This video demonstrates trabeculectomy surgery with mytomycin and releasable sutures. It was performed on a 61-year-old female with an advanced glaucoma. Her vision was good but she had an advanced visual field loss.
Surgeon: Dr. John Brookes, Moorfields Eye Hospital, London
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DR BROOKES: Mitomycin, please. So we’re just about to start this case. A 61-year-old lady. Advanced glaucoma. She’s got good vision, but advanced field loss. And the pressure is about 27. So this is just the mitomycin, again. So every time you touch the conj, we want plain forceps. And you can see I’m making my incision with the Banners, tangential to the limbus, so I don’t have any radial incisions. Just dry that for me. So I’ve got two forceps now. I’m holding on the anterior edge. So I’m not at risk of tearing the conjunctiva. So with my crescent knife, I’m going to sort of get the tissue plane, and when I’m in the right place, I’m going to then move the heel backwards, and then follow the contour of the sclera. When I made the radial incisions, again, we’re not gonna go right up to the limbus, because we don’t want anterior drainage. So you can see how it’s quite a nice, thick flap. Ideally we need a thick flap. And we’re into clear cornea. So we know we’re far enough forward. So I’m gonna make my corneal grooves, and I’m gonna make them at the end of the radial incision. So at the end of the radial incision, the groove. Same on this side. So I’m going to pre-place the releasable sutures. So reverse mount the needle. I’m just gonna go nasal to the flap. And then up into the groove that I’ve already made. Pull that through. And you can see it can be a bit of a mess with all the sutures. I’m gonna move that to the side. And it just keeps it out of the way. Good. Then forward-mount the needle. In through the same groove. And up into the flap. See, when I pull that, the loop gets buried in the corneal groove. So we can remove it easily, if we need to. So I’m gonna try to make this partial thickness in the groove. And then we’ll pull that through and leave a short loop, so we can tie the releasable. Same on this side. Temporal to the flap. Through the groove. And then this end we lay the suture over there. Lay the loop there, so that can be removed later. Partial thickness in this scleral flap. And then out in the corner. I’ve got the loop there to tie the releasable suture. Good. So before you enter into the eye, paracentesis, so we can always refill the anterior chamber. And that’s always a good — that’s always a good thing. That if the pressure preoperatively is very high, you can do a paracentesis, and then wait a few minutes, and just slowly release some fluid, some aqueous, to reduce the pressure, before you make the sclerostomy. Good. So we can see clear cornea. So we’re gonna make the full thickness incision. And then one bite with the Kelly punch is enough. And then iridectomy. You always get a little bit of iris tissue coming through. So we’ll just try and replace that. You’ve got to be a little bit careful when you do this, if the eye is phakic. So the pressure is quite high, then. So that’s why the iris prolapsed. I think — tying forceps — I think we’ll just tie one of these sutures first, just so we close the eye a little bit. And then it will be easier, I think, to replace the iris. So you can see a small loop here. We’re gonna tie that on four throws. One, two, three, four. When there’s a lot of iris coming out, I want to make sure that the eyes are secure as possible, really. Just in case anything else comes out. So I just want to at least tie one of these sutures. So I’m just gonna tie the other suture as well. So you can see the pupil is becoming back to its normal round shape now. There’s no drainage there. But we just need to make sure there’s no iris blocking it. So the pupil is completely round now. And if we test the flap… So it’s completely dry. So there’s no drainage there. And so what we’ll do now is see if we can, by just burping it, pressing here, whether there’s any drainage. There we are. With very gentle pressure, it drains. So that’s what we’re trying to look for. A dry field, but drains with gentle pressure. So just to make the point, for a routine trabeculectomy, we use — just as a routine — two releasable sutures. If you’ve got high-risk cases, and what I mean with high risk — young patients, high myopes, normal tension glaucoma, as a routine, we use three releasable sutures, at least. And that’s because, even if there doesn’t seem to be any drainage on the table, they tend to — a week later — tend to suddenly overdrain and become hypotonous. So leaving three releasables is much safer. Good. So we’ll do the pursestring suture. So… Scleral bite. And then we’ll draw the pursestring. So we’re on the inside of the conj. So we come inside to out. Then we go from the outside of the conj. So outside to in. Inside to out. And you can see I’m just doing this, just at the edge of the conjunctiva. And then the final one is outside to in, so the knot’s on the inside. Good. So we do the nasal side now. So nice… Side to the sclera. Outside to the conj, to inside, to out. So I’m pulling that, so we’ve got a nice, tight, watertight conj at the limbus. I’m trying as much as possible to bury, to cover the knots, so it’s more comfortable. And then finally, we’ll do the mattress suture. There’s a nice tight seal there at the limbus. So you can see we can — just with gentle pressure — the bleb forms. So we know we’ll be able to manipulate it postoperatively.
June 7, 2017