The combined procedure for cataract and glaucoma

from the editor • • • The combined procedure for cataract and glaucoma The idea of combining surgery for cataract removal and glaucoma has a relatively long history. The early operations combined a variety of glaucoma procedures with intracapsular cataract surgery. These techniques met with variable long-term success. Often the operation was unsuccessful because of the nature of the intracapsular cataract surgery and the opportunity for the presence of vitreous in the anterior segment to compromise the glaucoma filtering procedure. The concept of combined surgery with an intracapsular cataract technique remained quite controversial for a long time, even with intraocular lens (IOL) implantation. A major change in attitude occurred with the popularity of extracapsular cataract surgery. The prime variant in this technique was retention of the posterior capsule, which for the most part eliminated the complications associated with the presence of vitreous. Several other significant advances occurred concurrently. The use of posterior chamber IOLs removed the need for either pupil support, partial or total, or angle support that might further compromise the filtration angle. The IOL was inserted distant from the filtration angle and from the site of filtration. Another advance was the use of viscoelastic agents that aided in space maintenance, tissue manipulation, and tissue protection intraoperatively. As more ophthalmologists became skilled in extracapsular cataract surgery and posterior chamber IOL implantation, the logic of doing a concomitant filtering procedure in eyes of patients with glaucoma and a visual-function-disabling cataract gained in popularity. In this issue, Menezo and coauthors report a retrospective analysis of patients who had surgery for glaucoma and cataract. The patients were followed for between one and ten years. There was a satisfactory reduction in intraocular pressure (lOP) in the overall group and fewer medications were required

postoperatively than preoperatively. The authors report a gradual diminution of lOP control over time and an accompanying requirement for greater use of medicines. They emphasize that the risk of performing combined procedures should be weighed against the long-term effects on lOP. While we acknowledge this contribution to the clinical literature on combined surgery for cataract and glaucoma, there is another issue we should comment on. The ultimate goal of glaucoma intervention is to forestall continued optic nerve damage. The present report, like many others, was concerned largely with lOP control and the number of medications required to maintain the lOP at some desired level. This study does not discuss the progression of the disease but this is clearly an element that future long-term studies should address. The alternative to combined surgery is sequential surgery, first for glaucoma and then for cataract. In the past, this alternative was reserved for situations in which the glaucoma was significant and the cataract less critical in reducing visual function. The advent of newer techniques for combined surgery have obviated the need for this strategy. The recent interest in combining phacoemulsification with trabeculectomy appears promising in permitting us to control lOP and prevent progression of the disease process. Although a sufficient number of patients have not been followed long term, there is an indication of the salutary effect of this combined technique. The important message of the study by Menezo and coauthors is that glaucoma is a chronic disease and that patients have to be monitored carefully and diligently to assess its progression and to intervene appropriately.

J CATARACT REFRACT SURG-VOL 20, SEPTEMBER 1994

Stephen A. Obstbaum, M.D.

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