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COMPLICATIONS OF TRABECULECTOMY
Sumeet Agrawal
PG 3
UCMS and GTB Hospital,
Delhi
INTRAOPERATIVE POSTOPERATIVE
EARLY LATE
Buttonhole of conjunctiva
HYPOTONY
-Flat anterior chamber
-Deep anterior chamber
T...
Early
postoperative
complications
Hypotony
Flat Anterior
Chamber
Deep Anterior
Chamber
Elevated
IOP
Flat Anterior
Chamber
...
MEASURING IOP
• Digital palpation
• Avoid filtering site
Early
postoperative
complications
Hypotony
Flat Anterior
Chamber
Deep Anterior
Chamber
Elevated
IOP
Flat Anterior
Chamber
...
HYPOTONY with FLAT AC
• LEAKS
– Siedel’s test
• From the wound
• From a button hole
• Iridocorneal touch
– Spontaneous dee...
MANAGEMENT
• Conjunctival leak :
– Reduce steroids
– Pressure patch
– Large diameter
contact lens
– Fibrin glue
– Surgical...
CHOROIDAL EFFUSION:
• Easily visible ora
• Usually resolves
spontaneously
• Oral steroids
• Drain if :
– Corneo-lenticular...
HYPOTONY with DEEP AC
• Benign course
• Rule out treatable causes
• Persistent hypotony  Hypotony maculopathy
(reversible...
Early
postoperative
complications
Hypotony
Flat Anterior
Chamber
Deep Anterior
Chamber
Elevated
IOP
Flat Anterior
Chamber
...
ELEVATED IOP with SHALLOW AC
• Compare periphery and axial AC
– Aqueous misdirection (periphery and axial)
– Pupillary blo...
MANAGEMENT
(A good sized patent surgical PI rules out Pupillary block)
AQUEOUS MISDIRECTION
• Discontinue miotics
• Strong...
Delayed
Suprachoroidal
Hemorrhage
• Associated symptoms:
– Severe pain
– Nausea
– Marked sudden
diminution of vision
– Man...
ELEVATED IOP WITH DEEP AC
• INADEQUATE FILTRATION
Elevated IOP with a deep anterior chamber
Typical failing bleb
• Low to flat
• Heavily vascularized
• No microcysts
• 6.9 ...
Most important step : recognising its presence
• Preceded by a gradual increase in IOP
• Change in the bleb's appearance
–...
SEEK OUT THE CAUSE
• BLOCK OF INTERNAL OSTIUM
• EXTERNAL BLOCK (most common)
• INTERNAL BLOCK
– Iris
– Ciliary body
– Vitreous
– Blood clot
– Fibrin
• Gonioscopic evaluation
• EXTERNAL BLOCK
– Tenon’...
MANAGEMENT
RAISED IOP
• Digital ocular pressure
– steady pressure over the inferior sclera, through
the eyelids for 10 to 15 seconds
...
• Frequent anti-inflammatory therapy
• Laser suture lysis
– first 3 wks without antimetabolites; 8 wks with
antimetabolite...
• Without magnification
– Edge of a four-mirror gonioprism
– Hoskins laser suture lens
• High-magnification suture lysis c...
HOSKINS LENS
• Releasable sutures
• Topical mitomycin C (0.02% QID for 2 weeks)
• Bleb revision
BLOCKED INTERNAL OSTIUM
• Intracameral ...
EXTERNAL BLEB REVISION
• Tenon’s cyst / episcleral scarring unresponsive to
conservative management
• First described by F...
• Ewing and Stamper3
– 5-fluorouracil (5-FU) in bleb needle revisions
– Postop subconjunctival injections
– 91.6% success ...
• Mardelli et al.5 in 1996,
– Slit-lamp procedure
– Mitomycin C (MMC) injections
– 92% success rate
5.Mardelli PG, Lederer...
• Risk factors for failed needling
– Pre procedure IOP > 30 mm Hg
– Trabeculectomy without MMC
– Immediate post procedure ...
