Trabeculectomy, trabeculotomy, goniotomy and their complications
Complications of trabeculectomy
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COMPLICATIONS OF TRABECULECTOMY
Sumeet AgrawalPG 3
UCMS and GTB Hospital, Delhi
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INTRAOPERATIVE POSTOPERATIVEEARLY LATE
Buttonhole of conjunctivaHYPOTONY
-Flat anterior chamber-Deep anterior chamber
Thinning and leaking bleb
Scleral flap tearELEVATED IOP
-Flat anterior chamber-Deep Anterior chamber
Large overhanging bleb
Lens injury ‘Snuff out’ phenomenon Bleb related infections
Hemorrhage Cataract
Choroidal effusion
Descemet’s stripping
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Early postoperative complications
Hypotony
Flat Anterior Chamber
Deep Anterior Chamber
Elevated IOP
Flat Anterior Chamber
Deep Anterior Chamber
• Aqueous misdirection• Pupillary block• Delayed Suprachoroidal
hemorrhage
Failing bleb• Internal block• Encapsulation
• Leaking bleb• Overfiltration• Choroidal effusion
• Overfiltration
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MEASURING IOP
• Digital palpation
• Avoid filtering site
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Early postoperative complications
Hypotony
Flat Anterior Chamber
Deep Anterior Chamber
Elevated IOP
Flat Anterior Chamber
Deep Anterior Chamber
• Aqueous misdirection• Pupillary block• Delayed Suprachoroidal
hemorrhage
Failing bleb• Internal block• Encapsulation
• Leaking bleb• Overfiltration• Choroidal effusion
• Overfiltration
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HYPOTONY with FLAT AC
• LEAKS
– Siedel’s test
• From the wound
• From a button hole
• Iridocorneal touch– Spontaneous deepening in 7-14 days
• Corneo-lenticular touch– Look for corneal edema
– Aggressive intervention
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MANAGEMENT
• Conjunctival leak :
– Reduce steroids
– Pressure patch
– Large diameter contact lens
– Fibrin glue
– Surgical repair
• Overfiltration:
– Reduce steroids
– Pressure patch
– Mydriatic-cycloplegics
– Large diameter contact lens
– Surgical repair
Reformation of AC :• Viscoelastic
• Air• SF6• C3F8
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CHOROIDAL EFFUSION:
• Easily visible ora
• Usually resolves spontaneously
• Oral steroids
• Drain if :
– Corneo-lenticular touch with decompensation
– Kissing choroids
– Prolonged hypotony (no signs of improvement within 4 weeks)
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HYPOTONY with DEEP AC
• Benign course
• Rule out treatable causes
• Persistent hypotony Hypotony maculopathy(reversible till 6 months)
• Autologous blood injection in the bleb
• Bleb compression sutures • Surgical (resuturing, scleral patch
graft) • Reforming the bleb
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Early postoperative complications
Hypotony
Flat Anterior Chamber
Deep Anterior Chamber
Elevated IOP
Flat Anterior Chamber
Deep Anterior Chamber
• Aqueous misdirection• Pupillary block• Delayed Suprachoroidal
hemorrhage
Failing bleb• Internal block• Encapsulation
• Leaking bleb• Overfiltration• Choroidal effusion
• Overfiltration
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ELEVATED IOP with SHALLOW AC
• Compare periphery and axial AC
– Aqueous misdirection (periphery and axial)
– Pupillary block (only peripheral)
– Delayed Suprachoroidal Hemorrhage (peripheral and axial)
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MANAGEMENT(A good sized patent surgical PI rules out Pupillary block)
AQUEOUS MISDIRECTION
• Discontinue miotics
• Strong cycloplegics
• Topical steroids
• Aqueous suppressants
(50 % resolve in 5 days*)
• Disrupt the vitreous face (laser, PPV, needle aspiration)
*Yaqub M, et al: Malignant glaucoma. In: El Sayyad F, et al, editors: The refractory glaucomas, New York, Igaku-Shoin, 1995.
