Glaucoma Surgery

If a trabeculectomy produces a good result, the fellow eye will often follow suit. Why not here? In this patient, the first eye trab produced an almost perfect bleb, whereas the second eye trab. performed 13 years later, resulted in this. Was it the intervening 13 years of glaucoma medication that adversely influenced the result?

Single chamber eye with an Artisan lens and a flat AC. Aqueous misdirection? Not all that it seems!

Normally an IOL flat against the cornea is aqueous misdirection until proven otherwise. However an iris-supported lens, unlike IOls fixated by other means, can be driven forward against the cornea by pupil block alone. This patient had a laser PI in the past but after vitrectomy and gas for an RD, the surgeon did not do a surgical PI, a cardinal mistake in a single chamber eye, unless the vitrectomy is so complete that there would be no possibilty of vitreous blocking the PI.

An unsightly, dysaesthetic, non-functional bleb. See the full excision, repair and follow-up on youtube Glaucoma-Surgery.org. This patient underwent bilateral trabeculectomies 13 years ago. Apparently this bleb was not noticeable until 2 years ago. It has also become uncomfortable and is not functioning. The patient has relatively mild glaucoma that is controlled with medication so the bleb can be safely excised. In the full video, I remove the bleb and patch the sclerostomy with pericardium.

Phacolytic uveitis in a 30 year old dislocated lens.

A 71 year old highly myopic patient suffered spontaneously bilateral lens dislocation 30 years ago, eventually requiring bilateral Paul Glaucoma Implants for secondary glauocma. The left became occluded with vitreous early in 2024, requiring anterior vitrectomy and later flushing to remove any vitreous stuck inside. Two months after flushing the patient presented with a painful irritable eye and intense cellular reaction consisting of larger than normal cells in the anterior chamber.

Resting a tube on the iris, avoids the risk of corneal damage and does not cause uveitis, but a tube buried in the iris, such as this one, can easily obstruct.

Leaking overhaning bleb. Odd combination. Overhanging blebs seem to be due to the upper lid rubbing on the bleb ans pushing it forward over the cornea. The overhang is often completely solid (I seem to remember Paul Palmberg saying something like "just lop the sucker off"). On other hand some blebs dissect into the superficial corneal stroma and under epithelium, causing corneal oedema and often are very painful. This seems to be a bit of a hybrid. Needs to be removed because of the profuse leak.

Now you see it, now you don't!
A sulcus-fixated infero-termporal Paul Glaucoma Implant in an elderly sarcoid uveitic with a clear PK. The pupillary membrane has unusually formed over the implant, rather than on the IOL. Despite this, the IOP Is good, so aqueous much be getting into the tube somehow. It looks as if there is a hole in the membrane, but on OCT, there is no hole.

Referred for early postop hypotony after a Baerveldt 350. A very small inadvertent hole in the tube seems to be the cause. Unusual as Sherwood slits have routinely been used in the past without this dramatic leakage. An easy fix is to amputate the tube and attach to a Preserflo. The original entry site is plugged with the corner of the previous scleral patch graft.

The clinical appearance of Fuchs uveitis syndrome varies according to ethnicity. In patients of African origin, there are often iris nodules that are not seen in blue-eyed whites. In this patient with bilateral Fuchs, these nodules are more obvious than usual and in particular, they stand out in the pupillary ruff, which in most patients with Fuchs actually disappears.

The pitfalls of sulcus tube fixation. What can go wrong if you can't see the tip? Sulcus tube fixation is a good option for a number of reasons, but there are pitfalls, the risk of which is greatly increased by blind fixation in which the tip is not visible. Blind sulcus fixation is becoming increasingly popular and I would strongly advise against this. If the postop IOP is high and you cannot see the tube tip, it can be impossible to differentiate the causes, such as an obstructed tube, a failing tube or a tube where the ripcord or ligature is too tight.

Always make sure you can see the tip, even if it is only on gonioscopy!

A quick temporary fix for an iris obstructed tube. I like to have my tubes close to iris to avoid endothelial damage, but they should not dip into the iris as they may then obstruct, as seen here. This patient has a dense cataract and phaco will likely open the angle enough to prevent reobstruction. Flicking the tube out of the iris with an insuiln syringe at the slitlamp (29 gauge needle) is a quick temporary fix for this patient whose IOP is 45.

When this patient presented with these interesting looking lens vacuoles, KP and an IOP of around 30mmHg, having been on glaucoma meds and controlled for 20 years, it looked to me as if someone might have poked a hole in the lens capsule. However, they just seem to be vacuoles, nothing more.

Hypotony maculopathy after canal MIGS. Impossible? When 2 iStents failed to control the IOP in this high myope, the surgeon tried an OMNI. Why would you expect a second canal procedure to work if the first one failed? Presumably because of difficulty bypassing the iStents in the canal, the result was a small bifid cleft adjacent to the iStents and quite severe hyoptony maculopathy. You can see from the vision blue efflux how fast the drainage can be from even a small cleft.

The gonio video is intraoperative, so not quite as clear as a slitlamp gonio, but made possible thanks to the Ike K. Ahmed goniolens, probably one of the most useful surgical glaucoma instruments ever invented.

I repaired this 2 months after the OMNI. I would normally cryo very small clefts but this patient needed urgent definitive repair to prevent the macular folds becoming permanent and less invasive cleft procedures have a lower success rate. Ironically, the patient has a troublefree functioning trabeculectomy in the other eye.

Lens rising from the dead!
This Paul Implant initially obstructed with vitreous in this "aphakic" eye. After an anterior vitrectomy to reopen the tube, the pressure was even higher, despite ripcord removal. When flushing the tube to ensure no further vitreous stuck up it, the lens appeared from the deep. However, when an vitreous strand to the wound was released, the lens returned to its final resting place.

