TRABECULECTOMY Dr. Sandra M. Johnson, MD
FILTRATION OPTIONS Trabeculotomy, Schlemn s canal, internal Deep Non-penetrating Sclerectomy filtering to a scleral lake, or viscocanulostomy Trabeculectomy shunting fluid subconjunctival Tube Shunt shunting fluid subtenon s
EVOLUTION OF TRAB Full thickness; thermosclerostomy, Schei procedures Kearns Guarded filtration with a flap Hoskins laser suture lysis Antimetabolites
TRABS Still the best option for low IOP at AGIS level Other procedures more likely to have IOP in mid teens or require supplemental medication Knowing the CCT helps to set the target IOP
QUESTION #1 What is the AGIS IOP cutoff for patients with advanced glaucoma to be likely stable A. IOP over 18 B. IOP 14-18 C. IOP 14 and under D. IOP below the teens
WHEN TO DO SURGERY? FAILED MEDICAL THERAPY INABILITY TO LOWER IOP COMPLIANCE ISSUES Mental status Cost Llifestyle ALLERGIES ADVANCED DISEASE UNLIKELY TO ACHIEVE LOW TARGET WITH MEDS/LASER AND RISK OF VISION LOSS DURING ATTEMPT
CHOICES LIMBAL BASED FORNIX BASED*** COMBINED ANTIMETABOLITES Tube Implant; valved or not
QUESTION #2 Which of the following is a valved glaucoma tube implant? A. Baerveldt B. Auro Lab C. Ahmed D. None of the above
COMBINEDS If significant cataract and bad glaucoma or MTMT Moderate glaucoma with cataract likely to progress Narrow angle and PXF patients on multiple meds where lens removal is likely to enhance glaucoma control, allow manageable AC post-op
OPERATIVE MEDS Miotic if not a combined Topical antibiotics pre op if desired Subconj steroid and antibiotic at the end of surgery Keep up topical meds pre-op if a risk of elevated IOP during surgery Consider viscoelastic for maintaining IOP if IOP very elevated pre op
I prefer to operate in a quadrant to allow room for a future surgery
Limbal based
Kelly Punch
FLAP CLOSURE Consider releasable when melanosis, thick tenon s Long sutures to enhance LSL Tighter closure nasally to avoid nasal bleb and dellen Test the flap with BSS/saline through the para
ANTIMETABOLITES POST-OP 5-FU 5mg doses up to 14 days BID INTRA-OPERATIVE MMC 0.2 to 0.5mg/ml For up to 5 minutes- very toxic to corneal endothelium INTRA-OPERATIVE 5-FU 50 mg/ml for 5 minutes- not as toxic as MMC
QUESTION #3 Which anti metabolite is cell cycle specific? A. Mitomycin C B. 5 Flurouracil
ANTIMETABOLITE DECISIONS Consider 5-FU for high myopes, aged MMC 0.2mg/ml for whites, 0.4mg/ml for more pigment and combineds CONCEPT OF ONE MINUTE PER RISK FACTOR OF MMC: race, age, uveitis, advanced disease/need for low IOP/CCT, prior scarring, scleral thickness POST-OP 5-FU as needed
KHAW Results AFTER BEFORE Fornix based Large Area MMC 0.5 mg/ml Limbus based Small Area MMC 0.4 mg/ml Bleb related problems inc leaks / blebitis / endoph 0% 20% Ophthalmology 2003
POST-OP CARE Shield for two weeks or more, until sutures are loose and wound intact Antibiotic prophylaxis for 10-14 days, longer for BCL or leaks Steroids based on AC inflammation and conjunctiva, tapered over about 6-8 weeks Cycloplegia for phakic eyes, shallow CTM on selected visits to assess flow
