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Glaucoma Surgery Overview by Dr. Andrew Rabinowitz

Blog, Eye Surgery, Glaucoma  | 

The following chapter is a guide to glaucoma surgery. I have created this guide to help prepare patients for glaucoma surgery. It is intended to help patients understand the “why” and “how” of glaucoma surgery.

OVERVIEW:

Surgical procedures for glaucoma have been evolving over the past 100 years. Over the past 25 years, we have made large strides in improving surgical techniques and outcomes. Glaucoma surgery is intended to lower the intraocular pressure (eye pressure.) By lowering the eye pressure, we attempt to slow down progression of the disease. Glaucoma is defined as damage to the optic nerve. Abnormally elevated eye pressure is the most common cause of glaucomatous optic nerve damage. Some patients develop glaucomatous optic nerve damage despite the fact that they have intraocular pressures within normal range. These patients are said to have “low tension glaucoma.” Healthy people, who do not have glaucoma, have eye pressures ranging from 10mm to 20mm Hg. The average pressure among American adults is 16mm Hg. Therefore, glaucoma surgeries are intended to lower the eye pressure to 16mm Hg or less. Surgery attempts to lower eye pressure by creating a new “drain” to allow aqueous fluid to leave the eye. Fluid which has exited the eye through the new drain collects in a cyst-like cavity called a “bleb.” From here, the fluid enters the venous circulation (blood vessels) and leaves the orbit.

Roughly 15 to 25% of patients who have glaucoma do not have elevated pressures. These patients develop damage to their optic nerves even though the eye pressure rarely reaches the mid-twenties. These patients have what we call “low tension glaucoma.” The types of surgeries performed on these patients are similar to the surgeries performed on patients with elevated pressures. The main difference in surgery for “low tension glaucoma” is that we are attempting to lower the eye pressure to 12mm Hg or less. This is a more aggressive reduction than we aim for in glaucomas due to elevated pressures (16mm or less.)

WHAT SHOULD I EXPECT FROM GLAUCOMA SURGERY?

Glaucoma surgery attempts to lower the eye pressure by various methods. These methods will be clearly described in the following sections. Regardless of the method used, it must be clear to patients that it takes on average 3 to 6 weeks to recover from surgery. This does not mean that the patient must be a “couch potato” during this period, but rather that they must simply “take it easy” during this recovery period. Many patients are comfortable driving one to two weeks after surgery. Some patients, however, like to wait at least a month to 6 weeks prior to driving.

IS THERE PAIN DURING OR AFTER GLAUCOMA SURGERY?

Patients who undergo glaucoma surgery usually do not experience significant pain during or after the surgery. Like any surgery, many patients experience mild discomfort for a few weeks following surgery. Strong pain medication is not commonly needed. Most patients who undergo glaucoma surgery can achieve good pain relief with Tylenol.

The most common complaint patients express after glaucoma surgery is that they feel a “scratchy” sensation for the first 4 to 6 weeks. This is normal after glaucoma surgery! Patients are actually feeling the stitch that is used to close the surgical wound. This stitch is made of an absorbable material. This stitch dissolves over a period of 4 to 6 weeks. The stitch does not need to be “removed” because is will dissolve automatically. The “scratchy” sensation can be minimized by using artificial tears. Some patients also use lubricating eye ointments to improve their comfort.

IS THERE BLURRY VISION AFTER GLAUCOMA SURGERY?

Patient’s may experience blurry vision for the first 3 to 6 weeks following surgery. The blurry vision can be very upsetting to patients who do not expect this. However, if the 3 to 6 week recovery period is clearly explained and emphasized to the patient, many patients do not have difficulty during this period.

WILL I NEED EYEDROPS AFTER GLAUCOMA SURGERY?

Most patients do not require “glaucoma” eye drops after surgery. They do however, require three types of post-operative eye drops for the first 2 to 3 months following surgery. They types of drops needed include:
1. An antibiotic
2. An anti-inflammatory (usually prednisone)
3. A medication to dilate the pupil (this is used to help keep the eye comfortable.)

