Speaker shares pearls for better glaucoma management

Brian A. Francis, MD, MS

In his lecture on Glaucoma Day, Tom Samuelson, MD, presented several useful pearls in glaucoma management. The first was to avoid “unforced errors,” especially in surgery. For example, do not place a patient with mild to moderate glaucoma at risk for complications from  trabeculectomy, such as suprachoroidal hemorrhage, endophthalmitis or hypotony maculopathy, when a less risky procedure will suffice. The second pearl was the concept of “enhanced MIGS.” Even in patients with lower target IOP, this can frequently be achieved with a combination of a MIGS procedure, phacoemulsification and glaucoma medications. In the management of primary angle closure glaucoma, Samuelson believes that cataract extraction is the management of choice. Even in patients with elevated IOP, removing the lens and possibly performing lysis of goniosynechiae can be a safer and more physiologic alternative than trabeculectomy. Lastly, all anterior segment surgeons should be familiar with intraoperative gonioscopy. This is essential for the majority of current and future MIGS procedures, which are performed in the angle using an internal gonioscopic approach. It is also useful for procedures such as lysis of goniosynechiae as discussed above or more rare procedures such as repair of cyclodialysis cleft or iridodialysis.

These concepts should be applied to the treatment of glaucoma patients, whether by a comprehensive ophthalmologist or glaucoma specialist.  The surgical management of glaucoma is becoming more diverse and complex, and moving toward earlier intervention. This allows us to individualize therapy based on the patient’s disease state, anatomy and other risk factors.