Trabeculectomy Complications

DR. dr. Ikke Sumantri

Department Of Ophthalmology
Faculty of Medicine, University of Indonesia – Cipto Mangunkusumo Hospital
Characteristics of a Successful
Filtering Bleb

1. Quiet
2. Elevated
3. Diffuse
4. Paucity of vessels
5. Microcystic conjunctival changes
6. Appropriately low IOP
Signs of a Failing Bleb
1. Injection  diffuse; limited to the bleb area; along
suture line
2. Bleb vascularization ropy surface and deep vessels
3. Bleb thickening  loss of microcystic changes
Signs of a failing bleb

4. Bleb localization
5. High, domed bleb
 encapsulated bleb or Tenon’s cyst
6. Normal or high IOP
7. Inappropriately low IOP
 bleb leak or antimetabolite hypotony may
develop early or late
Causes of Failing Filtration:
Classification based on IOP and bleb configuration

A. High IOP
1. Low, localized bleb:
- External-
subconjunctival
fibrosis and
scarring
- Internal-
sclerectomy
obstruction
2. High, domed bleb:
- encapsulated bleb/
Tenon cyst
Causes of failing filtration…

B. Low IOP
- Low bleb  bleb leak
- Elevated/diffuse bleb
 over – filtration, hypotony

Bleb leak Diffuse bleb

A. High IOP :
Low, localized bleb  subconjunctival fibrosis

 Clinical characteristics and

associated contributing
factors

1. IOP elevated or normal,

usually not low
2. AC deep
3. Sclerectomy site patent
on gonioscopy
4. Bleb inflammation 
diffuse or localized
5. Bleb vascularization with
bleb thickening
 Treatment of subconjunctival fibrosis

1. Corticosteroids reduce inflammation

a. Topical  correlated with improved success of
filtration surgery
 4-6 times per day in quiet eye
b. Systemic
C. Consider preop. use of topical and systemic
steroids in high risk eyes
2. Digital pressure (DP)
a. Gonioscopy critical exclude internal obstruction as a
cause that should receive laser or other therapy prior
to digital pressure
B. Use with intensive topical steroids
 Digital pressure…

e. Slow, steady finger-tip pressure through eyelid 180

degrees away from bleb. Use in series of 10 seconds
on and 10 seconds off
f. Assess effect of DP in office: bleb elevation and
reduced IOP
g. Reassess patient’s technique and effect at each visit
3. Laser suture lysis (LSL)
increase flow through tight scleral flap

a. < 2 weeks post-op.  if no antimetabolite

Delay 3 2 weeks with antimetabolite.
1 suture / session.
b. Argon laser :
- 50 microns
- 250-1000 milliwatts
Hoskins
- 0,3 seconds
c. Hoskins or Zeiss 4 mirror lens  compress conjunctiva & blanch
vessels, improve vizualization of suture
d. Immediate DP or compression at edge of scleral flap at
completion of procedure
4. Antimetabolite therapy

a. Fluorouracil (5-FU)
- Inhibit fibroblast proliferation  increase
success in eyes with poor prognosis. (fluorouracil
filtering study group)
- 50 mg/ml concentration
0.1 ml injected subconjunctivally
180 degrees away from bleb
Move toward bleb with time
Fluorouracil (5-FU)…

- Topical proparacaine; 30 gauge needle; 1 cc

syringe
- Initiate – 3 days postoperatively
- Hold  if wound leaks (+) and large
corneal epithelial deffects;
SPK  common,not a contraindication.
- Use with intensive steroids and DP
b. Mytomycin-C

- Inhibits fibroblast proliferation.

Similar or lower IOP than 5-FU
- Topical use on conjunctiva and postoperative sub
conjunctival injectioninvestigational
- Complications:
similar to 5-FU – avascular bleb, wound
complications, scleral melt, hypotony, CME.
5. Needling of episcleral cap

 May be effective if laser not successful or not possible

 Slit lamp procedure, topical anesthesia
- 30 gauge needle,BSS or 5-FU
inject conjunctiva
- Needle at scleral edge, lift flap,
separate adhesion
- Aqueous release and raise bleb 
- Topical antibiotic
- DP and 5-FU
B. High IOP:
Low, localized bleb internal sclerectomy obstruction

