Operations for glaucoma

Take Home Points

Patients often say to me that they want to consider surgery in an operating room for glaucoma only as a last resort. Certainly in terms of the three main treatments (drops, laser, surgery), the one that could cause vision loss by itself is surgery. This is not very common, but it doesn’t help much to tell a person with a surgical complication that it only happens one in 100 times when they are the one. So, in general, patients do select surgery second or third in line as glaucoma treatments. But, remember that the Collaborative Initial Glaucoma Treatment Study found that surgery before anything else was at least as effective in protecting patients from vision loss as drops are. Surgery is the approach most likely to result in no need for daily medication. The decision about which of the three main treatment approaches you want to use was considered in section Which treatments are the right ones: drops, scissors, laser?see section What treatments are the right ones? Drops, scissors, laser Here, we will deal with what patients go through during the various types of glaucoma surgery, why we’d use one over the other one, and what the future holds for procedures that are now being tried out.

The main types of glaucoma surgery are trabeculectomy, tube-shunt surgery, and diode laser ciliodestruction. At the present time, eye surgeons would most often recommend them in that order, with trabeculectomy being the most commonly performed, especially for those who have not had surgery before. Let’s consider what you’d go through if you choose glaucoma surgery. Many of the events are similar with the 3 surgery types.

Pre-operatively, you would sign an informed consent form after a discussion, in which it is explained that the benefits of surgery are bigger than the risks, and that the risk of surgery is smaller than the risk you now have from the disease as it is being treated. This is a chance to ask questions and make sure that you understand the process. You will have a brief physical exam and review of your medical health and a review of what pills you now take(we need their real names and doses, not just “a blood pressure pill”, so bring along the bottles of medicine). All patients get some form of anesthesia, usually both on the eye itself and in the vein. Some doctors do this themselves with help from a nurse, while in hospitals and many surgicenters, there is a nurse anesthetist or an anesthesiologist present who monitors you during the surgery. The eye doctor and the anesthesia staff need to know if you’ve had recent health issues that could affect you during eye surgery. It isn’t that there are big effects on your heart as you might have in abdominal surgery, but the excitement of surgery can run your blood pressure up or get your heart skipping beats. We also need to assure that we don’t give you medicine that you are allergic to, or that would interact badly with your present medicines. We ask you not to eat the morning of surgery, so that in case you get an upset tummy, there’s nothing to bring up.

It is particularly important that you stop taking pills that can make you bleed more than we want during eye surgery. This includes aspirin, Coumadin (warfarin), Plavix, Eliquis, Pradaxa, Xarelto, heparin, and any multivitamin that contains vitamin E. Some persons need blood thinners because of serious medical conditions like clots in leg veins, atrial fibrillation heart rhythm, or artificial heart valves. In these cases, we have special ways to keep the blood thinning going and do the surgery anyway. But if you’re simply taking a baby aspirin or vitamins for good health, stop them as long prior to surgery as possible. Check with your medical doctor first before changing anything.

You’ll have a needle placed in a vein, both to give sedative medicine, and to be able to give you drugs in case they’re needed. You will have monitoring devices attached to you for your heart rate, blood pressure (the cuff gets tight), and oxygen level in the blood (on a finger clip). You will be flat on your back in a bed-like stretcher during the surgery, which will take less than an hour from coming into the operating room to going back to family. The area around the eye gets prepared in sterile fashion and plastic drapes stick to your face so only the eye is visible to the surgeon. You will not be able to see what is going on during the operation, though quite often you can hear what happens in the room, music, instruments being asked for, and chit chat about my beautiful grandchildren (to distract you pleasantly).

Before starting, our group gives a medicine that puts you to sleep for 5 or 10 minutes intravenously. During the brief time that you are asleep, we numb the whole area around the eyeball with a local anesthetic. You wake up in a few minutes with no feeling around the eye. You can’t move your eye, because the eye muscles on that side are paralyzed. An instrument is put in to hold your eye open, so you can’t blink the eye that is being worked on. All you have to do is try to relax and generally keep your body still. If you need to move or cough or scratch your nose, or if you’re in pain, you can just speak up and you will be taken care of by staff. It’s important not to move your arms or legs, and not to talk unless there is pain, since all that causes the eye to move. It’s not a good idea to give the microsurgeon a moving target. Some surgeons use less anesthesia, none in the vein, and only eyedrops and little injections near the eye during surgery. But, some patients don’t want to be that aware of what’s going on and receive more drugs. If you get anxious during the surgery, we can give more sedative and narcotics to stop any pain. It is rare, but some extremely anxious patients or others who cannot stay still during surgery, elect to have general anesthesia.

During surgery, the surgeon sees your eye through a binocular microscope hung over the eye aimed down at you. Also watching are one or more surgical assistants, a nurse handing instruments over, a nurse getting things for us, and anesthesia staff. In a teaching institution like ours, there are large plasma screens with your operation shown to those learning in the room. You will hear the surgeon asking assistants to cut things, hold things, and keep things moist. Believe it or not, we often have four different instruments on or in the eye at one time, so it takes a village.

Unlike general surgery, we never need to do blood transfusions for eye surgery. At the conclusion of surgery, you will most often have a patch placed on the eye to protect it for the first night. The local anesthetic blocks vision as well as feeling, so your vision would be pretty bad anyway, and the eye is much more comfortable patched that first 12 hours. It is tricky getting around with one eye patched; your depth perception is gone, so get help on stairs and curbs. Holding hands with someone friendly is a great idea anytime, but especially now.

It’s mandatory to bring someone with you to the surgicenter the day of surgery. Hospitals have rules that when you get a sedative you shouldn’t go home by yourself. For those having surgery on their better seeing eye, it is obvious that someone will need to help you the night of surgery to do all your essential things, like getting to the bathroom. Overnight admission to the hospital is no longer permitted for standard eye surgery.

For most glaucoma operations, you won’t need much pain medicine. Tylenol will usually keep you comfortable, but remember: nothing containing aspirin until you are told to restart it. The eye will be sore, especially when you look around, due to some bruising. Eyelids get swollen temporarily, and there can be a black eye as a small amount of blood can seep under the skin of the eyelid. Try to make up a better story for friends than walking into a door. The upper eyelid droops some after most surgeries (called ptosis with a silent “p”). Almost always this goes away by itself—and it keeps you more comfortable by covering the eye more as it heals. If the lowered eyelid lasts too long, a minor outpatient plastic surgery procedure can be done to raise the lid.

You will almost surely not have the same vision right after surgery as right before, but in most cases vision is back to how it was before surgery within 1-2 weeks. The blurring comes partly from microscopic particles of blood and other tissues inside the eye during this time, and unfortunately you’re looking through them. Any major worsening of your vision after surgery should be brought to the surgeon’s attention right away.

The operation changes the surface covering of the eye (conjunctiva) and there are buried stitches, so you will sometimes have a feeling that something is in the eye. We try to minimize this by making the stitches of really tiny material and material that absorbs on its own. You’ll be putting in frequent eyedrops as directed by the surgeon, and these help to smooth over the surface. Some of the drops are anti-inflammatory (they help with proper healing), while some surgeons prescirbe temporary antibiotics.

You will be given a set of written instructions with all the detailed “dos and don’ts” that the surgeon suggests. This will deal with physical activity, bathing habits, and travel. Along with this will be the emergency phone number. It is far better to call and ask a question that you think might be silly than to take a chance that you let something bad go on too long.

Except in infants, it is very rare for eye surgery to be done in both eyes on the same day.

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