Post Trabeculectomy (Trab) Care

Post Trabeculectomy (Trab) Care
Chat from August 5, 2010
Guest Speaker – Dr. Michael J. Pro
Steven Beck, Editor
Lorraine Miller, Editor, Chat Topic Researcher

On Wednesday, August 4, 2010, Dr. Michael Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed “Post Trabeculectomy (Trab) Care”.

Moderator: Our topic tonight is Post Trabeculectomy (Trab) Care. Dr. Pro, can a physician tell in the first six weeks if a trabeculectomy will be successful?

Dr. Pro: This is a great question. In general success for trabs is pretty high, about 80-85% at one year out. Although studies define success differently, we generally mean a reduction in the IOP by 30% and/or controlling the IOP around 21 or less. In my experience, a great predictive time point is about 1 month out from surgery. I find that patients who are doing well at that point, with a good IOP off drops, with a nice appearing bleb, tend to do well going forward.
Conversely some patients may have a more difficult course. Maybe they have more inflammation, maybe the bleb doesn’t look as good, and maybe they need glaucoma drops soon after surgery. It’s not to say that they can’t still do well, but it is this group that more frequently fails a trab and may go on to need additional procedures or surgeries.

P: When you speak of a Trab being successful is your criteria, is it the way the trab is working or that it is helping to stop the progression of the disease?

Dr. Pro: Well that’s a great point! As a surgeon we can point to a successful procedure as one that performs well. In this case, meaning controlling the IOP. It is generally regarded as true that controlling the IOP slows down the optic nerve related visual worsening from glaucoma.
Unfortunately there are a small percentage of patients who may continue to worsen. This is because not all glaucoma nerve damage is due to high IOP. Also there are rare instances when the vision worsens in spite of a totally uncomplicated and successful surgery. Never-the-less, in my experience those individuals who achieve a controlled, low or normal IOP with surgery tend to do very well with respect to glaucoma progression.

P: At what time would you feel another doctor could take over post-operatively if one wants to travel or be a snow bird and leave the state for months?

Dr. Pro: Every surgeon may have a different comfort zone. In general most of the important post-op interventions, like cutting sutures to help control the IOP, are done by the first month to six weeks.

P: Are there more floaters in the eye after a trabeculectomy? I see more floaters but have had several surgeries.

Dr. Pro: Could be. Also there may be visual disturbances, such as from the iridectomy (hole cut in the iris sometimes performed at the time of a trab). Any glaucoma surgery could affect the vision. Any dramatic change in the vision requires immediate evaluation. You should mention any concerns to your surgeon via telephone or at post-op visits.

P: What activities should never be continued after surgery? Water-related such as jet skiing or diving? Martial arts? Tennis? Swimming? Exercises where the head is lower than heart?

Dr. Pro: None of them right after surgery! I restrict my patients from strenuous activity for at least the first two weeks. After that, I allow a gradual resumption of some activities. Most if not all of the activities you mentioned above could be resumed at some point with careful consideration with your surgeon. Common sense usually applies. For instance, it is critical to wear protective eye wear during tennis.

P: What is the most important thing for a Trab patient to do to keep a Trab healthy?

Dr. Pro: To keep a trab healthy simply use your drops as directed and don’t miss your post-op visits in the short run. In the long run, you should remember RSVP as the signs and symptoms of a possible bleb infection: Redness, Sensitivity to light, Visual change, and Pain. Any of those systems requires you to contact the office immediately.

P: Should one always wear goggles when swimming after having had a trab?

Dr. Pro: Yes and try to get the kind that don’t press on the eyeball, but rather press on the orbital bones. Of course a mask would be even better, but impractical for the pool.

P: Is driving possible after surgery? Is driving possible during the six weeks post surgery? How will a patient know if driving will be possible?

Dr. Pro: Yes, driving is often okay. First, the laws of each state or region may be different, but often require 20/40 or better vision in one eye, (a commercial license is more restrictive) so each case is different. Even if the surgical eye has little change in the vision, I still tell my patients to take it easy for the first week. Obviously, they don’t drive the day of surgery and the next day.

P: What about cataracts afterwards, is that a myth or reality?

