Cataract Surgery and Glaucoma

A number of factors affect the decision of whether to surgically remove cataracts in the patient with glaucoma.

A cataract is a natural clouding of the lens in the eye. Since the lens is responsible for focusing objects clearly, if the lens is cloudy seeing clearly becomes difficult. Usually the cataract does not interfere with vision initially, and cataracts are not considered an urgent problem. Your ophthalmologist will probably detect a cataract long before you notice it.

A Natural Process

Again, cataracts are a natural process and, thus far, an unavoidable part of aging. As we age the chances of having a cataract increases. For example, it is estimated that in the U.S. less than 4% of men and 10% of women between the ages of 55 and 64 years have visually significant cataracts. Between the ages of 65 and 74 years, 14% of men and 24% of women experience cataracts. The incidence is even higher in those over 75 years old. Because age is a risk factor for glaucoma as well, many patients with glaucoma also have cataracts.

Although all of us will eventually develop cataracts, the good news is that the treatment for cataracts is very successful with the latest surgical techniques. When treatment for a cataract is warranted, it is surgically removed and an artificial lens is put in its place.

Glaucoma, however, damages the optic nerve, the critical structure that transmits the visual signal from the eye to the brain. Unfortunately, in contrast to cataracts, we are not yet able to repair or replace the optic nerve. This important difference affects the management of these two diseases when they co-exist in the same eye.

Tailored Treatment

The ophthalmologist tailors the specific treatment plan for the individual eye to maximize the benefits and minimize the risk to the eye. The ophthalmologist balances many factors that affect the decision as to when and how aggressively the glaucoma and cataract should be treated, including whether the two diseases should be treated at the same time or separately.

There are a number of options available to glaucoma patients with cataracts, and each situation must be assessed individually. If the cataract does not interfere with the glaucoma patient’s activities significantly then treating the glaucoma and monitoring cataract progression—but not removing the cataract immediately—may be an appropriate plan.

Often, the glaucoma can be managed with laser treatment and anti-glaucoma medications. When this is possible, it allows the ophthalmologist to monitor the eye while the cataract worsens.
For patients with mild glaucoma that is stable we might consider surgically removing the cataract and treating the glaucoma with pressure-lowering medications or laser treatments. Cataract surgery alone on an eye with glaucoma will sometimes lower the pressure in the eye.

For patients with more serious glaucoma and the need for cataract surgery, a combination cataract removal and glaucoma filtering procedure can be considered. For patients using multiple anti-glaucoma medications, a combination procedure such as this would be appropriate.

Combination procedures, however, are not for everyone. The decision to perform a combination procedure depends on the number of anti-glaucoma medications used, how mature the cataract is, and the state of the glaucoma.
As with any surgery, it is important to discuss the risks and benefits of cataract and combination surgery with your ophthalmologist to determine what is best for you.

Video: Cataracts Information

This video describes cataracts and how cataracts surgery is performed.

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Video Transcript

Cataracts are a leading cause of vision loss for people all around the world. While cataracts are a natural part of the aging process, they do not have to interfere with your lifestyle. A cataract is a clouding of a crystalline lens inside your eye. This lens is one of the key structures for focusing light at the back of your eye, where nerves send signals to your brain and you see an image. When the lens of your eye is clear and unclouded, it allows light to pass through. As your lens naturally clouds with age it blocks some light from coming through. This causes your vision to become yellowed and blurry almost like looking through an amber lens or dirty glasses. This makes it difficult to see, especially at night, as glare around light is the common symptom of cataracts. Because the cataract worsens over time, it eventually keeps you from fully enjoying the activities you love. Like most things related to aging, cataracts develop more slowly based on genetics and lifestyle choices, such as managing your stress level and making healthy dietary choices. Treating a cataract can open up a whole new world of possibilities when it comes to your vision. Talk to your doctor today about cataract surgery, which can help ensure your vision keeps up with your lifestyle.