TECHNIQUE FOR NEEDLING
• Goal :
– Increase the permeability of the bleb's wall
– Produce a more diffuse, better functionin...
• 25G needle (sturdier)
• 5 to 10 mm temporal from the bleb site
• Posteriorly directed, bevel up, tangential to sclera
• ...
• Can be accompanied with
– Subconjunctival injection of MMC (0.1 mL 0.04
mg/mL)
– 5-FU (5mg in 0.1 mL lignocaine) given
•...
COMPLICATIONS
• HYPOTONY
– Buttonhole
– Aggressive neeedling
• BLEBITIS
• ENDOPHTHALMITIS
• EPITHELIAL TOXICITY (5-FU)
• E...
• MMC drops comparable to 5-FU injections in
terms of
– IOP, bleb appearance,
– success rate, (68.4% MMC, 77.8% 5-FU)
– nu...
TOPICAL MMC
• SIDE EFFECTS
– Local irritation, hyperaemia,
– Epiphora (Punctal stenosis),
– Allergy,
– Keratoconjunctiviti...
• Subconjunctival 5-FU application more effective
therapy than bevacizumab for needling
procedures in failed trabeculectom...
OTHER COMPLICATIONS
• UVEITIS
• HYPHEMA
• DELLEN
• SNUFF OUT PHENOMENON
LATE COMPLICATIONS
• Thinning and leaking bleb
• Large overhanging bleb
• Bleb related infections
– Blebitis
– endophthalm...
INTRAOPERATIVE COMPLICATIONS
BUTTONHOLE OF
CONJUNCTIVA
• Avoid toothed forceps
• Avoid cutting needles
• Subtenon lignocaine
• Corneal traction sutures...
SCLERAL FLAP TEAR
• Avoid very thin flaps (half or more)
• Gentle handling
• Avoid cautery at the edges (retraction)
• Don...
LENS INJURY and VITREOUS PROLAPSE
• Most commonly during block removal
• During peripheral iridectomy
• Kelly’s punch inst...
HYPHEMA
• Predisposing conditions
• Irrigate with cold irrigating solution
• Epinephrine
SUPRACHOROIDAL HEMORRHAGE
• Preoperative intraocular pressure
• Hypertension and atherosclerosis
• Sudden decompression
• ...
Complications of trabeculectomy
Complications of trabeculectomy
Complications of trabeculectomy
Complications of trabeculectomy
Complications of trabeculectomy
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Complications of trabeculectomy

Everything one needs to know about complications of trabeculectomy and their management

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Complications of trabeculectomy

  1. 1. COMPLICATIONS OF TRABECULECTOMY Sumeet Agrawal PG 3 UCMS and GTB Hospital, Delhi
  2. 2. INTRAOPERATIVE POSTOPERATIVE EARLY LATE Buttonhole of conjunctiva HYPOTONY -Flat anterior chamber -Deep anterior chamber Thinning and leaking bleb Scleral flap tear ELEVATED IOP -Flat anterior chamber -Deep Anterior chamber Large overhanging bleb Lens injury ‘Snuff out’ phenomenon Bleb related infections Hemorrhage Cataract Choroidal effusion Descemet’s stripping
  3. 3. Early postoperative complications Hypotony Flat Anterior Chamber Deep Anterior Chamber Elevated IOP Flat Anterior Chamber Deep Anterior Chamber • Aqueous misdirection • Pupillary block • Delayed Suprachoroidal hemorrhage Failing bleb • Internal block • Encapsulation • Leaking bleb • Overfiltration • Choroidal effusion • Overfiltration
  4. 4. MEASURING IOP • Digital palpation • Avoid filtering site
  5. 5. Early postoperative complications Hypotony Flat Anterior Chamber Deep Anterior Chamber Elevated IOP Flat Anterior Chamber Deep Anterior Chamber • Aqueous misdirection • Pupillary block • Delayed Suprachoroidal hemorrhage Failing bleb • Internal block • Encapsulation • Leaking bleb • Overfiltration • Choroidal effusion • Overfiltration
