Volume 9, Number 1

Winter, 2000

• Cataract Surgery and the Glaucoma Patient 
• National Conference Accepts Record Number of Foundation Research Projects
• The New Wills
• 1999 Annual Fund Shows Steady Progress
• Glaucoma Chat Room

Cataract Surgery and the Glaucoma Patient

By Jeffrey Henderer, MD and Ken Parker, PhD

Cataract is a clouding of the eye's lens that typically occurs as part of the normal aging process. Since modern cataract surgery, in which the lens is removed and replaced with a clear plastic one, is usually quite safe and effective, deciding if and when to do so in otherwise normal eyes is usually fairly straightforward. If blurred images and glare caused by a cataract prevent a person from doing what he or she needs or likes to do, surgery is usually recommended. This could mean that a person can no longer read, drive a car, play golf or do fine needlework as well as they would like to. Other patients complain that glare from sunlight drastically reduces their activities outside. The message is that, quite often, the decision for cataract surgery is driven by the patient's symptoms as well as the doctor's interpretation of the likely success of the procedure to result in improved vision.

The choice facing a glaucoma patient in this situation is not so straightforward, depending on a particular patient's actual ocular situation:

• The amount of visual field damage and optic nerve damage
• The number of glaucoma medications a patient is taking before surgery
• Whether glaucoma surgery has already been performed in the eye
• The eye pressure before surgery
• The desired eye pressure after surgery
• Tolerance for specific glaucoma medications
  

Basically, one wants to perform the cataract surgery at a time and in a manner that is most likely to improve overall vision, taking into consideration the nature and stage of the glaucoma and the way in which it is being treated.

The decision is then influenced by the following more general considerations:

First, sometimes cataract surgery is more difficult to perform in patients with glaucoma.

• Many have small pupils that do not dilate well, making it difficult for the cataract surgeon to see inside the eye.  These small pupils may be the result of having used eye drops such as pilocarpine for a long time, laser procedures, or some type of inflammation.
• Some glaucomas may be associated with what is known as the exfoliation syndrome.  This means their glaucoma has been caused by deposits of flaky material in the front of the eye that clog up the drain of the eyes, causing the pressure inside the eye to rise and damage the optic nerve cells.  These same flakes can weaken the "strings" that hold the lens in place, making the lens "wobbly" during surgery.
• Just because cataract extraction can be more difficult in the glaucoma patient, both patient and doctor may wait as long as possible before removing the lens, and such lenses with far-advanced cataract maybe more difficult to remove.

Second, cataract surgery can cause problems in some glaucoma patients.

For example, continuing some glaucoma medications, mainly pilocarpine, Propine and Xalatan after cataract surgery, may cause problems.

Third, in patients who have undergone glaucoma surgery, subsequent cataract surgery may induce inflammation that causes the glaucoma surgery to lose its effectiveness or even fail. 

Fourth, glaucoma surgery can make a cataract worse.

Fifth, cataract surgery may decrease eye pressure.
Understanding the patient's individual ocular situation together with these general principles can help the patient and doctor decide what is most likely to produce the best visual result: (1) performing cataract surgery alone, (2) performing glaucoma surgery alone, (3) performing a combined cataract extraction and glaucoma surgery.

If a cataract is causing a person more problems than glaucoma, cataract surgery alone may be recommended in the hopes that the pressure can be well controlled with the same medications that were being used before surgery.  Or, as noted above, the cataract surgery itself may lower the pressure.  But if, again as noted above, pilocarpine, Propine or Xalatan are being used, they may cause problems if they are continued after surgery, and glaucoma surgery may need to be performed following cataract extraction.

If glaucoma is causing the person more problems than cataract, glaucoma surgery alone may be recommended.  But as noted above, in some patients glaucoma surgery may make the cataract worse, hastening the need for cataract surgery.  And, as also noted above, cataract extraction is more difficult to perform in patients who have undergone glaucoma surgery and may reduce the effectiveness of that surgery, requiring a return to medications to lower the eye pressure. 

In some patients, performing a cataract extraction at the same time as glaucoma surgery may be best.

