Physicians should anticipate, avoid bleeding issues in glaucoma surgery
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NASHVILLE, Tenn. — When treating a patient with glaucoma, surgeons should take steps to anticipate and avoid problems related to unwanted blood, according to an expert.
“I think we all realize that the best way to deal with bleeding is to avoid it in the first place,” Richard K. Parrish II, MD, said at the American Glaucoma Society meeting. “Blood is bad for the patient and for the glaucoma surgeon.”
Parrish said bleeding prevention comes in three stages: preoperative, operative and postoperative.
Before a glaucoma surgery, Parrish said to consider discontinuing a patient’s aspirin or clopidogrel but advised against stopping warfarin or apixaban if it is required for systemic anticoagulation. Anti-VEGF therapy or panretinal photocoagulation can be used to minimize retinal ischemia and associated anterior segment neovascularization. In addition, controlling a patient’s hypertension before surgery is key to preventing unwanted bleeding during surgery, he said.
During surgery, Parrish said to use topical anesthesia to reduce the risk for periorbital bleeding. He also said that surgeons should avoid scleral flap dissection in the Axenfeld nerve loop to minimize subconjunctival bleeding.
To help avoid bleeding after surgery, hypotony should be avoided in eyes that are at risk for delayed suprachoroidal hemorrhage; this includes eyes of elderly patients, eyes that are aphakic, eyes that were previously vitrectomized, eyes with active neovascular membranes and patients with a history of suprachoroidal hemorrhage in the fellow eye. In addition, patients should suppress coughing, minimize constipation and avoid lowering their head below heart level.
“The risks of complications such as delayed suprachoroidal hemorrhage are very rare, but when it happens to you or your patient, it’s a certainty,” Parrish said. “In every preoperative discussion, put the risks and benefits in perspective when providing informed consent.”
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Parrish RK. Heme, heme everywhere: How to deal with unwanted blood perioperatively. Presented at: American Glaucoma Society meeting; March 3-6, 2022; Nashville, Tennessee.
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