Eyeworld

I OCUR SURFACE CONSIDERATIONS FOR SURGERY N FOCUS 44 | EYEWORLD | JUNE/JULY 2020 About the doctors Christophe Baudouin, MD, PhD Professor of ophthalmology Quinze-Vingts National Eye Hospital & Vision Institute Paris, France Richard Lewis, MD Sacramento Eye Consultants Sacramento, California At a glance • The ocular surface is a con- sideration preop, intraop, and postop for trabeculectomy and trabeculectomy-like MIGS. • An inflamed ocular surface can lead to increased fibrosis and subsequent bleb failure. • Taking care of the ocular sur- face preoperatively and post- operatively can prevent some of this fibrosis, enhancing the potential for the procedure's success. • Considering less invasive surgical procedures at an earlier stage (rather than when patients might be on multiple drops causing ocular irritation) could have a protective effect for the ocular surface as well. O ptimization of the ocular surface is increasingly a discussion point in the realm of cataract surgery, but the ocular surface impacts the suc- cess of many other procedures as well, including glaucoma surgery. "A good ocular surface is necessary to have a good surgery," said Christo- phe Baudouin, MD, PhD, adding that patients on multiple topical treatments for glaucoma (the typical patient scheduled for a traditional trabeculectomy or MIGS-style trabeculectomy) often have a poor ocular surface preoperatively. "If it's not controlled, they will have a very poor surgery." If the ocular surface is already in a pro-in- flammatory state before surgery, Dr. Baudouin said it will be more inflammatory afterward, in- creasing the risk of fibrosis, which could lead to less efficacy of the bleb, bleb failure, and worse IOP control postop. "As preoperative inflammation underlies postoperative fibrosis and therefore surgical outcome, a better knowledge of ocular surface changes with appropriate evaluation and man- agement should thus become a new paradigm in glaucoma care over the long term," Dr. Baud- ouin wrote in a paper published in 2012. 1 The first step in achieving this paradigm shift, Dr. Baudouin said, is prevention, remov- ing the compounds responsible for inflamma- tion. This could be preservatives but not always. He said it's important to realize the compound- ing effects of preservatives from multiple drops as well as the potential for drug allergies that cause an inflammatory response, such as brimo- nidine. Richard Lewis, MD, echoed that brimoni- dine is a good one to stop a couple of weeks prior to surgery, if possible. "Their eyes get very irritated, and trying to do a trabeculectomy in that setting is difficult because they tend to bleed more, have more irritation, and are more likely to fibrose," Dr. Lewis said. Dr. Lewis mentioned that many drugs that have a mechanism of action based on vasodila- tion potentially have a similar effect. The ocular surface for trabeculectomy and trabeculectomy-like MIGS by Liz Hillman Editorial Co-Director Dr. Baudouin's second step is to treat the ocular surface. This can be done with preser- vative-free artificial tears, cyclosporine, or a low-dose steroid. Steroids, he noted, can raise intraocular pressure (an especially undesired effect for glaucoma patients), thus he recom- mended short-term use. "You need to balance between risk of the steroid and the interest of decreasing inflamma- tion," he said. Finally, Dr. Baudouin said his third point is to consider surgery at an earlier stage with, potentially, a less invasive technique. "For a patient with uncontrolled glaucoma on two eye drops, rather than adding a new drug or changing for a new drug, it's probably better to go to surgery," he said, noting laser trabeculoplasty and several MIGS options avail- able. "Propose surgery earlier than an end-stage glaucoma patient with a poor ocular surface." Postoperatively, Dr. Lewis said patients take a steroid four times a day for 3–6 weeks. Mitomycin, used intraoperatively, might also be needed postop as well to inhibit fibrosis. "We'll take a patient 6–8 weeks postop and in the office use mitomycin in a syringe, inject it near the bleb to try to kill any rapidly dividing cells, and that will slow down the fibrosis or stop it," he explained. Dr. Baudouin said he's very careful with steroids postop, using them for a short period of time (a few weeks) after surgery. He said he might also use a non-steroidal and prescribes preservative-free artificial tears. "Whatever the technique … the bleb remains a concern for the ocular surface, a concern preop, a concern periop, and also a concern postop." —Christophe Baudouin, MD, PhD

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