through the eye during phacoemulsification. These factors can increase the production of cytokines in the aqueous humor that stimulate the scarring process.

Whether to perform a limbus or fornix based conjunctival wound in phacotrabeculectomy is another common question. Similar long-term results are seen after either type of incision [23–25]. Although a fornixbased trabeculectomy allows better visualization during one-site cataract surgery, it is also associated with a higher risk of wound leakage. Generally after cataract surgery, a water-tight wound is desirable to decrease the risk of endophthalmitis; however, the trabeculectomy will lower eye pressure allowing the clear corneal wound to gape. In order to minimize this risk, corneal wounds should be sutured in combined two-site cases. Hypotony leading to shallow chambers can occur after phacotrabeculectomy, although the lens implant takes up less volume than a natural lens does and therefore lens-corneal touch may be less frequent. The use of releasable sutures constitutes an option to avoid hipotony in the early postoperative period (Fig. 41.2).

41.3.2  Postoperative Course

of a Phacotrabeculectomy vs. Phacoemulsification Alone

Visual recovery may be more prolonged with a greater incidence of postoperative refractive error following phacotrabeculectomy. It has been published that after phacotrabeculectomy, complete visual recovery may take up

to 6 weeks vs. 1 or 2 weeks at most with phacoemulsification alone. Chan et al. retrospectively evaluated the refraction of patients subjected to phacotrabeculectomy vs. phacoemulsification and found myopic refractive errors are more common after phacotrabeculectomy. The authors speculated that myopia was due to shallowing of the anterior chamber in a soft eye [26].

Usually combined cataract and glaucoma surgery is accompanied by a higher risk of intra and postoperative complications. Many of the complications associated with phacoemulsification may be particularly accen­ tuated in a combined surgery and may relate to increased inflammation, added surgical manipulation, wound integrity, and the presence of lens proteins associated with the cataract portion of the surgery [21].

Summary for the Clinician

››Following phacotrabeculectomy, there is in­­ creased inflammation compared to trabeculectomy alone.

››Following phacotrabeculectomy, the postoperative course may be less predictable than after phacoemulsification alone (i.e., refractive errors).

››There may be an increased rate of intraoperative and postoperative complications following phacotrabeculectomy.

Acknowledgements  Daniel Grigera, MD. Hospital Oftalmo­ logico Santa Lucia, Buenos Aires, Argentina. Virginia Zanutigh, MD. Centro Oftalmologico Quilmes, Buenos Aires, Argentina. The author appreciates the contributions, opinions, and recommendations of each of the above mentioned physicians.

Fig. 41.2  Phacotrabeculectomy: Two-site approach associated with releasable sutures Figure 2

References

 1. Jampel H, Friedman D, Lubomski L, et al. (2002) Effect of technique on intraocular pressure after combined cataract and glaucoma surgery: An evidence-based review. Ophthal­ mology, 109, 2215–2224.

 2. Kim D, Doyle J, Smith M. (1999) Intraocular pressure reduction following phacoemulsification cataract extraction with posterior chamber lens implantation in glaucoma patients. Ophthalmic Surg Lasers, 30, 37–40.

 3. Friedman D, Jampel H, Lubomski L, et al. (2002) Surgical Strategies for coexisting glaucoma and cataract: An evidencebased Update. Ophthalmology, 109, 1902–1915.

 4. Rich W, Cohan B. (1974) Early ocular hypertension after cataract extraction. Br J Ophthalmol, 58, 725–731.

 5. Shields M. (1989) Combined cataract extraction and glaucoma surgery. Ophthalmology, 89, 231–237

 6. Shields M. (1986) Combined cataract extraction and guarded sclerectomy: Reevaluation in the extracapsular era. Ophthal­ mology, 93, 366–370.

 7. Krupin T, Feitl M, Bishop K. (1989) Postoperative intraocular pressure rise in open angle glaucoma patients after cataract or combined cataract-filtration surgery. Ophthalmology, 96, 579–584.

 8. Storr-Paulsen A, Bernth-Petersen P. (2001) Combined cataract and glaucoma surgery. Curr Opin Ophthalmol, 12, 41–46.

 9. Storr-Paulsen A, Laugesen C. (1998) A prospective study of combined phacoemulsification-trabeculectomy versus con-

ventional phacoemulsification in cataract patients with coexisting open angle glaucoma. Acta Ophthalmol, 76, 696–699.

10.Hylton C, Friedman D, et al. (2003) Cataract after filtration surgery. Am J Ophthalmol, 135, 231–232.

11.AGIS Investigators (2001) The Advanced Glaucoma Intervention Study: 8. Risk of cataract formation after trabeculectomy. Arch Ophthalmol, 119, 1771–1779.