  6. 6. HYPOTONY with FLAT AC • LEAKS – Siedel’s test • From the wound • From a button hole • Iridocorneal touch – Spontaneous deepening in 7-14 days • Corneo-lenticular touch – Look for corneal edema – Aggressive intervention
  7. 7. MANAGEMENT • Conjunctival leak : – Reduce steroids – Pressure patch – Large diameter contact lens – Fibrin glue – Surgical repair • Overfiltration: – Reduce steroids – Pressure patch – Mydriatic-cycloplegics – Large diameter contact lens – Surgical repair Reformation of AC : • Viscoelastic • Air • SF6 • C3F8
  8. 8. CHOROIDAL EFFUSION: • Easily visible ora • Usually resolves spontaneously • Oral steroids • Drain if : – Corneo-lenticular touch with decompensation – Kissing choroids – Prolonged hypotony (no signs of improvement within 4 weeks)
  9. 9. HYPOTONY with DEEP AC • Benign course • Rule out treatable causes • Persistent hypotony  Hypotony maculopathy (reversible till 6 months) • Autologous blood injection in the bleb • Bleb compression sutures • Surgical (resuturing, scleral patch graft) • Reforming the bleb
  10. 10. Early postoperative complications Hypotony Flat Anterior Chamber Deep Anterior Chamber Elevated IOP Flat Anterior Chamber Deep Anterior Chamber • Aqueous misdirection • Pupillary block • Delayed Suprachoroidal hemorrhage Failing bleb • Internal block • Encapsulation • Leaking bleb • Overfiltration • Choroidal effusion • Overfiltration
  11. 11. ELEVATED IOP with SHALLOW AC • Compare periphery and axial AC – Aqueous misdirection (periphery and axial) – Pupillary block (only peripheral) – Delayed Suprachoroidal Hemorrhage (peripheral and axial)
  12. 12. MANAGEMENT (A good sized patent surgical PI rules out Pupillary block) AQUEOUS MISDIRECTION • Discontinue miotics • Strong cycloplegics • Topical steroids • Aqueous suppressants (50 % resolve in 5 days*) • Disrupt the vitreous face (laser, PPV, needle aspiration) *Yaqub M, et al: Malignant glaucoma. In: El Sayyad F, et al, editors: The refractory glaucomas, New York, Igaku-Shoin, 1995. PUPILLARY BLOCK • Peripheral iridectomy/otomy • Avoid cycloplegics/mydriatics • Topical steroids • Aqueous suppressants • Miotics
  13. 13. Delayed Suprachoroidal Hemorrhage • Associated symptoms: – Severe pain – Nausea – Marked sudden diminution of vision – Manage IOP – Wait for clot lysis (14 days) – Drain
  14. 14. ELEVATED IOP WITH DEEP AC • INADEQUATE FILTRATION
  15. 15. Elevated IOP with a deep anterior chamber Typical failing bleb • Low to flat • Heavily vascularized • No microcysts • 6.9 to 36 % • Tight sutures • Internal block • Early, aggressive intervention required Tenon’s cyst • Highly elevated • Smooth-domed • Large vessels but intervening avascular spaces, no microcysts • Patent sclerostomy • 3.6% to 28% • Within the first 2 months • Most resolve on conservative management
  16. 16. Most important step : recognising its presence • Preceded by a gradual increase in IOP • Change in the bleb's appearance – Less diffuse – Avascular (large vessels but intervening avascular spaces) – Opalescent – Flat / very elevated, smooth-domed – Surrounding fibrotic vascular ring – Loss of microcysts (fluorescein) • Pressure does not decreases after massaging