These three types of drops are used for roughly two to three months after surgery. They allow the eye to heal at a controlled speed, prevent infection, and keep the eye relatively pain-free. These medications are rarely used beyond 3 months following surgery

WHY DO WE PERFORM GLAUCOMA SURGERY?

Glaucoma surgery is an effective method of controlling the disease. The surgeries, however, DO NOT “cure” glaucoma. The goals of surgery are to lower the pressure so as to protect the optic nerve from continued damage. The surgeries do not restore sight which has already been lost. The surgeries do not improve vision. The primary goal of glaucoma surgery is to slow the progression of the disease.

The pressure reduction achieved by surgery does NOT last forever. Depending upon the type of surgery performed, a patient can hope to have their pressure lowered from a period of 6 months to 10 to 15 years. There are a host of reasons why glaucoma surgeries are not permanent. The most common cause for failure of glaucoma surgery is scarring of the newly created drainage passage. Medications are used to minimize scarring for the first few months following surgery. Over the course of a decade, there is little we can do to eliminate scarring altogether.
It is important to remember that recovery takes between 3 to 6 weeks following surgery. Many patients begin to worry that they are not healing properly if they are not completely healed by two to three weeks. It is important to share your fears with your doctors and allow them to alleviate any fears, which may develop after surgery.

WHAT TYPES OF GLAUCOMA SURGERY ARE THERE?

1. Trabeculectomy
2. Glaucoma Drainage Devices (Aqueous shunts)
3. Non-penetrating filtration procedures (Aqua Flow)
4. Diode laser cyclodrestruction

I will now outline each of these surgeries. The type of surgery chosen depends on the type and severity of glaucoma. Each patient has a different degree of disease. The surgeon will choose the type of procedure to perform based upon each individual case.

Each surgery has advantages and disadvantages. There is no “perfect” surgery. The goal is to choose the appropriate procedure for each individual patient.

GLAUCOMA SURGERY-TRABECULECTOMY

Glaucoma therapy is directed at protecting the optic nerve and preserving visual function. At present, this goal is achieved by lowering intraocular pressure using medications, laser treatments, or surgeries. In general, surgery is reserved for patients who have glaucoma, which has not been well controlled on medications, and have had complete laser treatment. Laser treatments are usually performed after a patient’s pressure becomes uncontrolled on a maximally tolerated medical regimen (MTMR.)

Although laser treatments can be effective, the pressure reduction they produce is not permanent. When a patient has failed medical therapy, they usually undergo laser therapy. When laser therapy in conjunction with, or in place of medical therapy fails, we resort to surgery. Although surgery has historically been the last treatment on our list, this thinking is changing rapidly. With advances in surgical devices and techniques, the role of surgery is rapidly growing. Surgery is no longer viewed as a “last-resort.” In certain cases, surgery may be a better “first step” than either medications or laser treatments.

Glaucoma surgeries attempt to make a relatively permanent “drain” in the eye. This drain will serve to remove aqueous humor from inside the eye to an extra-ocular reservoir.

The creation of a hole or fistula is called a trabeculectomy. Trabeculectomy first gained widespread notoriety in the 1970’s. The procedure has been performed continuously since that time.

WHAT DOES A TRABECULECTOMY ENTAIL?

With glaucoma filtering surgery, trabecular meshwork and sclera are excised, creating a fistula through which aqueous humor drains from the anterior chamber. The aqueous humor accumulates in the subconjunctival space, forming a filtering bleb. Although it is not known with certainty, aqueous humor within a functioning filtering bleb is thought either to drain through the conjunctiva into the tear-film, or to be absorbed from capillaries within episcleral and subconjunctival tissue and join the systemic circulation.

INDICATIONS FOR TRABECULECTOMY:

For most ophthalmic surgeons, the indications are as follows: A patient with glaucoma on maximum tolerable medical therapy who has had maximal laser benefit and whose optic nerve function is failing or is likely to fail.

The surgeon must be certain the patient has glaucoma, and not just ocular hypertension or nonglaucomatous optic neuropathy. This determination implies characteristic damage to the optic nerve, visual field, or both.