Possible Benefits:

• One surgery may succeed in both clearing up central vision loss from cataract and in controlling peripheral vision loss from glaucoma by lowering the eye pressure.
• The problem of possibly worsening cataract following glaucoma surgery alone is eliminated.
• Eye pressure control is usually better after a combined procedure than after cataract surgery alone.  In fact patients can often reduce or even eliminate the need for glaucoma medications after combined surgery just as after standard glaucoma surgery.
• A combined procedure can be especially beneficial for patients with glaucoma uncontrolled on medications who have a significant cataract.
• Also, for those with glaucoma well controlled on medications, it may offer the chance to reduce the need for medications or prevent anticipated pressure problems after the surgery.

Risks

• Usual risks of glaucoma surgery: leaking or infected blebs
• Low eye pressure
• Bleeding
• Swelling of the retina and choroid
• Somewhat longer and more complicated surgery

Summary

The management of cataract in the glaucoma patient can be very tricky.  Cataract surgery performed alone, or in combination with glaucoma surgery, can offer substantial benefits to patients, but it also carries substantial risks.  The choice very much depends on the individual patient's situation.

Clinical Research Coordinators Diana Meashey (left) and Fillis Samuel are familiar figures to many patients on the Glaucoma Service.  In addition to coordinating many pharmaceutical studies, they are involved with the national Advanced Glaucoma Intervention Study and molecular genetics studies just getting under way on the Glaucoma Service.

National Conference Accepts Record Number of Foundation Research Projects

The Association for Research in Vision and Ophthalmology (ARVO) announced mid February that nine abstracts from the GlaucomaService at Wills were accepted to be presented as posters at the Association's annual meeting the first week in May.  ARVO is the top venue for eye researchers from all over the world to report their investigations.

Dr. Spaeth commented: "While the Glaucoma Service is usually well represented each year at ARVO, this number of acceptances is unprecedented for us.  It shows that the Association believe our research is both sound and significant."

The nine accepted abstracts cover a wide spectrum of studies seeking to improve the diagnosis and treatment of glaucoma.

Diagnosis

• Drs. L. Jay Katz and George Spaeth, along with Glaucoma Fellow Dr. Richard Ten Hulzen, and Pharmacia & Upjohn fellow Dr. Jeffrey Henderer, compared the effectiveness of newer, more "user-friendly" methods of testing visual fields.
• Dr. Spaeth and Dr. Peter Savino, from Wills' Neuro-Ophthalmology Service, along with Glaucoma Fellow Dr. Helen Danesh-Meyer, evaluated the glaucomatous-like "cupping" that occurs in a condition that looks like glaucoma but is actually a condition caused by insufficient blood flow to the optic nerve (anterior ischemic optic neuropathy) with two instruments, one designed to evaluate the health of the optic nerve (the Heidelberg Retina Tomogram) and the other the blood flow to the nerve (the Heidelberg Retina Flowmeter).
• Dr. Spaeth, with Glaucoma Research Fellow Dr. Madhura Tamhankar, Wills Resident Dr. Anya Bitterman, former clinical coordinator Kelly Flartey, Wills study consultant Dr. Andrew Smith, and Glaucoma Service visual field technicians Joan Slagle and Stuart Slagle, will present "The Task Performance Test: A Visual Function Scale." (See picture.)
• Glaucoma Clinical Fellow Dr. Asher Weiner and Research Fellow Dr. Mary Luch Pereira worked along with Dr. Smith and Dr. Spaeth to compare Dr. Spaeth's new system for diagnosing glaucoma with two other methods: specialists' clinical impression and the Heidelberg Retinal Tomogram.
• Drs. Tamhankar and Spaeth, along with former Research Fellow, Dr. Graciela Blanco, who has now returned to her native Chile, studied aspects of pigmentation in the exfoliation syndrome.  In this type of glaucoma, particles of pigment from the iris "flake off' and clog the eye's drain, the trabecular meshwork, causing the intraocular pressure to rise.
  

