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It is not surprising that two relatively common diseases in the aging population has a combination of glaucoma and cataract can occur in same person.
Cataract which is clouding of natural lens of the eyes is commonly observed in aged population. When the cataract becomes dense interfering in the patient’s lifestyle it is the time for the cataract to be removed. An Intraocular Lens Implant (IOL) is used to restore the vision nearing to normal levels.
Glaucoma is the disease which is related to optical nerve and commonly associated with elevated intraocular pressure. Medications are used to reduce the pressure and stop the disease process. Unfortunately, glaucoma cannot be removed from the eye but cataract can be removed from the eye. Both the laser and traditional surgery can be used to control the disease.
When a patient has glaucoma and is in need of cataract surgery, the situation would be very different from the other patient who does not have glaucoma. The poor dilation of the pupil makes access of the cataract more limited. In such type of cataract the supporting structure of the cataract would be weak which would influence the way how the cataract must be removed with slightly greater risk. Eye surgeons do not performing surgery on glaucoma patients frequently thus surgery may be modified by not utilizing more advanced techniques.
The Decision As How To Proceed Depends On Many Factors:
If the glaucoma is relatively advanced with greater visual field loss, then the eye can be very sensitive to a post-cataract surgery which increases intraocular pressure. Which may further cause visual field loss?
Is the intraocular pressure controlled as low as the disease requires? This will be determined by the doctor for each patient depending on many risk factors. The goal is to preserve vision for the patient for lifetime.
What is the amount of medication that the patient takes and to which medicine the patient is intolerant or there may be? (or allergies, etc.)
- Is there any presence of other eye disease – Macular Degeneration, etc.?
- How healthy the other eye is?
Surgical Alternatives
If the glaucoma is significant or the pressure is uncontrollable on many medications or if the medications is poorly tolerated (or not used), this is likely an alternative. The reason for this choice is the frequent occurrence of increased pressure to dangerously high levels during the first few weeks after cataract surgery. The optic nerve may be very sensitive to this rise in pressure which may quickly damage the vision. By performing combined cataract and glaucoma surgery the rise in pressure can be avoided in most of the cases. The glaucoma operation may also make the glaucoma much easier to control after surgery which may requiring less medication.
If the glaucoma is not significant (amount of visual field loss), and the intraocular pressure is easily controlled on few well-tolerated or no medications, contract surgery is the likely alternative. This can be performed with a “no-stitch” technique. However it is more difficult to perform cataract surgery in glaucoma patients as the pupil may not be well dilate which requiring special surgical maneuvers. Laser trabeculoplasty has been recommended by some of the eye surgeons to be used before cataract surgery so the need for combined cataract and glaucoma surgery can be avoided. However this does not avoid the potential postoperative rise of pressure in the first few weeks after cataract surgery.
There are some patients with glaucoma whose cataract surgery should be delayed. When the patient is in the advanced stages of glaucoma with only one sighted eye and the glaucoma is well controlled, it may be good to wait until the vision is more affected by the cataract. Also there are certain glaucoma medications which make the pupil smaller. This may give an impression that the cataract is worse than what it really is. A laser procedure may be performed as an alternative to widen the pupil while the patient is on these medications allowing better vision until the cataract progresses. If the glaucoma is not controlled and requires surgery, Performing only the glaucoma surgery could be another alternative for these patients, as often the medications making the pupil small can be deleted, allowing better vision. The cataract can be removed when needed.
Medications Which Affect Wound Healing
There are certain medications which increase the success of the glaucoma part of the operation. At the time of writing, 5 fluorouracil and mitomycin-c which is an anticancer drugs is been used. Other drugs would be utilized in the future. These medications would decrease scar tissue formation which may lead to failure of the glaucoma operations. These drugs may increase the risk of the procedure, but the success rate may improve in the hands of an experienced surgeon. The decision as to which alternative should be used depends on the individual basis. The experience and skills of the surgeon influence the choice that is made.