Journal of Current Glaucoma Practice

Register      Login

VOLUME 10 , ISSUE 1 ( January-April, 2016 ) > List of Articles


Preoperative Preparation and Anesthesia for Trabeculectomy

Tom Eke

Keywords : Anesthesia, Intracameral anesthesia, Local anesthesia, Peribulbar anesthesia, Retrobulbar anesthesia, Subconjunctival anesthesia, Sub-Tenon's anesthesia, Topical anesthesia, Trabeculectomy

Citation Information : Eke T. Preoperative Preparation and Anesthesia for Trabeculectomy. J Curr Glaucoma Pract 2016; 10 (1):21-35.

DOI: 10.5005/jp-journals-10008-1198

License: CC BY-NC 4.0

Published Online: 01-08-2019

Copyright Statement:  Copyright © 2016; The Author(s).


Preoperative preparation should improve the likelihood of successful trabeculectomy surgery. The team can reconsider the appropriateness of the proposed surgery, and steps can be taken to maximize the chance of a good outcome. For example, adjustments to anti-hypertensive or anti-coagulant medications may be made, and topical ocular medications adjusted. Choice of anesthesia technique is of particular relevance to the trabeculectomy patient. Some anesthesia techniques are more likely to have serious complications, and glaucoma patients may be at higher risk of some sight-threatening complications, because the optic nerve is already damaged and vulnerable. Posterior placement of local anesthesia (retrobulbar, peribulbar, posterior sub-Tenon's techniques) could potentially damage the optic nerve, and thereby cause “wipe-out” of vision. Anesthesia technique may influence the likelihood of vitreous bulge and surgical difficulty. Regarding long-term control of intraocular pressure, there is no good evidence to indicate that any particular anesthesia technique is better than another. There is little high-quality evidence on this topic. The author's preferred technique for trabeculectomy is subconjunctival-intracameral anesthesia without sedation.

