Glaucoma patients not responding to maximum medical therapy with coexistent cataract are candidates for combined
cataract and glaucoma therapy. There are different therapy models. The choice of therapy depends on numerous patient
and surgeon related factors. Ex-PRESS mini glaucoma shunt is a modifi ed trabeculectomy and can be combined with
cataract surgery when indicated. In this paper we presented our experience with this combined procedure. Our results
showed good intraocular pressure control and visual acuity improvement, comparable to other therapy choices

Ana Didović Pavičić

Jadranka Katušić Bašić

Marija Škara Kolega

Samir Čanović

Suzana Kovačević

English

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239this paper we report a group of patients with pseudoex-pholiative glaucoma, with high, uncontrolled intraocular pressure on maximum medical therapy with coexisting cataract. Patients underwent combined cataract and glau-coma surgery using Ex-PRESS miniature glaucoma shunt implant. Postoperative fi ndings showed visual acuity im-provement and good intraocular pressure control with no additional glaucoma therapy. We had no unexpected com-plications or adverse effects.MethodsSix eyes in 6 patients, with pseudoexfoliative glaucoma, on maxiumum antiglaucomatous medical therapy, under-went combined two-site surgery PHACO with implanta-tion of acrylic IOL followed by fi ltrating surgery- Ex-PRESS miniature glaucoma shunt implantation was performed. We used 0.025% MMC. The standard proce-dure was performed without complications, implants were well positioned. We used parabulbar anesthesia with sup-plemental intracameral lidocaine injection. All surgery was performed by the same surgeon, in Department of Ophthalmology, General Hospital Zadar. Postoperatively we recommended combined antibiotic and steroid drops every four hours in the fi rst week followed by taper. Eval-IntroductionThe modern goal of glaucoma managament is to avoid glaucomatous damage and to preserve visual fi eld and total quality of life for patients with minimal side effects. Although intraocular pressure is only one of the major risk factors for glaucoma, lowering it via various pharmaceu-ticals and/or surgical techniques is currently the mainstay of glaucoma treatment1. Combined surgery has become the most commonly used surgical treatment for medically un-controled primary glaucoma with coexinsting cataract. In those patients combined phacoemulsifi cation and trabecu-lectomy offer profi t over a sequential approach. New de-vices are being developed to allow surgeons increased control with more predictable postoperative results. Ex- PRESS miniature glaucma shunt device shunts aqueous from the anterior chamber to a subconjunctival space in a similar way as terabeculectomy2,3. It is a non valved 3 mm long device, external diameter approx. 400 microns4. It is implanted under a scleral fl ap5. The advantages of Ex-PRESS miniature glaucoma shunt are atraumatic implan-tation, less complications and infl amation, low diffuse blebs and high success rate. Among others indication for Ex-PRESS miniature glaucoma shunt implantation are primary open angle glaucomas, candidates for fi ltrating surgery and combined glaucoma and cataract surgery. In Coll. Antropol. 39 (2015) 1: 239–242Professional paperCombined Procedure of Phacoemulsifi cation and Implantation of Ex-PRESS Miniature Glaucoma ShuntSamir Čanović1, Suzana Kovačević1, Ana Didović Pavičić1, Marija Škara Kolega1 and Jadranka Katušić Bašić21 General Hospital Zadar, Department of Ophthalmology, Zadar, Croatia2 General Hospital Dubrovnik, Department of Ophthalmology, Dubrovnik, CroatiaA B S T R A C TGlaucoma patients not responding to maximum medical therapy with coexistent cataract are candidates for combined cataract and glaucoma therapy. There are different therapy models. The choice of therapy depends on numerous patient and surgeon related factors. Ex-PRESS mini glaucoma shunt is a modifi ed trabeculectomy and can be combined with cataract surgery when indicated. In this paper we presented our experience with this combined procedure. Our results showed good intraocular pressure control and visual acuity improvement, comparable to other therapy choices.Key words: glaucoma, cataract, combined procedure, fi ltrating surgery, ExPRESS miniature glaucoma shuntReceived for publication June 12, 2014240S. Čanović et al.: Capsular Tension Ring, Coll. Antropol. 