Chapters Transcript My Best and Worst Trabeculectomy Course: Current Concepts of Ophthalmology 2025 All right, so, so what, what's The reason I, I kind of came up with the title for this talk is actually our fellow came back from, uh, is it IGC now, Interventional glaucoma, and that's, that's what everybody's doing these days. So he came back and he said, uh, they presented a bunch of videos on microinvasive glaucoma surgeon. I think Ike at the end of every single one said, why did that patient not have a tuberculectomy? And so I actually just texted Ike like 3 minutes ago and he gave me a bunch of like happy face emojis that we're gonna talk today about tuberculectomy a little bit here, so. Uh, financial disclosures, none of these companies, uh, do anything with tuberculectomy. Uh, what have I learned over the last 1015 years doing tuberculectomy, uh, a lot, a lot of things that have kept me up at night. Um, you know, I think TRB does get a, uh, a pretty tough, uh, um. Evaluation when you, when you talk to lots of docs out there, everybody will tell you about the complications associated with it. But you know, I, I think everybody up here would agree it's still the go to surgery for many, many surgeons, for those patients that need a very low intraocular pressure to prevent further visual field loss. And so, uh, I think it's, it's imperative that we continue to teach it and we continue to teach it, uh, so that our trainees can be performing this, you know, 1020 years down the line, down the line, even though we have so many. Great new, you know, advances in the field of glaucoma. And so again, easier said than done. trabeculectomy, I would argue is proven. It is inexpensive, it is effective, it is long lasting. It is not easy. It is not predictable. It is not reproducible and is not minimally anything. Um, lots of things I think that you should pay attention to. It's all about pre-op. I think I, I can't stress that enough ever with all the trainees. Your pre-op evaluation of the patient makes such a difference, so. Understand the refractive error, their axial length, eyes that are longer, could have thinner tissue, could be harder to work with. Look at their prior surgery. You never want to get in there and find out that this person had prior prior strabismus surgery or say a scleral buckle. Look at the lens status. A lot of our patients will. need cataract surgery and that can doom your really nice filtering bleb, uh, keep an eye on the, the macula. I, I would argue that I'm starting to look at this a little more carefully. A lot of patients who have macular pathology, it could be exacerbated, um, with the early hypoteny that you get with tuberculectomy. I like to block the patient. I'm curious. Doctor Prince, are you a, are you a fan of everybody else up here blocked berculectomies or are we doing just the this subcon or local thing? You, you know I love a good block. That's because you have to do everything I've taught you. Yeah, yeah, exactly, uh, I've been doing, uh, just something on at the site. Yeah, yeah, I, I, I think, I think you wanna do whatever you do, you wanna do so that the patient is comfortable. I think that is paramount when you're doing a complex surgery like this. I do think another, another thing for the residents, make sure you do learn how to block before you finish your residency. Um, I like to keep the incisions small, but I have enough room to work with. I like to keep my flap size consistent. I like to maintain my depth and I have a controlled osteon creation. I do like a really tight flap because I do think that makes a lot of the post op management a little bit easier. And so for, you know, those in the audience not familiar with tuberculectomy, it's, it's really as simple as it's a hole in the eye with basically a trapdoor on top of it that we're trying to titrate how open it is so that we can regulate the pressure inside the eye. And so in terms of flap creation, flap size, thoughts, John. Again, whatever I do. Yeah, you know, I'm, I'm JP Junior, uh, but no, no, I just talk a little bit. I need to feel better about myself. No, no, I, I talk slower but uh I'm essentially you'll get there, don't worry, you'll get there. But yeah, I, I, I don't know because Punna taught me another way, you know, two suture flops. I'm kind of In between, leaving a little bit of flow, but I do like, especially if I'm worried about a little bit of follow up issues, uh, having a tight flap or Ariana. I do about a 4 by 4 flap with two releasable sutures that are tight. Andy. I was uh trained with a square flap and a triangular flap, so I migrated to a trapezoidal. So, but I, I love that point because I will say that one of the things I felt like with tuberculectomy and I