EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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I JUNE/JULY 2020 | EYEWORLD | 45 Contact Baudouin: cbaudouin@15-20.fr Lewis: rlewiseyemd@yahoo.com "We also have to consider that the bleb is a cause of trauma—stress between the eyelid and the conjunctiva. If the lubrication is not very good, it may also cause discomfort, but again discomfort due to ocular surface disease is not only a question of discomfort but also mechan- ical stress that can cause inflammatory stress," he explained. In some cases, the trabeculectomy proce- dure can help continue improvement of ocular surface conditions. If the ocular surface was damaged by glaucoma medications and those mediations are stopped due to success of the procedure, the ocular surface improves. "The question here is to not do surgery too late. If we wait for too long with a very damaged ocular surface, the benefit of surgery and removal of the drug will be limited," Dr. Baudouin said. "The eye will be damaged with deep, chronic inflammation, fibrosis, and the bleb will not function properly, so it means it might be necessary again to use medication to control pressure after surgery. Prevention and the appropriate time for surgery are important to consider." Dr. Lewis noted that sometimes the bleb itself can be irritating postoperatively to the oc- ular surface, requiring patients to be on artificial tears. It also can be so large it causes disruption in the even tear flow over the cornea, causing dry spots called dellen. This condition, he said, usually goes away on its own if the bleb shrinks. Considerations for the ocular surface apply to traditional trabeculectomy procedures as well as trabeculectomy-like MIGS, such as the XEN Gel Stent (Allergan) and PRESERFLO (for- merly InnFocus Microshunt, Santen), the latter of which is not yet FDA approved. "Whatever the technique—trabeculectomy, tube in the category of MIGS, whatever—the bleb remains a concern for the ocular surface, a concern preop, a concern periop, and also a concern postop," Dr. Baudouin said. Flat neovascularized failed bleb after surgery Reference 1. Baudouin C. Ocular surface and external filtration surgery: mutual relationships. Dev Ophthalmol. 2012;50:64–78. Relevant disclosures Baudouin: Alcon, Allergan, Aerie Pharmaceuticals, Santen, Thea Lewis: Aerie Pharmaceuticals, Allergan, Alcon Highly inflammatory bleb with mitomycin-C application Ocular surface disease in a glaucomatous patient Source (all): Christophe Baudouin, MD, PhD