Cataract Surgery and Glaucoma

Cataract surgery, the most commonly performed surgery in the world (and one of the most successful) has just gained another accolade: the ability to treat glaucoma.

What Is Glaucoma

Glaucoma is a progressive loss of the “nerve fiber layer” of the eye. This layer is essentially a series of wires that transmit the signal from the eye to the brain.  Just as a frayed cable from your DVD to your TV would result in a poor quality picture, loss of the nerve fiber layer results in poor vision. The standard treatment for glaucoma is to lower the intraocular pressure in the eye with drops, laser or surgery. Unfortunately, all drops have local side effects, laser does not work for everyone, and surgical treatments such as trabeculectomy have significant risks assoiciated with them. For more on glaucoma, visit my practice website and search “glaucoma.”

Cataract Surgery Lowers IOP?

One of the risks of cataract surgery is a temporary increase in intraocular pressure (IOP). Because of this, in the past when someone had an elevated IOP and needed cataract surgery it was often done along with trabeculectomy (a glaucoma surgery). The problem with this approach was that trabeculectomy did not work that well when done at the same time as cataract surgery and vision could actually be limited or decreased for a time because of the glaucoma surgery – hardly what was intended or desired by the patient or surgeon.

So, with the blessing of the glucoma specialist, some cataract surgeons were removing the cataract without trabeculectomy even in patients with elevated IOP. If the IOP increased then the patient was taken back to the operating room for glaucoma surgery. If the IOP was OK, then vision generally improved and the patient and surgeon avoided the hassle of glaucoma surgery.

But, a trend was noted: fewer patients than expected needed the trabeculectomy. Could it be that cataract surgery alone lowered the IOP?

Dr. Richard Lindstrom wanted to know so he reviewed the charts of 712 patients with ocular hypertension (high pressures but no damage to the nerve fiber layer), glaucoma, or suspected glaucoma who had been treated with cataract surgery alone (no trabeculectomy at the time of cataract surgery). The results of his study were impressive. The higher the IOP the greater the effect of cataract surgery. IOP was lowered as much as 30% after cataract surgery!

These results are nothing short of amazing and could change the way we think about current methods of treating glaucoma. I just about fall out of my chair when a glaucoma drop lowers the IOP by 30% so it appears that cataract surgery is about as successful in treating IOP as the best of the prescription medications.

Huge Barrier

Now, before you go out and ask your eye doctor to remove your cataract to treat your glaucoma you should know that there is one huge barrier that will keep him or her from obliging you: Medicare and most insurances do not cover cataract surgery when the reason for surgery is anything other than “visually significant cataract affecting the activities of daily living.” And, although logic dictates that untreated glaucoma would eventually result in such a loss of vision, Medicare and most insurances don’t really care about the future (if they did they would cover cataract surgery in patients without cataracts simply because we know that “someday” the cataract would cause a loss of vision).

Oh, and don’t ask your surgeon to “fudge” the reason as a cataract. That’s fraud and I’m sure you wouldn’t really ask your surgeon to put his or her license on the line (as well as heavy fines, possible jail time, etc.) so that you can get coverage from your insurance.

So, what can be done? The same thing that must be done whenever a change in Medicare is necessary: write to your senators and congressmen and ask them to pressure the Centers for Medicare and Medicaid Services (CMS) to cover cataract surgery as a treatement for ocular hypertension, glaucoma, and suspected glaucoma. Once Medicare allows this other insurances generally follow suit.

Until then, if you have glaucoma and can convince your surgeon to treat it with removal of your lens (technically called a clear lens extraction, or refractive lens exchange) expect this to be treated as “refractive” surgery and have a price tag of anywhere between $3,300 and $6,000 per eye depending on the center, surgeon, and lens used.

Suddenly that 42 cent stamp required to send a letter to Washington DC doesn’t seem so bad. Hey, you can even email your representatives now for free.  You’re online already, what’s stopping you?

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