EyeWorld India September 2020 Issue

FEATURE 18 EWAP SEPTEMBER 2020 O ptimization of the ocular surface is increasingly a discussion point in the realm of cataract surgery, but the ocular surface impacts the success of many other procedures as well, including glaucoma surgery. “A good ocular surface is necessary to have a good surgery,” said Christophe Baudouin, MD, PhD, adding that patients on multiple topical treatments for glaucoma (the typical patient scheduled for a traditional trabeculectomy or MIGS-style trabeculectomy) often have a poor ocular surface preoperatively. “If it’s not controlled, they will have a very poor surgery.” If the ocular surface is already in a pro-inflammatory state before surgery, Dr. Baudouin said it will be more inflammatory afterward, increasing the risk of fibrosis, which could lead to less efficacy of the bleb, bleb failure, and worse IOP control postop. “As preoperative inflammation underlies postoperative fibrosis and therefore surgical outcome, a better knowledge of ocular surface changes with appropriate evaluation and management should thus become a new paradigm in glaucoma care over the long term,” Dr. Baudouin wrote in a paper published in 2012. 1 The first step in achieving this paradigm shift, Dr. Baudouin said, is prevention, removing the compounds responsible for inflammation. This could be preservatives but not always. He said it’s important to realize the compounding effects of preservatives from multiple drops as well as the potential for drug allergies that cause an inflammatory response, such as brimonidine. Richard Lewis, MD, echoed that brimonidine is a good one to stop a couple of weeks prior to surgery, if possible. “Their eyes get very irritated, and trying to do a trabeculectomy in that setting is difficult because they tend to bleed more, have more irritation, AT A GLANCE • The ocular surface is a consideration preop, intraop, and postop for trabeculectomy and trabeculectomy-like MIGS. • An inflamed ocular surface can lead to increased fibrosis and subsequent bleb failure. • Taking care of the ocular surface preoperatively and postoperatively can prevent some of this fibrosis, enhancing the potential for the procedure’s success. • Considering less invasive surgical procedures at an earlier stage (rather than when patients might be on multiple drops causing ocular irritation) could have a protective effect for the ocular surface as well. by Liz Hillman Editorial Co-Director The ocular surface for trabeculectomy and trabeculectomy-like MIGS Contact information Baudouin: cbaudouin@15-20.fr Lewis: rlewiseyemd@yahoo.com This article originally appeared in the June/July 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Flat neovascularized failed bleb after surgery. Highly inflamed bleb with mitomycin-C application.