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10
Modern Glaucoma Surgery
Selecting the Best Procedure for Each Patient
As can be seen from the previous discussion, there are many different glaucoma surgical procedures.
They vary in terms of their technical complexity, degree of invasiveness, efficacy, and safety. In general,
safer and less invasive procedures are employed for patients with early-to-moderate glaucoma whose
IOP target is not extremely low, while more invasive procedures with more serious safety profiles can be
appropriate for patients with moderate-to-advanced glaucoma who require greater IOP reductions.
Figure 6
illustrates how these various factors can inform the selection of surgical procedures based on
specific patients’ needs.
Clinical Evaluation of the Preoperative Glaucoma Surgery Patient
A basic understanding of the glaucoma surgical procedures can facilitate the technician’s preoperative
evaluation of glaucoma patients who are surgical candidates. There are specific aspects of both the
history and the examination that are important for the selection and subsequent success of glaucoma
surgery.
History
When taking a history from a patient who is a potential glaucoma surgical candidate, several issues
should be queried and documented. A history of prior eye surgery is important, and in particular, a history
of prior glaucoma surgery is relevant for two key reasons. Not only does it mean that the patient has
failed a prior glaucoma surgery (which might lead the surgeon to select a different procedure), but also
indicates some degree of scarring and/or a residual implanted device that must be addressed when
planning and performing the next surgery. Other operations, such as strabismus or retinal detachment
surgery, can result in significant scarring of the conjunctiva and make the creation of a subconjunctival
bleb difficult while increasing the risk for long-term failure. A prior cataract surgery through a clear-cornea
incision has very little, if any, effect on subsequent glaucoma surgery.
During surgery, patients are positioned on their backs with their entire face and head under sterile drapes
that leave only the eye exposed for the surgeon’s access. As previously explained, this is to minimize the
risk of infection. However, this process can be difficult for some patients. Patients with claustrophobia or
Figure 6.
Factors to consider when selecting a glaucoma surgical procedure.
(Image created by Anthony Realini, M.D.)