Combined Cataract Implant
22
and Filtering Surgery
Anup K. Khatana, MD, John S. Cohen, MD and
Robert H. Osher, MD
CONTENTS
• History
• Surgical Options in Patients with Cataract and Glaucoma
• Antimetabolites
• Results Following Combined Surgery
• Complications Following Combined Surgery
• Combined Surgery Method
• Conclusion
CHAPTER HIGHLIGHTS
>> Indications for combined surgery
>> Step-by-step surgical technique
>> Management of complications
▪ ▪
HISTORY
The indications for combined surgery have evolved full circle dur-
ing the past several decades. In the 1970s and early 1980s, cata-
ract surgery alone was thought to have a beneficial effect on
long-term glaucoma control.1–3 Although the precise mechanism
for this is not known, large incisions and large sutures often
resulted in unintentional filtering blebs in some eyes and probable
subclinical filtration in others, which had beneficial effects on
intraocular pressure (IOP) in glaucoma eyes. Combined surgery
at that time was technically more complex than present techni-
ques and was associated with greater risks and limited success.
To avoid the increased risks of this more complex surgery,
patients often underwent staged surgery with performance of
one procedure and then the other, resulting in a longer total
period of rehabilitation.
In the 1980s, with newer techniques of extracapsular surgery
and safer intraocular lenses (IOLs), cataract surgery was per-
formed earlier with improved visual results. In the late 1980s
and 1990s, more secure closure of surgical incisions and concern
about the risks of postoperative IOP elevations prompted greater
HISTORY
interest in combined cataract and glaucoma surgery.4–8 Enthusi-
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
asm, however, was dampened with clinicians' belief that the
more extensive combined procedure resulted in less filtration
than trabeculectomy surgery when performed alone. With the
ability to increase filtration after combined surgery by modifying
wound healing with antimetabolite therapy, the indications
became more liberal. Expectations increased that short- and
long-term IOP control would be improved, many patients
would be able to discontinue glaucoma medications altogether,
and both cataract and glaucoma would be effectively managed
with one surgical procedure. Several studies showed the benefits
of this approach with minimal complications.9–11 In time, how-
ever, it became evident that antimetabolite use was associated
with a small but troubling incidence of complications such as
leaking blebs, hypotony, “blebitis,” and endophthalmitis, which
represented a significant contrast to the infrequent incidence
of complications of cataract surgery alone. In addition, with
the development of small-incision surgery, clear corneal inci-
sions, foldable IOLs placed in the capsular bag, and improve-
ments in techniques of anesthesia and virtually same-day
rehabilitation, cataract surgery alone became much more desir-
able if it could be performed without risk of glaucoma damage
from perioperative IOP elevation.
With the realization that IOP elevations were uncommon
(although still possible) following the present minimally trau-
matic technique of phacoemulsification and IOL implantation,
cataract surgery alone is becoming the procedure of choice in
many patients with diagnoses of ocular hypertension, glaucoma
suspect, and early-to-moderate glaucoma. Combined surgery
may rarely be considered in eyes with diagnoses of ocular hyper-
tension and glaucoma suspect when IOP is significantly elevated
despite the use of multiple medications. (This may also be a situ-
ation in which cataract surgery combined with nonpenetrating
deep sclerectomy/viscocanalostomy or other still unproven newer
options such as endocyclophotocoagulation (ECP), Schlemm's
canal surgery, etc., can be considered.) Combined surgery is
usually advisable when glaucoma is uncontrolled with maximum
medical therapy, glaucoma control requires more than two med-
ications (or fewer if unused medications are contraindicated),
and damage is advanced with visual field loss threatening or
involving fixation even if the IOP is controlled.
259
 v Special Techniques for Cataract Extraction
▪SURGICAL OPTIONS IN PATIENTS
WITH CATARACT AND GLAUCOMA ▪
Before any surgical procedure is performed, advantages and dis-
advantages must be considered, taking into account the severity
of the disease, condition of the fellow eye, availability and
affordability of medications, compliance with medication sche-
dules, and compliance with follow-up visits. Patient compliance
with long-term follow-up is important to provide continued
monitoring of the IOP, discs, visual fields and bleb appearance.
As with most surgical procedures, the precise indications for
combined surgery vary among surgeons depending on the level
of comfort, experience, and skill. The surgeon and patient must
balance the benefits and risks of performing combined cataract
and glaucoma surgery with those of performing either procedure
SURGICAL OPTIONS IN PATIENTS WITH CATARACT AND GLAUCOMA
alone.
CATARACT SURGERY ALONE
(PHACOEMULSIFICATION)
Cataract surgery alone can be performed efficiently with rapid, if
not immediate, visual recovery in most cases. Postoperative eleva-
tion of IOP is a risk in all eyes. Its occurrence must be considered
when choosing a surgical procedure in eyes with ocular hyperten-
sion, pigment dispersion syndrome, pseudoexfoliation, primary
open-angle glaucoma, postoperative pressure spike in the fellow
eye, and a family history of glaucoma. One study measured
IOP after phacoemulsification performed with clear corneal and
sclerocorneal incisions in eyes without glaucoma. Peak elevations
were higher for sclerocorneal than clear corneal incisions, measur-
ing 43 and 37 mm Hg 6 h postoperatively for each group, respec-
tively, and 30 mm Hg for both groups 24 h postoperatively. At
15 months, peak IOP measured 19 mm Hg in both groups. Eyes
with glaucoma would be expected to be at greater risk of IOP
elevation.6,12–14
Although no formal surveys have polled surgeons regarding
approaches to coexisting cataract and glaucoma, as a general rule
of thumb, cataract surgery alone will be considered if the glau-
coma is adequately controlled with two or fewer medications
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(with no contraindications or allergy to the remaining available
medications) and visual field loss does not involve fixation
(Table 22-1). The surgeon must anticipate the possibility of an
acute and/or chronic postoperative elevation of IOP that could
require an increase in medical therapy. Perioperative beta-blocker
and carbonic anhydrase inhibitor therapy should be considered to
reduce this risk. Postoperative IOP elevation may be more likely
in the presence of coexisting uveitis, when iris manipulation or
posterior synechialysis is required, if peripheral anterior synechiae
are present, when cortex or viscoelastic agents are incompletely
removed, and so on. In addition, there may be a relative con-
traindication to the use of prostaglandin analogues and miotics
postoperatively because of the potential increased risk of inflam-
mation and cystoid macular edema. If visual field loss involves
or threatens fixation, delay in lowering a postoperative IOP spike
could result in progression of glaucoma damage with increased
visual disability. These risks warrant consideration of combined
surgery. The authors favor a conservative approach and, when
in doubt, consider combined surgery.
260
Table 22-1 Indications for single or combined surgery
Phacoemulsification
Indications
Presence of a cataract that impairs visual function or prevents
adequate view of the optic nerve, with:
• IOP controlled with fewer than two medications
• ability to use remaining available medications
• mild-to-moderate visual field loss that does not involve or
threaten fixation
Trabeculectomy
Indications
Cataract does not decrease visual function or impair view of
optic nerve, and cataract progression that would require surgery
is not anticipated (surgeon’s judgment), with:
• uncontrolled IOP with maximum tolerated medical therapy
• extreme IOP elevation (e.g., with corneal edema, even if
significant cataract is present) unless glaucoma is lens
induced
Combined surgery
Indications
Cataract decreases visual function or prevents view of optic
nerve or is likely to do so if trabeculectomy alone were
performed (surgeon’s judgment), and:
• uncontrolled IOP with two or more medications
• uncontrolled IOP with less than two medications with others
ineffective or contraindicated
• unable to use medications because of cost, compliance,
physical limitations, and so on
• pupil stretch or extensive posterior synechialysis required
(with resulting debris potentially blocking trabecular outflow
and increasing IOP postoperatively)
• extensive peripheral anterior synechia (increasing potential
for postoperative IOP elevation)
• visual field loss is moderate to advanced or involves fixation
Cataract surgery employing techniques other than small-
incision clear corneal phacoemulsification (such as extracapsular
cataract extraction, which usually requires a larger incision and
may be associated with more extensive inflammation) may have
a greater risk of postoperative IOP elevation and glaucoma dam-
age. Larger incisions and the use of superior incisions, especially
ones that involve conjunctiva and sclera, can make future trabecu-
lectomy surgery technically more difficult. This is another reason
that temporal “near clear” or clear corneal incisions are preferred,
particularly in glaucoma patients.
TRABECULECTOMY SURGERY
Trabeculectomy surgery alone may be considered when the IOP
is uncontrolled despite maximum medical therapy and the cata-
ract does not decrease visual function. Even with uneventful tra-
beculectomy surgery, however, a cataract can progress. If cataract
surgery is necessary in the near future, even a clear corneal
approach may result in scarring of the filtering bleb with elevation

