Like many older people, Nestor Pous, 73, was diagnosed with cataracts as well as with glaucoma, both eye conditions that arise with age.
But unlike many others, Pous had both conditions repaired through surgery.
New technology in use for about three years allows doctors to treat glaucoma as well as cataracts during one surgical procedure.
“It’s going to allow a big percentage of patients who are undergoing cataract surgery to kill two birds with one stone and attack the glaucoma,” said Dr. Carlos Buznego, ophthalmic surgeon with the Center for Excellence in Eye Care at Baptist Hospital Medical Arts Building.
Prior to this treatment, doctors would do surgery to treat cataracts but they usually wouldn’t do surgery to treat glaucoma unless it was a severe case. Long healing times and complications were common in glaucoma surgery. In general, doctors treated glaucoma with prescription eye drops that a patient would have to use for a lifetime.
The Food and Drug Administration approved the iStent device, in 2012 following a trial the FDA conducted on 240 eyes with cataracts and mild- to moderate glaucoma across 27 sites in the United States, including Baptist Medical Arts Surgery Center.
Buznego, who implanted the iStent in Baptist patients as part of the trial, said the trial showed the stent didn’t compromise the cataract procedure and that it allowed patients to stop glaucoma medication. Indeed, 68 percent of the patients who were part of the year-long trial are medication free, according to the iStent manufacturer, Glaukos.
The iStent targets glaucoma by unblocking the trabecular meshwork and allowing clear fluidthat nourishes parts of the front of the eye to flow through the meshwork. In open-angle glaucoma, which is the type the iStent treats, the trabecular meshwork is blocked and the clear fluid can’t flow through. As a result, pressure on the optic nerve, or the nerve that transmits images from the retina to the brain, builds up.
“The problem with traditional glaucoma surgery was we are diverting fluid to an area where it probably not ought to go,” Buznego said.
The trabecular meshwork, however, is the natural and correct path for the aqueous humor fluid to flow through.
The iStent represents a new generation of stent implants for glaucoma. A year before the iStent became available, the FDA approved lasers for cataract surgery.
Dr. Kendall Donaldson, associate professor of clinical ophthalmology and medical director of Bascom Palmer Eye Institute at Plantation, a division of the University of Miami Health System, said using lasers adopted from Lasik surgery reduces the trauma put on the eye from ultrasounds during cataract surgery.
In cataracts, the natural lens clouds over time, and it has to be removed and replaced by a lab-made acrylic or silicone lens. Doctors use ultrasound energy to convert the natural lens from solid to liquid form, Donaldson said. Using lasers, doctors can soften the cataract lens while applying less ultrasound energy on the eye. And less ultrasound energy is a good thing, Donaldson said.
“It’s less trauma to the eye,” she said, “Laser allows us to conserve energy, making the treatment less traumatic to the eye. Lasers can basically do half the surgery for us, not the whole surgery.”
Using the laser or the ultrasound has allowed doctors to make a smaller incision in the eye in cataract surgeries. In recent years, incisions for these surgeries are about 2.5 millimeters, much smaller than the 10-millimeter incisions done about 10 years ago, Donaldson said. At the time, doctors didn’t use ultrasound or lasers to liquefy lenses, meaning that the clouded lenses were pulled out of the eye in their solid form, requiring a much larger incision.
Neither the iStent for glaucoma nor the laser for cataracts is the standard of treatment. Nationally, fewer than 5 percent of patients getting cataract surgery are having the surgery done with a laser, Buznego said.
Donaldson, the ophthalmology professor at Bascom Palmer Eye Institute, said that’s because the lasers are costly.
The Glaukos iStent implant isn’t a standard of treatment for glaucoma patients because not a lot of ophthalmic surgeons have been trained to use it yet, Buznego added.
In the United States, about 22 million people 40 or older have cataracts and almost 2.3 million people 40 or older have glaucoma, said the American Academy of Ophthalmology.
Pous, of Kendall, was one of them. In early 2015, he had the iStent implanted in each eye and an artificial lens implanted for his cataracts. Since then, he hasn’t had to take any prescription eye drops that he used to take before the surgery.
“I’m taking just drops for lubrication of the eye, drops I can buy over the counter,” Pous said. “I feel fine.”