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Hypotony after glaucoma filtering surgery

Definition: intraocular pressure (IOP) of 5 mm Hg or less. Low IOP can adversely


impact the eye in many ways, including corneal decompensation, accelerated cataract
formation, maculopathy, and discomfort.

Causes
• Unilateral hypotony
o Wound leak
o Overfiltering or inadvertent bleb
o Ciliary body detachment – Serous, hemorrhagic, or tractional
o Cyclodialysis cleft
o Inflammation - Iridocyclitis or blunt trauma
o Retinal detachment or retinotomy
o Ocular ischemia
o Scleral perforation with needle or suture, or scleral rupture following
trauma
o Chemical cyclodestruction from antimetabolites
o Photocoagulation or cryoablation of the ciliary body
o Pharmacologic aqueous humor suppression
• Bilateral hypotony
o Systemic hypertonicity or acidosis - Dehydration, uremia, uncontrolled
diabetes, or use of hyperosmotic agents
o Myotonic dystrophy
I- WOUND LEAK

Risk factors and prevention:


1- Toothed forceps use
• They should not be used on the glaucoma tray.
• Suture-tying forceps should be used when the conjunctiva is handled.
• Dry cellulose sponge with its tip cut-off to stretch the conjunctiva up
2- Superior rectus bridle suture
• Replace by corneal traction suture
3- Rough manipulation of the conjunctiva
4- Postoperative trauma
5- Full-thickness sutures: leading to cheese-wiring through sclera
• Use a thicker scleral flap
• Place partial thickness sutures
6- Antimetabolite use
• Restrict its use to patients with risk factors
• Delay suturelysis in patients with antimetabolite use till 1 week for 5-FU
and 2 wks for MMC postoperatively
• Limit its spread to adjacent tissue by:

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a- staining with trypan blue
b- use special forceps (chalazion forceps or Dixey clamp) to limit area of contact
c- use of small beads of microsponge
d- Avoid touching the cut edge of cornea or sclera with your contaminated
forceps
e- Donot cut the scleral flap prior to antimetabolite application

Diagnosis:
1- Intraoperative detection; using the paracentesis to insufflate the globe with
BSS via a 25-gauge blunt cannula. The bleb will form then collapses within
few seconds. In case of doubt, we can paint the upper conjunctiva and bleb
region with fluorescein dye to look for a positive Seidle test
2- Postoperative detection: tetrad of shallow AC, hypotony, low bleb, and
positive Seidel test
 Concentrated fluorescein on a paper strip is preferable to topical
fluorescein/anesthetic solution.
 The slit lamp is set to blue light, and the paper is stroked over the surface
of the eye.
 Aqueous humor escape can be detected as spots of brighter yellow that
slowly expand.
 Gentle pressure on the globe may be required to detect subtle leaks.
 Wound leaks with overlying intact conjunctiva cause filtering blebs and
remain Seidel negative.

Types of postoperative bleb-leak:


1- Acute traumatic tears: sudden change in bleb function, and symptoms. Slit-like
or flap-shaped with raw edges.
2- Chronic atrophic tears: very thin blebs, chronic course, unstable bleb,round
hole with raised cuff around

CONSERVATIVE TREATMENT:
Indications:
1- acute tears
2- monocular patient
3- reliable patient
4- good central vision

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Methods:

1- Bleb compression:
 Pressure patch: fusiform-shaped cotton ball is placed over the lid in the area of
the fistula and held in place with gauze pads to produce mechanical pressure.
The patient should keep awake with the fellow eye looking straight ahead.
Examination of patient 1-4 h later may reveal deepening of the AC so the
patient can be discharged home with instructions to remove the patch in the
evening before going to sleep.
 Simmons shell
 Oversized-bandage contact lens

2- Aqueous suppression (turning down the faucet): oral or topical


carbonic anhydrase inhibitors and topical beta-blockers.

3- Topical antibiotics: being irritant to the ocular surface to initiate


a fibrotic response

4- Trichloroacetic acid: can be applied by a small stick.

5- Adhesive glue: (Histoacryl or Dermabond) with application of


bandage CL and topical antibiotics

SURGICAL MANAGEMENT:
Indications:
1- chronic threadbare holes
2- history of bleb-related infection
3- unreliable patient or poor hygiene
4- changing vision

Methods:

(A) Suturing:
1- Short limbal conjunctival tear: horizontal mattress suture of double-armed 10-
0 nylon to close, the cornea is de-epithelialized just anterior to the tear

One arm of the suture is passed to one side of the hole through the conjunctiva and
partial-thickness anterior tenon layer, into the cornea in front of the tear. The other needle
is passed similarly on the other side of the hole. When the two ends are tied, conjunctiva
is pulled safely down, with considerable overlap onto clear cornea.
2- Linear tears away from the limbus: closed in 2 layers with a running suture

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3- Linear tears near a fornix incision: incorporate the tear into the final incision
closure

(B) Amniotic membrane transplant can be used safely to cover a large


defect

(C) Lens extraction:


If the patient has cataract, lens removal can induce inflammation sufficient to close small
beleb leaks

(D) Autologous blood

Rationale: places plasma proteins to stimulate fibroblast migration and


proliferation
Technique: 1ml venous blood withdrawn from the patient then the needle is exchanged
for 30-gauge one that is bent to an angle. The patient looks down and needle inserted
under topical anesthesia posterior to the bleb and advanced into bleb and 0.2ml is
injected. Antibiotic is placed, torpedo patch and systemic CAIs.

