You hope to see increase in the bleb size indicating improved flow.
If this does not work you can also have the patient look up and press inferiorly. Have the patient look down while pressing firmly on the upper eyelid posterior to the scleral flap in an attempt to open the trap door. Carlo Traverso Maneuver: Used for opening scleral flap in the early post-operative period with elevated IOP. If the AC is moderately shallow may consider cycloplegia to rotate the ciliary body posteriorly and deepen the chamber. OK to restart steroid/NSAIDS and stop aqueous suppressants after leak healed Wound Leak: if there is a small conjunctival wound leak then stop NSAID, stop steroid, consider aqueous suppressant and consider large diameter BCTL use until leak resolved. Recheck POD#1 and then weekly for 4-6 weeks. Consider early needle bleb revision (within 3 months of original surgery) to try and revive bleb. Avoid prostaglandins after surgery (can increase inflammation around bleb). But OK to restart if IOP not controlled despite best efforts and promoting flow through bleb Stop all glaucoma drops at time of surgery to promote flow through the flap and reduce risk of scarring. Antibiotics QID for 1 week and then stop. For those more likely to scar may elect for Druezol QID for 1 month and then TID for 2 weeks BID for 2 weeks Qday for two weeks. Prednisolone 1%: q2 hrs while awake for the first 3-4 weeks and then a slow taper over 3 months (QID for 2 weeks, TID for 2 weeks, BID for 2 weeks, Qday for 2 weeks then stop). Dr traverso hand surgeon free#
NOTE: In figure the green loop at the limbus is tied to the free end of suture to finish the closure. Using loop of suture from this and free end of suture the closure is tightened, tied and cut short.
To end closure there will be two buried episcleral bits that emerge and re-enter near the limbus. Please refer to Figure below for closure tips Continue with modified Wise closure 1. Start with buried suture at far corner of peritomy. This is a critical step to reduce risk of post op hypotony after surgery. Begin conjunctival closure with 10-0 vicryl suture. If adequate flow then tie of suture (total 1-1-1), cut short, and rotate the knot. Pressure on the posterior edge of the flap with a surgical sponge should provide flow. Tie 1-1 first and check for no/minimal passive flow through the flap. Once posterior lip is engaged then rotate instrument and hand vertical before engaging punch. Pass punch into AC and catch posterior lip of tunnel. Use Kelly punch to remove cornea tissue. Ensure that you do not cut your 10-0 sutures May consider using small amount of dispersive OVD in the angle to maintain AC upon entrance Ensure adequate pressurization of the AC. These should actually be about 2/3 the distance posterior along the flap so that they will promote posterior flow through flap Pre-place 2 10-0 nylon sutures at corners of scleral flap. 
Create medial and lateral edges of scleral flap.Carry scleral flap dissection anterior into the cornea trying not to enter the AC at this time.Initiate posterior edge of scleral flap at ~50% depth (may use guarded diamond blade or scleratome blade.Measure 3.0mm posterior to the limbus for dimensions of scleral flap.Cautery to scleral bed where flap will be located.Blunt dissection in the superior sub Tenons space.Superior conjunctival peritomy leaving 1-2mm limbal skirt for improved closure.Displace across superior conjunctival bed while blocking limbus with surgical sponge.
Inject subconjunctival Mitomycin C (0.2ml of 0.2mg/ml) superiorly.Place corneal light shield soaked in BSS.Inject subconjunctival lidocaine superior and displace across superior conjunctival bed.Place 7-0 Vicryl traction suture partial thickness in superior cornea to provide infraduction.
The microscope is then rotated superiorly for the trabeculectomy portion of the surgery: Of note the cataract surgery is still performed with a standard temporal clear corneal incision which is closed with a 10-0 nylon suture at the end of the cataract portion of the surgery. Below is our standard protocol for the trabeculectomy portion of the surgery. Secondary CORE Category: Home / Glaucoma / Surgical Therapy for Glaucomaĭiagnosis: Glaucoma, Primary open-angle glaucoma (POAG), Cataractīrief Description: This video demonstrates a standard surgical technique for phaco-trabeculectomy at the University of Utah Moran Eye Center with Dr. Keywords/Main Subjects: Glaucoma, Trabeculectomy, Trab, Cataract, Phacoemulsification, Phaco Home / Ophthalmic Surgery / Glaucoma SurgeryĪuthor (s): Russell Swan, MD Craig Chaya, MD
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