of IOP, requiring additional medical therapy or glaucoma
surgery.15,16 The surgeon's judgment must be used in determin-
ing the best procedure for these patients (see Table 22-1).
In cases of marked IOP elevation (e.g., with corneal edema,
neovascular glaucoma, traumatic glaucoma) with coexisting cata-
ract, a staged approach with either trabeculectomy with mitomy-
cin C (MMC) or tube implant surgery may be the safest and best
choice, deferring consideration of the cataract to a future time
when conditions are more controlled. On the other hand, if
lens-induced glaucoma is suspected, combined surgery may be
the best approach.
COMBINED CATARACT AND
TRABECULECTOMY SURGERY
Combined surgery attempts to manage both cataract and glaucoma
using one surgical procedure. The choice of this procedure should
be determined on an individual basis for each patient (see
Table 22-1). Although combined surgery has been considered con-
troversial in the past, it is now accepted as an indicated procedure in
selected eyes with coexisting cataract and glaucoma. (For this dis-
cussion, combined surgery is defined as phacoemulsification with
posterior chamber IOL implantation and trabeculectomy.)7
Glaucomatous eyes have compromised trabecular meshwork and
reduced aqueous outflow. There is a greater risk of postoperative
IOP elevation that may further increase when posterior synechialy-
sis or pupil manipulation is required. Although visual recovery after
combined surgery may be delayed compared with cataract surgery
alone, it is more rapid than when the glaucoma and cataract are
managed separately in a two-stage approach. Combined surgery
facilitates the management of postoperative IOP elevations versus
cataract surgery alone.17 However, early postoperative elevations
of IOP can occur when combined surgery is performed.8,18 Use
of releasable sutures with combined surgery permits secure wound
closure, minimizing risk of a flat or shallow anterior chamber, and
permits suture removal to increase aqueous flow and lower IOP
postoperatively when the eye is stable.9 (Laser suture lysis of simple
interrupted sutures can be used in place of releasable sutures.)19
Although most filtering blebs function successfully, those that
fail are more likely to do so within 6 months, with the rest failing
years later.20 Although the use of antimetabolites decreases the
incidence of bleb failure, it is important to preserve conjunctiva
for possible future filtering surgery. Conjunctival dissection in
combined surgery should be restricted to a single superior
quadrant (the superotemporal quadrant provides the greatest
exposure), leaving the remaining superior quadrant for future
glaucoma surgery if needed.
Combined surgery with MMC has been reported to reduce
IOP from 13.4% to 34% with 1.2 to 1.4 fewer glaucoma medica-
tions. These results were statistically better than both combined
surgery with 5-fluorouracil (5-FU) and with no antimetabolite
use, which were the same.9,11 Lack of efficacy of MMC in an
additional study may have been due to surgical technique or the
risk factors in the patient population studied.21 It has been sug-
gested that more intensive follow-up and postoperative manipula-
tions were required in the non-MMC group to achieve results
statistically similar to the MMC group.
Combined phacoemulsification, IOL implantation, and trabe-
culectomy surgery with MMC is most applicable in eyes that
Combined Cataract Implant and Filtering Surgery 22
have uncontrolled glaucoma with maximum medical therapy
and a cataract that impairs vision. Eyes requiring more than
two glaucoma medications, eyes controlled on fewer than two
medications with others contraindicated or ineffective, and eyes
with visual field damage that is advanced or involves fixation
may also be good candidates for combined surgery with MMC
to minimize the possibility of potentially damaging postoperative
IOP elevation. Combined surgery will permit better management
of postoperative IOP elevation and provide a high probability of
improved short-term and long-term IOP control with fewer
medications. In these eyes, it is safer to perform one combined
procedure than two separate procedures. Although trabeculectomy
with MMC performed alone may have the potential for greater
reduction of IOP and glaucoma medications than combined sur-
gery with MMC, the success of combined surgery with MMC
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ANTIMETABOLITES
more than justifies its use in appropriate patients. In addition,
the techniques presently employed in combined surgery do not
increase risk more than performing the procedures separately and
may even reduce the risk with only one trip to the operating room.
If the glaucoma is controlled with fewer than two medications,
with the ability to add others, and visual field loss is mild in an
eye with a visually disabling cataract, combined surgery with
MMC may not be required. Phacoemulsification with IOL alone
may be performed to avoid some of the potential complications
of combined surgery, such as bleb dysesthesia, bleb infection,
endophthalmitis, etc. Although unlikely, significant IOP eleva-
tion can occur. One study showed that one of 17 eyes with stable
open-angle glaucoma requiring one or two medications for con-
trol had an IOP elevation to 30 mm Hg 1 day following clear
corneal phacoemulsification surgery.22 If postoperative elevation
of IOP does occur, significant glaucoma progression is unlikely.
Eyes with a functioning filtering bleb and controlled IOP also
require special decision making when planning cataract removal.
Present techniques of clear corneal phacoemulsification have a
decreased risk of early postoperative elevations of IOP. In 69 eyes
undergoing small-incision clear corneal phacoemulsification with a
functioning filtering bleb, two eyes required subsequent additional
glaucoma surgery. Sixteen eyes required more glaucoma medications
postoperatively than preoperatively. If preoperative IOP was less
than 15 mm Hg, the chance of needing more medications was
27.6%, and if greater than 15 mm Hg, the chance of needing more
was 41.7%. Thus, the surgeon must be aware that, even in this situa-
tion, dangerous elevations of IOP could occur with cataract surgery
alone and that there is a risk that increased glaucoma therapy will
be required.15,16 If a previously filtered eye has a questionably func-
tioning filtering bleb with a significant cataract and IOP is uncon-
trolled or controlled with multiple medications in the presence of
advanced glaucoma damage, combined surgery may be a good
option. Internal or external revision of the existing trabeculectomy
combined with phacoemulsification could also be considered.
▪ ▪
ANTIMETABOLITES
Daily postoperative subconjunctival 5-FU injections enhanced fil-
tration success when trabeculectomy was performed alone.23–25
