Eyeworld

EW FEATURE 52 Complicated glaucoma surgery management • November 2016 more versatile if there is a compli- cation in surgery. For example, iris hooks can be used to support the anterior capsule. Oftentimes, the iris wants to prolapse out of the incision during an IFIS situation, he said, so lower- ing the eye pressure will get the iris to go back in. Extra viscoelastic on top of the iris can help hold it down. Proper wound construction is also helpful. Preoperative and intraoperative surgical considerations It's been shown that stopping prostate medications does not make much difference in terms of IFIS, Dr. Shingleton said. When he's han- dling cases, he asks every patient, male or female, if they've been on any prostate-like medications. This information is then documented in the chart and surgery notes. Dr. Shingleton said that an underlying glaucoma diagnosis would not change the way a small pupil case is handled. "All the ad- juncts that we would use in patients without glaucoma can be used in patients with glaucoma." He added that medications used to treat glau- coma generally do not affect that management strategy for the pupil when cataract surgery is performed. "However, if the patient has been on previous miotics, these medicines are often stopped prior to cataract surgery to maximize dilation of the pupil," Dr. Shingleton said. "If they have been on medications that may have contributed in part to syn- echia, then the synechia has to be released at the time of surgery." Dr. Parekh said he doesn't ask the patient to stop any Flomax-type medications beforehand. "A dose or two of the medication has the effect on the iris," he said, adding that he doesn't want to cause urinary prob- lems for the patient by stopping the medication. Patients already on glaucoma medication should not be a concern during surgery, with the exception of those on pilocarpine. However, because prostaglandin analogs, cataract surgery, and manipulation of the iris may all be factors that increase the risk of macular edema, Dr. Parekh recommended watching those patients with multiple risk factors extra carefully after surgery. In an attempt to prevent small pupils, Dr. Harasymowycz said that he has almost completely stopped using pilocarpine in the treatment of primary angle-closure suspect (PACS), PAC, and PACG. "In patients where the angle remains occludable despite a patent iridotomy, I now offer and suggest lens extraction as a treatment in order to decrease the risk of acute or chronic an- gle closure, especially given that femtosecond laser-assisted cataract surgery (FLACS) may improve the precision of the surgery," he said. "If the patient is already on pilocarpine, the drop will be stopped the night before cataract surgery." Dr. Harasymowycz added that using NSAIDs 2 days preoperative- ly could decrease the incidence of intraoperative miosis and is given to all patients routinely barring any allergies or intolerances. "Aside from receiving a standard dilating regimen immediately preoperatively, if the patient does not have elevat- ed blood pressure, a drop of 10% phenylephrine will also be installed topically," he added. Additionally, Dr. Harasymowycz said that if apraclonidine is used routinely preoperatively in order to blanch the conjunctival vessels before FLACS and decrease subcon- junctival hemorrhages, he many consider not installing it in patients with smaller pupils in order to de- crease the biotic effects. He stressed that he asks patients if they are currently using or have used tamsulosin or other alpha-ad- renergic antagonists. If yes, intraca- meral phenylephrine will be pre- pared and mixed with intracameral unpreserved lidocaine and injected at the beginning of the surgery in patients with smaller pupils. Typical- ly, Dr. Harasymowycz does not ask patients to stop these medications preoperatively. When and how to stretch the pupil Dr. Parekh said that he doesn't often use the technique of stretching the pupil. Instead, he is a proponent of iris hooks. "Putting in iris hooks stretches and holds the iris," he said. Iris hooks or retractors are a defini- tive solution to solve the problem, he said. Dr. Harasymowycz said that if the pupil is smaller than 2 mm, he will typically use either a Malyugin ring, iris retractors, or occasionally perform mini-sphincterotomies and delicate pupil stretch, with the latter only in surgery centers that do not have hooks or iris retractors. Special consideration is given to patients undergoing FLACS, he added. "In cases where it is essential to have a decent size capsulorhex- is, and the pupil is small and there are signs of zonular weakness, the surgery is done in three steps." First, the patient is brought to the OR and a Malyugin ring is placed. Viscoelastic is left in place and the corneal wound sealed. The patient then undergoes the femtosecond laser portion of the surgery, includ- ing capsulorhexis and lens fragmen- tation, Dr. Harasymowycz said. It is important to increase the energy for the capsulorhexis portion, as viscoelastics may dampen the effect of the laser, he added. Finally, the patient is brought back to the OR for the lens extraction portion of the procedure. Dr. Shingleton utilizes all the support systems available, although he does prefer mechanical support over pharmacological injections. Iris retractors work well, he said, and all the different pupil expansion rings are similar and helpful. The choice also depends on the technique used to remove the lens. A nucleus flip technique is not suited to a pupil expander, he said, so an iris retractor may be the better choice. Meanwhile, for a chop technique, a pupil expander may be more helpful. EW Editors' note: Drs. Shingleton and Parekh have no financial interests related to their comments. Dr. Harasymowycz has financial interests with Alcon, Abbott Medical Optics, and Bausch + Lomb (Bridgewater, New Jersey). Contact information Harasymowycz: pavloh@igmtl.com Parekh: drparekh@ClearViewPA.com Shingleton: bjshingleton@eyeboston.com Small continued from page 51 " In the operating room, you always have to be ready for the iris to be a floppy iris. … The quicker you identify it, the safer you and the patient will be. " –Parag Parekh, MD

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