Combined Cataract Surgery
Tal Raviv, MD
Cataracts frequently coexist with other ocular comorbidities, and, in the modern history of the procedure, it was common to perform cataract surgery in combination with other procedures. For example, in the setting of significant glaucoma, performing cataract surgery with simultaneous filtering surgery is actually referred to simply as a combined procedure. But as our surgical acumen along with patient expectations have evolved, certain combined procedures have fallen out of favor, and newer ones have arisen.
The earliest “combined” cataract surgery was the addition of lens implantation to cataract extraction. Other common procedures in the early 2000s included combined cataract extraction and trabeculectomy; combined penetrating keratoplasty [PKP], cataract extraction, and IOL implantation (the triple procedure); and combined cataract extraction and pterygium excision.
Nowadays, glaucoma specialists perform cataract and filtering surgery separately whenever possible, as this enhances the results of each procedure. Endothelial keratoplasty has largely replaced PKP (in endothelial disease), and while triple procedures (with Descemet stripping endothelial keratoplasty [DSEK], Descemet membrane endothelial keratoplasty [DMEK]) are still performed, many surgeons would choose to separate the two to maximize the refractive benefit. The same goes for pterygium excision, which is usually done prior to cataract surgery when seeking a certain refractive result.
With the advent of refractive cataract surgery, old school combined surgery has been supplanted by lifestyle combined cataract surgery. As patients and surgeons focus on the lifestyle benefits of vision correction, we are using a combination of technologies to treat other “comorbidities” at the time of cataract surgery, such as farsightedness, nearsightedness, astigmatism, presbyopia, and lifelong glaucoma eye drop therapy. Even our terminology is finally evolving from cataract extraction (a term that seems more fitting to the barber surgeon era) to, “Mrs. Jones, would you like the Driving Vision package, blended vision, or the Forever Young package?”
My typical lifestyle cataract surgery combined case involves femtosecond laser arcuate incisions (along with lens-centered capsulotomy and lens softening), multifocal IOL (ie, Tecnis Multifocal; Abbott Medical Optics) implantation, ORA intraoperative aberrometry (Alcon WaveTec) for IOL optimization and arcuate refinement, and iStent (Glaukos) placement (in up to 20% of patients who are on glaucoma drops). On my chart, this is noted as: Phaco IOL OD/Femto/TMF/ORA/iStent.
Needless to say, these individuals are frequently our most grateful patients, as many of them have gained a degree of lifestyle freedom unrivaled by most surgical procedures. As our focus has shifted to treating refractive comorbidities, I am performing fewer combined functional surgeries. For example, I used to do a good number of combined phaco and pars plana vitrectomy procedures with my retina colleagues for epiretinal membranes or macular holes. Now, I typically stage the procedure to allow for use of the femtosecond laser, ORA, toric IOL implantation, limbal relaxing incision (LRI) fine-tuning, and a better refractive outcome that patients are demanding.
As our techniques and technologies are refined, I foresee more of these lifestyle combined procedures emerging. I have a colleague who is combining eyelid thermal pulsation (ie, LipiFlow; TearScience) with his refractive cataract package for enhanced tear film and quality of vision. Also, implantation of multiple microinvasive glaucoma surgery (MIGS) devices to eliminate glaucoma drops will surely increase. Interestingly, most of these lifestyle-enhancing technologies are paid for privately, outside of the overburdened government and third-party health care payment system. With these procedures, industry, investor, surgeon, and patient needs are all aligned, ensuring that lifestyle cataract surgery is here to stay. Or should I say lifestyle dysfunctional lens restoration and rejuvenation surgery?