Cataract Surgery in Patients with Glaucoma
Yes, cataract surgery can be safely performed in patients with glaucoma, but the approach depends on the patient's intraocular pressure (IOP) control and severity of both conditions. 1
Decision Algorithm for Surgical Approach
The surgical management strategy for patients with coexisting cataract and glaucoma should follow this evidence-based algorithm:
1. Well-Controlled Glaucoma (IOP at target on 1-2 medications)
- Cataract surgery alone is appropriate 1
- Benefits include:
- Modest IOP reduction (average 16.5% decrease that may persist for 3+ years) 1
- Visual acuity improvement
- No need for more invasive combined procedures
2. Moderately Controlled Glaucoma with Visually Significant Cataract
- Combined cataract and glaucoma surgery is recommended 1, 2
- Potential benefits include:
- Protection against IOP spikes that may occur after cataract surgery alone
- Long-term glaucoma control with a single operation
- Elimination of risk of bleb failure with subsequent cataract surgery 1
3. Poorly Controlled Glaucoma (uncontrolled on multiple medications)
- Glaucoma surgery first, followed by cataract surgery later once IOP is adequately controlled 1, 2
- This approach is particularly important when glaucoma is severe and progressive
Surgical Considerations
Combined Surgery Options
When combined surgery is chosen, several approaches are available:
- Cataract extraction with trabeculectomy
- Cataract surgery with aqueous shunts
- Cataract surgery with nonpenetrating glaucoma surgery
- Cataract surgery with minimally invasive glaucoma surgery (MIGS)
- Cataract surgery with endocyclophotocoagulation 1
Technical Considerations
- Use of mitomycin C (MMC) in combined procedures results in lower IOP 1
- Recent evidence shows no significant difference between one-site versus two-site combined procedures 1
Important Clinical Pearls
Benefits of Combined Surgery
- Greater IOP reduction compared to cataract surgery alone 3
- Approximately 50% reduction in the need for IOP-lowering medications postoperatively 3
- Single recovery period for the patient
Potential Pitfalls
- Combined cataract and glaucoma surgery is generally not as effective as glaucoma surgery alone for IOP lowering 1
- Patients with mild cataracts who require significant IOP reduction may benefit from filtration surgery alone first, followed by cataract surgery later 1
- Cataract surgery performed after previous glaucoma surgery may compromise bleb function 2
Postoperative Considerations
- Close monitoring for IOP spikes is essential in the immediate postoperative period 4
- Patients should be informed about the possibility of continued visual impairment after surgery and potential need for rehabilitation 1
- Appropriate referral to specialists should be considered if the postoperative course doesn't proceed as expected 1
Conclusion
The decision between cataract surgery alone, sequential surgeries, or combined procedures should be based on the severity of glaucoma, level of IOP control, visual impairment from cataract, and target IOP. The ophthalmologist and patient should discuss the risks and benefits of each approach to determine the optimal surgical strategy.