Eyeworld

EW FEATURE 46 Challenging cases • July 2018 AT A GLANCE • Among the most challenging glaucoma cases that surgeons see are pseudoexfoliation patients, those that don't respond to several surgeries, and younger patients with secondary conditions. • Surgeons are gaining experience with MIGS in some of the more challenging patient populations. • New medical options help surger- ies work better because they give surgeons more flexibility if patients are having intolerances. by Rich Daly EyeWorld Contributing Writer Innovations in challenging glaucoma cases Surgeons identify the latest treatments and innovations to help their most challenging glaucoma cases G laucoma specialists agree that emerging treatments offer growing hope for their most challenging cases. "As a specialist, the pseudoex- foliation patients can be the most challenging when it comes to com- bined cataract and glaucoma cases," said Valerie Trubnik, MD, attending physician, Ophthalmic Consultants of Long Island. "Also, patients who have retinal comorbidities and ele- vated intraocular pressures requiring surgery are challenging." Dr. Trubnik said these cases can be difficult because the patients have had multiple intracameral in- jections, compromised zonules, and may have smaller pupils. Among the most challenging glaucoma cases seen by Nathan Radcliffe, MD, assistant professor of ophthalmology, Icahn School of Medicine at Mount Sinai, New York, are cases that don't respond to several glaucoma surgeries. "Usually when you're on your third or fourth glaucoma surgery, you're running probabilities that these eyes are going to have some complication with each surgery. We always think one surgery ahead so if this surgery doesn't work, what am I doing next?" Dr. Radcliffe said. "These are the patients where you keep throwing surgeries at them and they fail through them all." Other challenging patients Dr. Radcliffe identified are those who do not tolerate any medications; patients with difficult personalities or unrealistic expectations; and late disease or "little-room-for-error cases." "In my practice, about one- third of the people I operate on only have the one eye," Dr. Radcliffe said. "They lost their other eye before I met them—often from glaucoma— so there is little room for error." Among patients who present with intraocular pressures in the 50s while on all available IOP-low- ering medications and with almost no vision remaining, Dr. Radcliffe must quickly move to surgery, even as he has to warn patients that not even perfect surgery is guaranteed to maintain their vision. The most challenging glauco- ma cases seen by Robert Rothman, MD, partner, Glaucoma Consultants of Long Island, are related to either severity of disease or age of onset. "Younger patients with secondary conditions—inflammatory glauco- ma associated with uveitis, young diabetics, Sturge-Weber syndrome— tend to be the most challenging cases for me," Dr. Rothman said. "I also would include normal tension glaucoma as a significant challenge both diagnostically and therapeu- tically, in terms of management decision making." Treatments improving Treatment options have expanded Optic nerve with moderate glaucoma damage Source: Robert Rothman, MD Monthly Pulse Challenging cases EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthal- mologist. Each month we send an online survey covering different topics so readers can see how they compare to our survey. If you would like to join the physicians who take a minute a month to share their views, please send us an email and we will add your name. Email anne@eyeworld. org and put "EW Pulse" in the subject line. In a patient who has pseudophakic bullous keratopathy, I would: Perform a penetrating keratoplasty Perform a DSEK Perform a DMEK Perform a PDEK When I do cataract surgery on a hypermature cataract, I: Perform phacoemulsification Perform an extracapsular cataract surgery Use a femtosecond laser to make the capsulotomy Refer the patient to a corneal surgeon Refer the patient

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