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Up Front | Oct 2011

Chief Medical Editor’s Page

Combined Phaco Procedures: To Do or Not To Do?

Today, it is a fair assumption that many cataract surgeons practicing in small- or medium-sized clinics focus on pure cataract surgery. But a growing number are also incorporating refractive cataract surgery and corneal refractive procedures into their practice, and a smaller number (the minority) are performing glaucoma and/or vitreoretinal surgery. Regardless of what category you fit into, this month's cover focus on the treatment of concurrent ocular pathologies is of invaluable importance to all.

The anatomy of the crystalline lens has a close relationship to the outflow capacity of the eye and the etiology of narrow-angle glaucoma. The lens is also closely linked to the vitreous cavity. Therefore, it is not uncommon for surgical interventions involving the lens to impact the vitreous (and retina) and vice versa.

This cover focus is packed with highquality articles that are easy to read and that update the cataract surgeon on treating more than one ocular condition at a time. In many instances, this is possible using combined surgical techniques, such as high-frequency deep sclerotomy combined with phacoemulsification, as described by Bojan Pajic, MD, PhD, FEBO, of Switzerland; or, as Stanley J. Berke, MD, FACS, of Long Island, New York, reviews, combined endolaser cyclophotocoagluation (ECP) and cataract surgery. Other combined techniques include phacotrabeculectomy, which Tanju Dada, MD, of India; and Kathryn B. Freidl, MD, and Marlene R. Moster, MD, of Philadelphia, highlight in their respective articles, as well as management of capsular rupture at cataract surgery, which Steve Charles, MD, FACS, FICS, of Tennessee, overviews.

An increasing number of surgeons prefer to treat potential narrow-angle glaucoma by lens extraction. Matteo Piovella, MD, of Italy, describes how his use of anterior segment imaging has standardized his decision-making process to remove the crystalline lens in patients with glaucoma. His rationale is that cataract surgery will increase the space and capacity for aqueous outflow. Along those same lines, Dr. Dada provides a good overview of pressure-lowering treatment options depending on the stage of visual field loss, and a second article by Dr. Piovella provides a compact and clear summary of novel IOP-lowering techniques and glaucoma implants.

Dr. Berke's article describes the position of ECP in his glaucoma treatment armamentarium. A well-balanced argument, his words of wisdom are helpful for those cataract surgeons considering adoption of this technology. Additionally, Drs. Freidl and Moster and Robert J. Noecker, MD, MBA, of Connecticut, discuss the use of toric IOLs and intraoperative aberrometry, respectively, to manage postoperative refractive error in conjunction with combined phacoglaucoma surgery. I must admit that if I counsel a patient for advanced glaucoma surgery, refraction is not my primary focus. Perhaps innovation and improved technology may change my strategy in the future.

Som Prasad, MS, FRCS(Ed), FRCOphth, FACS, and Farhan Qureshi, MBChB(Hons), FRCOphth, of the United Kingdom, have written a good article on cataract surgery in eyes with vitreoretinal pathology. It is easy to read and unbiased, with many useful facts. The article highlights the often poorly understood reverse pupil block syndrome and its simple management. I have observed many surgeons struggling with an excessively deep anterior chamber that could have been easily overcome by simply lifting the iris to unlock the reverse pupil block.

An absolute must-read is Dr. Charles' article. As the authority on vitreoretinal surgery, he advises us cataract surgeons how to manage a capsular rupture and better understand the do's and don'ts of handling the vitreous during complicated cataract surgery.

The introductory article by Gabor B. Scharioth, MD, PhD, of Germany, is probably the most complex of all. He is a renowned and highly skilled high-volume cataract, glaucoma, and vitreoretinal surgeon. It is extremely interesting to learn how someone with his experience has developed his skills and which technologies he prefers. According to Dr. Scharioth, when considering a combined phaco-glaucoma or phaco-vitreoretinal procedure, the decision should be based on the surgeon's preference and the patient's wishes; I would certainly prioritize a surgeon's expertise and comfort level as a basis for such an important decision. Very few surgeons can match his expertise! I certainly cannot…