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Approaches to prevention and management of Trabeculectomy Complications
Moaz Suleiman
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Objectives – Glaucoma Surgery
To describe the options available to lower IOP with incisional surgery
To understand the following with respect to trabeculectomy surgery: Essential principles of surgery Prevention of complications Recognition and management of intra-op, early,
and late post-op complications
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Choice of Glaucoma Surgery
Degree of optic nerve and VF damage Target IOP range
Mechanism of glaucoma Visual Potential Risk for devastating intra-op and post-op
complications Cataract Discussion with the patient
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Incisional Glaucoma Surgery Options
Enhance Outflow: Physiological pathways:
» Trabecular meshwork- trabectome» Schlemm’s canal – istent, ipass, icath» Suprachoroidal space - Gold shunt
Subconjunctival drainage:» Trabeculectomy» Aqueous drainage device
Reduce inflow: Endoscopic /External cyclophotocoagulation
Combined: Cataract extraction/IOL & one of the above
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Peng Khaw Technique
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Outline
Trabeculectomy Complications Recognition and initial management
Complications
Pre- and Intra-operative
Post-operative
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Pre-operative Complication
Retrobulbar Hemorrhage Urgent action required
» Risk of extrusion of intraocular contents
» May proceed only if limited and IOP not elevated
Management» Check IOP, status of CRA
IV mannitol or diamox Lateral canthotomy and cantholysis
– Orbital decompression– Infracture of medial inferior wall with
hemostat
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Intra-operative Complications
Conjunctival Buttonhole Prevention
» Treat conjunctiva with RC! Non-toothed forceps Broad based grip
Early in surgery» Consider changing site of surgery
Late in surgery» Horizontal mattress suture (10.0 nylon or 9.0 vicryl on a
vascular needle)
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Intra-operative Complications
Flap Disinsertion or Tear Attempt replacement
» Suture with 10.0 nylon Scleral patch graft Different location
Flap hole Suture if possible Patch with tenon’s capsule Manage as a full thickness fistula i.e. expect hypotony
for some time postop» Healon GV in AC if appropriate
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Intra-operative Complications
Vitreous Loss» May be early sign of suprachoroidal
hemorrhage
» Anterior vitrectomy Ensure vitreous is cleared from incision –
Weck cell or automated vitrectomy
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Intra-operative Complications – Bleeding
Choroidal hemorrhage
Risk factors Ocular hypotony Advanced age Arteriosclerosis - HTN Aphakia or myopia Nanophthalmos (~30% risk) Elevated EVP Anti-coagulants High pre-op IOP
» >40mmHg give IV mannitol
Choroidal hemangiomas» Sturge Weber (~30% risk)
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Intra-operative Complications – Bleeding
Choroidal hemorrhage
Signs sudden increase in firmness of eye flattening of the AC forward movement of intraocular
contents Loss of red reflex
Treatment Close eye
» Consider pre-placing flap sutures
» Consider scleral drainage 3-4 mm posterior to limbus
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Prevention - suprachoroidal hemorrhage
May wish to avoid filtering surgery in favor of valved drainage device, cyclophotocoagulation
Pre-operative considerations: Can anti-coagulation be safely discontinued? Mannitol or diamox to lower IOP
Intra-operative considerations: Consider prophylactic posterior sclerotomy Slow decompression of eye via paracentesis Avoid
» Large IOP drops intra-op» Excessive tissue distortion» Prolonged hypotony
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Intra-operative Complications – Bleeding
Iris root or ciliary body bleeding May cause blockage of internal os
Management Cold BSS Wet field 23G cautery Tamponade with Weck cells or viscoelastic Tight closure with extra sutures
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Intra-operative Complications – Bleeding
Hyphema Severe
» Washout
Minimal to moderate» Minimal irrigation» May leave
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Post-Operative Complications
Any IOP High IOPLow IOP
Post-Operative Complications
Early Late
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Hyphema Uveitis Dellen
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Usually conservative management» Wait it out» Identify bleeding vessels
Argon laser » Severe
May need washout
Hyphema Uveitis Dellen
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Hyphema Uveitis Dellen Treat aggressively
» Steroids» Atropine
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Hyphema Uveitis Dellen Lubrication
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Formed Bleb Flat Bleb
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Over filtration
Formed Bleb Flat Bleb
Cause» Loose flap
Management» Atropine 1%» Decrease steroids » +/- Aqueous suppressants» +/- Gentamycin
invoke inflammation
» Torpedo patch» Pressure patch» Oversized SCL
Prolonged» Reform chamber
Healon GV Surgical revision
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Formed Bleb Flat Bleb
Wound Leak Patch Large diameter SCL Gentamycin drops (small leaks)
» invoke an inflammatory response
Surgical repair (larger holes)
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Early Post-Operative: Low IOP
Choroidal effusions Setting of hypotony Chamber can be deep or shallow Choroidals themselves contribute to hypotony Will resolve with increased IOP
Any IOP Low IOP High IOP
Early
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Early Post-Operative: Low IOP
Choroidal effusions Must address underlying cause
» Wound leak» Loose flap
Management» Healon GV in AC initially» Surgical drainage
Any IOP Low IOP High IOP
Early
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Early Post-Operative: Low IOP
“Kissing” choroidals Urgent drainage Adhesions within 24 – 48 hours
» May cause central flattening of chamber Lens/Cornea damage
Any IOP Low IOP High IOP
Early
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Early Post-Operative: Low IOP – Normal Bleb
Any IOP Low IOP High IOP
Early
CB Shutdown or detachment