PDF Share
  1. Eke T. Anesthesia for glaucoma surgery. Ophthalmol Clin North Am 2006 Jun;19(2):245-255.
  2. Eke T. Anaesthesia for glaucoma surgery. Current Anaesthesia Crit Care 2010;21(4):168-173.
  3. Hawker M, Broadway DC. Preoperative conjunctival health and trabeculectomy outcome. Glaucoma-Surgical Management. In: Shaarawy T, Sherwood MB, Hitchings RA, Crowston JG, editors. Philadelphia: Elsevier; 2009.
  4. Broadway DC, Grierson I, Stürmer J, Hitchings RA. Reversal of topical antiglaucoma medication effects on the conjunctiva. Arch Ophthalmol 1996 Mar;114(3):262-267.
  5. Baudouin C, Nordmann JP, Denis P, Creuzot-Garcher C, Allaire C, Trinquand C. Efficacy of indomethacin 0.1% and fluorometholone 0.1% on conjunctival inflammation following chronic application of antiglaucomatous drugs. Graefes Arch Clin Exp Ophthalmol 2002 Nov;240(11):929-935.
  6. Royal College of Ophthalmologists & Royal College of Anaesthetists. Local Anaesthesia for Ophthalmic Surgery. (Internet). London, 2012 Feb. p. 38.
  7. Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology 2002 Jan;109(1):13-24.
  8. Cataract Surgery Guidelines. London: Royal College of Ophthalmologists; 2010.
  9. Kumar C, Dodds C, Gayer S, editors. Oxford Handbook of Ophthalmic Anaesthesia. Oxford: Oxford University Press; 2012.
  10. Eke T. Anaesthesia for glaucoma surgery. In: Kumar C, Dodds C, Gayer S, editors. Oxford Handbook of Ophthalmic Anaesthesia. Oxford: Oxford University Press; 2012.
  11. Kumar CM. Needle-based blocks for the 21st century ophthalmology. Acta Ophthalmol 2011 Feb;89(1):5-9.
  12. Vohra SB, Good PA. Altered globe dimensions of axial myopia as risk factors for penetrating ocular injury during peribulbar anaesthesia. Br J Anaesth 2000 Aug;85(2):242-245.
  13. Hustead RF, Hamilton RC, Lokew RG. Periocular local anesthesia medial orbital as an alternative to superior nasal infection: medial compartment block. J Cataract Refract Surg 1994 Mar;20(2):197-201.
  14. Burkat CN, Lemke BN. Retrobulbar hemorrhage: inferolateral anterior orbitotomy for emergent management. Arch Ophthalmol 2005 Sep;123(9):1260-1262.
  15. Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. Emergency lateral canthotomy and cantholysis: a simple procedure to preserve vision from sight threatening orbital haemorrhage. J Spec Oper Med 2009 Summer;9(3):26-32.
  16. Gross A, Cestari DM. Opt ic neuropathy following retrobulbar injection: a review. Semin Ophthalmol 2014 Sep-Nov;29(5-6):434-439.
  17. Schulenburg HE, Sri-Chandana C, Lyons G, Columb MO, McLure HA. Hyaluronidase reduces local anaesthetic volumes for sub-Tenon's anaesthesia. Br J Anaesth 2007 Nov;99(5):717-720.
  18. Leibovitch I, Tamblyn D, Casson R, Selva D. Allergic reaction to hyaluronidase: a rare cause of orbital inflammation after cataract surgery. Graefes Arch Clin Exp Ophthalmol 2006 Aug;244(8):944-949.
  19. Kumar CM, Dowd TC, Dodds C, Boyce R. Orbital swelling following peribulbar and sub-Tenon's anaesthesia. Eye 2004; 18:418-420.
  20. Chang BY, Hee WC, Ling R, Broadway DC, Beigi B. Local anaesthetic techniques and pulsatile ocular blood flow. Br J Ophthalmol 2000 Nov;84(11):1260-1263.
  21. Huber KK, Remky A. Effect of retrobulbar versus subconjunctival anaesthesia on retrobulbar haemodynamics. Br J Ophthalmol 2005 Jun;89(6):719-723.
  22. Pianka P, Weintraub-Padova H, Lazar M, Geyer O. Effect of sub-Tenon's and peribulbar anesthesia on intraocular pressure and ocular pulse amplitude. J Cataract Refract Surg 2001 Aug;27(8):1221-1226.
  23. Huber KK, Remky A. Colour Doppler imaging before and after retrobulbar anaesthesia in patients undergoing cataract surgery. Graefes Arch Clin Exp Ophthalmol 2005 Nov;243(11):1141-1146.
