EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW INTERNATIONAL 56 November 2014 by Lauren Lipuma EyeWorld Staff Writer Glaucoma pearls from down under T he success of glaucoma surgery is dependent on three phases—patient selection and preoperative planning, intraoperative management, and postoperative care, said Catherine Green, MBChB, FRANZCO, MMedSc, head of the glaucoma unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia, at the Women in Ophthalmology (WIO) 2014 Summer Symposium. Working at the largest eye hospital in Australia, Dr. Green sees mostly complicated glaucoma cases—20% of the patients in her clinic are blind in one eye, and 20% are under the care of a different ophthalmic specialty unit. In her presentation "Glaucoma Surgery in Oz: Ten Tips from Down Under," Dr. Green shared the pearls she has learned from operating on complex glaucoma cases and the tips that are most helpful to her residents when learning glaucoma procedures. Preoperative considerations Preoperatively, it is critical to know when to hold and when to fold, Dr. Green said—the surgeon needs to be able to detect when a patient's dis- ease is progressing and know which procedure is best for each patient. A big investment the surgeon should make upfront is to ensure the patient understands the indications for surgery. "Make sure your patient has re- alistic expectations and understands that they may be embarking on a bit of a roller coaster when you embark on surgery together," said Dr. Green in a video interview with EyeWorld. To optimize the intraoperative conditions preoperatively, find out if the patient has any allergies to eye drops, make sure that any inflammation or rubeosis is under control, and stop all anticoagulants, if possible. Intraoperative tips When it comes to the debate between fornix-based versus limbus-based surgery, Dr. Green prefers a fornix-based method. While the success rates in the literature are comparable, limbus- based flaps create blebs that are localized and high, making them more prone to long-term complica- tions such as bleb leak and infection. Fornix-based flaps, on the other hand, end up more diffuse and less avascular, with lower incidences of infection and leak. However, these advantages must be balanced with an earlier incidence of symptomatic hypotony and earlier cataract surgery, which can cause bleb failure, she said. Dr. Green prefers fornix-based surgery because it allows for a small- er incision, and the surgeon can get a larger area of filtration and apply the antimetabolite over a wider area. Her preferred technique is to use a releasable suture. She does not use an assistant, so from a technical standpoint, fornix-based surgery is preferable, she said. Respecting the conjunctiva is paramount in glaucoma surgery, Dr. Green said. Use non-toothed forceps Surgeon from Australia shares pearls for glaucoma cases