ALL ABOUT GLAUCOMA SURGERY: TRABECULECTOMY & SCLERECTOMY

The greatest benefit of glaucoma surgery is the normalization of intraocular pressure. If it is not controlled, the patient could experience a progressive and irreversible loss of vision.

Trabeculectomy or deep sclerectomy are the surgical options available for treating glaucoma. Both are highly effective, safe, and outpatient procedures.

What is Glaucoma?

Glaucoma is a chronic and progressive deterioration of the optic nerve that can cause vision loss and blindness.

The optic nerve is made up of nerve fibers at the back of the eye that carry visual signals from the retina to the brain, where we interpret them as images.

Glaucoma is mainly caused by a build-up of pressure in the eye when fluid can’t drain properly. This increase in pressure is what damages the optic nerve. Indeed, glaucoma is the second leading cause of blindness worldwide.

Many risk factors have been described for glaucoma’s development, including age (over age 60), genetic predisposition, ethnicity (Hispanic), high blood pressure, diabetes, short-sightedness, and long-sightedness.

A previous eye injury can also result in getting glaucoma.

Medically reviewed by Dr Osama Bahsas Zaky
Written by Joaquín Pineda
Updated on October 19, 2021

What is Glaucoma?

Types of Glaucoma and Symptoms.

Techniques Currently Used.

Which Patients Should Have Surgery?

Deep Sclerectomy vs Trabeculectomy.

Risks Involved in Glaucoma Surgery.

Ahmed Glaucoma Valve Surgery.

Success Rate for Glaucoma Surgery.

Preparing for Surgery.

Recovery After Glaucoma Surgery.

Glaucoma Surgery Cost.

FAQS About Glaucoma Surgery.

Types of Glaucoma and Symptoms

There are different types of glaucoma. The most common type is primary open angle glaucoma, which tends to develop slowly over many years.

Other types of glaucoma include:

  • acute angle closure glaucoma – is not very common. The drainage in the eye becomes suddenly blocked, raising the eye pressure very quickly.
  • secondary glaucoma – is secondary to underlying eye disease, such as inflammation of the eye (uveitis).
  • childhood glaucoma (congenital glaucoma) – is a rare type present in very young children, caused by an eye abnormality.

A few glaucoma types show warning signs, but most types of glaucoma don’t present with any symptoms. Because it happens so slowly, many patients can’t notice that their vision is changing at first.

Over time, you may start to slowly lose vision, mainly your side (peripheral) vision — especially the vision field closest to your nose.

Also, it is possible to have different stages of glaucoma in each eye. One eye may already be compromised at an advanced stage.

Proper testing is essential to determine whether you have the disease. You can’t prevent glaucoma! This makes it crucial to have routine eye exams done by your eye doctor every two years at least.

The only way to determine if you have glaucoma is to get a comprehensive dilated eye exam. Your doctor will check eye pressure and examine the optic nerve.

Also, the exam will include a visual field test to check your side vision.

What Techniques Are Currently Used for Glaucoma Surgery?

When glaucoma is diagnosed, it must be treated immediately! If not treated on time or adequately, glaucoma can lead to blindness.

Before opting for glaucoma surgery, medical treatment such as antihypertensive medication or eye drops is normally used. Another option is glaucoma treatment using a laser.

Laser treatment may be the next step if eye drops don’t improve your symptoms.

Laser surgery for glaucoma uses a high-energy beam of light aimed at the trabecular meshwork (the eye’s drainage system) to stop fluid from building up inside it.

There are different techniques:

  • Argon laser trabeculoplasty (ALT): a laser is used to widen the drainage tubes within your eye, allowing more fluid to drain out, reducing the pressure inside.
  • Cyclophotocoagulation: a laser is used to destroy selected eye tissue that produces the liquid.
  • Laser peripheral iridotomy (LPI): you can develop narrow-angle glaucoma if the space between the iris (the colored part of the eye) and cornea (the clear outer layer) is too small. In this case, LPI creates holes in your iris to allow fluid to drain from your eye.

Laser treatment is usually performed while you’re awake. Local anaesthetic drops numb your eyes – you may just feel slight discomfort or heat during the procedure.

The glaucoma specialists will propose the adequate option for you, whether medical, laser treatment, or surgery.

Which Patients Should Have Glaucoma Surgery?

Trabeculectomy or deep sclerectomy can effectively lower eye pressure when medication is not enough, or you can’t tolerate them.

