What is the role of medications in postoperative care following trabeculectomy?

Updated: May 18, 2020
  • Author: Maria Hannah Pia Uyloan de Guzman, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Answer

Answer

Preoperative medications

All preoperative IOP-lowering medications are discontinued after the trabeculectomy.

Antibiotics

Topical antibiotic eye drops are the standard of care. Systemic antibiotics are needed only for special circumstances (eg, breach in sterile technique).

Corticosteroids

Topical corticosteroid eye drops are used postoperatively. The dose of the steroid depends on the degree of scarring expected. High-risk cases can be given subconjunctival or peribulbar depot injections or oral steroids. Topical steroids are usually used for at least 6 weeks postoperatively, but the duration depends on the level of inflammation in the bleb and on the presence of risk factors for failure.

Cycloplegic

Atropine eye drops can prevent postoperative aqueous misdirection syndrome (malignant glaucoma). This is especially important in eyes at risk of aqueous misdirection such as angle-closure glaucoma cases or those with shallow anterior chambers, but some surgeons prefer to use this routinely. However, atropine eye drops cause mydriasis, which can be disturbing or uncomfortable for the patient. Atropine is usually given 3 times a day initially then slowly tapered over several weeks.

Antifibrotic injection

Severe bleb inflammation (severe congestion, presence of corkscrew vessels) can be managed using subconjunctival injection of 5-FU (5 mg in 0.1 mL) or MMC. The site of injection depends on surgeon preference but the trend now is to inject the antifibrotic adjacent to or into the bleb rather than away from the bleb. The injection can be repeated several times depending on the response of the bleb. This measure has the greatest potential for success if done in the first 2 weeks postoperatively (up to 4 weeks if intraoperative mitomycin-C was used). The potential complications of this injection are severe corneal epithelial toxicity and early or late bleb leak. The corneal toxicity can be minimized by irrigating the eye after injection to wash away antifibrotic agent that may have leaked from the injection site. See the image below.

Corkscrew vessels in a bleb 1 week after trabecule Corkscrew vessels in a bleb 1 week after trabeculectomy.

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