39 (2015) 1: 239–242uated parameters were visual acuity, intraocular pres-sure, slit lamp control on 1st, 7th postoperative day, 1 and 3 month after.ResultsPreoperative intraocular pressure values were 32–40 mmHg, visual acuity HM to 0.08. On the 1st postoperative day intraocular pressure values were 10–14 mmHg and hypotonia in one patient, visual acuity 0.02–0.08, slit lamp examination showed shallow anterior chamber in two patients, fl at anterior chamber in one patient and nor-mal anterior chamber depth in three patients. Seventh postoperative day IOP values were 12–18 mmHg, visual acuity 0.03–0.1, slit lamp examination showed shallow anterior chamber in 1 patient and in 5 patient normal anterior chamber depth. One month after surgery IOP values were 12–18 mmHg, visual acuity 0.07–0.4, slit lamp examination showed normal anterior chamber depth in all patients. Three months after surgery IOP values were 16–18 mmHg, visual acuity 0.08–0.5, slit lamp ex-amination showed regular anterior chamber depth. In Table 1 there are all patients presented with their preop-erative and postoperative fi ndings. In Table 2 there are results of IOP and VA presented. Figure 1 and 2 present IOP and VA changes in graphic manner. The patients were using no medical antiglaucomatous therapy.Discussion and ConclusionThe coexistence of cataract and glaucoma represents a challenging problem, and a currently available treatment options are cataract extraction alone, cataract followed by glaucoma surgery, glaucoma surgery followed by optional TABLE 1PATIENTS AND PREOPERATIVE AND POSTOPERATIVE FINDINGSPreop. 1st post op day 7th post op day 1 month post op 3 months post opCAT. IOP baselineVA baseline IOP VAAnt. segm. IOP VAAnt. segm. IOP VAAnt. segm. IOP VAAnt.segm.Pex1 Yes 40 0.01 14 0.08 16 0.10 12 0.4 16 0.5Pex2 Yes 36 0.02 12 0.03 14 0.03 16 0.1 16 0.3Pex3 Yes 38   0.001   8 0.02 Flat AC 18 0.05 Shall AC 18   0.08 18 0.1Pex4. Yes 32 0.05 10 0.05 Shall AC 14 0.07 14   0.07 16   0.08Pex5 Yes 40 0.05 14 0.07 12 0.08 16 0.1 16 0.3Pex6 Yes 32 0.08 10 0.08 Shall AC 10 0.10 14 0.3 16 0.4Neo – neovascular; Pex – pseudoexpholiative; SEC – secondary; TTC – trabeculectomy; CAT – cataract; IOP – intraocular pressure; VA – visual acuity; LP – light perceptionTABLE 2RESULTS: IOP AND VAPreop. 1st post op day7th post op day1 monthpost op3 monthspost opCAT. IOP baselineVA Baseline IOP VA IOP VA IOP VA IOP VAPex1 Yes 40 0.01 14 0.08 16 0.10 12 0.4 16 0.5Pex2 Yes 36 0.02 12 0.03 14 0.03 16 0.1 16 0.3Pex3 Yes 38   0.001 8 0.02 18 0.05 18   0.08 18 0.1Pex4. Yes 32 0.05 10 0.05 14 0.07 14   0.07 16   0.08Pex5 Yes 40 0.05 14 0.07 12 0.08 16 0.1 16 0.3Pex6 Yes 32 0.08 10 0.08 10 0.10 14 0.3 16 0.4M  36.33   0.042  11.33   0.055 14   0.071 15     0.175  16.33   0.28σ    3.67 0.03    2.42 0.03    2.83 0.03   2.10   0.14    0.82   0.16M – arithmetic mean; σ – standard deviation; Neo – neovascular; Pex – pseudoexpholiative; SEC – secondary; TTC – trabeculectomy; CAT – cataract; IOP – intraocular pressure; VA – visual acuity; LP – light perception; HM – hand motion241S. Čanović et al.: Capsular Tension Ring, Coll. Antropol. 