Although in an early report 5-FU mildly improved filtration suc-
cess in combined surgery, other studies found no benefit.26–29
Chen's pioneering work with MMC,30 a stronger antimetabo-
lite than 5-FU that could be applied topically at the time of
261
 v Special Techniques for Cataract Extraction
filtering surgery, offered the potential of improved filtration suc-
cess with combined surgery. The initial report of combined sur-
gery with MMC showed improved IOP control with fewer
glaucoma medications at 1-year follow-up. Subsequent investiga-
tions have supported these results.9,30–32
Although MMC improves the success of filtration in combined
surgery, it also may increase the risk of complications such as hypot-
ony maculopathy, bleb leaks, bleb infection, and endophthalmitis.
As a result, the concentration of MMC and duration of application
have decreased since its initial use. Although MMC appears to
have a fairly flat dose–response curve, reduced exposure seems to
decrease the incidence of complications.26,27,33,34
Many variables are associated with MMC use. Surgeons using
similar concentrations and exposure times of MMC may get differ-
ent results, and surgeons using different concentrations and exposure
COMPLICATIONS FOLLOWING COMBINED SURGERY
times may get similar results. The choice of sponge material may be
one of these variables. Different cellulose spears, instrument wipes,
and corneal caps may each absorb different amounts of MMC and,
when placed in contact with tissue, result in different antimetabolite
effect. Surgeons may choose materials that will not tear or fragment
during application, cut variable-sized pieces of the material to be
placed in contact with the tissue, place pressure on the material con-
taining MMC through the overlying conjunctiva to squeeze MMC
into the tissues, or use a cellulose spear to absorb any MMC contain-
ing liquid that seeps out from beneath the conjunctival flap and
threatens to contact the edges of the conjunctival incision. In addi-
tion, many surgeons wipe the subconjunctival space lateral and pos-
terior (the space posterior to the conjunctival incision in limbus-
based flaps) to the bleb area for about 15–20 s with the hope that a
more diffuse, lower-profile filtering bleb will form. This may result
in a less localized and cystic bleb with less potential to develop a late
leak through a thinned wall.
Each surgeon should develop his or her own technique, starting
with conservative MMC exposure times to minimize the risk of
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complications. The surgeon should consider the risk/benefit ratio
of MMC use and err on the side of less rather than more antimetab-
olite exposure to avoid complications, realizing that additional
glaucoma surgery could be required. When the surgeon is comfort-
able with the technique and the results, the exposure times can be
modified and individualized depending on the severity of glau-
coma, risk factors for failure, ability to perform additional glaucoma
surgery in the future, and so on. (See Application of Mitomycin for
specific parameters of one technique of MMC use.)
APPLICATION OF MITOMYCIN BEFORE OR
AFTER ENTERING THE ANTERIOR CHAMBER
When MMC was first used in combined surgery, many surgeons
applied the antifibrotic agent near the end of the procedure, after
watertight closure of the scleral flap. The area was irrigated with
balanced salt solution (BSS), and the conjunctiva was closed. No
clinically evident adverse effects were noted. Concern subse-
quently developed over the possibility of toxicity to corneal endo-
thelial cells and the ciliary body epithelium. Experiments in
rabbits showed that MMC penetrated the sclera and resulted in
detectible aqueous levels. A reversible decrease in aqueous pro-
duction followed application of MMC to the scleral surface in
monkey eyes. However, the dose of MMC used in these studies
was larger than that used clinically in humans.35–38
262
MMC can be applied before entering the anterior chamber or
after removing the cataract and securely closing the wound to
prevent MMC entry into the eye. Cohen26 provided evidence
that topical application of MMC at the end of the procedure after
secure closure of the scleral incision does not cause loss of corneal
endothelial cells. This method permits the surgeon to abort the
use of MMC if a defect occurred in the conjunctiva or in the
scleral wound that would contraindicate its use and, therefore,
might be safer for the surgeon who is less experienced with com-
bined surgery. When the surgeon is comfortable with the surgical
technique, if desired, MMC can be applied before entering the
anterior chamber. (See Application of Mitomycin.) Because of
the variability of response to MMC seen in the conjunctiva of
individual eyes, some surgeons have recently advocated a subcon-
junctival injection of a standard dose of MMC that is usually per-
formed at the beginning of the operation.
SUBCONJUNCTIVAL OR SUB-TENON’S
INJECTION OF ANTIMETABOLITE
POSTOPERATIVELY
Based on the work by Gressel, Parrish, and Folberg,23 which
initially showed that daily postoperative subconjunctival injec-
tions of 5-FU improve success of trabeculectomy surgery, many
surgeons will augment intraoperative antimetabolite therapy with
postoperative 5-FU if bleb failure is threatened (increased bleb
vascularization, decreased filtration, etc.). Kapetansky has very
recently shown a beneficial effect with the use of (usually a single)
postoperative subconjunctival injection of the vascular endothelial
growth factor (VEGF) inhibitor, bevacizumab, in trabeculectomy
eyes at high risk of failure in the first 1–2 months postoperatively
(personal communication).
▪
▪
RESULTS FOLLOWING
COMBINED SURGERY
Several prospective and retrospective studies, using varying tech-
niques of MMC application in varying concentrations, found sig-
nificantly lower IOP with fewer glaucoma medications. Mean
IOP decreased 5 mm Hg in the MMC group versus 3 mm Hg
in the placebo group. The mean number of medications required
for IOP control decreased 0.5 to 2.7 in the MMC groups versus
0.7 to 0.9 in the placebo groups. Fifty percent to 100% of eyes in
the MMC groups versus 10% to 67% in the placebo groups were
controlled without medications.9–11,39
▪
▪
COMPLICATIONS FOLLOWING
COMBINED SURGERY
Complications and their frequency were listed in several prospective
and retrospective studies and included vitreous loss (2–7%), wound
leak (1–30%), iris incarceration in sclerostomy (2%), shallow anterior
chamber (7–14%), serous choroidal detachment (14–27%), hypot-
ony (6–18%), and fibrin formation in the anterior chamber
(7–19%). With improved surgical techniques and modified methods
and durations of MMC application, complications have been
significantly reduced. (The management of complications is
discussed under Postoperative Management and Complications.)

