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Consultation section: Glaucoma

Coincident cataract and glaucoma surgery in an anticoagulated patient

January consultation #1

Samuelson, Thomas W. MD

Journal of Cataract & Refractive Surgery: January 2018 - Volume 44 - Issue 1 - p 111-113
doi: 10.1016/j.jcrs.2018.01.005
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A 68-year-old woman with visually significant cataract and moderate primary open-angle glaucoma (POAG) in each eye presented, hoping for an improvement in visual function because of difficulty with night driving. The patient’s current medications included bimatoprost 0.01% at bedtime in both eyes and timolol 0.5% in the morning in both eyes. The patient is allergic to brimonidine. In addition, the patient who is taking warfarin is chronically anticoagulated for cardiac purposes. Although a recent physical examination showed that the patient was completely stable from a cardiac perspective, it was unclear whether she would be able to discontinue the warfarin, even transiently.

On examination, the patient’s corrected distance visual acuity was 20/30 in each eye and the brightness acuity test was 20/50 in both eyes. The intraocular pressure (IOP) was 16 mm Hg in the right eye and 15 mm Hg in the left eye. The central corneal thickness (CCT) was 505 μm and 508 μm, respectively. Both eyes had +2 nuclear sclerosis and +1 axial posterior subcapsular cataract. The angles were wide open in both eyes. The cup-to-disc ratio was 0.85 in the right eye and 0.9 in the left eye, with an inferior notch in both eyes. There were no disc hemorrhages in either eye. Figures 1 to 3 show sequential visual fields for each eye.

Figure 1
Figure 1:
Generally stable right and left visual fields from 2009, 2010, and 2014, with mild loss in the right eye and moderate loss in the left eye.
Figure 2
Figure 2:
Generally stable right and left visual fields from 2009, 2010, and 2014, with mild loss in the right eye and moderate loss in the left eye.
Figure 3
Figure 3:
Current visual fields in the right eye and left eye, showing ongoing stability.

Please discuss the following considerations: How would you manage the cataract and glaucoma in each eye? In general, what is your approach when surgical glaucoma patients present on warfarin? In this case, which glaucoma procedure would you recommend for each eye assuming the warfarin cannot be discontinued? Would your preferred glaucoma procedure change if the warfarin can be safely discontinued perioperatively? Compliance in this patient is excellent, and she does not mind taking “a drop or 2” each day. Would compliance or willingness to take a simple drop regimen influence your procedure selection?

© 2018 by Lippincott Williams & Wilkins, Inc.