EyeWorld India September 2018 Issue

EWAP FEATURE 23 Challenging cases in glaucoma surgery by Rich Daly EyeWorld Contributing Writer AT A GLANCE • Among the most challenging glaucoma cases that surgeons see are pseudoexfoliation patients, those that don’t respond to several surgeries, and younger patients with secondary conditions. • Surgeons are gaining experience with MIGS in some of the more challenging patient populations. • New medical options help surgeries work better because they give surgeons more flexibility if patients are having intolerances. Surgeons identify the lat- est treatments and coming innovations to help their most challenging glau- coma cases G laucoma specialists agree that emerg- ing treatments offer growing hope for their most challenging cases. “As a specialist, the pseudo- exfoliation patients can be the most challenging when it comes to combined cataract and glaucoma cases,” said Valerie Trubnik, MD, attending physician, Ophthal- mic Consultants of Long Island. “Also, patients who have retinal comorbities and elevated intraocu- lar pressures requiring surgery are challenging.” Dr. Trubnik said these cases can be challenging because the patients have had multiple intra- cameral injections, compromised zonules, and may have smaller pupils. Among the most challenging glaucoma cases seen by Nathan Radcliffe, MD, assistant professor of ophthalmology, Icahn School of Medicine at Mount Sinai, New York, are cases that don’t respond to several glaucoma surgeries. “Usually when you’re on your third or fourth glaucoma surgery you’re running probabilities that these eyes are going to have some complication with each surgery. We always think one surgery ahead so if this surgery doesn’t work, what am I doing next?” Dr. Rad- cliffe said. “These are the patients where you keep throwing surger- ies at them and they fail through them all.” Other challenging patients Dr. Radcliffe identified are those who do not tolerate any medications; patients with difficult personalities or unrealistic expectations; and late disease or “little-room-for-error cases.” “In my practice, about one- third of the people I operate on only have the one eye,” Dr. Rad- cliffe said. “They lost their other eye before I met them—often from glaucoma—so there is little room for error.” Among patients who present with intraocular pressures in the 50s while on all available IOP-low- ering medications and with almost no vision remaining, Dr. Radcliffe must quickly move to surgery, even as he has to warn patients that not even perfect surgery is guaranteed to maintain their vision. The most challenging glauco- ma cases seen by Robert Roth- man, MD, partner, Glaucoma Consultants of Long Island, are related to either severity of disease or age of onset. “Younger patients with sec- ondary conditions—inflammatory glaucoma associated with uveitis, young diabetics, Sturge-Weber syn- drome—tend to be the most chal- lenging cases for me,” Dr. Rothman said. “I also would include normal tension glaucoma as a significant challenge both diagnostically and therapeutically, in terms of man- agement decision making.” Treatments improving Treatment options have expanded for younger patients—including infantile glaucomas—with second- ary conditions. “There has been some improve- ment in the available options for Optic nerve with moderate glaucoma damage Source: Robert Rothman, MD continued on page 24 September 2018