Are we on shaky ground to recommend cataract surgery for a patient who states that cataracts did not interfere with her quality of life?

Remove Cataracts to Lower IOP?

I read with interest Dr. Fanellis article on Perioperative Considerations"  (Glaucoma Grand Rounds, November 2008). This is an important clinical issue and one we are faced with often.

I would like to address some questions about this case. First, was a medication switch/change considered? We are all too familiar with compliance issues, but sometimes a change in meds and reasserting their importance can be beneficial.

Second, the article states that the patient underwent cataract surgery in an effort to facilitate better IOP control. Although it is well documented that in some patients cataract surgery can lower IOP, are we on shaky ground to recommend cataract surgery for a patient who states that cataracts did not interfere with her quality of life?

Third, if the decision is made to have cataract surgery, wouldnt a combined phaco + endocyclophotocoagulation (ECP) be a good alternative for compliance and control issues?

Thank you for your response.

Scott Seller, O.D.

Hot Springs, Ark.


Dr. Fanelli responds:

My thanks to Dr. Seller for his pertinent questions regarding this case.

The question of changing medications or not was the basis of this particular column. As I mentioned, in previous years when patients on prostaglandin analogs (PGAs) underwent cataract surgery, it was our choice to change medications preoperatively in order to reduce the likelihood of postoperative complications such as cystoid macular edema (CME) and uveitis.

However, recent studies indicate a lower incidence of CME and uveitis when PGAs are concurrently used. If that is the case, then it makes sense to keep the patient on a PGA when that PGA has been shown to be efficacious in that particular patient.

I agree that oftentimes after cataract surgery, IOP readings will be lower than preoperative readings. One must not get lulled into a false sense of security after cataract surgery when you see lower IOPs, and you cannot equate that decrease to better IOP control.

In this patients case, while the cataracts were not significantly interfering with her quality of life, they were causing shallowing of the anterior chamber angles as demonstrated by gonioscopy over several years. That was the basis of my recommendation for cataract surgery: to facilitate the development (again) of wide open angles, and to eliminate any effect the narrowing angles may have on increasing IOP.

Lastly, a combined phaco and ECP procedure is certainly an option, but one that I did not feel was necessary. Control of her IOP and glaucomatous optic neuropathy and compliance with her medication regimen has never been an issue in her management, at least until her inadvertent discontinuation of her glaucoma meds following cataract surgery. She simply did not realize she was supposed to take her glaucoma medications during the cataract postoperative perioda fact that was readily identifiable at her one week post-op visit.

Since that visit, and the publication of that particular column, the patients postoperative IOP has returned to preoperative target levels (on the same medications), and most importantly, her anterior chamber angles also assumed a pre-cataractous, more open appearance.

Dr. Seller brings up several good questions and scenarios regarding the perioperative management of our glaucoma patients, and this case, along with his comments, clearly demonstrate that each case should be evaluated separately from others in order to facilitate a best fit management plan for the patient.


What Does $150K Get You?

Regarding the question Are tuition costs for optometry schools out of control? in the article Cast Your Vote: The Results Are In (November 2008), the primary issue is not the cost of a four-year optometric education, but what it is buying.

The reality is that many new graduates are going to work at optical goods retailers such as Wal-Mart and Costco. While $150,000 is not an unreasonable debt for a professional education that leads to meaningful career opportunities, it is not a reasonable debt to incur to end up working in a discount department store.

I wonder how many students would actually enroll in optometry school if they knew they would be working in Wal-Mart after graduation?

The optometry schools need to behave professionally and ethically and disclose to all prospective students where recent graduates of their program are obtaining career positions.

Barry M. Lebowitz, O.D., M.P.H.

Gaithersburg, Md.

Vol. No: 146:01Issue: 1/15/2009