Anticipate complications, manage expectations, before initiating surgery

Proper precautions can be as important as surgical technique for a successful glaucoma surgery.

Issue: November 15, 2006

ByErin L. Boyle

NEW YORK — Before proceeding with surgery, glaucoma surgeons should be prepared to manage complications efficiently, which requires access to proper equipment and careful planning of follow-up schedules, said Richard K. Parrish II, MD.

Dr. Parrish outlined what he said were the best approaches to avoiding and managing surgical complications in an office-based setting in a presentation at the New Frontiers in Glaucoma meeting organized by Columbia University’s College of Physicians and Surgeons.

He said most offices have the equipment needed to deal with complications of glaucoma filtering surgery, including a slit lamp, 20-gauge needles and sterile syringes. But careful surgical scheduling and follow-up is needed.

For instance, he avoids removing sutures on the first postoperative day or on a Friday before a 3-day weekend, “unless I know I’m going to be in town and ready to deal with complications every day,” he said.

Dr. Parrish advised surgeons never to cut more than one trabeculectomy suture at a time. He said the surgeon should know where the tight suture is, based on operative notes or drawings, and cut that one first.

But no matter how prepared a surgeon is, complication will sometimes occur. To help protect against lawsuits, practitioners should be aware of the potentially litigious aspects of treating glaucoma patients, said Donald S. Minckler, MD.

Dr. Minckler said he was involved in a “bitter” medical malpractice lawsuit, lasting more than 7 years, which taught him about the legal process. Based on his experiences, he recommended that physicians learn and understand the common issues that cause patients to file malpractice suits, which can include physicians’ delays in performance, failure to treat, improper diagnosis, and failure to supervise or refer.

“Patients may come to you with unreasonable expectations,” Dr. Minckler said. “Problematic cases should be sent to a glaucoma specialist if you aren’t one, and even if you are one it does not hurt to spread the liability. If you engage a specialist, communicate with them.”

He said doctors can protect themselves by keeping detailed records, ensuring that their staff treats patients properly and addressing any adverse events in an honest and timely manner.

Different trabeculectomy flaps involve tradeoffs

When medication fails, and progression is detected, specialists need to consider advantages and disadvantages of surgical options. For example, two approaches to trabeculectomy flap creation are each effective for different reasons, noted Celso Tello, MD.

Dr. Tello discussed the tradeoffs involved in using limbus-based or fornix-based trabeculectomy flaps. He said that, despite the introduction of a number of nonpenetrating glaucoma surgical procedures in recent years, trabeculectomy is still the most commonly performed glaucoma procedure.

Limbus-based flaps offer a more secure and watertight wound closure. However, they are also more technically difficult to perform and require an experienced assistant, he said.

“Healing of the incision can limit posterior flow of aqueous and increase the likelihood of a small, focal and thin-walled bleb,” he said.

Fornix-based flaps produce a low-lying and diffuse bleb and are technically easier, with better exposure, he said. They also allow gentler handling of the conjunctiva, preventing damage to the tissue.

“The disadvantage is, it’s more difficult to obtain watertight closure,” he said.

Two-site combined trabeculectomy-phaco

Two-site combined trabeculectomy/phacoemulsification/IOL procedure is another surgical option that can lower IOP more than a single-site combined procedure, according to a study presented here.

Gregory L. Skuta, MD, conducted a retrospective chart review evaluating the two-site combined procedure in 60 eyes of 55 patients. He also compared the results with single-site trabeculectomy and cataract surgery in 100 eyes of 89 patients.

Dr. Skuta found that complications were minimal for both single- and two-site combined surgeries. However, the two-site procedures more effectively reduced IOP. At 1 month follow-up, IOP averaged 10.5 ± 3.7 mm Hg in the two-site group, compared with 12.2 ± 5.7 mm Hg in the single-site group. At 24 months, IOP averaged 11.9 ± 4.4 mm Hg in the two-site group, compared with 14.5 ± 4.6 mm Hg in the single-site group, he said.

Performing two-site trabeculectomy requires less manipulation of the conjunctiva and sclera, Skuta said. It also allows phacoemulsification energy to be delivered in a separate surgical quadrant, away from the site of the trabeculectomy, he said.