Procedural Treatments: Perioperative Medication

Abstract

Inflammation plays a significant role in the success of glaucoma surgery. It has been shown that chronic use of topical glaucoma therapy is associated with inflammatory and atypical changes of the conjunctiva. In a recently published study, conjunctival cells obtained from the ocular surface of patients receiving long-term glaucoma treatment demonstrated a significantly in­creased expression of inflammatory markers, suggesting that inflammatory mechanisms, both allergic and toxic, are at work on the ocular surface of these patients [1]. The response appears to be dose-related. HLA-DR class II antigen, a hallmark of inflammation, was elevated significantly in patients receiving multiple therapies, whereas patients on monotherapies showed only slight and insignificant increases [1]. Indeed it is not uncommon for patients to be on three to four different topical medications for a long period of time before trabeculectomy is considered. In these patients, the third and fourth medications added may have minimal or no intraocular pressure (IOP) reduction effect, yet they may incrementally add to conjunctival inflammation (Fig. 36.1). Ideally, one would discontinue as many topical drops as possible prior to surgery to allow the ocular surface to return to a less inflammatory state. If a drop is inducing an allergic reaction, the agent definitely should be discontinued prior to surgery. The effectiveness of a topical medication causing an allergic reaction is no longer reliable and the active inflammatory reaction is likely to adversely affect the outcome of the surgical procedure.