48 EWAP SEPTEMBER 2023 GLAUCOMA Greenwood reiterated that the ocular surface of these patients is “beat up,” which can interfere with obtaining accurate measurements and thus could affect outcomes. “If their surface is irritated, it needs to be optimized prior to doing their surgery,” he said. This could include stopping their glaucoma drops for a period of time, if they’re able to. It also can involve artificial tears, punctal plugs, and/or other dry eye treatments. “The therapies we have for ocular surface disease are growing rapidly, and we have a lot of tools to use for each patient,” Dr. Greenwood said. “But glaucoma patients may have more inflamed lids or meibomian glands, and paying attention to that can be helpful.” Dr. Greenwood said that if a patient cannot be taken off glaucoma medications, this is where a product like Durysta (bimatoprost intracameral implant, Allergan) could be useful. “That would be a perfect situation if you’re trying to lessen the medication burden and the patient’s glaucoma is severe enough that you can’t completely stop their medication, but you could take the topical drop off and put it inside the eye so it’s not aggravating the surface,” he said. “The postop side is another place where we’ve used it. You want to keep that inflammatory agent off the eye, and that’s where an implantable medication would work great.” Counseling of glaucoma patients takes on other layers before cataract surgery as well. Dr. Greenwood said if they’ve had prior ocular surgery, their zonules could be weak, which requires discussion. He also said his patient population has a higher rate of pseudoexfoliation. “Glaucoma patients in general but especially pseudoexfoliation patients are at higher risk for IOP spikes after cataract surgery, so be on the lookout for that,” he said, adding that he explains to both of these sets of patients that their healing might take longer. Dr. Sivaraman, in addition to detailing the importance of preoperative surface prep to ensure accurate measurements, also discussed the things she prepares certain glaucoma patients for from a counseling standpoint. “In patients with anatomically narrow angles or angle closure glaucoma, I always look at the anterior chamber depth and the density of the nucleus because the combination of a dense, thick lens with a shallow anterior chamber predisposes them to postoperative corneal edema, partly due to there being less physical distance between the ultrasound probe and the endothelium,” she said. “That becomes more significant with increasing density of the nucleus, especially if they have endothelial disease. I try to counsel patients with these risk factors that they may experience prolonged edema after surgery and potentially need a transplant later. IOL predictions also tend to be less accurate in patients with shallow anterior chambers, large lenses, and short axial length. … Although we can never guarantee glasses-free vision for any patient, it’s important for these patients to realize they may have a wider landing zone.” Dr. Sivaraman also said the presence of a temporal peripheral iridotomy affects where she makes her incision. “I now try not to make my incision directly over the peripheral iridotomy. I find that the iris tends to be floppy in the area of the iridotomy and can prolapse more easily when the incision is made directly above it.” Postoperative regimens can be affected by glaucoma as well. “You have to watch them closely for toxicity related to the additional preservative that you might have them on. That might be someone where you might consider using an intracameral antibiotic and skipping a postoperative antibiotic,” Dr. Sivaraman said. “You might consider doing some sort of implantable steroid. You’ve got to be careful with that though because these are the patients who are more likely to have a postoperative steroid response. Patients with a poor ocular surface, if they don’t otherwise have a lot of risk factors for CME, I might skip a prophylactic NSAID, which tends to be the biggest culprit in terms of exacerbating ocular surface disease after cataract surgery.” Dr. Sivaraman said she likes to have optimal control of glaucoma and IOP before heading into elective cataract surgery. A high IOP could put the patient at risk for perioperative IOP fluctuations and suprachoroidal hemorrhage. “When possible, I think the best treatment is prevention,” she said. Cornea surgery For a surface cornea procedure, Dr. Greenwood said limiting inflammation is a factor again. “You want to be very aggressive in getting that to heal, so consider putting in permanent plugs, using a different bandage contact lens, or maybe add an amniotic membrane that will give nutrients … and get the epithelial defect to heal in a timely fashion. Maybe back off on some of the glaucoma medications so that the epithelium has the support to heal over those few days or a week,” he said.
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