8.1.4Postoperative Management and Medication

8.1.4.1 Medication

After surgery topical antibiotics and anti-inßammatory medications are given to reduce the risk of bleb infection, endophthalmitis, and to prevent the onset of severe inßammation. A broad-spectrum topical antibiotic may be used Þve times a day, with a dose that is progressively tapered after 2Ð3 weeks. Because deep sclerectomy is a nonpenetrating procedure, the postoperative inßammation is highly reduced from what would normally be the case with trabeculectomy [19]. Anti-inßammatory medications, such as corticosteroids, improve the success of glaucoma surgery, the inßuence of which is greatest during the initial inßammatory phase, the Þrst 3Ð4 days after surgery [20]. The effect of corticosteroids is to prevent excessive scarring and development of Þbrosis of the tissues involved in the Þltration, i.e., the conjunctiva, the subconjunctival space, and the superÞcial ßap. The dosage of topical corticosteroids is between 3 and 5 drops a day, and this medication is often combined with topical antibiotics. It is worth mentioning in this context that some eyes might be sensitive to topical corticosteroids, a situation that can eventually lead to steroidinduced ocular hypertension. The corticosteroids are therefore tapered after a few weeks, followed by nonsteroidal inßammatory drugs, three times a day for at least 3 months after surgery.

8.1.4.2 Management

The eye is regularly checked at the slit lamp for postoperative assessment. The examination should be performed on the Þrst and third postoperative day, every week for the Þrst month, then every month for the 3 Þrst months, then twice a year thereafter. This schedule is to be adjusted according to the clinical situation, depending on the severity and complexity of the case, with more frequent examination if required. During the assessment, the bleb is carefully examined and the clinical aspect, the extent, the vascularization, and any sign of infection are reported. The cornea is checked as well for any decrease in clarity or epithelial defect. The anterior chamber depth is assessed, and any degree

Fig. 8.16 Trabeculo-DescemetÕs membrane (TDM), gonioscopic view. The collagen implant is seen through the TDM

Fig. 8.17 Decompression hemorrhage

of iris touch reported. A mild hyphema from minor iris hemorrhages might be present that resolves in a few days. Flare and cell count is generally moderate, and any sign of severe inßammation shall immediately be addressed by the use of adequate medication. The IOP and time of measurement are reported. An inspection of the angle by gonioscopy reveals the dissected TDM and SchlemmÕs canal (Fig. 8.16). It is not uncommon to observe some blood in the canal during the Þrst postoperative days, e.g., after a Valsalva maneuver, which disappears within a week. As is the case for every Þltering procedure, the Þltration might temporarily be important, leading to transient ocular hypotony. In severe cases the fundus might show signs of choroidal detachment or suprachoroidal hemorrhages (Fig. 8.17). Most of these complications resolve themselves upon recovery to a normal IOP above 6 mmHg. In the most complicated cases and when the situation lasts for weeks, drainage of the choroidal ßuid might be proposed to solve the problem.