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University of Gondar CMHS Department of Optometry Seminar on Trabeculectomy complication Presenter: Henock Erkeno(1st yr. Msc student) Moderators:- Dr. Fissaha ( Specialist of glaucoma & cataract) Jun, Gondar Ethiopia
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Objectives To understand trabeculectomy surgery and its procedure
To understand idication and contra indication of trabeculectomy surgery To aware on trabeculectomy complications To aware on trabeculectomy complication management
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Out line Introduction Intra-op complication Post-op complication
Bleb Related infections management
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Trabeculectomy Trabeculectomy is an external filtering procedure where an aqueous drains from the anterior chamber to the subconjuctival space under a partial thickness scleral flap.
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Trabeculectomy procedure steps
Corneal traction suture Conjunctival peritomy performed Partial thickness scleral flap of 4mm square or triangular dissected and pass to limbus in to clear cornea Sclerotomy opening is made by removing a block of tissue = mm from sclero limbal junction.
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Con.. A peripheral iridoctomy is performed.
Scleral flap is replaced and sutured. Conjunctiva then replaced and sutured.
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Cont….
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Cont.. Bleb Ideal bleb -Diffuse -Mildly vascular -Relatively thick wall -translucent enough to see scleral flap -Mirocystic change in wall -Moderate elevation Iop - < or equal 14 good - 14 to 18 moderate - > 18 not good
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Sing of a fail Bleb Low to flat Heavily vascularized No microcyst
Opaque Internal block Rise iop >18 mm Hg
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Indication of trabeculectomy surgery
When medical and laser therapy fail to lower IOP adequately. Inability to afford medical therapy. Rapid progress of glacomatous damage. Advanced glaucoma at presentation. When iridoctomy fails to control IOP Childhood glaucomas Secondary glaucomas not responding to conventional treatments.
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Contra-Idications for trabeculectomy
A blind eye Rubeosis iridis active anterior uveitis extensive conjunctival injury extremely thin sclera success rate is lower in younger patients or in aphakic or pseudophakic patients who have had cataract extraction through a scleral tunnel incision and on black race.
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Complication of Trabeculectomy
Intra – op complication Post – op complication
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Intra –op complication
Conjunctival buttonhole or tear -Fragile conjunctiva -inappropriate instruments -spatulated needles Management -suturing the defect part -changing surgical site ( to other quadrant) -Auto-graft: taking part of a conjunctiva from the inferior fornix and close the defect at bleb area.
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Complication cont.. Scleral flap tear
-flap must be 1/3 to ½ of sclera thickness - tin flap can be tear Management -suturing for small tear -if their complete amputation of flap we can suture at the base and create another scleral flap -change site
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Complication conti… Intra – op bleeding -mild bleeding
-more bleeding from pi,CB Management -direct pressure -cautery -increase iop after AC formation and flap suturing.
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Intra-op bleeding conti..
Suprachoroidal Hemorrhage -Blood fills within the space B/n the choroid and the sclera from the cilliary arteries
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Suprachoroidal hemor…cont..
Risk factors are -anti coagulants -aphakia -high pre-op iop -prolonged hypotomy -generalized atherosclerosis
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SCH Cont..
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SCH Cont… Management -immediate closure -control iop
-sclerotomies help blood to drain out of the eye( after 14 days)
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Post-op complications
High iop with Deep AC -Tight flap sutures On digital pressure to superior of the flap over the eye lid then if bleb is formed it is tight suture. Management -Digital pressure -Suturelysis ( using argon laser to brake the sutures)
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High Iop with Deep AC Blood in AC( Hyphaema) Fibrinous Reaction
Management -increase steroid use frequency -TPA injection -AC wash out Iris and vitreous also block the sclerotomy opening can be removed with yag laser or manually.
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High IOP with Deep AC cont..
