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AGS 2024: Laser refractive surgery in high-risk glaucoma suspects


Michael Greenwood, MD, discusses the safety of laser refractive surgery for patients at high risk for glaucoma, focusing on the need for thorough pre-surgery assessment, careful monitoring of eye pressure during and after the procedure, and awareness of prolonged steroid use following PRK.

Michael Greenwood, MD, shared highlights of his presentation on laser refractive surgery for high-risk glaucoma patients at the 2024 meeting of the American Glaucoma Society with Ophthalmology Times' Group Editorial Director Sheryl Stevenson.

Video Transcript

Editor's note - This transcript has been edited for clarity.

Sheryl Stevenson: We are joined today by Dr. Michael Greenwood, who is among the faculty at this year's American Glaucoma Society. We're really interested in the title of your talk regarding laser refractive surgery in high-risk glaucoma suspects. What can you tell us about your presentation this year?

Michael Greenwood, MD: Thanks for having me. I'm excited to present on this. The bottom line when we're talking about laser refractive surgery and high-risk glaucoma subjects is laser refractive surgery, LASIK, PRK, SMILE—it's safe and these patients can have the refractive surgery but there's a couple of things you want to watch out for either on the refractive surgeon side or on the glaucoma surgeon side that you want to keep in mind with these patients.

Preoperatively you want to know what are these people at risk for. One of their biggest risk factors for developing glaucoma is they're usually myopic and so keeping that in mind, but take a detailed history on the glaucoma side, family history, those types of things.

You maybe want to do a little bit extra preoperative testing, perhaps getting an OCT individual field on these patients before they have the refractive surgery so you've got it documented and you've got a nice baseline for them over the long term, not that the refractive surgery is going to cause glaucoma to happen but you've got a baseline before they had refractive surgery in a 'normal eye.'

Intraoperatively, there's not a whole lot that you need to worry about but you can and do raise the eye pressure when we create the LASIK flap, and to a certain extent doing the SMILE procedure. And so just knowing that the IOP is going to go up very shortly during that part of the procedure is something to take note of but again shouldn't cause any damage to the patient in the short or the long term.

And then postoperatively a couple of things to watch out for. These patients, if they've had PRK, they could be on steroids maybe a little bit longer so knowing that they may be more at risk for a pressure spike from steroid use, keeping an eye on that.

And then educating these patients that even though you've had refractive surgery, and maybe you're out of your glasses, you still need to have lifelong eye care. One, it's good for your eye health. Two, you're at high risk for developing glaucoma.

We want to make sure that they continue to see their eye care providers for the rest of their lives, even though they might not need to see them for their glasses or contacts checked.

The last thing I'll mention is just that intraoperative pressure measurements can change after having refractive surgery. And so doing a really good job again on the front end of taking IOP and making a note of it, and then maybe 3 to 6 months after they've had their refractive surgery, repeating with the same instrument and making a note of maybe what the difference is so you can kind of carry that forward in their chart. Because usually with the Goldmann applanation, the IOP, you measure a little bit lower after refractive surgery so we need to keep that in mind. And it's also maybe a good idea to take the IOP measurement with a variety of devices so that you've got a couple of different measurements and you can use that to guide you making sure that these patients are taken care of for the long term.

Overall, refractive surgery is safe in these patients but there's some things to worry about on the front end and on the back end that you want to be mindful of.

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