39 (2015) 1: 239–242Fig. 2. VA changes.Fig. 1. IOP changes.cataract surgery an combined glaucoma and cataract sur-gery. The treatment of choice is based both on visual fi eld defect and loss of visual acuity. Combined procedure is the therapy of choice when glaucoma is prevailing and the IOP spike after cataract surgery may cause signifi cant damage to the optic nerve6. Recent studies report that trabeculec-tomy in no longer the gold standard for combined cataract glaucoma surgery, considering the successful results fol-lowing cataract surgery combined with trabeculotomy, viscocanalostomy and canaloplasty7. Some authors claim that the newer glaucoma procedures apear to be less ef-fective than trabeculectomy but they are also associated with a lower risk of surgical complications8. In some glau-coma cases not responding to maximum antiglaucoma therapy combined with senile cataract the implantation of Ex-PRESS miniature glaucoma shunt following cataract surgery could be the therapy of choice. The procedure pro-vides signifi cant and long lasting intraocular pressure lowering after cataract surgery thereby reducing the risk for further glaucomatous visual fi eld damage and avoiding topical antiglaucomatous therapy. The largest published case series of the Ex-PRESS miniature glaucoma shunt was by Kanner et al.9 reporting that the Ex-PRESS min-iature glaucoma shunt was effective for IOP lowering both alone and combined with cataract surgery. Advantages of the combined procedure are patient’s convenience – a single operation, avoiding postoperative IOP spikes that can follow cataract surgery, especially dangerous in ad-vanced optic neuropathy. Some authors consider combined procedures, primary phacotrabeculectomy to be indicated in end stage glaucomas10. Also the factors are costs of medical therapy and poor compliance with glaucoma med-ications. The decision should be made in discussion with the patient regarding the potential risks and benefi ts of the procedure.R E F E R E N C E S1. PARIKH RS, PARIKH SR, NAVIN S, ARUN E, THOMAS R, In-dian J Ophthalmol, 56 (2008) 223. PMCID: PMC2636120. — 2. SARKI-SINAN SR, Middle East Afr J Ophthalology, 16 (2009) 134. DOI: 10.4103/0974-9233.56226. — 3. MOISSIEV E, ZUNZ E, TZUR R, KUR-TZ S, SHEMESH G, J Glaucoma, 21 (2014) 283. DOI: 10.1097/IJG.0000000000000047. — 4. NYSKA A, GLOVINSKY Y, BELKIN M, EPSTEIN Y, J Glaucoma, 12 (2003) 275. — 5. DAHAN E, CARMICHAEL TR, J Glaucoma, 14 (2005) 98. — 6. MERCHINI G, CERUTI P, VIZZARI G, Dev Ophthalmol, 50 (2012) 146. DOI: 10.1159/000334796. — 7. DI-ETLEN TS, WIDDER RA, JORDAN RF, JONESCU-CUIPERS C, ROSENTRETER A, Current Options Ophthalmoloe, 110 (2013) 310. DOI: 10.1007/s00347-012-2765-y. — 8. BUDEZ DL, GEDDE SJ, Curr Opin Ophthalmol, 25 (2014) 141. DOI: 10.1097/ICU.0000000000000027. — 9. KANNER EM, NETLAND PA, SARKISIAN SR JR, DU H, J Glaucoma, 18 (2009) 488. DOI: 10.1097/IJG.0b013e31818fb44e. — 10. HUSAIN R, Med Hypothesis Discov Innov Opththalmol, 3 (2014) 20. PMID: 24804277.A. Didović PavičićGeneral Hospital Zadar, Department of Ophthalmology, Bože Peričića 5, 23 000 Zadar, Croatiae-mail: adidovic@yahoo.com242S. Čanović et al.: Capsular Tension Ring, Coll. Antropol. 39 (2015) 1: 239–242KOMBINIRANA POSTUPAK – FAKOEMULZIFIKACIJA I IMPLANTACIJA EX-PRESS MINIATURE GLAUKOMA SHUNTAS A Ž E T A KGlaukomski pacijenti koji ne reagiraju na makimalnu topičku antiglaukomsku terapiju sa pridruženom kataraktom kandidati su za kombinirano opertivno liječenje glaukoma i katarakte. Više je terapijskih mogućnosti. Izbor terapije ovisi o brojnim faktorima vezanim kako za pacijenta tako i za operatera. Implantacija Ex-PRESS mini glaukoma shun-ta je modifi cirana trabekulektomija I može se kombinirati sa operacijom katarakte. U ovom radu prikazali smo naše iskustvo sa ovim kombiniranim postupkom. Naši su rezultati pokazali dobru kontrolu intraokularnog tlaka i poboljšanje vidne oštrine usporedivo sa drugim terapijskim mogućnostima.

Combined Procedure of Phacoemulsififi cation and Implantation of Ex-PRESS Miniature Glaucoma Shunt

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