SURGICAL TECHNIQUE:

Trabeculectomy is, in essence, a filtering procedure designed to divert the aqueous humor through an eye-wall fistula (hole) to a subconjunctival filtering reservoir, the filtering bleb. The goal of glaucoma filtering surgery, like that of medical and most laser therapies, is to lower the intraocular pressure (IOP) below the threshold that causes optic nerve damage.

THE ROLE OF ANTI-METABOLITES:

The use of anti-metabolites during filtration surgery has greatly enhanced surgical success rates in high-risk eyes. These chemicals are applied to the eye at the time of surgery. They serve to decrease scaring of the surgically created wound. This allows the newly created glaucoma drain to remain open. Unfortunately, they are not without a significant downside. They have been shown to increase the rate of post-operative infection. In addition, they increase the incidence of postoperative wound leak. Intra-operative or post-operative use of 5-fluorouracil (5-FU) or mitomycin C (MMC), to limit scarring following glaucoma filtering surgery can improve the surgical outcome of an eye with a poor prognosis.

RISKS OF TRABECULECTOMY:

The risks of glaucoma surgery include bleeding, infection, blindness, and loss of the eye. These risks are not unique to glaucoma surgery. However, eyes with glaucoma are usually “sicker” than eyes without glaucoma. Despite these risks, the benefits of long-term pressure reduction are great. Numerous scientific studies have repeatedly demonstrated that patient’s whose pressures are lowered by at least 30% from their untreated levels have better preservation of visual function over the course of their lifetime.

POST-OPERATIVE COURSE:

Glaucoma surgery attempts to lower the intraocular pressure without the aid of glaucoma medicines. During the early postoperative period, the intraocular pressure can by variable. In some patients, the pressure is quite low. In other patients, the postoperative pressure can be higher than it was before surgery.

When the pressure fluctuates, often a patient’s vision will fluctuate. Patients often experience blurred and frankly poor vision for the first 6 weeks after surgery. Fortunately, by the beginning of the second month following surgery, vision usually returns to its preoperative level and stays there. One of the paramount goals of glaucoma surgery is to minimize an individual’s dependence on glaucoma medication. Although this is not achieved in 100% of cases, it is certainly attainable in a good number. The following pages illustrate and describe a surgical trabeculectomy.

POST-OPERATIVE PATIENT INFORMATION

TRABECULECTOMY SURGERY:

1. TRABECULECTOMY lowers the pressure inside the eye! They do not cause the fluid to drain into your tears. The fluid, which is drained out of your eye, is shunted to the back of the eye, and from there it enters the venous system to be removed from the eye as it mixes into the bloodstream.

2. BLURRY VISION IS NORMAL AFTER THIS SURGERY!
Your vision will be very blurry for the first 3 to 6 weeks following this surgery. Many patients become anxious during the first month after surgery because their vision does not return to normal immediately after surgery. I cannot over-emphasize that it is normal to have very blurry vision for 6 full weeks following the surgery. It is important to keep this in mind so as not to become worried that something has gone wrong with your surgery.

3. WATERING OF THE EYE IS NORMAL AFTER SURGERY!
Tearing, watering, and mattering are all common complaints after this type of surgery. The excessive tearing and watering will resolve on their own over the first 3 to 6 weeks. It is not a permanent problem. Be patient, this problem is very common, but always resolves spontaneously over time.

4. A SCRATCHY OR “SANDY” SENSATION IS NORMAL AFTER SURGERY!
Glaucoma surgery requires stitches (sutures). The stitches dissolve spontaneously. It takes about 3 to 6 weeks for the stitches to dissolve. During this period, you may feel the stitch scratching the eye. This is NORMAL! Some people feel this scratchy sensation a few days after surgery; some do not experience it until many weeks after surgery. Do not be alarmed if you experience this. One way to lessen the discomfort is to use an eye ointment, which your doctor can prescribe for you in the office, or call it in to your pharmacy. There are also over the counter ointments available, which your doctor may recommend. The ointments lubricate the stitches and minimize the friction between the stitches and your eyelids. The ointments help the comfort of the eye but can cause blurry vision because they are very thick. They are very helpful if used before going to sleep because they will have minimal effect on your vision, and keep the eye moist when you sleep. They might cause your eye to be stuck shut in the morning, but this can easily be removed with a cool compress.

