Trabeculectomy

Sugiarti Kadarhartono RS. Mata Cicendo

s05105k

Introduction
Elevated IOP is a significant risk factor for
Glaucomatous neuropathy Visual field loss

Decrease the IOP will preserve visual function Filtering surgery is the most popular for lowering IOP

History of Filtering Surgery

For more than 100 years, filtering surgery for glaucoma has attempted The popularity continued in 1900 1960

Full thickness corneosclerectomy

Communication between COA and subconjunctival space directly

This procedure was success but has many complication: hypotonic, shallow AC etc

Partial thickness of filtering surgery

Has been hypotised AH from AC flow to Cut end of canalis Schlemm directly Around the edge of scleral flap subconjuctival space transconjunctival filtration, lymphatics and vessels of subconjunctival tissue

 The goal of filtering surgery

Creation and maintenance of patent fistula from anterior chamber to the subconjunctival space The surgery is performed on patients for whom medical and laser therapy has failed

The indication are complex and varied Aim : lowering IOP to preserve visual function

INDICATION
Failed to control IOP after maximum tolerable medical therapy and laser therapy Allergic to medical therapy Incompliance patient Irregular follow up Advance glaucoma-> optic nerve damage Prolonged antiglaucoma
pilocarpine damage TM Timolol maleat conjunctival change

Factor that influence the choice of surgical technique

Severity of the disease Patient quality of life Long time application of topical medication The type of glaucoma

Pre operative evaluation

Diagnosis Previous surgical history Target IOP Status of the fellow eye Progressivism of the disease

Factors that affect the outcome of surgery

Young age Black race The type of glaucoma Previous surgical history Active inflammation Conjunctival cicatrical disease Significance peripheral anterior synechiae

Concomitant ocular disease

Cataract-- combined cataract and glaucoma surgery Require concomitant vitrectomy- tube shunt implantation into vitreus cavity rather than to AC

Overall prognosis
Severity elevated IOP need:
Less invasive procedure
Non penetrating trabeculectomy Viscocanalostomy Tube shunt implant

Cyclocryotherapy or cyclo photocoagulation

Preoperative preparation
Inform consent Discussion of the risk, benefit and prognosis Major and minimal risk of the surgery Postoperative restriction The discussion should not be rush, let the patient understand

Discontinued a certain medication before surgery

Anticoagulant: aspirin, persantin -> hyphema, suprachoroidal hemorrhage Pilocarpine 2-4 prior to surgery ->
Break blood aqueous barrier Inflammation If will be combined with lens extraction

Epinephrine cause conjunctival vasculature Steroid

 Medication that has to be continued is aqueous suppressant Especially in advance glaucomatous optic neuropathy

 Take attention to concomitant medical problem, which will advent to topical/ systemic sedation
Hypertension Pulmonary diseases Diabetes mellitus Cardiac disease

Anesthesia
General anesthesia for infants, children and non cooperative patient Retrobulbar Peribulbar Sub Tenon Subconjunctival Topical

Surgical technique
Bridle suture :
Superior rectus muscle ( muscle hemorrhage, ptosis, diplopia) Corneal traction with 8-0 vicryl suture to cutting needle to mid-corneal stroma, 3mm at the limbus

Conjunctival flap : limbal base / fornix base

Surgical technique
Conjunctival flap Fornix base
Peritomy at 2 clock hours Tenon capsule dissected anteriorly

Limbal base Incision 8-10 mm posterior limbus parallel to the limbus 10 15 mm -> limbus Incision of Tenon capsule in front of conj. Incision -> limbus Episcleral tissue gently removed by scraping Hemostasis by fine tip cauter

 Scleral flap
Scleral bed Scleral flap thickness Dissected into clear cornea

 Paracentesis Temporal peripheral cornea To access anterior chamber intra/post operative to manage the depth of AC, outflow pathway

 Sclerostomy
Create the internal ostium Anterior chamber entered at the base of scleral flap Rectangular/ triangle 1x1 mm With / without trabecular meshwork

 Iridectomy It must be perform in all trabeculectomy To prevent iris incarceration into internal ostium The size of iridectomy > sclerectomy Should not extend centrally Reposition of the iris by irrigation Bleeding can be controlled by entering viscoelastic into AC irrigation reformed AC

 Scleral flap closure

Sutured the scleral flap to the scleral bed with 2-3 sutures of 10-0 nylon

Tenon capsule and conjunctival suture to finish the surgery

 Be sure that
AC depth is sufficient, clear No over filtration Pupil centre and round Patent Iridectomy and can be seen

Subconjunctival injection of antibiotic Atropine 1%, and antibiotic ointment -> closed

Variation of trabeculectomy
Conventional trabeculectomy Trabeculectomy with antimetabolite agent Small incision trabeculectomy Nonpenetrating trabeculectomy Viscocanalostomy Trabeculectomy combined with
Cataract surgery in one site or separate site Vitrectomy Trabeculotomy in infant with congenital glaucoma

Post operative care

Atropine1% bid & Phenylephrine 2,5% qid (Cycloplegics+ midriatics):
Paralyzing ciliary muscle, tighten the zonularlens- iris diaphragm-> deepened AC Maintain blood-aqueous barrier-> inflammation< Relief post operative ciliary spasm Prevent posterior synechias

 Prednisone acetate 1% qhl

while awake reduced gradually Inhibit inflammation, fibroblastics proliferation Improved the success of surgery It used for 8 weeks after surgery

Tobramycine 0,3% bid

Non irritative antibiotics Used 1 month after surgery Gentamycin is contra indicated

 Antimetabolite agent
5 Fu 5mg / diluted 0,5cc of 10mg/cc 5Fu subconjunctival 180 degree from surgical site MMC 0,5% topical on the conjunctival bleb for 5 minute,3 days

Argon laser suture lysis

Complication
Intraoperative
Conjuctival perforation Amputation of scleral flap Hemorrhage in AC, conjunctiva, choroid, expulsive hemorrhage Damage of the lens Vitreous loss Choroidal effusion Cyclodyalisis cleft Malignant glaucoma

Early post operative

Ocular hypotony Shallow and flat AC Choroidal separation Suprachoroidal hemorrhage Elevated IOP Hyphema Inflammation-> synechias Cataract Malignant glaucoma

Late complication
Bleb leak,bleb infection, endophthalmitis Cyst of Tenon capsule Pupillary membrane Scleral staphyloma Cataract Malignant glaucoma Failure of filtration

The success of trabeculectomy

Trabeculetomy is effective in lowering IOP A tonometric success rate of IOP less than 21 mmHg of about 70% without medication in 2 years More than 90% with adhesion of anti glaucoma therapy

Target pressure
Some glaucoma patients progress even after achieving target pressure reductions recommended in guidelines for glaucoma management. More aggressive treatment that reduces IOP can minimize the risk factor of glaucoma progression Need minimal medical glaucoma adhesion to prevent the progression, to maintain diurnal IOP

Thank you