CATARACT EXTRACTION IN GLAUCOMA M I L E S A. G A L I N , M.D.,
P O R T. H U N G , M.D.,
AND S T E P H E N A. O B S T B A U M ,
M.D.
New York, New York
When cataract surgery is necessary in a glaucomatous patient,1""4 many surgeons advocate simple lens extraction. Normali zation of intraocular pressure may occur particularly if fine, buried sutures are used, implying some type of filtration. 5 Hyposecretion, has also been implicated as the mechanism for pressure normaliza tion when no other obvious explanation is apparent. 5 More predictable results than those ob tained by cataract extraction alone occur with combined procedures, 6 - 1 3 but are associated with greater surgical risk and are not universally recommended. The data of published studies of the effect of cataract extraction or combined procedures on intraocular pressure gener ally have been pooled and do not have adequate controls. We report herein on a combined procedure, either cyclodialysis cataract extraction or cyclodialysis canalicular trabeculectomy cataract extraction, performed in one eye of glaucomatous patients, and a standard procedure per formed in the second equally glaucoma tous eye, in order to determine the physi ology of intraocular pressure control after cataract extraction, as well as which sur gical approach is more appropriate. M A T E R I A L AND M E T H O D S
We performed combined surgery on 120 patients who have been observed for From the Department of Ophthalmology of the New York Medical College (Drs. Galin and Hung), and the Department of Ophthalmology, Mt. Sinai Medical Center, (Dr. Obstbaum) New York, New York. This study was supported by grants from the Ophthalmological Foundation of America, Inc., and by United States Public Health Service Internation al Research Fellowship F052080. Reprint requests to-Miles A. Galin, M.D., Depart ment of Ophthalmology, New York Medical Col lege, 1249 Fifth Ave., New York, NY 10029. 124
at least two years. All patients required cataract extraction for visual purposes and all but two patients had open-angle glaucoma with field and disk changes. Two patients had previous peripheral iridectomies for angle-closure glaucoma and required miotics. They also had marked field changes. Forty-seven pa tients were suitable for this present study, as they had reasonably similar bilateral glaucoma and cataracts. Twenty-four pa tients had undergone a combined pro cedure in one eye and simple cataract extraction in the other. Twenty-three pa tients have had surgery to one eye; the fellow eye has either not been operated on or been observed for two years. Sixteen of the eyes undergoing a combined proce dure would have required glaucoma sur gery if no cataract were present because of inadequate glaucoma control. The re maining eight, though needing cataract surgery, were well controlled. In the fel low control eyes, 14 had inadequate glau coma control and ten were well con trolled. The 24 combined procedures were equally divided among cyclodialysis cat aract extraction and cyclodialysis canalicular trabeculectomy cataract extraction. The ages of both groups ranged from 50 to 87 years. The follow-up period was from five to 12 years in the cyclodialysis group, two to four years in the cyclodialy sis canalicular trabeculectomy group, and from three to ten years in the cataract extraction control group. Though both eyes were similar in all cases, the combined procedure was al ways performed in the eye with the more severe glaucoma, as evidenced by higher pressure, more severe field loss, or greater cupping. Surgery was usually delayed in either
AMERICAN JOURNAL O F OPHTHALMOLOGY 87:124-129, 1979
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CATARACT EXTRACTION IN GLAUCOMA
eye until the patient was visually symp tomatic or glaucoma control was inade quate. Attributing field loss to glaucoma rather than to further reduction in visual acuity is not simple, and frequent kinetic, and static fields were performed. Surgery in all control cases involved a limbal based conjunctival flap, a vertical groove, preplaced 6-0 silk sutures, a biplaned incision, peripheral iridotomies, synechiotomy when necessary, and lens extraction. This series was not complicat ed by vitreous loss, wound leakage, or any other complication. In the cyclodialysis lens extraction pro cedure, cyclodialysis was done after groove formation and suture placement, as described previously. 14 No anterior segment complications occurred though one patient had a choroidal hemorrhage, which occurred at the time of surgery and subsequent secondary vitreous hemor rhage. This took months to clear but re sulted in visual acuity of 6/6 (20/20). Cyclodialysis canalicular trabeculectomy cataract extraction altered the lens extrac tion only slightly. A 3 X 3- to 4-mm scleral flap 0.25 to 0.5 mm deep was made at 12 o'clock (Fig. 1). The anterior extent of the flap ended at the surgical corneosceral limbus and a limbal groove with preplaced 6-0 sutures was created later ally and medially, as for routine cataract extraction (Fig. 2). The posterior scleral flap was excised (Fig. 3, top), the eye opened with scissors, and iridotomies performed (Fig. 3, bottom). Since the deep scleral flap was created posterior to the scleral spur, a cyclodialysis done under total visual control, slightly larger than the 3-mm width of the scleral flap15 resulted. After the cataract was removed, the flap site was closed with two inter rupted 8-0 silk sutures, and the remainder of the wound closed routinely. One anterior chamber complication oc curred in the cyclodialysis canalicular trabeculectomy lens extraction procedure
125
Fig. 1 (Galin, Hung, and Obstbaum). After a limbal based conjunctival flap is created, a 3 x 3to 4-mm limbal based lamellar scleral flap is made.
