Several less invasive glaucoma procedures can be performed right in the doctor's office. This chapter details the necessary clinical supplies and protocols.

LASER PERIPHERAL IRIDOTOMY

Assess the patient's visual acuity (VA) and intraocular pressure (IOP).

Review the procedure's risks with the patient and have him or her sign a consent form. The risks of laser peripheral iridotomy include increased IOP, decreased VA, diplopia, difficulties with glare, bleeding, iridotomy closure, inflammation, cataract formation, a need for further surgery, corneal or retinal burns, and blindness. Have your doctor answer any questions from the patient prior to the procedure.

In the examination room, place pilocarpine 2% in the presurgical eye. Arrange the patient at the YAG laser. Make sure he or she is comfortably situated and ready for the procedure. Prepare an Abraham iridotomy lens with hydroxypropyl methylcellulose (Goniosol; Novartis Ophthalmics, Inc.). Place a drop of brimonidine tartrate ophthalmic solution (Alphagan P; Allergan, Inc.) in the presurgical eye. Call the physician.

Check the patient's IOP approximately 1 hour after the procedure.

Routine postoperative care is prednisolone acetate 1% q.i.d. for 1 week. Patients return in 1 week for an IOP check.

YAG LASER POSTERIOR CAPSULTOMY

Assess the patient's VA and IOP.
Review the procedure's risks with the patient and have him or her sign a consent form. The risks of posterior capsulotomy include increased IOP, inflammation, pitting of the intraocular lens, retinal detachment, cystoid macular edema, a need for further surgery, and blindness.

Dilate the pupil with tropicamide (Mydriacyl 1%; Alcon Laboratories, Inc.) approximately 5 to 10 minutes before the procedure. Situate the patient comfortably at the YAG laser. Prepare an Abraham capsulotomy lens with hydroxypropyl methylcellulose. Place a drop of brimonidine tartrate in the presurgical eye. Call the physician.
Check the patient's IOP approximately 1 hour after the procedure.
Patients return in 1 week for an IOP check and dilated examination.

ARGON/SELECTIVE LASER TRABECULOPLASTY

Assess the patient's VA and IOP.
Review the procedure's risks with the patient and have him or her sign a consent form. The risks of argon and selective laser trabeculoplasty include increased IOP, failure, pupillary abnormalities, inflammation, cataract formation, a need for further surgery, bleeding, and blindness. Have your doctor answer any questions from the patient prior to the procedure.

Bring the patient to the laser room. Make sure he or she is comfortably situated and ready for the procedure. Prepare a Goldmann or Ritch trabeculoplasty lens with hydroxypropyl methylcellulose. Place a drop of brimonidine tartrate in the presurgical eye. Call the physician to let him or her know that the patient is ready.

Check the patient's IOP approximately 1 hour after the procedure. Routine postoperative care is commonly a mild topical anti-inflammatory drug. Glaucoma medications are commonly continued but may be discontinued in select cases.

Patients return in 1 to 2 weeks for a follow-up examination and an IOP check.

ARGON LASER SUTURE LYSIS

Suture lysis is a part of routine postoperative trabeculectomy care. A Blumenthal, Hoskins, Ritch, or Mandelkorn lens is used for this procedure.
Bring the patient to the laser room. Situate him or her comfortably at the argon or diode laser.
Call the physician to let him or her know that the patient is ready.

Bleb Revision

Assess the patient's VA and IOP.
Review the procedure's risks with the patient and have him or her sign a consent form. The risks of bleb revision include bleeding, infection, cataract formation, hypotony, choroidal detachment, bleb failure, a need for further surgery, and blindness. Use a glaucoma surgery stamp for the clinic note.

Instrumentation for the procedure is as follows: tetracaine 0.5%, povodine-iodine swabs, a 27-gauge needle, a lid speculum, Healon5 (Abbott Medical Optics Inc.), and possibly a combination of lidocaine and mitomycin C in a tuberculin syringe (0.2 mL lidocaine hydrochloride solution 1% [Xylocaine MPF; AstraZeneca LP] and 0.2 mL 0.4 mg/mL mitomycin C). Be prepared for a possible postoperative injection of 5-fluorouracil.

DIODE TRANSSCLERAL CYCLODESTRUCTIVE PROCEDURE

Assess the patient's blood pressure, pulse, and respiratory rate.
Review the procedure's risks with the patient and have him or her sign a consent form. The risks of a diode transscleral cyclodestructive procedure include blindness, phthisis bulbi, a neurotrophic cornea, hypotony, choroidal detachment, cataract formation, failure, a need for further surgery, and inflammation.

Ask the surgeon about oral sedation (diazepam 5-10 mg). For the retro- or peribulbar injection, draw up the surgeon's preferred anesthetic in a 5- to 10-mL syringe. Do not forget to set up the G-probe with the diode laser.

At the end of the procedure, place the surgeon's preferred cycloplegic and anti-inflammatory medication on the eye. Patch the eye with two eye pads (paper tape) for approximately 2 hours after the procedure.
Recheck the patient's vitals at the conclusion of the case.

A CAUTIONARY WORD

Always label syringes with exactly what is in them and show your doctor the bottles from which you drew them.