GLAUCOMA EWAP SEPTEMBER 2023 47 Optimizing ocular conditions prior to surgery is standard for any procedure, but eyes with glaucoma present some extra considerations. EyeWorld spoke with Kavitha Sivaraman, MD, and Michael Greenwood, MD, to get their insights and best practices on how to prepare eyes with glaucoma for different ocular procedures. They also shared a few intraoperative and postop considerations along the way. In general, Dr. Greenwood said the main reason these eyes need so much attention is due to topical drop use. “These patients start taking an eye drop once a day, twice a day, then it’s multiple drops,” he said. “When they’re getting set up for surgery, their ocular surface and conjunctiva have been chronically irritated. It requires a bit of special attention for that.” Dr. Sivaraman expounded on this, saying that preservatives in the glaucoma drops are often the culprit and noted that surgery itself and being on postop drops can further stress the ocular surface. The other issue to watch for is postoperative IOP fluctuations. She said it’s important to educate patients about the potential up front, in case glaucoma treatment might need to be escalated in response. Glaucoma surgery Dr. Greenwood spoke about preparing these eyes for tubes or trabeculectomy. “Because these eyes are already inflamed, you’ve got to start reversing that trend. If you’re able to get the eye to quiet down, that involves slowing down or stopping some of their glaucoma medications and starting a steroid,” he said. “You remove the agent that’s causing the inflammation and you layer on an agent that inhibits that inflammation, so you have a nice quiet eye with the hopes that they don’t over heal; if they do, it either closes off the bleb or inhibits the flow of aqueous and their pressure goes back up and the surgery has ‘failed.’” Dr. Greenwood said reducing inflammation preop and in the early postop period is also important with the XEN Gel Stent (Allergan). For other MIGS that are not performed in conjunction with cataract surgery, he said there’s not a lot of surface prep. You do have to pay attention to where you’re doing the procedure. For example, Dr. Greenwood said the population is heavily Caucasian where he practices. For these patients who have glaucoma and are older, they often have more fat loss in the orbit, so their orbit is deeper set. Placement of the gonioprisim can be challenging. “I use a stabilizer ring on my gonioprism to help stabilize the eye, and sometimes you need to take that off to get everything in there,” he said. “That’s one special consideration with MIGS. Trying to get a good view for MIGS can be challenging sometimes.” Cataract surgery For cataract surgery, Dr. Making Practice Perfect – Optimizing the glaucoma eye for surgery by Liz Hillman Editorial Co - Director Contact information Greenwood: michael.greenwood@ vancethompsonvision.com Sivaraman: ksivaraman@cvphealth.com This article originally appeared under the title “Optimizing the glaucoma eye for surgery” in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Example of coarse and diffuse punctate keratopathy from BAK toxicity. Source: Kavitha Sivaraman, MD
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