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