Choosing Combined Surgery for Cataract and Glaucoma

Multiple issues factor into the decision to add a trabecular bypass MIGS procedure to phacoemulsification. Cheryl Guttman Krader reports the 39th Congress of the ESCRS in Amsterdam. Combined phacoemulsification and minimally invasive glaucoma surgery (MIGS) with a trabecular bypass device can be an excellent option for some patients with cataract and high-risk ocular hypertension or early to mild glaucoma, but it is not the best option for all patients, noted Julián García-Feijoo MD. “Cataract surgery is a good opportunity to reconsider treatment for lowering IOP, and I think it is worth adding the MIGS procedure in many cases, even if IOP and the disease is medically controlled, considering it offers the chance for medication-free time and better quality IOP control,” Dr García-Feijoo said. “Undertaking combined surgery assumes the procedure adds value and will increase quality of life. Considering the downsides of medication for IOP-lowering, it is probable that adding a trabecular bypass MIGS procedure to cataract surgery for appropriately selected patients can improve quality of life. However, we still need more data from real-life experiences and well-designed studies investigating the impact on quality of life,” he added. Trabecular bypass MIGS devices include two options—the iStent inject® W (Glaukos), which creates two bypass pathways through the trabecular meshwork, and the Hydrus® Microstent (Ivantis). Both technologies have benefits for such a risk: benefit profile, an expectation of IOP results in the mid to high teens, and evidence supporting their cost-effectiveness. Dr García-Feijoo described two clinical scenarios where he believes adding trabecular bypass MIGS to cataract surgery would be a good option. The first involves patients with stable early to mild glaucoma whose IOP is medically controlled. The objective for performing the glaucoma procedure in these cases is to eliminate or reduce the medication burden and improve quality of life. Secondly, the combined procedure can be an option for patients whose IOP or glaucoma is suboptimally controlled on medications if their target IOP is in the range reachable with combined cataract-trabecular bypass MIGS. “If the target IOP is in the mid or high teens, combined surgery with a trabecular MIGS device is an excellent option. Other types of surgeries, however, are better if there is a need to achieve a lower IOP,” Dr García-Feijoo said. He added that surgeons should consider individual patient preferences, recognising that some patients would rather undergo surgery than undertake chronic topical treatment. “Remember that we need to listen to our patients because they may have a different perspective of their disease and its treatment. In addition, medical treatment is just not feasible for some patients,” Dr García-Feijoo said. Surgical success when performing trabecular bypass MIGS depends on the surgeon’s ability to place the implant in the correct location. Dr García-Feijoo advised his colleagues to take their time finding a comfortable position that enables good angle visualisation, becoming familiar with the inserter and the device, and checking both pieces of hardware before entering the anterior chamber. “If surgeons are comfortable in the operating theatre, surgery will be easier, results will be better, and we will be more confident offering the surgery,” he said.