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Phaco-Trabeculectomy

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Title: Phaco-Trabeculectomy
Author (s): Russell Swan, MD; Craig Chaya, MD
Date: 7.18.2016
Keywords/Main Subjects: Glaucoma, Trabeculectomy, Trab, Cataract, Phacoemulsification, Phaco
Secondary CORE Category: HomeGlaucoma / Surgical Therapy for Glaucoma
Diagnosis: Glaucoma, Primary open-angle glaucoma (POAG), Cataract
Brief Description: This video demonstrates a standard surgical technique for phaco-trabeculectomy at the University of Utah Moran Eye Center with Dr. Craig Chaya. Below is our standard protocol for the trabeculectomy portion of the surgery. Of note the cataract surgery is still performed with a standard temporal clear corneal incision which is closed with a 10-0 nylon suture at the end of the cataract portion of the surgery. The microscope is then rotated superiorly for the trabeculectomy portion of the surgery:

  1. Place 7-0 Vicryl traction suture partial thickness in superior cornea to provide infraduction
  2. Inject subconjunctival lidocaine superior and displace across superior conjunctival bed
  3. Place corneal light shield soaked in BSS
  4. Inject subconjunctival Mitomycin C (0.2ml of 0.2mg/ml) superiorly
  5. Displace across superior conjunctival bed while blocking limbus with surgical sponge
  6. Superior conjunctival peritomy leaving 1-2mm limbal skirt for improved closure
  7. Ensure underlying Tenon’s is free.
  8. Blunt dissection in the superior sub Tenons space
  9. Cautery to scleral bed where flap will be located
  10. Measure 3.0mm posterior to the limbus for dimensions of scleral flap
  11. Initiate posterior edge of scleral flap at ~50% depth (may use guarded diamond blade or scleratome blade
  12. Carry scleral flap dissection anterior into the cornea trying not to enter the AC at this time
  13. Create medial and lateral edges of scleral flap
  14. Ensure flap is free of adhesions
  15. Pre-place 2 10-0 nylon sutures at corners of scleral flap. These should actually be about 2/3 the distance posterior along the flap so that they will promote posterior flow through flap
  16. Ensure adequate pressurization of the AC. May consider using small amount of dispersive OVD in the angle to maintain AC upon entrance
  17. Use keratome to enter AC. Ensure that you do not cut your 10-0 sutures
  18. Use Kelly punch to remove cornea tissue. Pass punch into AC and catch posterior lip of tunnel. Once posterior lip is engaged then rotate instrument and hand vertical before engaging punch.
  19. Use sliding knot to tighten sutures. Tie 1-1 first and check for no/minimal passive flow through the flap.
  20. Pressure on the posterior edge of the flap with a surgical sponge should provide flow
  21. If adequate flow then tie of suture (total 1-1-1), cut short, and rotate the knot
  22. Begin conjunctival closure with 10-0 vicryl suture. This is a critical step to reduce risk of post op hypotony after surgery.
  23. Start with buried suture at far corner of peritomy
  24. Continue with modified Wise closure1. Please refer to Figure below for closure tips
  25. To end closure there will be two buried episcleral bits that emerge and re-enter near the limbus. Using loop of suture from this and free end of suture the closure is tightened, tied and cut short. NOTE: In figure the green loop at the limbus is tied to the free end of suture to finish the closure.

Phaco-Trab-1-21527

Trab Post-op Guidelines

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Format: Video
Faculty Approval by: Craig Chaya, MD
Identifier: Moran_CORE_21527
Copyright statement: Russell Swan, MD, ©2016. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/
Attribution/citation suggestions:
Swan, R and Chaya, C. Phaco-Trabeculectomy . Moran CORE. Available at: http://morancore.utah.edu/section-14-ophthalmic-surgery/phaco-trabeculectomy/. Accessed July 27, 2016.