By Lisa B. Arbisser, MD
This editorial in the October issue of the Journal of Cataract & Refractive Surgery says it is difficult to argue from a global public health perspective that there is currently a better surgical treatment for early to moderate glaucoma than uncomplicated phacoemulsification with posterior chamber IOL implantation.
The authors, Robert T. Chang, MD, Bradford J. Shingleton, MD, and Kuldev Singh, MD, MPH, say the time has come to broaden the medical necessity for cataract surgery in glaucoma patients who may benefit from several millimeters of mercury of IOP reduction without resorting to glaucoma filtering surgery and the potential complications associated with these bleb-producing procedures.
This is yet another cry to recommend cataract surgery for borderline controlled glaucoma patients. I wish the government read the journals. This should become more mainstream, and the workup of glaucoma patients should include a glare test and recording of complaints related to daily living.
The authors say that the bulk of the evidence is consistent with the findings of a recently completed analysis from the observation group of the Ocular Hypertension Treatment Study arm that found an approximate mean IOP reduction of 4 mmHg following cataract surgery, which persisted at least three years.
They say that removing the cataract prior to filtration surgery eliminates the problem that glaucoma filtration surgery can accelerate cataract formation and may shallow the anterior chamber. The small risk of complications with early cataract surgery is outweighed by the benefits in most patients with mild, moderate, and, in some circumstances, advanced glaucomatous disease. They add that this argument is perhaps stronger for patients with exfoliative glaucoma and those with higher IOPs and/or narrow angles for whom an even greater IOP reduction may be anticipated. Additionally, they point out that one can now look forward to an increasing array of minimally invasive "cataract plus" procedures that can safely be combined with cataract surgery to further lower IOP.
Nevertheless, the authors say that many ophthalmologists continue to shy away from early cataract surgery for glaucoma, particularly when the patient does not meet the conventional threshold criteria for this procedure, for fear of criticism or audit.
For chronic angle-closure glaucoma, early cataract surgery is supported by a randomized clinical trial of phacoemulsification versus phacotrabeculectomy and has become a widely accepted treatment paradigm in parts of Asia, the authors point out. However, they say that adoption of a similar approach for patients with open- or narrow-angle glaucoma diagnoses will require the ophthalmology community to make a convincing argument for such a change not only to patients, but also to those who pay for health care.
The cost of early cataract surgery may be more than compensated for by a decreased future dependence on glaucoma medications, the use of which are often associated with poor compliance and reduced quality of life, they say. However, further studies are needed to assess the effects of early cataract surgery, with or without adjunctive bleb-free micro-invasive glaucoma surgery, on morbidity and cost.