  24. Hulbert MF, Yang YC, Pennefather PM, Moore JK. Pulsatile ocular blood flow and intraocular pressure during retrobulbar injection of lignocaine: influence of additives. J Glaucoma 1998 Dec;7(6):413-416.
  25. Eke T. Meeting report: ophthalmic anaesthesia. Expert Rev Ophthalmol 2012 Oct;7(5):409-411.
  26. Henry JC. Snuff syndrome. J Glaucoma 1994 Spring;3(1):92-95.
  27. Costa VP, Smith M, Spaeth GL, Gandham S, Markovitz B. Loss of visual acuity after trabeculectomy. Ophthalmology 1993 May;100(5):599-612.
  28. Chin YC, Kumar CM. Brainstem anaesthesia revisited: Mechanism, presentation and management. Trends in Anaesthesia and Critical Care 2013;3(5):252-256.
  29. Rossiter JD, Wood M, Lockwood A, Lewis K. Operating conditions for ocular surgery under general anaesthesia: an eccentric problem. Eye (Lond) 2006 Jan;20(1):55-58.
  30. Quinn CD, Greenfield DS. Choroidal Effusion & Haemorrhage. In: Glaucoma- Surgical Management. Shaarawy T, Sherwood MB, Hitchings RA, Crowston JG, editors. Elsevier; 2009.
  31. Schrieber C, Liu Y. Choroidal effusions after glaucoma surgery. Curr Opin Ophthalmol 2015 Mar;26(2):134-142.
  32. Tuli SS, WuDunn D, Ciulla TA, Cantor LB. Delayed suprachoroidal hemorrhage after glaucoma filtration procedures. Ophthalmology 2001;108(10):1808-1811.
  33. Chu TG, Green RL. Suprachoroidal hemorrhage. Sur Ophthalmol 1999;43(6):471-486.
  34. Kong KL, Khan J. Ophthalmic patients on antithrombotic drugs: a review and guide to perioperative management. Br J Ophthalmol 2015;98(8):1025-1030.
  35. Mather SJ, Kong KL, Vohra SB. Loco-regional anaesthesia for ocular surgery: Anticoagulant and antiplatelet drugs. Current Anaes Crit Care 2010;21(4):158-163.
  36. Alwitry A, King AJ, Vernon SA. Anticoagulation therapy in glaucoma surgery. Graefes Arch Clin Exp Ophthalmol 2008 Jun;246(6):891-896.
  37. Cobb CJ, Chakrabarti S, Chadha V, Sanders R. The effect of aspirin and warfarin therapy in trabeculectomy. Eye (Lond) 2007 May;21(5):598-603.
  38. Balbino M, Bion P, Prata TS. Perioperative management of anticoagulant users scheduled for glaucoma surgery: a survey among the Brazilian Glaucoma Society members. Arq Bras Oftalmol 2013 Nov-Dec;76(6):363-365.
  39. Lung S, Luksch A, Weigert G, Georgopoulos M, Menapace R, Polska E, Garhofer G, Findl O, Schmetterer L. Influence of infusion volume on the ocular hemodynamic effects of peribulbar anesthesia. J Cataract Refract Surg 2006 Sep; 32(9):1509-1512.
  40. Kallio H, Harju MP, Ihanamäki T, Vesti ET, Kivelä T. Reduction of intra-ocular pressure by ocular compression before combined peri- and retrobulbar block. Anaesthesia 2011;66(4):278-282.
  41. Hoshikawa Y, Tsutsumi N, Ohkoshi K, Serizawa S, Hamada M, Inagaki K, Tsuzuki K, Koshimizu J, Echizen N, Fujitani S, et al. The effect of steep Trendelenburg positioning on intraocular pressure and visual function during roboticassisted radical prostatectomy. Br J Ophthalmol 2014 Mar; 98(3):305-308.
  42. Taketani Y, Mayama C, Suzuki N, Wada A, Oka T, Inamochi K, Nomoto Y. Transient but significant visual field defects after robot-assisted laparoscopic radical prostatectomy in deep trendelenburg position. PLoS One 2015 Apr 23;10(4):e0123361.
  43. Carey TW, Shaw KA, Weber ML, DeVine JG. Effect of the degree of reverse Trendelenburg position on intraocular pressure during prone spine surgery: a randomized controlled trial. Spine J 2014 Sep 1;14(9):2118-2126.
  44. Lazzaro EC, Mallick A, Singh M, Reich I, Elmann S, Stefanov DG, Lazzaro DR. The effect of positional changes on intraocular pressure during sleep in patients with and without glaucoma. J Glaucoma 2014 Jun-Jul;23(5):282-287.
  45. Mansour AM, Al-Dairy M. Modifications in cataract surgery for the morbidly obese patient. J Cataract Refract Surg 2004 Nov;30(11):2265-2268.