SEIDEL TEST
BLEB LEAKS AQUEOUS SUPPRESSION IRRITATING ANTIBIOTIC LIKE GENT BCLS BLOOD INJECTION BLEB NEEDLING SURGICAL REVISION
CTM=Carlos Traverso Maneuver Focal pressure at the edge of the flap To lyse adhesions, allow flow Use Q tip or finger with patient looking down
Carlos Traverso Maneuver CTM/DP Focal pressure at the edge of the flap To lyse adhesions, allow flow Use Q tip or finger with patient looking down
LASER SUTURE LYSIS Hoskins or Ritch lens ARGON LASER USED TO CUT THE SUTURE AND ALLOW MORE FLOW
LSL
Releasables: one week post op a 10
QUESTION #4 In the prior photos what predicts a failing bleb? 1. Height of the bleb 2. some injection 3. corkscrew vessels 4 inability to see the flap through the conjunctiva
FAILING BLEB Consider LSL even if IOP is low Increased Steroid 5-FU 5 to 7.5mg up to 3-5 doses based on cornea
5-FU.1 or.15 cc of 50mg/ml for 5-7.5mg dose LSL and/or massage (CTM) before to increase bleb Topical proparacaine and 4% lidocaine and antibiotic pre & post 30G to inject away from bleb I use slit lamp
BLEB NEEDLING TOPICAL ANESTHESIA AND ANTIBIOTIC PLUS NEO INJECT 1% PF LIDOCAINE TO FURTHER NUMB AND CREATE A WORKING SPACE OR BLOCK FIRST
INTERNAL BLEB REVISION DONE IN THE OR FOR STERILITY same anesthesia as needling or a block needs intraoperative gonio
SURGERY: MAKE A PLAN PRE-OP Includes mmc/fu, combo, approach One day post op: Check wnd integrity and inflammation May need BCL, decide on steroid Cycloplegia for phakic pts 5 days post op: consider suture for any persistent or new leak Consider LSL or CTM for red or low bleb, high IOP A NVG may need 5 FU Subsequent weeks, consider LSL, 5-FU
SHALLOW ANTERIOR CHAMBER OVERFILTRATION WOUND LEAK AQUEOUS MISDIRECTION CHOROIDAL EFFUSION OR HEME MAY NEED TO DEEPEN
OVERFILTRATION RESTRICT FLOW WITH BCL or air bubble DECREASE STEROID CYCLOPLEGIA WOUND LEAK BCL SUTURE AQUEOUS SUPPRESSION LESS STEROID, ANTIBIOTIC, CYCLOPLEGIA
AQUEOUS MISDIRECTION ATROPINE YAG HYALOID VIA CAPSULOTOMY VITRECTOMY NEED UNICAMERAL EYE
MALIGNANT GLAUCOMA AQUEOUS MISDIRECTION
CHOROIDAL EFFUSIONS MORE COMMON IN ELDERLY, HIGH PRE-OP IOP STEROIDS FOR INFLAMMATORY COMPONENT, CYCLOPLEGIA AC REFORMATION MAY NEED DRAINAGE: FAILING BLEB, COMPROMISED CORNEA
SCH ASSOCIATED WITH HYPOTONY RISKS INCLUDE ELEVATED IOP, PRIOR VITREOUS LOSS, AGE, ELEVATED HR/BP, VALSALVA VERY PAINFUL CONSIDER SYSTEMIC STEROID POORER PROGNOSIS WITH VIT HEME MAY NEED TO DRAIN 7-10 DAYS
Hypertensive phase
TENON S CYST HIGH DOME PHASE THICKENED/COMPRESSED TENON S CAUSES BLEB TO BE EXTENSION OF AC TREAT WITH MASSAGE AND AQUEOUS SUPPRESSION SOME DOCTOR S NEEDLE WITH 5-FU MORE LIKELY TO STAY ON MEDS (AGIS)
LATE BLEB COMPLICATIONS
HYPOTONY WITH MACULOPATHY MACULA STRIAE AND DECREASED VISION REQUIRES INTERVENTION TO AVOID PERMANENT VISION LOSS INTERVENE IN FIRST SEVERAL MONTHS BLOOD INJECTIONS, TCA, LASER BLEB REVISION
LESS DESIRABLE BLEB
BLEBITIS ASSOCIATED WITH LEAKING BLEBS AN EMERGENCY NEEDS TAP AND INJECT OF VITREOUS CONSIDER SUBCONJ ANTIBIOTICS WARN PATIENTS ABOUT SIGNS