Eyeworld

96 | EYEWORLD | SPRING 2026 G UCOMA that involves iris manipulation or endoscopic laser is also a risk factor for a spike. Dr. Trubnik said most patients without risk factors won't experience true damage to the optic nerve should a pressure spike occur. "It would be exceptionally unlikely. It's possible that very high IOPs can lead to a vein occlusion or an artery occlusion. But again, in all the years that I've been practicing glaucoma, I have not seen it," she said. The patients that merit concern over vision loss or nerve damage due to pressure spikes are those with preexisting glaucoma or undetected glaucoma, Dr. Trubnik added. As such, she said it's now her routine to get an OCT of the macula and optic nerve preoperatively. "If there's any concern, we do something ahead of time, so we don't have to worry about potential complications postop," she said. "The risk of damage is highest in people with severe glaucoma. I always, if I have a severe glaucoma patient, particularly if they're not getting a tube or trabeculectomy, make sure that we have some form of a plan periop- eratively," Dr. Radcliffe said, which can include drops at the end of surgery, topical IOP-lowering drops, and oral acetazolamide. "I think oral acetazolamide is underused in prophylaxis for IOP spikes. A surgeon could use one or even a series of three oral acetazolamide tablets after high-risk cataract surgeries and go a long way to mitigate problems related to postoperative IOP spikes." If a pressure spike occurs days to weeks postop, Dr. Trubnik said a steroid response is often to blame. Preventing pressure spikes In terms of preventing pressure elevations, Dr. Radcliffe said there are things that can be done before, during, and after surgery. "You can have the patient continue their eye drops right up un- til the morning of surgery," he said. "During the surgery, you can take extra time and attention to evacuate the viscoelastic from the eye. Then you can treat them afterward with both IOP-lower- ing drops as well as with oral acetazolamide." Dr. Trubnik said to prevent pressure spikes, she also keeps patients on any pressure-reduc- ing medications they might have been on preop. If their pressure was very high preop and they're a candidate, she offers them a MIGS procedure. This is why Dr. Trubnik said she encourages comprehensive anterior segment ophthalmolo- gists to learn at least one MIGS that can be per- formed along with cataract surgery. However, not all patients want to have a MIGS procedure. "I can't tell you how often I'll have patients say to me, 'I don't want anything else. I just want cataract surgery.'" To this, Dr. Trubnik said she tells them that she strongly advises the additional pressure-lowering procedure because "I don't want you to have a complication or pressure spike." Some studies, such as the HORIZON study with the Hydrus microstent (Alcon), demonstrated a MIGS device can re- duce postop IOP spikes, she said. If a patient has preexisting advanced glaucoma, then the cataract surgery needs to be paired with something more advanced like a tube shunt or trabeculectomy. Intraoperatively, Dr. Trubnik said it's critical to remove all the viscoelastic at the end of the case. Dr. Radcliffe echoed this, saying that it's especially important to be cognizant of visco- elastic removal in cases with floppy iris where it could be missed. Dr. Trubnik said she uses carbachol or acetylcholine, if there are no contraindications. This constricts the pupil, so they have better vi- sion postop day 1, but it also lowers their IOP in the short term. Patients who are at higher risk can also receive a fixed-dose combination agent like brimonidine-timolol or dorzolamide-timolol immediately postop in Dr. Trubnik's practice. "One drop right after surgery blunts an IOP spike," she said. Going further, if she's con- cerned about an increased risk for IOP spikes (like preexisting glaucoma or someone who has had an anterior vitrectomy), she gives acetazol- amide, provided there are no contraindications. Treating pressure spikes Dr. Trubnik said she considers a clinically mean- ingful postop pressure spike in an "average" pa- tient to be 30–35 mm Hg. If this were to occur, she gives the patient a drop in the office and tells them they likely have retained viscoelastic that will take a day or two to subside. She pro- vides these patients with her email and phone number in case they need to call. Performing a paracentesis in the office in those situations is also a viable option. A clinically meaningful pressure spike in a glaucoma patient is based on what their target pressure should be. "If they're 30–40% over continued from page 94

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