Trabeculectomy Surgery for Glaucoma

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Lowering Eye Pressure Through Glaucoma Surgery Trabeculectomy

A successful glaucoma procedure for many years has been trabeculectomy. In the US, it is typical to start treating glaucoma with medications and laser therapy before resorting to surgery. Trabeculectomy is frequently suggested as the next course of action when these procedures are unsuccessful or cannot be employed. In order to reduce the risk of pressure injury to the optic nerve, which transfers vision from the eye to the brain, this procedure is intended to drastically reduce the fluid within the eye. Trabeculectomy is frequently effective in regulating pressure and lowering the risk of further vision loss over many years in the majority of patients, even though no procedure can restore vision loss that has already happened or reverse glaucoma that has not yet been treated permanently. 

How does a Trabeculectomy surgery work?

When medication therapies or laser surgery are unable to sufficiently lower the eye pressure, trabeculectomy is a common procedure for glaucoma. In this procedure, a tiny hole is formed in the eye’s wall, and a flap or “trapdoor” is produced to cover it, allowing fluid to exit the eye in a controlled manner. Through the tiny hole and “trapdoor,” the fluid is diverted from inside the eye, avoiding the clogged trabecular meshwork and staying below the outer transparent membrane of the eye (conjunctiva). This causes a little “bleb” or blister to develop under the upper eyelid. By simply gazing at the eyes, no one will typically be able to see the “bleb.” 

An operating room, a local anesthetic for the eye, an anesthesiologist, and around an hour of operating time are all necessary for the extremely delicate procedure known as trabeculectomy. Over the course of five years, it successfully controls eye pressure roughly 60 to 80 percent of the time. 

Following surgery, patients usually cease taking any glaucoma medications that had been given and start using a prescription of steroid and antibiotic eye drops to treat inflammation and prevent infection. Trabeculectomy is one of our “gold standard” treatments because it is so effective at lowering eye pressure when done correctly, particularly for patients with intermediate to severe glaucoma.

What steps are included in surgery? 

Trabeculectomy Surgery for Glaucoma

The operating room is where the procedure is carried out. Eye drops and numbing jelly will be used to numb your eye. You will get drugs through your IV from the anesthesiologist to help you relax and remain composed while having surgery. Typically, local anesthetic and intravenous sedation are used during the procedure. The eye is totally numbed by a local anesthetic injection administered through the eyelid, preventing any discomfort or movement of the eye during the operation. General anesthesia, which renders the patient unconscious during the procedure, is occasionally utilized. There are various benefits to local anesthesia. After surgery, there may be less discomfort and no sore throat from the breathing tube used during general anesthesia. Patients experience no nausea after general anesthesia, returning rapidly to normal alertness. Particularly in the elderly or those with health issues, local anesthesia carries less danger than a general anesthetic. A sterile drape will be placed over the face once the eye is cleaned. The eyelids are opened using a device. In most instances, the procedure itself lasts less than an hour. 

The conjunctiva, the thin, filmy covering that covers the surface of the eye, develops an aperture. Through this aperture, the sclera, the white portion of the eye, is visible. 

The thick, hard sclera is partially pierced through by a “flap.” Under the flap, there is a hole that provides access to the eye inside. At the edge of the iris of the eye, another aperture might be made. This gap prevents the iris tissue from obstructing the new drainage pathway for fluid. 

The sclera is reattached to the flap’s margins using sutures, and these aid in regulating the rate of fluid drainage, which impacts the ultimate pressure inside the eye. 

The conjunctiva, a thin layer of skin that covers the eye’s surface, is then stitched up to conceal the flap and drainage.

ExPRESS Mini Shunt for Glaucoma 

A sclerotomy is made under a partial thickness scleral flap during a typical trabeculectomy technique to produce a new drain. In the early postoperative phase, the intraocular pressure response can be unpredictable due to the varying size of this sclerotomy. 