▪ COMBINED SURGERY METHOD ▪ the same long-term IOP results, an incision leak is counter-
PREOPERATIVE PREPARATIONS
Medications
As with operative technique, the preoperative regimen varies by
surgeon. Topical corticosteroid eyedrops are used every 2 h start-
ing the day before surgery. Topical antibiotic eyedrops are used
every 2 h starting the evening before surgery. A combination
antibiotic-steroid ointment is applied to the eyelashes at bedtime
the evening before surgery. A nonsteroidal anti-inflammatory
eyedrop is applied twice the morning of surgery. Cyclopentolate
1%, phenylephrine 2.5%, and homatropine 2% eyedrops are
applied every 5–10 min for four applications before surgery.
One drop of betaxolol (Betoptic) is applied 30 min before
surgery. One drop of 5% povidone-iodine (Betadine) solution is
administered immediately before the facial prep.40
Topical antiglaucoma therapy has been shown to have an
adverse effect on the conjunctival inflammatory cellular profile
and on filtering surgery success. The use of steroid drops has been
shown to have a beneficial effect on both of these parameters.
This is why corticosteroid eyedrops are started preoperatively.41
Consideration should be given to discontinuing IOP-lowering
agents that compromise the blood–aqueous barrier, increase the
risk of iritis, and make pupillary dilation difficult (such as miotics)
several days to a week before surgery. This should not be done
if other glaucoma medications cannot be substituted to blunt
possible IOP elevation in eyes with advanced glaucoma.
Anesthesia
Although topical anesthesia is used by many surgeons for com-
bined surgery, the authors usually use either a short- or long-act-
ing retrobulbar block. The short-acting block is performed with
3–4 mL of 2% lidocaine (xylocaine) with 150 units of hyaluroni-
dase. The long-acting retrobulbar block is performed with 3–4 mL
of 4% lidocaine (xylocaine) and 0.75% bupivacaine (marcaine) in a
1:1 mixture, with 150 units of hyaluronidase combined with a Van
Lint block using the same anesthetic mixture and requiring a patch
postoperatively. Preoperative discussion with the patient of
anesthetic options may be helpful. A postoperative eye patch is
not used with short-acting blocks.
The long-acting block may be helpful in more difficult cases
when pupil stretch or posterior synechialysis is required and
phacoemulsification and cortex removal will be done through a
small pupil and capsulorrhexis.
OPERATIVE TECHNIQUE
Conjunctival Flap
One author (JC) prefers a limbus-based flap, while another (AK)
prefers a fornix-based flap. Although a limbus-based flap requires
more manipulation and is technically more cumbersome than a
fornix-based flap, it provides greater certainty of watertight
closure and avoidance of postoperative incision leak. In contrast,
the fornix-based flap provides easier and better surgical exposure
but has a greater risk of postoperative wound leak. Although
there is evidence that limbus- and fornix-based flaps result in
Combined Cataract Implant and Filtering Surgery 22
productive to bleb formation.18,42 When antimetabolites are used
with the surgery, leaks may heal more slowly and be more diffi-
cult to repair with a fornix-based flap.9,23 However, the authors
will usually perform a fornix-based flap if significant subconjunc-
tival scar tissue exists from previous surgery. The morphology of
the blebs that form with limbus-based vs. fornix-based flaps is
different. Although both techniques can create broad and diffuse
blebs, the bleb may be more elevated, increasing the risk of
dysesthesia, with limbus-based flaps. The modified fornix-based
technique of creating the conjunctival incision approximately
1.5 mm posterior to the conjunctival insertion at the limbus can
create a bleb that is fairly flat anteriorly. This may decrease the
risk of dysesthesia and increase the possibility of being able to
resume contact lens wear after the incision has healed.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- COMBINED SURGERY METHOD
Limbus-based conjunctival flap
Dissection is performed in the superotemporal quadrant to mini-
mize anatomic restrictions from the brow and the superior orbital
rim. The initial incision should be made 8–9 mm posterior to the
limbus and penetrate the conjunctiva and Tenon's capsule to
expose the sclera, using sharp scissors and toothed forceps. Blunt
scissors and nontoothed forceps (e.g., Pierse forceps, instrument
#2-136, Duckworth & Kent, St. Louis, Mo.) extend the incision
parallel to the limbus and laterally in both directions to permit
adequate exposure. The incision width usually approximates
12 mm (Figure 22-1). The incision should remain about 8–9 mm
from the limbus along the entire length to minimize the limita-
tion of filtration from the incision scar and to avoid the thinner
and more delicate conjunctiva that is sometimes present closer
to the limbus. Tenon's tissue is bluntly pushed anteriorly with a
dry cellulose sponge or curved edge of a blade to expose the lim-
bus. (Sometimes the insertion of Tenon's tissue must be cut to
provide adequate exposure. If at all possible, Tenon's capsule
insertion should be left intact to provide extra integrity to the
bleb.) Blunt dissection is also performed beneath the edge of