Indeed, if glaucoma eye drops cause you severe side effects like rapid heartbeat, high blood pressure, or impotence, you may want to give surgery a try.

On occasions, laser treatment is unsuccessful, unavailable, or contraindicated. Hence, in the case of advanced glaucoma, the best option is surgery (trabeculectomy or deep sclerectomy), as it offers more reliable and effective control of eye pressure.

Some patients need it right away as a first choice if their eye pressure is dangerously high and puts their vision at risk.

However, the patient should know that glaucoma surgery will not result in vision recovery. The damage to the optic nerve is irreversible, and the nerve fibers can’t be regenerated.

What Are the Differences Between Deep Sclerectomy and Trabeculectomy Surgery?

Currently, there are different types of surgery. The glaucoma specialists must do a personalized follow-up for each case and choose the technique that best suits the patient.

Factors that influence the decision are the patient’s age (healing wound potential), previous surgery or eye conditions.

The most common technique is trabeculectomy. It is considered the surgical “gold standard” for primary open-angle glaucoma and primary angle-closure glaucoma.

Trabeculectomy, also called filtration, involves creating drainage or a fistula that allows the liquid (aqueous humor) to flow out of the eye.

This new opening allows the intraocular fluid to effectively bypass the clogged eye drainage canals and flow out using this new, artificial drainage passway.

Trabeculectomy is the most common surgery, but it is riskier than non-penetrating deep sclerectomy. The latter creates a new outflow pathway for the drainage of fluid (aqueous humor) while maintaining the integrity of the eye’s anterior chamber.

Deep sclerectomy is a minimally invasive procedure that keeps a very thin membrane that allows the aqueous humor to come out, but in a more controlled way and with fewer complications.

A complete opening is not made, so sudden decompression is avoided. The postoperative period is much easier, and recovery is faster.

In both cases, for the surgery to be successful, it is necessary that the newly created duct remains permeable and that it drains the right amount of aqueous humor.

What Risks Are Involved in Glaucoma Surgery?

Any surgery presents two main risks, infection and bleeding. In glaucoma surgery, these complications are unusual.

The biggest challenge is scarring and wound healing.

The ability of a normal healthy body to heal wounds means that the fistula created to drain the aqueous humor gets healed. Therefore, the outlet made during surgery gets closed, causing the eye pressure to increase again.

The body tries to heal the new eye-opening as if it were dealing with a wound. This “fast wound healing” is more frequent in younger patients.

When your doctor performs trabeculectomy surgery, they most likely apply an anti-scarring substance called Mitomycin (MMC) or 5-Flurouracil (5FU) to the tissues of your eye to slow down the closing of the opening and reduce surgical failure.

Hence, the benefits of glaucoma surgery could last a long time. For other patients, though, if the opening in the eye begins to close, the intraocular pressure will increase, and they may need surgery again.

On the other hand, if the aqueous humor flows out excessively, the intraocular pressure will go down too much, causing ocular hypotony.

Regular check-ups with your doctor are mandatory to test your eye pressure. It is possible to perform filtration surgery for glaucoma several times on the same eye if necessary.

Also, surgery may increase cataract formation. Sometimes glaucoma surgeries can be combined with cataract surgery if your ophthalmologist deems adequate.

Ahmed Glaucoma Valve or Glaucoma Implant Surgery

Implantation of Ahmed glaucoma valve is a practical surgical approach to reduce intraocular pressure in glaucoma patients.

A few years ago, the use of this device was reserved for glaucoma refractory to multiple filtration surgical procedures. However, new research has encouraged its use also as a primary surgery for selected cases.

This surgery is used to treat several types of glaucoma, including congenital glaucoma, neovascular glaucoma, and glaucoma secondary to trauma.

Also, tube shunts have become really popular for use in younger patients whose more vigorous healing response can jeopardize the success of trabeculectomy.

Aqueous shunt devices (glaucoma implants) are artificial drainage devices with plastic microscopic tubes attached to a plastic reservoir.

The reservoir is placed right beneath the conjunctival tissue. The actual tube (attached to the reservoir) is placed inside the eye to create a new pathway for fluid to exit the eye. This tube helps extra fluid drain out of your eye, lowering your eye pressure.

The surgery usually takes between 1 to 2 hours.

Although the valve mechanism in the Ahmed device decreases the risk of postoperative hypotony-related complications, it does not avoid the need for a careful follow-up.

What Is the Success Rate for Glaucoma Surgery?

