Moran CORE

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: Home / Glaucoma / 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.

Trab Post-op Guidelines

Drops:

• Prednisolone 1%: q2 hrs while awake for the first 3-4 weeks and then a slow taper over 3 months (QID for 2 weeks, TID for 2 weeks, BID for 2 weeks, Qday for 2 weeks then stop)
• For those more likely to scar may elect for Druezol QID for 1 month and then TID for 2 weeks BID for 2 weeks Qday for two weeks
• Antibiotics QID for 1 week and then stop
• NSAIDS only if phaco/trab
• Stop all glaucoma drops at time of surgery to promote flow through the flap and reduce risk of scarring. But OK to restart if IOP not controlled despite best efforts and promoting flow through bleb
• Avoid prostaglandins after surgery (can increase inflammation around bleb). Ok to restart if bleb failed
• Consider early needle bleb revision (within 3 months of original surgery) to try and revive bleb

Visits:

• Recheck POD#1 and then weekly for 4-6 weeks

Misc:

• Wound Leak: if there is a small conjunctival wound leak then stop NSAID, stop steroid, consider aqueous suppressant and consider large diameter BCTL use until leak resolved. OK to restart steroid/NSAIDS and stop aqueous suppressants after leak healed
• If the AC is moderately shallow may consider cycloplegia to rotate the ciliary body posteriorly and deepen the chamber
• Carlo Traverso Maneuver: Used for opening scleral flap in the early post-operative period with elevated IOP.
  • Have the patient look down while pressing firmly on the upper eyelid posterior to the scleral flap in an attempt to open the trap door.
  • If this does not work you can also have the patient look up and press inferiorly. You hope to see increase in the bleb size indicating improved flow.
  • This second technique can be taught to the patient for them to do at home in the setting of a failing bleb (stress to use the broad base of your finger and press firmly.)
• Suture Lysis:
  • Ok to perform as early as 1 week depending on response to digital pressure.
  • Cut suture away from the scleral flap to decrease risk of scarring
  • Check response to suture lysis immediately and if you need to cut another suture the same day you can
• 5-FU: Consider 5-FU for trabs at high risk of failure (0.1ml of 50mg/ml concentration = 5mg)
  • At the VA you have to request this as an inpatient non-formulary request and have the pharmacy deliver it to clinic (or send someone down to get it)
  • Do NOT inject over the scleral flap or in the bleb. Instead inject adjacent to (or even 180 degrees away from the bleb)
  • Use 30 gauge needle bevel down and slide just under the conjunctiva. If some 5-FU leaks out then use q tip to reduce more leakage and rinse cornea to reduce risk of epithelial breakdown
  • Repeat up to 3 times with 2-3 days between each injection
• Needle Revision: Often reserved for after aggressive PF, suture lysis and 5-FU fail, but these steps should all occur quickly so that needling can occur at within 3 months of original trab.
  • Can be done at the slit lamp but most likely will be taken to the OR.
  • Use 30 gauge needle essentially as a crow bar to break adhesions and lift the scleral flap and reform the bleb.

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.