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Triple procedure for cataract and glaucoma

Triple procedure lowers IOP and medication use at one year

Howard Larkin

Posted: Saturday, June 6, 2020


Linda L Burk MD

Combining dual-blade goniotomy and viscodilation of the outflow channels with cataract surgery is a safe and effective way to reduce intraocular pressure (IOP) and reliance on IOP-lowering medications for cataract patients with moderate-to-advanced glaucoma, Linda L Burk MD told the 37th Congress of the ESCRS in Paris, France. The triple procedure also reduces the financial burden of, and improves patient compliance with, glaucoma treatment, said Dr Burk, of UT Southwestern Medical School, Dallas, Texas, USA.In a study involving 120 patients, Dr Burk removed 180 degrees of the trabecular meshwork with a Kahook Dual Blade and then directly flushed the collector channels with viscoelastic in a procedure she refers to as “clean the gutters and power-wash the down spouts.” The patients, half of whom had moderate-to-severe glaucoma and one-third of whom had previous glaucoma surgery, also underwent cataract surgery and implantation of an intraocular lens. Because so many patients had active disease, no medication washout was attempted before surgery.

One year after surgery, mean IOP fell 2.3mmHg, from 18.8 ± 5.4 to 16.5±5.4mmHg; mean topical glaucoma medication use fell by 1.5, from 1.7± 0.9 to 0.2 ± 0.5; and the percentage of patients using no drops to control IOP increased from 0% to 90%, Dr Burk reported. This improves patient therapy compliance and greatly reduces medication costs. At $50 per bottle, the saving would be $84,000 annually for the group, she pointed out.

Overall, 94% of patients were at or under 21mmHg and 42% at or under 15mmHg. Among patients with moderate-to-advanced glaucoma, 45% reached an IOP of 15mmHg or less with no medications, Dr Burk said.

Top: Kahook Dual Blade removes trabecular meshwork Above: Viscoelastic cannula fits snug into Schlemms Canal and allows viscoelastic to directly dilate the collector channels.

Rejuvenation

The combined goniotomy-viscodilation-cataract procedure results from a four-year search for a combined glaucoma procedure that is effective in lowering IOP, economical and compatible with implantation of premium lenses, Dr Burk said. Among its advantages are ease of combining the glaucoma procedures with cataract surgery, no expensive hardware needed, no foreign bodies left behind, a low complication rate and fast recovery.

Perhaps more importantly, the procedure removes diseased trabecular meshwork and creates direct access to multiple collector channels. This allows direct viscodilation with nothing more than a Healon cannula, restoring aqueous outflow, Dr Burk said.

“Many glaucoma experts think the collection channels are damaged beyond repair. I beg to differ. I think they can be rejuvenated by this technique,” Dr Burk concluded.