the conjunctival incision posteriorly with scissors.
Fornix-based conjunctival flap
Either directly superiorly or in the superotemporal quadrant, non-
toothed tissue forceps and sharp scissors are used to create a limbal
conjunctival incision approximately 7 mm wide. The authors prefer
making the conjunctival incision approximately 1.5 mm posterior
to the conjunctival insertion in contrast to the standard fornix-
based technique of incising the conjunctiva at its insertion to the
cornea. Blunt scissors are used to extensively bluntly dissect poste-
riorly to provide adequate exposure for the scleral incision and a
larger potential space for filtration (Figure 22-2).
Scleral Incision and Paracentesis
A three-stage tunnel incision is made with the initial vertical inci-
sion approximately 2 mm posterior to the limbus. The first-stage
vertical incision is performed at about one-half scleral depth and
the necessary width for insertion of the desired IOL (the authors
use a 0.37 mm preset diamond blade) (Figure 22-3A). The sec-
ond stage of the incision is made horizontally, parallel to Desce-
met's membrane (the authors use a crescent steel blade), and
263
 v Special Techniques for Cataract Extraction
COMBINED SURGERY METHOD
Figure 22-1 A, Initial incision for limbus-based conjunctival flap is made with sharp scissors and toothed forceps,
8–9 mm posterior to the limbus, exposing sclera. B, Limbus-based flap should be about 12 mm wide to provide adequate
exposure.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
extends approximately 1–2 mm anterior to the limbus. MMC is
now used. (See Application of Mitomycin later in text.) If the
initial scleral incision inadvertently is made full thickness (as in
eyes with thin sclera), the flap can still be dissected anteriorly
using only half the scleral thickness. However, it is important to
tightly suture the deeper full-thickness area of the incision sepa-
rately from the rest of the superficial flap prior to MMC applica-
tion to prevent the development of postoperative hypotony from
ciliary body toxicity or a second pathway for aqueous outflow. A
keratome blade (appropriate for the size of the phacoemulsifica-
tion tip) makes the vertical third stage of the incision and enters
the anterior chamber (see Figure 22-3B). A narrow, sharp-
pointed blade is then used to make a small peripheral paracentesis
opening in the cornea, at a position 3 clock hours to the left of
the scleral incision (right-handed surgeon) for insertion of a
manipulating instrument. A viscoelastic agent is then injected
to fill and maintain the anterior chamber.
Alternatively, some surgeons prefer creating the same type of
scleral flap they usually create for a straight trabeculectomy –
whether triangular, trapezoidal, rectangular or square. This can
help to create consistency in management and results between
straight trabeculectomies and combined phaco-trabeculectomies.
Application of Mitomycin
Two small pieces of a cellulose spear (the authors use i-Spear
ophthalmic sponge, Alcon, Fort Worth, Tex.), each the approxi-
mate size of the scleral flap, are soaked in MMC (0.4 mg/mL).
These two pieces are then placed on the scleral surface, over-
lying and extending beyond the scleral tunnel on both sides
264
12
–1
4
m
m
8 mm
(Figure 22-4A). This will spread the MMC effect beyond the
area overlying the scleral tunnel and hopefully extend the area
of filtration laterally in both directions. The conjunctiva is
brought down over the sponges (see Figure 22-4B). The edges
of the conjunctival incision should not touch the sponges or any
liquid containing MMC. A cellulose sponge should be used to
absorb any excess liquid that flows out from under the conjuncti-
val flap. After 1 min of tissue exposure, one of the sponges is
removed, and the remaining sponge is positioned centrally on
the scleral flap. After an additional minute, the second sponge is
removed, and the conjunctival and corneal surfaces, the tissues
beneath the edges of the conjunctiva laterally, and the scleral tunnel
are irrigated with 15 mL of BSS. An intact piece of cellulose
sponge, about 23 mm in size, is securely grasped by toothed for-
ceps and wiped beneath the previously dissected posterior subcon-
junctival space (limbus-based flap) for 15–30 s (see Figure 22-4C).
This area is also irrigated with 15 ml of BSS. (When a fornix-based
flap is used, a similar maneuver can be performed deeper than the
area previously exposed.)
A total of 1 3/4 min of MMC exposure time beneath the limbus-
based conjunctival flap is used for most eyes. The duration of expo-
sure may be decreased by 15–30 s if the need for IOP reduction is
less because of less severe glaucoma, a reduced tendency for healing
related to older age, systemic use of corticosteroids or other immu-
nocompromising drugs, and so on. The duration may be increased
by 15–30 s if there are risk factors for failure, such as thicker tissue,
younger age, previous surgery, African-American race, or history of
inflammation. Evidence has shown that the dose–response curve of
MMC is fairly flat but that longer exposure times may have an
increased incidence of complications.33
 Combined Cataract Implant and Filtering Surgery 22

