Eyeworld

MAY 2020 | EYEWORLD | 69 G Contact Grover: dgrover@glaucomaassociates.com Kahook: malik.kahook@cuanschutz.edu Rhee: dougrhee@aol.com Robin: arobin@glaucomaexpert.com Voicu: lavoicu@eyeboston.com Management of OSD Laura Voicu, MD, discussed management of ocular surface disease (OSD) before and after glaucoma surgery. There is a significant amount of OSD among glaucoma patients, and these can be some of the most challenging cases with the addition of devices, topical medications, pre- servatives, elevated blebs, and anti-metabolite exposure to the eye, she said. Dr. Voicu discussed lid margin disease, noting that to treat, she first uses hypochlorous acid spray and lid scrubs. In addition, BlephEx is good for in-office treatment of lid margin disease, and doxycycline/minocycline are useful, she said. Dr. Voicu said reducing glaucoma drops helps, and thermopulsation and intense pulsed light therapy can work in certain patients. Addressing dry eye before glaucoma sur- gery may be easier than treating what could be worse conditions after surgery. Withdrawal of BAK-containing glaucoma drops in the case of medication toxicity is possible with multiple substitutes available. Significantly elevated blebs or dellen can often be managed with aggres- sive lubrication (but surgical revision may be required), she said. Dr. Voicu suggested reducing repeated ex- posure to antimetabolites in patients with OSD, if possible. To manage limbal stem cell deficien- cy in glaucoma patients after surgery, Dr. Voicu mentioned amniotic membrane techniques. Postoperatively, she recommended preserva- tive-free steroids and antibiotics. In some cases of patients with OSD and the need for ongoing glaucoma management, early surgical intervention, including MIGS pro- cedures, can often be beneficial to reduce the burden of topical medications, she said. Dr. Robin discussed how mitomycin may cause a shift toward vertical flattening and not- ed the potential correlation between astigma- tism and an overhanging bleb. He also said that cautery has been associated with astigmatism in multiple studies, and the use of topical epineph- rine on the eye at the beginning of surgery can minimize the need for cautery. Intraoperatively, Dr. Robin suggested several steps to reduce astigmatism, including reducing cautery, using a smaller sclerostomy to reduce "sinking of the corneal edge of the os- tomy internally," not using overtight or unequal tightness scleral flap sutures, and perhaps using an aberrometer. Corneal hysteresis Davinder Grover, MD, covered corneal hystere- sis (CH), which he described as the only in vivo measurement of corneal/ocular biomechanics. CH is an important factor to be consid- ered in the assessment of risk for glaucoma progression. It represents how well an eye can absorb and dissipate energy, Dr. Grover said, adding that CH is an independent risk factor for glaucoma development and progression. It is reflective of overall ocular tissue properties and provides insight into biomechanical principles of the eye. Dr. Grover said that he will not make clinical decisions in a patient without knowing CH, as it is a "glaucoma vital sign." He added that he's more likely to operate on a patient with uncontrolled glaucoma and a low CH than an uncontrolled glaucoma patient with high CH. However, he noted there are no prospective studies that have evaluated CH and glaucoma surgery. Dr. Grover called central corneal thickness a weak surrogate for CH and a "poor man's corneal hysteresis." The take-home point is that a low CH is associated with an increased risk of glaucoma development and progression (usually a CH less than 10 mm Hg), while a higher CH is associated with a lower risk of glaucoma de- velopment and progression (usually a CH above 10 mm Hg). Relevant disclosures Grover: Aerie, Allergan, Bausch + Lomb, New World Medical, Reichert Technologies, Glaukos, MicroOptix, New World Medical Kahook: SpyGlass Ophthalmics, Equinox, Ivantis, Fluent Ophthal- mics, ShapeTech, Aurea Medical, Alcon, Johnson & Johnson Vision, New World Medical Rhee: Aerie, Ivantis, Allergan, Al- con, Ocular Therapeutix, Glaukos Robin: None Voicu: New World Medical, Katena

• Blank Page
• Blank Page (1)