Information about trabeculectomy

[AmanGrover]

So here is my old post about my injury leading to glaucoma - https://www.medhelp.org/posts/Eye-Care/Blunt-trauma-to-the-eye-while-playing-badmintonfollow-up-to-another-question/show/3028625

So today after almost 2 months of my injury, my eye swelling has come down considerably, redness is gone, blood cells have almost dissolved, vision is almost ok(as the Opthalmologist said, they can save about 90-95% of my vision).
But the most important thing is, my eye pressure even after 2 months of medication hasn't come down. I just went to my Opthalmologist yesterday and the he specifically told me to not take any medication a day prior to my checkup to see what my pressure is without the medication. By the way, I was on glycerol os solution for the past 2 weeks(4 tbspns 2 times a day). So my pressure when I was taking that medication was around 23-24 mm hg, and yesterday without glycerol it was around 27-28 mm hg. So the Opthalmologist suggested my eye pressure is not coming under controlbwo they need to to trabeculectomy surgery. He also told me there is no guarantee that the surgery will solve my problem of high IOP. And after searching online a bit, I am very scared and confused as to what should be done next. Ofcourse I will be taking a second opinion from another Opthalmologist before deciding anything, but what I have found online is that this kind of surgery is generally not successful in younger patients and also can lead to several complications and infections(I am 26 yrs old as of now). I am really confused if this surgery is the way to go? How safe is it? What's the assurity that the eye pressure will be in control after this? How long does it take to recover from this surgery? Will I be able to lead a normal life after this(like I was a very active person prior to my injury, I played badminton and was a regular in my gym). Can patients after this surgery continue to play and have an active life in future?

[John C Hagan III, MD, FACS, FAAO]

You have a severe problem with a guarded prognosis. The surgery would be regarded as high risk but leaving your IOP where it is now almost assuredly will lead to loss of vision in the eye.  A trabeculectomy is  an old operation dating to the 1970's.  The newest thing in glaucoma surgery is MIGS  (minimally invasive glaucoma surgery  or some say micro-invasive)  It inserts tiny drainage valves into the eye. It safer and more predictable.  Many older glaucoma specialists cannot or do not do this type of surgery. So I would suggest you find a glaucoma specialist that does MIGS surgery and get a consultation from that person.  No surgery is without risks and your situation involves major risks with or without surgery.   In our area (Kansas City Missouri USA) virtually none of the glaucoma specialists do trabeculectomy's anymore.

[AmanGrover]

Thanks for the reply. As I have read on the internet, trabeculectomy tends to fail with younger patients, is it the same with MIGS?

[John C Hagan III, MD, FACS, FAAO]

No MIGS is a whole new generation of devices/surgery.  Much better/safer than trab     Also would allow much more activity post MIGS surgery and be a much stronger eye in case of blow.   Where do you live? Do you have access to full service glaucoma specialists?

[AmanGrover]

I live in India, and yes, since my injury, I have been visiting a top glaucoma specialist in my area. I haven't enquired about the surgical procedures he would use because I just want a second opinion before deciding anything. So in the coming 2 days I would be visiting another glaucoma specialist and I would consult him too(that if the surgery can be avoided in any ways, which I think has very low possibility). One thing I have been meaning to ask is, are there any special care that u would have to take after the surgery(of course I would be on antibiotics and steroids immediately after the surgery, but I am asking about the long term)?

[AmanGrover]

Follow up on the last comment - like they say the patient after such surgery shouldnt lift heavy weights and such, is this applicable even in the long term?

[John C Hagan III, MD, FACS, FAAO]

I think it a fair question to ask any glaucoma consultant if they do MIGS, then what type. There are many MIGS devices. Some like IStent are not approved for severe glaucoma while others are so you would want something for severe.  Most modern glaucoma surgeons use several devices.    You could also ask your retina surgeon if he can recommend a full service glaucoma specialist he respects.   No one is going to want you to stand on your head, do full contact sports (e.g. soccer) or lift ultra heavy weight-lifting.   Your glaucoma surgeon will have to advice you the specifics.  Very unlikely you can get along without glaucoma surgery, you cant take glycerol the rest of your life.

