In the management of a patient with a visually significant cataract and coexisting glaucoma, there are three basic surgical approaches:
(a) cataract extraction alone, which may need to be followed by a trabeculectomy later;
(b) glaucoma filtering surgery alone, followed by cataract removal later (two-stage approach); and
(c) combined cataract and glaucoma surgery.
Combined procedures have certain advantages and disadvantages in comparison with the other two options. When compared to a cataract surgery alone, which itself has an increased risk for posterior capsule break in glaucomatous eyes (1), particularly when pseudoexfoliation is present (2,3,4), combined procedures have greater risk of postoperative complications such as increased inflammation, hyphema, hypotony, shallow anterior chambers, and choroidal detachments, but have the advantage of reducing early intraocular pressure (IOP) rise.
As compared to a filtering operation alone, with or without subsequent cataract extraction, the combined procedures may have a lower chance of long-term glaucoma control, but have the obvious advantage of one trip to the operating room instead of two. For these reasons, the surgeon should consider each of the basic surgical options, evaluate the severity of the glaucoma, and the visual need and potential for each individual patient, and select the approach that seems to be most appropriate.
With advances in both cataract and glaucoma surgery, success rates with combined procedures have improved and relative indications have shifted. We first review the general indications for the three basic surgical approaches and then consider how advances in surgical techniques are influencing the relative indications for these procedures.