have up here. You know, I think tuberculectomy is a wonderful surgery if you are comfortable with it, but I will tell you, my 1st 3 years in practice, I was so uncomfortable with it. I, I love doing it now. I feel like it is an art form. I will say that, you know, when I look at the patient sitting right in front of me, I feel very comfortable telling them I think they need atrab, but I will tell you, my 1st 3 years out in practice, I did not feel that way. I varied my technique tremendously and so you'll see me here. I agree trapezoidal flap about 3.5 millimeters by 3 millimeters back from the limbus. I like it pretty broad base because I think we've all would agree that Pena, kind of the master of tuberculectomy, has taught us that we want these, these traps that have really diffuse posteriorly directed flow. So Yvonne, your thoughts? What did you guys do up at Cornell? Um, we did a rectangular flap. Yeah. All right. So I like this. This is the trapezoid. It's about 3.5 by 3. This I think is the hardest part of the surgery. This is where we're creating the flap. The, the key here is you don't wanna be too deep, but you don't wanna also be too thin. It's, it's like Goldilocks. We gotta be perfect when we're doing this step, and I think this is really. Just something that you residents can go to the wet lab and practice this. I, I know it won't feel like it's like you're doing much, but just getting comfortable with the blades, getting comfortable holding the tissue and understanding how to do this because this is crucial. I think the worst thing here is a thin flap, and I'm curious, anybody else thoughts on that? And John, why do I not like a thin flap? Hypoteny hypoteny. There's no way to. There's a hole here and on top of this hole is gonna be a flap that's that's keeping this closed. If the tissue is very thin, that that fluid is gonna permeate out through that very thin flap. So I like to pre-place my 100 ylon sutures because once we make this hole in the eye, the eye is gonna collapse, and this is probably the scariest moment, uh, for a lot of us. So here we are. I'd like a controlled osteon creation like that, and then we'll make a small iridectomy, uh, because if you take too much of the iris, it looks really bad the next day. So and it. We've all done that. I see you shaking your head. Yeah, no iridectomy on pseudohaca. OK, you don't. OK. Do you use Visco, Andy, during this? Yeah, so that's a big question is maintaining the eye during this surgery. So I think a lot of the big fear is, you know, the collapse of the eye as we're trying to sort of do this, you know, somewhat controlled procedure. So some people will keep an AC maintainer, some will keep viscoelastic in the eye. I personally do not like any viscoelastic. I wanna see if I can titrate this entire procedure just under balanced salt solution, so. You'll see here I like the flap tight. So what we're talking about is this step here, making sure that these sutures create, you know, a water tight seal such that when we close the conjunctiva, um, it has some time to heal and we don't have any actual limbo leaks and so curious, Ariana, you, did you guys learn in a similar way or do you guys like a little bit of flow here? Uh, I aim for tight, uh, we would. Do a little bit of flow looking for an IOP uh in the high teens, low twenties by the end of the case, but I do aim for tight sutures. Yvonne, how about you guys? Yeah, I think I would agree, um, definitely very tight at the end of the case, but we'll see if that we would get like a little bla before. All right, so, so for the trainees, I think this is kind of the way we all are doing it now. So you can either take a limbus-based approach or a Fornic-based approach, and as we all will sort of laugh at, it is the complete opposite. So most of us will take a Fornic-based approach, meaning that we're opening up the conjunctata at the limbus, and the reason we do that is that when you do that, you do tend to get more posteriorly directed flow and you get better blebs long term. The trick though is the fact that you gotta get that area at the limbus to seal because if it doesn't seal well you're gonna have a leak and if there's fluid leaking out right there at the at the limbus where the tissue is sutured secure, you're not gonna get height to your lab and you're gonna get ultimate failure. So you know I think for a lot of us we like to see very little flow through that flap so that the front edge of our wound has time to heal. So for me that's kind of how I want it done. I want to see it done that way every single time, but unfortunately that is not the case. um, you know, handling mistakes or complications in the OR is, is really. Something that is um tough to do I think