I. List the indications/contraindications
A. Indications
1. Visually significant cataract
a. Poorly controlled intraocular pressure (IOP) on multiple medications
b. Well controlled in IOP, but a desire to reduce dependence on glaucoma medications
2. The need to minimize operative and anesthetic risks and the time to final visual recovery associated with two separate procedures
3. Controlled IOP in the presence of advanced glaucomatous damage
B. Contraindications
1. Mild or visually insignificant cataract
2. Glaucoma suspect status
3. Well-controlled IOP on one or two topical medications
II. Describe the pre-procedure evaluation
A. Assessment of cataract by the usual methods (visual function deficit, best-corrected visual acuity measurement, glare testing, slit-lamp biomicroscopic examination, fundus examination)
B. Assessment of glaucoma status by the usual methods (IOP determination, pachymetry, gonioscopy, slit-lamp biomicroscopic examination, optic nerve evaluation, visual field examination)
III. List the alternatives to this procedure
A. Staged surgery
1. Glaucoma surgery first followed by cataract surgery (several studies say the long-term success of the glaucoma filter is better if surgery is staged) although some studies show that IOP is frequently higher after second stage cataract surgery
2. Cataract surgery first followed by glaucoma filtering surgery
B. Cataract surgery alone
1. IOP drops 2-3 mm Hg, on average, after cataract surgery
2. IOP can usually be managed medically
3. Combined endoscopic laser cyclophotocoagulation
IV. Describe the technique
A. Both procedures at same site
1. Surgery is usually performed superiorly
a. Fornix-based conjunctival flap (limbal incision); may initially have more conjunctival wound leak
b. Limbus-based conjunctival flap (fornix incision)
c. Both incision types provide the same degree of long-term IOP control in combined surgery
2. Cataract surgery is performed through a sclerocorneal tunnel incision
3. After cataract removal, the tunnel is converted into a glaucoma filter
B. Procedures at separate sites (See Cataract Figure 38)
1. Glaucoma filter should be placed superiorly
a. Fornix-based conjunctival flap (limbal incision); may initially have more conjunctival wound leak
b. Limbus-based conjunctival flap (fornix incision)
c. Again, both incision types provide the same degree of long-term IOP control in combined surgery
2. Phacoemulsification incision can be placed temporally or superiorly
3. The cataract operation is usually performed first
C. Adjunctive therapy in combined cataract and glaucoma surgery
1. 5-Flurouracil is not beneficial in further lowering IOP
2. Mitomycin C is beneficial in further lowering IOP
V. List the complications of this procedure, their prevention and management
A. All the usual risks of cataract surgery
B. All the risks of glaucoma filtering surgery
1. Short-term (wound leak, hypotony, flat anterior chamber, choroidal effusions, hypotony maculopathy, aqueous misdirection, increased postoperative inflammation
2. Long-term (increased corneal astigmatism, bleb irritation, bleb infection, late endophthalmitis, lens decentration, lens dislocation, optic capture, chronic hypotony, pressure rise, failure of the filter)
VI. Describe the follow-up care
A. Routine follow-up care as for glaucoma filtering surgery
B. Final refraction when astigmatically stable
VII. Describe appropriate patient instructions (post-op care, vision rehabilitation)
A. Special precautions with regard to postoperative eye trauma, eye rubbing, Valsalva maneuvers
Additional Resources
1. AAO, Focal Points: Cataract Surgery in the Glaucoma Patient, PT 1: A Cataract Surgeon, Module #3, 1998, p. 7.
2. AAO, Focal Points: Cataract Surgery in the Glaucoma Patient, PT 2: A Glaucoma Surgeon, Module #4, 1998 p. 2-10.
3. AAO, Basic and Clinical Science Course. Section 11: Lens and Cataract, 2004-2005.
4. Tong JT, Miller KM. Intraocular pressure change after sutureless phacoemulsification and foldable posterior chamber lens implantation. J Cataract Refract Surg. 1998; 24: 256-62.