August consultation #6

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This case presents a clinical challenge because the glaucoma, if left unchecked, will cause irreversible blindness. My strategy would be to operate on the right eye first, giving a mannitol 12.5 g intravenous push after a B-scan to determine how much room the lens occupies in this small eye. The plan would be to remove 0.1 cc of vitreous from a pars plana approach with a scored and marked 25-gauge needle or, if the tap is dry (formed vitreous), have a retina colleague perform a very small vitrectomy to provide enough room to proceed. It is likely that the angle is irreversibly closed; therefore, I would combine phacoemulsification with trabeculectomy because this patient requires a low IOP for both the short and long run. I would start at 12 o’clock (under the Blitz anesthesia technique …