New research indicates that in older patients, filtration surgery for glaucoma (trabeculectomy or deep sclerectomy) is successful in about 70% to 90% of the cases, at least for one year.

Preparing for Surgery.

Before surgery

In general, trabeculectomy or deep sclerectomy is an outpatient procedure that doesn’t require overnight hospitalization.

It is essential to verify the coagulation status of the patient before surgery to avoid complications. In case of taking aspirin or blood thinners, they must be stopped a few days before surgery.

Is glaucoma surgery painful?

It is not painful. Surgery is usually done under local anaesthetic with additional intravenous sedation if needed.

Local anaesthesia will stop the eye muscles from moving. You will feel relaxed and drowsy and won’t feel any pain or discomfort during the surgery.

How Is the Recovery After Glaucoma Surgery?

The immediate post-surgery period

Immediately after the surgery, the eyes will be red, itchy, and watery.

Within a few days after the surgery, the specialists will need to check the eye pressure. The doctor will also check for signs of infection or inflammation.

For at least one week after the operation, try to avoid putting the eye in contact with water.

It is possible to carry out most daily activities. However, it is important to avoid driving, reading, reclining, and lifting heavy weights for the first weeks.

The first month

We can’t say that the surgery has been a success until a month after the intervention.

The risk of the fistula closing will still exist, and even some years after the intervention, which is why the intraocular pressure must be closely monitored.

For several weeks, you must put drops in your eyes to avoid infection and inflammation.

About six weeks after the surgery, you may experience blurred vision. After this period, your vision will generally return to the same level as before the intervention.

It is possible that patients who used pilocarpine experience a partial visual recovery. After stopping using pilocarpine drops, the pupil may return to its normal size, which would allow a greater amount of light into the eye.

After the surgery, you may have to change your contact lenses or glasses prescription.

You will need about a month for a full recovery. Quicker recovery periods last about three weeks.

How Much Does Glaucoma Surgery Cost?

Glaucoma surgery cost depends on the performed technique (trabeculectomy or deep sclerectomy).

Please, fill in the contact form. If you have any medical reports or examination results from other centers, we would appreciate it if you could send these tests to us by email so we can offer you the solution that best suits your needs.

You can be sure that this information will always be treated with maximum confidentiality.

FAQS about glaucoma surgery:

In the initial phase, glaucoma may be only present in one eye, but ultimately it will affect both of them. It usually develops at different speeds in each eye.

In general, eye surgeries are done with a period of four to six weeks between one eye and the other.

Not necessarily. High pressure inside the eye means that you are at risk of developing glaucoma, but it doesn’t mean you have the disease. A person only has glaucoma if the optic nerve is damaged.

Yes, glaucoma can develop without an increase in the pressure inside the eyes. This type of glaucoma is called low-tension or normal-tension glaucoma. It is not as common as closed-angle glaucoma.

The risk of glaucoma is higher after 60 years of age, but it is good to have check-ups as of 40 years old.

Qualified personnel is placed at your disposal, and they will advise you in your language and accompany you during the hospital process. If the doctor does not speak your language, a personal interpreter can accompany you throughout all your visits.

In general, trabeculectomy or deep sclerectomy is an outpatient procedure that does not require spending the night in the hospital.

International patients should anticipate a stay of 10 days in Barcelona (Spain) for the postoperative tests. These visits and tests are completely free.

Best glaucoma specialists at Barraquer Eye Hospital

Doctor Rafael I. Barraquer

Doctor Rafael I. Barraquer

Doctor Mª Isabel Canut

Doctor Mª Isabel Canut

Doctor Francisco Ruiz Tolosa

Doctor Francisco Ruiz Tolosa

Doctor Bachar Kudsieh

Doctor Bachar Kudsieh

External links – Bibliography

Efficacy of Ologen matrix implant in Ahmed Glaucoma Valve Implantation. Sastre-Ibáñez M, Cabarga C, Canut MI, Pérez-Bartolomé F, Urcelay-Segura JL. 2019 Feb 28

Anterior segment changes following intravitreal bevacizumab injection for treatment of neovascular glaucoma. Canut MI, Alvarez A, Nadal J, Abreu R, Abreu JA, Pulido JS.Clin Ophthalmol. 2011

Neovascular glaucoma treatment with extraction of anterior chamber fibrovascular tissue. Nadal J, Carreras E, Kudsieh B, Canut M.JAMA Ophthalmol. 2013 Aug

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