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Consultation section: Glaucoma

January consultation #7

Mattox, Cynthia MD

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Journal of Cataract & Refractive Surgery: January 2018 - Volume 44 - Issue 1 - p 116
doi: 10.1016/j.jcrs.2018.01.012
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This patient’s willingness to continue with glaucoma drops does indeed factor into the decision-making. Some patients are not aware of the toll on their daily life until their drops are eliminated, but we will take her at her word. That the progression of visual field damage has been slow, albeit I would say not nonexistent especially in the more severely damaged left eye, also helps with the decision-making because presumably the level of IOP control has been appropriate with the medications prescribed at present.

The anticoagulation is much less a concern for me than these other factors. My preference is to maintain patients on anticoagulants (at an appropriate, but low-end, INR for warfarin) in the face of all glaucoma surgeries including filtration because of the real risk for causing a stroke or other catastrophic consequence of the hypercoagulable state that can happen as patients are taken off or restarted on anticoagulants.1 There is a small risk for ocular consequences while on anticoagulants that can be discussed with patients in relative terms. However, for this patient, I think the choice will be a microbypass stent or a supraciliary microstent given all the information provided. Although if this patient had medication intolerance or a desire to eliminate medications, I would opt for a trabeculectomy, especially for the left eye. With the anticoagulated status, I would give a slight edge to the microbypass stent to avoid the risk for a larger amount of bleeding from an inadvertent trauma to the iris or choroid during creation of the supraciliary microstent cleft, although bleeding can certainly occur from Schlemm’s canal with a routine microbypass stent placement also; and I might consider implanting 2 microbypass stents if the patient agrees. I would counsel the patient, explaining that it is likely that she might need to be maintained on 1 medication and might need additional surgery in the future.

No matter what glaucoma procedure is chosen, I would proceed with temporal clear cornea phacoemulsification for the cataract surgery. I would operate on the right eye first to get some idea of the response to the glaucoma procedure and reassess before operating on the left eye. I would also counsel the patient that she might notice more improvement in the right eye because the left eye certainly lost more contrast acuity and vision will be perceived as dimmer and of less quality even after the cataract has been removed.

Reference

1. Armstrong MJ, Schneck MJ, Biller J. Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients. Neurol Clin. 2006;24:607-630.
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