Both glaucoma and cataracts are diseases of older populations and therefore some patients invariably require treatment for both conditions. In these cases, surgeons must decide among three options: glaucoma surgery first, followed by cataract surgery; cataract surgery first, followed by glaucoma surgery (if needed); or a combination procedure.
Because of the inherent complexity of a combined procedure and the lower efficacy of filtering blebs when they are created in conjunction with cataract surgery, my preference is to perform sequential procedures whenever possible. If one of the surgeries can be safely postponed without the risk of further visual loss in the intervening period, then the more urgently needed surgery should be performed first, followed several months later by the second procedure, if needed.
In patients with advanced glaucoma whose intraocular pressure (IOP) cannot be adequately controlled by medications or laser trabeculoplasty, glaucoma surgery should be performed first, followed by cataract surgery. Glaucoma surgery should also take precedence in patients who would be at risk of optic nerve damage if cataract surgery were to increase IOP temporarily.
On the other hand, in patients whose cataract is visually significant and whose IOP can be adequately controlled with medication or laser trabeculoplasty, cataract surgery should be performed first. Additionally, cataract surgery alone can reduce IOP, so performing this procedure first sometimes obviates the need for a subsequent glaucoma procedure.
Although one of the comorbid conditions usually requires more immediate attention, some patients present with an urgent need for both cataract and glaucoma surgery, in which case a combination procedure is indicated. A combination procedure may also be considered if a patient’s advanced age or medical condition precludes performing two separate surgeries, or if a patient’s adherence to medical therapy is poor.
With most glaucoma-cataract combination surgery, one or two incisions is used—either a clear corneal incision for the cataract surgery and a scleral incision for the glaucoma surgery, or a single scleral incision that is used for both parts of the combined procedure. Whatever combination surgery is performed, I believe successful outcomes depend on performing both the cataract surgery and the glaucoma surgery with minimal ocular trauma. Because inflammation will interfere with proper wound healing, I use the gentlest surgical technique possible, and I try to keep bleeding to a minimum.
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