Cataract Surgery In Advanced Glaucoma - Case Report

We report the case hereby due to a controversy in the most adequate surgical plan: trabeculetomy or cataract surgery in a case of an advanced, not optimally controlled primary open angle glaucoma (POAG) patient and clear lens.

A 61 years old female POAG patient, functional monophthalmos due to OD absolute glaucoma and OS advanced stage, with less than optimal IOP control, under maximal topical medication. Clinical examination revealed PCIOL in OD, well centered and minimal age related lens changes in OS.

Initial BCVA in OD=nlp and OS=1.0 sc (Snellen); IOP OD=10 mmHg (Duotrav, Simbriza), variable IOP OS=26-40 mmHg (Duotrav, Simbrinza, systemic Acetazolamide 250 mg, daily); fundus examination showed total excavation in OD (C/D=1) and cvasi-total in OS (C/D=0.9). Gonioscopy (Spaeth grading system) revealed wide open AC angle in OD (C35f) and narrow in OS (B20c) with significant anterior lens vaulting.

Careful consideration of this functional monophthalmos patient with certain particular aspects corroborated with biometry, computerized Humphrey perimetry and dynamic gonioscopy pleaded for clear lens extraction over trabeculectomy in this patient; postoperatory interval revealed sinuous recovery with significant IOP (10-36mmHg) and vision (hm to 1.0 sc, Snellen)  fluctuations due to some immediate complications (e.g. anterior segment inflammation, pigment dispersion etc).

At the 8 weeks post-operatory visit the patient became stable with excellent anatomical and functional recovery (BCVA OS=1.0 sc and IOP OS =14 mmHg) and topical medication reduction.

Cataract surgery alone before trabeculectomy in such advanced glaucoma patients can be controversed and wide IOP fluctuations can be met. General guidelines are not unanimously pointing towards particular advantages of one procedure over the other, therefore careful consideration should be given to each particular case, according to individual circumstances and risk factors.