Combined Surgical Procedures
Chat Highlights
April 2, 2003

Norma Devine, Editor

On Wednesday, April 2, 2003, Dr. Jeff Henderer, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Combined Surgical Procedures."

Moderator:  Welcome, Dr. Jeff.  What a nice surprise.  Our topic tonight is combined surgical procedures.

Dr. Jeff Henderer:  Excellent!  I have a couple on for tomorrow.

Moderator:  Can you start by telling us about combined surgical procedures that a glaucoma patient might have?

Dr. Jeff Henderer:  I guess the most common is to combine glaucoma and cataract surgery. You most often see it with trabeculectomy, but a shunt could be combined, as well.

P:  Are combined procedures done at the same time, or if two separate procedures are scheduled, are they still called combined?

Dr. Jeff Henderer:  If the two are done during the same session, the whole operation is referred to as a combined procedure.    They might be done at the same incision site or different sites, depending on the preference of the surgeon. 

P:  Are the risks for a combined procedure higher?   

Dr. Jeff Henderer:  The risks are a bit higher to do two things at once, but not that much higher. Most would say that the risk of a second anesthesia and surgery might be as great.

P:  I had a goniosynechiolysis,  a trab (trabeculectomy), and a lens implant at the same time for angle-closure glaucoma.  Is that common or is it more usual to combine only two procedures?  

Dr. Jeff Henderer:  You are correct that this would be a "combined" procedure, but typically we mean cataract and glaucoma.  Your surgery was unusual in that three things were done.  There really isn't a word for that, so you just describe it as you have.

P:  You mean a shunt with a trabeculectomy, or a shunt with a cataract implant, would be "combined" surgery?

Dr. Jeff Henderer:  Yes, a trab and a shunt would be "combined," but that's not common.

P:  Please explain what you mean by a shunt. 

Dr. Jeff Henderer:  I'm sorry.  One way to lower eye pressure surgically is to implant a tube that is connected to a plate in the eye that acts as a reservoir.  The tube then drains fluid from the eye and the pressure goes down.

P:  How long have combined trabeculectomies and cataract surgery been performed?

Dr. Jeff Henderer:  Since the surgeries were invented, I suppose. It's just that now with phaco surgery, the trabeculectomy is more likely to work.

P:  What is phaco surgery?  

Dr. Jeff Henderer:  Phaco stands for "phacoemulsification," which has been the cataract surgery of choice now for the past 15 to 20 years.

P:  When someone has a cataract and glaucoma, do you always combine the operations or do them separately? 

Dr. Jeff Henderer:  People often have them done individually, for a variety of reasons.  Usually, the patient's glaucoma is worse than the cataract, or vice versa.  Then only one procedure is done.  Remember, there are risks to all surgery.  I feel that minimizing the risk is important. 

P:  How often is a shunt inserted at the same time another shunt is revised in the same eye?   How is a revision done?

Dr. Jeff Henderer:  I'm not sure I can say on the whole, because that sounds like a very special situation.  Most of the time, either a second shunt is implanted or a revision is done.  Combining the two is unusual.  A revision of a tube shunt usually means removing scar tissue from over the plate to allow more flow of fluid up the tube.

P:  Before a shunt is revised, can a needle be run through the existing tube to clear out any debris that may be clogging it?  If so, how successful is that procedure?  

Dr. Jeff Henderer:  Yes, that can certainly be done, if the surgeon thinks that the blockage is in the tube. That is not common in my experience,  although when it occurs,  it is dramatic.  If that is the case and the tube is cleaned, then it should work fine.

P:  Would a laser trabeculoplasty and a cataract implant be done at the same time?  I was awake for my previous cataract implant.  Would anesthesia be necessary for the laser trabeculoplasty?

Dr. Jeff Henderer:  No, they would not be done together, but cataract surgery and endocyclophotocoagulation might be combined.  That is different from an ALT (argon laser trabeculoplasty) as the laser is aimed at the ciliary body, not the trabecular meshwork. You only need topical eye drop anesthesia for an ALT.

P:  When a non-surgical procedure is being done (that is, a laser, specifically a laser trabeculoplasty), no other surgery is combined with it, right?  So we are really only talking about combining surgical procedures.  Is that correct? 

Dr. Jeff Henderer:  Yes, we are talking about combined surgical procedures.  However, ALT is technically surgery, as are all laser procedures.

P:  When we lived up North, my doctors there insisted on combining cataract surgery with trabeculectomies, even if the patient didn't need cataract surgery. But in the South, my doctors don't do that.  Which way is better?  I will be having a trab in the second eye.  

Dr. Jeff Henderer:  There is no right or wrong answer.  It depends on the amount of cataract and the amount of glaucoma.  Often we combine them, but just as often we don't.

P:  Do you ever do a lens implant just because you already doing a trab?

Dr. Jeff Henderer:  Well, I would not say it that way.  I would say that if there is a patient who is unlikely to return to the operating room, and it appears that the patient has a cataract that might worsen after the glaucoma surgery, the combined surgery seems reasonable.  Since most of my patients have glaucoma as the main problem, I feel that the likelihood of a trabeculectomy working is higher with just the trabeculectomy. 

P:  I had the combined surgery, because my eye is so small and the doctor said that giving me a thin lens might help.  