PUPILLARY BLOCK
• Peripheral iridectomy/otomy
• Avoid cycloplegics/mydriatics
• Topical steroids
• Aqueous suppressants
• Miotics
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Delayed Suprachoroidal
Hemorrhage
• Associated symptoms:– Severe pain
– Nausea
– Marked sudden diminution of vision
– Manage IOP
– Wait for clot lysis (14 days)
– Drain
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ELEVATED IOP WITH DEEP AC
• INADEQUATE FILTRATION
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Elevated IOP with a deep anterior chamber Typical failing bleb
• Low to flat
• Heavily vascularized
• No microcysts
• 6.9 to 36 %
• Tight sutures
• Internal block
• Early, aggressive intervention required
Tenon’s cyst• Highly elevated
• Smooth-domed
• Large vessels but intervening avascular spaces, no microcysts
• Patent sclerostomy
• 3.6% to 28%
• Within the first 2 months
• Most resolve on conservative management
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Most important step : recognising its presence
• Preceded by a gradual increase in IOP
• Change in the bleb's appearance– Less diffuse
– Avascular (large vessels but intervening avascular spaces)
– Opalescent
– Flat / very elevated, smooth-domed
– Surrounding fibrotic vascular ring
– Loss of microcysts (fluorescein)
• Pressure does not decreases after massaging
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SEEK OUT THE CAUSE
• BLOCK OF INTERNAL OSTIUM
• EXTERNAL BLOCK (most common)
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• INTERNAL BLOCK
– Iris
– Ciliary body
– Vitreous
– Blood clot
– Fibrin
• Gonioscopic evaluation
• EXTERNAL BLOCK
– Tenon’s cyst
– Episcleral scarring
• Careful slit lamp evaluation
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MANAGEMENT
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RAISED IOP
• Digital ocular pressure
– steady pressure over the inferior sclera, through the eyelids for 10 to 15 seconds
– intermittent
– taught to the patient
• Medical
– Topical (avoid PG anlogues, Brimonidine)
– Systemic
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• Frequent anti-inflammatory therapy
• Laser suture lysis
– first 3 wks without antimetabolites; 8 wks with antimetabolites
– argon or green light laser
– Nd YAG laser. Ruptures conjunctival and episcleralblood vessels
– 400 mW, 0.01 seconds and 50 μm
– one suture at a time, if no effect within 1 hour, second suture lysis or removal may be considered
RESTORING BLEB FUNCTION
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• Without magnification
– Edge of a four-mirror gonioprism
– Hoskins laser suture lens
• High-magnification suture lysis contact lenses
– Mandlekorn lens
– Blumenthal lens
– Ritch lens
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HOSKINS LENS
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• Releasable sutures
• Topical mitomycin C (0.02% QID for 2 weeks)
• Bleb revision
BLOCKED INTERNAL OSTIUM
• Intracameral tissue plasminogen activator (blocked internal ostium; blood or fibrin clot )– 6 to 12.5 µg
– Frozen (TPA) - 25 g/ 0.1ml is diluted with 0.9 % NaCl
• Low-energy argon laser therapy / Nd:YAG laser disruption (retract the tissue)– Iris
– Vitreous
• Internal bleb revision
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EXTERNAL BLEB REVISION• Tenon’s cyst / episcleral scarring unresponsive to
conservative management
• First described by Ferrer1 in 1941
– conjunctival dialysis
– incising the scar tissue
– conjunctiva from the sclera with a spatula
• Pederson and Smith2
– needling encapsulated blebs
– 69% success
1.Ferrer H. Conjunctival dialysis in the treatment of glaucoma recurrent after sclerectomy. Am J Ophthalmol. 1941;24:788-790.
2.Pederson JE, Smith SG. Surgical management of encapsulated filtering blebs. Ophthalmology. 1985;92:955-958.
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• Ewing and Stamper3
– 5-fluorouracil (5-FU) in bleb needle revisions
– Postop subconjunctival injections
– 91.6% success rate
– 63.6% : adjunctive medications
• Shin et al4
– single injections of 5-FU during needling
– 80% success rate
– 79% : adjunctive medications
3.Ewing RH, Stamper RL. Needle revision with and without 5-FU for the treatment of failed filtering blebs.Am J Ophthalmol. 1990;110:254-259.
4. Shin DH, Juzych MS, Khatana AK, et al. Needling revision of failed filtering blebs with adjunctive 5-fluorouracil. Ophthalmic Surg. 1993;24:242-248.
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• Mardelli et al.5 in 1996,
– Slit-lamp procedure
– Mitomycin C (MMC) injections
– 92% success rate
5.Mardelli PG, Lederer CM Jr, Murray PL, et al. Slit-lamp needle revision of failed filtering blebs using mitomycin C. Ophthalmology. 1996;103:1946-1955.
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• Risk factors for failed needling
– Pre procedure IOP > 30 mm Hg
– Trabeculectomy without MMC
– Immediate post procedure IOP >10 mm Hg
– After 4 months of trabeculectomy6
6.Gutierrez-Ortiz C, Cabarga C, Teus MA. Prospective evaluation of preoperative factors associated with successful mitomycin C needling of failed filtration blebs. J
Glaucoma. 2006;15:98-102.