group. A hyphema developed on the third day which nearly progressed to an eightball hemorrhage. The clot was evacuated, and the patient's postoperative course
Fig. 2 (Galin, Hung, and Obstbaum). A standard limbal groove is created medial and lateral to the lamellar scleral flap and threaded with preplaced sutures.
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FEBRUARY, 1979
Fig. 3 (Galin, Hung, and Obstbaum). The posteri or scleral lamella is excised (top), the eye opened as for cataract extraction with scissors, and iridotomies performed (bottom).
was uneventful. No obvious cause of the bleeding was apparent at the initial sur gery or subsequent intervention. RESULTS
Visual acuity was 6/12 (20/40) or better in 20 control eyes. Visual acuity was less than this level in four cases, three from advanced glaucoma, and one from a raacular lesion. In the combined procedure group, visual acuity was 6/12 (20/40) or better in 18 eyes. As in controls, the cause of reduced visual acuity was glaucoma in four cases and macular degeneration in
two. In the cyclodialysis lens extraction group, six of 12 eyes required no medica tion. The other combined group had nine of 12 patients free of medication. The cutoff point on no medication was arbi trarily set at a diurnal curve that did not exceed 18 mm Hg. In this group without medication, no progression of glaucomatous visual field loss or further disk changes occurred. Besides the previous complication men tioned in the cyclodialysis lens extraction group, one patient had a large choroidal detachment and two had small hyphemas.
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CATARACT EXTRACTION IN GLAUCOMA
No therapy was given to any of these patients, and all absorbed the transudate or blood without difficulty. No other com plication occurred in the cyclodialysis canalicular trabeculectomy cataract ex traction group. In the cataract extraction group, two eyes required no further medication by using the above criteria. All others re quired medication. There were no surgi cal or postoperative problems in any case. One of the two cures in the control group had a significantly improved outflow fa cility, and the other did not. No blebs and no clefts were present, and a rise in intra ocular pressure on perilimbal suction oc curred in both cases. In the successful cyclodialysis cataract extraction group, a cleft was visible in each instance and perilimbal suction cup analysis resulted in a fall in intraocular pressure. 16 Clefts were visible in two of the remaining six patients, but functional analysis by perilimbal suction induced a rise in intraocular pressure in each in stance. Gross bleb formation was present in six of nine successful cyclodialysis canalicular trabeculectomy cases and clefts visible in three, two with blebs and one without. Perilimbal suction cup anal ysis was impossible to perform adequate ly because of the bleb area in this group. DISCUSSION
The evaluation of the effect of cataract extraction on glaucoma control has been expressed as changes in mean intraocular pressure or alteration in glaucoma medi cation. More meaningful criteria that have been suggested are the number of patients that require no medication or have required further glaucoma surgery. 5 These criteria have been reserved primar ily in cases where the glaucoma was uncontrolled preoperatively and after sur gery. The present series cannot be ana lyzed by the latter standard, and though the series is too small for statistical analy
127
sis, there is little question that the com bined procedures were more predictable and more consistent, despite a success rate of only 50 to 75% without medica tion. Every effort was used to assure good cataract wound closure in both series, and a two-planed incision closed with mul tiple 6-0 silk sutures rarely results in serious leakage. The choice of operation for cataract coexisting with open-angle glaucoma has historically varied, depending for the most part, on the status of glaucoma con trol. In well-controlled cases, most sur geons will perform cataract extraction alone. 17 For inadequately controlled glau coma, it had been common to perform glau coma surgery as an initial procedure. 1 8 - 2 0 However, subsequent surgical difficul ties at the time of cataract surgery and difficulties in the preservation of bleb function were discouraging. 2 1 These problems, coupled with better surgical technique, have encouraged the develop ment of combined procedures. 2 2 A further stimulus to combined surgery is the ob servation that glaucoma surgery in eyes with existing immature cataracts often enhances cataract maturation. We are presently performing a modi fied cyclodialysis canalicular trabeculec tomy cataract extraction for patients with cataract and glaucoma in which the cyclo dialysis is remarkably larger than the width of the lamellar scleral flap. Since the trabeculectomy flap is initiated pos terior to the scleral spur, a cyclodialysis under direct visualization is performed as part of the procedure in order to disinsert the scleral spur. The disinsertion is ex tended laterally and medially to create at least a 30-degree cyclodialysis (Fig. 4). These maneuvers do not lead to signifi cant hyphema, nor does the initial scleral spur disinsertion, as evidenced by the rare occurrence of hyphema after such operations in phakic eyes. Usually hyphe ma after cyclodialysis is caused by tearing