5. YOU WILL NOTICE A CYST ON THE UPPER PART OF YOUR EYE!
This cyst is called a “bleb.” This is a normal occurrence. In fact, we hope to have a good-sized bleb because this is where your new drain is. The bleb often looks like a blister. Do not be alarmed if you see it. It is supposed to be there!

6. SEVERE PAIN, HEADACHE AND NAUSEA ARE NOT NORMAL!
MUCUS, PUS, OR GREEN-YELLOW DISCHARGE IS NOT NORMAL.
If you experience any of these, please call our office immediately at (602)-955-1000.

GLAUCOMA SURGERY-GLAUCOMA DRAINAGE DEVICES (GDD) OR AQUEOUS SHUNTS

During the past two decades, glaucoma drainage devices (GDD’s) have been increasingly used in the treatment of glaucoma. Approximately 5000 GDD’s are used in the United States annually. Most GDD’s consist of a segment of silicone rubber tubing attached to a rigid plastic or flexible silicone rubber explant.

As previously discussed, glaucoma occurs when the pressure in the eye becomes elevated. The pressure usually becomes elevated due to damage to the natural drain within the eye. GDD’s work by “shunting” excess fluid out of the eye through the silicone rubber tubing. Once removed from the eye, the fluid joins with venous blood, which is returned to the heart

Over the past 5 years, the use of GDD’s has grown rapidly. This increase is due to both improved devices, as well as improved surgical techniques.

GDD’s are less prone to failure than traditional “trabeculectomy” because they are less effected by post surgical scarring. An important advantage which GDD’s have over trabeculectomy is that they do not leave the eye as susceptible to infections following otherwise successful surgery.

The following illustration displays several types of GDD architecture.

The first GDD was the Malteno glaucoma implant, which initially appeared in 1969. Commercially manufactured GDD’s currently available in the U.S. included both “valved” or “flow-restricted” designs (Ahmed, Krupin) and “nonvalved” (Malteno, Baerveldt) designs. While differing in size, shape, and details of instillation, all of these devices share common features and utilize the same physiologic principles.

GLAUCOMA SURGERY-GLAUCOMA DRAINAGE DEVICES

HOW TO GDD’S WORK?

The human eye produces a clear, water-like, fluid called aqueous humor. In a healthy individual, this fluid is drained out of the eye at the same rate it is produced. In patients with glaucoma, the eye loses its ability to drain the fluid out as fast as it is being produced. As a consequence, the aqueous humor accumulates in the eye and the pressure within the eye increases. The increase in pressure leads to damage of structures within the eye. The structure within the eye which is most susceptible to increased pressure is the optic nerve. Thus, glaucoma is defined as damage to the optic nerve resulting from increased intraocular pressure.

As we have discussed, patients with glaucoma usually have a damaged drainage system. GDD’s lower pressure because they allow the excess fluid to bypass the damaged drainage system. GDD’s work by “shunting” fluid out of the eye. They consist of a one way drain attached to a straw like piece of tubing. The drain is referred to as the “plate.” The tubing is surgically inserted into the eye. It runs from inside the eye to the plate, which is sutured onto the outside of the eye. Thus, aqueous humor is shunted from inside the eye to the plate, where it is absorbed by blood vessels, which return it to the systemic circulation.

INDICATIONS:

The general indications for installing GDD’s include failure of conventional therapies such as medications, laser trabeculoplasty, and standard trabeculectomy with or without antifibrotic agents.

GLAUCOMA SURGERY-GLAUCOMA DRAINAGE DEVICES

POST-OPERATIVE COURSE:

GDD’s have demonstrated, as do some trabeculectomies, a period of elevated pressure before the ultimate lowering occurs. Intraocular pressure often falls initially, and then rises to preoperative levels or even higher for weeks before falling again. Resumption of medications is indicated to minimize the transient pressure rise.

POST-OPERATIVE MEDICATIONS:

Post-operative medications following GDD surgery include topical corticosteroids such as Pred Forte 1% from 4 to 6 times a day. In addition, topical antibiotic (Ciloxan, Oxuflox) drops should be used. Glaucoma medications will usually need to be resumed promptly after placement of a GDD, pending spontaneous or surgical opening of the tube as the absorbable ligature dissolves or is cut with a laser

WHAT ARE THE MOST COMMON COMPLICATIONS?

