TRABECULECTOMYDr. Sandra M. Johnson, MD
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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 THERAPYINABILITY TO LOWER IOPCOMPLIANCE ISSUESMental statusCostLlifestyle
ALLERGIESADVANCED DISEASEUNLIKELY TO ACHIEVE LOWTARGET WITH MEDS/LASER ANDRISK OF VISION LOSS DURINGATTEMPT
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
Bleb related problems inc leaks / blebitis / endoph
0% 20%
Fornix basedLarge Area
MMC 0.5 mg/ml
Ophthalmology 2003
Limbus basedSmall AreaMMC 0.4 mg/ml
BEFOREAFTER
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 flapTo lyse adhesions, allow flowUse Q tip or finger with patient looking down
Carlos Traverso Maneuver –CTM/DP
Focal pressure at the edge of the flapTo lyse adhesions, allow flowUse 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 NEOINJECT 1% PF LIDOCAINE TO FURTHER NUMB AND
CREATE A WORKING SPACE OR BLOCK FIRST
INTERNAL BLEB REVISION
DONE IN THE OR FOR STERILITYsame anesthesia as needling or a block – needs intraoperative gonio
SURGERY: MAKE A PLAN PRE-OPIncludes mmc/FU, combo, approach
One day post op:Check wnd integrity and inflammationMay need BCL, decide on steroidCycloplegia for phakic pts
5 days post op: consider suture for any persistent or new leakConsider LSL or CTM for red or low bleb, high IOPA 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
OVERFILTRATIONRESTRICT FLOW WITH BCL or air bubbleDECREASE STEROIDCYCLOPLEGIA
WOUND LEAKBCLSUTUREAQUEOUS SUPPRESSIONLESS STEROID, ANTIBIOTIC,
CYCLOPLEGIA
AQUEOUS MISDIRECTION
►ATROPINE►YAG HYALOID VIA
CAPSULOTOMY►VITRECTOMY►NEED UNICAMERAL EYE
MALIGNANT GLAUCOMAAQUEOUS 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
TRABECULECTOMYFILTRATION OPTIONSSlide Number 3EVOLUTION OF TRABTRABSQUESTION #1WHEN TO DO SURGERY?CHOICESQUESTION #2COMBINEDSOPERATIVE MEDSSlide Number 12Slide Number 13Slide Number 14FLAP CLOSUREANTIMETABOLITESQUESTION #3ANTIMETABOLITE DECISIONS KHAW ResultsSlide Number 20Slide Number 21POST-OP CARESlide Number 23BLEB LEAKSCTM=Carlos Traverso ManeuverCarlos Traverso Maneuver –CTM/DPLASER SUTURE LYSISLSLReleasables: one week post op – a 10 Slide Number 31Slide Number 32Slide Number 33QUESTION #4FAILING BLEB5-FUBLEB NEEDLINGINTERNAL BLEB REVISIONSlide Number 39Slide Number 40SHALLOW ANTERIOR CHAMBEROVERFILTRATIONAQUEOUS MISDIRECTIONSlide Number 44Slide Number 45Slide Number 46Slide Number 47CHOROIDAL EFFUSIONSSlide Number 49SCHSlide Number 51TENON’S CYST�����LATE �BLEB �COMPLICATIONSSlide Number 54HYPOTONY WITH MACULOPATHYSlide Number 56Slide Number 57Slide Number 58BLEBITIS
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