  46. Tsatsos M, Chong L, Eke T. Patients’ preferences for positioning during phacoemulsification under topicalintracameral anaesthesia. Clin Experiment Ophthalmol 2009 Sep;37(7):646-648.
  47. Rojanapongpun P. Acute intraocular pressure rise. In: Glaucoma-Surgical Management. Shaarawy T, Sherwood MB, Hitchings RA, Crowston JG, editors. Elsevier; 2009.
  48. Mannitol. British National Formulary 69. London: BMJ group publishers; 2015 March. p. 1164.
  49. Speaker MG, Guerriero PN, Met JA, Coad CT, Berger A, Marmor M. A case-control study of risk factors for intraoperative suprachoroidal expulsive hemorrhage. Ophthalmology 1991 Feb;98(2):202-209; discussion 210.
  50. Ling R, Kamalarajah S, Cole M, James C, Shaw S. Suprachoroidal haemorrhage complicating cataract surgery in the UK: a case control study of risk factors. Br J Ophthalmol 2004 Apr;88(4):474-477.
  51. Mukkamala SK, Patel A, Dorairaj S, McGlynn R, Sidoti PA, Weinreb RN, Rusoff J, Rao S, Gentile RC. Ocular decompression retinopathy: a review. Surv Ophthalmol 2013 Nov-Dec;58(6):505-512.
  52. Jung KI, Lim SA, Lopilly Park HY, Park CK. Risk factors for decompression retinopathy after glaucoma surgery. J Glaucoma 2014 Dec;23(9):638-643.
  53. Edmunds B, Bunce CV, Thompson JR, Salmon JF, Wormald RP. Factors associated with success in first-time trabeculectomy for patients at low risk of failure with chronic open-angle glaucoma. Ophthalmology 2004 Jan;111(1):97-103.
  54. Dietlein TS, Moalem Y, Lappas A, Rosentreter A. Glaucoma filtering surgery in the elderly over eighty years old: an analysis of postoperative risks. Klin Monbl Augenheilkd 2014 Dec;231(12):1224-1229.
  55. Dietlein TS, Moalem Y, Schild AM, Lappas A, Rosentreter A, Dinslage S. Subconjunctival or general anaesthesia in trabeculectomy— a retrospective analysis of the bleeding risk from a glaucoma surgeon's point of view. Klin Monbl Augenheilkd 2012 Aug;229(8):826-829.
  56. Gutiérrez-Ortiz C, Teus M, Castro M, Bolívar G, Castejón M. Combined topical plus subconjunctival anesthesia versus retrobulbar anesthesia in non-penetrating sclerectomy. Arch Soc Esp Oftalmol 2007 May;82(5):285-290.
  57. Pablo LE, Ferreras A, Pérez-Oliván S, Polo V, Honrubia FM. Comparison of the efficacy and safety of contact versus peribulbar anaesthesia in combined eye surgery. Ophthalmologica 2009;223(1):60-67.
  58. Geffen N, Carrillo MM, Jin Y, Trope GE, Buys YM. Effect of local anesthesia on trabeculectomy success. J Glaucoma 2008 Dec;17(8):658-661.
  59. Klink T, Grehn F. Modern filtration surgery: an update. Ophthalmologe 2013 Apr;110(4):299-305.
  60. Noureddin BN, Jeffrey M, Franks WA, Hitchings RA. Conjunctival changes after subconjunctival lignocaine. Eye (Lond) 1993;7(Pt 3):457-460.
  61. Jonas J. Penetrating trabeculectomy in topical anesthesia. J Glaucoma 2005 Feb;14(1):88.
  62. Carrillo MM, Buys YM, Faingold D, Trope GE. Prospective study comparing lidocaine 2% jelly versus sub-Tenon's anaesthesia for trabeculectomy surgery. Br J Ophthalmol 2004 Aug;88(8):1004-1007.
  63. Pablo LE, Pérez-Oliván S, Ferreras A, Polo V, Gómez ML, Honrubia FM. Contact versus peribulbar anaesthesia in trabeculectomy: a prospective randomized clinical study. Acta Ophthalmol Scand 2003 Oct;81(5):486-490.
  64. Bellucci R, Morselli S, Pucci V, Babighian S. Sub-Tenon's anesthesia for combined cataract and glaucoma surgery. J Cataract Refract Surg 1999 May;25(5):606-607.
  65. Kansal S, Moster MR, Gomes MC, Schmidt CM Jr, Wilson RP. Patient comfort with combined anterior sub-Tenon's, topical, and intracameral anesthesia versus retrobulbar anesthesia in trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery. Ophthalmic Surg Lasers 2002 Nov-Dec;33(6): 456-462.
  66. Kumar CM, Eid H, Dodds C. Sub-Tennon‘s anaesthesia: complications and their prevention. Eye 2011;25:694-703.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.