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Glaucoma Experts | Nov/Dec '14

Minimalism in Eye Care

With every passing day in my career as a cataract and glaucoma surgeon, I have grown to more greatly appreciate the mantra that less is more. Minimalism in eye care is the gift that keeps on giving, and due to increasing demands for efficiency, minimalism may be an essential part of the future of eye care.

Minimalism in glaucoma treatment often begins with the benefits of using monotherapy, a single eye drop given once daily to treat glaucoma. Using a single drop once daily follows the 80/20 rule, as monotherapy can stabilize perhaps 80% of patients with only 20% of the effort compared with maximum eye drop therapy. Additional eye drops may only lower the pressure marginally, while bringing on disproportionately more side effects and perhaps exponential difficulties with compliance.

The only treatment better than monotherapy is no drop therapy, which can be achieved using a laser. For the minimalist (and for the patient), laser trabeculoplasty is a fantastic first-line treatment. Selective laser trabeculoplasty (SLT) has been shown to be as effective as medications,1 prompting many to question why one would start glaucoma therapy with medications rather than first performing laser.

The use of postoperative anti-inflammatory medications after laser trabeculoplasty does not impact efficacy, so I have eliminated the use of post-SLT drops in my practice. This made patients happier and, in turn, prompted me to look for other opportunities to reduce eye drop use.

In patients with blue or hazel irises undergoing laser iridotomy, as well as in patients undergoing laser capsulotomy, I similarly found that postoperative topical anti-inflammatory agents are unnecessary in routine cases; therefore, these agents have also been eliminated from my practice.

Of course, with cataract and glaucoma surgery, efficiency in the operating room has intrinsic benefits. Every surgical step has the potential for a complication, and thus every eliminated step reduces the risk of complications, provided the surgeon isn’t leaving out anything that is truly essential.

Shortly after finishing my glaucoma surgical fellowship, I began to question whether some of the steps I had been taught for glaucoma drainage device implantation were necessary. To begin with, it did not seem necessary to me to sew a pericardial patch graft to the sclera overlaying the region of tube-sclera entry, as there are really no forces that would cause the patch graft to migrate after the conjunctiva had been closed. I eliminated this step.

I similarly found that most Ahmed valves seem to not move once placed in position behind the equator of the globe. Because stitching these devices to the sclera causes additional bleeding, inflammation, and discomfort for the patient and also requires a larger region of dissection, I eliminated this step. After noticing the significant amount of inflammation caused by Vicryl sutures placed through the conjunctiva to close the conjunctival incision after tube shunt surgery, I also sought to eliminate this step. With the use of Tisseel tissue glue (Baxter International) and a long scleral tunnel where the tube enters the sclera, I have finally arrived at a sutureless valve placement technique that provides my patients with a shorter intraoperative procedure and a more rapid postsurgical recovery. Patients who have undergone sutureless valve placement are more comfortable, and their eyes appear less inflamed from day 1. These benefits pay forward into more rapid symptom resolution and a reduced need for postoperative eye drops.

But can we eliminate the need for eye drops after intraocular surgery? Because glaucoma patients undergoing cataract surgery carry the double burden of needing both IOP-lowering and anti-inflammatory drops, I sought to help my patients find a simpler solution. Additionally, I had found that far too many patients were having adverse outcomes because of confusion regarding the use of their IOP-lowering and anti-inflammatory drops. Further, I had seen many patients who experienced adverse outcomes from noncompliance, yet I could never identify in advance who it would be.

When I heard about Imprimis and its formulation of antibiotic and steroid to be placed in the vitreous cavity at the end of cataract surgery, I felt that this could be an incredible benefit for my patients. Although intravitreal injection of postoperative medications is a slight departure from the standard of care, the reality is that the standard of care far from ideal. Patients often don’t fill their prescriptions and forget or neglect to self-administer drops. Even patients who intend to apply eye drops accidentally deliver the medication outside of the eye (eg, the cheek) and also touch and occasionally injure the cornea or conjunctiva when they do deliver the medication. When eye drops actually get into the eye, more often than not too many drops are applied, resulting in wasted medication and the potential for the bottle to become empty prematurely. Finally, the administration of the drops themselves introduces the potential for stinging and consequent eyelid squeezing, corneal abrasion, and ocular surface contamination—all things one would want to avoid in the postoperative period.

My initial experience with TriMoxi (Imprimis) for cataract surgery and combined cataract and glaucoma surgery has been exceptionally positive. The placement of the medication itself was very straightforward; however, closing the corneal wounds after required a bit of extra attention due to the increased volume in the vitreous cavity. This adjustment was more than made up for by excellent-appearing postoperative eyes and patients who are able to escape the burden of postoperative medications.

Yesterday, I examined a postoperative patient who had been on five pressure-lowering medications and oral acetazolamide prior to his surgery. He had undergone a combined cataract extraction with sutureless glaucoma drainage device placement and TriMoxi injection. His IOP and visual acuity are dramatically improved. While we might debate which one of us was happier now that he did not need to use any eye drops, one thing was not up for debate: In this case, less was definitely more.

1. Katz LJ, Steinmann WC, Kabir A, Molineaux J, Wizov SS, Marcellino G; for the SLT/Med Study Group. Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: a prospective, randomized trial. J Glaucoma. 2012;21(7):460-468.

Nathan M. Radcliffe, MD

Nathan M. Radcliffe, MD, is an Assistant Professor of Ophthalmology at Weill Cornell Medical College, New York-Presbyterian Hospital, New York. Dr.Radcliffe may be reached at (646)962-2020;drradcliffe@gmail.com.