Eyeworld

92 | EYEWORLD | MARCH 2020 by Stefanie Petrou Binder, MD EyeWorld Contributing Writer P ost-keratoplasty glaucoma or elevated pressures can cause optic nerve dam- age, leading to irreversible vision loss after corneal surgery. According to ret- rospective research that compared full thickness corneal transplants to newer, partial thickness transplant techniques for glaucoma incidence and associated risk fac- tors, endothelial keratoplasties benefited from lower IOP and reduced need for topical steroids but did not diminish the need for glaucoma drops or surgery over a 2-year postoperative period. The study was shown as an e-poster at the 2019 ASCRS ASOA Annual Meeting. Full-thickness PKP vs. DMEK and DSAEK/DSEK The retrospective review of keratoplasties was performed by Priscilla Vu, MD, and her team from July 2012–July 2017 at the Gavin Herbert Eye Institute. It compared IOP, daily steroid frequency, mean number of glaucoma medi- cations, and recommendations for glaucoma surgery preoperatively and at several postopera- tive time points, for a follow-up period of up to 24 months. The analysis revealed 635 corneal trans- plants within the 5-year time period. Of these, 396 were excluded for fulfilling exclusion criteria, including prior history of glaucoma, prior corneal or glaucoma surgery, concurrent major surgery, need for emergent surgery, active infection, and eye disease with synechiae (i.e., iridocorneal endothelial syndrome or uveitis neovascular glaucoma). Of the 239 cases of corneal transplants that were included in the retrospective analysis, 127 were full-thickness penetrating keratoplasties (PKP), 46 were DMEK, and 66 were DSAEK or DSEK, be- longing to the newer, partial thickness corneal transplant techniques. G UCOMA Study shows better IOP after endothelial keratoplasty compared to PKP PRESENTATION SPOTLIGHT About the doctor Priscilla Vu, MD Department of ophthalmology Gavin Herbert Eye Institute University of California, Irvine Irvine, California continued on page 94 estrogen and progesterone," she said. This may translate into less of a pressure-lowering need for women during pregnancy. Clinical possibilities In cases where IOP lowering is needed, howev- er, Dr. Wirostko said SLT is a good option. "I think also if the patient knows that they want to get pregnant, then you can do the laser ahead of time and see if you can get them off of their medications while they're trying to conceive," she said. Use of MIGS may be another possibility. "The only problem with MIGS is that some of the shunting procedures have to be performed at the same time as cataract surgery in order to get reimbursed," Dr. Wirostko said. Other surgical approaches may be problem- atic as well in pregnant women due to increased levels of VEGF and platelet-derived growth factor in the blood, she continued, adding that a lot of these proteins and cytokines can induce scar tissue. This may raise questions as to whether a pregnant woman would be a good candidate for a trabeculectomy, for example. The need for anesthesia may also play a role when considering glaucoma surgery. "We gen- erally prefer not to put pregnant women under anesthesia," Dr. Wirostko said. If using a medication to lower IOP, a beta blocker would be preferable. "Obstetricians use beta blockers quite comfortably during pregnancy," she said. "I think as clinicians that gives us comfort in using a topical beta blocker during pregnancy." The fact that beta blockers are also used in children and have been around longer than most glaucoma medications also adds to this comfort level, Dr. Wirostko said. Due to ethical and legal concerns Dr. Wirostko doesn't envision a time when it would be possible to run a prospective trial on preg- nant women with glaucoma. "I think it's just collecting data where we can and being mindful that the fetus is getting exposure to plasma and that there also may be ingestion of drug through breast milk," she concluded. continued from page 90

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