Eyeworld

DECEMBER 2023 | EYEWORLD | 69 G by Ellen Stodola Editorial Co-Director About the physicians Erin Boese, MD Clinical Assistant Professor of Ophthalmology and Visual Sciences Carver College of Medicine University of Iowa Iowa City, Iowa Michael Boland, MD, PhD Associate Professor of Ophthalmology Mass Eye and Ear Harvard Medical School Boston, Massachusetts with a MIGS procedure. However, the caveat that Dr. Boland mentioned was patients who may have had trabeculectomy a long time ago when fewer surgical options were available. If you decide that the pressure doesn't need to be that low, Dr. Boland suggested that the surgeon try a less invasive procedure if that trabeculec- tomy fails. "If your target is not 12 but maybe 18, I would potentially consider some other kind of procedure at the same time," he said. "I tend to think of MIGS as important for certain targets, but they're not currently interchange- able with trabeculectomy." Erin Boese, MD, said that cataract surgery with a well-functioning trabeculectomy can be particularly tricky for a couple of reasons: the risk of bleb failure and errors/variability in the IOL calculations. In both cases, a good preop- erative conversation is necessary to manage expectations appropriately. "What I worry about the most is that the cataract surgery may cause W hen performing cataract surgery on patients who have a function- ing trabeculectomy, there may be an increased risk of trabe- culectomy failure. Michael Boland, MD, PhD, and Erin Boese, MD, dis- cussed this risk and how to approach patients. Dr. Boland said it's important to be sure patients are aware that there is an increased risk that the trabeculectomy will fail if you do surgery, including cataract surgery. In some cases, the trabeculectomy may not be working optimally preop, and cataract surgery may be a good opportunity to revive it. Dr. Boland would consider some sort of bleb needling procedure at the time of cataract surgery. He said that since MIGS procedures gener- ally don't get the pressure as low as trabeculec- tomy, he usually wouldn't choose to do cataract surgery plus MIGS if the trabeculectomy failed. He usually tries the needling procedure first because if the patient needed lower pressures to begin with, you're much less likely to get that Complications in cataract surgery with a functioning trabeculectomy continued on page 70 Needling of a focal trabeculectomy bleb at the time of cataract surgery. The anterior chamber infusion helps the surgeon identify a successful needling by producing a fluid wave into the bleb as adhesions are lysed. Source: Michael Boland, MD, PhD

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