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- COMBINED SURGERY METHOD

Figure 22-2 A, Limbal conjunctival incision is made to create a standard fornix-based conjunctival flap. B, Alternate
technique for fornix-based conjunctival flap, with the conjunctival incision performed 1.5 mm from the conjunctival insertion.

With fornix-based flaps, two round methylcellulose corneal
shields are cut in half. The corneal shield material has excellent
integrity, eliminating any concerns over pieces of the sponge
material falling apart or being left behind. It also keeps a fairly
low profile even after being soaked, allowing a greater surface area
of contact with the sclera and Tenon's capsule. The first two
pieces are wiped around and then placed in the superonasal
and superotemporal subconjunctival space. The third piece is
placed over the superior rectus insertion, and the fourth piece is
wiped around anteriorly, both nasally and temporally, and then
265
 v Special Techniques for Cataract Extraction

12
–1
4
m
m
8 mm
COMBINED SURGERY METHOD

Figure 22-3 A, First-stage vertical incision is performed at about one-half scleral depth and the necessary width for
insertion of the desired intraocular lens. B, Three-stage scleral incision is made into the anterior chamber.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Figure 22-4 A, Two pieces of cellulose sponge are placed on the

scleral surface, overlying and extending beyond the scleral tunnel on both
sides. B, Conjunctiva is brought down over the sponges. C, An intact piece
of cellulose sponge, about 23 mm in size, is securely grasped by toothed
forceps and wiped beneath the previously dissected posterior
subconjunctival space.

266
 Combined Cataract Implant and Filtering Surgery 22
placed anteriorly near the area where the posterior edge of the
scleral flap will be created. This creates a wedge-shaped area of
MMC exposure with the greatest exposure applied posteriorly.
While the sponges are in place, the anterior edge of the conjunc-
tival flap is pressed down onto the sclera at the incision site with a
cyclodialysis spatula to prevent any external leakage of MMC.
The incision surface is then briefly irrigated with BSS to remove
any MMC that may have oozed out while the sponges were being
inserted. Exposure time varies from a total of 1.5 to 2.5 min for
combined surgery, depending on the multiple factors listed in
the previous paragraph.

