Eyeworld

JULY 2023 | EYEWORLD | 77 G Contact Greenwood: michael.greenwood@ vancethompsonvision.com Sivaraman: ksivaraman@cvphealth.com Relevant disclosures Greenwood: None Sivaraman: None "Glaucoma patients in general but especial- ly pseudoexfoliation patients are at higher risk for IOP spikes after cataract surgery, so be on the lookout for that," he said, adding that he ex- plains to both of these sets of patients that their healing might take longer. Dr. Sivaraman, in addition to detailing the importance of preoperative surface prep to en- sure accurate measurements, also discussed the things she prepares certain glaucoma patients for from a counseling standpoint. "In patients with anatomically narrow an- gles or angle closure glaucoma, I always look at the anterior chamber depth and the density of the nucleus because the combination of a dense, thick lens with a shallow anterior chamber pre- disposes them to postoperative corneal edema, partly due to there being less physical distance between the ultrasound probe and the endothe- lium," she said. "That becomes more significant with increasing density of the nucleus, espe- cially if they have endothelial disease. I try to counsel patients with these risk factors that they may experience prolonged edema after surgery and potentially need a transplant later. IOL pre- dictions also tend to be less accurate in patients with shallow anterior chambers, large lenses, and short axial length. … Although we can nev- er guarantee glasses-free vision for any patient, it's important for these patients to realize they may have a wider landing zone." Dr. Sivaraman also said the presence of a temporal peripheral iridotomy affects where she makes her incision. "I now try not to make my incision directly over the peripheral iridotomy. I find that the iris tends to be floppy in the area of the iridotomy and can prolapse more easily when the incision is made directly above it." Postoperative regimens can be affected by glaucoma as well. "You have to watch them closely for toxicity related to the additional preservative that you might have them on. That might be someone where you might consider using an intracameral antibiotic and skipping a postoperative antibiotic," Dr. Sivaraman said. "You might consider doing some sort of im- plantable steroid. You've got to be careful with that though because these are the patients who are more likely to have a postoperative steroid response. Patients with a poor ocular surface, if they don't otherwise have a lot of risk factors for CME, I might skip a prophylactic NSAID, which tends to be the biggest culprit in terms of exacerbating ocular surface disease after cataract surgery." Dr. Sivaraman said she likes to have optimal control of glaucoma and IOP before heading into elective cataract surgery. A high IOP could put the patient at risk for perioperative IOP fluctuations and suprachoroidal hemorrhage. "When possible, I think the best treatment is prevention," she said. Cornea surgery For a surface cornea procedure, Dr. Greenwood said limiting inflammation is a factor again. "You want to be very aggressive in getting that to heal, so consider putting in permanent plugs, using a different bandage contact lens, or may- be add an amniotic membrane that will give nutrients … and get the epithelial defect to heal in a timely fashion. Maybe back off on some of the glaucoma medications so that the epitheli- um has the support to heal over those few days or a week," he said. If an endothelial transplant is needed, Dr. Greenwood said, in the setting of a tube or trab, the difficulty is getting the air bubble to stay inside the eye. "It's a battle between how well your glaucoma device is working versus keep- ing the gas inside the eye," he said. "There is a little bit more education on the front end and guiding expectations." He also said these eyes are at higher risk for pressure spikes, so heavy steroids might be used, but then you're at risk for the glaucoma procedure to fail. "There are a couple of steps, so it may not be on optimization of the eye, but education and the aftercare gets quite detailed," he said. Dr. Sivaraman also said that graft adher- ence can be more difficult in the presence of a filtering bleb or tube, and in general, the lifetime of these grafts is shorter than in an oth- erwise anatomically normal eye. It is important for patients to be aware that they may need repeat endothelial keratoplasty in the future. Example of coarse and diffuse punctate keratopathy from BAK toxicity. Source: Kavitha Sivaraman, MD

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