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bines the most favorable features of each procedure while reducing the risk compo nents. The cyclodialysis is carried out under direct visualization, reducing the potential for bleeding, and the lamellar scleral flap is reasonably well closed, re ducing the potential for a flat chamber. The ease of performing lens extraction remains unaltered. We believe more ex tensive application of this procedure should be used in combined disease. SUMMARY
Fig. 4 (Galin, Hung, and Obstbaum). Cyclodialysis canalicular trabeculectomy cataract extraction in which the cyclodialysis is approximately 30 degrees.
of ciliary muscle by the cyclodialysis spatula as one blindly attempts to disin sert this muscle at its attachment. This is frequent in the aphakic eye where the ciliary body is not under traction. When performing the cyclodialysis as part of a trabeculectomy, the surgeon sees the at tachment of the ciliary body and should be able to disinsert it cleanly. Though loose closure of the lamellar scleral sec tion is desirable in the phakic eye to assure filtration, a firm closure is neces sary in the combined procedure to assure a deep chamber. Filtration will occur in a moderate percentage of cases and the ad ditional controlled cyclodialysis results in a highly successful procedure. Long-term follow-up studies for simple cataract surgery in glaucomatous patients are rare. Balanced against a predictable, reproducible success rate of at least 50% with combined procedures, simple cata ract extraction would not be indicated even for cases of well-controlled glau coma, were it not for the increased mor bidity of combined procedures. The procedure of cyclodialysis canalicular trabeculectomy cataract extraction com
Cyclodialysis lens extraction or cyclo dialysis canalicular trabeculectomy lens extraction in one eye and cataract extrac tion in the fellow eye were performed in 24 glaucoma patients. The combined pro cedure follow-up was from five to 12 years in the first group, two to four years in the second group, and from three to ten years in the control group. The 50% success rate of cyclodialysis lens extraction can be enhanced with no significant increase in surgical morbidity or postoperative complications by per forming a cyclodialysis canalicular trabecjilectomy where the disinsertion of the scleral spur is carried out under direct visualization. REFERENCES 1. Guyton, J. S.: Choice of operation for primary glaucoma combined with cataract. Arch. Ophthalmol. 33:265, 1945. 2. Ramsey, G. A. S.: Glaucoma and cataract. Arch. Ophthalmol. 43:195, 1950. 3. Linn, J. G.: Cataract extraction in management of glaucoma. Trans. Am. Acad. Ophthalmol. Otolaryngol. 75:273, 1971. 4f Bigger, J. F., and Becker, B.: Cataracts and open angle glaucoma. The effect of cataract extrac tion on visual fields. Am. J. Ophthalmol. 71:335, 1971. 5. : Cataracts and primary open angle glau coma. The effect of uncomplicated cataract extrac tion on glaucoma control. Trans. Am. Acad. Oph thalmol. Otolaryngol. 75:260, 1971. 6. O'Brien, C. S.: Ocular surgery. Random obser vations. Arch. Ophthalmol. 37:1, 1947. 7. Hauer, J.': Simultaneous cataract glaucoma op eration. Isr. J. Med. Sci. 19:254, 1960. 8. Stocker, F. W.: Combined cataract extraction
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and scleral cauterization. Arch. Ophthalmol. 72:503, 1964. 9. MacLean, A. L.: Limbal lip cautery for glauco ma. Arch. Ophthalmol. 71:653, 1964. 10. Harrington, D. O.: Cataract and glaucoma. Management of the coexistent conditions and a description of a new operation combining lens ex traction with reverse cyclodialysis. Am. J. Ophthal mol. 61:1134, 1966. 11. Galin, M. A., Baras, I., and Sambursky, J.: Glaucoma and- cataract. A study of cyclodialysislens extraction. Am. J. Ophthalmol. 67:522, 1969. 12. Maumenee, A. E., and Wilkinson, C. P.: A combined operation for glaucoma and cataract. Am. J. Ophthalmol. 69:360, 1970. 13. Rich, W.: Cataract extraction with trabeculectomy. Trans. Ophthalmol. Soc. U.K. 94:458, 1974. 14. Galin, M. A.: Surgical technique of cyclodial ysis lens extraction. Ann. Ophthalmol. 7:1257, 1975. 15. Galin, M. A., Boniuk, V., and Robbins, R. M.: Surgical landmarks in trabecular surgery. Am. J. Ophthalmol. 80:696, 1975.
