EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW MEETING REPORTER 138 October 2014 There are surgical considerations to take into account when doing cataract surgery on a patient with glaucoma. Wound placement par- ticularly needs to be considered in these cases, especially if the surgeon thinks a trabeculectomy is in the patient's future. A superior clear cor- neal wound provides better comfort, and a temporal clear corneal wound will have a better effect on bleb for- mation. Both of these factors should be considered. Dr. Ursell also advised surgeons to used relaxed and famil- iar techniques in wound creation to help get the patient through the operation safely. In terms of postoperative pres- sure management, the first thing to remember, Dr. Ursell said, is that if the patient has a damaged glauco- matous disc, they are susceptible to high pressure. Low pressure is also a concern because this can cause malignant glaucoma. "The last thing to think about is that patients who are on treat- ment for glaucoma do have a high risk of pseudophakic CME," he said. To help guard against this, pretreat the patient with an NSAID up to a week before surgery, which has been shown to be effective. A postop NSAID and steroid drops are helpful for 1 month to several months after surgery. Addressing the cataract early is helpful for glaucoma patients, Dr. Ursell concluded, and avoiding cat- aract surgery after glaucoma surgery is best for these patients. "Cataract surgery gives them better comfort because you get them off drops and it gives them better vision," he said. Canalicular surgery and phaco: The internal approach Thomas W. Samuelson, MD, Minneapolis, Minn., U.S., discussed canalicular surgery and phaco using an internal approach, looking at the Hydrus microstent (Ivantis, Irvine, Calif.). Microinvasive glaucoma surgery offers a diverse group of alternative glaucoma surgeries that are inherently safe and induce con- siderably less tissue disruption than traditional procedures, he said, and prospective randomized trial data suggests that canal-based procedures have similar safety to phaco alone. Phaco already provides modest IOP benefit, the ancilla y effects are beneficial, and it is safe. "We don't want to disrupt those favorable things with our glaucoma management," Dr. Samuelson said. In his work, his glaucoma "portfolio" generally consists of 4 different treatment options: phaco, ab interno stent- ing, trabeculectomy, or an aqueous drainage device. These can handle about 90% of surgeries, he said. The Hydrus microstent is currently in a clinical trial in the U.S. This stent scaffolds and dilates Schlemm's canal, and it is important to make that distinction, he said. It has an open window design and open posterior channel to prevent obstruction of collector chan- nels. An inlet also provides a path through the trabecular meshwork. So far, it seems that the Hydrus provides good biocompatibility and tolerability. The device can be easily put in through the same incision as cataract surgery, generally after the cataract has been removed, Dr. Samuelson said, with elegant im- plantation and preservation of the subconjunctiva and sclera. Dr. Samuelson discussed the 18-month results from the Hydrus II trial, a randomized controlled trial of 100 eyes recruited from 7 European sites. Patients had wash-outs at each visit, and a single masked diurnal IOP at an initial and annual visits. The Hydrus showed promise in a number of results in the trial. In terms of medication, control subjects were 4 times more likely to require medication to control IOP, and control subjects were 2 times more likely to require 2 or more medications. Also, the chance of having a 20% drop of IOP on no medication was greater in the Hydrus group. Dr. Samuelson concluded that the effectiveness of the Hydrus microstent was stable from 12 to 18 months. The Hydrus II trial suggests that phaco and Hydrus is a safer and effective combined procedure for mild to moderate open angle glaucoma (OAG), he said. Surgical challenges of combining MICS and MIGS Dr. Malyugin highlighted some of the surgical challenges of combining MICS and MIGS. About 15% to 20% of patients undergoing cataract surgery have glaucoma, he said. MIGS is done earlier in the course of glaucoma, has a low Reporting from the 2014 European Society of Cataract & Refractive Surgeons (ESCRS) Congress, London 2500 Sandersville Rd., Lexington, KY 40511 USA Phone: 800-354-7848, 859-259-4924 Fax: 859-259-4926 E-Mail: sales@stephensinst.com www.stephensinst.com Femtosecond Laser Cataract Surgery Instruments S5-1535 LRI Enhancement Forceps Cross-action provides accurate spreading of incisions pre- or post-operatively, or during slit-lamp examinations. S4-1700 Femtosecond Spatula Double ended sizing and spear shaped, thin blunted tips offer versatility for opening primary and secondary femtosecond laser incisions. S4-1710 Femtosecond Chopper Special design chops femtosecond laser fragmented nuclei with its unique shaped tip. Visit Us at AAO Booth #3335