Education Committee Highlights WGC-2021 | part 5.2

My Glaucoma Surgical Nightmare (Video Symposium)

Urrets-Zavalia Syndrome after GATT
Dr. Juan Jose Mura presented a case of a 46-year-old high myopic female patient, who underwent an uncomplicated GATT surgery in her right eye due to uncontrolled POAG. After six months of stable follow-up of the right eye, the patient’s left eye had an uneventful GATT surgery. Unfortunately, the exam on postoperative day 5 revealed a fixed, dilated pupil with no reaction to light and accommodation. The intraocular pressure was 14 mmHg, and gonioscopy revealed a 180-degree synechia at the inferior angle.

The diagnosis was Urrets-Zavalia Syndrome which usually occurs unilaterally despite bilateral surgery. The most widely accepted theories include iris ischemia and an acute IOP spike. Consequently, Dr. Mura performed phacoemulsification, IOL implantation, goniosynechiolysis, and pupilloplasty on the left eye. He stated that preventing Urrets-Zavalia Syndrome is difficult because the precise cause of the syndrome is unknown. It is recommended that any viscoelastic substance be cleared meticulously and that only a small amount of air in the anterior chamber is needed. Dr. Mura believes that he used an excessive amount of air in this patient, resulting in short-term blockage, IOP rise, and iris ischemia, which caused the problem.

Late trabeculectomy surgical revisions
Dr. Sameh Mosaed discussed bleb-related complications following trabeculectomy surgery, including tenon encapsulation, conjunctival thinning, avascularity, mechanical breakdown of the bleb, and medication-induced conjunctival compromise.

She discussed the elements that contribute to encapsulated, necrotic blebs such as focal application of MMC, limbal-based trabeculectomy, inadequate subconjunctival dissection, and excessive MMC duration/concentration.

In case-based discussion, Dr. Mosaed showed several bleb revision techniques such as conjunctival advancement, overhanging bleb excision, autologous tenon’s graft, and double-thickness scleral graft revisions.

She concluded that trabeculectomies do age and have a 1%/year risk of blebitis/endophthalmitis. Thin-walled, avascular, encapsulated blebs are particularly vulnerable, and leaky blebs must be avoided. She advised performing a thorough inspection and seidel test when necessary, as well as exercising caution with intravitreal injections, speculum implantation, automated blepharitis treatments, femtolaser, and other conjunctival manipulation in eyes with trab.

Surgical nightmares
Dr. Augusto Paranhos presented a 70-year-old male patient with bilateral chronic angle closure glaucoma with plateau iris configuration. He performed combined phacoemulsification and trabeculectomy surgery in both eyes. However, the patient developed a kissing serous choroidal detachment in one eye after day 15 of the surgery. Dr. Paranhos discussed the possible etiologies and available treatment options in the presented case.

My glaucoma surgical nightmare
Dr. Esther Hoffman presented two cases of complications following two different glaucoma surgeries. The first case was a three-year-old patient with advanced congenital glaucoma who underwent a routine probe trabeculotomy. Four days following surgery, the patient presented to the clinic with a suprachoroidal hemorrhage. Despite a successful sclerotomy and a controlled IOP, the patient lost vision after 12 months. Dr. Hoffman discussed the etiology and risk factors for the occurrence, emphasizing the importance of a treatment guideline.

In her second case of post-trabeculectomy conjunctival dehiscence, she displayed repeated attempts to repair the conjunctiva with patch grafts, tight suturing, and bandage contact lenses.

Our worst day in the OR
Dr. Marlene Moster presented a 79-year-old patient with open-globe injury repair which resulted in high IOP and corneal dehiscence. The patient was scheduled for K-pro surgery first followed by Baerveldt implantation in the same session. Unfortunately, the patient experienced expulsive choroidal hemorrhage during the K-pro implantation and lost vision. Dr. Moster discussed the distinct challenges of suprachoroidal hemorrhage as well as the potential etiologies such as anticoagulant therapy, advanced age, glaucoma, and hypertension. She emphasized the importance of special monitoring in patients using blood thinners. She advised being aware that expulsive hemorrhage is occurring, acting fast, and applying strong pressure on the wound.

Watch the presentations