Eyeworld

MAR 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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March 2012 phacoemulsification on undergone trabeculectomy. It is not possible based on this study to deter- mine whether a more aggressive anti-inflammatory post-op regimen would have decreased the risk of sur- gical failure. An additional limitation of the study is the inclusion of patients with both POAG and PXG. It is not possible to determine based on the data presented whether the glau- coma diagnosis played any signifi- cant role in the patients' post-op outcomes. Although the univariable analysis was not significant, it is not clear if the study was adequately powered to detect a difference. Fur- thermore, additional analyses would be useful to address the impact of other factors such as why different MMC dosages were used in the study, the amount of phaco power required during surgery (reflects density of cataract), and whether there is a difference in failure rates among limbus or fornix-based inci- sions. Finally, the exclusion criteria, which include pre-trabeculectomy IOP less than 21 as well as any prior ocular surgery, may limit the gener- In the wake continued from page 115 blocker. Propranolol 10 mg can help the hand tremor and tachycardia that accompanies surgical anxiety. A drop of sublingual timolol oph- thalmic solution can also work. But don't try it the first time on the morning of your case. Test it a few days in advance to make sure that you can tolerate the medication. Intraoperative: 1) Surgeon com- fort is key. Correct body and hand position is critical in controlling a tremor. 2) Before the patient is prepped the resident should position the patient and microscope and make sure the foot pedals of the mi- croscope and phaco machine are in a good position. 3) Wrist fatigue can cause a tremor. During the case the surgeon's wrist should be supported either on the patient's cheek or brow or on a wrist rest affixed to the stretcher. 4) Holding the instru- ments too tightly causes muscle cramps, finger fatigue, and a tremor. Taking a break for a few relaxing breaths and finger stretches help. Holding instruments too close to the tip decreases the range of motion and fluidity of movement with the fingers, again leading to wrist and finger fatigue. 5) Sometimes I just hold a resident's hand to calm the tremor and guide the instrument through a difficult step. Once I feel the resident relax and take over the maneuver I let go—surgical training wheels. EW References 1. Elman MJ, Sugar J, Fiscella R, Deutsch TA, Noth J, Nyberg M, Packo K, Anderson RJ. The effect of propranolol versus placebo on resi- dent surgical performance. Trans Am Ophthal- mol Soc. 1998;96:283-91; discussion 291-4. 2. Humayun MU, Rader RS, Pieramici DJ, Awh CC, de Juan E Jr. Quantitative measurement of the effects of caffeine and propranolol on surgeon hand tremor. Arch Ophthalmol.1997 Mar;115(3):371-4. Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Karp: ckarp@med.miami.edu Mian: smian@med.umich.edu Miller: eydie.miller-ellis@uphs.upenn.edu alizability of these conclusions to glaucoma patients that do not meet these criteria. In summary, this study provides important considerations prior to performing phacoemulsification sur- gery in post-trabeculectomy pa- tients. The authors report that higher pre-trabeculectomy IOP and phacoemulsification within 1 year after trabeculectomy are important risk factors for trabeculectomy fail- ure. Due to the limitations noted above, the study cannot address some important clinical questions such as whether a more intensive anti-inflammatory regimen after phacoemulsification helps prevent surgical failure and whether it would be beneficial for patients who de- velop cataracts soon after trabeculec- tomy to defer phacoemulsification until 1 year post-trabeculectomy. Fu- ture prospective randomized trials will be required in order to address these questions and provide impor- tant guidance for clinicians. EW Contact information Challa: pratap.challa@duke.edu

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