( usually streptococcus and haemophilus spp)
• Instil povidon-iodine 5% into the conjunctival sac.
• Fortified ofloxacin hourly and cefuroxime hourly (day and night) for at least 24 hours, reducing frequency as clinically indicated.
• Ciprofloxacin 750 mg b.d. p.o. and co-amoxiclav 625 mg t.d.s. p.o. (azithromycin 500mgs b.d. p.o. if penicillin allergy) for 7 days.
• Review patients with blebitis or bleb-related infection within 6 hours to exclude progression to bleb-related endophthalmitis (BRE).
• Intravitreal vancomycin 2 mg and either amikacin 0.4 mg or ceftazidime 2mg in cases of BRE.
• prednisolone 1% (once the course of infection is clear in blebitis).
• Prednisolone 1mg/kg p.o. commenced 12 hours after admission.
• Consider intravitreal dexamethasone 0.4 mg to minimize inflammation-related retinal toxicity in cases of BRE.
1. COMPLICATIONS OF TRABECULECTOMY Sumeet Agrawal PG 3 UCMS and GTB Hospital, Delhi
2. INTRAOPERATIVE POSTOPERATIVE EARLY LATE Buttonhole of conjunctiva HYPOTONY -Flat anterior chamber -Deep anterior chamber Thinning and leaking bleb Scleral flap tear ELEVATED IOP -Flat anterior chamber -Deep Anterior chamber Large overhanging bleb Lens injury ‘Snuff out’ phenomenon Bleb related infections Hemorrhage Cataract Choroidal effusion Descemet’s stripping
3. Early postoperative complications Hypotony Flat Anterior Chamber Deep Anterior Chamber Elevated IOP Flat Anterior Chamber Deep Anterior Chamber • Aqueous misdirection • Pupillary block • Delayed Suprachoroidal hemorrhage Failing bleb • Internal block • Encapsulation • Leaking bleb • Overfiltration • Choroidal effusion • Overfiltration
4. MEASURING IOP • Digital palpation • Avoid filtering site
5. Early postoperative complications Hypotony Flat Anterior Chamber Deep Anterior Chamber Elevated IOP Flat Anterior Chamber Deep Anterior Chamber • Aqueous misdirection • Pupillary block • Delayed Suprachoroidal hemorrhage Failing bleb • Internal block • Encapsulation • Leaking bleb • Overfiltration • Choroidal effusion • Overfiltration
6. HYPOTONY with FLAT AC • LEAKS – Siedel’s test • From the wound • From a button hole • Iridocorneal touch – Spontaneous deepening in 7-14 days • Corneo-lenticular touch – Look for corneal edema – Aggressive intervention
7. MANAGEMENT • Conjunctival leak : – Reduce steroids – Pressure patch – Large diameter contact lens – Fibrin glue – Surgical repair • Overfiltration: – Reduce steroids – Pressure patch – Mydriatic-cycloplegics – Large diameter contact lens – Surgical repair Reformation of AC : • Viscoelastic • Air • SF6 • C3F8
8. CHOROIDAL EFFUSION: • Easily visible ora • Usually resolves spontaneously • Oral steroids • Drain if : – Corneo-lenticular touch with decompensation – Kissing choroids – Prolonged hypotony (no signs of improvement within 4 weeks)
9. HYPOTONY with DEEP AC • Benign course • Rule out treatable causes • Persistent hypotony Hypotony maculopathy (reversible till 6 months) • Autologous blood injection in the bleb • Bleb compression sutures • Surgical (resuturing, scleral patch graft) • Reforming the bleb
10. Early postoperative complications Hypotony Flat Anterior Chamber Deep Anterior Chamber Elevated IOP Flat Anterior Chamber Deep Anterior Chamber • Aqueous misdirection • Pupillary block • Delayed Suprachoroidal hemorrhage Failing bleb • Internal block • Encapsulation • Leaking bleb • Overfiltration • Choroidal effusion • Overfiltration
11. ELEVATED IOP with SHALLOW AC • Compare periphery and axial AC – Aqueous misdirection (periphery and axial) – Pupillary block (only peripheral) – Delayed Suprachoroidal Hemorrhage (peripheral and axial)
Trabeculectomy Surgery for Glaucoma, Animation. – YouTube
Glaucoma avascular bleb with positive Seidel test by Perez … – YouTube
Bleb leak seidel positive – YouTube
Treatment of bleb-related infection