Management of Concomitant Cataract and Glaucoma.

The coexistence of cataract and glaucoma represents a challenge for the ophthalmologist and the issue is still open to debate. The surgical management is based on both the visual field defect and the loss of visual acuity. The surgical options currently available are: (1) cataract extraction alone, (2) sequential glaucoma surgery and cataract extraction, and (3) combined surgery by 1 site or by 2 separate sites. Phacoemulsification alone is suggested when glaucoma can be controlled by medication and the visual field defect is moderate and nonprogressive. In case of a refractory glaucoma (3 or more types of medication required) with associated early-stage cataract, phacoemulsification could be postponed until after glaucoma surgery. The cataractogenous effect of the procedure should be considered in this situation. Moreover, cataract extraction performed after a filtering surgery may lead to a reduction of the bleb function. When both glaucoma and cataract are sight impairing, combined surgery is indicated since it allows a greater intraocular pressure decrease than phacoemulsification alone.

Long-term Outcomes of a Modified Technique Using the Baerveldt Glaucoma Implant for the Treatment of Refractory Glaucoma.

PURPOSE OF THE STUDY: The purpose of the study was to evaluate the long-term effectiveness and safety profile of Baerveldt glaucoma implant (BGI) in patients with refractory glaucoma operated using a modified technique to avoid postoperative complications. PATIENTS AND METHODS: A total of 160 eyes from 147 glaucomatous patients were enrolled in a consecutive interventional noncomparative case series. All the patients were treated with a 350-mm BGI using a modified technique. Intraocular pressure (IOP), the number of medications, the complications, and the postoperative interventions were reported preoperatively and during the follow-up. Postoperative IOP and the rate of complications were the primary outcome measures. The complete and qualified surgical success was the second endpoint. RESULTS: BGI obtained a mean IOP reduction from 31.8±6.4 mm Hg (baseline) to 14.4±3.5 mm Hg after a mean follow-up period of 38.4±9.6 months. The mean number of medications reduced between preoperative (n=3.17±1.03) and postoperative period (n=0.58±0.83) (P<0.0001). Cumulative probability of maintaining an IOP between 5 and 21 mm Hg and/or a 25% or greater reduction in IOP was 78.7% at 1 year and 72.1% at 4 years, including 39 eyes (24.4%) in which postoperative interventions were required (qualified success). If we exclude those eyes from the analysis, the probability of complete success was 93.4% at 1 year and 91.4% at 4 years in 75.4% of the eyes. CONCLUSIONS: This modified technique achieved a high percentage of surgical success during the whole follow-up time and was effective in preventing the most serious immediate complications of nonvalved tube shunts.

Management of concomitant cataract and glaucoma.

The coexistence and management of cataract and glaucoma represents a challenging and unsolved problem. The surgical management of this problem is based on both visual field defect and loss of visual acuity. The surgical options currently available are: (1) cataract extraction alone; (2) cataract extraction followed by glaucoma surgery; (3) glaucoma surgery and afterwards, if necessary, cataract extraction; (4) combined surgery of cataract and glaucoma by one site or by two separate sites. Phacoemulsification alone is suggested when glaucoma can be sufficiently controlled by medication and visual field defect is moderate and not progressive. When glaucoma needs three or more types of medication to reduce intraocular pressure (IOP) or when the offset is unpredictable, phacoemulsification associated with glaucoma surgery at two different times allows a higher IOP reduction than that with a cataract extraction alone. Finally, when glaucoma is prevailing and the surgeon fears that an IOP spike after phacoemulsification may cause significant damage to the optic nerve, combined surgery allows to achieve a greater IOP decrease than phacoemulsification alone and a more predictable low-IOP range in the immediate postoperative period.