Eyeworld

59 EW FEATURE an eye sensitized by surgery. Alpha agonists are also a good choice, but intolerance reaction risks provoking eye rubbing in some patients," Dr. Fudemberg said. "I am more liber- al with combination agents in the postoperative period to help gain control of an IOP spike and simplify a drop regimen already complicated by postoperative medications like steroids, antibiotics, and NSAIDs." As for his steroid regimen, Dr. Fudemberg said he doesn't alter his usual treatment or taper in glauco- ma patients without prior filtering surgery. Patients who have had filtering surgery, however, could benefit from more aggressive steroid therapy because inflammation could interfere with the function of a trab- eculectomy or tube shunt surgery. "However, no evidence-based regimen of steroid use following filtering surgery or after cataract sur- gery in patients with prior filtering surgery has been established," Dr. Fudemberg added. Dr. Parekh said his steroid regimen—topical drops four times a day for a month, stopping without a taper—is not altered for glaucoma patients, but he does watch them more closely during postop visits. Dr. Ansari also does not vary his steroid regimen—Durezol (diflupred- nate, Alcon, Fort Worth, Texas) for 3 weeks with a three-drop, two-drop, one-drop taper—among glaucoma and non-glaucoma patients. has glaucoma. If the patient has ocular hypertension, I routinely stop glaucoma drops and monitor the pressure and add back the glaucoma drops if I see the pressure going up again in the weeks or months after surgery." "I do not routinely stop glau- coma medications after cataract extraction in the early postopera- tive period, with the exception of prostaglandin analogues in some cases," Dr. Fudemberg said. "Per- haps as a result of selection bias in my tertiary referral glaucoma patients, I am sensitive to the risk of postoperative IOP spikes. However, in patients with good IOP control beyond the early postoperative period, I will consider a systematic withdrawal of glaucoma medications in which patients hold a glaucoma medication for a few days prior to their next scheduled visit with me so significant IOP spikes are quickly identified." Dr. Fudemberg added that he's open to the use of any glaucoma medication following cataract extraction, thinking that the side ef- fects of these medications need to be balanced with each patient's clinical situation. "Ideally, I prefer aqueous sup- pression. Beta blockers have a good topical side effect profile, but may be contraindicated systemically. Carbonic anhydrase inhibitors are usually well tolerated, but could challenge the corneal endothelium, and stinging may be a problem in continued on page 60 " Evidence connecting use of prostaglandin analogues before and after cataract extraction with increased risk of cystoid macular edema is insufficient to judge the relative risk of withdrawing prostaglandins versus continuing them. " –Scott Fudemberg, MD Highlights of EyeWorld's coverage of managing glaucoma and cataract surgery through the years November 2007 Preventing IOP spikes after cataract surgery by Matt Young "Postop IOP spikes are common, resulting from remaining ophthalmic viscosurgical device (OVD) material, for instance, and may threaten those with glaucoma. Current measures to prevent IOP from spiking beyond certain thresholds are warranted, but are they enough? One study, published online in Ophthalmology, suggests that they may not be." www.eyeworld.org/article-preventing- iop-spikes-after-cataract-surgery January 2008 Glaucoma pharmacotherapy continually evolving by Michelle Dalton "Few would argue against the fact that prostaglandins are the first line medical treatment option for those with primary open angle glaucoma. Beyond that, though, a plethora of drugs in development in a variety of classes as well as those already marketed are helping glaucoma specialists customize treatments based on the individual patient." www.eyeworld.org/article-glaucoma- pharmacotherapy-continually-evolving February 2011 New strategies for glaucoma surgery by Michelle Dalton "While trabeculectomy remains the gold standard for the surgical management of glaucoma, technologic advances in other areas are helping to make the procedure safer and helping physicians diagnose earlier, experts say." www.eyeworld.org/article-new-strategies- for-glaucoma-surgery March 2011 Predicting pressure spikes after cataract surgery by Tony Realini, MD "Cataract surgery is the most commonly performed surgery on adults in the United States, and it is among the safest procedures. One relatively common postop complication is an acute rise in IOP within the first day or so after surgery. IOP spikes on the day after cataract surgery can be quite high, into the 30–40 mm Hg range." www.eyeworld.org/article-predicting-pressure- spikes-after-cataract-surgery November 2012 Glaucoma surgical option may appeal to cataract surgeons by Rich Daly "Surgeons considering cataract removal for the side benefit of treating mild glaucoma gained a new option last summer. And clinical investigators for the iStent Trabecular Micro- Bypass (Glaukos), which received FDA approval in June, expect those cataract surgeons to become the primary users of the device." www.eyeworld.org/article-glaucoma-surgical January 2014 The role of cataract surgery in glaucoma management by Tony Realini, MD "The two conditions [cataract and glaucoma] can be managed completely separately from one another, and often are. However, emerging data suggest that cataract surgery alone can provide significant IOP reduction. Is there a role for cataract extraction in the management of glaucoma, and does the diagnosis of glaucoma alter the indication for cataract surgery?" www.eyeworld.org/article-the-role-of-cataract- surgery-in-glaucoma-management

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