[AmanGrover]

Thank you doctor, one more thing I wanted to ask is, I have been prescribed Pred Forte eye drops which I believe are corticosteroids, and that can also cause an increase in IOP if used for longer periods of time? I have been using those eye drops for the past 2 months daily, 4-6 times a day.

[John C Hagan III, MD, FACS, FAAO]

Yes, it is quite possible you have at least some IOP increase due to the steroids. That is called steroid glaucoma.  There is a drop called Lotemax that is less likely to raise the IOP.  I don't know if it is available in India but I would assume it might be obtained.  Steroids are for inflammation. You might ask your ophthalmologists why you have to stay on the steroids so long.

[AmanGrover]

So, do you believe that may also have affected my elevated IOP? I was also on Wysolone tablets for the last 2 months. For the first month i took 60mg and gradually reduced it to 10 mg last week, and completely stopped taking it from last Saturday.

[John C Hagan III, MD, FACS, FAAO]

I can't examine your eye to see how much inflammation there is or look at how the fluid is draining out of your eye.  And there is no specific test for steroid glaucoma/steroid responders.  But it is highly likely it is contributing to some of the IOP elevation. Steroid drops are much more likely to cause steroid glaucoma than oral or injected steroid.

[AmanGrover]

Thanks a lot again. I was previously prescribed Nevanac eye drops by a different Opthalmologist but when I went to a glaucoma specialist he substituted it for Pred forte. Does Nevanac also work the same way as Pred forte(I mean, are they both used for same purpose? As I believe Nevanac are non steroidal eye drops)?

[John C Hagan III, MD, FACS, FAAO]

Nevanac is an anti-inflammatory that does not cause steroid glaucoma. It is related to NSAIDs medicine like Motrin/Advil/Aleve.  It is also used to prevent swelling in the macula post surgery. It is not as strong of anti-inflammatory med at PF.

[AmanGrover]

Can permanently dilated pupil due to an injury to the eye also cause elevated IOP and ultimately lead to glaucoma ?

[John C Hagan III, MD, FACS, FAAO]

No not the pupil but the injury is usually associated with damage at the base of the pupil in the filtration angle.  That can cause angle recession glaucoma and often accompanies traumatic iridoplegia.

[AmanGrover]

So it won't make a difference on IOP even if the pupil is constricted? I am asking because I went to a different Opthalmologist, and he may be the topmost in my country, and he said an IOP of 27-28 can be controlled with medication and the eye shouldn't be operated on. So he increased my glycerol dose for now and asked me not to put homide in my eye, and prescribed pilocarpine 2%. I read somewhere pilocarpine is used to constrict the pupil? And also for better flow of liquid inside the eye to reduce the IOP? He did my field test and OCT and said everything looks fine, optic nerve and retina are absolutely fine. That maybe the only reason he feels there should be no surgery done since it involves a lot of complications.

[JohnHaganMD]

I don’t have much more to say about your situation. Homide dilates the pupil and pilocarpine constricts it.  I have never prescribed both at the same time and wonder why is being done now? Also pilo is normally not prescribed in an inflamed eye as it can make inflammation worse and in a traumatized eye can cause retinal detachment.   I have absolutely no explanation for that choice of drops especcially from a ‘top expert”.  You may want to run that by your other ophthalmologists. Or see another glaucoma specialist.  

[AmanGrover]

An update on my condition.  6 days ago when I went to my OP he measured the pressure to be 34, so my condition was getting worse. He prescribed Latonoprost RT with pilocarpine( at bedtime, Latonoprost first and pilocarpine 1 hour after) as a last resort, and he said if the pressure is still not under control he will need to operate on the eye. So I took Latonoprost and pilocarpine for 3 days and on the 4th day when I went to my OP again, the eye pressure was reduced considerably. He measured it to be 18 mm Hg and has prescribed I take it another 4 days.

[John C Hagan III, MD, FACS, FAAO]

Okay best of luck