Management of Surgical Complications

Abstract

•Glaucoma filtration surgery (GFS) has been associated with higher long-term failure rates and a substantially higher risk profile than most other ophthalmic surgeries. •Identifying and properly managing complications associated with GFS is essential in ensuring the best possible outcome. •Infection is a devastating complication of GFS that must be considered in a separate category (please see Chapter 7 for blebitis and bleb-related endophthalmitis). •Complications unique to glaucoma drainage devices (GDD; see Chapter 12) will be discussed at the end of the chapter. •One simple way to diagnose a complication resulting from GFS is to subcategorize possibilities according to the IOP and anterior chamber (AC) depth. •Table 13.1 shows the four potential outcomes after GFS, and the text below provides additional details about each potential complication. •Usually occurs in the first few months after surgery. •The most common complication of trabeculectomy. •Due to progressive episcleral fibrosis and blockage under the scleral flap. •Incidence has decreased due to intraoperative use of antifibrotics. •Bleb appears constricted, shallow, or flat with increased vascularity and loss of microcysts. •Negative Seidel test. •Gonioscopy reveals an open sclerostomy site, which is essential to differentiate from an inadequate fistula or fistula blockage from iris, blood, fibrin, or vitreous. •Anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) may reveal adherence of Tenon’s capsule and conjunctiva to underlying sclera. •Approached in a stepwise fashion. • Decreases rate of episcleral fibrosis in hopes of rescuing the function of the bleb.•Prednisolone acetate 1% every 2 hours for first 1 to 2 weeks, then taper slowly over 2 to 3 months. •Administered if early signs of bleb failure/episcleral fibrosis are present. •Technique •Instill topical anesthesia followed by direct application of a cottontipped pledget approximately 90 to 180 degrees away from the bleb. •Use a 30-gauge needle on a tuberculin syringe to inject 5 mg (0.1 cc) of undiluted 5-fluorouracil (5-FU; available in a concentration of 50 ug/mL) under the conjunctiva at the anesthetized site. •Avoid areas of bleb elevation and areas that show increased conjunctival vascularity.