Dr. Pro: It is not a myth. It is true that cataracts may develop more quickly after a trab. Studies have reported this. I find, though, that in an uncomplicated trab, the rate of cataract development seems about the same as in the other eye.

P: Dr. what about the eye shield. How long is that usually worn? I know I kept mine on at night for many months just to be safe.

Dr. Pro: Again, there are lots of differences between surgeons. Usually about one to two weeks is okay, maybe longer in an eye with a low IOP or someone who admits to eye rubbing.

P: Is a weepy eye normal post-surgery?

Dr. Pro: It is normal to tear somewhat more. Sometimes there are sutures which may irritate. Sometimes the post-op drops irritate. Also it is normal to have a dry eye after surgery and this can cause a reflex tearing. Excessive tearing may indicate a bleb leak and needs to be evaluated.
P: Are puffy eyelids in the surgical eye six weeks post surgery a sign of a problem? What could cause the puffiness in just one eye?

Dr. Pro: Puffy eyelids are pretty common right after surgery. Maybe it’s due to the lid speculum that held the eye open during surgery. Maybe it’s due to some inflammation due to surgery or maybe a reaction to the post-op drops. Excessive puffiness six weeks after surgery is not usual and should be evaluated. Pain and puffiness could mean an infection.

P: How common is it to have a trab in both eyes done? I have trab in both eyes, not at same time, but years apart.

Dr. Pro: Yes, glaucoma is usually bilateral. It is not uncommon to need a trab in both eyes. Usually there is time between them, but there are emergency cases where I have operated on one eye and then the other in the space of a week.

P: I had a trabeculectomy in May, 2009, and in July, 2010 I had cataract surgery. What actually causes the rapid growth of the cataract?

Dr. Pro: Possible culprits are post-op inflammation, steroid drops, and dramatic change in the anterior chamber depth during surgery or in the post-op period.

P: What eyeliner or any of kind of make up near the eye should be avoided after a trab?

Dr. Pro: For the first month, I tell my patients to avoid eye make-up. I am not an expert in types of eyeliner, but mascara bottles are known to be contaminated with bacteria because they may sit around for awhile. Avoid touching the eye and especially the bleb with any applicator.

P: Is cataract surgery any more difficult with a patient with a trab?

Dr. Pro: Most of the time it is not. Sometimes the cataracts are more difficult because maybe the pupil doesn’t dilate well. Also some patients with glaucoma have pseudoexfoliation syndrome. These patients can have more difficult cataract surgery.

P: What is pseudoexfoliation?

Dr. Pro: It is a condition that may cause glaucoma. It is evidenced by tiny white material that can be seen with a slit lamp exam.

P: Is a trab visible to others? Will I see it in the mirror? Will my grandchildren notice?

Dr. Pro: It is usually hidden under the lid. Sometimes the bleb (this is the pocket of fluid which forms on the top of the eye under the lid) can be seen when you look down and lift your lid. Sometimes a relative or friend may notice it as a white area on top of your eye.
P: Would I know if my bleb is leaking? Can it leak at anytime?

Dr. Pro: Some blebs are more likely to leak than others. Every person heals differently. Some blebs can be very thin, with no blood vessels visible. These blebs may be more likely to leak and could leak many years after surgery. Most people with leaks report that the eye seems to tear even with the lids closed or laying in bed.

P: At any point, can you predict how long a bleb will function?

Dr. Pro: History and examination are the best predictors. Has this bleb been working well for an extended period of time? What does the bleb look like today? Is it moderately elevated? Is it free of excessive redness and blood vessels? It is broad or diffuse appearing? Those are good things and may predict on-going good bleb function.

Moderator: Thanks so much Dr Pro for your time! The group and many other readers appreciate your continued support!!

Dr. Pro: Thanks to you and all the others who work so hard to make to chat run and the foundation, too. Good night.


About the Author:

The Glaucoma Service Foundation’s mission is to preserve or enhance the health of all people with glaucoma and to provide a model of medical care by supporting the educational and research efforts of the physicians on the Wills Eye Institute Glaucoma Service, the largest glaucoma diagnosis and treatment center in the country.
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