When glaucoma and cataracts co-exist

New Orleans-When mild glaucoma and a visually significant cataract are both present, the risk/benefit calculus now seems to fall on the side of doing phaco, or a phaco-plus procedure, said James D. Brandt, MD.

Previously, especially in the era of extracapsular cataract extraction (ECCE), Dr. Brandt said there was a significant downside to cataract extraction in how it affected subsequent glaucoma management. The balance of risk to benefit then often fell on the side of waiting, or doing a filter and dealing with the cataract later. 

Modern phaco and phaco-plus-especially the ab interno procedures-have changed the equation, because the procedures do not affect the conjunctiva and complications are rare and rarely catastrophic, said Dr. Brandt, director of glaucoma service, UC Davis Health System, Sacramento, CA. 

“All [patients with] glaucoma will get cataracts at some point,” Dr. Brandt said. So it is essential that the timing and sequencing of cataract surgery over the course of a patient’s glaucoma management be carefully thought out.

He said this is similar to a game of chess, with the best practitioners thinking several steps ahead and anticipating how new surgical interventions today might affect treatment options later.

“I take the long view,” Dr. Brandt said. 

In general, he said that phaco alone usually helps in the management of glaucoma, but an asymptotic cataract should not be removed solely to manage the glaucoma. If glaucoma is mild and well controlled, wait until the cataract is symptomatic enough for surgery. 

On the other hand, Dr. Brandt said, in the presence of an obvious cataract and unacceptable IOP control, it is now reasonable to consider phaco alone or phaco-plus to help in glaucoma management. This is especially true, he said, if doing so has a chance of delaying or preventing the patient from trabeculectomy.

If the IOP remains poorly controlled, he said phaco or phaco-plus will not do as much to lower the success of filtering surgery should it be necessary.

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