combined cataract and glaucoma surgery

7/28/2019 Combined Cataract and Glaucoma Surgery

1/20

Combined cataract and

glaucoma surgery


2/20

IntroductionO Cataract and glaucomaboth are leading

causes of blindness world wide

O The prevelance of both is incresing with aging

populationO The prevelance of significant cataract in 65-

74yrs-is 20%

O The prevelance of chronic glaucoma in >70yrsage is 4.5%

O

The 5yrs incidence of nuclear cataract inpatients with open angle glaucoma & aged>50yrs is 20%


3/20

ManagementO cataract surgery ----> trabeculectomy

O Trabeculectomy ----- > cataract surgery

O Combined cataract surgery andtrabeculectomy

- ECCCE + Trabeculectomy

- SICS + Trabeculectomy

- phacotrabeculectomy


4/20

factorsO Visual need & visual potential of the

patient

O Severity of glaucomaO Target IOP

O Current IOP

O Health status of the patient


5/20

Cataract surgery aloneO Indication

-only mild glaucomatous damage with

IOP well controlled with 1 or 2 medications- Better results are obtained in angle closure

glaucoma


6/20

Advantages -

O Cataract surgery alone can lower IOP

upto 5mmhg - thus avoiding need fortrabeculectomy

Disadvantages-

O Early postoperative rise in IOP


7/20

Trabeculectomy -- > cataractO Indications

-In a eye with incipient cataract wherevisual impairment is mild & glaucoma is

uncontrolledAdvantages-

O Better IOP control than combined procedure

Disadvantages-

O Increased cataractogenesisO Increased risk of bleb failure if cataract

surgery is done within 6 months oftrabeculectomy


8/20

Combined surgeryIndications

O Adequate IOP control with medications butdrug related side effects or cost or

compilance problemsO Adequate IOP control but advanced

glaucomatous optic atrophy

O IOP on only boderline control or uncontrolledwith maximam medications

O Urgent need to restore vision and 2 surgeriesis neither feasible nor in patients best interest


9/20

Surgical approachO Smaller is the incision the better is the IOP control

O Decrease in the IOP when the incision size isdecreases from 11mm to 6mm is much

pronounced than from 6mm to 3mmO One site versus two site appproach

O One site approach- both procedures are donesuperiorly through one insicion

O Two site approach trabeculectomy is done

superiorly & catarct surgery done by temporalapproach


10/20

One site surgery-techniqueO Conjunctival flap is raised superiorly

limbal based flap or

fornix based flapO Wound leaks & vitreous loss more & less

maneuverability of instruments during

cataract surgery limbal based flap

O Bare sclera is exposed & cautery done ifneeded


11/20

O Partial thickness scleral flap is raised

using a V shaped incision ( with its base

at limbus ) using a scleratome bladeO Alternately scleral tunnel is made initially,

with completion of flap after the cataract

portion of the surgery using vanass

scissors

O Keratotome of 3.2mm is used to enter the

anterior chamber

O Phacoemulsification is performed as usual


12/20


13/20

O IOL is inserted

O Sclerectomy of about 2mm is performed

under the flap using kelleys descemetspunch

O Vanass scissors is used to perform a

peripheral iridectomy

O Any bleeders are cauterized & scleral flapclosed with 10.0 nylon


14/20


15/20


16/20

Advantages of single site

surgery over two siteO Saves time

O Only one wound made

O No need to change surgeons position ormicroscope

DISADVANTAGES

O More postoperative inflammation

O Care needed to avoid spillage ofantimetabolites into anterior chamber


17/20

Two site surgeryO Temporal clear corneal cataract surgery is

performed in usual manner

O It is recommended to suture the incisionsite to prevent wound leak

O Trabeculectomy performed superiorly

ADVANTAGES OVER ONE SITE

O Improved exposure for catarct extraction

O Enhanced bleb survival due to lessmanipulation of conjunctiva


18/20

DISADVANTAGES-

O Longer time

O Microscope requires adjustmentO Surgeon needs to change position


19/20

Advantages of combined

surgery over cataract ortrabeculectomy aloneO Patients convenience in terms of cost , risks

of anaesthesia, presence of medical

conditions precluding multiple surgeriesO Avoids potential postoperative IOP spikes

which can be seen after cataract surgery

O Long term control of IOP with trabeculectomy

& quick visual recovery from cataract surgery

O Less chance of shallow anterior chamber

O Less chance of bleb infection or

endophthalmitis


20/20

disadvantagesO More intraoperative & postoperative

complications

-cataract surgery can be difficult due to poor

pupil dilation or synechiae or weak zonules dueto PXF syndrome e.t.c

O IOP control is less with combined surgerythan with trabeculectomy alone

O Complex postoperative care & Longer visualrecovery

O More astigmatism or myopic shift

O Long term bleb problems

combined cataract and glaucoma surgery

Documents