EyeWorld Asia-Pacific June 2019 Issue

38 EWAP JUNE 2019 'FKVQTUo PQVG &T .GYKU JCU ƂPCPEKCN KPVGTGUVU YKVJ #GTKG 2JCTOCEGWVKECNU +TXKPG %CNKHQTPKC #NNGTICP &WDNKP +TGNCPF #NEQP (QTV 9QTVJ 6GZCU CPF QVJGT QRJVJCNOKE EQORCPKGU &T 8QNF JCU ƂPCPEKCN KPVGTGUVU YKVJ #GTKG 2JCTOCEGWVKECNU #NEQP )NCWMQU 5CP %NGOGPVG %CNKHQTPKC CPF QVJGT QRJVJCNOKE EQORCPKGU 6JG QVJGT RJ[UKEKCPU JCXG PQ ƂPCPEKCN KPVGTGUVU TGNCVGF VQ VJGKT EQOOGPVU Contact information Lewis: rlewiseyemd@yahoo.com Rhee: dougrhee@aol.com Song: brian.j.song@kp.org Vold: svold24@gmail.com W ith a sizable number of older patients on anticoagulation therapy, glaucoma specialists must constantly decide ܅>Ì ÃÕÀ}ˆV> “œ`ˆwV>̈œ˜Ã are needed to prevent complications in this patient subgroup—particularly if the patients are unable to stop chronic anticoagulation therapy. Managing medications Generally speaking, Douglas Rhee, MD , University Hospital Eye Institute, Cleveland, prefers to have patients on chronic anticoagulation therapy continue their medication, unless they are using it only for general health or as preventative medicine. If they are using it for prior deep vein thrombosis, prior pulmonary embolism, cardiac stents or other vascular stents, or a history of >ÌÀˆ> wLÀˆ>̈œ˜] À° ,…ii `œià not request that patients stop using the medications. “I may be a little more conservative, but my rationale is in the worst-case scenario, I’d opt to have a risk of complications from glaucoma surgery rather than risk a stroke, heart attack, or death,” he said. “I have found that most internists and cardiologists are more than happy to assist with a heparin bridge or adjusting warfarin in preparation for intraocular surgery,” said Brian Song, MD , Kaiser Permanente – Southern California Permanente Medical Group, Fontana, California. Richard Lewis, MD , Sacramento, California, also will not stop anticoagulants before surgery. A conversation with these patients about surgical risks and medication use also is important, said Steven Vold, MD , Vold Vision, Fayetteville, Arkansas. A detailed talk about risks and Li˜iwÌà LœÌ…ˆ˜vœÀ“à «>̈i˜Ìà and addresses medicolegal concerns, he said. “In these patients, I will have a detailed discussion about the increased risks associated with glaucoma surgery, particularly vision loss from a suprachoroidal hemorrhage, so that the patient is able to make the most informed decision possible,” Dr. Song said. He also considers other factors such as patient age, glaucoma severity, rate of glaucoma progression, and other comorbidities when deciding if and how to proceed with surgery. Dr. Song will advise patients to avoid oral nonsteroidal anti- ˆ˜y>““>̜ÀÞ `ÀÕ}à vœÀ «œÃ̜« pain, and if anticoagulation therapy is stopped, he will have them restart therapy right after surgery. Something that will be helpful for glaucoma surgeons to know going forward is the effect of newer direct-acting oral anticoagulation agents such as dabigatran (Pradaxa, Boehringer Ingelheim, Ingelheim, Germany) and rivaroxaban (Xarelto, Janssen Pharmaceuticals, Raritan, New Jersey), Dr. -œ˜} Ã>ˆ`° -«iVˆwV>Þ]…i would like to know how their discontinuation or reversal affect the risk of hemorrhagic complications associated with glaucoma surgery. Glaucoma surgeons should do their best to keep up with the constantly expanding $CNCPEKPI TKUMU CPF DGPGƂVU by Vanessa Caceres EyeWorld Contributing Writer Managing anticoagulation therapy in glaucoma patients requires careful review of medications, techniques AT A GLANCE • Many glaucoma surgeons want patients on chronic anticoagulation therapy to continue medications before and during surgery. • However, surgical choice and technique often are altered due to use of anticoagulant therapy. • MIGS should be done with caution in this patient population. • Studies that demonstrate the effects of newer direct-acting anticoagulants on hemorrhaging would be useful for glaucoma surgeons. Heme after Kahook Dual Blade procedure. Heme viewed through gonioscopy after MIGS procedure. 6JKU CTVKENG QTKIKPCNN[ CRRGCTGF KP VJG (GDTWCT[ KUUWG QH EyeWorld . It JCU DGGP UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ RGTOKUUKQP HTQO VJG #5%45 1RJVJCNOKE 5GTXKEGU %QTR SECONDARY FEATURE