Eyeworld Daily News

18 | EYEWORLD DAILY NEWS | APRIL 23, 2022 ASCRS ANNUAL MEETING DAILY NEWS T he 12th Annual Complications and "Reay of Hope" Video Session during Glaucoma Day featured several complicated video case presentations. The session was moderated by Manjool Shah, MD. Poonam Misra, MD, presented "Search and Rescue," a case by Joseph Panarelli, MD. In this case, an exposed Ahmed valve (New World Medical) needed to be removed and replaced with a Baerveldt (Johnson & John- son Vision). Dr. Panarelli took out the plate and tube but when attempting to remove the capsule ended up cutting a rectus muscle. Dr. Misra asked, what's next? Dr. Panarelli decided to find and rescue the muscle, sewing it with Vicryl and a weaving technique with locking passes on either end of the muscle. "One thing I tell our residents every time is to hook the muscles, hook the muscles, and hook them again, be- cause you really want to know where they are," Dr. Misra said. She also said it's important to isolate the muscle to separate any Tenon's and capsule so that the muscle is not overly tense. This was a recent case, Dr. Misra said so they don't have a full outcome to report yet. Kuldev Singh, MD, presented a case involving an 18-year-old patient with ROP with laser treatment at birth, cataract surgery in both eyes, 20/400 vision, and terrible nystagmus. He was on five medications and acetazolamide with a pressure of 13 mm Hg. Dr. Singh said this patient needed single-digit pressures. He was planning a limbus-based trab but found in the OR that a trab attempt had been made there before, so he pivoted and ended up doing a tunnel to the clear cornea. He made a flap and noted how the conjunctiva was "just tacked down," meriting more dissection to create a bigger bleb. He used 0.4 mg of MMC on a sponge for 5 minutes. "Now the question is, is this go- ing to work? It will depend on what happens in the next couple weeks," Dr. Singh said, adding later that he's got a good feeling about it based on the first weeks postop. Nathan Radcliffe, MD, took the audience on a "wild ride." His case involved a patient who presented with an IOP of 60 mm Hg, exfoliation glaucoma, and a small pupil. Preop visual acuity was hand motion only. He said you might wonder why do surgery if the patient was hand motion only, but the patient was on "all drops" and likely would end up with a decompen- sated cornea and pain. Thus, he leaned toward intervention. Things were going well with the cataract procedure, but there was a bit of an anesthesia issue, he thinks due the patient's pressure being 60. He did a little pars plana vitrectomy to make more space, then the patient started moving. When he was later cleaning up a little bit of cortex, he noticed that the red reflex looked only half red. "What am I looking at? I seem to have a limited choroidal hemorrhage," he said. Would you still place an Ahmed valve? His IOL was in the bag, the Ma- lyugin ring was taken out, and things were looking reasonably well when the IOL spontaneously dislocated in the bag. "The plan at this point is leave this chamber with viscoelastic in it, use [acetazolamide], MicroPulse [Iridex], and prayer, and see how we can go," he said. Postoperatively, Dr. Radcliffe said the patient was "not that bad," with pressure in the 30s (a 50% reduction, he said to some laughs). "This eye retained vision, the pres- sure was controlled, and the patient was not in pain," Dr. Radcliffe said. Ema Avdagic, MD, showed a case of persistent anterior chamber shal- lowing after PRESERFLO MicroShunt (Santen). At postop day 1, the patient's anterior chamber was moderately deep. By postop week 1, her anterior chamber was flat and she had an IOP of 7 mm Hg. Dr. Avdagic performed a PROVISC fill (sodium hyaluronate, Alcon). Between postop week 2–4, the patient's IOP was less than 10 mm Hg. A PROVISC fill was performed at week 2, and SF 6 fill at week 3.5. VISCOAT (chondroitin sulfate, Alcon) fill, GSL, and needle IZHV were per- formed at postop week 4. At this point the anterior chamber was now mod- erately deep but choroidals persisted. By postop week 6, there were "kissing choroidals." From here, Dr. Avdagic said cho- roidal drainage (with scleral windows), IZHV, and GSL were performed. At postop month 1 the patient had an IOP of 11 mm Hg on no medications, the PRESERFLO bleb looks good, the ante- rior chamber is deep, and the choroidal effusions resolved. After seeing each of the presen- tations, the audience voted for Dr. Radcliffe's case. Editors' note: Drs. Misra and Avdagic have no financial interests related to their comments. Drs. Singh and Radcliffe has financial interests with various oph- thalmic companies. Video cases offer a 'Reay of Hope' at Glaucoma Day Dr. Radcliffe presents a "wild ride" video that was voted by the audience as the best case of the session.

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