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TECHNIQUE FOR NEEDLING
• Goal :
– Increase the permeability of the bleb's wall
– Produce a more diffuse, better functioning bleb.
• Slit lamp / Operation theatre
– Informed consent
– Antibiotic drops
– Clean-drape if in OT
– Topical anaesthetic
– Lid speculum
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• 25G needle (sturdier)
• 5 to 10 mm temporal from the bleb site
• Posteriorly directed, bevel up, tangential to sclera
• Advanced in the bleb with a twisting motion
• Subconjunctival fibrosis cut with firm back & forth , side to side motions till eye softens
• Can enter AC (pseudophakes; flat bleb)
• Avoid conjunctival buttonhole
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• Can be accompanied with
– Subconjunctival injection of MMC (0.1 mL 0.04 mg/mL)
– 5-FU (5mg in 0.1 mL lignocaine) given
• 180 degrees away from the bleb
• 15 to 50 mg in 3-10 injection over 3 weeks
• Antibiotic/steroid drops for 2-3 weeks
• Digital massage
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COMPLICATIONS
• HYPOTONY
– Buttonhole
– Aggressive neeedling
• BLEBITIS
• ENDOPHTHALMITIS
• EPITHELIAL TOXICITY (5-FU)
• ENDOTHELIAL TOXICITY (MMC)
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• MMC drops comparable to 5-FU injections in terms of
– IOP, bleb appearance,
– success rate, (68.4% MMC, 77.8% 5-FU)
– number of glaucoma medications,
– visual outcome,
– overall complications
Pakravan M, Miraftabi A, Yazdani S.Topical Mitomycin-C versus Subconjunctival 5-Fluorouracil for Management of Bleb Failure. J Ophthalmic Vis Res. 2011
Apr;6(2):78-86.
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TOPICAL MMC
• SIDE EFFECTS– Local irritation, hyperaemia,
– Epiphora (Punctal stenosis),
– Allergy,
– Keratoconjunctivitis
– Corneal abrasion (superficial punctate keratitis)
– Cataract,
– Persisting keratoconjunctivitis,
– Limbal stem cell deficiencyShields CL, Naseripour M, Shields JA. Topical mitomycin C for extensive, recurrent conjunctival-corneal squamous cell carcinoma. Am J
Ophthalmol 2002;133:601–6.Fucht-Pery J, Rozenman Y. Mitomycin C therapy for corneal intraepithelial neoplasia. Am J Ophthalmol1994;117:164–8.
Song JS, Kim JH, Yang M, et al. Mitomycin-C concentration in cornea and aqueous humor and apoptosis in the stroma after mitomycin-C application. Cornea 2007;26:461–
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• Subconjunctival 5-FU application more effective therapy than bevacizumab for needling procedures in failed trabeculectomy blebs.
Simsek T1, Cankaya AB, Elgin U. Comparison of needle revision with subconjunctivalbevacizumab and 5-fluorouracil injection of failed trabeculectomy blebs. J Ocul Pharmacol Ther.
2012 Oct;28(5):542-6.
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OTHER COMPLICATIONS
• UVEITIS
• HYPHEMA
• DELLEN
• SNUFF OUT PHENOMENON
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LATE COMPLICATIONS• Thinning and leaking bleb
• Large overhanging bleb
• Bleb related infections
– Blebitis
– endophthalmitis
• Cataract
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INTRAOPERATIVE COMPLICATIONS
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BUTTONHOLE OF CONJUNCTIVA
• Avoid toothed forceps• Avoid cutting needles• Subtenon lignocaine• Corneal traction sutures
• Repair (layered)• Avoid antimetabolite over the defect (sodium
hyaluronate)• New site• Bandage contact lens
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SCLERAL FLAP TEAR
• Avoid very thin flaps (half or more)
• Gentle handling
• Avoid cautery at the edges (retraction)
• Donor sclera / pericardium
• Limbal hinge by 10-0 nylon
• New site
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LENS INJURY and VITREOUS PROLAPSE
• Most commonly during block removal• During peripheral iridectomy
• Kelly’s punch instead of Vanna’s scissors• Constrict pupil before PI• Oblique paracentesis
• Merocel sponge assisted vitrectomy (avoid automated vitrectomy)
• Tighter flap closure
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HYPHEMA
• Predisposing conditions
• Irrigate with cold irrigating solution
• Epinephrine
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SUPRACHOROIDAL HEMORRHAGE
• Preoperative intraocular pressure
• Hypertension and atherosclerosis
• Sudden decompression
• Immediate closure
• Posterior sclerotomy