12.Lichter P, Musch D, Gillespie B, et al. (2001) Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology, 108, 1943–1953.

13.ChandrasekaranS,RochtchinaE,MitchellP.(2006)Associations between elevated intraocular pressure and glaucoma, use of glaucoma medications, and 5-year incident cataract: The Blue Mountains Eye Study. Ophthalmology, 113, 417–424.

14.Verges C, Cazal J, Lavin C. (2005) Surgical strategies in patients with cataract and glaucoma. Curr Opin Ophthalmol, 16, 44–52.

15.Lee R. (2004) Surgical management of coexisting cataract and glaucoma. Int Ophthalmol Clin, 44, 151–166.

16.Wishart P. (1993) Combined cataract extraction and trabeculectomy: Phacoemulsification compared with extracapsular technique. Ophthalmic Surg Lasers, 24, 814–821.

17.Shingleton B, Kuperwaser M. (1995) Comparison of combined cataract and glaucoma surgery using planned extracapsular and phacoemulsification techniques. Ophthalmic Surg Lasers, 26, 414–419.

18.Lochhead J, Salmon J. (2003) Long term effect on intraocular pressure of phacotrabeculectomy compared to trabeculectomy. Br J Ophthalmol, 87, 850–852.

19.Park H, Caprioli J. (1997) Temporal corneal phacoemulsification combined with superior trabeculectomy. A retrospective case-control study. Arch Ophthalmol, 115, 318.

20.Chang L, Thiagarajan M, Moseley M, et al. (2006) Intraocular pressure outcome in primary 5FU phacotrabeculectomies compared with 5FU trabeculectomies. J Glaucoma, 15, 475–481.

21.Heffelfinger B, Berman M, Krupin T, et al. (2000) Surgical management of coexisting glaucoma and cataract. Ophthal­ mol Clin North Am, 13, 545–551.

22.Siriwardena D, Minassian D, Dart J, et al. (2000) Anterior chamber flare after trabeculectomy and after phacoemulsification. Br J Ophthalmol, 84, 1056–1057.

23.Lemon L, Shin D, Kim C, et al. (1998) Limbus-based vs fornix-based conjunctival flap in combined glaucoma and cataract surgerv with adjunctive mitomycin C. Am J Ophthal­ mol, 125, 340–345.

24.Shingleton B, O’Donoghue M, et al. (1999) Phacotrabe­ culectomy: Limbus-based versus fornix-based conjunctival flaps in fellow eyes. Ophthalmology, 106, 1152–1155.

25.Tezel G, Kass M, et al. (1997) Comparative results of combined procedures for glaucoma and cataract: II: Limbusbased versus fornix-based conjunctival flaps. Ophthalmic Surg Lasers, 28, 551–557.

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Core Messages

››In end-stage glaucoma patients there is higher likelihood of vision loss that will affect activities of daily living than in early glaucoma, therefore monitoring is more frequent and treatment decisions must be made more quickly.

››Target intraocular pressures in end-stage glaucoma are lower than in earlier stages of glaucoma.

››Surgery should be considered in end-stage glau­ coma if necessary.

››The “wipe-out” phenomenon describes an immediate postoperative unexplained vision loss and is a rare complication in end-stage glaucoma.

42.1  What Is End-Stage Glaucoma?

End-stage glaucoma is a term used to describe glaucoma that has reached a stage of extreme or near totalvision loss; however, there is no universally accepted formal definition. One definition implies that patients with end-stage glaucoma have a very constricted visual field, less than 10o in diameter [1]. According to the Advanced Glaucoma Intervention Study (AGIS) an AGIS visual field score of 17–20 classifies an eye as having end-stage glaucoma [2]. Others define end­ -stage

F. Topouzis

A’ Department of Ophthalmology, Aristotle University

of Thessaloniki, AHEPA Hospital, Stilponos Kyriakidi 1, 54636, Nea Efkarpia, 56403, Thessaloniki, Greece

e-mail: ftopouzis@otenet.gr

glaucoma based on a visual acuity (VA) of 20/200 or worse that is attributable to glaucoma [3].

There are several reasons why end-stage glaucoma patients should be evaluated and managed differently than those with earlier stages of the disease. Patients with end-stage glaucoma have a high risk of further disease progression [4]. Also, although peripheral vision is seriously affected in end-stage glaucoma, these patients may maintain good central vision. Furthermore, even with a visual acuity characterizing them as legally blind, it is possible for these patients to perform simple daily tasks [5]. Therefore, the preservation of this already seriously threatened vision is of major importance.

