February 2019


Facing complicated glaucoma cases

Nathan Radcliffe, MD,
Glaucoma editor

With the voluntary recall of the CyPass Micro-Stent (Alcon, Fort Worth, Texas), the glaucoma community has turned its attention to the corneal endothelium, and EyeWorld has enlisted glaucoma and cornea experts Ramesh Ayyala, MD, and John Berdahl, MD, to teach us about the complex relationship between the cornea, particularly the corneal endothelium, and glaucoma. We learn that everything from a high IOP to a low IOP and a variety of other factors may embarrass the corneal endothelium. Both experts weigh in on combined glaucoma and corneal surgery, with Dr. Ayyala noting that ab externo canaloplasty is still a great procedure to protect the cornea because of its non-penetrating nature.
While we generally consider MIGS to be very safe, bleeding is still top of mind, particularly for cataract surgeons providing premium outcomes. Because many of the aging population will be using chronic anticoagulation therapy, EyeWorld reached out to glaucoma experts Douglas Rhee, MD, Brian Song, MD, Richard Lewis, MD, and Steven Vold, MD, to learn more about balancing the risks and benefits of MIGS in patients treated with anticoagulants. All the surgeons agreed that communicating with the treating primary care physician is important, as is a discussion with the patient about surgical risks and the risks of stopping anticoagulant medications. In cases where the risk is too high, a transscleral laser may be a viable option, although our experts also discuss a variety of other technical considerations to make high-risk surgeries safer.
With so many new developments in the world of MIGS, where does endoscopic cyclophotocoagulation (ECP) fit in 2019? EyeWorld spoke with Ronald Fellman, MD, Steven Sarkisian Jr., MD, and Brian Francis, MD, about ECP and other ways to boost surgical outcomes. ECP can be used diagnostically and therapeutically as an adjunct to both traditional and MIGS procedures. In some cases, transscleral laser such as micropulse may be used in a similar fashion.
To consider the impact that ophthalmic viscoelastic devices (OVDs) have had on glaucoma surgery and the management of complications,
Robert Noecker, MD, Jacob Brubaker, MD, and I spoke with EyeWorld about their developing use. Cohesive and dispersive OVDs can aid the glaucoma surgeon in traditional and MIGS procedures, both in and out of the operating room.

Facing complicated glaucoma cases Facing complicated glaucoma cases
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