What is the role of trabeculectomy in the treatment of hyphema?

Updated: Jan 18, 2019
  • Author: David L Nash, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Answer

Answer

Generally, trabeculectomy is not used in smaller hyphemas. However, in patients with total hyphema, trabeculectomy with peripheral iridectomy should be considered. Trabeculectomy is performed with gentle irrigation of the anterior chamber hyphema. This surgery is relatively safe and should be performed early for patients with total hyphema unless the elevated intraocular pressure is medically controlled and resolution of the hyphema is clearly imminent.

The authors currently perform trabeculectomy on patients with total hyphema persisting to day 4 and find it superior to clot evacuation. Several patients referred to the authors' institution have had attempts at clot evacuation. One patient sustained complete iridodialysis related to attempted clot evacuation. In addition, the authors have treated other patients who have been referred after optic atrophy developed with total hyphemas.

When trabeculectomy is performed, the authors use a partial-thickness lamellar technique. Superficial episcleral vessels are coagulated with the bipolar cautery. A superficial lamellar flap is developed through one-third scleral thickness, creating a 3 X 3-mm trap door hinged at the limbal area. A 1 X 4-mm window through the scleral root and the trabecular meshwork into the anterior chamber is fashioned with a diamond knife. Peripheral iridectomy is performed, followed by gentle irrigation of the clot in the area of the trabeculectomy site. Two 10-0 nylon scleral flap sutures are used to close the trabeculectomy site. First the Tenon capsule and then the conjunctiva are closed with a running 8-0 or 9-0 Vicryl suture in a layered, anatomical fashion. Once the conjunctiva has healed, the nylon scleral suture(s) can be lasered to open the trabeculectomy site (when necessary). This technique has been invaluable in difficult total hyphema cases.

Topically applied mitomycin-C may be a useful adjunct in the prevention of long-term trabeculectomy failure, particularly in patients with trauma and, therefore, a predisposition to inflammation.

Because each of these surgical procedures has its own set of complications, the surgeon should approach each patient with caution and individualize the surgical strategy. Postoperative care should include meticulous control of nausea and emesis to avoid significant fluctuations in intraocular pressure.

Postoperative hyphemas may be seen at the time of surgery or within the first 2-3 days after surgery. If bleeding is identified intraoperatively, it must be identified and coagulated if it does not cease on its own. The surgeon can reduce postsurgical hyphemas by creating internal sclerostomy as anteriorly as possible to reduce bleeding during filtration surgery. In uveitis-glaucoma-hyphema (UGH) syndrome associated with archaic design anterior chamber IOLs and sulcus posterior chamber IOLs, the treatment may require removal of the lens that is causing the problem and replacing it with another lens.

A chaffing lens haptic can be diagnosed with ultrasound biomicroscopy (UBM) [69] or the video feature of endoscopic cyclophotocoagulation (ECP). ECP may also serve a role in treating areas of chaffing, potentially resolving UGH.


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