Complication rates for GDD’s have fallen drastically over the past decade due to improved knowledge and experience with the devices. In general, the most common complications seen with any ocular surgery are bleeding, or infection, which in the worst-case scenario, can lead to total blindness and loss of the eye. The most common short term complication is low pressure. The major long-term problems seen with GDD’s are double vision, and corneal decompensation. The reasons for double vision are varied and not always predictable. Corneal decompensation occurs when the tube migrates and comes into contact with the inner surface of the cornea. Both of these problems can be surgically remedied. Double vision can be remedied by removing the GDD. Corneal decompensation can be improved by corneal transplantation.

SUMMARY:

In summary, GDD’s offer an excellent alternative to conventional filtration surgery. Surgery should be performed by a surgeon with broad experience with GDD’s. Once functioning, GDD’s can provide good long-term intraocular pressure reduction and glaucoma control. Unfortunately like all glaucoma procedures, the pressure control produced by these devices is not always permanent. However, GDD’s offer the most predictable long-term pressure control for glaucoma patients.

GLAUCOMA SURGERY-GLAUCOMA DRAINAGE DEVICES

SURGICAL TECHNIQUE:

The white part of the eye is called the sclera. The sclera is covered with a thin, film-like layer of clear tissue known as the conjunctiva. Surgery involves opening the conjunctiva thereby exposing the sclera. The drainage device is then placed in a selected quadrant and sutured to the sclera. The tube is then inserted into the eye through a tract created by a small needle. The tube is then temporarily closed off with an absorbable suture and anchored to the sclera. The tube is then covered with a piece of donor sclera or pericardium. The conjunctiva is then closed in a watertight fashion, completely covering the drainage device and the tube.

FIGURE A.

The conjunctiva has been opened. The supero-temporal Quadrant has been exposed. The superior and lateral rectus muscles have been isolated. The plate is placed under the superior rectus muscle.

FIGURE B:

The plate is placed under the lateral rectus muscle. You can see the tube attached to the plate. In this picture, the tube has not yet been placed into the eye.

FIGURE C:

The tube has been placed into the eye. The tube is covered with a square piece of donor sclera or pericardium. As you can see, the tube sits in the anterior chamber (front of the eye). The conjunctiva has not yet been closed.

POST-OPERATIVE PATIENT INFORMATION

GLAUCOMA DRAINAGE DEVICE SURGERY:

ANDREW RABINOWITZ, M.D.

1. GLAUCOMA DRAINAGE DEVICES lower the pressure inside the eye!. They do not cause the fluid to drain into your tears. The fluid, which is drained out of your eye, is shunted to the back of the eye, and from there it enters the venous system to be removed from the eye as it mixes into the bloodstream.

2. DOUBLE VISION IS NORMAL AFTER THIS SURGERY! .
It is not unusual to experience double or triple vision after this type of surgery.
The double vision is usually worst during the first 3 weeks and then slowly improves over the first 3 months. Many patients become alarmed when they experience double vision, but I stress that this is a normal occurrence, and does not mean that something has gone wrong with your surgery. Some people find that patching the eye for a few weeks makes the double vision go away. There is not harm in covering the operated eye even during the daytime to lessen the double vision. I often recommend this to patients who experience double vision.

3. WATERING OF THE EYE IS NORMAL AFTER SURGERY!
Tearing, watering, and mattering are all common complaints after this type of surgery. The excessive tearing and watering will resolve on its own over the first 3 to 6 weeks. It is not a permanent problem. Be patient, this problem is very common, but always resolves spontaneously over time.

4. A SCRATCHY OR “SANDY” SENSATION IS NORMAL AFTER SURGERY

5. BLURRY VISION IS NORMAL AFTER THIS SURGERY!
Your vision will be very blurry for the first 3 to 6 weeks following this surgery. Many patients become anxious during the first month after surgery because their vision does not return to normal rapidly. I cannot over-emphasize that it is normal to have very blurry vision for 6 full weeks following the surgery. It is important to keep this in mind so as not to become worried that something has gone wrong with your surgery.

