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 zonular-
lens- 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