The Case for Combined Cataract and Glaucoma Surgery

This dual procedure requires a deft balancing of what’s best for the patient and the bottom line.

Many patients suffer from both cataracts and glaucoma, so why not address both conditions during the same surgery? While such an efficient option seems like a no-brainer, in reality it’s not quite that simple.

Surgeons and facilities must answer two critical questions before adding combined cataract-glaucoma procedures: 

• Is this dual procedure best for the patient? 
• Can it be performed profitably for the facility?

Safety plus effectiveness

Elizabeth Catherine Ciociola, BA, a fourth-year medical student at UNC School of Medicine, delivered new research at the American Academy of Ophthalmology’s (AAO’s) Annual Meeting in Chicago this fall about the safety and effectiveness of combined cataract and glaucoma surgeries. Specifically, her study, also published in the AAO’s Ophthalmology Glaucoma journal, evaluated the effectiveness of trabeculectomy and glaucoma drainage device (GDD, a.k.a., tube shunt) implantation combined with phacoemulsification (phaco) in comparison with standalone procedures.

The multicenter retrospective cohort study, on which Ms. Ciociola joined forces with researchers at Harvard Medical School in Boston, Wills Eye Hospital in Philadelphia, the University of Washington in Seattle, Stanford University in Palo Alto Calif., and the AAO itself, evaluated patients in the Intelligent Research in Sight Registry who underwent trabeculectomy or GDD from 2013 through 2019 to determine rates of reoperation, defined as any subsequent glaucoma surgery occurring one month to three years after the initial procedure. They also examined measures such as intraocular pressure (IOP), visual acuity, reoperation procedure type, postoperative complications and predictors of surgical failure. A total of 117,697 eyes undergoing glaucoma surgery alone and 35,657 eyes undergoing glaucoma surgery with phaco were included.

Here’s what they found in terms of cumulative reoperation rates at postoperative years one and three, respectively:

• Reoperation for trabeculectomy alone: 4.9% and 11.5
• Trabeculectomy with phaco: 3.0% and 7.3% 
• GDD alone: 3.8% and 7.8%
  
• GDD with phaco: 2.1% and 5.4%

Key takeaway: Standalone procedures were actually more likely to require reoperation than combined procedures. However, the team also found standalone procedures achieved greater IOP reduction by percentage change from baseline:

• Trabeculectomy alone: 35.3%
• Trabeculectomy with phaco: 23.1%
• GDD alone: 36.0%
• GDD with phaco: 29.3%

“There was an understanding and some controversy over whether traditional surgeries were as effective when performed with phaco,” says Ms. Ciociola. “The previous understanding was that when they were performed with phaco, they tended to be less effective. However, there had been some studies showing it was still as effective and some showing it was less effective,” who adds that her team was a bit surprised that procedures performed with phaco resulted in lower reoperation rates compared to standalone procedures.

Ms. Ciociola notes that although IOP reduction with the combined procedures was lower than with standalone procedures, the reduction was still significant. “By one year, mean IOP was relatively similar across groups,” she says. Further bolstering the case for dual procedures was that the standalone procedures group had higher baseline IOP and thus more room for decline, boosting their reduction percentages.

“Additionally, we think there’s probably a difference in the indication for these two groups,” she says, noting the procedures performed with phaco for both trabeculotomies and tubes not only had lower baseline IOP, but also less severe glaucoma. “We think it’s possible the indication for these patients’ procedures might have been more related to removing the cataracts in addition to meeting glaucoma control, whereas for the standalone group, the main indication was to control the glaucoma. Those patients might have had a more aggressive disease at baseline, requiring a lower target IOP and therefore need for more reoperation.”

Regarding complications during the first three months, Ms. Ciociola and her team found low rates — between 1% and 3% — and the most common complications were nothing too severe or significant. “There again was not too much difference between the two groups,” she says.

Ms. Ciociola notes the limitations of the study, which was conducted in a registry database in which numerous variables can’t be accounted for and studied, but feels the trends identified are compelling enough to encourage further study. “For example, we weren’t able to analyze medication data because it’s not available in a robust way in the database,” she says. “There’s definitely room for more studies.”

Realities in practice

MOVING RIGHT ALONG Proponents say efficient, high-volume cataract lines won’t be severely disrupted by adding concurrent cataract-glaucoma procedures.

Some ophthalmologists have been performing dual cataract-glaucoma procedures for some time.

AAO spokesperson Davinder S. Grover, MD, MPH, is an ophthalmologist at Glaucoma Associates of Texas in Dallas, which he says is the U.S.’s largest private practice glaucoma group; the group operates at a facility that he says is the busiest eye surgery center in the country. Dr. Grover has regularly been performing cataract and glaucoma surgery at the same time for more than 12 years. “The community has been doing it for probably 12 to 15 years, but it has really taken off over the past five or 10 years,” he says. “In my opinion, it’s the standard of care. If I or my family had glaucoma and cataracts, I would want them both addressed at the same time.”

Dr. Grover says some studies have shown that cataract surgery alone can lower IOP, which is the treatment for glaucoma. “When patients with glaucoma have cataract surgery, they’re at higher risk of a spike in eye pressure, which can make the glaucoma worse,” he says, adding that an increasing number of studies show that eyedrops, a mainstay treatment for glaucoma, are not as benign as many thought and also present patient compliance challenges.

