EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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World view Secondary glaucomas: believing is seeing S ome things have to be seen to be be- lieved. Others have to be believed to be seen. Secondary glaucomas have to be at least suspected to be seen and diag- nosed. Every eye exam should include a careful look for pseudoexfoliation (PXF) and pig- mentary dispersion. The early signs can be quite subtle and may easily be missed. Even when you don't see them on your initial exam, you must continue to look for them at each subsequent exam. Secondary glaucomas have a starting point—especially pseudoexfoliation—and just because something wasn't there last year doesn't mean it won't appear this year. So the key to seeing them is to believe they may be present at each exam. Secondary pigment dispersion is particularly easy to misdiagnose. I have seen many cases that have been treated as steroid responses or chronic uveitis—even to the point of immune suppression. The cost of missing the diagnosis is quite high since the treatment will not be effective unless the lens/haptic is repositioned, removed, or exchanged. We are very fortunate in this issue of EyeWorld to have Jason J. Jones, MD, Samuel Masket, MD, and Garry Condon, MD, share their insights on managing secondary pigment dispersion. Secondary glaucomas challenge us since they may be marked by acute pressure elevations. Pseudoexfoliation and pigmentary glaucomas are partic- ularly prone to pressure spikes that may demand urgent treatment. Marlene Moster, MD, Nathan Radcliffe, MD, and Lama Al-Aswad, MD, discuss their pearls for treating pseudoexfoliation. Since PXF is associated with cataracts, performing phacoemulsification may be helpful in controlling p essure. Cataract surgery gives us the chance to perform a MIGS procedure. Primary pigmentary glaucoma causes classic changes in the anterior segment—iris defects, increased pigment in the meshwork, a Krukenberg's spindle, and others. The mechanism appears to be the posterior iris rubbing on zonular bundles, which releases pigment that impairs outfl w. But there are still many puzzles. Robert Noecker, MD, Robert Ritch, MD, Paul Harasymowycz, MD, and Brian Francis, MD, share their insights on pigmentary glaucoma. Secondary glaucomas often display alterations in the meshwork— increased pigment or pseudoexfoliation material—that may be the cause of the outflow impairment and elevated pressure. This raises the uestion of whether angle surgery—an iStent (Glaukos, Laguna Hills, Calif.) or Trabectome (NeoMedix, Tustin, Calif.)—could be helpful. Another option is a trabeculotomy. An exciting new method of internal trabeculotomy is called gonioscopy-assisted transluminal trabeculotomy (GATT). The devel- opers of this procedure—Davinder Grover, MD, and Ronald L. Fellman, MD—discuss their experience and the role that GATT is playing in their glaucoma practice. Making the right diagnosis of a secondary glaucoma can be critical. I re- member seeing a referral patient years ago for iritis, recurrent hyphema, and glaucoma. The patient had variable vision and had been treated for iritis for an extended period without success. I had just read one of the early papers describing secondary pigment dispersion from IOL-iris contact. With this paper in mind, it was easy to see that the optic of the patient's 3-piece IOL was rubbing against the posterior iris. All I had to do was push the IOL optic posteriorly and capture it behind the intact capsulorhexis. The hyphemas stopped, the vision cleared, and the glaucoma disappeared. But if I hadn't read the article—and believed—I might not have seen the true cause of the glaucoma. EW Reay H. Brown, MD, glaucoma editor The official public tion of the American Society of Cataract & Refractive Surgery A S C R S May 2015 Volume 20 • No. 5 Publisher Donald R. Long don@eyeworld.org Editorial Editor Erin L. Boyle erin@eyeworld.org Managing Editor Stacy Majewicz stacy@eyeworld.org Staff Writer Ellen Stodola ellen@eyeworld.org Staff Writer Lauren Lipuma lauren@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org 703-383-5702 Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Vanessa Caceres Lakeland, Fla. Michelle Dalton Reading, Pa. Matt Young Malaysia Enette Ngoei Dublin Rich Daly Arlington, Va. Senior Contributing Writer Maxine Lipner Nyack, N.Y. 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