EyeWorld Asia-Pacific June 2019 Issue

EWAP JUNE 2019 39 SECONDARY FEATURE anticoagulation options, Dr. Vold advised. When in doubt, discuss individual patient risks with the patient’s primary care doctor. Proceeding with MIGS The decision to perform microinvasive glaucoma surgery (MIGS) in a patient on chronic anticoagulation therapy can be a challenging one. For his part, Dr. Song prefers to avoid MIGS with this subgroup. “I think the most attractive feature of MIGS is predicated on the increased safety «Àœwi œv ̅iÃi «ÀœVi`ÕÀià when compared to traditional transscleral glaucoma surgery,” Dr. Song said. “However, hyphemas are a known complication of trabecular bypass procedures and tend to be more common in patients on anticoagulation therapy.” /…i «œÌi˜Ìˆ> Li˜iwÌà œv - could be compromised if there is blood in the anterior chamber, especially when the IOP decrease with a given MIGS procedure is modest, he added. That said, Dr. Song sometimes will offer MIGS to a patient using only antiplatelet therapy, such as aspirin. “In our own study of hemorrhagic complications from glaucoma surgery, continuation of anticoagulation therapy was associated with a higher rate of hemorrhagic complications than antiplatelet therapy. While our study did not include MIGS procedures, I do think this w˜`ˆ˜} ˆÃ >««ˆV>Li ˆ˜ œÌ…iÀ clinical scenarios as well,” Dr. Song said. In Dr. Vold’s experience, it’s better to avoid trabecular bypass cutting procedures such as a goniotomy or the Kahook Dual Blade (New World Medical, Rancho Cucamonga, California) in anticoagulant therapy patients. However, he sees fewer issues with most other MIGS approaches. “The key thing is you don’t want to open a blood vessel,” he said. Stay aware of potential long-term risks; after a Trabectome (NeoMedix, Tustin, California), a patient could cough years later and have a small hyphema in the anterior chamber, Dr. Vold cautioned. Other surgical approaches and pearls Proper surgical technique in patients on chronic anticoagulation therapy can …i« i>` ̜ > y>Ì >˜ÌiÀˆœÀ chamber and reduce the risk for bleeding. A few pearls shared with EyeWorld by glaucoma specialists include the following: • Consider transscleral laser, such as micropulse cyclophotocoagulation. “Though I routinely perform a retrobulbar block prior to transscleral diode laser, I w˜` ̅>Ì Ãœ“i «>̈i˜Ìà >Ài able to tolerate micropulse cyclophotocoagulation with heavy intravenous sedation in the absence of a block,” Dr. Song said. “I like this option for anticoagulated patients since it is noninvasive and also avoids the risk of a retrobulbar hemorrhage by forgoing the block.” r 2TG RNCEG UENGTCN ƃCR sutures when performing a trabeculectomy , Dr. Song advised. However, consider using a non-valved glaucoma drainage device such as a Baerveldt 250 (Johnson & Johnson Vision, Santa Ana, California) or Molteno3 (Molteno, Dunedin, New Zealand) if the patient does not require an immediate IOP reduction. “These devices potentially allow for more controlled pressure reduction via laser suture lysis of the ligature suture during the postop period,” he explained. • Tie the sutures a little more tightly during trabeculectomy , Dr. Vold recommended. Wait a couple of weeks to cut the stitches. • Make a paracentesis at the 6 o’clock position in case of a postop hyphema. “The inferior paracentesis can be used to drain a hyphema at the slit lamp and avoid returning to the OR for an anterior chamber washout in some cases,” Dr. Song said. • Don’t overlook anesthesia , said Dr. Song, who usually will give a sub-Tenon’s block instead of a peribulbar or retrobulbar block. • If a patient is able to stop anticoagulant therapy, make sure it is out of his/her system before proceeding with surgery . For instance, Dr. Vold generally waits 3 days after Ü>À>w˜ ˆÃ Ã̜««i`° "̅iÀ܈Ãi] you still could experience negative after effects. • Consider using a drainage device such as the Ahmed valve (New World Medical) instead of a trabeculectomy , and use a sutured tube to avoid postop hypotony, Dr. Lewis recommended. • Use an ophthalmic viscosurgical device more copiously intraoperatively to help limit bleeding , Dr. Lewis advised. EWAP Heme after OMNI Glaucoma Treatment System procedure. Diffuse heme after OMNI Glaucoma Treatment System procedure. Source (all): Steven Vold, MD