Difference between revisions of "Glaucoma surgery: MIGS, trabeculectomy, and others"
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Sarah Glier (talk | contribs) (started a page for trabeculectomies and other glaucoma specific procedures) |
Sarah Glier (talk | contribs) (updated page w/ additional considerations) |
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = | | anesthesia_type = MAC | ||
| airway = | | airway = Noninvasive O2 | ||
| lines_access = | | lines_access = PIV | ||
| monitors = | | monitors = Standard, 5 lead ECG | ||
| considerations_preoperative = | | considerations_preoperative = | ||
| considerations_intraoperative = | | considerations_intraoperative = Oculocardiac reflex | ||
| considerations_postoperative = | | considerations_postoperative = | ||
}} | }} | ||
| Line 72: | Line 72: | ||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
Regional blocks are briefly painful and stimulating. Consider remifentanil (0.25-1mcg/kg), alfentanil (5-7mcg/kg), or propofol bolus (30-50mg) prior to block. Prepare to treat apnea or drop in BP. | |||
# <u>Peribulbar block</u>: injecting a local anesthetic into the space surrounding the eye (the peribulbar space). Provides a dense block of the sensory nerves supplying the eye and can also induce temporary paralysis of the ocular muscles. Risks include potential injury to the optic nerve, hemorrhage, or globe perforation | #<u>Peribulbar block</u>: injecting a local anesthetic into the space surrounding the eye (the peribulbar space). Provides a dense block of the sensory nerves supplying the eye and can also induce temporary paralysis of the ocular muscles. Risks include potential injury to the optic nerve, hemorrhage, or globe perforation | ||
# <u>Retrobulbar block</u>: local anesthetic injected behind the eyeball (retrobulbar space) to block the optic nerve and other sensory nerves. Provides profound anesthesia for the eye. Can also produce akinesia (paralysis of eye movement). Higher risk block including potential injury to the optic nerve, hemorrhage, globe perforation, or systemic toxicity | # <u>Retrobulbar block</u>: local anesthetic injected behind the eyeball (retrobulbar space) to block the optic nerve and other sensory nerves. Provides profound anesthesia for the eye. Can also produce akinesia (paralysis of eye movement). Higher risk block including potential injury to the optic nerve, hemorrhage, globe perforation, or systemic toxicity | ||
# <u>Subtenon block</u>: anesthetic injected into the subtenon space, which is located just outside the sclera (the white part of the eye but under the Tenon's capsule). Allows anesthetic to diffuse around the eye. Lower risk of complications compared to the above blocks. Will have preservation of eye movement which may be suboptimal for surgical conditions. | # <u>Subtenon block</u>: anesthetic injected into the subtenon space, which is located just outside the sclera (the white part of the eye but under the Tenon's capsule). Allows anesthetic to diffuse around the eye. Lower risk of complications compared to the above blocks. Will have preservation of eye movement which may be suboptimal for surgical conditions. | ||
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=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* Standard ASA monitors | |||
* 5 Lead EKG | |||
* 1 Peripheral IV | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
* Most commonly use nasal cannula for O2 supplementation, but LMA for select patient populations | |||
* Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort | |||
* Consider use of precedex as an adjunct throughout case given its sedative effects and ability to lower the IOP<ref>{{Cite journal|last=Senthil|first=Sirisha|last2=Burugupally|first2=Keerthi|last3=Rout|first3=Umashankar|last4=Rao|first4=Harsha L.|last5=Krishnamurthy|first5=Rashmi|last6=Badakere|first6=Swathi|last7=Choudhari|first7=Nikhil|last8=Garudadri|first8=Chandrasekhar|date=2020-10|title=Effect of Intravenous Dexmedetomidine on Intraocular Pressure in Patients Undergoing Glaucoma Surgery Under Local Anesthesia: A Pilot Study|url=https://pubmed.ncbi.nlm.nih.gov/32740512|journal=Journal of Glaucoma|volume=29|issue=10|pages=846–850|doi=10.1097/IJG.0000000000001621|issn=1536-481X|pmid=32740512}}</ref><ref>{{Cite journal|last=Pereira|first=Eduardo Maia Martins|last2=Viana|first2=Patrícia|last3=da Silva|first3=Rodrigo Araujo Monteiro|last4=Silott|first4=Pedro Furlan|last5=Amaral|first5=Sara|date=2025-02|title=Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthetics in Peribulbar Block: A Meta-analysis With Trial-Sequential Analysis|url=https://pubmed.ncbi.nlm.nih.gov/39033834|journal=American Journal of Ophthalmology|volume=270|pages=140–153|doi=10.1016/j.ajo.2024.07.011|issn=1879-1891|pmid=39033834}}</ref> | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* supine | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* Short cases ranging between 30 - 90 min depending on complexity and technique | |||
* Oculocardiac reflex, caused by traction on extraocular muscles, can result in rapid decrease in heart rate and blood pressure | |||
** Stop surgical manipulation, give [[atropine]]/[[glycopyrrolate]] | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* Short post-op monitoring | |||
* Usually home same day | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* Tylenol | |||
* +/- Ketorolac | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* hemorrhage | |||
* infection | |||
* cataract formation | |||
* corneal edema | |||
* ocular hypotony (IOP iatrogenically too low) | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
Latest revision as of 10:39, 7 August 2025
Glaucoma surgery: MIGS, trabeculectomy, and others
| Anesthesia type |
MAC |
|---|---|
| Airway |
Noninvasive O2 |
| Lines and access |
PIV |
| Monitors |
Standard, 5 lead ECG |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
Oculocardiac reflex |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Open-angle glaucoma (OAG) is the most common form of glaucoma and is characterized by a gradual increase in intraocular pressure (IOP) due to the slow blockage of the drainage canals in the eye. Management includes medications, laser therapies, and surgical procedures including minimally invasive glaucoma surgery (MIGS). MIGS aims to lower IOP with less risk and faster recovery than traditional surgeries.
