstrated with a video clip the case of woman who presented with cataract nearly  20 years after undergoing a trabeculectomy with a still-functioning bleb and well-controlled IOP.

 After receiving carefully considered and through information and having some time to consider her options and the risks involved, she opted for phacoemulsification and IOL implantation. Special measures that Dr Rudolph used during the  procedure included iris hooks to stabilise the pupil and the placement of a capsular tension ring for zonular support. At her most recent follow-up the patient had a corrected visual acuity of 20/25 and her IOP returned to its preoperative  level of 16.0 mmHg.