  17. 17. SEEK OUT THE CAUSE • BLOCK OF INTERNAL OSTIUM • EXTERNAL BLOCK (most common)
  18. 18. • INTERNAL BLOCK – Iris – Ciliary body – Vitreous – Blood clot – Fibrin • Gonioscopic evaluation • EXTERNAL BLOCK – Tenon’s cyst – Episcleral scarring • Careful slit lamp evaluation
  19. 19. MANAGEMENT
  20. 20. RAISED IOP • Digital ocular pressure – steady pressure over the inferior sclera, through the eyelids for 10 to 15 seconds – intermittent – taught to the patient • Medical – Topical (avoid PG anlogues, Brimonidine) – Systemic
  21. 21. • Frequent anti-inflammatory therapy • Laser suture lysis – first 3 wks without antimetabolites; 8 wks with antimetabolites – argon or green light laser – Nd YAG laser. Ruptures conjunctival and episcleral blood vessels – 400 mW, 0.01 seconds and 50 μm – one suture at a time, if no effect within 1 hour, second suture lysis or removal may be considered RESTORING BLEB FUNCTION
  22. 22. • Without magnification – Edge of a four-mirror gonioprism – Hoskins laser suture lens • High-magnification suture lysis contact lenses – Mandlekorn lens – Blumenthal lens – Ritch lens
  23. 23. HOSKINS LENS
  24. 24. • Releasable sutures • Topical mitomycin C (0.02% QID for 2 weeks) • Bleb revision BLOCKED INTERNAL OSTIUM • Intracameral tissue plasminogen activator (blocked internal ostium; blood or fibrin clot ) – 6 to 12.5 µg – Frozen (TPA) - 25 g/ 0.1ml is diluted with 0.9 % NaCl • Low-energy argon laser therapy / Nd:YAG laser disruption (retract the tissue) – Iris – Vitreous • Internal bleb revision
  25. 25. EXTERNAL BLEB REVISION • Tenon’s cyst / episcleral scarring unresponsive to conservative management • First described by Ferrer1 in 1941 – conjunctival dialysis – incising the scar tissue – conjunctiva from the sclera with a spatula • Pederson and Smith2 – needling encapsulated blebs – 69% success 1.Ferrer H. Conjunctival dialysis in the treatment of glaucoma recurrent after sclerectomy. Am J Ophthalmol. 1941;24:788- 790. 2.Pederson JE, Smith SG. Surgical management of encapsulated filtering blebs. Ophthalmology. 1985;92:955-958.
  26. 26. • Ewing and Stamper3 – 5-fluorouracil (5-FU) in bleb needle revisions – Postop subconjunctival injections – 91.6% success rate – 63.6% : adjunctive medications • Shin et al4 – single injections of 5-FU during needling – 80% success rate – 79% : adjunctive medications 3.Ewing RH, Stamper RL. Needle revision with and without 5-FU for the treatment of failed filtering blebs.Am J Ophthalmol. 1990;110:254-259. 4. Shin DH, Juzych MS, Khatana AK, et al. Needling revision of failed filtering blebs with adjunctive 5-fluorouracil. Ophthalmic Surg. 1993;24:242-248.
  27. 27. • Mardelli et al.5 in 1996, – Slit-lamp procedure – Mitomycin C (MMC) injections – 92% success rate 5.Mardelli PG, Lederer CM Jr, Murray PL, et al. Slit-lamp needle revision of failed filtering blebs using mitomycin C. Ophthalmology. 1996;103:1946-1955.
  28. 28. • Risk factors for failed needling – Pre procedure IOP > 30 mm Hg – Trabeculectomy without MMC – Immediate post procedure IOP >10 mm Hg – After 4 months of trabeculectomy6 6.Gutierrez-Ortiz C, Cabarga C, Teus MA. Prospective evaluation of preoperative factors associated with successful mitomycin C needling of failed filtration blebs. J Glaucoma. 2006;15:98-102.
