Approaches to prevention and management of Trabeculectomy Complications Moaz Suleiman

Approaches to prevention and management of Trabeculectomy Complications

Moaz Suleiman

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

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

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

Peng Khaw Technique

Outline

Trabeculectomy Complications Recognition and initial management

Complications

Pre- and Intra-operative

Post-operative

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

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)

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

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

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)

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

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

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

Intra-operative Complications – Bleeding

Hyphema Severe

» Washout

Minimal to moderate» Minimal irrigation» May leave

Post-Operative Complications

Any IOP High IOPLow IOP

Post-Operative Complications

Early Late

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Hyphema Uveitis Dellen

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

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Hyphema Uveitis Dellen Treat aggressively

» Steroids» Atropine

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Hyphema Uveitis Dellen Lubrication

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Formed Bleb Flat Bleb

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

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)

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

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

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

Early Post-Operative: Low IOP – Normal Bleb

Any IOP Low IOP High IOP

Early

CB Shutdown or detachment

Cyclodialysis Cleft Retinal Detachment

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

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

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Deep Chamber Flat Chamber

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Deep Chamber Flat Chamber

Internal Blockage External BlockageTight Flap

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

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

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Deep Chamber Flat Chamber

Internal Blockage Tight Flap External Blockage Blood/fibrin Early Encapsulation

Post-Operative Complications

Any IOP Low IOP High IOP

Early

Deep Chamber Flat Chamber

Suprachoroidal hemorrhagePupillary Block Aqueous misdirection

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

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

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

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

Post-Operative Complications

Any IOP Low IOP High IOP

Late

Post-Operative Complications

Any IOP Low IOP High IOP

Late

Cataract Uncomfortable Bleb Infection

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

Post-Operative Complications

Any IOP Low IOP High IOP

Late

Cataract Uncomfortable Bleb Infection

Blebitis Endophthalmitis

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

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

Organisms – blebitis and endophthalmitis

Strep: can penetrate intact conjuctiva, can rapidly progress to endophthalmitis

Staph Haemophilus influenzae Moraxella Pseudomonas Serratia

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

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

Prevention

PATIENT EDUCATION!! RSVP

» Red» Sensitivity to light» VA decline» Pain

Staff education Can mean the difference between blebitis and

endophthalmitis!

Late post-op – Any IOP

Corneal dissection or overhang

Post-Operative Complications

Any IOP Low IOP High IOP

Late

Hypotony Maculopathy Risk factors

– Male– Young age– High myopia

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

Post-Operative Complications

Any IOP Low IOP High IOP

Late

Internal Blockage External BlockageTight Flap

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

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

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

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

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

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