Complications:
1- Hyphema
2- Corneal blood staining
3- Endophthalmitis
4- IOP rise
5- Bleb failure

II- Bleb Overfilteration


Elements:
6- Avascular acellular conjunctiva
7- Antimetabolite use
8- Internal aqueous barotraumas
9- External trauma

Risk Factors:
1- Loose scleral flap closure
2- Antimetabolite use
3- Early suture release in patients with antimetabolite use

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Diagnosis:
1- High elevated bleb.
2- Low IOP
3- Shallow AC
4- Siedle negative

Prevention:
1- Test the bleb function at the end of surgery
2- Antimetabolite use: see bleb-leak
3- Place extra scleral flap sutures adjusting both the number and tightness: a
scleral flap that is too tight can be managed easier than one that is too loose

Management:
CONSERVATIVE:
Indications: as in bleb-leak
Methods: as in bleb-leak

SURGICAL:
Indications: as in bleb-leak plus expanding unstable bleb
Methods:
1- Cryotherapy:

Technique: Under peribulbar anesthesia, 3-mm flat glaucoma probe is placed over the
surface of bleb with 4-6 applications. With each application, the ice ball penetrates the
bleb and reaches the episclera after 6-10 seconds. Then torpedo patch and oral CAIs are
administered for 48h.
2- Compression sutures:

Technique: 9-0 nylon suture is placed in a mattress manner from the cornea just anterior
to the bleb and parallel to the limbus then posterior to the bleb incorporating conjunctiva
and Tenon capsule
3- Lens Extraction: if the patient has cataract.
4- Autologous blood injection
5- Laser treatment:

 Argon laser: under topical anaesthesia, rose-bengal or methylene blue dye is


placed over the bleb and the epithelium is abraded by cotton-tipped applicator.
The bleb surface is treated in a grid manner using 500-um spot size, 0.1-0.5
second, and 500mW shots. This is followed by torpedo patch and oral CAIs for 48
h.
 Nd-YAG Microrupter-II laser: using 3 joules, offset of 3-4 mm.
 Diode laser: 3000mW shots using the G-probe

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Complications: uveitis, inadvertent bleb leak, and transient rise in IOP
6- Surgical Revision: in case of failure or unavailability of the above measures

 Resuturing the scleral flap


 Bleb excision with autologous conjunctival transplant
 Conjunctival advancementwith or without bleb excision
 AMT
 Scleral patch graft with or without bleb excison

III- Cilio-choroidal Detachment


Risk factors:
10- Hypotony
11- Uveitis
12- Raised episcleral venous pressure e.g. Sturge-Weber syndrome

Diagnosis:
1- Hypotony
2- Shallow AC
3- Low bleb height
4- Fundus exam: smooth dome-shaped brownish peripheral fundus elevation
5- U/S scan: M-pattern spike in A-scan. Dome-shaped choroidal elevation with
choroidal thickening and clear suprachoroidal fluid (unlike hemorrhagic
detachment)
6- OCT: diagnostic
7- Anterior segment OCT or UBM: in case of anterior ciliochoroidal detachment

DD:
1- Retinal Detachment: corrugated, can reach ONH and ora seratta. U/S scan
shows retinal origin for the nearly 100% reflectivity and low-to-moderate
kinetic mobility. Visual loss is rapid
2- Hemorrhagic Choroidal Effusion: associated with severe agonizing pain and
vomiting. U/S scan shows heterogenous fluid in the suprachoroidal space.

Management:
A- Medical:
Cycloplegic: ATROPINE 1% eyedrops tds

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Topical steroid: PREDENISOLONE ACETATE 1% eydrops every hour
B- AC Reformation:

Indications:
1- Corneolenticular touch
2- Prolonged hypotony with imminent bleb failure
Technique: under topical anaesthesia
1- can be done using 30-gauge needle and through the original paracentesis
2- can be done using a viscoelastic e.g. sodium hyalouronate 1%, air, long-acting
gas e.g. SF6 or C3F8, or air-viscoelastic mixture
NB: use of gas in phakic eyes has been associated with the development of anterior
subcapsular cataract
C- Drainage of Suprachoroidal Fluid:

Indications:
1- Kissing choroids
2- Failure of AC reformation with extensive choroidal detachment
Technique: under subconjunctival anesthesia
1- Through the original paracentesis place an AC maintainer connected to BSS
bottle
2- 3-mm radial scleral incision is made in the mosr dependant quadrant 4-mm
from the limbus
3- Once in the suprachoidal space the AC maintainer is opened making pressure
for the suprachoroidal fluid to egress
4- Cyclodialysis spatula can be used to help drainage
5- At the end, the lips of sclerotomy are gaped by cautery or excising a small snip
by trephine or punch

IV- Cyclodiaylsis Cleft


Definition: disinsertion of the ciliary body from the scleral spur. It causes hypotony
through overdrainage of aqueous fluid through the cleft.

