March 2017




Older patients and glaucoma surgery

by Vanessa Caceres EyeWorld Contributing Writer


Dr. Rhee and colleagues stand while doing glaucoma surgery in an elderly patient with advanced glaucoma. They had to stand because the patient had congestive heart failure and could not lay flat.
Source: Douglas Rhee, MD

Surgical planning requires forethought, a comparison of risks versus benefits

As we live longer and as baby boomers continue to age, it’s inevitable that glaucoma specialists will more frequently face the decision to perform surgery in older patients.
In fact, those age 65 and older are expected to make up 20% of the U.S. population by the year 2030, according to a report from the American Geriatrics Society (AGS). Older adults already make up a large chunk of healthcare services, including 26% of physician office visits. And about 80% need care for chronic conditions like hypertension, arthritis, and heart disease, according to the AGS.
So exactly how does age affect decisions about glaucoma surgery? It’s one factor, along with general health and glaucoma stage, that specialists consider when they decide on glaucoma treatment and the need for surgery, said Douglas Rhee, MD, professor of ophthalmology, Case Western Reserve University School of Medicine, Cleveland. All three factors influence what may be the best treatment for an individual.
Don Abrams, MD, ophthalmologist-in-chief, Krieger Eye Institute, Baltimore, actually sees a trend toward glaucoma surgery earlier in life. “It used to be that most of our patients were over age 65. Now, we often do glaucoma surgery in many patients—obviously in patients with no choice but in some cases, we recommend it to relatively stable people with borderline control,” he said. Additionally, compliance with a multi-drop glaucoma treatment regimen isn’t perfect, so surgery is often the most definitive treatment modality.

Surgical decisions

The decision to perform glaucoma surgery takes on certain concerns when patients are older. “An example of when a surgery should not take place is when the patient’s health condition is acute, and proceeding with surgery could cause more harm than benefit,” said Karen Saland, MD, Texas Health Dallas.
In older patients with comorbid conditions, “you probably would want to do a surgery that’s a little lower risk,” said Barbara Smythe, MD, Glaucoma Consultants of Texas, Grapevine. “A trabeculectomy has a higher risk of complications. Tube shunts have fewer complications. Microinvasive glaucoma surgery [MIGS] is also lower risk and in some cases, depending on how advanced it is, this could be a safer option. It doesn’t always lower the pressure as much, but it does have lower risks.”
However, MIGS may not be an option if the patient can’t lay flat during surgery. “It’s back to trabs and tubes [in those patients],” Dr. Rhee said.
There are sometimes patients with other comorbidities, and they have difficulty managing glaucoma; at the same time, they may not be surgical candidates. “We can be caught between a rock and a hard place,” Dr. Abrams said. That said, he recently performed a successful surgery in an 89-year-old man with glaucoma uncontrolled by medications and with only one eye. The patient had severe diabetes and hypertension as well as a stable lymphoma. “Fortunately, there were no complications, but there could have been,” he said.
There are also risk/benefit and quality-of-life decisions. Dr. Abrams had a 97-year-old female patient with very early glaucoma who was referred by another ophthalmologist. The patient had started to use IOP-lowering medication that could have side effects. “With just a little glaucoma damage, she probably wouldn’t have significant damage until she was 105 or 110. Is it worthwhile to put someone, who probably won’t live long enough to see the damage, on meds that can have side-effects? I told her, ‘Yes, you have glaucoma, but go home and don’t bother with this.’ It’s not that you don’t want to treat them, but you have to make sound decisions,” Dr. Abrams said.
Similarly, patients who have glaucoma and also have a high risk of mortality, such as patients with end-stage cancer, may opt not to go through the pressures of surgery, Dr. Rhee said. Still, surgery does sometimes happen in those patients.
One advantage of surgery, when it’s necessary, is that it may eliminate the need for eye drops, Dr. Saland said. Eye drop compliance is a common problem for many glaucoma patients.

Concerns during surgery

With older patients more likely to have health conditions like atrial fibrillation, pulmonary embolism, or cardiac valve replacement, the use of anticoagulant medication is common. It’s usually necessary to stop anticoagulation therapy before glaucoma surgery; in some patients, the prescribing physician thinks it’s important for the patient to continue anticoagulation therapy. “You sometimes have to do a relatively bloody surgery,” Dr. Abrams said. “You can have complications related to that.”
Dr. Rhee observed that sometimes patients who may have a condition like osteoarthritis take a nonsteroidal anti-inflammatory drug, not thinking about the anticoagulant side effect.
Another risk factor is blood pressure at the time of surgery—a problem that can be more common in older adults. “With full-thickness procedures, high blood pressure can increase the risk of suprachoridal hemorrhage,” Dr. Rhee said. So, blood pressure is another factor considered when deciding on surgery in older adults.
Depending on the patient’s other health conditions, wound healing can be harder, especially in a patient who does not have good circulation, Dr. Smythe said. This is more common in patients with severe heart disease or patients who are smokers. “They don’t have good oxygenation of the blood, and that can’t promote good healing. There’s nothing to do except to be aware of it and try to tighten wounds more tightly,” Dr. Smythe said. Wound healing also can be a concern if the patient has diabetes, Dr. Abrams said.
When performing surgery in an older patient with comorbidities, extra clearances from pulmonologists or cardiologists may be necessary. “Sometimes, something else comes to light—such as newly diagnosed atrial fibrillation or a finding or concern on an X-ray that may be cancer. I’ve had that happen,” Dr. Smythe said.
Dr. Abrams also recommends performing surgery at a center attached to a hospital when comorbidities are present. “I had a patient 3 or 4 years ago who had a heart attack in the recovery room but ended up in a ventilator in the recovery room because we had the proximity to care,” he said. That would have been a lot harder to manage if the surgical center was not adjacent to the hospital.
Dr. Smythe once had a patient who was so medically unstable that when she showed up in preop, she ended up going to the adjacent hospital’s ICU.

Surgical positioning

Although patients of any age may have a health condition that precludes them from lying flat for surgery, this is more likely to occur in older patients. When Dr. Smythe has surgical patients with a curvature of the spine from osteoporosis or kyphosis, she props up pillows under their neck.
In patients with asthma or chronic obstructive pulmonary disease, in whom it’s hard to get a good breath when laying down—especially if they are overweight or obese—Dr. Smythe has a suction under the drape that is placed just below the chin. The suction helps to remove the carbon dioxide, and the patient is usually more comfortable.
Dr. Rhee recently performed surgery in a patient in his 90s who could not lay flat due to congestive heart failure. Dr. Rhee had to do the surgery standing up, while the head of the patient’s bed was elevated up by about 30 degrees.

Patient education

All patients should be educated about their glaucoma surgery, of course, but older adults may have more issues with their senses and their memory. “Written instructions and communicating the concepts with patients and their caregivers become even more helpful,” Dr. Rhee said.
Dr. Abrams finds it best to have a child or grandchild with the patient to talk about glaucoma or glaucoma surgery; if it’s an aide, the person may not spend enough time with the patient to clearly convey surgical information to family members. If a family member does not come to the appointment with the patient, he will often get them on the phone and put it on speaker so everyone hears the same message, he explained.
It’s also crucial that glaucoma patients understand the importance of returning for regularly scheduled screenings, especially if they have other ailments such as diabetes, arthritis, high blood pressure, a history of strokes, heart attacks, or cancers, Dr. Saland said. 

Editors’ note: The physicians interviewed have no financial interests related to their comments.

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