A Typical Uncomplicated TRABECULECTOMY

A patient’s perspective on what to expect ~ by Pat Dickson
Physician review ~ by Dr. Rick Wilson

This article is intended to help those who have decided to have a trab(eculectomy). It describes a typical experience when there are no complications, and provides helpful hints for making things go as smoothly as possible. