Eyeworld

76 | EYEWORLD | JULY 2023 G UCOMA BEST PRACTICES by Liz Hillman Editorial Co-Director About the physicians Michael Greenwood, MD Vance Thompson Vision Fargo, North Dakota Kavitha Sivaraman, MD Cincinnati Eye Institute Cincinnati, Ohio O ptimizing ocular conditions pri- or to surgery is standard for any procedure, but eyes with glaucoma present some extra considerations. EyeWorld spoke with Kavitha Sivaraman, MD, and Michael Greenwood, MD, to get their insights and best practices on how to prepare eyes with glaucoma for different ocular procedures. They also shared a few intraopera- tive and postop considerations along the way. In general, Dr. Greenwood said the main reason these eyes need so much attention is due to topical drop use. "These patients start taking an eye drop once a day, twice a day, then it's multiple drops," he said. "When they're get- ting set up for surgery, their ocular surface and conjunctiva have been chronically irritated. It requires a bit of special attention for that." Dr. Sivaraman expounded on this, saying that preservatives in the glaucoma drops are often the culprit and noted that surgery itself and being on postop drops can further stress the ocular surface. The other issue to watch for is postoperative IOP fluctuations. She said it's important to educate patients about the poten- tial up front, in case glaucoma treatment might need to be escalated in response. Glaucoma surgery Dr. Greenwood spoke about preparing these eyes for tubes or trabeculectomy. "Because these eyes are already inflamed, you've got to start reversing that trend. If you're able to get the eye to quiet down, that involves slowing down or stopping some of their glaucoma medications and starting a steroid," he said. "You remove the agent that's causing the inflammation and you layer on an agent that inhibits that inflam- mation, so you have a nice quiet eye with the hopes that they don't over heal; if they do, it either closes off the bleb or inhibits the flow of aqueous and their pressure goes back up and the surgery has 'failed.'" Dr. Greenwood said reducing inflammation preop and in the early postop period is also im- portant with the XEN Gel Stent (Allergan). For other MIGS that are not performed in conjunc- tion with cataract surgery, he said there's not a lot of surface prep. You do have to pay atten- tion to where you're doing the procedure. For example, Dr. Greenwood said the population is heavily Caucasian where he practices. For these patients who have glaucoma and are older, they often have more fat loss in the orbit, so their orbit is deeper set. Placement of the gonioprisim can be challenging. "I use a stabilizer ring on my gonioprism to help stabilize the eye, and sometimes you need to take that off to get everything in there," he said. "That's one special consideration with MIGS. Trying to get a good view for MIGS can be challenging sometimes." Cataract surgery For cataract surgery, Dr. Greenwood reiterated that the ocular surface of these patients is "beat up," which can interfere with obtaining accurate measurements and thus could affect outcomes. "If their surface is irritated, it needs to be optimized prior to doing their surgery," he said. This could include stopping their glaucoma drops for a period of time, if they're able to. It also can involve artificial tears, punctal plugs, and/or other dry eye treatments. "The therapies we have for ocular surface disease are growing rapidly, and we have a lot of tools to use for each patient," Dr. Greenwood said. "But glaucoma patients may have more inflamed lids or meibomian glands, and paying attention to that can be helpful." Dr. Greenwood said that if a patient cannot be taken off glaucoma medications, this is where a product like Durysta (bimatoprost intracameral implant, Allergan) could be useful. "That would be a perfect situation if you're trying to lessen the medication burden and the patient's glaucoma is severe enough that you can't completely stop their medication, but you could take the topical drop off and put it inside the eye so it's not aggravating the surface," he said. "The postop side is another place where we've used it. You want to keep that inflam- matory agent off the eye, and that's where an implantable medication would work great." Counseling of glaucoma patients takes on other layers before cataract surgery as well. Dr. Greenwood said if they've had prior ocular surgery, their zonules could be weak, which re- quires discussion. He also said his patient popu- lation has a higher rate of pseudoexfoliation. Optimizing the glaucoma eye for surgery

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