Management of the Small Pupil

and Posterior Synechia

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- COMBINED SURGERY METHOD

Long-term use of glaucoma (especially miotic) eyedrops may
limit the effectiveness of pupillary dilation in preparation for pha-
coemulsification. If the patient is using miotic eyedrops and the
IOP and stage of glaucoma permit, discontinuation of the miotics
and, if possible, substitution of other glaucoma drops may
enhance the mydriasis. The minimum acceptable and comfort-
able pupil size may vary depending on the specific type and sever-
ity of the cataract. A “soft” cataract may not require surgical
enlargement of the pupil even if dilation is poor. A brunescent
cataract, however, may require surgical enlargement of the pupil
even if it dilates moderately. Although manipulation of the pupil
may result in decreased sphincter function, patients rarely com-
plain of any problems and are far better off avoiding more serious
events such as a capsule defect or vitreous loss. Each surgeon
must determine what pupil size is adequate.
The dilated preoperative examination helps predict whether
pupil manipulation will be necessary. Stripping a pupillary mem-
brane or lysis of posterior synechia may significantly enhance
pupil size. “Viscodilation” with a cohesive viscoelastic may be all
that is required to enlarge the pupil to a comfortable size for cap-
sulorrhexis. If further enlargement is required, the authors have
found pupil stretch to be successful virtually 100% of the time.
Although iris hooks, pupil ring expanders, and minisphinctero-
tomies will enhance pupil size, they are rarely required because
of the success of pupil stretch, improved techniques of phaco-
Figure 22-5 A, Pupil is stretched by simultaneously pushing and pulling
emulsification, and newer viscoelastics. (See Chapter 21, Phaco- the pupillary edge of the iris in opposite directions in the same meridian
emulsification in the Presence of a Small Pupil.) (6 clock hours apart). B, Additional enlargement can be achieved by
If pupil enlargement is required, the authors employ a biman- performing a second stretch maneuver 90 away from the first.

ual stretch maneuver. Two instruments designed for iris manipu-

lation are used (Osher Y-hook, E0577, Storz, Claremont, Calif.;
Kuglen Iris Hook and IOL Manipulator, 6-400 and 6-402,
Duckworth & Kent, St. Louis, Mo.). One instrument is placed
in the anterior chamber through the paracentesis opening while
the other enters through the phacoemulsification incision, and
the pupil is stretched by simultaneously pushing and pulling the
pupillary edge of the iris in opposite directions in the same
meridian (6 clock hours apart) (Figure 22-5A).43–45 For addi-
tional enlargement, a second stretch maneuver can be performed
in a meridian about 90 from the first (see Figure 22-5B), or the
two stretch instruments can be placed less than 6 clock hours
apart before stretching. A slow and gradual stretch will minimize
the risk of an atonic pupil. Self-limited bleeding may occur from
the tears in the pupillary margin of the iris. Elevation of the IOP
by filling the anterior chamber with BSS or viscoelastic can help
tamponade the bleeding.
In the rare cases when bimanual stretch inadequately dilates the
pupil, iris retraction hooks can be helpful. Pupil stretching usually
does not have any long-term effect on postoperative vision, IOP
or inflammation.72,73
Capsulorrhexis
Continuous circular capsulorrhexis is performed using a 22-gauge
needle with a right-angle bend made about 1 mm from the tip.
An alternate method using capsule forceps is preferred by many
267
 v Special Techniques for Cataract Extraction

surgeons. The size of the capsulorrhexis is often limited by sub-

optimal pupillary dilation and may require enlargement later in
the procedure when the chamber has been deepened by a visco-
elastic agent. (See earlier section, Management of the Small Pupil
and Posterior Synechia.) Too small a capsulorrhexis may compro-
mise phacoemulsification and cortical aspiration, increase the risk
of a radial extension of the capsulorrhexis, and result in intra-
operative and postoperative complications. (Also see Chapter 14,
Capsulorrhexis.)

Hydrodissection, Hydrodelineation,
and Viscodissection Cortex

The nuclear and cortical lens layers are hydrodissected from the
lens capsule by gently injecting BSS just beneath the edge of
COMBINED SURGERY METHOD

the capsulorrhexis with a blunt 27-gauge cannula, using moderate

infusion pressure. The pupil is observed for passage of a fluid
wave across the red reflex. When dense cataracts preclude obser-
vation of the fluid wave, slight anterior movement of the nucleus
confirms hydrodissection. Injection of fluid into the cataractous
lens can achieve hydrodelineation by separating the nuclear, epi-
nuclear, and cortical layers. (A 27-gauge J-shaped cannula can
direct the hydrodissection to the cortex beneath the scleral inci-
sion and achieve better mobilization of the more difficult-to-
remove cortex in this area.) Successful hydrodissection is crucial
in poorly dilated pupils. It is helpful to test for adequate hydro- A
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

dissection by rotating the nucleus (with viscoelastic in the anterior

chamber) using one or two manipulating instruments. The injec-
tion of a viscoelastic may also be used to dissect cortex or nucleus
away from the lens capsule when normal irrigation–aspiration Attached to
techniques may be dangerous (e.g., with a small pupil or capsu- syringe
lorrhexis, capsule defect). (Also see Chapter 15, Hydrodissection containing BSS
and Hydrodelineation.)

