Eyeworld

EW GLAUCOMA 38 byline goes here plus fade November 2018 Text goes here like avoiding myotic drugs and the prolonged use of atropine after trab- eculectomy, placing laser peripheral iridotomies, using transscleral diode before surgery, avoiding anterior chamber shallowing with visco- elastics, tight scleral flap suturing, adjustable sutures, and performing lens extraction are all steps to take to avoid malignant glaucoma," Dr. Fekih said. "For a phakic patient with PACG, lens extraction should be the primary procedure, even be- fore trabeculectomy, because there is a lower risk of malignant glauco- ma after cataract surgery and it is easier to manage the condition in pseudophakic eyes. Finally, prophy- lactic vitrectomy combined with phacoemulsification is indicated when there is a history of malignant glaucoma in the fellow eye. For the management of malignant glauco- ma, we can propose the following: medical, then Nd:YAG laser, and finally surgical. Surgical treatment is indicated when medical treatment fails," she said. EW References 1. Wong MMY, et al. Aqueous misdirection. EyeWiki. 2. Debrouwere V, et al. Outcomes of different management options for malignant glaucoma: a retrospective study. Graefes Arch Clin Exp Ophthalmol. 2012;250:131–41. 3. Dorairaj S, et al. Diagnosis and manage- ment of malignant glaucoma. EyeNet. Ameri- can Academy of Ophthalmology. April 2010. Editors' note: Dr. Fekih has no finan- cial interests related to her comments. Contact information Fekih: olfa.fekih@gmail.com a 65% success rate. "This process is called vitrectomy/phacoemulsi- fication/vitrectomy for the man- agement of aqueous misdirection syndromes in phakic eyes," Dr. Fekih said. "The first step is a partial vitrectomy to unblock the vitreous and soften the eye and deepen the anterior chamber. This is followed by phaco. Lens removal is important in phakic patients with malignant glaucoma because lens extraction and the effective removal of the anterior hyaloid create space, and the artificial IOL is much thinner than the crystalline lens. It is also recommended to cut the posterior capsule in the center. The last step is to complete the core vitrectomy. In severe cases, a complete pars plana vitrectomy is indicated." A review of the literature reveals that surgical treatment allows patent communication between the vitreous cavity and the anteri- or chamber. Compared with other modalities, surgery, especially, compete vitrectomy with phaco and zonulo-hyaloidectomy, is the most successful modality, when compared to laser and medical treatments. A complete vitrectomy combined with iridectomy and zonulectomy (and phacoemulsification, if applicable) was seen in a study of 24 eyes in 21 patients with malignant glaucoma to most successfully manage aque- ous misdirection syndrome. 2 Once the AC deepens and IOP has been normalized, medical treatment can be withdrawn gradually. The patient may require indefinite treatment with cycloplegics to prevent recur- rence if vitrectomy was not per- formed. 3 Avoiding malignant glaucoma "Screening predisposing eyes, use of prophylactic perioperative measures It's time to rethink and redefine the medical conference. FEBRUARY 15-18, 2019 • PUERTO RICO REGISTER ONLINE: www.envisionsummit.org Diagnostic continued from page 37 " For the management of malignant glaucoma, we can propose the following: medical, then Nd:YAG laser, and finally surgical. " —Oifa Fekih, MD

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