 Diagnosis
1. Low bleb
2. Deep chamber
3. Elevated IOP
4. Gonioscopy is criticaldetermines site of
obstruction and treatment options
 Sites of obstruction

1. Internal
 anterior to sclerectomy
- Thin membrane
- PAS-iris, vitreous, capsule
2. Fibroblastic proliferaton at
level of scleral channel
3. Tightly closed scleral flap
 laser suturelysis
 Treatment of internal obstruction

1. Topical steroids for inflammatory membranes

2. Digital pressure
3. Laser  best for internal membranes

Argon  for thin, pigmented, veneer-like membrane over

sclerectomy 50 microns; 1000+ milliwatts 0.1 – 0.2
seconds, endpoint-fenestration

Nd:YAG  for dense membranes, descemet’s infolding

1-3 pulses/burst, 5-15 millijoules; higher energy levels
C. High IOP:
High, domed bleb

 Encapsulated bleb, Tenon’s cyst, exteriorized anterior chamber

 Characteristics
1. Elevated
2. Localized
3. Domed-shaped
4.  microcystic changes
5. Variable vascular engorgement
6. Elevated IOP
7. Dellen formation common
8. Open sclerostomy
Treatment High, domed bleb

1. Compression
- Direct compression over cyst by surgeon
- DP by patient
2. Medical treatment
- Glaucoma medications
- Steroids
- 5-FU
3. Laser cyst puncture or needling
4. Therapeutic ultrasound
Treatment High, domed bleb…

5. Needling-outpatient, at slit lamp, couple with 5-

FU, crucial for success with difficult tenon’s cysts.
May repeat on a weekly basis through critical
period.
Very effective when coupled with medical therapy.
6. Surgical
- Total cyst excision-result poor
- Small incision, punch cystectomy
D. Low IOP:
Low bleb  bleb leak

 Characteristics:
1. Soft eye
2. Tearing
3. Decreased vision
4. Shallow AC
5. Cells and flare
6. Choroidal detachment
7. Macular edema
8. Striate keratopathy
9. Positive Seidel test with 2% fluorescein
 Treatment Low bleb  bleb leak

1. Prevention
- Protect conjunctiva from surgical trauma
- Tight closure

2. Medical
- Reduce steroids
- Aqueous suppressants
- Topical antibiotics
Treatment Low bleb  bleb leak…

3. Tamponade
a. Pressure patch/torpedo dressing
b. Contact lens (large diammeter; Kontur-Richmond, CA,
Westcon-Grand Junction Co., Optickem Polymers
(McAllister) Englewood,CO)
c. Collagen shield
d. Cyanoacrylate glue
e. Biological glue
f. Shell
g. Symblepharon ring
Treatment Low bleb  bleb leak…

4. Surgical
a. Conjunctival suture  at slitlamp
b. Button-hole closure  matterss, 4-wire tapered
vascular needle,10.0 nylon
c. Leak at limbus  suture to cornea 10.0 nylon
d. Test with 2% fluoroscein
e. Conjunctival advancement flap and graft
 Complications of bleb leaks

a. Bleb infection/endophthalmitis
 especially with blebs positioned inferiorly
1. Diagnosis:
a. Decreased vision, pain, photophobia
b. Inflamed bleb/purulence
c. AC inflammation
d. Culture/gram stain
e. Differentiate from “bleb-it is”
2. Treatment Bleb infection/endophthalmitis

a. Intensive topical antibiotic

i.e. Vancomycin 25 mg/cc & Tobramycin 13
mg/cc alternate q 15-30 min around-the clock
b. Topical cycloplegia
c. Topical steroids prn
d. Vitrectomy, intraocular antibiotics and possibly
steroid, IV antibiotics for endophthalmitis
e. All treatment guided by culture results
E. Low IOP :
Elevated or Diffuse Bleb

Over-filtration
 Choroidal detachment with/without shallow AC

Diffuse bleb Choroidal detachment

- Cycloplegia
- Steroids, topical or systemic prn
- Stop aqueous suppressants  fellow eye also
- Pressure patch
- Bandage CL large, Mc Allister platform type
- Shell tamponade
- Viscoelastic AC reformation
- Choroidal tap-lens:
corneal touch is an emergency indication