REVIEW URRENT C OPINION
New options for combined cataract and glaucoma surgery Donald L. Budenz a and Steven J. Gedde b
Purpose of review To review the current literature regarding the effectiveness and risks of new surgeries that can be combined with phacoemulsification in the management of cataract and glaucoma. Recent findings Surgical options for concurrently managing cataract and glaucoma have expanded in recent years. Endoscopic cyclophotocoagulation, trabecular micro-bypass stent, ab interno trabeculectomy, and canaloplasty may be performed in conjunction with cataract extraction to provide additional intraocular pressure (IOP) reduction. Studies evaluating these new glaucoma procedures combined with phacoemulsification generally include retrospective case series without a comparison group. Because cataract surgery alone is associated with IOP reduction, the relative contribution of the glaucoma procedure in lowering IOP cannot be determined in these studies. Randomized clinical trials are needed to better evaluate the efficacy and safety of newer glaucoma procedures in combination with cataract surgery. Summary The newer glaucoma procedures appear less effective than trabeculectomy, but they are associated with a lower risk of surgical complications. Keywords cataract surgery, glaucoma surgery, phacoemulsification
INTRODUCTION Cataract and glaucoma frequently coexist in our elderly patient population. It has been estimated that 20% of cataract procedures are performed annually in the USA in individuals with comorbid glaucoma and ocular hypertension. Phacoemulsification combined with trabeculectomy has historically been the preferred surgical approach for concurrently managing cataract and glaucoma. However, a growing concern about intraoperative and postoperative complications associated with trabeculectomy has prompted many surgeons to explore alternative procedures. Several new glaucoma procedures have been introduced into clinical practice which may be performed in conjunction with cataract surgery [1 ]. Recent studies have evaluated the safety and efficacy of endoscopic cyclophotocoagulation (ECP), trabecular micro-bypass stent (iStent), ab interno trabeculectomy (Trabectome), and canaloplasty combined with phacoemulsification. Most of these studies consist of retrospective case series that lack a control group. Retrospective [2] and &&
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prospective [3 ] studies have shown that cataract surgery alone may result in a modest (2–3 mmHg) reduction in intraocular pressure (IOP). Therefore, determination of the relative contribution of a glaucoma procedure in lowering the IOP requires prospective comparison with a control group consisting of cataract surgery alone. Unfortunately, randomized clinical trials that assess the new glaucoma procedures are generally lacking. The purpose of this article is to provide an evidence-based review of the new options for combined cataract and glaucoma surgery.
a Department of Ophthalmology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina and bBascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
Correspondence to Donald L. Budenz, MD, MPH, 5151 Bioinformatics, CB7040, Chapel Hill, NC 27517, USA. Tel: +1 919 843 0297; fax: +1 919 966 1908; e-mail: [email protected] Curr Opin Ophthalmol 2014, 25:141–147 DOI:10.1097/ICU.0000000000000027
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Glaucoma
KEY POINTS Glaucoma and elevated IOP are common in patients undergoing cataract surgery.
phacoemulsification has not been clearly demonstrated. Most studies reporting the outcomes of phacoemulsification–ECP are retrospective case series that lack a control group [4 ,5 ,6–8]. A randomized clinical trial comparing phacoemulsification alone with phacoemulsification–ECP would help to clarify the efficacy of phacoemulsification– ECP (Table 1). A prospective randomized trial compared phacoemulsification–ECP to phacoemulsification– trabeculectomy (48% of cases received adjunctive mitomycin C) in a relatively small number of patients (29 in each treatment group) [10]. A higher success rate (IOP
New options for combined cataract and glaucoma surgery Donald L. Budenz a and Steven J. Gedde b
Purpose of review To review the current literature regarding the effectiveness and risks of new surgeries that can be combined with phacoemulsification in the management of cataract and glaucoma. Recent findings Surgical options for concurrently managing cataract and glaucoma have expanded in recent years. Endoscopic cyclophotocoagulation, trabecular micro-bypass stent, ab interno trabeculectomy, and canaloplasty may be performed in conjunction with cataract extraction to provide additional intraocular pressure (IOP) reduction. Studies evaluating these new glaucoma procedures combined with phacoemulsification generally include retrospective case series without a comparison group. Because cataract surgery alone is associated with IOP reduction, the relative contribution of the glaucoma procedure in lowering IOP cannot be determined in these studies. Randomized clinical trials are needed to better evaluate the efficacy and safety of newer glaucoma procedures in combination with cataract surgery. Summary The newer glaucoma procedures appear less effective than trabeculectomy, but they are associated with a lower risk of surgical complications. Keywords cataract surgery, glaucoma surgery, phacoemulsification
INTRODUCTION Cataract and glaucoma frequently coexist in our elderly patient population. It has been estimated that 20% of cataract procedures are performed annually in the USA in individuals with comorbid glaucoma and ocular hypertension. Phacoemulsification combined with trabeculectomy has historically been the preferred surgical approach for concurrently managing cataract and glaucoma. However, a growing concern about intraoperative and postoperative complications associated with trabeculectomy has prompted many surgeons to explore alternative procedures. Several new glaucoma procedures have been introduced into clinical practice which may be performed in conjunction with cataract surgery [1 ]. Recent studies have evaluated the safety and efficacy of endoscopic cyclophotocoagulation (ECP), trabecular micro-bypass stent (iStent), ab interno trabeculectomy (Trabectome), and canaloplasty combined with phacoemulsification. Most of these studies consist of retrospective case series that lack a control group. Retrospective [2] and &&
&&
prospective [3 ] studies have shown that cataract surgery alone may result in a modest (2–3 mmHg) reduction in intraocular pressure (IOP). Therefore, determination of the relative contribution of a glaucoma procedure in lowering the IOP requires prospective comparison with a control group consisting of cataract surgery alone. Unfortunately, randomized clinical trials that assess the new glaucoma procedures are generally lacking. The purpose of this article is to provide an evidence-based review of the new options for combined cataract and glaucoma surgery.
a Department of Ophthalmology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina and bBascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, Florida, USA
Correspondence to Donald L. Budenz, MD, MPH, 5151 Bioinformatics, CB7040, Chapel Hill, NC 27517, USA. Tel: +1 919 843 0297; fax: +1 919 966 1908; e-mail: [email protected] Curr Opin Ophthalmol 2014, 25:141–147 DOI:10.1097/ICU.0000000000000027
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Glaucoma
KEY POINTS Glaucoma and elevated IOP are common in patients undergoing cataract surgery.
phacoemulsification has not been clearly demonstrated. Most studies reporting the outcomes of phacoemulsification–ECP are retrospective case series that lack a control group [4 ,5 ,6–8]. A randomized clinical trial comparing phacoemulsification alone with phacoemulsification–ECP would help to clarify the efficacy of phacoemulsification– ECP (Table 1). A prospective randomized trial compared phacoemulsification–ECP to phacoemulsification– trabeculectomy (48% of cases received adjunctive mitomycin C) in a relatively small number of patients (29 in each treatment group) [10]. A higher success rate (IOP
