Eyeworld

51 EW FEATURE November 2016 • Complicated glaucoma surgery management higher risk of failure with a subse- quent conjunctival-based surgery. So I would consider trying a different approach with a suprachoroidal shunt in these patients," he said. EW Editors' note: Dr. Fellman has financial interests with Allergan and InnFocus. The other physicians have no financial interests related to their comments. Contact information Ayyala: rayyala@tulane.edu Fellman: rfellman@glaucomaassociates.com Gedde: sgedde@med.miami.edu Seibold: leonard.seibold@ucdenver.edu Tanaka: ghtanakamd@gmail.com Closer look at newer innovations The pending approval of the AqueSys Xen Gel Stent (Allergan, Dublin) in the U.S. may change some practitioners' surgical prefer- ences. "From the data I have seen on Xen outcomes and safety, I think it may become a preferred surgical option in patients with moderate to severe glaucoma who are not good candidates for MIGS and need low IOP goals," Dr. Seibold said. In fact, Dr. Tanaka thinks it will replace trabeculectomy at his practice de- pending on its cost and insurance coverage. "There's been encouraging data about the Xen, especially when it's used in conjunction with mitomy- cin-C," Dr. Gedde said. "Like all newer procedures, we need to look at long-term data to clearly define the efficacy and safety." The Xen and the MicroShunt (InnFocus, Miami) may be shown to lower IOP in rates similar to stan- dard filtration surgery and produce better bleb morphology, Dr. Fellman said. Still, "a bleb is a bleb is a bleb, even with better morphology, and filtration surgery will always be high maintenance to a degree for both the patient and surgeon, but cer- tainly to a lesser degree than exists now," he said. There are also mixed thoughts on using the recently U.S.-approved CyPass Micro-Stent (Alcon, Fort Worth, Texas) in trab and tube patients. Dr. Ayyala is eager to use it in trab or tube patients who develop higher-than-target IOPs due to post- op fibrosis. "I plan to use the CyPass in these patients to reduce the IOP to the range that the optic nerve deserves," he said. Dr. Seibold, on the other hand, prefers to wait and see how effective the CyPass is in other patients. "If a patient has already failed an exter- nal filtration procedure, they are at AT A GLANCE • Patients with small pupils and glaucoma may require extra considerations before proceeding with cataract surgery. • In these cases, it's important to know ahead of time if the patient has ever taken tamsulosin or other prostate medication. • Pupil expansion rings, iris hooks, and retractors can all be useful additions during surgery. by Ellen Stodola EyeWorld Senior Staff Writer quicker you identify it, the safer you and the patient will be." While in the operating room, Dr. Parekh said he has a few tech- niques to address these situations, one of which is using Shugarcaine. He injects it at beginning of the case to help prevent IFIS-type issues. In addition, if Dr. Parekh is wor- ried about IFIS in a moderate-sized pupil, he uses a dispersive visco- elastic, like VISCOAT (Alcon, Fort Worth, Texas). He added that using a heavy cohesive viscoelastic, like Healon 5 (Abbott Medical Optics, Abbott Park, Illinois), can be helpful because it pushes the iris back out of the way. His third line of treatment is to go to iris hooks and manually retract the iris. Dr. Parekh prefers hooks over rings because he thinks they are for a number of reasons, including pseudoexfoliation syndrome, IFIS, posterior synechiae secondary to the use of pilocarpine for primary angle closure (PAC) or primary angle-clo- sure glaucoma (PACG), and with post synechiae secondary to past episodes of uveitis. The role of IFIS In the glaucoma patient population, it's not uncommon, even without IFIS, to deal with smaller pupils, Dr. Shingleton said. The issue with IFIS is not just the small pupil, it's a floppy iris; if incisions are not done properly, there may be issues with iris prolapse. Physicians can usually identify an IFIS situation by the way the iris looks and the way it reacts when they make the first incision or put lidocaine into eye, Dr. Parekh said. Even in the preoperative clinical evaluation, he will ask extensively about the use of prostate and uri- nary medications. Dr. Parekh finds significant differences between the brand name Flomax (tamsulosin, Boehringer Ingelheim Pharmaceu- ticals, Ridgefield, Connecticut) and generic tamsulosin. Flomax seems to have more impact on the iris than the generic, he said. "In the operating room, you al- ways have to be ready for the iris to be a floppy iris," Dr. Parekh said. It's important to be observant and treat all patients like they'll be floppy iris cases. "It's almost like 'guilty until proven innocent' for older men. The chanical options to deal with pupil size. "Glaucoma does not necessar- ily affect pupil size," he said. "But people who have been on miotics for treatment of their glaucoma will have smaller pupils." Dr. Shingleton said that pseudoexfoliation is a com- mon cause of secondary open-angle glaucoma, and these patients would have smaller pupils. "In patients who have had previous inflamma- tion or laser treatments, inflamma- tion can occur to a level that causes synechia to form, which can result in small pupils," he added. Dr. Parekh said that he likes the pupil to be at least 5 to 6 mm, but that this is not necessarily a make- or-break measurement, and that a 5 mm pupil with IFIS can be harder to deal with than a 4 mm pupil with- out IFIS. It is important to watch small pupils when performing cata- ract surgery in patients with glauco- ma. Pseudoexfoliation, neovascular glaucoma, inflammatory glaucoma, and acute glaucoma may all impact the pupil. A history of neovascular glaucoma can lead to significant iris damage, and the pupil may not react as well, Dr. Parekh said. He added that if the patient had an attack of acute glaucoma, it can cause significant iris damage, and it might not dilate as well. He noted that iris retractors or hooks, the Malyugin ring, or stretching the pupil can be used to help in these cases. Dr. Harasymowycz said physi- cians may encounter small pupils Surgeons discuss specifics when dealing with these challenging cases A ny surgery comes with its own intricacies and challenges, but when dealing with a small pupil in cataract surgery, there are special considerations surgeons must keep in mind. Additional- ly, a patient with glaucoma may require extra consideration before proceeding with cataract surgery. Paul Harasymowycz, MD, medical director, Bellevue Ophthalmology Clinics and the Montreal Glaucoma Institute; Bradford Shingleton, MD, Ophthalmic Consultants of Boston; and Parag Parekh, MD, ClearView Eye Consultants, State College, Pennsylvania, commented on how they handle small pupil cases and intraoperative floppy iris syndrome (IFIS). Pupil size and causes There's no particular minimum or maximum in terms of pupil size, Dr. Shingleton said. The bigger the bet- ter, but he added that it's possible to deal with small pupils. "We'd like to get a 4 mm diameter, and we strive for more if we can," he said. With iris support systems, it's uncommon to have to deal with a pupil too small, Dr. Shingleton said. It's almost a non-issue because there are many pharmacological and me- Small pupils and IFIS in glaucoma patients continued on page 52 Trabs continued from page 50

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