Phacoemulsification and Cortical Aspiration

Phacoemulsification is performed using the preferred technique
of the surgeon. The authors usually create a central groove greater
than two-thirds of the depth of the lens and use a second instru-
ment to help crack the nucleus into two halves. Each half is then
rotated and chopped into smaller pieces, which permit easier and
safer phacoemulsification in the posterior chamber.
Aspiration of the cortex is performed in the usual manner. This
can be more challenging in the presence of a small pupil and cap-
sulorrhexis. An iris manipulating hook should be used to push
the iris peripherally and expose the peripheral capsular bag, when
it is inadequately seen, to ensure removal of hidden cortex. Use of
a separate aspiration cannula (Surgical Design Corporation, Long
Island City, NY; Oasis Medical Inc., Glendora, Calif.) that is
small enough to be passed through the paracentesis opening or
the use of a 90 angled irrigation–aspiration tip can be extremely
helpful in removing cortex from the capsular bag opposite the para-
centesis and beneath the area of the scleral incision (Figure 22-6A). B
A J-shaped cannula on a syringe containing BSS can also be used Figure 22-6 A, Separate aspiration canula, small enough to be passed
to remove the subincisional cortex after having inflated the bag through the paracentesis opening, can be extremely helpful in removing
and anterior chamber with viscoelastic (see Figure 22-6B). (Also cortex from beneath the area of the scleral incision. B, J-shaped cannula
on a syringe containing balanced salt solution can also be used to
see Chapter 16, Principles of Nuclear Phacoemulsification, and remove the subincisional cortex after inflating the capsular bag with viscoelastic.
Chapter 17, Phaco Chop.)
268

Intraocular Lens Implantation
The tunnel incision is enlarged to the required size for IOL
implantation. Use of IOL injectors may require little or no
enlargement, depending on the specific IOL, cartridge and injec-
tor used. (Also see Part VI, Intraocular Lenses.)
Trabeculectomy or Sclerectomy
The left side of the scleral tunnel is cut anteriorly to permit elevation
of the corner and exposure of the tunnel floor (Figure 22-7A). This
creates an “L” shaped flap. A pair of nontoothed forceps is used to
Combined Cataract Implant and Filtering Surgery 22
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- COMBINED SURGERY METHOD
Figure 22-7 A, Left side of the scleral tunnel is cut anteriorly to permit
elevation of the corner and exposure of the tunnel floor. B, Sharp blade is used
to make an incision in the scleral floor of the tunnel, parallel to the limbus, about
0.5–1 mm anterior to the posterior edge of the tunnel. C, Kelly punch is used to
create a sclerectomy on the left side of the tunnel.
elevate the roof of the scleral tunnel to perform the trabeculectomy
or sclerectomy.
A sharp blade is used to make an incision in the scleral floor
of the tunnel, parallel to the limbus, about 0.5–1 mm anterior to
the posterior edge of the tunnel (see Figure 22-7B). A Kelly
punch (instrument #E-2798, Storz, Claremont, Calif.) is used
to create a 12 mm opening into the anterior chamber on the
left side of the tunnel (Figures 22-7C and 22-8A). Trabecular
meshwork or peripheral cornea anterior to the trabeculum is
removed. (Alternatively, the punch can be passed into the
phacoemulsification incision and punch posteriorly; see
269
 v Special Techniques for Cataract Extraction
COMBINED SURGERY METHOD
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Figure 22-8 A, Kelly punch creates a sclerectomy (side view of
Figure 22-7C). B, Alternatively, the punch can be passed into the
phacoemulsification incision and punch posteriorly.
Figure 22-8B.) If preferred, a freehand dissection is performed
by making the same incision in the tunnel floor. Radial incisions
are made anteriorly with a fine scissors (e.g., Vannas, instrument
#E3389, Storz, Claremont, Calif.) on both sides of this incision.
While the deep scleral tissue is grasped with toothed forceps,
the scissors are used to cut the anterior edge, excising the tissue
and creating a 1–2 mm filtration opening (Figure 22-9). An
assistant can elevate the roof of the tunnel with nontoothed
forceps or a cellulose sponge, or the surgeon can use the edge
of the Vannas scissors to elevate the scleral flap during this
dissection.
It is important to avoid extending the sclerectomy to the poste-
rior edge of the tunnel floor to prevent simulation of a “full-thick-
ness filtering procedure” with free access of aqueous flow through
the incision to the scleral surface. Leaving a portion (0.5–1 mm)
of the scleral floor intact forces the aqueous humor to percolate
from the trabeculectomy or sclerectomy opening, across a short
portion of the scleral floor, and through the incision to the
scleral surface, resulting in slight resistance to flow. If the
270
Figure 22-9 Sclerectomy can be created freehand with scissors and
forceps.
trabeculectomy or sclerectomy opening is inadvertently created
over the ciliary body and uvea, the dissection should be extended
anteriorly over the iris. If required, a fine-needle-tip cautery can
be used at low power to control bleeding.
Peripheral Iridectomy
Although some surgeons have suggested that an iridectomy is not
necessary, it is safest to perform one.74 Without an iridectomy, a
shallow anterior chamber or application of digital pressure could
result in occlusion of the trabeculectomy or sclerectomy opening
from iris prolapse.
The iridectomy is performed by carefully grasping the periph-
eral iris as posteriorly as possible through the trabeculectomy or
sclerectomy opening with a fine-toothed forceps. The peripheral
iris is elevated with a slight side-to-side pulling motion, and Van-
nas scissors create the iridectomy opening (Figure 22-10A). The
size of the iridectomy should approximate the size of the trabecu-
lectomy or sclerectomy opening. Prolapsed iris tissue should be
irrigated or gently massaged into the anterior chamber by bluntly
rubbing in a peripheral to central motion on the corneal surface
over the iridectomy with the elbow of the 19-gauge irrigation
cannula. Aqueous humor will pass through the sclerectomy
opening and the scleral incision into the subconjunctival space
(Figure 22-10B). A fine-needle-tip cautery can be used at low
power to control bleeding from the iridectomy edge. Great cau-
tion must be taken while cauterizing in this area. If the cautery
disrupts the zonules in the area, vitreous can prolapse through
the iridectomy and sclerostomy even in a phakic eye. Vitreous
prolapse from any cause must be meticulously managed to pre-
vent the vitreous from occluding the internal sclerostomy and
causing failure of the trabeculectomy.