1. 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

2. 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

3. Out line Introduction Intra-op complication Post-op complication
Bleb Related infections
management

4. 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.

5. 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.

6. Con.. A peripheral iridoctomy is performed.
Scleral flap is replaced and sutured.
Conjunctiva then replaced and sutured.

7. Cont….

8. 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

9. Sing of a fail Bleb Low to flat Heavily vascularized No microcyst
Opaque
Internal block
Rise iop >18 mm Hg

10. 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.

11. 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.

12. Complication of Trabeculectomy
Intra – op complication
Post – op complication

13. 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.

14. 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

15. Complication conti… Intra – op bleeding -mild bleeding
-more bleeding from pi,CB
Management
-direct pressure
-cautery
-increase iop after AC formation and flap
suturing.

16. Intra-op bleeding conti..
Suprachoroidal Hemorrhage
-Blood fills within the space B/n the choroid
and the sclera from the cilliary arteries

17. Suprachoroidal hemor…cont..
Risk factors are -anti coagulants -aphakia -high pre-op iop -prolonged hypotomy -generalized atherosclerosis

18. SCH Cont..

19. SCH Cont… Management -immediate closure -control iop
-sclerotomies help blood to drain
out of the eye( after 14 days)

20. 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)

22. 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.

23. 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 %

24. Management
-increase topical steroid
-suturelysis,5-Fu injection and digital
massage
-Needling + Sub conjunctival injection
of mitomycin c and 5-Fu
-Revision

25. 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

26. Management
-continue medication
-Needling
-sub conj.injection of MMC and 5 fu
-Revision of bleb

27. High Iop with shallow AC
Pupillary block
-No PI
-iris bombe ( iris bulging at periphery
with shallow AC)
-Deeper AC centrally
-Clear fundus

28. Cont…
Management is -performing PI -Miotics

29. High IOP with shallow AC
Suprachoroidal hemorrhage
-shallow AC
-loss of redleflex
-dark brown dome shaped choroidal
elevation

30. 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

31. Cont…
Management -cycloplegia -aqueous supressants -Yag through iridoctomy to disrupt anterior hyaloid phase -capsulotomy in pseduaphakic eyes. - vitrectomy

32. 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

33. Hypotony maculopathy Signs -presences of retinal fold
-Congested retinal veins
-swollen congested optic
disc
Choroidal enffussion
Abmormal accumulation of fluid in the suprachoroidal space

34. Causes of hypotomy
Conjunctiva leak
-seidel test
Luminous
Green flow

35. If we have conj leak check
-the bleb formed or flat
-AC is Deep or flat
-choroidal detachment or
Maculopathy

36. CONJ.Leak cont…..
Management of early leak -occurs in the first two weeks post surgery -Management depend on site,size and associated complication

37. 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

38. 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

39. Hypotony cont…
Serous choroidal detachment transudation of serum into the suprachoroidal space.

40. Cont…

41. Serous choroidal Detacm…
Management -Cycloplegia -Treating the cause of hyptomy FOR - Non resolvig -Kissing choroidal Drainage -Flat AC surgery

42. Kissing choroidal detachment

43. Hypotomy Over filtration -Large formed bleb -loose sutures Management
-Observe
-decrease frequency steroid to induce
fibrosis
-Aqueous suppressants
-compression sure

44. Management cont…
-Trans conjunctival sutures with figure of eight compress the bleb and scleral flap down - Autologous blood injection - Revision surgery

45. Bleb related infection
Risk factors -thin wall with leak -myopia -URTI -ocular surface infection -DM

46. Bleb related infection cont..
Sign of infection
-Pain
-Decrease VA
-tearing
- FB sensation
-Redness
-Discharge

47. Bleb Related infection cont….
-bleb has milky
white appearance
-loss of clarity
-associated with
-bleb leak
-hypopyon
-vitreous reaction

48. Bleb Related Infection cont…
Has three stages stage I: Bleb involved( Blebitis) stage II:I + AC Reaction stage III: II+ Vitreous reaction(endophthal mitis)

49. 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

50. Reference Clinical pathways in glcaucoma,Thom J.Zimmerman.
BCSC,Glaucoma, American acadamy of opthalmology.
On line opthalmology lecture videos
Research article view.

51. Thank you!!