Managing Intraocular Pressure Spikes Post-OVD Use: Strategies and Prevention

 

Managing Intraocular Pressure Spikes Post-OVD Use: Strategies and Prevention

While ophthalmic viscosurgical devices (OVDs) are essential for safe and effective intraocular surgery, particularly cataract surgery, a well-recognized potential complication is a transient but potentially significant spike in intraocular pressure (IOP) in the immediate postoperative period. This IOP elevation can pose a risk to the optic nerve, especially in patients with pre-existing glaucoma or compromised optic nerve health. Therefore, understanding the mechanisms behind these IOP spikes and implementing effective management and prevention strategies are crucial.  

The primary cause of postoperative IOP elevation following OVD use is the incomplete removal of the viscoelastic material from the anterior chamber at the end of the surgery. Residual OVD can obstruct the trabecular meshwork, the eye's natural drainage system, leading to a buildup of aqueous humor and a subsequent increase in IOP. The risk of IOP spike can vary depending on the type of OVD used. Cohesive OVDs, while generally easier to remove completely due to their tendency to aspirate as a single mass, can still cause obstruction if remnants remain. Dispersive OVDs, which tend to coat tissues, can be more challenging to remove entirely and may be more likely to cause a diffuse blockage of the trabecular meshwork.  

Several strategies can be employed to minimize the risk and manage postoperative IOP spikes related to OVD use. Thorough and meticulous removal of the OVD at the end of the case is paramount. This often involves using a low aspiration flow rate and carefully irrigating the anterior chamber, paying particular attention to removing any OVD trapped behind the iris or in the angle. Techniques like bimanual irrigation and aspiration can enhance OVD removal.  

The choice of OVD can also influence the risk. While both cohesive and dispersive OVDs have their advantages, surgeons may choose an OVD with properties that facilitate easier removal, particularly in patients at higher risk for IOP spikes. Viscoadaptive OVDs, designed for easier aspiration at higher flow rates, may offer an advantage in this regard.  

Prophylactic measures can also be considered in high-risk patients. This may include the intraoperative administration of miotics to constrict the pupil and open the angle, facilitating OVD removal and aqueous outflow. Postoperatively, topical IOP-lowering medications, such as beta-blockers, alpha-adrenergic agonists, or prostaglandin analogs, may be prescribed prophylactically, especially in patients with pre-existing glaucoma or a history of postoperative IOP spikes. Close monitoring of IOP in the immediate postoperative period is essential, and prompt treatment with IOP-lowering medications is necessary if a significant spike occurs. In rare cases of severe and persistent IOP elevation, anterior chamber washout to remove residual OVD may be required.

By understanding the mechanisms, implementing meticulous surgical techniques, carefully selecting OVDs, and considering prophylactic and management strategies, surgeons can significantly minimize the risk and impact of postoperative IOP spikes associated with OVD use, ensuring better visual outcomes and the long-term health of their patients' eyes.

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