Preoperative Selective Laser Trabeculoplasty For Intraocular Pressure Optimization Before Cataract Surgery In Mild Primary Open-Angle Glaucoma

To describe the perioperative management of cataract surgery in a patient with mild primary open-angle glaucoma (POAG), highlighting preoperative intraocular pressure (IOP) optimization using selective laser trabeculoplasty (SLT) to improve surgical safety and avoid combined intraocular procedures.

Instituto da Visão, Brazil – Private ophthalmology practice specialized in glaucoma and cataract surgery.

A 76-year-old male presented with decreased visual acuity in the left eye (0,4) due to corticonuclear cataract. He had a prior diagnosis of primary open-angle glaucoma (POAG) and was using timolol irregularly. Intraocular pressure (IOP) measured 21 mmHg OS(7AM).Central corneal thickness was 525 µm. Gonioscopy demonstrated open angles to the ciliary body band (360°). Fundoscopy revealed a cup-to-disc ratio of 0.6 with superior temporal rim thinning OS. Optical coherence tomography confirmed focal superior retinal nerve fiber layer loss, and standard automated perimetry(24-2) showed a corresponding inferior nasal step, establishing structural-functional concordance consistent with mild POAG.

Considering the known risk of early postoperative IOP spikes after isolated phacoemulsification in glaucomatous eyes, preoperative IOP optimization was chosen instead of isolated cataract surgery or combined phacoemulsification with minimally invasive glaucoma surgery.

A 360° SLT was performed (120 applications; energy 1,0 mJ). IOP decreased to 17 mmHg at 2 weeks and 16 mmHg at 4 weeks, when timolol was discontinued. At 6 weeks, IOP reached 15 mmHg without medication, representing a 28% reduction from baseline. Biometry was performed after pressure stabilization, and phacoemulsification was carried out at 8 weeks.

Cataract surgery occurred without intraoperative or postoperative IOP spikes. Postoperative IOP remained stable at 15 mmHg without medication, with no evidence of disease progression

Cataract surgery in patients with glaucoma requires careful perioperative IOP control. In this case, preoperative SLT achieved significant pressure reduction and allowed discontinuation of topical therapy before surgery, enabling safe phacoemulsification without pressure spikes and avoiding combined intraocular glaucoma procedures.

Selective laser trabeculoplasty is a cost-effective, technically straightforward outpatient procedure with a well-established impact on IOP control in POAG. When appropriately selected, it may enhance surgical safety and reduce procedural complexity prior to cataract extraction.