Eyeworld

DECEMBER 2023 | EYEWORLD | 71 G Relevant disclosures Boese: None Boland: Allergan, Carl Zeiss Meditec, Janssen, Topcon Healthcare Contact Boese: erin-boese@uiowa.edu Boland: Michael_Boland@ meei.harvard.edu cataract surgery, Dr. Boese said, adding that intraoperative iris manipulation increases the risk of inflammation and bleb failure. "Anything intraoperatively that increases inflammation will increase the risk of postop failure, but many of these factors are unavoidable," she said. "You can't treat a cataract after a trabeculec- tomy the same way as a cataract in someone without a bleb," Dr. Boese said. "You wouldn't be faulted to send the patient to have the cataract surgery done by a glaucoma specialist or even better, the person who performed the trabeculectomy. The most important thing is to increase the postoperative steroid regimen sig- nificantly. Even a quick, straightforward cataract surgery can lead to enough inflammation to scar down the bleb." She doesn't rely on intracam- eral antibiotics and will often have patients use topical antibiotics after the surgery for a week. Dr. Boland didn't note any particular tech- nologies to reduce the risk of the trabeculec- tomy failing, but he did say it's important to minimize the surgery time because you want to create the least amount of inflammation possi- ble. He injects an antimetabolite adjacent to the bleb after the cataract surgery and uses frequent topical steroids to reduce inflammation and any fibrosis that may occur. Bleb failure following cataract surgery is always disappointing, Dr. Boese said, but some- times unavoidable. "We can add back glaucoma drops, revise/needle the bleb, or in some cases, perform another trabeculectomy or tube," she said. "I typically find that bleb needling is less effective in mature blebs, but I have had a lot of success with needling a mature bleb failing shortly after cataract surgery. If the conjunctiva is healthy enough to withstand a needling, this is where I'd start, often with an antimetabo- lite like mitomycin-C. If we just need the IOP down slightly, adding back glaucoma drops is a possibility." Dr. Boese said that intraoperatively, she doesn't find that the fluidics change much following a trabeculectomy, as long as it is a mature bleb. "However, I often use a lower infusion pressure with the goal of causing less bleb turbulence," she said. "I used to try to put a dollop of cohesive viscoelastic material near the sclerostomy, but this never made any differ- ence. I am a bit more careful not to disturb the trabeculectomy externally as well. This means not using a fixation ring, toothed forceps on the conjunctiva, or nicking the bleb with your main or paracentesis wounds." LESSONS LEARNED 1. In order to improve flow in a busy glaucoma clinic, I have learned from senior colleagues that it may be helpful to split up the exam into two parts on separate visits. Perform an OCT RNFL, gonioscopy, and a non-dilated exam with a 90 D lens on the first visit, and bring the patient back for a visual field, dilated exam, and disc photos on follow-up. Portable VR visual field sets may also help improve efficiency. 2. I've learned that it's critical to be firm with patients about their set target pressures and IOP control and to hold them accountable regularly during their visits. 3. My cornea colleagues have taught me that cyclosporine drops are often underutilized in glaucoma in improving dry eye, which is ubiquitous among our patients, and to help quiet inflamed eyes, especially prior to any filtering surgery. Valerie Trubnik, MD, Glaucoma Editorial Board member, shared lessons she has learned to "level up":

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