early on in your career. I think uh I, I can't tell you how many times I, I have, uh, maybe I try not to let it be seen, but you lose your composure. It's, it's very hard to maintain it sometimes. Uh, you really do have to slow things down, take a deep breath, and I think ask for help. So I, I try to make sure that I'm present, uh, when some of my colleagues are doing new procedures, and I'll be honest, I ask for help if I'm doing a new procedure, and I have no problem doing that at this point in time. So if I'm doing a surgery I've never done, even if somebody else hasn't done it, I, I still prefer to have someone sitting next to me when I do it. Make sure the patient's comfortable. So again, if, if you do run into a complication even during stages cataract surgery, make sure you block that patient, get them comfortable. There's nothing worse than you feeling a little bit unnerved and the patient being uncomfortable. The whole room just gets tense. And then I even say have the staff go out and talk to your next patient. Just get comfortable and treat the patient that's sitting right in front of you. So many times we're worried about how this is gonna affect the rest of our day. You really gotta just really sit down, buckle down and focus, and that is kind of what's gonna happen here, you see for for this case I'm about to show you, so. Trebek, you like me, you can have a slew of complications. I'm gonna focus on what happened to me one time when I was creating this flap here. I've seen it all though, so I've, I've had, I always joke around, it's like the Tootsie Roll commercial where it's like 123. I saw somebody, one of my trainees just amputated the flap completely one time, which was, uh, challenging. I've, I've had people go down to the super roal space, massive high femurs. I don't know, Andy, what's the worst thing you've seen during trab? OK, yeah, it's it's, that's never fun. So I guess turn around here, see what's kind of going on here. So I'm, I'm it's pretty routine. I, I have my trap going exactly the way I wanted it to do. I'm pre-placing my sutures and I'm about to make, uh, make the ostium, um, and then move on and, and hopefully just close, move on to my next case. So the ostium is nice. I'm gonna cauterize to make sure that's a nice good opening there, and now I'm gonna start closing the flap and kind of, I don't know anybody there see what's what's already going on? Let's see if I can, sorry about that. Now we'd have to let's see. All right, so right there, anybody? Right over where the osteum is, I have a small area of perforation in the sclera, so I essentially have a ruptured globe here. I have a nice hole right on top of another hole and I gotta tell you there's nothing that. Um, is gonna make this surgery fail more than doing something like that. So I, I already know that this procedure that I told this patient that they absolutely need to keep them from going blind is likely gonna be a failure. And on top of that, I now have to be able to just get this eye closed so that I don't have this patient have something really bad happen. So curious, Ariana, what are you, what are you doing in this case? You're gonna watch me do a few things here, but I'm just, what, what would you do? I haven't seen a case exactly like this but with an amputated flap, I have patched with sclera to get the hole covered. So I'm trying to suture this and he thoughts, Andy, am I gonna get that sutured? suturing pizza dough. Yeah, I mean, I wish I knew that. I'm like I'm passing what I think are just, I mean they look like great sutures. They look, I'm like, I am happy. The problem is every time I pass the suture I made that hole bigger. I made another hole adjacent to it because the tissue was very thin over that area, so you'll see I'm, I'm trying again. I'm gonna give it a whirl. John, can you try a focal amount of cyanoacrylate glue there? I know it'd be hard not to get it more posterior in the flap, but that's the only thing I can think of it or just shutting it down, abandoning it and is also right now it's so anterior here, so anything I do, I'm gonna create what am I what am I gonna create here. It's gonna really hamper this patient. What's that you got? Astigmatism. I mean this patient had about 38 diopters of astigmatism by the time I was, I was done with this, so again. Doctor Lazar is kind enough to say how nice things come, but yeah, here I am actually taking a dry the area. I put some cyanuric glue after I slow the leak down to what I think is fairly reasonable, but I don't want to leave it like that, so I put a patch graft on top because that's gonna be horribly uncomfortable once it starts poking through the conjunctiva. So I put a piece of cornea that is, uh, split