EyeWorld India December 2021 Issue

GLAUCOMA EWAP DECEMBER 2021 45 chamber, especially when transitioning from phaco to I/A and from I/A to lens implantation. Before pulling out the phaco handpiece, inject balanced salt solution simultaneously while turning off the continuous irrigation, and gently pull out the phaco handpiece. Prior to removing the I/A handpiece, turn off continuous irrigation while simultaneously injecting viscoelastic into the capsular bag, then remove the I/A handpiece. Dr. Shareef highlighted the role of capsular tension rings, which help with centration with less than 3 clock hours of zonulopathy. But he said they do not prevent late lens subluxation or capsular bag contraction (phimosis). Erin Boese, MD, discussed cataract surgery in patients with an over filtering trabeculectomy. In cases of an over filtering trabeculectomy, Dr. Boese said preoperative planning for cataract surgery is an important step, with some questions to ask. First, how long has your patient been hypotonus? If it has been more than 6 months to a year, they may have some irreversible components to the hypotony. Second, how much IOP increase do you need? You have to decide if you should fix the over filtration before, during, or after cataract surgery. With significant hypotony, Dr. Boese suggested addressing it prior to cataract surgery. One reason has to do with IOL calculations. With an increasing IOP, the axial length may increase, leading to myopic surprise, Dr. Boese said. She added that keratometry readings may also shift significantly, so be wary of placing toric lenses. There are a number of techniques to increase the IOP depending on how much increase you need, including surgical revision, fewer postop steroids with cataract surgery, and a blood patch. Surgical revision of the trabeculectomy should be addressed before cataract surgery. With revision, you are looking to significantly increase the IOP by slowing down flow through the scleral flap by replacing the interrupted nylon flap sutures. If it’s an old trabeculectomy, you may need to use additional techniques, she added. Reducing postop steroids following cataract surgery is an easy technique, Dr. Boese said. Post-trabeculectomy phacoemulsification causes small blebs and increased IOP. When she’s trying to keep a bleb working, Dr. Boese counteracts with frequent steroids. However, if she’s looking to increase the IOP in the case of an over filtering trabeculectomy, she will use fewer or no postoperative steroids to use the inflammation from cataract surgery to promote scarring. The blood patch option is another nice tool, Dr. Boese said. With this technique, the patient’s blood is drawn and immediately used to inject into the bleb using a 27-gauge needle. It’s easy and quickly done in the clinic, but physicians should expect a small IOP increase. Dr. Boese mentioned several intraoperative considerations for cataract surgery in an over filtering bleb, specifically lowering the bottle height and being careful not to nick the conjunctiva with the clear corneal incision. She doesn’t find that fluidics change much with a mature bleb. Wrapping up the presentations, Arsham Sheybani, MD, spoke about new surgical technology on the horizon. He mentioned treatment to the trabecular meshwork, highlighting excimer laser trabeculostomy (ELT). This is non-thermal laser removal of TM. There is less overall tissue removal than goniotomy, and it does not create a flap of TM, he said. Dr. Sheybani discussed iDose (Glaukos), a small titanium implant with a reservoir of travoprost that is inserted into the trabecular meshwork through a clear corneal incision. It involves travoprost elution at two different rates. In the suprachoroidal space, Dr. Sheybani mentioned the iStent Supra (Glaukos), which has a titanium sleeve. While similar to other suprachoroidal devices, he said there are differences in material and flexibility. He also mentioned the MINIject (iSTAR Medical), which has a porous silicone material, not as long as prior suprachoroidal devices and very flexible. The green ring on the device helps with ideal implantation, he added. EWAP Editors’ note: Dr. Berdahl practices at Vance Thompson Vision, Sioux Falls, South Dakota, and has interests with Alcon, Allergan, Carl Zeiss Meditec, Glaukos, Johnson & Johnson Vision, and New World Medical. Dr. Boese is Clinical Assistant Professor of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, and declared no relevant financial interests. Dr. Grover is Attending Surgeon and Clinician, Glaucoma Associates of Texas, Dallas, Texas, and has interests with Aerie, Allergan, New World Medical, and Santen. Dr. Shareef is Professor, Case Western Reserve University School of Medicine, Cleveland, Ohio, and declared no relevant financial interests. Dr. Sheybani is Associate Professor of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri, and has interest with Alcon, Allergan, Ivantis, New World Medical, and Santen. Dr. Tai is Associate Professor of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, and declared no relevant financial interests.