GLAUCOMA
129
16. Galin, M. A., and Baras, I.: Combined cyclo dialysis cataract extraction. A review. Ann. Ophthal mol. 7:721, 1975. 17. Roberts, W.: The cataract problem in the glaucoma patient population. Arch. Ophthalmol. 84:279, 1970. 18. Becker, B.: In round-table discussion. In Armaly, M. F . (ed.): Symposium on Glaucoma. St. Louis, C.V. Mosby, 1967, p. 255. 19. Shaffer, R. N.: In round-table discussion. In Armaly, M. F. (ed.): Symposium on Glaucoma. St. Louis, C. V. Mosby, 1967, p. 276. 20. Pollack, I. P.: In round-table discussion. In Armaly, M. F. (ed.): Symposium on Glaucoma. St. Louis, C. V. Mosby, 1967, p. 257. 21. Hughes, W. L., Kazdan, M. S., Brackup, A. H., and Marinakos, C : Combination operation for cataract and glaucoma. A further report. Am. ] . Ophthalmol. 56:391, 1963. 22. Jerndal, T., and Lundstrom, M.: Trabeculectomy combined with cataract extraction. Am. J. Ophthalmol. 81:227, 1976.
P O R T. H U N G , M.D.,
AND S T E P H E N A. O B S T B A U M ,
M.D.
New York, New York
When cataract surgery is necessary in a glaucomatous patient,1""4 many surgeons advocate simple lens extraction. Normali zation of intraocular pressure may occur particularly if fine, buried sutures are used, implying some type of filtration. 5 Hyposecretion, has also been implicated as the mechanism for pressure normaliza tion when no other obvious explanation is apparent. 5 More predictable results than those ob tained by cataract extraction alone occur with combined procedures, 6 - 1 3 but are associated with greater surgical risk and are not universally recommended. The data of published studies of the effect of cataract extraction or combined procedures on intraocular pressure gener ally have been pooled and do not have adequate controls. We report herein on a combined procedure, either cyclodialysis cataract extraction or cyclodialysis canalicular trabeculectomy cataract extraction, performed in one eye of glaucomatous patients, and a standard procedure per formed in the second equally glaucoma tous eye, in order to determine the physi ology of intraocular pressure control after cataract extraction, as well as which sur gical approach is more appropriate. M A T E R I A L AND M E T H O D S
We performed combined surgery on 120 patients who have been observed for From the Department of Ophthalmology of the New York Medical College (Drs. Galin and Hung), and the Department of Ophthalmology, Mt. Sinai Medical Center, (Dr. Obstbaum) New York, New York. This study was supported by grants from the Ophthalmological Foundation of America, Inc., and by United States Public Health Service Internation al Research Fellowship F052080. Reprint requests to-Miles A. Galin, M.D., Depart ment of Ophthalmology, New York Medical Col lege, 1249 Fifth Ave., New York, NY 10029. 124
at least two years. All patients required cataract extraction for visual purposes and all but two patients had open-angle glaucoma with field and disk changes. Two patients had previous peripheral iridectomies for angle-closure glaucoma and required miotics. They also had marked field changes. Forty-seven pa tients were suitable for this present study, as they had reasonably similar bilateral glaucoma and cataracts. Twenty-four pa tients had undergone a combined pro cedure in one eye and simple cataract extraction in the other. Twenty-three pa tients have had surgery to one eye; the fellow eye has either not been operated on or been observed for two years. Sixteen of the eyes undergoing a combined proce dure would have required glaucoma sur gery if no cataract were present because of inadequate glaucoma control. The re maining eight, though needing cataract surgery, were well controlled. In the fel low control eyes, 14 had inadequate glau coma control and ten were well con trolled. The 24 combined procedures were equally divided among cyclodialysis cat aract extraction and cyclodialysis canalicular trabeculectomy cataract extraction. The ages of both groups ranged from 50 to 87 years. The follow-up period was from five to 12 years in the cyclodialysis group, two to four years in the cyclodialy sis canalicular trabeculectomy group, and from three to ten years in the cataract extraction control group. Though both eyes were similar in all cases, the combined procedure was al ways performed in the eye with the more severe glaucoma, as evidenced by higher pressure, more severe field loss, or greater cupping. Surgery was usually delayed in either
