Trabectome is an FDA approved device that is use in a minimally invasive glaucoma surgery to improve the drainage of Aqueous Humor out of the eye.
In Open Angle Glaucoma, the main problem is found in trabecular meshwork and Canal of Schlemm which act like a resistant barrier against the drainage of aqueous out of the eye. In this surgery, a strip of Trabecular meshwork (60°-120°) and inner wall of Canal of Schlemm will be ablated by using a focused electrosurgical cautery, restoring the drainage ability of the eye.
The surgery is performed through a small cornea-scleral incision and does not require leaving a permanent hole and bleb as in trabeculectomy or an implant as in Ahmed Valve.
Good Candidates for Trabectome
1- Open-Angle Glaucoma
2- Pseudoexfoliation Glaucoma
3- Pigmentary Glaucoma
4- Steroid Response Glaucoma
5- High Intra-ocular pressure with maximal anti-glaucoma medications
6- Target Intra-ocular pressure after surgery of mid-teens
7- Good visualization of angle structures
8- No previous angle surgery or laser.
Complications of Trabectome
The risk of complications of this surgery is very low comparing to traditional glaucoma surgeries.
1- Possible bleeding inside the eye with delay in vision return.This is the main complication and it is easy to treat.
2- A very small risk of infection or loss of vision. This risk presents in any intraocular surgery.
3- Injury to other parts of the eye such as Descemet membrane, Zonules and Ciliary Body.
There are many advantages of Trabectome over traditional glaucoma surgical procedures such as:
1- Minimally invasive out-patient procedure.
2- Restores the normal drainage pathways of the eye.
3- Safer surgical procedure than traditional glaucoma surgery with less short term and long term complications.
4- Simple and faster procedure which takes less than 30 minutes.
5- Rapid patient recovery.
6- reduce the patient ' s reliance on glaucoma medications
7- Fewer follow-up visits are needed.
8- Can easily be combined with cataract eye surgeries.
9- Does not preclude subsequent Glaucoma surgery such as Trabeculectomy because it spares conjunctiva.
10- Alternative to traditional Goniotomy or Trabeculotomy in Children.
11- Easy learning skills for the surgeon.
Steps of Trabectome
A- Pre-operative Preparation
1- Consider discontinuing anticoagulation to minimize intraoperative Hyphema (bleeding in the anterior chamber).
2- Topical antibiotic to decrease the risk of post operative infection
3- Apraclonidine 0.5-1% to decrease intraocular pressure
4- Pilocarpine 1-2% to constrict the pupil for better visualization of the angle.
B- Intra-operative steps
1- Sclera-corneal Incision
Small (1.7 mm) clear sclera-corneal incision is made.
2- Injection of Visco-elastic material
Injection of visco-elastic material through the incision to the anterior chamber to maintain the pressure inside the anterior chamber during the surgery.
It is a special lens that is used to localize trabecular meshwork at the angle of the eye. It is placed on the cornea. After visualization of the angle, the goniolens is removed and a tip of the Trabectome-hand piece is inserted into the angle and the goniolens is placed again on the cornea to view the angle and the tip.The hand-piece has a fluid irrigation port and a fluid aspiration port.
Ablation of the trabecular meshwork and the inner layer of Canal of Schlemm for (30°-60°) in clockwise direction is done with continuous irrigation and aspiration.
5- Rotation of the Tip
The tip is rotated inside the anterior chamber but away from the angle.
Ablation of trabecular meshwork in anti-clockwise direction for (30°-60°).
7- Aspiration of visco-elastic material from Anterior chamber
8- Suturing of the incision
C- Post-Operative Care and Recovery
Trabectome is an outpatient procedure which means the patient is able to return home when the surgery is complete. The patient’s eyes will be patched for a few hours after surgery. Normal daily activities can be performed 24 hours following surgery.
Normally, you will be examined by your ophthalmologist at day 1, then seven days and 28 days after surgery.
Standard Medications for Post-operation period
1- Pilocarpine 1-2% twice a day for two weeks.
2- Topical antibiotic four times a day for one week.
3- Topical steroid 4 times a day, continued as needed depending on degree of Hyphema ( Bleeding in the anterior chamber).
4- Resume glaucoma medications.