EyeWorld Asia-Pacific March 2017 Issue

EWAP SECONDARY FEATURE 23 March 2017 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 glaucoma medications after cataract extraction in the early postoperative period, with the exception of prostaglandin analogs in some cases,” Dr. Fudemberg said. “Perhaps 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 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 effects of these medications need to be balanced with each patient’s clinical situation. “Ideally, I prefer aqueous suppression. 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 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 liberal 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 glaucoma 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 trabeculectomy or tube shunt surgery. “However, no evidence- based regimen of steroid use following filtering surgery or after cataract surgery 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 (difluprednate, Alcon, Fort Worth, Texas) for 3 weeks with a three-drop, two-drop, one-drop taper—among glaucoma and non- glaucoma patients. The increase in dropless antibiotic and steroid options, as well as combined options for fewer drops, could impact postoperative glaucoma medication regimens, Dr. Parekh said. “With the new ‘dropless’ regimens, I think there is a higher rate of breakthrough inflammation requiring ‘rescue,’ compared to the traditional topical regimens,” Dr. Parekh said. “Based on this, I would deduce that the topical regimen has more anti- inflammatory power than the dropless regimen … because you have a lot more breakthrough in one situation than you do in the other. Therefore, I would be more nervous if I was going to do the ‘dropless’ intravitreal injection and the patient was on a prostaglandin. I would watch those patients extra carefully or do something additional on those patients.” That “something additional” could include using a low-dose, topical anti-inflammatory regimen to supplement the intravitreal ‘dropless’ formulation, which Dr. Parekh said could result in less breakthrough and less need for rescue. In this case, he would then recommend leaving the previous prostaglandin treatment alone. “It’s a new idea so people are going to experiment with it and see what works, see what makes the most sense,” Dr. Parekh said. Cataract surgery combined with a microinvasive glaucoma surgery (MIGS) is another case where glaucoma drop treatments might be altered—in fact, that’s often the point of a MIGS procedure. In MIGS cases, Dr. Parekh follows the same postop regimen, letting the steroid wash out afterward, followed by taking the patient off prostaglandins or other glaucoma drops in a step- wise fashion. Dr. Ansari said after a goniotomy or iStent (Glaukos, San Clemente, California) coupled with cataract surgery, he will keep patients on their original glaucoma drops and will assess their pressure 1 week postop. If their pressure is low, he will cut back on the drops, reevaluating the pressure again at 1 month postop. “Anecdotally, about half of my patients seem to derive some benefit from the MIGS procedure. When I say benefit, I mean that they are on the same number of eye drops but with a lower pressure than they were before surgery or they’re on fewer eye drops with the same or better pressure than before surgery,” Dr. Ansari said. Dr. Ansari hasn’t observed any difference in IOP spikes after MIGS procedures compared with typical cataract surgery. Another consideration for glaucoma patients in cataract surgery, Dr. Ansari offered, is to pay close attention to the ocular surface. “Chronic use of glaucoma drops can lead to chronic dry eye and chronic ocular surface disease,” Dr. Ansari said, reinforcing how many know such conditions can skew measurements for IOL power calculations. “As glaucoma specialists who do a lot of cataract surgery or cataract surgeons who take care of a lot of glaucoma patients, we have to pay extra attention to the ocular surface and make sure we are taking steps to optimize the ocular surface of a patient on glaucoma drops before we do their cataract surgery. If you think you’re going to be discontinuing a patient’s glaucoma drop after cataract surgery, maybe you consider discontinuing it immediately before cataract surgery to help optimize the ocular surface, if you think it’s safe for their glaucoma.” EWAP Reference 1. Ayyala RS, et al. Cystoid macular edema associated with latanoprost in aphakic and pseudophakic eyes. Am J Ophthalmol . 1998;126:602–4. 2. Lima MC, et al. Visually significant cystoid macular edema in pseudophakic and aphakic patients with glaucoma receiving latanoprost. J Glaucoma . 2000;9:317–21. 3. Wand M, et al. Latanoprost and cystoid macular edema in high-risk aphakic or pseudophakic eyes. J Cataract Refract Surg . 2001;27:1397–1401. 4. Ahad MA, et al. Stopping prostaglandin analogues in uneventful cataract surgery. J Cataract Refract Surg . 2004;30:2644–2645. Editors’ note: Dr. Parekh has financial interests with Glaukos. Dr. Fudemberg has financial interests with Alcon, Allergan (Dublin, Ireland), Aerie Pharmaceuticals (Irvine, California), and Inotek Pharmaceuticals (Lexington, Massachusetts). Dr. Ansari has financial interests with Ivantis Incorporated (Irvine, California). Contact information Ansari: hansari@eyeboston.com Fudemberg: sjf003@gmail.com Parekh: parag2020@gmail.com