FEATURE EWAP DECEMBER 2023 27 is that the long-term issues are less likely compared to the other filtration procedures.” Prevention In general, with all of these complications, prevention is key. Here are some points Dr. Shah provided to help prevent complications: • Make sure you’re choosing the right patients for any given procedure. • Ensure you have an en face view for angle procedures and operate in reverse Trendelenburg. • Know your landmarks, using trypan blue to stain the trabecular meshwork and Schlemm’s canal if needed. • Use OVDs appropriately (a dispersive OVD to protect the endothelium and cohesive in the nasal angle); cohesive OVD can displace blood away from your view. In his interview with EyeWorld, Dr. Shah also emphasized making sure incisions are watertight and potentially leaving a bit of cohesive viscoelastic in the anterior chamber for extra pressurization for eyes at risk of complications from decompression, such as choroidals or anterior chamber shallowing. “To realize the promise of MIGS, we have to continue to put safety above all else. These procedures are safe when the proper steps are taken, when we take the time to get good visualization, when we recognize the right patient for the right process, when we’re meticulous with surgical technique,” Dr. Shah said. “The onus is on all of us as practitioners to maintain that high vigilance to be exacting in our technique, in our fundamental principles to live that promise that MIGS are meant to provide.” EWAP Editors’ note: Dr. Shah is Associate Professor of Ophthalmology, NYU Langone Health, New York, New York, and has interests with Alcon, Allergan, Glaukos, and Nova Eye Medical. Dr. Sheybani is Associate Professor of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis, St. Louis, Missouri and has interests with Alcon, Allergan, Glaukos, and Nova Eye Medical. Common complications - from page 23 References 1. von Graefe A. Beitrage zur pathologie und therapie des glaucoms. Archiv fur Ophthalmologie. 1869;15:108–252. 2. Quigley HA. Angle-closure glaucoma—simpler answers to complex mechanisms: LXVI Edward Jackson Memorial Lecture. Am J Ophthalmol. 2009;148:657–669. 3. Varma DK, et al. Malignant glaucoma after cataract surgery. J Cataract Refract Surg. 2014;40:1843–1849. Editors’ note: Dr. Aboobakar is Instructor in Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School, Boston, Massachusetts. Dr. Schlenker is Associate Professor, University of Toronto, Toronto, Canada. Dr. Varma is Assistant Professor of Ophthalmology, University of Toronto, Toronto, Canada. None of the doctors declared any relevant financial interests. you have a big decompression, it doesn’t matter if you’ve made space, you can still induce malignant glaucoma,” he said. Dr. Schlenker said in eyes with an axial length less than 20 mm, he will consider doing a prophylactic irido - zonulo - hyaloidotomy when doing cataract surgery. He might also do this if a patient is at higher risk, such as if they had malignant glaucoma in their other eye. Dr. Schlenker emphasized that early recognition of malignant glaucoma is important. “The worst case scenario is someone who has subtle malignant glaucoma, their angles are closed, and it gets sat on for years, and they slowly develop scar tissue in their drainage system. By the time they get sent to me, their drainage system is completely closed off (peripheral anterior synechiae), and their eye pressure is really high,” he said. “Retrospective case series suggest that most individuals with malignant glaucoma will go on to need vitrectomy combined with irido - zonulo - hyaloidotomy for definitive management,” Dr. Aboobakar said. “With prompt diagnosis and treatment, malignant glaucoma can resolve, though irreversible vision loss may occur depending on the duration and level of IOP elevation.” EWAP
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