34 EWAP DECEMBER 2022 GLAUCOMA IOP elevation - from page 32 he’s a believer in doing fewer trabeculectomies, but “there are patients who clearly need a trabeculectomy, and they might not be getting the care they need in the next 10–15 years.” Dr. Herndon said a “cataract cowboy or cowgirl” is not likely going to do trabs, leaving the procedure within the purview of glaucoma trained surgeons or comprehensive ophthalmologists who don’t otherwise have glaucoma specialists nearby. MIGS, Dr. Herndon continued, are mainly indicated for mild to moderate disease. If the glaucoma is more advanced, performing a MIGS procedure rather than a filtering procedure, which can achieve lower pressures, could be a disservice to the patient. If patients truly have severe disease and need significant pressure lowering, Dr. Herndon’s message is: If you can’t do a trabeculectomy and its postop management, it’s important to refer. “Trabeculectomy is not dead. It’s a sight-saving procedure, and if someone isn’t comfortable doing it, please find someone who is,” he said. In terms of when he, as a surgeon trained in filtering procedures, is comfortable returning a patient to a referring physician for care post-trabeculectomy, that’s generally after 2 months. “Ideally, I like to make sure pressures are well controlled and the bleb is functioning fine, and many of my patients are referred in from glaucoma specialists who know how to handle this postop period. The most crucial period of time is the first 2 months. I like to get them through that time, then I am comfortable referring them back,” he said. Dr. Herndon said that glaucoma is a practice that builds over time with long-term patient relationships. He knows he can’t hold on to all of his patients, and this is why he thinks it’s important for more ophthalmologists to get comfortable handling the common postop issues that these patients might face. The two main complications are pressures being too low or too high. As a takeaway, Dr. Herndon said to not be scared of trabeculectomy. “[Trabeculectomy] requires a lot of follow up. It’s not a money maker in many cases,” he said. “But it’s what’s in the best interest of the patient in saving sight. Don’t be afraid to consider trabeculectomy if there is no one in the near vicinity who can do it for the patient. You have to put the patient first and strive to get low pressures for these more severe patients.” EWAP Editors’ note: Dr. Herndon is Director of the Glaucoma Service, Duke Eye Center, Durham, North Carolina. He declared no relevant financial interests. IOP-lowering drops. “If the patient has a higher than average risk for glaucoma, I would also consider referring to a glaucoma specialist for baseline evaluation,” she said. Dr. Weng added that the risk of vision loss from the many diseases that intravitreal injections treat is significantly greater than the small risk of injection-induced glaucoma. “However, there needs to be more research conducted in this area so that we can continue to optimize the safety profile of intravitreal injections, the most common ophthalmic procedure we do today,” she said. EWAP References 1. Liu L, et al. Silicone oil microdroplets and protein aggregates in repackaged bevacizumab and ranibizumab: effects of long-term storage and product mishandling. Invest Ophthalmol Vis Sci. 2011;52:1023–1034. 2. Kahook MY, et al. High-molecularweight aggregates in repackaged bevacizumab. Retina. 2010;30:887–892. 3. Atchison EA, et al. The real-world effect of intravitreous anti-vascular endothelial growth factor drugs on intraocular pressure: an analysis using the IRIS Registry. Ophthalmology. 2018;125:676–682. 4. Good TJ, et al. Sustained elevation of intraocular pressure after intravitreal injections of anti-VEGF agents. Br J Ophthalmol. 2011;95:1111–1114. Editors’ note: Dr. Kahook is the Slater Family Endowed Chair in Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, and has interests with Alcon, Aurea Medical, Equinox, Fluent Ophthalmics, Johnson & Johnson Vision, New World Medical, SpyGlass Ophthalmics, and SpyGlass Pharma. Dr. Mandava is Professor and Chair, Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, and declared no relevant financial interests. Dr. Weng is Professor of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, and has interests with Allergan, Alcon, Alimera Sciences, DORC, Genentech, Novartis, Regeneron, and REGENXBIO.
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