Laser cataract surgery has the potential to improve the refractive predictability and outcome of cataract surgery. Newer, less invasive glaucoma surgical options also generally induce less refractive error. We ophthalmologists can now treat patients with both cataracts and glaucoma more safely and achieve better visual outcomes than ever before. Laser cataract patients are the happiest in my practice. As a whole, they are very pleased with their refractive outcomes, especially with the reduction of their astigmatism. They tend to recover their vision relatively rapidly after surgery and to experience lower levels of postoperative inflammation and corneal edema.
Microinvasive glaucoma surgery (MIGS) such as ab interno trabeculotomy (Trabectome; NeoMedix Corporation), the placement of an iStent Trabecular Micro-Bypass Stent (Glaukos Corporation), and endocyclophotocoagulation (ECP) tend to be neutral in terms of inducing astigmatism or other refractive errors. Compared with trabeculectomy or the implantation of glaucoma drainage devices, MIGS is relatively less traumatic to the eye. Additionally, the IOP-lowering effect of MIGS is likely to be less acute with less chance of hypotony that can alter the architecture and refractive state of the eye. These newer procedures, however, generally do not lower IOP as much as filtering surgeries. MIGS procedures can be combined to provide additional IOP lowering. For example, with laser cataract surgery, I have paired ECP with the iStent as well as ECP with the Trabectome to further reduce IOP from the glaucoma portion of the combined procedure.
In patients with mild or moderate glaucoma, I find that laser cataract surgery combined with MIGS consistently results in the discontinuation of medication and a lower pressure. In my experience, patients typically have very rapid visual recovery without sacrificing the optimal refractive results that we surgeons can offer to patients without glaucoma. As new cataract and glaucoma surgical technologies become available, we need to rethink how we treat patients with concurrent cataract and glaucoma.
Robert J. Noecker, MD, MBA, is in private practice at Ophthalmic Consultants of Connecticut in Fairfield. He is a consultant to EndoOptiks, Inc., and Iridex Corporation, and he as received research support from Glaukos Corporation. Dr. Noecker may be reached at (203) 366-8000; noeckerrj@gmail.com.
