When glaucoma continues to progress despite the use of medication regimens and possibly laser treatments, a glaucoma filtration procedure (trabeculectomy) may be recommended. In general, a glaucoma filtration procedure is recommended when these other methods of glaucoma management have failed or have insufficiently controlled the progression of glaucoma.
However, in some cases, a glaucoma filtration procedure may be recommended before other methods of treatment are attempted. This decision is based on the type of glaucoma, the degree that it has advanced, the general health of the patient and ability to comply with treatment regimens, and other circumstances. In a smaller proportion of patients, the glaucoma filtration procedure is combined with a cataract operation.
The trabeculectomy has the advantage of lower pressures postoperatively and a longer track record, and thus is generally the procedure of choice for patients with more pronounced glaucomatous damage.
The Procedure
Once the decision is made to proceed with a glaucoma filtration procedure, the surgery is scheduled. The procedure is completed in the operating room, usually under local anesthesia. Some ophthalmologists will complete the procedure under topical (eye drop) anesthesia. On the day of surgery, one should expect to have several eye drop medications applied multiple times to the eye for approximately one hour prior to the procedure.
Finally, the eye drop anesthetics or local anesthetic is applied just prior to the procedure. Once in the operating room, your eye will be "prepped" for surgery with sterilizing solutions. Usually, a semi-opaque sterile drape will be applied over the operative field, using a small instrument to hold your lids apart for the procedure.
Your eye should be entirely comfortable during the operation. Your surgeon may recommend mild sedation during the procedure, and this is usually determined on a case-by-case basis.
The goal of the glaucoma filtration procedure is to create a new passageway by which aqueous fluid inside the eye can escape, thereby lowering the pressure. The escape route, however, is not directly to the external surface of the eye, as this would obviously allow access for bacteria inside the eye and thus, potential infection.
The filter, therefore, allows the drainage of fluid from inside the anterior chamber of the eye to a "pocket" created between the conjunctiva , which is the outermost covering of the eye, and the sclera , which is the underlying white anatomical structure of the eye. The fluid is eventually absorbed by blood vessels. In many cases, medication to control scarring, and thus to help prevent closure of the filtration site, is applied to the eye during the operation or just afterwards. These medications, known as Mitomycin C and 5-Fluorouracil (5-FU), will be used in some cases and not others, depending on both surgeon and patient variables.
Diagnosis/Preparation
The procedure is fully explained and any alternative methods to control intraocular pressure are discussed. Antiglaucoma drugs are prescribed before surgery. Added pressure on the eye caused from coughing or sneezing should be avoided.
Several eye drops are applied immediately before surgery. The eye is sterilized, and the patient draped. A speculum is inserted to keep the eyelids apart during surgery.
After Your Operation
In most cases, a patch and shield will be placed over your eye on the day of surgery. This is usually removed later that day or the day after surgery and eye drop medications are begun. Your surgeon will usually want to evaluate your eye on the day of surgery or on the first post-operative day. At that time, depending on pressure in the eye, your surgeon might elect to cut sutures on the flap of the filter to modulate the filtration process. This is often done with a laser while in the office.
Antibiotic and anti-inflammatory eye drop medications are continued after surgery for up to 6 weeks or more. In some cases, the surgeon will apply additional medicines (e.g., 5-FU) to further prevent scarring and failure of the filter. The exact regimen will vary from one surgeon to another as well as surgical outcome variables. Cutting of sutures may be completed up to several weeks after surgery, again depending on the degree of filtration noted at each office visit.
The number of visits to your doctor after surgery may vary widely depending on circumstances. In general, follow-up visits after filtration procedures are quite frequent, as often as every day or two shortly after surgery, with office visits decreasing in frequency as healing progresses.
Aftercare
Eye drops, and perhaps patching, will be needed until the eye is healed. Driving should be restricted until the ophthalmologist grants permission. The patient may experience blurred vision. Severe eye pain, light sensitivity, and vision loss should be reported to the physician.
Antibiotic and anti-inflammatory eye drops must be used for at least six weeks after surgery. Additional medicines may be prescribed to reduce scarring.
Eye drops, and perhaps patching, will be needed until the eye is healed. Driving should be restricted until the ophthalmologist grants permission. The patient may experience blurred vision. Severe eye pain, light sensitivity, and vision loss should be reported to the physician.
Antibiotic and anti-inflammatory eye drops must be used for at least six weeks after surgery. Additional medicines may be prescribed to reduce scarring.
Risks
Infection and bleeding are risks of any surgery. Scarring can cause the drainage to stop. One-third of trabeculectomy patients will develop cataracts.
Alternatives
Physicians will first try to lower IOP with glaucoma medications. Several types of eye drops are effective for this use. Sometimes a patient must instill more than one eye drop, several times a day. Compliance is very important when using these eye drops; missed dosages will raise IOPs.
Lasers are now used to treat both closed-angle and open-angle glaucoma. Peripheral iridectomy is used for people with acute angle-closure glaucoma attacks and chronic closed-angle glaucoma. The procedure creates a hole to improve the flow of aqueous humor.
Laser trabeculoplasty uses an argon laser to create tiny burns on the trabecular meshwork, which lowers IOP. The effects, however, are not permanent, and the patient must be retreated.
Transscleral cyclophotocoagulation treats the ciliary body with a laser to decrease production of aqueous humor, which reduces IOP.
A tube shunt might be implanted to create a drainage pathway in patients who are not candidates for trabeculectomy.
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When glaucoma continues to progress despite the use of medication regimens and possibly laser treatments, a glaucoma filtration procedure (trabeculectomy) may be recommended. In general, a glaucoma filtration procedure is recommended when these other methods of glaucoma management have failed or have insufficiently controlled the progression of glaucoma. 
