Eyeworld

EW GLAUCOMA 106 March 2017 by Vanessa Caceres EyeWorld Contributing Writer phoma. "Fortunately, there were no complications, but there could have been," he said. There are also risk/benefit and quality-of-life decisions. Dr. Abrams had a 97-year-old female patient with very early glaucoma who was referred by another ophthalmolo- gist. The patient had started to use IOP-lowering medication that could have side effects. "With just a little glaucoma damage, she probably wouldn't have significant damage until she was 105 or 110. Is it worth- while to put someone, who probably won't live long enough to see the damage, on meds that can have side-effects? I told her, 'Yes, you have glaucoma, but go home and don't bother with this.' It's not that you don't want to treat them, but you have to make sound decisions," Dr. Abrams said. Similarly, patients who have glaucoma and also have a high risk of mortality, such as patients with end-stage cancer, may opt not to go through the pressures of surgery, Dr. Rhee said. Still, surgery does some- times happen in those patients. One advantage of surgery, when it's necessary, is that it may elim- inate the need for eye drops, Dr. Saland said. Eye drop compliance is a common problem for many glau- coma patients. Concerns during surgery With older patients more likely to have health conditions like atrial fibrillation, pulmonary embolism, or cardiac valve replacement, the use of anticoagulant medication is common. It's usually necessary to stop anticoagulation therapy before glaucoma surgery; in some patients, the prescribing physician thinks it's important for the patient to con- tinue anticoagulation therapy. "You sometimes have to do a relatively bloody surgery," Dr. Abrams said. "You can have complications related to that." Surgical planning requires forethought, a comparison of risks versus benefits A s we live longer and as baby boomers continue to age, it's inevitable that glaucoma specialists will more frequently face the decision to perform surgery in older patients. In fact, those age 65 and older are expected to make up 20% of the U.S. population by the year 2030, according to a report from the American Geriatrics Society (AGS). Older adults already make up a large chunk of healthcare services, including 26% of physician office visits. And about 80% need care for chronic conditions like hyperten- sion, arthritis, and heart disease, according to the AGS. So exactly how does age affect decisions about glaucoma surgery? It's one factor, along with general health and glaucoma stage, that specialists consider when they de- cide on glaucoma treatment and the need for surgery, said Douglas Rhee, MD, professor of ophthalmology, Case Western Reserve University School of Medicine, Cleveland. All three factors influence what may be the best treatment for an individual. Don Abrams, MD, ophthalmol- ogist-in-chief, Krieger Eye Institute, Baltimore, actually sees a trend toward glaucoma surgery earlier in life. "It used to be that most of our patients were over age 65. Now, we often do glaucoma surgery in many patients—obviously in patients with no choice but in some cases, we recommend it to relatively stable people with borderline control," he said. Additionally, compliance with a multi-drop glaucoma treatment regimen isn't perfect, so surgery is often the most definitive treatment modality. Surgical decisions The decision to perform glauco- ma surgery takes on certain con- cerns when patients are older. "An example of when a surgery should not take place is when the patient's health condition is acute, and proceeding with surgery could cause more harm than benefit," said Kar- en Saland, MD, Texas Health Dallas. In older patients with comorbid conditions, "you probably would want to do a surgery that's a little lower risk," said Barbara Smythe, MD, Glaucoma Consultants of Texas, Grapevine. "A trabeculectomy has a higher risk of complications. Tube shunts have fewer compli- cations. Microinvasive glaucoma surgery [MIGS] is also lower risk and in some cases, depending on how advanced it is, this could be a safer option. It doesn't always lower the pressure as much, but it does have lower risks." However, MIGS may not be an option if the patient can't lay flat during surgery. "It's back to trabs and tubes [in those patients]," Dr. Rhee said. There are sometimes patients with other comorbidities, and they have difficulty managing glaucoma; at the same time, they may not be surgical candidates. "We can be caught between a rock and a hard place," Dr. Abrams said. That said, he recently performed a successful surgery in an 89-year-old man with glaucoma uncontrolled by medica- tions and with only one eye. The patient had severe diabetes and hypertension as well as a stable lym- Older patients and glaucoma surgery implantation during small-incision cataract surgery for open-angle glaucoma or ocular hypertension: long-term results. J Cataract Refract Surg. 2015;41:2664–71. 5. Emi K, et al. Hydrostatic pressure of the suprachoroidal space. IOVS. 1989;233–8. 6. Höh H, et al. Two-year clinical experience with the CyPass micro-stent: safety and surgical outcomes of a novel supraciliary micro-stent. Klin Monbl Augenheilkd. 2014; 231:377–81. 7. Grisanti et al. [Supraciliary microstent for open-angle glaucoma: clinical results of a pro- spective multicenter study]. Ophthalmologe. 2014;111:548–52. 8. Brown R. Minimally invasive supracili- ary microstent for IOP control in combined POAG-Cataract surgery: 2-year COMPASS RCT results. Presented at the ASCRS Symposium and Congress. New Orleans. May 7, 2016. 9. García-Feijoo J, et al. Supraciliary micro-stent implantation for open-angle glau- coma failing topical therapy: 1-year results of a multicenter study. Am J Ophthalmol. 2015;159:1075–81. Editors' note: Dr. Bacharach has finan- cial interests with Glaukos. Contact information Bacharach: jbacharach@northbayeye.com MIGS continued from page 104 Dr. Rhee and colleagues stand while doing glaucoma surgery in an elderly patient with advanced glaucoma. They had to stand because the patient had congestive heart failure and could not lay flat. Source: Douglas Rhee, MD

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