Special Considerations in the Surgical Management of Elderly Patients
When deciding whether to perform surgery in an elderly patient, the surgeon must consider several issues specific to this population. Considerations include the severity of the glaucoma and the risk of functional vision loss in relation to the patient’s life expectancy, as well as the presence of any major systemic disease that could affect the outcome. The surgeon must also assess the patient’s ability to adhere to medical therapy. For example, a patient who has poor medication adherence preoperatively (because of memory loss, poor vision, tremor, or arthritis) is likely to be nonadherent in the postoperative phase as well, which could jeopardize the outcome.
Once the decision has been made to proceed with surgery, the surgeon should determine which procedure is most likely to be adequately successful in reducing IOP with the fewest possible complications. The surgeon should consider the patient’s ability to return for multiple follow-up visits. If a patient is not mobile or lacks easy transportation options, a nonpenetrating surgery, MIGS, or cyclodestructive procedure may be preferred, as these procedures require fewer postoperative visits than does a trabeculectomy or tube shunt surgery. If a trabeculectomy is selected, a limbus-based conjunctival flap might be considered, as it is less likely to leak than a fornix-based flap. The patient’s use of anticoagulants and antiplatelet medications should also be evaluated, as these drugs increase the risk of serious complications from intraocular hemorrhage; however, stopping them is associated with a risk of vascular events. Finally, the surgeon must factor in compromised healing in elderly persons and be cautious about the use of antifibrotics in this group, as their tissues tend to be thinner and more fragile compared with those of younger patients.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.