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Glaucoma Surgical Problem
CONSULTATION SECTION
Glaucoma Surgical Problem Edited by Thomas W. Samuelson, MD
A 79-year-old white man presents with a long history of primary open-angle glaucoma (POAG) managed with medical therapy (prostaglandin, carbonic anhydrase inhibitor, and b-blocker). He reports good compliance with his medications and seems to tolerate them well. Examination showed a visually significant cataract in both eyes. The patient wants surgery to improve his ability to drive at night. The distance visual acuity with moderate spherical myopic correction is 20/30 in both eyes. The angle is wide open in each eye. He has moderate cupping in the right eye and severe cupping in the left eye. The disc and visual field have slowly progressed over the previous 5 years, although they have been relatively stable for the past 1 to 2 years. Figure 1 shows the current visual field and intraocular pressure (IOP) data. What is your recommended surgical approach for each eye? In your response, please include your recommendations for cataract and glaucoma management as well as intraoperative and perioperative pearls that might be useful. The patient would like to be as independent of glasses as possible and expresses an interest in multifocal technology, although he primarily wants to emphasize distance acuity. What are your intraocular lens (IOL) recommendations?
- This patient has symptomatic cataracts with advanced glaucomatous field loss in the left eye and mild disease in the right eye with IOPs that are not at target on 3 classes of medications (target low-teens in left eye; mid-teens in right eye). Aside from the level
Figure 1. Current visual field and IOP data (BB Z b-blocker; CAI Z carbonic anhydrase inhibitor; CCT Z central corneal thickness; IOP Z intraocular pressure; PG Z prostaglandin).
240
Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
of disease, current IOP and proximity to target pressures, medication tolerability, the patient's health/ life expectancy, and the surgical risk profile, we also consider the indications for surgery and the patient's expectations postoperatively. Although visual fields have been stable over the past 1 to 2 years, it is unlikely that cataract surgery alone will yield the target IOP. This patient is already at or near the maximum tolerated medical therapy. Thus, we recommend combined cataract and glaucoma surgery keeping in mind the possible limitation in visual function improvement, in particular in the left eye. We would perform microinvasive glaucoma surgery (MIGS) synergistically combined with phacoemulsification in each eye. In the right eye, with mild disease and a target IOP in the mid-teens, this decision is more straightforward because we can achieve additional IOP lowering and/or medication reduction with a procedure that is no riskier than cataract surgery alone. Aggressive and riskier traditional glaucoma surgery is not indicated here. Our preferred approach is the use of multiple trabecular bypass Schlemm canal microstents targeted and placed strategically in areas of larger capacity aqueous veins. This can reasonably achieve an IOP in the mid-teens or lower, although this patient will still likely require at least 1 class of medication.1 The left eye poses more of a challenge considering the very advanced level of disease and uncontrolled IOP. Often in these scenarios, we strongly consider combining phacoemulsification with a more traditional bleb-forming procedure such as trabeculectomy or tube-shunt implantation. However, in this case, because of the patient's age, apparent stable visual field over the past 2 years, tolerance of medications, and serious risks including snuff out with bleb surgery,2 we would also proceed with a similar procedure in the right eye. Even with multiple targeted Schlemm canal microstents, we would expect this patient to remain on 2 or 3 medication classes postoperatively to achieve target pressures in the low teens. This approach would leave the door open for more aggressive surgery in the future, without preclusion, if required. Intraocular lens selection in patients with glaucoma seeking spectacle independence should be carefully discussed.3 Given the advanced level of disease in http://dx.doi.org/10.1016/j.jcrs.2014.11.019 0886-3350
Glaucoma Surgical Problem Edited by Thomas W. Samuelson, MD
A 79-year-old white man presents with a long history of primary open-angle glaucoma (POAG) managed with medical therapy (prostaglandin, carbonic anhydrase inhibitor, and b-blocker). He reports good compliance with his medications and seems to tolerate them well. Examination showed a visually significant cataract in both eyes. The patient wants surgery to improve his ability to drive at night. The distance visual acuity with moderate spherical myopic correction is 20/30 in both eyes. The angle is wide open in each eye. He has moderate cupping in the right eye and severe cupping in the left eye. The disc and visual field have slowly progressed over the previous 5 years, although they have been relatively stable for the past 1 to 2 years. Figure 1 shows the current visual field and intraocular pressure (IOP) data. What is your recommended surgical approach for each eye? In your response, please include your recommendations for cataract and glaucoma management as well as intraoperative and perioperative pearls that might be useful. The patient would like to be as independent of glasses as possible and expresses an interest in multifocal technology, although he primarily wants to emphasize distance acuity. What are your intraocular lens (IOL) recommendations?
- This patient has symptomatic cataracts with advanced glaucomatous field loss in the left eye and mild disease in the right eye with IOPs that are not at target on 3 classes of medications (target low-teens in left eye; mid-teens in right eye). Aside from the level
Figure 1. Current visual field and IOP data (BB Z b-blocker; CAI Z carbonic anhydrase inhibitor; CCT Z central corneal thickness; IOP Z intraocular pressure; PG Z prostaglandin).
240
Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
of disease, current IOP and proximity to target pressures, medication tolerability, the patient's health/ life expectancy, and the surgical risk profile, we also consider the indications for surgery and the patient's expectations postoperatively. Although visual fields have been stable over the past 1 to 2 years, it is unlikely that cataract surgery alone will yield the target IOP. This patient is already at or near the maximum tolerated medical therapy. Thus, we recommend combined cataract and glaucoma surgery keeping in mind the possible limitation in visual function improvement, in particular in the left eye. We would perform microinvasive glaucoma surgery (MIGS) synergistically combined with phacoemulsification in each eye. In the right eye, with mild disease and a target IOP in the mid-teens, this decision is more straightforward because we can achieve additional IOP lowering and/or medication reduction with a procedure that is no riskier than cataract surgery alone. Aggressive and riskier traditional glaucoma surgery is not indicated here. Our preferred approach is the use of multiple trabecular bypass Schlemm canal microstents targeted and placed strategically in areas of larger capacity aqueous veins. This can reasonably achieve an IOP in the mid-teens or lower, although this patient will still likely require at least 1 class of medication.1 The left eye poses more of a challenge considering the very advanced level of disease and uncontrolled IOP. Often in these scenarios, we strongly consider combining phacoemulsification with a more traditional bleb-forming procedure such as trabeculectomy or tube-shunt implantation. However, in this case, because of the patient's age, apparent stable visual field over the past 2 years, tolerance of medications, and serious risks including snuff out with bleb surgery,2 we would also proceed with a similar procedure in the right eye. Even with multiple targeted Schlemm canal microstents, we would expect this patient to remain on 2 or 3 medication classes postoperatively to achieve target pressures in the low teens. This approach would leave the door open for more aggressive surgery in the future, without preclusion, if required. Intraocular lens selection in patients with glaucoma seeking spectacle independence should be carefully discussed.3 Given the advanced level of disease in http://dx.doi.org/10.1016/j.jcrs.2014.11.019 0886-3350