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22 EW SHOW DAILY Monday, April 22, 2013 ASCRS Symposia Experts debate the best options for glaucoma patients with cataract by Enette Ngoei EyeWorld Contributing Writer Gary Foster, MD, agrees that the mean IOP is reduced by cataract surgery. A ttendees at a symposium titled, "Cataract surgery in the glaucoma patient: How to select the best option for my patient?" were treated to a lively series of presentations by cataract and glaucoma experts, each arguing in favor of various procedures. Gary Foster, MD, Fort Collins, and Kuldev Singh, MD, Palo Alto, Calif., set the stage for the discus- sion with presentations on the effect of phacoemulsification on IOP and whether glaucoma affects the timing of cataract surgery, respectively. Dr. Foster presented a literature review, which included the Ocular Hypertension Treatment Study among others. He concluded that there is an agreement that the mean IOP is reduced by cataract surgery and that the higher the mean preop IOP, the greater the mean postop re- duction of IOP. However, he said there is a disagreement over the amount of IOP reduction brought about by phacoemulsification, as well as how stable the gains are over time. In his presentation, Dr. Singh said it makes sense to take out the cataract early in glaucoma patients for a variety of reasons, though it will be a challenge to convince regulators to consider glaucoma as an indication for earlier cataract surgery. David F. Chang, MD, Palo Alto, Calif., Steven D. Vold, MD, Fayetteville, Ark., and Robert J. Noecker, MD, Pittsburgh, presented arguments for various combined procedures for early to moderate glaucoma patients with cataracts. They included phaco with ab interno stenting of Schlemm's canal, phaco with ab interno trabeculectomy, and phaco with endoscopic cyclophotocoagulation, respectively. Steven Dewey, MD, Colorado Spring, Colorado, argued for why phaco alone is the best approach. After hearing all the arguments, the audience voted Dr. Chang the winner. Dr. Chang presented various studies that showed that when phaco is combined with the iStent (Glaukos, Laguna Hills, Calif.), there is an additional reduction in IOP versus phaco alone. There is also a better chance of reducing glaucoma medications. The procedure is safe, with no hypotony or bleb, he said. It does not increase inflammation, there's no change in recovery and no change in astigmatism. Phaco with the iStent also provides room for future options as it spares the conjunctiva and a trabeculectomy may be performed later on if needed, he said. Experts also debated on which combined procedures are best for advanced glaucoma patients with cataracts. Douglas J. Rhee, MD, Boston, Ike K. Ahmed, MD, Toronto, and Paul Harasymowycz, MD, Montreal, argued for phaco and trabeculectomy, phaco and minishunt, and phaco and canaloplasty, respectively. Reay H. Brown, MD, Atlanta, argued for doing cataract surgery alone. The audience voted Dr. Brown the winner in this segment. Dr. Brown said that especially in advanced glaucoma patients, surgeons should keep it simple and do cataract surgery alone because "these very delicate damaged eyes are so vulnerable to the complications that are so common with glaucoma surgery." He cited the Tube Versus Trabeculectomy (TVT) study that showed a patient undergoing a trabeculectomy had a 27% risk of reoperation or the loss of two or more lines of vision. "We're trying to prevent our patients from experiencing these complications. Many combined surgeries are unnecessary," Dr. Brown said. Cataract surgery alone would help most of these patients with much less risk. "It's not about refusing to do glaucoma surgery—glaucoma treatment is like a chess match. We need to use the strategy of using cataract surgery as a glaucoma therapy; that means doing cataract surgery earlier. Our goal is to make the cataract move before the glaucoma surgery move, and avoid the checkmate of combined surgery," he said. EW