As the Cataract grows larger and clouds more of your lens, more noticeable symptoms will develop. These symptoms may include cloudy or blurred vision, faded colors, double or multiple images, and poor night vision.

If a cataract grows large enough to impair your vision, and affect your daily activities, cataract removal is recommended. Cataract removal is a common procedure and is safely performed millions of times each year. During the procedure, the cataract surgeon removes the clouded lens that has affected your vision, and replaces it with a clear, artificial, intraocular lens. As a result, most patients can achieve a noticeable improvement in their vision. Cataract surgery used to require a fairly large incision in the eye and the use of sutures to close that incision. Today, technological advances allow surgeons to work through an incision much smaller than in the past, usually requiring no sutures at all. Small incision cataract surgery is made possible by using high-frequency sound waves known as “ultrasound” or “phacoemulsification”. The sound waves break a cataract up into tiny fragments that can then be removed through the small incision. The other advance that makes small incision cataract surgery possible is the “foldable” intraocular lens implant. These implants are made of soft materials which can be folded like a taco, or rolled up with a special instrument allowing them to fit through very small incisions. Once inside the eye, these lenses unfold and return to their original shape. Small incision cataract surgery is less invasive, allows patients to resume normal activity soon after surgery, and provides the fastest recovery of vision.

Cataract surgery is one of the safest and most commonly performed operations around the world. First, the surgeon will create an incision in the cornea. This incision is just large enough to pass the surgical instruments through. Following the incision, the surgeon will gently peel off the front layer of the lens.This will allow access to the inner areas of the lens where the cataract is formed. Next, the surgeon will use a tool to break up the cataract into smaller segments. As the cataract is divided into segments the surgeon will vacuum the smaller fragments out of the remaining good lens. Once the cataract has been removed, the replacement lens is then inserted into the capsular bag where the natural lens used to be. In most cases, this is an intraocular lens, which is foldable and slips in through the tiny incision. Because the incision is so small it is often water tight and does not require any sutures, particularly if a folded lens has been used.

Cataract surgery is one of the safest and most commonly performed operations around the world. As surgical tools and techniques continue to advance, cataract surgery has become safer, more effective and more predictable. One such advancement in cataract surgery now combines a computer-controlled laser, with 3D imaging to more precisely remove the cataract. First the surgeon will use the laser to create an opening in the front layer of the lens. The surgeon then uses the laser to break the cloudy lens into smaller pieces, instead of using manual instruments. Next, instead of using a surgical blade, the laser creates small incisions in the cornea, which allows access to the cloudy lens inside the eye. The pieces of lens are then removed using a tiny ultrasound suction device that is inserted through the corneal incision. Once the cataract has been completely removed and artificial replacement lens is then implanted through the tiny incision into the capsular bag, where the natural lens used to be. Because the incision is so small it is often water tight and does not require any sutures. If you have astigmatism your doctor may also recommend using the computer-controlled laser to create special astigmatism correcting incisions. These incisions are called Corneal Relaxing Incisions, and are often performed during the cataract procedure. Corneal Relaxing Incisions correct the uneven shape of the cornea by flattening it’s steeper axis. When the incisions are made, areas of the corneal structure are relaxed, reforming it into a more rounded shape. The goal of Corneal Relaxing Incisions is to improve vision, and reduce the need for eyeglasses after surgery. In summary, using a laser for certain steps of the Cataract procedure reduces the number of instruments needed for surgery, increases the precision, and may improve accuracy of the procedure. Other benefits may include quicker recovery time and reduced chances of complications after surgery. Refractive and visual outcomes also may be improved, resulting in true refractive cataract surgery that greatly reduces or eliminates the need for eyeglasses after surgery.

End of transcript.

Article by Andrew G. Iwach, MD. Last reviewed on April 19, 2022.

Andrew G. Iwach, MD

Andrew G. Iwach, MD, is Associate Clinical Professor of Ophthalmology at the University of San Francisco, Executive Director of the Glaucoma Research and Education Group in San Francisco, and a faculty instructor at the California Pacific Medical Center Department of Ophthalmology.