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Patients with both cataracts and glaucoma require special consideration. Cataracts may naturally coexist with glaucoma, have a causative effect on glaucoma, and/or may even be a result of glaucoma surgery.
A cataract is a clouding of the lens inside the eye which leads to a decrease in vision. When a patient has glaucoma that requires an operation, there may be a unique opportunity to remove the coexisting cataract without significantly increasing the risk of the glaucoma surgery. Additionally, when a patient has cataracts affecting their vision along with glaucoma, removing the cataract may provide an opportunity to perform a glaucoma surgery at the same time that may decrease the patient’s need for glaucoma eye drops or improve eye pressure control.
Cataract surgery may be combined with one of several glaucoma surgeries including trabeculectomy, glaucoma drainage devices, canaloplasty, endocyclophotocoagulation, and the newer micro-invasive glaucoma surgeries (MIGS). The MIGS procedures are especially suited for combining with cataract surgery since they can usually be performed by using the same incision through which the cataract is removed. However, they rely on the eye’s natural drainage system and may not get the eye pressure to a low enough level for some patients. The iStent is a MIGS procedure that is currently FDA approved for use in combination with cataract surgery.
In certain situations, cataract surgery alone may also be considered. For example in some patients with narrow angles, the cataract becomes too big and crowds the other structures in the eye (especially the drainage angle). When this occurs, performing a cataract surgery with a lens replacement may open the drainage angle and improve the eye pressure.
The decision of whether or not combined cataract-glaucoma surgery should be performed, and the choice of glaucoma surgery, depends on various factors including the type of glaucoma and its severity. Your doctor will take all these important factors into consideration when advising what is best for your eye.
Cataract surgery in a patient with glaucoma may give rise to unique concerns. For example, in patients with exfoliation glaucoma there is a higher risk of complications due to inherent weakness in the supportive structure of the natural lens (the zonules). Some newer types of intraocular lenses may not be suitable for patients with advanced glaucoma because they affect contrast sensitivity (the ability to distinguish between an object and its background) or may cause additional sensitivity to glare. Eye pressure spikes after cataract surgery may be more common in patients with underlying glaucoma and importantly, glaucoma patients are more likely to be susceptible to damage from a transient increase in eye pressure.
To conclude, in patients with coexisting cataract and glaucoma, surgical treatment poses unique challenges. There are several treatment options and many variables factor into the decision to choose a particular procedure. A detailed discussion with your doctor is important in order to determine the best option for you.
Article by Davinder S. Grover, MD, MPH. Dr. Grover is an Attending Surgeon and Clinician at the Glaucoma Associates of Texas, located in Dallas, Texas. He specializes in the medical and surgical management of complex glaucoma as well as cataract surgery.
Last reviewed on October 29, 2017