Combined Cataract and Glaucoma Surgery Paired with Premium IOL

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CATARACT SURGERY feature story Combined Cataract and Glaucoma Surgery Paired With Premium IOL Implantation MICS and sutureless glaucoma surgery, performed simultaneously, should not induce optical changes.

By Kirill Pershin, MD

urgical strategies for the treatment of concomi- tant cataract and glaucoma require special efforts that, if not approached properly, can result in disputes between the cataract and glaucoma Ssurgeons comanaging these cases. This article presents a combination procedure that accomplishes the respective goals of both specialties—safe cataract surgery and the reduction of intraocular pressure (IOP)—and also creates an avenue for the implantation of premium IOLs to decrease spectacle dependence. In many cases, modern microinvasive nonpenetrating glaucoma surgery can be performed immediately before phacoemulsification to treat patients with cataract and Figure 1. The base of the superficial scleral flap is dissected glaucoma in a single step. In my practice, these combined 1.5 to 2.0 mm into the limbus and clear cornea. single-step cataract and glaucoma operations account for approximately 10% to 15% of all my cataract surgeries—about 400 to 600 procedures per year. In patients with cataract and uncontrolled glaucoma, combining cataract and glaucoma surgery is faster, cheaper, and more convenient for the patient as well as for the surgeon. I have found that, when performed before phacoemulsification with IOL implantation, nonpenetrating deep sclerectomy (NPDS) with autodrainage achieves reduction of IOP similar to full-thickness trabeculectomy but with fewer intra- and postoperative complications and changes in refraction and optical performance. Therefore, implantation of modern premium IOLs can Figure 2. A deep, triangular scleral flap is dissected to expose be considered in this population. Schlemm canal.

DISCLOSE POSSIBLE CONSEQUENCES should thoroughly understand a patient’s expectations The presence of glaucoma, even minimal initial glauco- and his or her job and lifestyle and confirm that alterna- matous changes in visual function, is a relative contraindica- tive options (monovision or accommodating IOLs) to tion to multifocal IOL implantation. Therefore, the surgeon decrease spectacle dependence are inadvisable before sug-

32 Cataract & Refractive Surgery Today Europe September 2012 CATARACT SURGERY feature story

A B C

Figure 3. (A) The incision is created, (B) the capsulorrhexis is performed, (C) and the anterior lens capsule is stained with a drop of methylene blue. gesting multifocal IOLs. Only in this case can multifocal IOL Following hydrodissection and hydrodelineation, the implantation be considered in glaucoma patients. Possible nucleus and cortex are extracted using the dig-and-split consequences of this decision, including decreased contrast technique,1 and the remaining lens fragments are removed sensitivity with multifocal IOLs, the possibility of peculiari- using a bimanual I/A system with obligatory posterior cap- ties due to glaucomatous central visual field loss, changes in sular polishing. IOL implantation is preceded by injection of pupil function (such as dilation caused by certain antiglau- OVD into the anterior chamber. comatous agents), and possible future glaucoma progres- If even a slight posterior capsular opacity is present or sion, should be discussed before surgery. development of a secondary opacity is anticipated, we sug- Taking the above into account, the final decision should be gest performing a primary posterior capsulorrhexis under a joint effort with the surgeon and patient. Of the more than the IOL optic using the layered-pie technique.2 1,500 multifocal IOLs implanted in our clinic, not more than At this time, after asking the patient to look down, the scleral 40 have been implanted in glaucoma patients, even though flap should be removed, along with the outer wall of Schlemm the percentage of glaucoma patients operated on for cataract canal and some corneal tissue, to expose approximately 1.0 to is 30% to 40% higher than in the general population. 1.5 mm of Descemet membrane (Figure 4). IOLs can be implanted at various stages of glaucoma pro- The preserved anterior lens capsule is then sutured to the gression, except in end-stage glaucoma when central vision sclera behind the scleral spur with 10-0 nylon. To avoid sutures is no longer preserved. In cases of uncontrolled glaucoma, completely, during my most recent surgeries I have pushed we typically perform simultaneous cataract surgery and the stained capsule through the scleral window and into the NPDS with autodrainage. In the past year, we have started subchoroidal space with a spatula (Figure 5). This allows the using the patient’s own anterior lens capsule to enhance capsule itself to act as a collagen drainage device, not only pre- drainage into the subchoroidal space. This is explained venting closure of the intraocular fluid outflow tract we have below in a review of our surgical technique. created but also joining the intrascleral outflow tract with the subchoroidal space to stimulate uveal outflow. SURGICAL TECHNIQUE If surgery has been performed without microperforations, Surgery is performed under topical anesthesia. With the patient looking down, the conjunctiva is separated from the limbus in the area where the incision is planned. Following diathermy coagulation, a one-third thickness superficial round scleral flap is created. The base of the superficial flap is dissected 1.5 to 2.0 mm into the limbus and clear cornea (Figure 1). Then a deep, triangular flap is created, exposing Schlemm canal (Figure 2). At the top of this triangle, a window is cut over the ciliary body. With the patient now asked to look straight ahead, the surgeon can proceed to phacoemulsification. Following cre- ation of a 1.8-mm temporal clear corneal incision and two paracenteses (Figure 3A), the anterior chamber is filled with an ophthalmic viscosurgical device (OVD) and the capsulorrhexis is performed (Figure 3B). The anterior lens capsule Figure 4. As the patient looks down, the deep scleral flap is then stained with a drop of methylene blue (Figure 3C), and some corneal tissue are removed to expose Descemet removed, and preserved. membrane.