A 27G needle track is used to introduce the ExPRESS® Glaucoma micro shunt, a less than 3 mm long stainless steel implant, behind a scleral flap to produce a new drain. It lowers intraocular pressure by directing aqueous humor through a standardized conduit into the subconjunctival area. Depending on the implanted model, the shunt’s internal resistor generates a standard opening of either 50 or 200 microns (P50, R50, P200). A safer closed system makes the entire treatment less likely to result in anterior chamber collapse or possible vitreous displacement. The implant has been tested in magnetic fields up to 3 Tessa forces and is totally MRI-safe. 

When you decide to have glaucoma surgery, your doctor will go over your options with you and, if necessary, bring up the possibility of having the ExPRESS® glaucoma micro shunt implanted. This shunt device’s insertion process is quite similar to trabeculectomy surgery. Most frequently, anti-scarring drugs like 5-Flurouracil or Mitomycin C will be used during surgery to lessen the possibility of postoperative scarring.

Pros of the Shunt 

The shunt has a number of benefits, including some research demonstrating quicker vision recovery and reduced postoperative inflammation inside the eye. 

Cons of the Shunt 

The EX-PRESS shunt has several drawbacks, such as the potential necessity for removal in the event of a severe infection, cost variations depending on the insurance provider, and the presence of an additional piece of hardware inside the eye, which some patients may not prefer. The cornea, or clear window part of the eye, may sustain long-term damage if the shunt is not positioned correctly. 

It is crucial for patients to discuss these options with their surgeon in order to determine which option is appropriate for their specific condition. Some surgeons favor normal trabeculectomy, while others prefer trabeculectomy with an EX-PRESS shunt.

What Happens After Trabeculectomy Glaucoma surgery?

Trabeculectomy Surgery for Glaucoma

The eye is often covered with an eye patch and shielded with plastic overnight following a trabeculectomy. It is taken out the morning after the procedure, and your ophthalmologist examines the eye. Then, eye medications are recommended to calm the eye’s muscles, stop infection, and lessen inflammation. On rare occasions, a tablet may also be suggested to reduce inflammation further. It is crucial to take them as prescribed by your ophthalmologist because they might significantly affect how successfully the treatment goes. Check out the postoperative instructions. 

Following the procedure, your ophthalmologist will constantly monitor your eye and conduct periodic exams. It is occasionally possible for too much fluid to drain following surgery since it is impossible to determine the precise size of the opening to make in the eye to drain fluid. Additionally, it is impossible to estimate how well you will heal after surgery. During your postoperative visits, your doctor might use a laser to cut the sutures holding the trap door in place if your eye pressure is greater than it should be in order to encourage more fluid flow from the eye. The full healing process may take up to 12 weeks following your surgery. Your intraocular pressure may change throughout this period, as well as your vision. Around 6 to 8 weeks after surgery, you’ll be prepared to get a new prescription for glasses

Managing Scarring 

As part of the body’s natural healing process, the “trapdoor” or “bleb” may frequently scar over. Eye surgeons frequently use anti-scarring drugs like Mitomycin-C or 5-fluorouracil at the time of surgery to attempt and prevent this issue, but it can still happen occasionally. In order to regulate the scarring process after surgery, eye specialists frequently inject these drugs during office visits. 

This scarring issue is more common in young people, members of particular racial groupings, and persons who have glaucoma brought on by trauma or inflammation. In rare cases, the operation may need to be repeated, or additional surgical procedures including a more comprehensive bleb revision in the operating room are necessary if scarring is seen. Doctors can try to break up the scar tissue using an in-office procedure, a sort of “bleb revision,” if it is present. 

Successful Trabeculectomy Surgery Factors 

The frequency of follow-up appointments for medication and “bleb” treatment may perhaps be more crucial than the operation itself for the outcome of trabeculectomy. There are various techniques that are occasionally employed in the clinic following the surgery in addition to the anti-scarring drugs that may need to be injected (described above). To allow the ocular fluid to escape, the doctor might stitch the “trapdoor,” for instance. Occasionally, the sutures are removed with a laser during an office visit, allowing more fluid to escape. If a “releasable suture” is employed, the surgeon may also “free” the sutures by gently pushing on them. Finally, in order to maintain the flow and the well-formed bleb, your surgeon can advise you to perform a type of “eye massage.” 

