EyeWorld Asia-Pacific December 2021 Issue

GLAUCOMA 44 EWAP DECEMBER 2021 many drops, and if the patient’s lifestyle is compatible with suLconunctiÛal filtration. Another factor to consider when looking at surgical options is the patient’s use of blood thinners. He will avoid GATT in patients who can’t be taken off blood thinners or who have to restart use quickly. He would consider iStent or Hydrus instead, depending on the degree of IOP lowering needed. He also said to consider XEN if the patient needs significant "* lowering. If the patient has had a prior tube shunt, Dr. Grover said that cilioablation works extremely well. He recommended CPC or ECP. Dr. Grover also mentioned angle closure disease, secondary OAG, and the health of the cornea as important factors to consider. For those with angle closure disease, he recommended phaco alone or possibly phaco and goniotomy, depending on the IOP and stage of the disease. For those with secondary OAG, Dr. Grover said these patients tend to do better with goniotomy or ab interno trabeculotomy. He also noted that if the patient has endothelial dysfunction and may need some form of corneal replacement, you may want to consider a tube shunt. For patients with “real” disease who are not able to use drops appropriately, Dr. Grover said he considers subconjunctival MIGS to maximize the chance of a lower IOP, or he may consider phaco/ Hydrus or phaco/goniotomy first] with a possiLle standalone XEN at a later time. It’s very important to manage patient expectations, Dr. Grover said. In general, the greater the IOP lowering, the greater the risk of surgery. The main goal of MIGS in most cases of moderate to advanced glaucoma, Dr. Grover said, is to decrease the dependence on drops. He rarely promises to get a patient off all drops. Tak Yee Tania Tai, MD, presented on cataract surgery in patients with primary angle closure glaucoma. When considering cataract extraction in patients with shallow anterior chamber, Dr. Tai said that a good preoperative evaluation should be performed, assessing for zonular dehiscence and secondary causes of shallow AC. Gonioscopy is also useful for determining if any angle procedure should be done, she said. Endothelial cell count is helpful for surgical planning. Even without other preexisting factors, operating in the limited space of a shallow AC is challenging, she said. There is increased risk of endothelial compromise and Descemet’s detachment. ifficulty maintaining a deep AC may allow the lens to move forward, and the posterior capsule may be harder to avoid. Aqueous misdirection and suprachoroidal hemorrhage may also be more common. Dr. Tai said it’s important to have a game plan for these cases. er fiÛe steps include\ 1. Control the pressure. This starts preoperatively with topical and oral medications. Make sure the speculum is not tight or resting on the eyeball. 2. Make the patient comfortable. Don’t be stingy on anesthesia. 3. Deepen the chamber (but not too much). You only need a few seconds to deepen. 4. Take advantage of technology. Dr. Tai suggested using the femtosecond laser to assist. 5. Stay in the bag. Try not to do supracapsular cataract extraction in a shallow AC. Shakeel Shareef, MD, discussed cataract surgery in patients with pseudoexfoliation. He said to assume all patients have pseudoexfoliation, noting that it might not be evident during an office eÝam and might come up for the first time in the OR. Some of the preoperative signs of zonulopathy include asymmetry of the anterior chamber and angle depth, lens subluxation, phacodonesis, iridodonesis, and poor dilation, among others. “We can decrease the risk of late subluxation by taking steps to respect the zonules intraoperatively,” Dr. Shareef said. He said that it’s important to minimize side-to-side and up-and-down movements, maintain a stable anterior chamber, perform careful hydrodissection/delineation, and perform tangential phaco and I/A vs. radial forces. Dr. Shareef also discussed the possibility for a small pupil in these cases and said it’s important to enlarge to gain access. This can be done with cohesive viscoelastic or with mechanical options. He added that it’s “vital to create an optimal anterior capsulorhexis.” /he optimal size is aLout xqÈ mm; too small of a rhexis could lead to damage to the zonules during lens rotation. He added that hydrodissection/ hydrodelineation is an essential step for separating the lens from the capsule zonular complex. When sculpting, don’t push. “Let the phaco handpiece lead you, like a dog pulling his owner on a leash” to avoid stress on the zonules, Dr. Shareef said. He also gave tips for maintaining a stable anterior