AMERICAN JOURNAL O F OPHTHALMOLOGY 87:124-129, 1979
VOL. 87, NO. 2
CATARACT EXTRACTION IN GLAUCOMA
eye until the patient was visually symp tomatic or glaucoma control was inade quate. Attributing field loss to glaucoma rather than to further reduction in visual acuity is not simple, and frequent kinetic, and static fields were performed. Surgery in all control cases involved a limbal based conjunctival flap, a vertical groove, preplaced 6-0 silk sutures, a biplaned incision, peripheral iridotomies, synechiotomy when necessary, and lens extraction. This series was not complicat ed by vitreous loss, wound leakage, or any other complication. In the cyclodialysis lens extraction pro cedure, cyclodialysis was done after groove formation and suture placement, as described previously. 14 No anterior segment complications occurred though one patient had a choroidal hemorrhage, which occurred at the time of surgery and subsequent secondary vitreous hemor rhage. This took months to clear but re sulted in visual acuity of 6/6 (20/20). Cyclodialysis canalicular trabeculectomy cataract extraction altered the lens extrac tion only slightly. A 3 X 3- to 4-mm scleral flap 0.25 to 0.5 mm deep was made at 12 o'clock (Fig. 1). The anterior extent of the flap ended at the surgical corneosceral limbus and a limbal groove with preplaced 6-0 sutures was created later ally and medially, as for routine cataract extraction (Fig. 2). The posterior scleral flap was excised (Fig. 3, top), the eye opened with scissors, and iridotomies performed (Fig. 3, bottom). Since the deep scleral flap was created posterior to the scleral spur, a cyclodialysis done under total visual control, slightly larger than the 3-mm width of the scleral flap15 resulted. After the cataract was removed, the flap site was closed with two inter rupted 8-0 silk sutures, and the remainder of the wound closed routinely. One anterior chamber complication oc curred in the cyclodialysis canalicular trabeculectomy lens extraction procedure
125
Fig. 1 (Galin, Hung, and Obstbaum). After a limbal based conjunctival flap is created, a 3 x 3to 4-mm limbal based lamellar scleral flap is made.
group. A hyphema developed on the third day which nearly progressed to an eightball hemorrhage. The clot was evacuated, and the patient's postoperative course
Fig. 2 (Galin, Hung, and Obstbaum). A standard limbal groove is created medial and lateral to the lamellar scleral flap and threaded with preplaced sutures.
126
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FEBRUARY, 1979
Fig. 3 (Galin, Hung, and Obstbaum). The posteri or scleral lamella is excised (top), the eye opened as for cataract extraction with scissors, and iridotomies performed (bottom).
was uneventful. No obvious cause of the bleeding was apparent at the initial sur gery or subsequent intervention. RESULTS
Visual acuity was 6/12 (20/40) or better in 20 control eyes. Visual acuity was less than this level in four cases, three from advanced glaucoma, and one from a raacular lesion. In the combined procedure group, visual acuity was 6/12 (20/40) or better in 18 eyes. As in controls, the cause of reduced visual acuity was glaucoma in four cases and macular degeneration in
two. In the cyclodialysis lens extraction group, six of 12 eyes required no medica tion. The other combined group had nine of 12 patients free of medication. The cutoff point on no medication was arbi trarily set at a diurnal curve that did not exceed 18 mm Hg. In this group without medication, no progression of glaucomatous visual field loss or further disk changes occurred. Besides the previous complication men tioned in the cyclodialysis lens extraction group, one patient had a large choroidal detachment and two had small hyphemas.