6. IT TAKES 6 WEEKS BEFORE THE SHUNT LOWERS EYE PRESSURE!
The drainage device is used to control pressure by shunting fluid out of the eye. The device, however, is designed to lower the pressure gradually over 6 weeks following surgery. In fact, the drain does not work at all for the first month after surgery. After that time, it slowly starts to drain out the fluid and lower the pressure. By six weeks after surgery, the drain will be working at full capacity.

7. SEVERE PAIN, HEADACHE AND NAUSEA ARE NOT NORMAL!
If you experience any of these, please call our office immediately at (602)=955-1000.

GLAUCOMA SURGERY-DEEP SCLERECTOMY WITH VISCOCANALOSTOMY (DSVC)

The most commonly performed glaucoma procedure in the United States is the trabeculectomy. Trabeculectomy attempts to make a partial hole in the white part of the eye (sclera). Aqueous humor drains through this hole into a small blister-like cyst known as the “bleb.” Unfortunately, the bleb obtained in successful glaucoma surgery has many unfavorable characteristics. Firstly, the bleb may be elevated, causing the patient to feel as though there is something in their eye. Secondly, large blebs can grow onto the cornea and become cosmetically unacceptable. Finally, blebs make the eye susceptible to severe infections. The risks of developing a profound infection leading to blindness are much greater in eyes with functioning blebs.

Glaucoma surgeons have spent the past decade attempting to invent a glaucoma surgery which does not result in the creation of a bleb. DSVC attempts to bypass the obstructed trabecular meshwork without creating a scleral hole or fistula. DSVC is referred to as non-penetrating filtration because no hole is created in the eye as is done with trabeculectomy.

DSVC involves the creation of a drainage channel without creating a full thickness hole in the sclera. Theoretically, this will greatly decrease the incidence of post-operative wound leaks and infections. In addition, because no hole is made, the surgery is less susceptible to failure because scarring is less critical to the long-term success of the surgery.

DSVC is a surgery in its infancy. The results of our initial experience with DSVC are encouraging enough to stimulate significant worldwide interest in his procedure.

I have performed over 200 of these procedures with promising results. The rate of postoperative complications has been lower than that seen with trabeculectomy. Bleb formation does occur in about 25% of cases. These blebs however, are low lying, and usually disappear by 6 months. The intraocular pressure has remained controlled even in
cases in which the bleb becomes extinct.
DSVC will not completely replace conventional filtration surgery. However, it will likely assume a crucial role as an alternative to trabeculectomy. DSVC may in fact become the treatment of choice in juvenile glaucomas, pigmentary glaucomas, and open angle glaucomas in myopic eyes. Results of DSVC have been less favorable in far-sighted patients, and eyes with inflammatory glaucomas.

Further studies and refinement of the technique will undoubtedly push the envelope of glaucoma surgery. DSVC offers an excellent alternative to trabeculectomy. This is important in patients who have undergone unsuccessful trabeculectomy in one eye and require initial surgery in the fellow eye.

In glaucoma, hope springs eternal. Clinical trials are underway for another novel glaucoma surgery, which involves using a synthetic “wick” to draw aqueous fluid out of the eye through a non-penetrating scleral reservoir. We hope to participate in this international clinical trial in the coming months. This would enable The Barnet Dulaney Eye Center to offer cutting-edge surgical treatment for glaucoma.

POST-OPERATIVE PATIENT INFORMATION

DEEP SCLERECTOMY SURGERY:

1. DEEP SCLERECTOMY lowers the pressure inside the eye. The fluid, which is drained out of your eye, is shunted to the back of the eye, and from there it enters the venous system to be removed from the eye as it mixes into the bloodstream. The fluid removed from your eye does not join with your tears.

2. BLURRY VISION IS NORMAL AFTER THIS SURGERY!
Your vision will be very blurry for the first 3 to 6 weeks following this surgery. Many patients become anxious during the first month after surgery because their vision does not return to normal rapidly. I cannot over-emphasize that it is normal to have very blurry vision for 6 full weeks following the surgery. It is important to keep this in mind so as not to become worried that something has gone wrong with your surgery.

