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Today's Practice | Jan 2014

Combined Laser-Assisted Cataract Surgery and MIGS

As new cataract and glaucoma technologies become available, surgeons must rethink how they treat concurrent diseases.


A new column in CRST Europe debuts this month. “Sound Off” allows authors to select and discuss a hot topic in cataract or refractive surgery. This column replaces the 5 Questions feature.

Laser-assisted cataract surgery has the potential to improve the refractive predictability and outcome of cataract surgery. Newer, less invasive glaucoma surgical options also generally induce less refractive error. Ophthalmologists can now treat patients with both cataracts and glaucoma more safely and achieve better visual outcomes than ever before.

Laser cataract patients are the happiest in my practice. As a whole, they are pleased with their refractive outcomes, especially with the reduction of their astigmatism. They tend to recover their vision relatively rapidly after surgery and experience lower levels of postoperative inflammation and corneal edema.

Microinvasive glaucoma surgery (MIGS) techniques such as ab interno trabeculotomy (Trabectome; NeoMedix Corporation), placement of an iStent Trabecular Micro-Bypass Stent (Glaukos Corp.), and endocyclophotocoagulation (ECP) tend to be neutral in terms of inducing astigmatism or other refractive errors. Compared with trabeculectomy or the implantation of glaucoma drainage devices, MIGS is relatively less traumatic to the eye. Additionally, the intraocular pressure (IOP)-lowering effect of MIGS is likely to be less acute with less chance of hypotony that can alter the architecture and refractive state of the eye. These newer procedures, however, generally do not lower IOP as much as filtering surgeries. MIGS procedures can be combined to provide additional IOP lowering. For example, with laser-assisted cataract surgery, I have paired ECP with the iStent as well as ECP with the Trabectome to further reduce IOP in the glaucoma portion of the combined procedure.

In patients with mild or moderate glaucoma, I find that laser-assisted cataract surgery combined with MIGS consistently results in the discontinuation of medication and a lower IOP. In my experience, patients typically have rapid visual recovery without sacrificing the optimal refractive results that we can offer to our patients without glaucoma. As new cataract and glaucoma surgical technologies become available, we need to rethink how we treat patients with concurrent cataract and glaucoma.

Robert J. Noecker, MD, MBA, is in private practice at Ophthalmic Consultants of Connecticut in Fairfield. He states that he is a consultant to EndoOptiks, Inc., and Iridex Corporation, and he has received research support from Glaukos Corp. Dr. Noecker may be reached at tel: +1 203 366 8000; e-mail: noeckerrj@gmail.com.