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CATARACT EXTRACTION IN GLAUCOMA
No therapy was given to any of these patients, and all absorbed the transudate or blood without difficulty. No other com plication occurred in the cyclodialysis canalicular trabeculectomy cataract ex traction group. In the cataract extraction group, two eyes required no further medication by using the above criteria. All others re quired medication. There were no surgi cal or postoperative problems in any case. One of the two cures in the control group had a significantly improved outflow fa cility, and the other did not. No blebs and no clefts were present, and a rise in intra ocular pressure on perilimbal suction oc curred in both cases. In the successful cyclodialysis cataract extraction group, a cleft was visible in each instance and perilimbal suction cup analysis resulted in a fall in intraocular pressure. 16 Clefts were visible in two of the remaining six patients, but functional analysis by perilimbal suction induced a rise in intraocular pressure in each in stance. Gross bleb formation was present in six of nine successful cyclodialysis canalicular trabeculectomy cases and clefts visible in three, two with blebs and one without. Perilimbal suction cup anal ysis was impossible to perform adequate ly because of the bleb area in this group. DISCUSSION
The evaluation of the effect of cataract extraction on glaucoma control has been expressed as changes in mean intraocular pressure or alteration in glaucoma medi cation. More meaningful criteria that have been suggested are the number of patients that require no medication or have required further glaucoma surgery. 5 These criteria have been reserved primar ily in cases where the glaucoma was uncontrolled preoperatively and after sur gery. The present series cannot be ana lyzed by the latter standard, and though the series is too small for statistical analy
127
sis, there is little question that the com bined procedures were more predictable and more consistent, despite a success rate of only 50 to 75% without medica tion. Every effort was used to assure good cataract wound closure in both series, and a two-planed incision closed with mul tiple 6-0 silk sutures rarely results in serious leakage. The choice of operation for cataract coexisting with open-angle glaucoma has historically varied, depending for the most part, on the status of glaucoma con trol. In well-controlled cases, most sur geons will perform cataract extraction alone. 17 For inadequately controlled glau coma, it had been common to perform glau coma surgery as an initial procedure. 1 8 - 2 0 However, subsequent surgical difficul ties at the time of cataract surgery and difficulties in the preservation of bleb function were discouraging. 2 1 These problems, coupled with better surgical technique, have encouraged the develop ment of combined procedures. 2 2 A further stimulus to combined surgery is the ob servation that glaucoma surgery in eyes with existing immature cataracts often enhances cataract maturation. We are presently performing a modi fied cyclodialysis canalicular trabeculec tomy cataract extraction for patients with cataract and glaucoma in which the cyclo dialysis is remarkably larger than the width of the lamellar scleral flap. Since the trabeculectomy flap is initiated pos terior to the scleral spur, a cyclodialysis under direct visualization is performed as part of the procedure in order to disinsert the scleral spur. The disinsertion is ex tended laterally and medially to create at least a 30-degree cyclodialysis (Fig. 4). These maneuvers do not lead to signifi cant hyphema, nor does the initial scleral spur disinsertion, as evidenced by the rare occurrence of hyphema after such operations in phakic eyes. Usually hyphe ma after cyclodialysis is caused by tearing
128
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FEBRUARY, 1979
bines the most favorable features of each procedure while reducing the risk compo nents. The cyclodialysis is carried out under direct visualization, reducing the potential for bleeding, and the lamellar scleral flap is reasonably well closed, re ducing the potential for a flat chamber. The ease of performing lens extraction remains unaltered. We believe more ex tensive application of this procedure should be used in combined disease. SUMMARY
Fig. 4 (Galin, Hung, and Obstbaum). Cyclodialysis canalicular trabeculectomy cataract extraction in which the cyclodialysis is approximately 30 degrees.