That’s why many ophthalmologists are examining how to best control patients’ IOP while minimizing their dependence on eyedrops. “If I’m going into somebody’s eye who needs cataract surgery, and they have glaucoma and are on a few drops, it’s a unique opportunity to address both at the same time,” says Dr. Grover. “That will then allow me to improve the patient’s vision and pressure, and decrease their dependence on drops. A lot of these glaucoma procedures add just a little to the risk of the surgery, but add a lot of potential benefits.”

When Dr. Grover performs dual procedures, he focuses on minimally invasive glaucoma surgeries (MIGS) rather than more traditional approaches. “Patients who have milder forms of disease do better with MIGS procedures within reason,” he says. MIGS provides him with numerous options for the combination surgery depending on the patient: different forms of goniotomies; implants such as the iStent and Hydrus; and slightly more invasive procedures such as gonioscopy-assisted transluminal trabeculotomy (GATT), which he helped invent with his partners and which he says provides even better IOP control.

“When patients have very mild disease, they do better with the stents,” he says. “If they’re moderate, they do better with a goniotomy or GATT, and if they have advanced glaucoma, they do better with traditional tubes, trabeculectomies and/or microshunts.”

Compared to standalone cataract surgery, Dr. Grover says there is some variability with the combination. “Having both procedures performed at the same time doesn’t significantly change the patient experience, but glaucoma eyes can behave just a little differently, can be a bit more challenging and sometimes take a little longer to heal,” he says. “When you’re doing a dual cataract and glaucoma surgery, especially MIGS procedures, it’s a bit more involved than a routine cataract follow-up in terms of post-op management and decision-making than a traditional glaucoma surgery follow-up. A lot of these MIGS procedures really don’t add much time to the healing process and there’s not usually a major change to the post-operative drop regimen.” During post-op exams, Dr. Grover says the surgeon needs to carefully evaluate the healing of the eye from a cataract perspective while also paying close attention to the glaucoma health process.

The most common worst-case scenario is some prolonged bleeding in the eye from the MIGS procedure that could cause blurred vision and a spike in IOP. These problems tend to clear on their own with proper treatment, says Dr. Grover, adding that in some patients, IOP is no better off than it was before dual cataract-MIGS procedures — though patients are usually protected from eye pressure spikes in the immediately postoperative period that can occur after glaucoma patients undergo standalone cataract surgeries. Patient selection is a matter of surgeon preference, he says, but he won’t perform dual procedures on patients on blood-thinners due to the potential bleed risk, whereas other MIGS procedures are ideal for patients on blood thinners.

Performing these dual procedures likely won’t throw a huge wrench into the well-oiled machines of high-volume, peak-efficiency cataract facilities. “It does not severely disrupt the efficiency of the OR,” says Dr. Grover. “It’s not going to affect patient flow, and it doesn’t add much to the risk of the surgery.” However, surgeons will require some additional training, especially in terms of better understanding outflow anatomy and subtle nuances of pre-operative glaucoma patient selection and post-op care. “It is a slightly unique skill set, but it can be easily learned,” he says, noting that training is available through AAO as well as industry sources.

Equipment-wise, facilities don’t need to worry about huge upfront investments. “It’s not a tremendously large amount of capital expense to incorporate many of these MIGS procedures into your surgical armamentarium,” says Dr. Grover. “You need a scope that can tilt and a gonioprism that helps you visualize certain structures of the eye.” Many MIGS procedures involve handheld items such as stents that don’t require much additional instrumentation or electronics, but procedure variation can pose a problem, according to Dr. Grover. “There are probably six or seven different types of MIGS surgeries you can do,” he says. “Some are one or two dollars; some will cost the facility $1,500 or more. There’s a huge range, and there are not a lot of head-to-head studies showing which MIGS is better.” Surgeons and facilities should therefore choose and focus on one or two options. “Instead of the surgeon saying, ‘I’m going to do all six of them,’ just pick one and get comfortable with it before delving into any other things,” says Dr. Grover. “That gives you the ability to incorporate it in an efficient way, and the facility can negotiate with the company on a higher level to get a better price point.”

Reimbursement, however, is an issue. This is particularly apparent in the glaucoma component of the dual procedure, where despite two codes being billed, payments are rapidly declining. “It needs to make sense financially, and that’s the biggest hit right now,” says Dr. Grover. “From the surgeon’s perspective, they’re thinking, ‘Why am I going to take extra time talking to the patient about this additional surgery, add to the risk slightly, throw off my efficiency and not be properly compensated for my time and added risk exposure?’” The reality is, if the facility isn’t making any revenue off the dual procedure, and the surgeons aren’t making any revenue, then the procedure isn’t likely to happen. “For a comprehensive eye doctor who has a patient who is stable on one drop and otherwise doing well, the decision to incorporate this into their wheelhouse must be worth the added risk and liability,” says Dr. Grover.

To make this happen, Dr. Grover encourages interested facilities to be upfront about their reimbursement concerns when speaking with MIGS vendors, because often they’ll adjust their pricing to make sure the facility doesn’t lose money. “These procedures can add to the potential revenue stream for any facility savvy enough to negotiate appropriately,” he says. OSM