Eyeworld

EW FEATURE 46 Facing complicated glaucoma cases • February 2019 • Consider using a drainage device such as the Ahmed valve (New World Medical) instead of a trabeculectomy, and use a sutured tube to avoid postop hy- potony, Dr. Lewis recommended. • Use an ophthalmic viscosurgical device more copiously intraop- eratively to help limit bleeding, Dr. Lewis advised. EW Editors' note: Dr. Lewis has financial interests with Aerie Pharmaceuticals (Irvine, California), Allergan (Dublin, Ireland), Alcon (Fort Worth, Texas), and other ophthalmic companies. Dr. Vold has financial interests with Aerie Pharmaceuticals, Alcon, Glaukos (San Clemente, California), and other oph- thalmic companies. The other physi- cians have no financial interests related to their comments. Contact information Lewis: rlewiseyemd@yahoo.com Rhee: dougrhee@aol.com Song: brian.j.song@kp.org Vold: svold24@gmail.com Balancing continued from page 44 the IOP decrease with a given MIGS procedure is modest, he added. That said, Dr. Song sometimes will offer MIGS to a patient using only antiplatelet therapy, such as aspirin. "In our own study of hemor- rhagic complications from glaucoma surgery, continuation of anticoagu- lation therapy was associated with a higher rate of hemorrhagic compli- cations than antiplatelet therapy. While our study did not include MIGS procedures, I do think this finding is applicable in other clinical scenarios as well," Dr. Song said. In Dr. Vold's experience, it's better to avoid trabecular bypass cutting procedures such as a goniot- omy or the Kahook Dual Blade (New World Medical, Rancho Cucamon- ga, California) in anticoagulant therapy patients. However, he sees fewer issues with most other MIGS approaches. "The key thing is you don't want to open a blood vessel," he said. Stay aware of potential long-term risks; after a Trabectome (NeoMedix, Tustin, California), a patient could cough years later and have a small hyphema in the anteri- or chamber, Dr. Vold cautioned. Other surgical approaches and pearls Proper surgical technique in patients on chronic anticoagulation thera- py can help lead to a flat anterior chamber and reduce the risk for bleeding. A few pearls shared with EyeWorld by glaucoma specialists include the following: • Consider transscleral laser, such as micropulse cyclophotocoag- ulation. "Though I routinely per- form a retrobulbar block prior to transscleral diode laser, I find that some patients are able to tolerate micropulse cyclophotocoagula- tion with heavy intravenous se- dation in the absence of a block," Dr. Song said. "I like this option for anticoagulated patients since it is noninvasive and also avoids the risk of a retrobulbar hemorrhage by forgoing the block." • Pre-place scleral flap sutures when performing a trabeculec- tomy, Dr. Song advised. Howev- er, consider using a non-valved glaucoma drainage device such as a Baerveldt 250 (Johnson & John- son Vision, Santa Ana, California) or Molteno3 (Molteno, Dunedin, New Zealand) if the patient does not require an immediate IOP reduction. "These devices poten- tially allow for more controlled pressure reduction via laser suture lysis of the ligature suture during the postop period," he explained. • Tie the sutures a little more tightly during trabeculectomy, Dr. Vold recommended. Wait a couple of weeks to cut the stitches. • Make a paracentesis at the 6 o'clock position in case of a postop hyphema. "The inferior paracentesis can be used to drain a hyphema at the slit lamp and avoid returning to the OR for an anterior chamber washout in some cases," Dr. Song said. • Don't overlook anesthesia, said Dr. Song, who usually will give a sub-Tenon's block instead of a peribulbar or retrobulbar block. • If a patient is able to stop anti- coagulant therapy, make sure it is out of his/her system before proceeding with surgery. For instance, Dr. Vold generally waits 3 days after warafin is stopped. Otherwise, you still could experi- ence negative after effects. Heme after Kahook Dual Blade procedure Heme viewed though gonioscopy after MIGS procedure Heme after OMNI Glaucoma Treatment System procedure Diffuse heme after OMNI Glaucoma Treatment System procedure Source (all): Steven Vold, MD

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