thickness half moon on top, and then I close the conjunctiva up. Uh, I learned just an absolute ton from this situation. This was a patient who I saw probably every day for the first, uh, I don't know, a week or two. This is a patient who actually came to me from outside the state where, you know, it's even, even more embarrassing as you're, uh, having probably one of the worst types of complications I've had, and it took probably about 6.5 months for the glue to fall off, all the viralls to melt and for his vision to get back to 2020, 2030-ish, um, and then at that point. I had to basically go back and start this this whole project over and put a tube in the eye, so curious in the last 2-3 minutes here, uh, thoughts on, on cases like this that you've had. I, I, I think these are humbling, but I think they're real. I think they happen to all of us. We sit up here most of the time and I think show you a lot of our best cases and how things do work out, but, um, that is really just not the case every time unfortunately. I feel like a dampened the mood. We learned such great stuff about optic neuritis, and here I am just being like, uh, we're all human. you started the talk mentioning um our trainee and it's always a discussion in glaucoma groups and conferences about how we need to teach more tribs um and I think part of it is we need to more cases to see more complications and issues and stress during surgery to be able to manage them. And with all the exciting new tech and glaucoma and new procedures um in fellowship we somehow have to find a way for our fellow to do enough traps and learn Zen and all the the tube options and all the Migs so, uh, is a challenging issue but more cases is better to learn how to manage things like this. Yeah, I also think. Hello? OK, I also think it's important the conversation you have with the patient before taking them to surgery. I love to say there are no guarantees, um, so I think that that's important too because patients they're awake and they'll talk to you or and maybe that they've had a different surgery and then they will say oh it's. That's that's an amazing point because I always will say sometimes you don't want to scare a patient out of surgery you know that they need it but if you tell them all the real risks a lot of times they they're gonna be out that door before you finish your sentence. Yeah, so it's a careful balance. I think one of the toughest parts is the post-op management is timing of the suture lysis, dealing with leaks and things like that I think also just just keeping the emotions up for a patient like that as he comes in and you know his vision is now not nearly as good. I have no idea what his pressure is gonna look like every single visit, uh, even for me just emotionally handling that case was was challenging. Uh, just to piggyback off what Yvonne said, I mean, I frame it for the patient. This is a 2 or 3 month investment for the future to try to get off drops or minimally maybe one agent long term, uh, and like you said, I'm prepping them that they're gonna have to come back maybe every 2 days, at least once a week. Uh, it's gonna be a lot of drops. It's gonna be a lot of follow up care, but that if we're successful, this is a surgery that can last a lifetime. And then the other thing I kind of get the sense if they'll be comfortable having a blab for their entire life, um, I think that's, I think those, those are all great points. I think just, just the, the final, the sort of final sum up here is you're, you're gonna have complications you have to be able to manage them in the moment and then in the postoperative period then. You know, be able to keep the patient in its, uh, as you continue to sort of fight the, the long battle and I think, uh, in the end I think this is one of the cases I'm most proud of in that, you know, I'm able to, you know, still achieve the outcome I needed down the road by following it up with subsequent surgery and I think that that's uh. You know, something that that teaching, I always tell the trainees teaching as the art of doctoring and not just how to do certain types of surgery that you know I'm still gonna have to keep doing tuberculectomy. I mean that may be burned in my brain, but you know it's still a surgery that is needed to keep people from going blind. So even though you have a bad outcome, that doesn't mean you shouldn't, uh, you know, do that procedure ever again. It just means get better at it and and sort of learn from your mistakes and that's why I try to present cases like this, but thank you all for helping me out with this. Published January 24, 2025 Created by Related Presenters Joseph Panarelli, MD View full profile
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