Recovery, and side effects of trabeculectomy surgery

It can take the eye two to six weeks to recover from a trabeculectomy, as opposed to the fast recovery experienced after other laser treatments. Even though they are extremely rare, significant consequences such as eye infections, internal bleeding, vision loss, and low eye pressure can happen. Therefore, this procedure is only for eyes that haven’t reacted well to medical treatment, laser surgery, or other minimally invasive procedures. The “bleb” growing to a size that is obvious or uncomfortable is another uncommon side effect, although there are techniques to handle these changes. Even many years after the procedure, anti-scarring drugs can raise the risk of an eye infection. Therefore, patients should call the office immediately away rather than waiting if they experience discomfort, unusual tearing, pus-like discharge, or growing redness even years after the surgery. A late infection may cause considerable vision loss, although an early infection can be treated and vision can be retained. 

Accelerated cataract formation is one of the more frequent trabeculectomy adverse effects. This can be reversed, though, as cataract surgery can be done in the future. Alternately, some surgeons will conduct cataract surgery concurrently with the trabeculectomy, albeit it has been demonstrated that doing so lowers the trabeculectomy’s success rates.

FAQs for Trabeculectomy Surgery

How will I feel both during and following the procedure? 

The surgery may involve bright lights, but you shouldn’t experience any pain. You will be released with a transparent plastic shield over the operated eye, either with or without a patch. Since you were given sedative meds, you will need an adult to drive you home. 

How often will I be examined following surgery? 

The first day following surgery, around a week later, and a few weeks after that, you will visit your doctor. There may be a need for more or fewer visits, depending on how well your eye heals. 

Following surgery, what eye drops will I use? 

For the vast majority of patients, steroid and antibiotic eye drops will be prescribed. The extent of eye irritation determines how frequently you should use steroid eye drops. 

After surgery, may I stop taking my glaucoma drops? 

Depending on how your eye is doing, your doctor will advise you on which drops to keep using and how frequently at each appointment. Patients occasionally have the ability to cut back on the amount of eye drops they use. If your pressure is lower following the treatment, the surgery was successful even if you continue to take your glaucoma drugs. 

Will I see better immediately away after surgery? 

Vision may be cloudy and possibly worse during the first several days following surgery. Though it occasionally takes longer, this will get better over a few weeks. During rehabilitation, the eye that wasn’t operated on won’t be impacted and may be used for vision (if it has vision). 

What can I anticipate in terms of recuperation time? 

You should be able to go back to work in a few days to a few weeks, depending on your position and the condition of your other eye. There might need to be restrictions on physical activity at work. Your eye may be painful and feel as though an eyelash is lodged there after surgery. When you first put the drops in, they could burn and your eye might wet or tear a lot. These symptoms are typical but typically moderate, and they go away for the majority of people in 1-2 days. If you are not able to take this drug, Tylenol (acetaminophen) is an excellent option. Please contact our office or the on-call doctor right once if you experience significant eye discomfort, a rapid worsening of your symptoms, or changes in your vision following surgery. 

Do I face any limitations following surgery? 

Following your procedure, you will receive comprehensive instructions tailored to the needs of your eye. The following principles generally apply: 

  • For at least two weeks following surgery, the plastic shield must be worn at night to safeguard the eye. 
  • Sunglasses must be worn outside during the day to shield the eyes from the sun and wind. 
  • Avoid intense activity during the first few weeks, including swimming, bending, rubbing your eyes, lifting more than 10 pounds, and running. 
  • There are no restrictions on what you can do, but you could get tired more quickly when you read, watch TV, use your phone, tablet, or computer, etc. 

Will I still have Glaucoma after the trabeculectomy? 

“Yes” is the clear-cut response. Glaucoma must be continuously monitored and treated because it is a chronic condition. Your eye pressure will be reduced with the trabeculectomy treatment. However, it won’t stop eyesight loss that has already started.

About the Author:
Dr Shaun Larsen

Dr Shaun Larsen

Dr. Shaun Larsen is an optometrist who specializes in low vision services and enhancing vision with contact lenses. He has a passion for making people's lives better by helping them see well enough to read, write, or drive again. He always keeps up with the latest technology so he can help people regain their independence.

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