Eyeworld

EW NEWS & OPINION February 2016 17 In most cases, medical man- agement of the pressure will suf- fice. Most iStent-related bleeding and pressure spikes do not require surgical intervention. Even with suboptimal placement (not the case here), if the stent position is stable, observation alone will usually prove the safest course. Prolonged inflam- mation, bleeding, or uncontrollable pressure are very uncommon with the iStent, which is part of its appeal as a choice for appropriate patients." Eva Liang, MD, Las Vegas, said this about the case: "Hyphema is a well-known complication of the iStent. Usually it is early, but in this case there was a delayed onset. It may have occurred due to increased activity in a very active patient, localized trauma (i.e., eye rubbing), Valsalva, or contraction of a clot from the normal healing process. The iStent appears to be perfectly positioned, and I think the long-term benefits are still worth the short-term pain of the hyphe- ma. I would manage this medically by keeping her pupil dilated. My choice would be atropine to keep the lens iris diaphragm as posteri- or as possible and away from the iStent. I would limit her activity and keep the eye protected with glasses or a shield. I would also advise the patient to sleep with the head ele- vated. I would keep her on frequent steroids, manage the pressure with whatever is necessary to get her through this acute bleed, and may add phenylephrine for the vaso- constriction if I did not see enough resolution of the hyphema over the first few days. The good thing about this case is that she had great vision and great pressures in the immedi- ate postoperative period. I would use that to remind the patient that surgery obviously went well, but it's how we manage this healing process that is going to make the difference in the long run." Yuri McKee, MD, Mesa, Ariz., commented: "There are a few con- siderations in the differential diag- nosis of elevated IOP and hyphema. "First is the case of a herpet- ic reactivation after surgery. This typically leads to an inflamed eye, elevated IOP and a hyphema. This is treated with cycloplegics, steroids, combination ocular hypotensives, I have used many times over the years for cataract patients with high IOP on the first postop day presum- ably from retained viscoelastic and underlying poor outflow. At the slit lamp I make an incision just inside the inferior limbus with a 15-de- gree blade. Then I use a 23-gauge needle on a 3-cc syringe with sterile balanced salt solution to flush out the anterior chamber. This works beautifully to reduce the IOP and prevent it from bouncing right back up. However, I have never done this in an iStent situation and would do it only if medical means had been unsuccessful. My main concern would be more bleeding if the IOP is lowered quickly. "The iStent has been an incred- ibly safe glaucoma intervention. But cases like this still happen and need to be managed. This is probably a temporary, bleeding-related pres- sure elevation that can be managed successfully with medical treatment. Once she is managed through this high pressure phase, she will likely have a very successful outcome." Jonathan Myers, MD, Philadel- phia, said: "In this case, the patient has experienced a small intraocular hemorrhage in the early postopera- tive period, which has led to a signif- icant pressure spike. Hemorrhage following iStent may be the result of blood reflux through the device, reflux or hemorrhage from the cut edges of the trabecular meshwork and Schlemm's canal, or trauma to the angle structures such as cyclodi- alysis or iridodialysis. "As surgeons, we are always tempted by the surgical fix. Howev- er, reentering an eye with a recent bleed may trigger more bleeding and further pressure spikes. One must weigh that risk against the risk that the elevated pressure presents in the short and intermediate term. Patients with significant glaucoma damage, for example paracentral visual field defects or sickle cell trait/disease, may be at risk for poor outcomes if the pressure is not con- trolled. "In this case, it is unclear if stent removal would hasten resolution of the problem. Although usually straightforward, iStent removal has in some cases led to hyphema, iridodialysis, and pressure eleva- tions leading to incisional glaucoma surgery. The Folden* Femto Double-Ended Dissector 3360 Scherer Drive, Suite B, St. Petersburg, FL 33716 800-637-4346 • Tel: 727-209-2244 • Fax: 727-341-8123 Email: Info@RheinMedical.com • Website: www.RheinMedical.com *Developed In Coordination With David Folden, M.D. Lamentation, Michelangelo ACBF 1360 Rev.A 8-10144: Folden Femto Double-Ended Dissector, 0.7mm & 1.2mm • Clear Corneal Incisions (CCIS): The 1.2mm End Provides Easy Entry Into Standard Small Incisions As Well As Sub-2.0mm Micro-Incisions. 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