Surgery: Trabeculectomy with a triangular scleral flap and pre surgical injection of mitomicin C

Dr. Piltz-Seymour: So this patient has a steroid induced glaucoma. And is count fingers in the left eye and has advanced glaucoma but a good central vision in this eye. I injected the mitomycin before the surgery, I wound up having a little subconjunctival hemorrhage here.

We’re going to make our peritomy.

If you are doing mitomycin with sponges you have to open up a wider area. The tenon’s inserts a millimeter to two millimeters behind the conjunctiva. So I want to make sure I have that cleared off. And I have nice

loose conjunctiva, so we don’t have to dissect that too much. Just go back a little bit more. So I’m going to create my scleral flap, first I will cut sides up.

Just trying to get a nice even plain, there we go. Up in to clear cornea.

We can see how far I can put my blade in there, So I have a nice, a nice extension into the cornea lamellae. So, you can see that we have the transition to the blue zone right anterior to where my weksel is. And as long as we stay working in that zone, we should have a nice anterior trabeculectomy. I am going to pre-place my apical suture. And then I will make a paracentesis. I a m going to keep the flap centered right. No, you do not have to use healon during trabeculectomy, you can just try to either use an anterior chamber maintainer, or pre-replace your stitch and have that and be sure that you can close the eye very quickly.

I’m going to want it because she’s phakic. I’m going to want to do an iridectomy.

So I’m going to enter the chamber and I’m going to have the punch. Enter and go across. Punch with the Kelly punch.

Go in, lift up, make it vertical and punch back. Then I’m going to loosely tie down this, re-form the chamber, and make sure my iris goes back in. We can sort of encourage the iris to come back in. Little bit of BSS, please. And because we have access to a diode laser, we’re going to put in permanent sutures. So, the slip knot again. A single pass, then we go under there and around the back.

Grab, keep your needle holder hand steady and slide your other knot on top.

And now we’re going to evaluate how much flow we have.

So I put BSS in the anterior chamber. First thing I do is make sure that I can maintain the chamber, so she has a nice deep chamber. And then I’m going to press on the eye and feel, the eye actually feels a little bit firm.

So I’m going to see how much flow is coming. And there’s not enough flow for that high pressure. Now I can loosen my stitches.

Now let’s see how much is flowing, just for loosening that one stitch. That’s quite a lot. And I’m going to see how firmly eye feels.

Still a little bit firm. Let’s see how the flow goes, where it settles down. I can loosen this one a little bit too. That seems pretty good, we’re going to take some BSS again.

So now we’ll tie them down, two tiers please. Try not to change the tension on the suture.

We can see, if they will bury. Sometimes they do. I use a very fine needle so they don’t always bury.

Before we close will double check the eye, chamber is good, pressure is good. And I take a nice big bite.

So if you make a relaxing incision you’re going to have to run that, run that suture back. That’s why I usually make my initial incision straight across so I don’t have a relaxing that I need to do. I’m just going to put these extra stitches in, just for security. So we can see our trabeculectomy flap,
with our three stitches in it. Our wound across nice and taut along the limbus, well-sealed on either side. Anterior chamber is deep.

The bleb is blowing up nicely.

So now you can see the bleb is elevated all in here and nice and taut along the limbus.