Eyeworld

EW CATARACT 31 June 2015 Tenth question "When do you see the patient back for a final post-YAG check for an ordinary case where there is little reason to anticipate a need for a refractive change (e.g., pre-YAG refraction close to worn glasses)? Choose the closest match." by Mitch Gossman, MD It may be prudent to measure postoperative IOP for patients known to be predisposed to this (e.g., pseudoexfoliation), on mul- tiple medications already, with already high pressures, or with con- siderable cupping or field loss. There is a case report of post-YAG pressure of 80 mm Hg resulting in no light perception vision, although restored with urgent paracentesis. 2 Ninth question "When do you see the patient back for a final post-YAG check for an ordinary case where a satisfactory refraction could not be achieved before the YAG (e.g., capsule too cloudy for a meaningful refraction, indication of a difference from worn glasses, etc.)? Choose the closest match." Preoperative use of topical hypotensive drops is associated with a lower postoperative spike than without, especially apraclonidine. 1 Avoiding medications containing a beta blocker has the advantage of not having to consider compli- cations for the chronic obstructive pulmonary disease or asthmatic patient. Seventh question "Do you perform a 1-hour pressure check for an ordinary case (e.g., excluding advanced glaucoma, propensity to pressure spike such as pseudoexfoliation, etc.)?" I n the first article for the new column "Pulse of ophthalmol- ogy: Survey of clinical practices and opinion," I discussed the first 5 questions and results of a survey of 100 practicing oph- thalmologists on the topic of YAG capsulotomy (see page 30 of the May issue of EyeWorld). In this survey, physicians volunteered to take part from the ranks of participants of the eyeCONNECTIONS online community and volunteers around the U.S. Responses are anonymous in order to encourage candor. Sixth question "What drop(s) do you give after YAG to blunt pressure spike?" YAG capsulotomy, part 2 Brimonidine 50% Combigan 10% Apraclonidine 8% Prostaglandin analogue 2% Beta blocker 1% Pilocarpine 1% Carbonic anhydrase inhibitor 0% Cosopt 0% None 32% Yes 20% No 80% A postoperative pressure check is safe but does result in patient inconvenience, especially if per- formed late in the day, which results in greater office overhead. However, anecdotes exist of rare but danger- ously high post-YAG pressures. This is the art of medicine, weighing patient inconvenience and costs for the rare postoperative complication, although in the case of elevated pressure, unfortunately not all dan- gerous pressures result in symptoms and therefore may elude detection. Steven Safran, MD, in private prac- tice in Lawrenceville, N.J., uses bri- monidine, and routinely checks IOP 1 hour postoperatively. He allows those patients who cannot remain in the office to return in a few days. He notes that postoperative pressure spikes are rare, but he has had at least 1 that was dangerously ele- vated after surgery and was glad to have detected it. I do not perform a postoperative pressure check except in cases of higher than normal risk, such as pseudoexfoliation, multiple glaucoma medications being used, and more severe field loss or optic nerve cupping. Eighth question "Do you perform a 1-day pressure check for an ordinary case?" Yes 3% No 96% 1–2 weeks 68% 4 weeks 21 2–3 months 1% 4 months 0% 6 months 0% 1 year 1% PRN 9% The benefits of a postoperative check after YAG capsulotomy are to screen for complications (however rare), to assure patient satisfaction, to afford an opportunity to recheck the glasses prescription, and if the opacity is severe to take advantage of the improved view to examine the posterior segment. Here, 90% see the patient back. However, a signifi- cant minority, 10%, sees the patient back on a routine basis, perhaps instructed to return if symptoms are unimproved. 1–2 weeks 37% 4 weeks 22% 2–3 months 7% 4 months 5% 6 months 4% 1 year 11% PRN 14% Mitch Gossman, MD In this case, while the majority of physicians see the patient back within the 3-month period (66%) a more significant minority than the previous question wait longer (34%). The upside of seeing the patient back is in the reasons stated previously, but in the case of a patient where a meaningful change in glasses prescription is unexpected and complications rare, it appears that many surgeons heavily factor patient inconvenience and econom- ics. EW References 1. Minello AA, et al. Efficacy of topic ocular hypotensive agents after posterior capsulotomy. Arq Bras Oftalmol. 2008 Sep-Oct;71(5):706–10. 2. Vine AK. Ocular hypertension following Nd:YAG laser capsulotomy: a potentially blinding complication. Ophthalmic Surg. 1984 Apr;15(4):283–4. Editors' note: Dr. Gossman is in private clinical practice at Eye Surgeons & Phy- sicians, St. Cloud, Minn. Drs. Gossman and Safran have no financial interests related to this article. Contact information Gossman: n1149x@gmail.com Safran: safran12@comcast.net Pulse of ophthalmology: Survey of clinical practices and opinion

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