Cyclodialysis Cleft Retinal Detachment
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Early Post-Operative: Low IOP – Normal Bleb
Any IOP Low IOP High IOP
Early
CB Shutdown Cyclodialysis Cleft Excessive inflammation
Steroids Atropine
Avoid beta blockers, CAI inhibitors
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Early Post-Operative: Low IOP – Normal Bleb
Any IOP Low IOP High IOP
Early
CB Shutdown Cyclodialysis Cleft
Identify with gonio or UBM Atropine, decrease steroids Argon laser with Goldmann lens
» Treat the scleral region of the cleft For large cleft, definitive management
is surgical repair
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Internal Blockage External BlockageTight Flap
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Internal Blockage Tight Flap External Blockage Identify with gonio
» Iris» Blood
» Uvea» Vitreous
Manage based on etiology» Steroids» TPA» Disengage iris (laser,
mechanical)» Revision
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Internal Blockage Tight Flap External Blockage
Digital massage after 48 hours Suture lysis
Argon green Window is ~ 1-4 weeks
» Longer with MMC
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Internal Blockage Tight Flap External Blockage Blood/fibrin Early Encapsulation
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Suprachoroidal hemorrhagePupillary Block Aqueous misdirection
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Suprachoroidal hemorrhage Aqueous misdirectionPupillary Block
PI at time of surgery rule out
Management: Laser PI
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Suprachoroidal hemorrhage Aqueous misdirectionPupillary Block
24 -72 hours post-op in a hypotonous eye
Dark choroidal swelling Typical symptoms
pain nausea and/or vomiting
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Suprachoroidal hemorrhage Aqueous misdirectionPupillary Block Diagnosis
Indirect B-scan
Management May observe
» IOP OK» No central touch
Drainage at 10-14 days PRN
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Post-Operative Complications
Any IOP Low IOP High IOP
Early
Deep Chamber Flat Chamber
Suprachoroidal hemorrhage Aqueous misdirectionPupillary Block
Very shallow or flat central AC Aqueous suppressants Cycloplegia (A1%, BID)
» 50% resolve YAG anterior vitreous face
(aphakic/pseudophakic) Pars plana vitrectomy
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Cataract Uncomfortable Bleb Infection
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Cataract Uncomfortable Bleb Infection Lubricants Watch for loose sutures Eyelid riding high
Gold weight Other lid procedure
Revision
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Cataract Uncomfortable Bleb Infection
Blebitis Endophthalmitis
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Question
The major feature that distinguishes “blebitis” from endophthalmitis is:
a. Appearance of the bleb
b. Degree of conjunctival discharge
c. Degree of pain
d. Intraocular inflammatory reaction
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Late Post-Operative: Infectious
BLEBITIS ENDOPHTHALMITIS
Pain + / ++ ++++
Vision Normal Decreased
AC RXN 0-1+ 2-4+, hypopyon
Vitreous RXN Never Hallmark
Main differentiating feature: VITREAL INFLAMMATION in endophthalmitis
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Organisms – blebitis and endophthalmitis
Strep: can penetrate intact conjuctiva, can rapidly progress to endophthalmitis
Staph Haemophilus influenzae Moraxella Pseudomonas Serratia
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Late Post-Operative: Infectious
Blebitis Treat aggressively with topical fortified antibiotics or
broad spectrum fluoroquinolone PO Cipro Steroid in 48 hours Very close follow-up
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Late Post-Operative: Infectious
Endophthalmitis Different group from EVS
» Vitreous tap and intravitreal antibiotics Vancomycin 1 mg (10 mg/ml) Amikacin 400 micrograms in 0.1 ml Ceftriaxone 2mg in 0.1 ml, or Ceftazidime
» PPV – when to do it controversial » Use fortified topical antibiotics as well» Consider PO Ciprofloxacin » Cycloplegia
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Prevention
PATIENT EDUCATION!! RSVP
» Red» Sensitivity to light» VA decline» Pain
Staff education Can mean the difference between blebitis and
endophthalmitis!
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Late post-op – Any IOP
Corneal dissection or overhang
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Hypotony Maculopathy Risk factors
– Male– Young age– High myopia
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Management – address underlying cause: Autologous blood injection Compression suture (corneal or
incorporate bleb) Surgical revision (fresh conjunctiva with
or without scleral patch graft) Amniotic membrane
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Internal Blockage External BlockageTight Flap
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Internal Blockage Tight Flap External Blockage Delayed suture lysis
Window is ~ 1-4 weeks
» Longer with MMC Bleb needling with 5-
FU or MMC
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Post-Operative Complications
Any IOP Low IOP High IOP
Late
Internal Blockage Tight Flap External Blockage Bleb encapsulation
Tenon’s cyst Conjunctival scarring May need re-op
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Late Post-Operative: High IOP
Tenon’s cyst: Treat IOP
» Allow 3 months for spontaneous resolution
More aggressive management» Needling
50% success Higher success if 5-FU or MMC
» Surgical excision
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Late Post-Operative: High IOP
Tenon’s cyst: Treat IOP
» Allow 3 months for spontaneous resolution
More aggressive management» Needling
50% success Higher success if 5-FU or MMC
» Surgical excision
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Late Post-Operative: High IOP
Failed bleb Treat IOP
» Restart meds
More aggressive management» Needling
Approx. 50% success Higher success with 5-FU and
MMC
» Surgical Repeat trab with MMC Glaucoma drainage device Other
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Summary
Any IOP Low IOP High IOP
Post-Operative Complications
Early Late
Any IOP Low IOP High IOP
Hyphema
Uveitis
Dellen
Formed Bleb
Flat Bleb
Deep Chamber
Flat Chamber
Cataract
Uncomfortable Bleb
Infection
Overfiltering/leak
or CB shutdown
Internal Blockage
Tight Flap
External Blockage