Eyeworld

107 EW GLAUCOMA March 2017 in older patients. When Dr. Smythe has surgical patients with a curva- ture of the spine from osteoporosis or kyphosis, she props up pillows under their neck. In patients with asthma or chronic obstructive pulmonary dis- ease, in whom it's hard to get a good breath when laying down—especial- ly if they are overweight or obese— Dr. Smythe has a suction under the drape that is placed just below the chin. The suction helps to remove the carbon dioxide, and the patient is usually more comfortable. Dr. Rhee recently performed surgery in a patient in his 90s who could not lay flat due to congestive heart failure. Dr. Rhee had to do the surgery standing up, while the head of the patient's bed was elevated up by about 30 degrees. Patient education All patients should be educated about their glaucoma surgery, of course, but older adults may have more issues with their senses and their memory. "Written instructions and communicating the concepts with patients and their caregivers become even more helpful," Dr. Rhee said. Dr. Abrams finds it best to have a child or grandchild with the patient to talk about glaucoma or glaucoma surgery; if it's an aide, the person may not spend enough time with the patient to clearly con- vey surgical information to family members. If a family member does not come to the appointment with the patient, he will often get them on the phone and put it on speaker so everyone hears the same message, he explained. It's also crucial that glaucoma patients understand the importance of returning for regularly scheduled screenings, especially if they have other ailments such as diabetes, arthritis, high blood pressure, a history of strokes, heart attacks, or cancers, Dr. Saland said. EW Editors' note: The physicians inter- viewed have no financial interests related to their comments. Contact information Abrams: don60@aol.com Rhee: Douglas.Rhee@uhhospitals.org Saland: karenorli@yahoo.com Smythe: caroline@arrowatwork.com Dr. Rhee observed that some- times patients who may have a condition like osteoarthritis take a nonsteroidal anti-inflammatory drug, not thinking about the antico- agulant side effect. Another risk factor is blood pressure at the time of surgery—a problem that can be more common in older adults. "With full-thickness procedures, high blood pressure can increase the risk of suprachoridal hemorrhage," Dr. Rhee said. So, blood pressure is another factor con- sidered when deciding on surgery in older adults. Depending on the patient's oth- er health conditions, wound healing can be harder, especially in a patient who does not have good circulation, Dr. Smythe said. This is more com- mon in patients with severe heart disease or patients who are smokers. "They don't have good oxygenation of the blood, and that can't promote good healing. There's nothing to do except to be aware of it and try to tighten wounds more tightly," Dr. Smythe said. Wound healing also can be a concern if the patient has diabetes, Dr. Abrams said. When performing surgery in an older patient with comorbidities, ex- tra clearances from pulmonologists or cardiologists may be necessary. "Sometimes, something else comes to light—such as newly diagnosed atrial fibrillation or a finding or concern on an X-ray that may be cancer. I've had that happen," Dr. Smythe said. Dr. Abrams also recommends performing surgery at a center attached to a hospital when comor- bidities are present. "I had a patient 3 or 4 years ago who had a heart attack in the recovery room but end- ed up in a ventilator in the recovery room because we had the proximity to care," he said. That would have been a lot harder to manage if the surgical center was not adjacent to the hospital. Dr. Smythe once had a patient who was so medically unstable that when she showed up in preop, she ended up going to the adjacent hos- pital's ICU. Surgical positioning Although patients of any age may have a health condition that precludes them from lying flat for surgery, this is more likely to occur Uniform epithelium removal in only 5 - 7 seconds Corneal Xlinking, PRK Advanced Surface Ablation Improved clinical outcomes of CXL and PRK with Amoils Epithelial Scrubber ds Visit us at ASCRS 2017 in booth 1107 Minimize total procedure time Avoid alcohol damage to surrounding tissue No need for subsequent scraping T. 800.461.1200 www.innovativexcimer.com order online www.innovativexcimer.com AMOILS EPITHELIAL SCRUBBER AMOILS www.innovativexcimer.com

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