of ciliary muscle by the cyclodialysis spatula as one blindly attempts to disin sert this muscle at its attachment. This is frequent in the aphakic eye where the ciliary body is not under traction. When performing the cyclodialysis as part of a trabeculectomy, the surgeon sees the at tachment of the ciliary body and should be able to disinsert it cleanly. Though loose closure of the lamellar scleral sec tion is desirable in the phakic eye to assure filtration, a firm closure is neces sary in the combined procedure to assure a deep chamber. Filtration will occur in a moderate percentage of cases and the ad ditional controlled cyclodialysis results in a highly successful procedure. Long-term follow-up studies for simple cataract surgery in glaucomatous patients are rare. Balanced against a predictable, reproducible success rate of at least 50% with combined procedures, simple cata ract extraction would not be indicated even for cases of well-controlled glau coma, were it not for the increased mor bidity of combined procedures. The procedure of cyclodialysis canalicular trabeculectomy cataract extraction com
Cyclodialysis lens extraction or cyclo dialysis canalicular trabeculectomy lens extraction in one eye and cataract extrac tion in the fellow eye were performed in 24 glaucoma patients. The combined pro cedure follow-up was from five to 12 years in the first group, two to four years in the second group, and from three to ten years in the control group. The 50% success rate of cyclodialysis lens extraction can be enhanced with no significant increase in surgical morbidity or postoperative complications by per forming a cyclodialysis canalicular trabecjilectomy where the disinsertion of the scleral spur is carried out under direct visualization. REFERENCES 1. Guyton, J. S.: Choice of operation for primary glaucoma combined with cataract. Arch. Ophthalmol. 33:265, 1945. 2. Ramsey, G. A. S.: Glaucoma and cataract. Arch. Ophthalmol. 43:195, 1950. 3. Linn, J. G.: Cataract extraction in management of glaucoma. Trans. Am. Acad. Ophthalmol. Otolaryngol. 75:273, 1971. 4f Bigger, J. F., and Becker, B.: Cataracts and open angle glaucoma. The effect of cataract extrac tion on visual fields. Am. J. Ophthalmol. 71:335, 1971. 5. : Cataracts and primary open angle glau coma. The effect of uncomplicated cataract extrac tion on glaucoma control. Trans. Am. Acad. Oph thalmol. Otolaryngol. 75:260, 1971. 6. O'Brien, C. S.: Ocular surgery. Random obser vations. Arch. Ophthalmol. 37:1, 1947. 7. Hauer, J.': Simultaneous cataract glaucoma op eration. Isr. J. Med. Sci. 19:254, 1960. 8. Stocker, F. W.: Combined cataract extraction
VOL. 87, N O . 2
C A T A R A C T E X T R A C T I O N IN
and scleral cauterization. Arch. Ophthalmol. 72:503, 1964. 9. MacLean, A. L.: Limbal lip cautery for glauco ma. Arch. Ophthalmol. 71:653, 1964. 10. Harrington, D. O.: Cataract and glaucoma. Management of the coexistent conditions and a description of a new operation combining lens ex traction with reverse cyclodialysis. Am. J. Ophthal mol. 61:1134, 1966. 11. Galin, M. A., Baras, I., and Sambursky, J.: Glaucoma and- cataract. A study of cyclodialysislens extraction. Am. J. Ophthalmol. 67:522, 1969. 12. Maumenee, A. E., and Wilkinson, C. P.: A combined operation for glaucoma and cataract. Am. J. Ophthalmol. 69:360, 1970. 13. Rich, W.: Cataract extraction with trabeculectomy. Trans. Ophthalmol. Soc. U.K. 94:458, 1974. 14. Galin, M. A.: Surgical technique of cyclodial ysis lens extraction. Ann. Ophthalmol. 7:1257, 1975. 15. Galin, M. A., Boniuk, V., and Robbins, R. M.: Surgical landmarks in trabecular surgery. Am. J. Ophthalmol. 80:696, 1975.
GLAUCOMA
129
16. Galin, M. A., and Baras, I.: Combined cyclo dialysis cataract extraction. A review. Ann. Ophthal mol. 7:721, 1975. 17. Roberts, W.: The cataract problem in the glaucoma patient population. Arch. Ophthalmol. 84:279, 1970. 18. Becker, B.: In round-table discussion. In Armaly, M. F . (ed.): Symposium on Glaucoma. St. Louis, C.V. Mosby, 1967, p. 255. 19. Shaffer, R. N.: In round-table discussion. In Armaly, M. F. (ed.): Symposium on Glaucoma. St. Louis, C. V. Mosby, 1967, p. 276. 20. Pollack, I. P.: In round-table discussion. In Armaly, M. F. (ed.): Symposium on Glaucoma. St. Louis, C. V. Mosby, 1967, p. 257. 21. Hughes, W. L., Kazdan, M. S., Brackup, A. H., and Marinakos, C : Combination operation for cataract and glaucoma. A further report. Am. ] . Ophthalmol. 56:391, 1963. 22. Jerndal, T., and Lundstrom, M.: Trabeculectomy combined with cataract extraction. Am. J. Ophthalmol. 81:227, 1976.
