Eyeworld

55 EW FEATURE November 2016 • Complicated glaucoma surgery management Lama Al-Aswad, MD, MPH, as- sociate professor of ophthalmology, and glaucoma fellowship director, Edward S. Harness Eye Institute, Columbia University, New York, likewise begins by determining the cause of the shallow chamber. "It could be because of narrow angle from hyperopia due to nanoph- thalmos or zonular weakness," she said, adding that each has to be dealt with accordingly. With a nanophthalmic eye, there's an issue of a small cornea, shallow anterior chamber, and the iris is a bit more convex compared to a regular eye with a normal or increased lens thickness. "That can make the surgery more difficult and has the potential of uveal effusion due to thickened sclera and choroid," Dr. Al-Aswad said. The fact is the complication rate is higher in this population. "We know that complications tend to happen less than 2% of the time in cataract surgery, but in nanoph- thalmic eyes, they can be as high as 28%," Dr. Al-Aswad said. Other potential complications known to occur in this population include uveal effusion, exudative retinal detachment, hemorrhage inside the eye, corneal decompensa- tion because of the shallow anterior chamber, malignant glaucoma, CME, a high risk of vitreous loss, iritis, and IOL errors. When Dr. Al-Aswad sees a patient with a cataract and shal- low chamber, she first evaluates if the angle is closed or not. "Then I perform an axial length measure- ment to see how small the eye is," Dr. Al-Aswad said. "If it's very small—less than 20.5 mm or at least two standard deviations below age- matched controls—then you might have to consider performing scleral cut-down before performing cataract surgery." In cases where the eye is extremely shallow, Dr. Al-Aswad tries injecting some viscoelastic to see how deep she can get the eye to be. If, after this, she determines it's deeper, then she begins doing her capsulorhexis and modifies her technique. "Once I hydrodissect, I remove all of the anterior cortical material from the lens, and that will deepen the anterior chamber even continued on page 56 93398 EW 5/1/16 Sustained 30 % IOP lowering at 12, 14, and 20 hours post-dose in a 3-month study 1,2 * CHOOSE TRAVATAN Z ® Solution: A POWERFUL START INDICATIONS AND USAGE TRAVATAN Z ® (travoprost ophthalmic solution) 0.004% is indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. Dosage and Administration The recommended dosage is 1 drop in the affected eye(s) once daily in the evening. TRAVATAN Z ® Solution should not be administered more than once daily since it has been shown that more frequent administration of prostaglandin analogs may decrease the IOP-lowering effect. TRAVATAN Z ® Solution may be used concomitantly with other topical ophthalmic drug products to lower IOP. If more than 1 topical ophthalmic drug is being used, the drugs should be administered at least 5 minutes apart. IMPORTANT SAFETY INFORMATION Warnings and Precautions Pigmentation—Travoprost ophthalmic solution has been reported to increase the pigmentation of the iris, periorbital tissue (eyelid), and eyelashes. Pigmentation is expected to increase as long as travoprost is administered. After discontinuation of travoprost, pigmentation of the iris is likely to be permanent, while pigmentation of the periorbital tissue and eyelash changes have been reported to be reversible in some patients. The long-term effects of increased pigmentation are not known. While treatment with TRAVATAN Z ® Solution can be continued in patients who develop noticeably increased iris pigmentation, these patients should be examined regularly. Eyelash Changes—TRAVATAN Z ® Solution may gradually change eyelashes and vellus hair in the treated eye. These changes include increased length, thickness, and number of lashes. Eyelash changes are usually reversible upon discontinuation of treatment. Use With Contact Lenses—Contact lenses should be removed prior to instillation of TRAVATAN Z ® Solution and may be reinserted 15 minutes following its administration. Adverse Reactions The most common adverse reaction observed in controlled clinical studies with TRAVATAN Z ® Solution was ocular hyperemia, which was reported in 30 to 50% of patients. Up to 3% of patients discontinued therapy due to conjunctival hyperemia. Ocular adverse reactions reported at an incidence of 5 to 10% in these clinical studies included decreased visual acuity, eye discomfort, foreign body sensation, pain, and pruritus. In postmarketing use with prostaglandin analogs, periorbital and lid changes including deepening of the eyelid sulcus have been observed. Use in Specifi c Populations Use in pediatric patients below the age of 16 years is not recommended because of potential safety concerns related to increased pigmentation following long-term chronic use. For additional information about TRAVATAN Z ® Solution, please see the brief summary of Prescribing Information on the adjacent page. Help patients start strong and stay on track with TRAVATAN Z® Solution has no FDA-approved therapeutic equivalent available TRAVATAN Z® Solution has no FDA-approved therapeutic equivalent available * Study Design: Double-masked, randomized, parallel-group, multicenter non-inferiority comparison of the effi cacy and safety of travoprost 0.004% preserved with benzalkonium chloride (BAK) to TRAVATAN Z ® Solution after 3 months of treatment in patients with open-angle glaucoma or ocular hypertension. Baseline IOPs were 27.0 mm Hg (n=322), 25.5 mm Hg (n=322), and 24.8 mm Hg (n=322) at 8 AM, 10 AM, and 4 PM for TRAVATAN Z ® Solution. At the end of Month 3, the TRAVATAN Z ® Solution group had mean IOPs (95% CI) of 18.7 mm Hg (-0.4, 0.5), 17.7 mm Hg (-0.4, 0.6), and 17.4 mm Hg (-0.2, 0.8) at 8 AM, 10 AM, and 4 PM, respectively. Statistical equivalent reductions in IOP (95% confi dence interval about the treatment differences were entirely within ±1.5 mm Hg) were demonstrated between the treatments at all study visits during the 3 months of treatment. References: 1. Data on fi le, 2013. 2. Lewis RA, Katz GJ, Weiss MJ, et al. Travoprost 0.004% with and without benzalkonium chloride: a comparison of safety and effi cacy. J Glaucoma. 2007;16(1):98-103. © 2015 Novartis 10/15 US-TRZ-15-E-0278 Not actual patient 93398 EW 5/1/16 gery makes it much easier to deepen [the chamber]." The next option is to do a dry vitrectomy, Dr. Crandall noted. "Going in through the pars plana, using a quick 1- to 1.5-second burst with the vitrector with no infusion will allow it to deepen nicely," he said, adding that it's important to be particularly careful in patients with nanophthalmos because their pars plana isn't always in the normal an- atomic location. With such patients there is some risk of being too far posterior.

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