Overview
Indications
Failure of medical and laser therapy to adequately control IOP or continued progression of optic nerve or visual field damage despite maximal tolerated non-surgical treatment.
Surgical procedure
- Laser therapies
- Laser Trabeculoplasty: This procedure uses a laser to improve the drainage of fluid through the trabecular meshwork
- Selective Laser Trabeculoplasty (SLT): A more recent and less invasive option that targets specific cells in the trabecular meshwork and can be repeated if necessary
- Surgical procedures
- Trabeculectomy: creates a new drainage pathway to reduce IOP by removing a part of the trabecular meshwork and sclera
- Tube Shunt Surgery: Involves placing a small tube (shunt) in the eye to assist with the drainage of aqueous humor
- MIGS
- iStent: A tiny device that creates a new drain for fluid
- Hydrus Microstent: A small stent implanted in the drainage canal to help fluid drain better
- Kahook Dual Blade: A technique that removes tissue in the trabecular meshwork to facilitate drainage
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | |
| Cardiovascular | |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
Regional blocks are briefly painful and stimulating. Consider remifentanil (0.25-1mcg/kg), alfentanil (5-7mcg/kg), or propofol bolus (30-50mg) prior to block. Prepare to treat apnea or drop in BP.
- Peribulbar block: injecting a local anesthetic into the space surrounding the eye (the peribulbar space). Provides a dense block of the sensory nerves supplying the eye and can also induce temporary paralysis of the ocular muscles. Risks include potential injury to the optic nerve, hemorrhage, or globe perforation
- Retrobulbar block: local anesthetic injected behind the eyeball (retrobulbar space) to block the optic nerve and other sensory nerves. Provides profound anesthesia for the eye. Can also produce akinesia (paralysis of eye movement). Higher risk block including potential injury to the optic nerve, hemorrhage, globe perforation, or systemic toxicity
- Subtenon block: anesthetic injected into the subtenon space, which is located just outside the sclera (the white part of the eye but under the Tenon's capsule). Allows anesthetic to diffuse around the eye. Lower risk of complications compared to the above blocks. Will have preservation of eye movement which may be suboptimal for surgical conditions.
Intraoperative management
Monitoring and access
- Standard ASA monitors
- 5 Lead EKG
- 1 Peripheral IV
Induction and airway management
- Most commonly use nasal cannula for O2 supplementation, but LMA for select patient populations
- Benzodiazapenes (ex. midazolam) and opioids (ex. fentanyl) are commonly administered throughout the case as needed for patient comfort
- Consider use of precedex as an adjunct throughout case given its sedative effects and ability to lower the IOP[1][2]
Positioning
- supine
Maintenance and surgical considerations
- Short cases ranging between 30 - 90 min depending on complexity and technique
- Oculocardiac reflex, caused by traction on extraocular muscles, can result in rapid decrease in heart rate and blood pressure
- Stop surgical manipulation, give atropine/glycopyrrolate
Emergence
Postoperative management
Disposition
- Short post-op monitoring
- Usually home same day
Pain management
- Tylenol
- +/- Ketorolac
Potential complications
- hemorrhage
- infection
- cataract formation
- corneal edema
- ocular hypotony (IOP iatrogenically too low)
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Indications | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Senthil, Sirisha; Burugupally, Keerthi; Rout, Umashankar; Rao, Harsha L.; Krishnamurthy, Rashmi; Badakere, Swathi; Choudhari, Nikhil; Garudadri, Chandrasekhar (2020-10). "Effect of Intravenous Dexmedetomidine on Intraocular Pressure in Patients Undergoing Glaucoma Surgery Under Local Anesthesia: A Pilot Study". Journal of Glaucoma. 29 (10): 846–850. doi:10.1097/IJG.0000000000001621. ISSN 1536-481X. PMID 32740512. Check date values in:
|date=(help) - ↑ Pereira, Eduardo Maia Martins; Viana, Patrícia; da Silva, Rodrigo Araujo Monteiro; Silott, Pedro Furlan; Amaral, Sara (2025-02). "Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthetics in Peribulbar Block: A Meta-analysis With Trial-Sequential Analysis". American Journal of Ophthalmology. 270: 140–153. doi:10.1016/j.ajo.2024.07.011. ISSN 1879-1891. PMID 39033834 Check
|pmid=value (help). Check date values in:|date=(help)
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