Eyeworld

88 | EYEWORLD | SEPTEMBER 2021 G UCOMA Relevant disclosures Berdahl: Alcon, Allergan, Carl Zeiss Meditec, Glaukos, Johnson & Johnson Vision, New World Medical Boese: None Grover: Aerie, Allergan, New World Medical, Santen Shareef: None Sheybani: Alcon, Allergan, Ivantis, New World Medical, Santen Tai: None 1. Control the pressure. This starts preoperative- ly with topical and oral medications. Make sure the speculum is not tight or resting on the eyeball. 2. Make the patient comfortable. Don't be stingy on anesthesia. 3. Deepen the chamber (but not too much). You only need a few seconds to deepen. 4. Take advantage of technology. Dr. Tai sug- gested using the femtosecond laser to assist. 5. Stay in the bag. Try not to do supracapsular cataract extraction in a shallow AC. Shakeel Shareef, MD, discussed cataract surgery in patients with pseudoexfoliation. He said to assume all patients have pseudoexfolia- tion, noting that it might not be evident during an office exam and might come up for the first time in the OR. Some of the preoperative signs of zonulop- athy include asymmetry of the anterior chamber and angle depth, lens subluxation, phacodo- nesis, iridodonesis, and poor dilation, among others. "We can decrease the risk of late sublux- ation by taking steps to respect the zonules intraoperatively," Dr. Shareef said. He said that it's important to minimize side- to-side and up-and-down movements, maintain a stable anterior chamber, perform careful hy- drodissection/delineation, and perform tangen- tial phaco and I/A vs. radial forces. Dr. Shareef also discussed the possibility for a small pupil in these cases and said it's import- ant to enlarge to gain access. This can be done with cohesive viscoelastic or with mechanical options. He added that it's "vital to create an optimal anterior capsulorhexis." The optimal size is about 5–6 mm; too small of a rhexis could lead to damage to the zonules during lens rotation. He added that hydrodissection/hy- drodelineation is an essential step for separating the lens from the capsule zonular complex. When sculpting, don't push. "Let the phaco handpiece lead you, like a dog pulling his own- er on a leash" to avoid stress on the zonules, Dr. Shareef said. He also gave tips for maintaining a stable anterior chamber, especially when transitioning from phaco to I/A and from I/A to lens implan- tation. Before pulling out the phaco handpiece, If the patient has had a prior tube shunt, Dr. Grover said that cilioablation works extremely well. He recommended CPC or ECP. Dr. Grover also mentioned angle closure dis- ease, secondary OAG, and the health of the cor- nea as important factors to consider. For those with angle closure disease, he recommended phaco alone or possibly phaco and goniotomy, depending on the IOP and stage of the disease. For those with secondary OAG, Dr. Grover said these patients tend to do better with goniotomy or ab interno trabeculotomy. He also noted that if the patient has endothelial dysfunction and may need some form of corneal replacement, you may want to consider a tube shunt. For patients with "real" disease who are not able to use drops appropriately, Dr. Grover said he considers subconjunctival MIGS to maximize the chance of a lower IOP, or he may consider phaco/Hydrus or phaco/goniotomy first, with a possible standalone XEN at a later time. It's very important to manage patient expec- tations, Dr. Grover said. In general, the greater the IOP lowering, the greater the risk of surgery. The main goal of MIGS in most cases of mod- erate to advanced glaucoma, Dr. Grover said, is to decrease the dependence on drops. He rarely promises to get a patient off all drops. Tak Yee Tania Tai, MD, presented on cat- aract surgery in patients with primary angle closure glaucoma. When considering cataract extraction in patients with shallow anterior chamber, Dr. Tai said that a good preoperative evaluation should be performed, assessing for zonular dehiscence and secondary causes of shallow AC. Gonios- copy is also useful for determining if any angle procedure should be done, she said. Endothelial cell count is helpful for surgical planning. Even without other preexisting factors, operating in the limited space of a shallow AC is challenging, she said. There is increased risk of endothelial compromise and Descemet's de- tachment. Difficulty maintaining a deep AC may allow the lens to move forward, and the poste- rior capsule may be harder to avoid. Aqueous misdirection and suprachoroidal hemorrhage may also be more common. Dr. Tai said it's important to have a game plan for these cases. Her five steps include: continued from page 87

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