Surprise, surprise. At the time of the surgery for a brunescent lens, the surgeon thought a piece had gone awol but was unable to find it. Two weeks later it shows up. The patient has good vision and no inflammation and took some convincing that this needs to come out!

More about "Rockapathy!" Before, during and after. Reticular epithelial corneal oedema after one month of netarsudil. OCT 4 months beforehand, then clinical appearance and OCT 1 month after withdrawal. Significant but incomplete resolution.

Thanks again to Laura De Benito-Llopis and Alessandra Martins

If a preserflo is draining too fast, it has become common practice to partially occlude it with a ripcord. This was especially important in this uveitic patient with propensity to macular oedema.

I've always used 9-0 Prolene, some use 10-0 Nylon. What is the difference? In this demonstration both seem to slow up the flow reasonably well. The 10-0 Nylon needs to be threaded further up the MicroShunt than the 9-0 Prolene.

Trabeculectomy flap resuture for severe hypotony after early suture removal in a 39 year old with traumatic glaucoma.

The most common cause of hypotony in my practice is overreaction to very high early postoperative pressure levels. This patient had an IOP in the high 30s on diamox before surgery and 48 mmHg on day 1 postop, either because the sutures were too tight, or possibly haem under the flap. Early removal of releasable sutures resulted in severe hypotony necessitating flap resuture less than 2 weeks later. All's well that ends well. 10 months later, the IOP is 12 mmHg without medication and the vision is 6/6. The moral of the story, avoid very tight flap sutures and early suture removal unless absolutely necessary.

Oculo-cutaneous albinism, post-vitrectomy glaucoma, residual silicone oil droplet, infero-nasal Paul Glaucoma Implant reducing the IOP, but not quite enough. Needs a second tube supero-temporally. It is often claimed that oil drops such as this might block the tube. This has never been my experience. With a Baerveldt or Ahmed, the oil will go up the tube. With a Paul Implant the surface tension, in combination with the smaller tube, usually prevents this.

With aphakic eyes, unless vitrectomised, there is always a risk of tube obstruction with vitreous. I usually implant the tube relatively short in the AC, close to iris and as far as possible from the pupil or any PI, in order to minimise the risk. If there is no vitreous in the AC, I will usually sneak the tube in, without a paracentesis or AC reformation, to avoid encouraging any forward prolapse of vitreous. This tube is a little longer than ideal and mid-AC, though occasionally vitreous can come forward and go up the tube, no matter what you do. This patient is due to have a Paul Glaucoma Implant in the fellow eye, so I'll perform an anterior vitrectomy in this eye at the same time. The pressure has been controlled with medication in the meantime.

Removal of a 6-0 polypropylene ripcord from a Paul Glaucoma Implant. I usually wait 3 months and then remove if necessary and leave if the IOP is ok. If high IOP before 3 months, I might remove if low hypotony risk, but more often partially remove and trim the end.

Long Paul Glaucoma Implant in the AC but flat on the iris. Long tubes in the anterior chamber can bump against the cornea when the eye is rubbed. However, the actual position of this tube is ideal ie. flat on the iris without indenting or pointing forward towards the cornea so corneal damage unlikely. The polypropylene ripcord can be removed via the corneal loop.

"ROCKopathy". Thanks to Laura de Benito Llopis and Alessandra Martins for sharing this case of reticular epithelial corneal oedema that has previously been described with both netarsudil and ripasudil in patients with pre-existing corneal oedema. This patient's cornea was pretty clear a month ago, but developed this appearance on netarsudil.

Tertiary Referral: Right eye trauma in childhood. Phaco-Xen 2022. Subsequent iris implant), amniotic membrane (blebitis?) and sutured IOL exchange 2023. A mess! Secondary glaucoma in patients with a high ethnic risk of surgical failure needs to be taken seriously. Phaco-Xen in an aftro-caribbean patient with a history of serious trauma and an IOP of 37. Seriously? MIBS have a low chance of success in afrocaribbean patients, even as standalone in primary glaucomas. Also the artificial iris is subluxed in the anterior chamber.

Axenfeld Rieger Syndrome. IOP 35 mmHg on 3 topical drugs + acetazolamide before Paul Glaucoma Implant. IOP 20 mmHg on Cosopt, 5 months after implantation, while Prolene ripcord still in place. Mild optic nerve changes so ripcord removal temporarily deferred. Fellow eye has corneal decompensation from an Ahmed Valve. This tube is sulcus positioned, so the cornea should be safe

Axenfeld Rieger Syndrome. IOP 35 mmHg on 3 drugs + acetazolamide before Paul Glaucoma Implant. IOP 20 mmHg on Cosopt, 5 months after implantation, while Prolene ripcord still in place. Mild optic nerve changes, so ripcord removal temporarily deferred. Fellow eye has corneal decompensation from an Ahmed Valve. This Paul is sulcus positioned, so the cornea should be safe.

Definitive Glaucoma Surgery! IOP well controlled without medication, 5 years after a right Baerveldt with MMC and 2 years after a left Paul Glaucoma Implant with MMC, in a high myope with POAG who is completely intolerant of topical medication. Bilateral failed Preserflo and Preserflo Revisions (right revised twice, left revised and then needled in 2018).

IOP 13 right and 14 left unmedicated.

Transconjunctival removal of a 3-0 Nylon ripcord suture from an infero-nasal Baerveldt Glaucoma Implant at the slit lamp, in chronic anterior uveitis, 6 years after implantation. Supramid sutures would typically have degraded if removed more than a year after implantation. This monofilament nylon (Ethilon) is still in one piece.