Treatment

• Drs. Spaeth, Ten Hulzen, Tamhankar, Pereira, and Smith, along with Glaucoma Service observer, Dr. Tatiana Franco from Venezuela, studied treatment of pigmentary glaucoma using a laser to reshape the eye's drain.
• Drs. Spaeth, Katz, and Henderer along with Drs. Jonathan Myers, Marlene Moster, and Courtland Schmidt of the Glaucoma Service staff, and Jefferson Medical College student Michael Heeg, studied the long-term effects of pressing on the eyeball following glaucoma surgery, a controversial method of controlling intraocular pressure.
• Drs. Pereira, Ten-Hulzen, Spaeth, Franco, and Smith, along with former Glaucoma Research Fellow, Drs. Karin Baez (from Germany) and Silvana Minella (from Brazil) studied three ways of treating a common problem following glaucoma surgery, insufficient intraocular pressure to allow the eye to function properly.
• Dr. Spaeth along with researchers from the Indiana University School of Medicine, including former Glaucoma Fellow, Dr. Louis Cantor, studied the effect of estrogen replacement therapy on blood flow to the optic nerve in women.

Clinical Research Coordinators Diana Meashey (left) and Fillis Samuel are familiar figures to many patients on the Glaucoma Service. In addition to coordinating many pharmaceutical studies, they are involved with the national Advanced Glaucoma Intervention Study and molecular genetics studies just getting under way on the Glaucoma Service.

Research Fellow Dr. Madhura Tamhankar (left) works with a "normal control" to develop the Task Performance Test.  In addition to determining how well glaucoma patients' vision allows them to use a hand-held calculator, Dr. Tamhankar and volunteers are testing these patient's ability to walk, shake hands, thread a needle, put a key in a lock, dial a telephone, read, find various small objects around the room, and climb stairs.  "Surprisingly," notes Dr. Spaeth, "we still have no way of measuring in an objective, standardized way how glaucoma at various stages of severity actually affects visual function.  By that I mean the ability of the eyes to help us do what we need or like to do in our everyday lives."

Dr. Muge Kesen, from Istanbul, Turkey, joined the Glaucoma Service in January for a one-year appointment as Research Fellow.  Dr. Kesen received her medical degree from the "English track" program at the leading medical training institution in Turkey Hacettepe University School of Medicine, in Ankara.  She spent July 1998 as a visiting medical student at the Department of Ophthalmology at the University of Minnesota Medical School, where she concentrated on neuro-ophthalmology. 

Photos by Jamie Nicholl.

THE NEW WILLS...

Several patients in the Glaucoma Service recently expressed concern after reading an article in the Philadelphia Inquirer that the Wills Eye Hospital building at 9th and Walnut would be sold to Thomas Jefferson University.  True, the familiar building is being sold, but Wills Eye Hospital is not closing! In fact, we're simply moving to a new building that will be built right across the street. The move, scheduled to take place in about two years, recognizes that ophthalmology has largely become an outpatient specialty.  We want to be able to give our patients even better care, and to do that we need to make sure that our costs are reasonable, that we have the best facilities available, and that they are used in the most efficient way.  Said Dr. Spaeth, "I'm very excited about our move to new facilities across the street, because I think it will allow us to serve our patients even better."  More in the next Searchlight.

1999 Annual Fund Shows Steady Progress

Thanks to the generosity of an increasing number of donors, the Foundation's 1999 Annual Fund continued its steady advance.  The amount raised by the Fund from individuals, foundations, and corporations for unrestricted operating expenses increased from $192,776 to $223,601 and the number of contributions from 1386 to 1560.  Especially gratifying was the fact that a growing number of individuals gave multiple gifts throughout the year and provided matching funds from their companies.  To each and every one of you, THANK YOU!

Glaucoma Chat Room

The computer screen used by participants in the Foundation's "chat room."  Sign in is on the right, and messages are typed in the empty space at the bottom. A few seconds after questions or comments are sent, they appear under the participant's name or nickname as shown, and the blank space reappears, ready for a new comment to be typed in.  A Glaucoma physician moderates the "room" every Wednesday evening from 8:30 to 9:30 PM.  Patients and family members can talk with each other about glaucoma on Mondays from 8:00 to 9:00 PM.  Chatters can not only get authoritative answers to their questions, but also the emotional support from others experiencing the problems of living with glaucoma.  To participate in the chat, click here.