September 2012 Cataract & Refractive Surgery Today Europe 33 CATARACT SURGERY feature story

A Take-Home Message

• A combined cataract and glaucoma procedure should aim to accomplish the respective goals of both specialties and create an avenue for the implantation of premium IOLs. • Multifocal IOL implantation should be avoided in patients with glaucoma unless alternative options are inadvisable.

glaucoma and high myopia; and one with developed glaucoma and isolated scotomas in the central visual B field. The high percentage of satisfied patients is largely due to thorough and stringent patient selection. Glaucoma surgery in pseudophakic eyes does not differ from that in phakic eyes with primary open-angle glaucoma; however, it does for cases of secondary open-angle glaucoma. Exclusions are any intra- or postoperative complications of cataract surgery. In cases with wide open-angle glaucoma, NPDS is my first choice. Even if filtration does not occur on the operating table, laser puncture of the angle and Descemet membrane can be performed several days after surgery, usually result- C ing in good outcomes. This approach does not lead to changes in refraction or induced astigmatism, which is especially important in combined cases in which a premium IOL is implanted, and the patient’s visual activity and quality of life remain unchanged.3 If antiglaucomatous interventions have been performed in a pseudophakic eye several times already, the best approach must be chosen on a case-by-case basis, beginning with determining the level of intraocular fluid retention and the reasons for recurrent failures before selecting a customized approach to surgery. Possible approaches include NPDS with drainage, fis- Figure 5. (A-C) A spatula is used to push the stained capsule tulizing surgery, implantation of shunts or drainage through the scleral window and into the subchoroidal space. devices, endo- or transscleral cyclodestructive surgery, and adjunctive use of cytostatic agents. n there is no need to suture the superficial scleral flap, and the procedure is completed with one buried conjunctival suture. Kirill Pershin, MD, is an ophthalmic surgeon at the Excimer Clinic in Moscow, Russia. Dr. STRINGENT PATIENT SELECTION Pershin states that he has no financial interest This combined procedure allows surgeons to use in the products or companies mentioned. He premium IOLs (ie, toric, multifocal, multifocal toric, may be reached at tel: +7 495 912 14 22; e-mail: and accommodating) when warranted, as it does not [email protected]. induce any optical changes in the eye. In general, the results in our group are positive, and most patients 1. Pershin K. ‘Dig & split’ phaco technique for hard and challenging cataracts. Video presented at: the 26th Congress of the European Society of Cataract and Refractive Surgeons; September 13-17, 2008; Berlin. assess their postoperative vision as good or excellent. 2. Pershin K, Solovyeva G, Pashinova N, et al. Posterior capsulorhexis as a method for prevention of secondary Unsatisfactory results have occurred in four cases, cataract. Poster presented at: the 24th Congress of the European Society of Cataract and Refractive Surgeons; September 9-13, 2006; London. one with advanced glaucoma, a concentric visual field 3. Pershin K. Combined glaucoma and cataract surgery with AcrySof Restor IOL Implantation. In: Glaucoma— defect, and a 3-mm rigid pupil; two with developed Trends and Technology. Moscow; 2007;79-80.

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