  29. 29. TECHNIQUE FOR NEEDLING • Goal : – Increase the permeability of the bleb's wall – Produce a more diffuse, better functioning bleb. • Slit lamp / Operation theatre – Informed consent – Antibiotic drops – Clean-drape if in OT – Topical anaesthetic – Lid speculum
  30. 30. • 25G needle (sturdier) • 5 to 10 mm temporal from the bleb site • Posteriorly directed, bevel up, tangential to sclera • Advanced in the bleb with a twisting motion • Subconjunctival fibrosis cut with firm back & forth , side to side motions till eye softens • Can enter AC (pseudophakes; flat bleb) • Avoid conjunctival buttonhole
  31. 31. • Can be accompanied with – Subconjunctival injection of MMC (0.1 mL 0.04 mg/mL) – 5-FU (5mg in 0.1 mL lignocaine) given • 180 degrees away from the bleb • 15 to 50 mg in 3-10 injection over 3 weeks • Antibiotic/steroid drops for 2-3 weeks • Digital massage
  32. 32. COMPLICATIONS • HYPOTONY – Buttonhole – Aggressive neeedling • BLEBITIS • ENDOPHTHALMITIS • EPITHELIAL TOXICITY (5-FU) • ENDOTHELIAL TOXICITY (MMC)
  33. 33. • MMC drops comparable to 5-FU injections in terms of – IOP, bleb appearance, – success rate, (68.4% MMC, 77.8% 5-FU) – number of glaucoma medications, – visual outcome, – overall complications Pakravan M, Miraftabi A, Yazdani S.Topical Mitomycin-C versus Subconjunctival 5- Fluorouracil for Management of Bleb Failure. J Ophthalmic Vis Res. 2011 Apr;6(2):78-86.
  34. 34. TOPICAL MMC • SIDE EFFECTS – Local irritation, hyperaemia, – Epiphora (Punctal stenosis), – Allergy, – Keratoconjunctivitis – Corneal abrasion (superficial punctate keratitis) – Cataract, – Persisting keratoconjunctivitis, – Limbal stem cell deficiency Shields CL, Naseripour M, Shields JA. Topical mitomycin C for extensive, recurrent conjunctival-corneal squamous cell carcinoma. Am J Ophthalmol 2002;133:601–6. Fucht-Pery J, Rozenman Y. Mitomycin C therapy for corneal intraepithelial neoplasia. Am J Ophthalmol1994;117:164–8. Song JS, Kim JH, Yang M, et al. Mitomycin-C concentration in cornea and aqueous humor and apoptosis in the stroma after mitomycin-C application. Cornea 2007;26:461–
  35. 35. • Subconjunctival 5-FU application more effective therapy than bevacizumab for needling procedures in failed trabeculectomy blebs. Simsek T1, Cankaya AB, Elgin U. Comparison of needle revision with subconjunctival bevacizumab and 5-fluorouracil injection of failed trabeculectomy blebs. J Ocul Pharmacol Ther. 2012 Oct;28(5):542-6.
  36. 36. OTHER COMPLICATIONS • UVEITIS • HYPHEMA • DELLEN • SNUFF OUT PHENOMENON
  37. 37. LATE COMPLICATIONS • Thinning and leaking bleb • Large overhanging bleb • Bleb related infections – Blebitis – endophthalmitis • Cataract
  38. 38. INTRAOPERATIVE COMPLICATIONS
  39. 39. BUTTONHOLE OF CONJUNCTIVA • Avoid toothed forceps • Avoid cutting needles • Subtenon lignocaine • Corneal traction sutures • Repair (layered) • Avoid antimetabolite over the defect (sodium hyaluronate) • New site • Bandage contact lens
  40. 40. SCLERAL FLAP TEAR • Avoid very thin flaps (half or more) • Gentle handling • Avoid cautery at the edges (retraction) • Donor sclera / pericardium • Limbal hinge by 10-0 nylon • New site
  41. 41. LENS INJURY and VITREOUS PROLAPSE • Most commonly during block removal • During peripheral iridectomy • Kelly’s punch instead of Vanna’s scissors • Constrict pupil before PI • Oblique paracentesis • Merocel sponge assisted vitrectomy (avoid automated vitrectomy) • Tighter flap closure
  42. 42. HYPHEMA • Predisposing conditions • Irrigate with cold irrigating solution • Epinephrine
  43. 43. SUPRACHOROIDAL HEMORRHAGE • Preoperative intraocular pressure • Hypertension and atherosclerosis • Sudden decompression • Immediate closure • Posterior sclerotomy

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