Combined Approach to Coexisting Glaucoma and Cataract: Choice of Surgical Techniques

Both glaucoma and cataract are diseases with an increasing prevalence with age, and thus one often finds that they are coexistent in the elderly patient population. The association of glaucoma with cataract has become more frequent because of increase in life expectancy. The use of antiglaucoma medication has only strengthened their association. The presence of cataract can affect the ability to assess glaucoma progression, while cataract extraction affects the intraocular pressure and effectiveness of glaucoma surgery. On the other hand, glaucoma surgery significantly increases the risk for the development of cataracts. For this reason, as well as to reduce the trauma induced by two surgical procedures, the prevailing trend is to perform a combined procedure, taking care of both pathologic conditions in a single setting.(Parker & Stark, 1992;Vass & Menapace, 2004). Recent developments in bimanual small incision phacoemulsification, improvements in trabeculectomy and nonpenetrating filtering surgery as well as implant drainage devices have favoured combined surgery. The goal of treatment in a glaucoma patient with cataract, is to achieve an adequate long term control of intraocular pressure (IOP), avoid postoperative IOP spikes which are deleterious to the health of the optic nerve head, obtain an optimal visual rehabilitation thus improving the quality of life of the patient. Cataract surgery alone has significant effects on the intraocular pressure. Following an early rise in the intra ocular pressure, the IOP tends to fall in the long run. The effect is however small averaging around 2–4 mmHg and one cannot depend on this as a means of lowering the IOP. The most important step before operating on a patient with cataract and glaucoma is the preoperative evaluation as well as the decision regarding the type of surgery to be performed. The combined surgical technique of Phacotrabeculectomy has become the standard technique for management of eyes with co-existent cataract and glaucoma.(Casson & Salmon,2001).The moderate uncomplicated glaucoma with cataract can also be managed with a combined technique of Phacoemulsification and Non penetrating Deep Sclerostomy surgery. Phacotrabeculectomy is either done as a single site surgery with both phacoemulsification and trabeculectomy performed from the same site or more commonly as a two site surgery which entails performing a temporal phacoemulsification and a superior trabeculectomy.(Caprioli et al., 1996; Mermoud & Schnyder 2000).Separating the two incisions may decrease the inflammation and subsequent fibrosis induced by the