Performing visual field examination with reliable results may be difficult or in some cases impossible for patients with end-stage glaucoma. If only a central island of vision is spared and a visual field test can be performed, a central Humphrey 10-2 program may be more informative than 24-2 or 30-2 programs (on Octopus machine one would use the C08 program) [6]. End-stage glaucoma patients need more frequent monitoring of their remaining vision. In advanced glaucoma one does not have the luxury of a “wait and see” approach, as additional changes in visual field may be deleterious to central vision. Even small changes may be clinically significant. However, progression is very difficult to assess because small changes, possibly indi­ cating progression, can be difficult to differentiate from inter-test fluctuation [7].

In addition, it is difficult to assess changes in the optic disc when it presents with severe neuroretinal rim loss. In end-stage, very subtle and small neuroretinal rim changes may correspond to disproportionately significant changes in the visual acuity. For these reasons there may be less value in optic disc examination than in assessment of visual function at this stage of disease [8].

Elevated intraocular pressure (IOP) is an identified risk factor for progression, and currently IOP reduction remains the only validated management approach to prevent progression [9, 10]. Individualization of glaucoma management involves the use of target IOP, which are based on a patient’s risk factors for progression, the level of IOP that caused damage, the severity of disease and patient’s expected longevity [11]. Target IOP should be set low in end-stage glaucoma.On the basis of literature target pressures seem to drop to lower and lower levels each decade [12].

Summary for the Clinician

››There is no universally accepted definition of end-stage glaucoma.

››End-stage glaucoma patients are managed differently than those patients with earlier stages of glaucoma.

››If only a central island of vision remains, visual field tests of the central degrees should be chosen.

››Assessing a nerve with very advanced neuroretinal rim loss may not provide useful information in terms of monitoring for progression.

››IOP target should be much lower in end stage glaucoma.

42.2  Should I Operate on a Patient with End-Stage Glaucoma?

Glaucoma procedures are required for the prevention of visual field loss when further IOP reduction is needed despite maximum medical therapy [13]. In cases of unre­ liable visual fields or inability to perform a visual field examination, visual acuity loss or a patient’ s perception of vision decline may be critical in our decision to surgically intervene, as there is a strong association between some types of perceived visual deterioration and measured bilateral visual field deterioration [14].

Deciding whether to operate on such patients depends on an evaluation of the benefits and risks of such an action. First, one must assess whether medical therapy is failing to reach the target IOP [15]. To prevent progression IOP needs to be consistently low [16]. It has been suggested recently that large IOP fluctuation is

one of the strongest risk factors for progression of glau­ comatous damage [17–23], though there are still contro­ versies in the literature concerning this issue [24, 25]. Trabeculectomy has been reported to be associated with less diurnal IOP fluctuation compared to maximum medical therapy in patients with advanced glaucoma [26, 27].

There are specific characteristics of end-stage eyes that could make surgical intervention difficult and endanger the outcome. Eyes with end-stage glaucoma are likely to have undergone previous operations (glaucoma or cataract) and/or to have used topical glaucoma drugs for a long time, both of which may have negative effects on the conjunctiva, and therefore, on the outcome of a new operation [28–31].

The surgical options are the same as for earlier stages of glaucoma. Trabeculectomy with antimetabolites effectively reduces IOP compared to trabeculectomy alone, as well as the risk of surgical failure in eyes with or without previous surgery [32–35]. Alternatively, glaucoma drainage implants are indicated for cases in which glaucoma filtration surgery has failed or for cases of refractory glaucomas (neovascular, uveitic, other secondary open-angle and angle-closure glaucomas) which do not respond well to standard filtration surgery [36–38]. Nonpenetrating glaucoma surgery may also be considered [39], however, given the low levels of IOP needed in end-stage glaucoma [10, 16], a trabeculectomy with antimetabolite may more reliably achieve the desired pressure [40].

Cycloablation is yet another option in the form of cyclophotocoagulation (transscleral or endoscopic) or cyclocryotherapy. Traditionally, cycloablation has been reserved for eyes with poor vision to prevent pain from high IOP or for those with significant conjunctival scarring [41–43]. Recent studies have suggested that cycloablation can be used as an alternative approach to incisional surgery in the treatment of primary openangle and pseudoexfoliative glaucoma [44, 45], as well as for chronic angle-closure glaucoma [46]. Cyclocryother­ apy has similar indications for implementation [47, 48]. However, it must be stated that the visual outcomes after cycloablation in patients with end-stage glaucoma and only a small island of central vision have not been fully studied.

Finally, one can consider the option of withholding surgery if central fixation has already been lost. It is essential to discuss with the patient the benefits vs. the costs and risks of all management options.