Episcleral fibrosis (low bleb) -contractile fibrosis -Flat bleb -Happen at early post op < one month -early stage 20 % -late stage %
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Management -increase topical steroid -suturelysis,5-Fu injection and digital massage -Needling + Sub conjunctival injection of mitomycin c and 5-Fu -Revision
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High iop with Deep AC Bleb encapsulation(formed bleb)
- Non-contractile fibrosis -there is filtration through the scleral flap -sub conjunctival fibrosis -occurs one to six month after surgery -10 to 20% in patients after six month
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Management -continue medication -Needling -sub conj.injection of MMC and 5 fu -Revision of bleb
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High Iop with shallow AC
Pupillary block -No PI -iris bombe ( iris bulging at periphery with shallow AC) -Deeper AC centrally -Clear fundus
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Cont… Management is -performing PI -Miotics
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High IOP with shallow AC
Suprachoroidal hemorrhage -shallow AC -loss of redleflex -dark brown dome shaped choroidal elevation
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High Iop with shallow AC
Aqueous misdirection…cause posterio rotation of the ciliary body. …also called malignant glaucoma signs -PI can be present -shallow AC both at the center and periphery -clear fundus
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Cont… Management -cycloplegia -aqueous supressants -Yag through iridoctomy to disrupt anterior hyaloid phase -capsulotomy in pseduaphakic eyes. - vitrectomy
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Hypotony Iop of 6 mm Hg or less Uncommon and self limiting Can cause
-choroidal effusion -accelerated cataract formation -hapotony maculopathy -Astigmatism -corneal edema -uveitis
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Hypotony maculopathy Signs -presences of retinal fold
-Congested retinal veins -swollen congested optic disc Choroidal enffussion Abmormal accumulation of fluid in the suprachoroidal space
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Causes of hypotomy Conjunctiva leak -seidel test Luminous Green flow
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If we have conj leak check
-the bleb formed or flat -AC is Deep or flat -choroidal detachment or Maculopathy
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CONJ.Leak cont….. Management of early leak -occurs in the first two weeks post surgery -Management depend on site,size and associated complication
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Management cont…. Best way is to avoid it is at the begning,well closure of conj,no missing of conj tear . Observe Decrease the frequency of steroids Apply pressure patch Wide diameter BCL Aqueous suppressants suturing
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Hypotony cont… Late leak ..after month or year
…thinning and necrosis of sclero flap tissue Management -Irritating antibiotics ex gentamycine -Bcl -Aqueous suppressants -Autologous blood injection in side the bleb ( has 50 % success ) -revision
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Hypotony cont… Serous choroidal detachment transudation of serum into the suprachoroidal space.
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Cont…
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Serous choroidal Detacm…
Management -Cycloplegia -Treating the cause of hyptomy FOR - Non resolvig -Kissing choroidal Drainage -Flat AC surgery
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Kissing choroidal detachment
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Hypotomy Over filtration -Large formed bleb -loose sutures Management
-Observe -decrease frequency steroid to induce fibrosis -Aqueous suppressants -compression sure
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Management cont… -Trans conjunctival sutures with figure of eight compress the bleb and scleral flap down - Autologous blood injection - Revision surgery
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Bleb related infection
Risk factors -thin wall with leak -myopia -URTI -ocular surface infection -DM
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Bleb related infection cont..
Sign of infection -Pain -Decrease VA -tearing - FB sensation -Redness -Discharge
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Bleb Related infection cont….
-bleb has milky white appearance -loss of clarity -associated with -bleb leak -hypopyon -vitreous reaction
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Bleb Related Infection cont…
Has three stages stage I: Bleb involved( Blebitis) stage II:I + AC Reaction stage III: II+ Vitreous reaction(endophthal mitis)
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Intravitreous antibiotic topical: vancomycin
Endophthalmities Blebitis Intravitreous antibiotic topical: vancomycin subconjunctival ‘’ mg/ml hrly + topical ‘’ cefuroxine. Systemic ‘’ :streroid Pars plana vitrectomy systemic:Tab ciprofloxaciline 750 mg bid
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Reference Clinical pathways in glcaucoma,Thom J.Zimmerman.
BCSC,Glaucoma, American acadamy of opthalmology. On line opthalmology lecture videos Research article view.
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Thank you!!
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