Trabeculectomy: A safe surgery to lower intraocular pressure in uncontrolled glaucoma

There are many operations for the treatment of glaucoma. Some procedures are recent developments in the surgical treatment of glaucoma, while others have been invented, performed and time tested for many years.  One such operation that has been around for decades is a trabeculectomy.

A trabeculectomy is a surgical operation that has been used successfully in a very large number of glaucoma patients all over the world. Since its development it has undergone a great deal of fine tuning and changes made to the original operation have made it increasingly safer and able to deliver more consistent results for patients. This operation allows a patient’s glaucoma to be managed and their vision to thus be preserved. All over the world, it is common to treat glaucoma with medicines and laser first, as these are less invasive options with minimal to no risk. However, there are always patients who will need more than medicines or the benefit that can be provided through laser treatment in the effective and optimal management of their disease and the preservation of their eye-sight. In these circumstances an experienced glaucoma specialist will advise his or her patient to consider proceeding with glaucoma surgery. If the disease is severe and a very low and constant intraocular pressure is needed, often a trabeculectomy will be recommended. This surgical operation has been carefully designed to significantly lower the fluid pressure within the eye, allowing to exit the eye and return to the body’s circulation without disrupting its appearance or function. In turn this significantly decreases the chance of damage to the optic nerve. It is important to understand that damage to the optic nerve is like damaging a cable to a television.  The optic nerve is teh main cable or connection from the eye to the brain. Without it a “picture” or eye-sight or vision is not possible. It is extremely important to understand that no medications or surgery exist that can reverse vision loss once it has already occurred, however, it is possible to stop further damage. It is for this reason that is important to not delay surgery if advised. A trabeculectomy is often a very safe and effective means of controlling eye pressure and very significantly reducing the risk for additional vision loss in a patient for a very long time.

How does a trabeculectomy work?

A trabeculectomy creates a new pathway or passage for fluid build-up that causes eye pressure and hence glaucoma to exit the eye more easily. From here it can be reabsorbed by the tissue surrounding the eye leading the fluid back to our normal circulation. Any time a new passage is created in the human body the human body will try to excessively heal and seal the passage. Specialized surgical technique is used to allow the body to heal without scarring or sealing this opening. Anti-scarring medications are used at the time of the operation, and sometimes used in the clinic shortly after the surgery help to prevent excessive scar tissue from forming.

Can you describe the surgery?

The surgery is performed in the operating room under very controlled circumstances and with utmost care for sterilization. The eye will be numbed with eye drops and an injection given to numb the eye completely.  A trained anesthesiologist will be on hand to give a patient medication through an IV to keep them relaxed and pain free. If general anesthesia is required, safe anesthesia will be made available to the patient. The eye area will be cleaned using special medication and the face will be covered with a sterile drape. An instrument will help keep the eyelids open. The drain will then be created using instruments and closed in a controlled fashion so that at the end of the procedure the eye will look and function as before except at lower eye pressure. Sutures or stiches are used at the time of surgery, which can be of both self-dissolving and removable types. The patient does not feel the presence of these sutures or stitches as the eye heals.

Once the trabeculectomy has been performed and a new passage created, fluid uses this new passage to exit the eye.  This fluid raises the filmy skin covering the surface of the eye creating a “filtering bleb.” This “bleb” or bubble is an elevation of the surface of the eye that is covered by the upper lid and is neither visible to the patient nor to anyone else until the upper lid is raised mechanically for examination. The fluid is reabsorbed from the bleb by the tissues and blood vessels that are built in and around the eye and taken back into the normal circulation around it.

Do I need to follow up with my eye specialist after trabeculectomy?

Yes, it is extremely important that you return for follow up in the clinic as advised to you by your eye specialist. Immediately after the surgery your doctor will advise you to start the use of certain eye drops at a certain frequency or interval. These eye drops are necessary for the healing process and is extremely important that you pay attention to the use of your medications at the appropriate time and at the appropriate dosage. These eye drops are different from the ones you will often have used before your operation. In the beginning immediately after your surgery your doctor will see you more often. You will be seeing the first day after surgery and then a few days later. However, as time goes by your follow-up visits in the clinic will be spaced further apart and eventually you will be seeing your glaucoma specialist approximately once every four months. During the time of your follow up your doctor may decide to remove the stitches that he or she has placed in your eye this is often done in the clinic using laser or sometimes just by mechanically removing the stitches at the machine that is used in your examination called the slit lamp. This procedure of removing the suture at their slit lamp or using a laser is not painful for a patient and there is no reason to feel anxious about it.

Are there certain restrictions that a patient should keep in mind or immediately after surgery? Are there things a patient needs to be careful about?

It is extremely important that you keep in mind that the medications that have been given to you should be used at the appropriate intervals. It is also extremely important to keep the eye area clean including the eyelids and as well as your facial skin. Keeping the skin of the eyelids clean and maintaining overall good hygiene is an important way in which you can avoid any kind of infection. It is also important not to do any heavy lifting or straining immediately after the surgery until your eye surgeon or eye specialist has given you the instructions that it is safe to do so. It is alright to do light exercise like walking. It is fine for you to use your computer for your digital devices, read and to watch television. There is no reason that you cannot move your head. You do not need to lie still. You can continue your activities of daily living except it is important for you to remember that no heavy lifting or straining should be done and particularly you should avoid bending down and lifting something from the floor. Should you need to do lift something from the floor, ask for help or bend at your knees and do so. A good rule of thumb is to not allow your head to go below the level of your waist while bending down. These restrictions are temporary and only in place for a few weeks after your surgical procedure. A good discussion with your eye specialist will allow you to understand what needs to be done and what can or cannot be done at a particular time.

It is important to remember that treating glaucoma is a bit like treating coronary artery disease, in that it requires life-long management. While there is no way for us to cure glaucoma, it is entirely possible to control the glaucoma and therefore avoid any further vision loss. Many patients ask the question if there is only one surgical operation that will be required. The answer to this question is that one operation may be all that is required for one glaucoma patient while more than one operation may be required for other. The important takeaway is that glaucoma can be controlled, and your glaucoma specialist’s expertise and experience help you to accomplish that together.

If you have been advised to have a trabeculectomy or any other glaucoma medical or surgical treatment or procedure, please contact us at 03028291799, 0300 8939977, 0300 0822218, 021 35836713 or through our website for an appointment with our glaucoma specialist.

Dr. Mahnaz Naveed Shah is a United States fellowship trained, United States Board Certified glaucoma specialist who has over twenty years of experience of treating routine and complex, pediatric and adult glaucoma patients in Karachi. The Eye Center – Dr. Mahnaz Naveed Shah & Associated provides the most advanced diagnostic testing, technical expertise, equipment and most importantly clinical expertise in the care of glaucoma patients. Our nine eye specialists, who hold subspeciality expertise in all aspects of ophthalmology work as a team to take care of the most complex eye care problems to ensure that the best quality of care is provided to every single patient who places their trust in us.

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