Risk factors:
1- During phacotrab surgery: during dissection of a scleral flap that is too deep
2- Sclerectomy that is too posterior
3- Trauma

Diagnosis:
1- Hypotony
2- Shallow AC
3- Siedel negative

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4- Gonioscopy: ma show the cleft, but the shallow AC and PAS may hinder its
visualization. Sometimes injection of a viscoelastic through the paracentesis
may facilitate its detection
5- UBM or anterior segment OCT: diagnostic

Management:
1) Observation: may be for 6-8 weeks till they close spontaneously. Withdrawal
of steroids may help by allowing a degree of inflammation ending in fibrosis.
Cycloplegic such as ATROPINE 1% eyedrops TDS should be used.
2) Argon Laser Surgery:
Indications; the first choice when observation fails
Technique: using Goldmann-3 mirror contact lens and under topical anaesthesia
1- Pilocarpine should be used to constrict the pupil and a viscoelastic is used to
inflate the AC
2- start by 0.1 second, 100-um, 1000-3000mW shots applied to the scleral side
first
3- shift to 0.1 second 200-um, 800-1000mW shots on the uveal side moving
anteriorly to avoid uveal edema
4- Remove the viscoelastic, donot use steroids, use ATROPINE eyedrops TDS
for 2-3 wks
3) Cryotherapy:
Indication: usually as adjunct to surgical repair

Rationale: induce inflammation in the ciliary body and iris root


Technique: trans-scleral application till create a superficial ice ball avoiding
cyclodestruction
4) Incisional Surgery:
Indication: failure of Argon laser surgery to repair the cleft

Technique;
1- Direct cyclopexy: after creation of a partial thickness scleral flap 4-mm from
the limbus and extending 1-mm from the posterior extent of the cleft. 10-0
nylon sutures are taken including the scleral spur, the ciliary body root, and the
scleral lip after creation of a circumferential full-thickness incision 1-mm
behind the limbus directly over the cleft. Mild cryo-application is used at the
end
2- Cross-chamber cyclopexy: used in aphakic eyes. Transcorneal double-armed
10-0 polyprpylene sutures are taken in the region of the ciliary cleft in a
manner similar to trans-scleral suturing of IOL using 27-gauge needle. Mild
cryo is applied at the end.
3- Iris-base fixation: 2-mm keratotomy is made in the clear cornea adjacent to
the cleft after creation of a rectangular partial-thickness scleral flap overlying
the cleft. 10-0 nylon suture is passed through the keratotomy including the iris

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base to emerge through the scleral bed 1-mm behind the limbus. Mild cryo is
applied at the end.

V- Retinal Detachment
Risk factors:
1- exudative RD associated with uveitis
2- rhegmatogenous RD due to needle perforation

Diagnosis:
1- Defective vision
2- Field defect
3- Floaters or flashes of light
4- Retinal elevation: smooth with shifting fluid if exudative, but corrugated with
minimal shifting and the presence of retinal break with rhegmatogenous RD
5- U/S scan: diagnostic

Treatment:
1- Exudative RD: corticosteroids and cycloplegics
2- Rhegmatogenous RD: surgical repair (pneumatic, scleral buckle, vitrectomy)

VI- Uveitis

Risk factors:
1- secondary iridocyclitis
2- Fuch iridocyclitis
3- Pigmentary glaucoma
4- Surgical trauma

Diagnosis:
1- red painful eye
2- anterior segment: cells, flare, kps , ciliary injection

Treatment:
1- Corticosteroids: PREDENISOLONE ACETATE 1% eyedrops every hour
2- Cycloplegics: ATROPINE 1% eyedrops TDS
3- Systemic steroids in resistant cases

VII- Ciliary Shutdown


Definition: aqueous hyposecretion due to temporary interruption of ciliary function.

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Diagnosis: should be a diagnosis of exclusion

Risk factors:
1- uveitis
2- antimetabolite toxicity
3- excessive cyclocryoapplication or laser photocoagulation

Treatment:
1- Observation
2- Corticosteroids

VIII- Scleral Perforation


Risk factors:
1- previous scleral buckle
2- long axial length
3- poor retrobulbar injection maneuver
4- posterior staphyloma

Diagnosis:
1- Hypotony
2- Shallow AC
3- Negative Siedel test
4- Fundus examination: can reveal the perforation site

Treatment:
1- Observation: it usually closes within 2-3 weeks
2- Retinal cryopexy or laser photocoagulation for a retinal break

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