Los Angeles is an amazing city which is very diverse and when I am teaching the UCLA ophthalmology residents, we see a wide spectrum of disease including neo-vascular glaucoma (NGV). We see patients with NGV on a daily basis at our clinic because of the high incidence of vascular disease such as diabetes and hypertension leading to proliferative diabetic retinopathy and retinal vein occlusion. We have patients like this who are well-controlled with the glaucoma shunt / valve and then develop cataracts years later. Other patients need to have cataract surgery at the same time as the glaucoma procedure.
For patients who present with neo-vascular glaucoma and cataract at the initial visit, the treatment first focuses on treating the underlying issue: vascular disease causing ischemia which then leads to VEGF release which drives neo-vascularization. This means that in addition to strict systemic control of blood pressure and blood sugar, these patients receive pan-reintal photo-coagulation (PRP) as well as injection of anti-VEGF agents like bevacizumab (Avastin). In certain severe cases, this can be done at once during the same sitting: cataract removal, then while the eye is aphakic PRP is done with the indirect argon/diode laser, injection of bevacizumab, placement of the IOL, and finally placement of the glaucoma valve.
In other cases, when the eye is stable with a glaucoma shunt and then needs cataract surgery years later, we must account for the leakage of fluid through the shunt during the procedure. The inflow of fluid may need to be raised to compensate for this or the tube may need to be temporarily plugged or ligated.
A very useful technique is to use triamcinolone particles to visualize the aqueous outflow via the glaucoma shunt during the surgery. This will ensures a patent tube and effective pressure-lowering effect in the post-operative period.
In rare cases, we can even have more than one glaucoma drainage tube in the same eye.
Click below for a combined cataract + glaucoma valve procedure (from 2007):
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