EyeWorld Asia-Pacific March 2017 Issue

March 2017 22 EWAP SECONDARY FEATURE by Liz Hillman EyeWorld Staff Writer Managing glaucoma medication after cataract surgery Balancing possible risks while maintaining safe IOP control F or a glaucoma patient, cataract surgery alone can have an IOP-lowering effect, though perhaps short lived. So when is it safe to reduce a patient’s glaucoma medications? Is there an optimal paradigm for managing glaucoma medication post-cataract surgery? Several studies have associated prostaglandin analogs—often the first line of treatment for IOP lowering—with the possibility of cystoid macular edema (CME). 1,2,3 Couple that with cataract surgery, which itself carries a risk for macular edema, and “the risk factors start adding up,” said Parag Parekh, MD , Clearview Eye Consultants, State College, Pennsylvania. Despite these theoretical risks, Dr. Parekh, Scott Fudemberg, MD , Wills Eye Hospital, Philadelphia, and Husam Ansari, MD, PhD , Ophthalmic Consultants of Boston, said they are comfortable leaving most glaucoma patients on prostaglandin analogs after cataract surgery while they’re also on a steroid regimen. “Evidence connecting use of prostaglandin analogs 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,” Dr. Fudemberg said. “Therefore, if I perceive the risk of complications from IOP elevation without a prostaglandin to be low, I will stop the medication on the day of surgery and evaluate the patient’s need for IOP lowering agents during the postoperative period.” Dr. Ansari doesn’t think the risk for inflammation or CME is high enough to stop prostaglandins when the patient’s glaucoma control is critical, especially because he uses a strong steroid to reduce inflammation. Dr. Parekh said that while he knows of ophthalmologists who stop prostaglandin medications, he doesn’t find continuing them to be an issue and has his patients stick with these drops during the peri- operative period. A survey sent to consultant ophthalmologists in the UK in 2003 revealed that of the 519 who responded, 59.7% did not stop prostaglandins with cataract surgery, 20.8% stopped if there were other risk factors for CME, and 19.5% routinely stopped. 4 Most resumed prostaglandin analogs 30 to 60 days postop. There are some patients, however, in whom the physicians interviewed for this article said they would discontinue prostaglandins. Patients with diabetic retinopathy, retinal vascular occlusion, and epiretinal membrane, for example, are at risk for CME without surgery, Dr. Fudemberg said, noting that they are, however, less likely to be on a prostaglandin anyway. Surgical complications, such as posterior capsule rupture, could prompt withdrawal of a prostaglandin analog postop as well, he added. Dr. Ansari said he routinely stops prostaglandins—and other glaucoma drops for that matter— in patients who have been taking them for ocular hypertension. “In many patients with ocular hypertension, we treat them with eye pressure lowering drops to reduce the risk of them developing glaucoma in the future and when those patients are presenting to me for cataract surgery. I do often stop their glaucoma drops immediately after cataract surgery because I see their pressure becomes quite good after the cataract is removed, and they no longer need the glaucoma drop to lower their eye pressure,” he said. Dr. Parekh said he might consider taking ocular hypertension patients being treated prophylactically with prostaglandins off these drops after steroids used post-cataract surgery have washed out to reveal the new pseudophakic baseline IOP where their pressure levels out. If there is concern for CME while continuing a prostaglandin post-cataract surgery, Dr. Parekh advised watching the macula closely with a slit lamp examination, and also with OCT imaging. As for other glaucoma medications post-cataract surgery, Dr. Parekh said he generally would continue patients with what they were on prior to surgery. Drs. Ansari and Fudemberg said altering other drop regimens would depend on the patient’s glaucoma status. “If the patient happens to be on pilocarpine, I feel comfortable stopping that after cataract surgery, but not too many patients are on pilocarpine,” Dr. Ansari said. “Then when it comes to stopping other glaucoma drops, it depends on the status of their glaucoma. I typically don’t stop glaucoma drops if the patient has glaucoma. If the patient has ocular hypertension, AT A GLANCE • Despite the risk of CME with prostaglandin analog use as published in literature, many ophthalmologists are comfortable leaving glaucoma patients on these drops after cataract surgery with steroid use. • Ophthalmologists interviewed did not alter their typical steroid regimens in most glaucoma patients after cataract surgery. • In the case of cataract surgery coupled with a MIGS procedure, some ophthalmologists maintained their typical drop routine until 1 month postop, while others considered reducing glaucoma drops, depending on the patient’s pressure at 1 week postop.