I. List the indications/contraindications
A. Indications
1. Increased intraocular pressure unable to be controlled medically, and which is high enough that risk of progressive optic nerve damage is expected to occur
B. Contraindications
1. Active anterior segment inflammation
2. Active surface infection
3. Poor visual potential (relative contraindication)
II. Describe the pre-procedure evaluation
A. History
1. Course of pressure rise (rapid, gradual)
2. Previous eye surgery/trauma
B. Medical history
C. Medications (ocular and systemic)
D. Comprehensive eye examination including refraction and dilated fundus examination
1. Special attention should be paid to concurrent conjunctival disease; cataract that would require concurrent extraction
2. Extra special attention should be paid to the status of the conjunctiva
3. If no view of posterior segment, B-scan is required to rule out retinal detachment and intraocular mass
E. Decision regarding type of surgery
1. Filter
2. Seton
3. Other
4. Gonio membrane stripping, “non-penetrating surgeries”
III. List the alternatives to this procedure
A. Oral or topical medications
B. Laser trabeculoplasty is contraindicated
IV. Describe the technique
A. Pre-procedure
1. Increased, prophylactic use of corticosteroids may be desired (topical, regional, systemic, or combination) to decrease incidence of post-operative flare up and enhance success
2. Discuss realistic outcome expectation with patient and family
3. Possible continued need for medications
B. Procedure
1. Anesthesia
a. Topical
b. Peribular
c. Retrobulbar
d. General
2. Approach
a. Filter
i. Limbus versus fornix based flap
ii. Antimetabolite usage
i) Mitomycin-C
ii) 5-Flourouracil
b. Seton
i. Valved versus non-valved
C. Pathologic examination should be carried out on removed tissue including iris and/or trabecular meshwork
V. List the complications of the procedure/therapy, their prevention and management
A. Intraoperative
1. Expulsive hemorrhage
a. Prevention: Small wound; Counsel patient regarding need to avoid Valsalva; Ensure patient’s use of prescribed antihypertensives on morning of procedure.
b. Management: Close the eye. Intraoperative retina consult. Consider posterior sclerotomies to relieve pressure after eye closed
2. Hyphema
a. Prevention: Minimize iris trauma
b. Management: Bleeding will stop. Irrigate gently to regain visualization, if needed
3. Conjunctival button hole
a. Prevention: Use non-toothed forceps; gentle handling of conjunctiva
b. Management: depending on location, excise if near conjunctiva edge, if not, suture
B. Post-operative
1. Endophthalmitis
a. Prevention: Treat blepharitis pre-operatively; pre-operative 5% povidone-iodine solution to conjunctival fornix
b. Management:retina consult, intravitreal antibiotics
2. Retinal detachment
a. Management:retina consult
3. Hypotony
a. Prevention: avoid wound leaks by adequate suturing
4. Increased intraocular pressure
a. Management: aqueous suppressants, may be hypertensive phase of seton, suture lysis
5. Corneal decompensation
a. Management: topical corticosteroids, hypertonic saline, consider toxic reaction versus endothelial damage due to procedure
6. Ptosis
a. Prevention: Avoid excessive pressure from speculum
b. Management: observation, oculoplastics consult
7. Cystoid macular edema
a. Management: topical corticosteroids, non-steroidal anti-inflammatory agents, regional corticosteroids
8. Uveitis flare up
a. Prevention: control inflammation pre-operatively, if possible
b. Management: treat as appropriate
9. Wound leak
a. Prevention: adequate suturing in operating room
b. Management: aqueous suppressants, bandage contact lens, patch eye; wound revision
VI. Describe the follow-up care
A. Post op examinations frequently during first 90 days, based on condition afterwards
B. Topical corticosteroids
C. Topical antibiotics
D. Protect eye (shield, glasses)
E. Limit strenuous activity for initial postop period
VII. Describe appropriate patient instructions
A. Inform the ophthalmologist of any worsening in visual acuity (VA), pain, redness of eye
B. Stress compliance with medications, limitations, and follow up visits
C. Provide instructions for contacting office in emergency, including after hours
Additional Resources
1. AAO, Focal Points: Management of Glaucoma Secondary to Uveitis, Module #5, 1995.
2. AAO, Basic and Clinical Science Course. Section 9: Intraocular Inflammation and Uveitis, 2004-2005.