Dr. Jeff Henderer:  Well, you are an example of a difficult situation.  In your case, cataract surgery was deemed to be helpful.

P:  Is a combined procedure less traumatic for the eye than two separate procedures?    

Dr. Jeff Henderer:  No, I wouldn't say less traumatic, as two surgeries are always more than one.  The good news is that recovery from most cataract surgeries is not the ordeal that it once was.  So now it is much safer to combine cataract surgery with glaucoma surgery. 

P:  What would be the deciding factor between shunt surgery and a laser trabeculoplasty?

Dr. Jeff Henderer:  Shunts are usually reserved for eyes that have failed medical or laser treatment.  In fact, shunts are often used in eyes that have failed a trabeculectomy, or when it seems as though a trabeculectomy would be at high risk to fail.

P:  Does cataract surgery frequently cause the bleb created by a trabeculectomy to stop functioning?

Dr. Jeff Henderer:  That is always a fear, but in my experience it is not as likely as people have reported.

P:  I know you said that combined trab and shunt surgery is seldom performed, but why would it be performed?  

Dr. Jeff Henderer:  The most common reason would be to provide some IOP (intraocular pressure) lowering effect while you wait for a shunt to start to work.  One of the most common shunts takes about a month to start to work.

P:  Is tube shunt surgery the last hope, or can something else be tried?   What is the tube made of?

Dr. Jeff Henderer:  The options after a tube are a second tube or a cyclodestructive procedure.  Of course, that only follows restarting the medications.  A tube is made of plastic and silicone.  Some are impregnated with barium to show up on x-ray, but they contain no metal.

P:  Does astigmatism slow down recovery of vision after a combined cataract-trabeculectomy?  

Dr. Jeff Henderer:  Yes and no.  Certainly not for the trab part.  Certainly yes for the cataract part.  But usually that is correctable with spectacles after the surgery.

P:  I have Chandler's syndrome, with secondary glaucoma.  I recently had a tube shunt and was never really offered the option of a trabeculectomy.  Was that because a trabeculectomy was highly likely to fail?  

Dr. Jeff Henderer:  In your case, there is no clear way to proceed.  Some do a trab, some do a tube.  The tube is probably less likely to scar long term, so it is better in that way.  On the other hand, some say that a tube can always follow a trab, but not usually the other way; so save the tube for later.  There is no right or wrong way.  What is almost certain is that any surgery may fail, and the need for more surgery is likely.

P:  Have patients reported a problem with glare after a trab?

Dr. Jeff Henderer:  Sure, but I'm not sure that it's the trab or perhaps some increased cataract, which can follow the trab.

P:  Is hypotony a greater danger when cataract surgery is combined with a trab?

Dr. Jeff Henderer:  Usually not, as the cataract surgery often causes some inflammation and causes the trab to not work as well.  Therefore, I would say hypotony is more common with a trab alone, but it is certainly possible with either.

P:  Since my cataract lens implant two years ago, the pupil in that eye glows if the light hits it at a certain angle.  To others, the pupil looks almost like a mirror.  Is that always the case?

Dr. Jeff Henderer:  No, that is not always the case.  That is a feature of the implant that was placed.  I have seen that a lot with a certain, very common implant.

P:  My doctor said I would still sustain some vision loss even though I had the trab surgery, but at a slower pace.  Is that the norm?  

Dr. Jeff Henderer:  Well, that is hard to say.  There is certainly a feeling that glaucoma can progress in some eyes even at low pressures.  Unfortunately, there is no way to know if that will be you.  On the other hand, it appears that, with adequate lowering of IOP,  most patients can be slowed to the point of "no progression," at least for a few years. 

P:  Is a lens implant after cataract surgery in a patient with borderline glaucoma advisable?  That is, will the lens implant add to possible complications down the road?  

Dr. Jeff Henderer:  I almost always say that an implant is the way to go. Why?  Well, the present materials are very biocompatible (the exception might be in an eye with uveitis), and aphakic correction can be a drag, with both the spectacles and the contacts.  Much better to have an implant.

P:  If the angle is closed and the pressure is okay now, but the trab is barely working, what happens when the trab stops working?  What if the iris is stuck to the lens?  

Dr. Jeff Henderer:  If the trab fails, that is not really a concern for the iris. If the iris sticks to the lens? Well, that's not a big deal for a repeat trab.

P:  How long, on average, does a trab last?  How many trabs can a person have in a lifetime?  I had my trab almost ten years ago, and I feel like a ticking time bomb, because I know it is not working well.

Dr. Jeff Henderer:  That's a hard one.  I'd say that by five years at least half of the eyes are back on meds.  But that doesn't mean the pressure is high and that doesn't mean failure.  People can get as many trabs as the scarring of the eye will permit.  But in all practical situations, two tries is about the limit before opting for a shunt.  Perhaps three, but that's less likely.  At least that's my typical limit.

Moderator:  Dr. Jeff, thank you for your help.

Dr. Jeff Henderer:  Great to talk to you all!  Have a great week and enjoy the spring.

End of highlights for April 2, 2003.

On April 9, Dr. Wilson discussed "Traumatic and Inflammatory Glaucomas" in the Chat room. Click here for highlights of that meeting.

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