GLAUCOMA EWAP MARCH 2024 35 an antimetabolite adjacent to the bleb after the cataract surgery and uses frequent topical steroids to reduce inflammation and any fibrosis that may occur. Bleb failure following cataract surgery is always disappointing, Dr. Boese said, but sometimes unavoidable. “We can add back glaucoma drops, revise/needle the bleb, or in some cases, perform another trabeculectomy or tube,” she said. “I typically find that bleb needling is less effective in mature blebs, but I have had a lot of success with needling a mature bleb failing shortly after cataract surgery. If the conjunctiva is healthy enough to withstand a needling, this is where I’d start, often with an antimetabolite like mitomycin - C. If we just need the IOP down slightly, adding back glaucoma drops is a possibility.” Dr. Boese said that intraoperatively, she doesn’t find that the fluidics change much following a trabeculectomy, as long as it is a mature bleb. “However, I often use a lower infusion pressure with the goal of causing less bleb turbulence,” she said. “I used to try to put a dollop of cohesive viscoelastic material near the sclerostomy, but this never made any difference. I am a bit more careful not to disturb the trabeculectomy externally as well. This means not using a fixation ring, toothed forceps on the conjunctiva, or nicking the bleb with your main or paracentesis wounds.” EWAP Editors’ note: Dr. Boese is Clinical Assistant Professor of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa, and declared no relevant financial interests. Dr. Boland is Associate Professor of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, and has interests with Allergan, Carl Zeiss Meditec, Janssen, and Topcon Healthcare. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. LESSONS LEARNED Valerie Trubnik, MD, Glaucoma Editorial Board member: 1. In order to improve flow in a busy glaucoma clinic, I have learned from senior colleagues that it may be helpful to split up the exam into two parts on separate visits. Perform an OCT RNFL, gonioscopy, and a non-dilated exam with a 90 D lens on the first visit, and bring the patient back for a visual field, dilated exam, and disc photos on follow-up. Portable VR visual field sets may also help improve efficiency. 2. I’ve learned that it’s critical to be firm with patients about their set target pressures and IOP control and to hold them accountable regularly during their visits. 3. My cornea colleagues have taught me that cyclosporine drops are often underutilized in glaucoma in improving dry eye, which is ubiquitous among our patients, and to help quiet inflamed eyes, especially prior to any filtering surgery. Prin Rojanapongpun, MD Chulalongkorn University 1873 Rama4 Road, Pathumwan, Bangkok, Thailand prinoph@gmail.com ASIA-PACIFIC PERSPECTIVES Cataract surgery, including routine phacoemulsification, can lead to filtering bleb function failure. Ultrasound energy to lens crystallins likely increases the production of fibrogenic cytokines in the aqueous humor leading to further scarring at the conjunctival-scleral or scleral flap interface. 1 The most critical period could be the first 6 months after Phaco but last as long as a year. 2 Needling at the time of Phaco is a good option to prevent bleb failure. The surgeon needs to be experienced. It may be performed after IOL implantation while OVD is still in the eye, then followed by I&A to enhance the bleb function and area. Should OVD come out to the bleb, it acts as a favorable spacer, especially high molecular weight hyaluronic acid, which is anti-inflammatory. IOL calculation in an eye with filtering bleb is subject to errors. Multifocal IOL is not a choice in most of the cases. Toric IOL can be inaccurate in both power and axis of placement. Unless the surgeon does not do needling and plans to add medication(s) in a fully mature bleb, toric IOL could be preferable if the remaining vision is good. Check the topography to see if it is a regular astigmatism. However, if the eye is soft, all calculations could be wrong. I employ intraoperative aberrometry to add more information for IOL power selection. Delaying phaco as long as possible is a good strategy in patients with good functioning bleb. Nevertheless, if lens removal outweighs all the risks, monitor postop IOL vigilantly, as IOP spikes could be phenomenal with a longer duration. It is all right to start oral acetazolamide and topical medications to ensure safe IOP. Discuss with the patient and the family the possibility of further intervention and inaccuracy of power beforehand. An office procedure like needling can be performed at a slitlamp or in a minor room. Discuss the necessity of adding medications and even another glaucoma intervention if target IOP cannot be achieved. Inform about the options of refractive correction with glasses or even add-on IOL in an appropriate case. References 1. Siriwardena D, et al. Anterior chamber flare after trabeculectomy and after phacoemulsification. Br J Ophthalmol. 2000 Sep;84(9):1056–7. 2. Salaga-Pylak M, et al: Deterioration of filtering bleb morphology and function after phacoemulsification. BMC Ophthalmol 2013, 13:17. Editors’ note: Dr. Prin Rojanapongpun declared no relevant financial interests.
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