3. WATERING OF THE EYE IS NORMAL AFTER SURGERY!
Tearing, watering, and mattering are all common complaints after this type of surgery. The excessive tearing and watering will resolve on its own over the first 3 to 6 weeks. It is not a permanent problem. Be patient, this problem is very common, but always resolves spontaneously over time.

4. A SCRATCHY OR “SANDY” SENSATION IS NORMAL AFTER SURGERY!
Glaucoma surgery requires stitches (sutures). The stitches are self-absorbing. It takes about 3 to 6 weeks for the stitches to dissolve. During this period, you may feel the stitch scratching the eye. This is NORMAL! Some people feel this scratchy sensation a few days after surgery; some do not experience it until many weeks after surgery. Do not be alarmed if you experience this. One way to lessen the discomfort is to use an eye ointment, which your doctor can prescribe for you in the office, or call it in to your pharmacy. There are also over the counter ointments available, which your doctor may recommend. The ointments lubricate the stitches and minimize the friction between the stitches and your eyelids. The ointments help the comfort of the eye but can cause blurry vision because they are very thick. They are very helpful if used before going to sleep because they will have minimal effect on your vision, and keep the eye moist when you sleep. They might cause your eye to be stuck shut in the morning, but this can easily be removed with a cool compress.

5. YOU WILL NOTICE A CYST ON THE UPPER PART OF YOUR EYE!
This cyst is called a “bleb.” This is a normal occurrence. The bleb often looks like a blister. Do not be alarmed if you see it. It is supposed to be there!

6. SEVERE PAIN, HEADACHE AND NAUSEA ARE NOT NORMAL!
MUCUS, PUS, OR GREEN-YELLOW DISCHARGE IS NOT NORMAL.
If you experience any of these, please call our office immediately at (602)=955-1000.

GLAUCOMA SURGERY:-TRANS-SCLERAL LASER CYCLOPHOTOCOAGULATION (CPC)

WHAT IS CPC?

The ciliary body is the structure that produces aqueous humor. Aqueous humor is a clear liquid. This liquid is responsible for keeping the eye formed. Cyclodestruction is a treatment, which destroys cells of the ciliary body. In so doing, the treatment attempts to shut down the production of fluid within the eye. Cyclodestructive procedures are recommended in patients with advanced glaucomas and otherwise poor prognoses. Often these patients have been relative failures of medical therapy and glaucoma filtering surgery. In many respects, CPC can be viewed as a “last-step effort to save the eye.”

The cyclodestructive procedures are also useful in patients in whom conventional surgery is contraindicated by their systemic health or local ocular condition. Generally, these patients have little or no functional vision. Reduction of intraocular induced pain in this clinical setting is an important indication.

WHO IS A CANDIDATE FOR CPC?

CPC is reserved for patients who undergone multiple eye surgeries including glaucoma surgeries who still have elevated eye pressure. Often, these patients have lost a significant amount if not all of their vision

WHAT ARE THE INDICATIONS FOR THIS PROCEDURE?

1. Persistently elevated eye pressure despite aggressive surgical treatment.
2. A painful eye with little or no sight remaining.
3. Uncontrolled glaucoma in a patient who is not a good surgical candidate.
4. Reduction of pain in a blind eye.

HOW DOES THE LASER GET TO THE EYE?

The laser energy is delivered to the eye through a probe, which resembles a pen.
The entire procedure usually takes 2 to 5 minutes. The procedure is well tolerated because the patient is treated with a local anesthetic prior to the treatment. The treatment does not require any incisions, sutures, or needles.

WHAT IS THE SUCCESS RATE OF CPC?

The results of CPC are generally quite good. Most patients can be successfully treated with one to two sessions of laser therapy. In severe glaucomas, the treatment may have to be repeated two to three times over the first year to obtain maximum pressure control. One of the greatest advantages of the procedure is that it can be repeated as often as is needed.

WHAT ARE THE MAIN RISKS?

The most significant risk with this procedure is the eye pressure becomes too low and stays that way. This is a very rare occurrence, and often not a problem because control of pain is usually the main indication for this procedure. Like other eye surgeries, bleeding and infection are very low, but possible risks.

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