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Watch postop IOP in cataract surgery patients with glaucoma
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 Maynard L. Pohl |
Glaucoma patients who are being treated after cataract surgery should continue their topical therapy, and practitioners should watch closely to make sure they do so, several clinicians told Primary Care Optometry News.
“I typically do not modify a patient’s glaucoma therapy during his or her perioperative cataract care period,” Maynard L. Pohl, OD, FAAO, clinical director at Pacific Cataract and Laser Institute, Bellevue, Wash., told PCON in an interview. “In fact, I emphasize compliance in taking the antiglaucoma medicines as prescribed during this time period when IOP potentially may increase significantly.”
Watch them closely
J. James Thimons, OD, of Ophthalmic Consultants of Connecticut, Fairfield, said he keeps a keen eye on his glaucoma patients after cataract surgery.
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| This patient had advanced Axenfeld’s glaucoma with cupping in the right eye (left) and diffuse optic atrophy in the left eye (right). Images: Prouty RE | |
“The typical glaucoma patient who has cataracts requires a little more attention in the postoperative period,” the PCON Editorial Board member said in an interview. “If left unguarded, they can and do develop some pretty remarkable IOP spikes.”
Dr. Thimons said viscoelastics used in cataract surgery, such as Healon (sodium hyaluronate, AMO), may cause significant rises in pressure.
“My sense is that it tends to be a little more common in the glaucoma patient because the trabeculum is already compromised, and so the Healon will give you a short-term spike that may last a day or two,” he said.
Oftentimes compliance can be the cause of a postsurgical IOP spike. “Usually it is because the patient has stopped taking the glaucoma medications,” Dr. Thimons added,” maybe at the recommendation of the surgeon or maybe because the instructions weren’t as clear as they needed to be about maintaining the current regimen and then adding the three other drops that are used. It’s simple for somebody to forget a medication.”
Managing IOP spikes
Paul C. Ajamian, OD, FAAO, of Omni Eye Services of Atlanta, said a simple procedure performed right in the office can help lower IOP that is in the high 30s.
 This image shows a milky sclerotic cataract with PSC. Image: Prouty RE |
He performs a paracentesis on the eye, using a needle to create a small opening to “burp the wound.” The pressure generally will come down to about 12 mm Hg once the aqueous humor flows out, Dr. Ajamian said in an interview.
He uses a newer-generation fluoroquinolone before and after the paracentesis and a 30-gauge needle for performing the procedure.
“More and more ODs are getting comfortable with doing that,” he said. “If they’re not familiar with the procedure they should talk to their comanaging surgeon about how to do it. It’s so easy in most cases. If you can do it while the patient is in your office, so much the better.”
Dr. Pohl also turns to paracentesis when needed, followed by topical therapy.
“Should the IOP be extremely elevated, such as 40 mm Hg or higher, a modified anterior chamber paracentesis may be performed to reduce the IOP immediately,” he said. “Follow this with dispensing a drop such as brimonidine to be used every 12 hours as a preventive measure, until the IOP is re-evaluated at the 1-week postoperative exam,” he said.
ODs may want to check their state laws regarding performing this procedure.
Practitioners should see the patients at 1 day, 1 week and 1 month postoperative visits and check the pressure and best corrected vision each time. If the patient’s angles are suspicious, follow up with a gonioscopy, Dr. Ajamian advised.
CME concerns
Some physicians believe the use of a prostaglandin analog after surgery may lead to cystoid macular edema (CME), but others believe using the drop is relatively safe.
“In the presence of an abnormal surgical procedure, such as posterior capsular rupture, subluxation secondary to pseudoexfoliative disease or remnants of cortex or nucleus in the eye after surgery, the use of a prostaglandin may cause a higher level of inflammatory response and possibly initiate a cystoid macular edema component,” Dr. Thimons said. “It would be inappropriate to initiate IOP therapy in the immediate postoperative period with a prostaglandin in patients of that type, but there is no significant increase in risk with a prostaglandin after the immediate postop period.”
Dr. Ajamian said he uses nonsteroidals on every patient, pre- and postoperatively, and keeps high risk patients on them longer.
Dr. Pohl said he, too, looks for cases in which CME may be more likely to appear.
“Although I routinely do not discontinue prostaglandins, should a referred cataract surgery patient currently on a prostaglandin have a secondary eye condition predisposing to macular edema, such as diabetic retinopathy, venous occlusive disease or uveitis, I will discontinue the drop as a preventive measure in this higher risk patient and substitute another antiglaucoma drop not already being taken,” he said.
Alternatives available
Dr. Ajamian said other reasons may exist for halting the use of the prostaglandin analog for a short time.
“It depends on what other medications they have tried and how low their pressure needs to be and how advanced the glaucoma is,” Dr. Ajamian said. “If they are on multiple medications and we can drop the prostaglandin and we feel like the pressure will be low enough for that next month to prevent any progression, then we will just temporarily drop it out of their regimen.”
Dr. Ajamian suggested substituting with either a beta-blocker or Combigan (0.2% brimonidine tartrate, 0.5% timolol maleate, Allergan) or Alphagan P (brimonidine tartrate 0.15%, Allergan) twice a day.
Robert E. Prouty, OD, FAAO, center director of Omni Eye Specialists in Denver, also prescribes Combigan.
“That’s a recent addition to our armamentarium,” he told PCON. “If their pressure is 25 mm Hg or greater, I ask them to use it twice a day. Usually they resolve.”
The best course of action still seems to be to continue the regimen the patient was on before the cataract surgery. “It’s important to remind glaucoma patients to continue their topical antiglaucoma medicines throughout the perioperative period as previously prescribed,” Dr. Pohl concluded. “It’s also important to ascertain the true level of all abnormal IOPs, either high or low, through careful Goldmann applanation tonometry.”
For more information:
- Maynard L. Pohl, OD, FAAO, can be reached at Pacific Cataract & Laser Institute, 10500 NE 8th St., Ste. 1650, Bellevue, WA 98004; (800) 926-3007; fax: (425) 462-6429; e-mail: maynard.pohl@pcli.com. Dr. Pohl has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- J. James Thimons, OD, can be reached at Ophthalmic Consultants of Connecticut, 75 Kings Highway Cutoff, Fairfield, CT 06430; (203) 257-7336; fax: (203) 330-4958; e-mail: jthimons@sbcglobal.net. Dr. Thimons has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Paul C. Ajamian, OD, FAAO, can be reached at Omni Eye Services of Atlanta, 5505 Peachtree Dunwoody Road, Atlanta, GA 30342; (404) 257-0814; e-mail ajamian@aol.com. He is a member of Allergan’s Speaker’s Bureau.
- Robert E. Prouty, OD, FAAO, can be reached at Omni Eye Specialists, 55 Madison St., Ste. 355, Denver, CO 80206; (303) 377-2020; fax: (303) 377-2022; e-mail: RProuty@DrMyii.com. He is a member of Allergan’s Speaker’s Bureau.