What preoperative testing and medication management are recommended for an 84-year-old male with hypertension, prostate cancer, and action tremors, taking Mysoline (Primidone), Finasteride, Dyazide (Triamterene/Hydrochlorothiazide), and Nigediline (Nifedipine), undergoing cataract and glaucoma surgery with a microinvasive glaucoma stent?

From the Guidelines

For an 84-year-old male with hypertension, prostate cancer, and action tremors undergoing cataract and glaucoma surgery with a microinvasive glaucoma stent, recommended preoperative testing should include a comprehensive metabolic panel, complete blood count, and electrocardiogram. The patient should continue taking Mysoline (primidone) for tremors, Finasteride for prostate cancer, and his antihypertensive medications (Dyazide and Nifedipine) on the day of surgery with a small sip of water, as recommended by the 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. Electrolyte levels should be checked due to Dyazide use, which can cause hypokalemia. Blood pressure should be well-controlled before surgery, with a target below 150/90 mmHg, as suggested by the 2017 ACC/AHA guideline 1. The surgeon should be informed about the patient's tremors, as they may affect surgical positioning. The anesthesiologist should be aware of all medications to avoid potential drug interactions. Primidone levels should be maintained to prevent withdrawal seizures. The patient should temporarily discontinue any blood thinners or NSAIDs 7-10 days before surgery if applicable, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1. This approach balances the risks of medication discontinuation against potential surgical complications, particularly important in elderly patients where maintaining physiological stability is crucial. It is also important to consider the patient's overall health status and medical history, including his prostate cancer and hypertension, when making decisions about preoperative testing and medication management, as emphasized by the 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1. Additionally, the patient's antihypertensive medications should be continued during the perioperative period, as recommended by the 2002 ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery 1.

From the Research

Preoperative Testing

• The patient's medical history, including hypertension, prostate cancer, and action tremors, should be thoroughly evaluated before undergoing cataract and glaucoma surgery with a microinvasive glaucoma stent 2, 3.
• Preoperative testing should include intraocular pressure (IOP) measurements, as well as assessments of the patient's overall health and any potential risks associated with surgery 3, 4.
• The patient's current medications, including Mysoline, Finasteride, Dyazide, and Nigediline, should be reviewed and managed accordingly to minimize potential interactions or complications during surgery 5.

Medication Management

• The use of non-steroidal anti-inflammatory drugs (NSAIDs) may be considered in the preoperative period, but should be used at the discretion of the surgeon 2.
• Preservative-free ocular antihypertensive drugs and steroids may be preferred in the preoperative period to reduce the risk of surgical failure and promote better recovery of the ocular surface 2.
• The patient's antihypertensive medications, including Dyazide and Nigediline, should be carefully managed to avoid potential hypotension or other complications during surgery 5.
• The patient's Finasteride, used to treat prostate cancer, does not have direct implications for cataract and glaucoma surgery, but should be continued as prescribed by the patient's physician.

Microinvasive Glaucoma Stent (MIGS) Surgery

• MIGS surgery has been shown to be safe and effective in reducing IOP and minimizing the need for antiglaucoma medications in patients with open-angle glaucoma 3, 4.
• The learning curve for MIGS surgery is relatively short, and experienced surgeons can achieve successful outcomes with minimal complications 4.
• However, potential complications, such as shunt dislocation, should be considered and monitored for during the postoperative period 6.