Surgical Management for Glaucoma

•The most commonly performed incisional procedures for glaucoma are trabeculectomy and glaucoma tube shunts (glaucoma drainage device [GDD]). Trabeculectomy is the more prevalent surgical procedure, yet the use of GDD is increasing. Although practice patterns may change with the results of the Tube vs. Trabeculectomy Study, for most surgeons trabeculectomy remains their primary procedure. • A GDD is typically indicated when a trabeculectomy is judged likely to fail •Trabeculectomy in its current form was described by Cairns in 1968. •The basic concept is to create an alternate path for aqueous egress out of the eye into the subconjunctival space. •General anesthesia is indicated in pediatric patients as well as adults not able to cooperate during surgery. Local anesthesia with monitored anesthesia care (MAC) is used in the vast majority of adults. Methods of local anesthesia vary based on surgeon preference as well as patient characteristics. See Table 12.2 for common routes of anesthetic administration. A traction suture allows manipulation of the globe to provide adequate surgical exposure, which is essential for successful filtering surgery. •Superior rectus bridle suture provides good exposure but has been associated with worse outcomes, produces holes in the conjunctiva that could potentially leak, may increase conjunctival scarring, and carries a small risk of scleral perforation. •Superior corneal traction suture (Fig. 12.1A) provides good exposure but may interfere with wound closure in a fornix-based incision and carries a risk of corneal perforation. •Clinical Pearl: If a corneal perforation occurs, remove the suture and pass it in an adjacent area of cornea. Usually there is no leakage once the suture is removed. If leakage is present, the surgeon can hydrate the suture track. •Inferior corneal traction suture provides less exposure than superior sutures. There is less risk of wound superior distortion, so it may be useful for fornix-based incisions. Can be placed either at the limbus (fornix-based conjunctival flap) or in the fornix, 10 mm back from the limus (limbal-based conjunctival flap).