Eyeworld

I MIGS UPDATE JULY 2019 | EYEWORLD | 43 blood reflux," he said. Although MIGS mimics cataract surgery, there are other considerations because he wants patients to know that it's more than just removing a cataract. You have to adjust for the pressure, and vision may not be as clear postop day 1 as with traditional cataract surgery. More serious complications that can occur include cyclodialysis and Descemet's detach- ment, Dr. Patrianakos said, and the best way to avoid them is to ensure that you have a crystal clear view of the angle when performing sur- gery. A cyclodialysis cleft may occur by inserting an iStent in the wrong position or by doing GATT where you could inadvertently create this. Procedures that require ab interno vis- codilation of Schlemm's canal have a risk of developing a Descemet's tear, if you inject viscoelastic too vigorously. Dr. Patrianakos said that if the tear is superior, the surgeon can leave it and use an air bubble to push Descemet's back into place. Even in other locations, he said the tears tend to be more peripheral and don't affect visual acuity much. "While each MIGS has its own possible complications, we as surgeons continue to modify our technique to minimize these and to better manage them when they arise," he said. This ultimately provides a safer alternative for patients than more invasive traditional glaucoma procedures. To handle blood reflux, Dr. Patrianakos suggested using viscoelastic, "your best friend when it happens." Make sure you push the blood away, he said, and be sure to use it as frequently as needed to ensure a good view. Putting the patient in a reverse Trendelen- burg position can decrease episcleral venous pressure and can also be helpful in reducing blood reflex intraoperatively. It is also essential to minimize trauma to the iris or ciliary body, as this can cause additional bleeding. If possible, consider stopping anti-coag- ulation preoperatively, Dr. Patrianakos said. This requires consulting with the primary care physician to see if it's a plausible option. Finally, he added knowing "when to aban- don ship" is important. If you're doing a proce- dure and there's a constant reflux of blood that keeps coming despite all efforts to impede it, it may be best to stop. Consider transferring to another site or revisiting the surgery on another day. "In general, when I consent patients for these procedures, my consents mimic that for cataract surgery," he said. "We are making an incision in the eye, so there's a chance of infection, pain, bleeding, and a need for another surgery." He warns patients that there may be fluc- tuations in IOP that need to be dealt with early, though they tend to even out. "I also warn them about the possibility of decreased vision on postop day 1 depending on About the doctors Jacob Brubaker, MD Sacramento Eye Consultants Sacramento, California Thomas Patrianakos, MD Cook County Health Northwest Chicago Eye Specialists Chicago Financial interests Brubaker: New World Medical, Ivantis, Glaukos Patrianakos: None Intraoperative hyphema during insertion of an OMNI Glaucoma Treatment System Source: Thomas Patrianakos, MD

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