The most widely performed type of Glaucoma surgery is Trabeculectomy. This is usually performed when intraocular pressure cannot be lowered enough with medication or laser treatments. Trabeculectomy is often referred to as "filtering surgery" because a new filter is created within the wall of the eye for drainage of fluid. This drain is usually placed at the top of the eye just underneath the upper eyelid.

After surgery, fluid will drain through the new filter to a reservoir known as a bleb. The bleb often looks like a blister on the white of the eye, usually under the upper eyelid.

The appearance of the bleb is used by the doctor to determine the condition of the eye and the success of the surgery. Trabeculectomy is performed in an operating room on an outpatient basis. A local anesthetic, which is given by injection, is used to prevent any discomfort during the procedure. Sedation is also available. During the surgery the patient lies on his/her back. Except for the eye, the face is covered by a drape. This drape is positioned to ensure that the nose and mouth are open for normal breathing.

A special microscope will be suspended over the eye so that the doctor can see very fine details clearly. Tiny stitches, thinner than a human hair, are used to close the incision. In order to reduce scarring, a special medication is sometimes applied during the procedure. A trabeculectomy is usually performed in less than an hour.

After Surgery

Immediately after the procedure, the eye will be soft and very delicate. Therefore, the patient must restrict his/her physical activity and avoid lifting, straining or bending. During the recovery period vision is often blurred. Post-operative care is extremely important to the long-term success of the operation. Dr. Schwartz will continue to provide intricate care so that the earliest signs of any problem will be detected. Keep in mind, each person heals differently after surgery. Therefore, care will be individualized depending on the appearance of the bleb and the condition of the eye itself. Patients are generally seen several times during the first six weeks. After surgery as the eye begins to heal, it is not necessary to be seen as often.

Examination after Surgery

Blurring of vision is normal after the procedure. The doctor will examine:

1. The bleb and appearance of the eye. If there is      any inflammation, the eye
     may be veryred.
2. The surgical area to ensure there is no leakage.
3. The cornea and chamber in the front of the eye.     The cornea should be clear and the chamber      should be filled with aqueous humor.
4. The retina and optic nerve to ensure no fluid or      hemorrhaging are present and
5. The eye pressure.

Common Concerns with Trabeculectomy

1. Vision - Preservation of vision is the primary reason for this procedure. It is designed specifically to lower pressure. Vision can be quite blurry during the first days to weeks after the procedure. In some cases, fluid collects in the back of the eye and further blurs the vision. This fluid can move around the eye, thus causing fluctuations in vision depending on time of day or position of the head. Sudden loss of vision accompanied by severe pain often means bleeding has occurred in back of the eye. Permanent loss of vision can occur following this procedure, but it is very rare.

2. Pain - Severe pain is unusual after the procedure. Some mild discomfort or irritation is common. Tylenol or an equivalent is usually sufficient to control discomfort. Aspirin should be avoided immediately following the procedure. Atropine relaxes eye muscles and reduces pain in most cases. Sudden, severe pain, associated with a loss of vision, If this occurs, the doctor should be contacted immediately. Experiencing a feeling of "something in the eye" or unusual itchiness, is common. Dryness of the eye may also occur. This is usually relieved with an eye lubricant (such as tears) or with an ointment.

3. Eye Pressure - The purpose of this procedure is to lower eye pressure. Pressure is lowered by directing eye fluid to the new bleb (reservoir). Healing and formation of the bleb may take anywhere from weeks to months and may even change over time. The first few days after the procedure, eye pressure will usually be very low.

It gradually begins to rise over the next couple of weeks. However, if the pressure rises too high,the doctor may need to adjust your therapy. When high pressure exists post operatively, it is often caused by a scar which impedes the drainage of fluid.

Possible Complications After Trabeculectomy

1. Encapsulated Bleb - Thick scar tissue may form on the wall of the bleb. This prevents sufficient drainage and causes the bleb to be more round, which can be uncomfortable and may increase pressure. This is common and usually improves over several months. Eye drops may be prescribed during this time to lower the pressure. If the pressure is too high, an additional procedure may be necessary.

2. Flat Anterior Chamber - If fluid drains more rapidly than it is formed, the anterior chamber may collapse and flatten. This causes the eye to be very unstable and vision will be blurry. The chamber will generally reform in a few weeks during which time eye drops will be necessary. In rare cases, additional surgery may be required.

3. Choroidal Detachment - After surgery when pressure is lowered some blood vessels will become leaky. A collection of fluid in the back of the eye may cause a choroidal detachment, distorting vision. The fluid usually reabsorbs by itself. In very rare cases, this fluid may have to be surgically drained. Choroidal detachment may also occur when a blood vessel suddenly breaks. This is usually accompanied by severe pain and loss of vision. The blood may reabsorb or need surgical drainage.

4. Cataracts - In some cases after this procedure, cataracts (cloudy lenses) may be advanced. Usually this is unnoticeable. However, sometimes it may occur rapidly with increasing vision loss. This problem is easily corrected.

5. Infection - There is always a chance of infection after surgery. It is extremely rare to lose vision due to infection. Antibiotics are given during and after the surgery to reduce the possibility of infection.

6. Filtration Failure - In some cases, this procedure will fail to reduce eye pressure to an adequate level. This occurs most often from scar tissue closing the surgical drain. Eye drops may be needed to reduce pressure and/or additional surgeries may be necessary.

Summary

In most cases, Glaucoma surgery is safe and effective. Complications may occur but most are treatable.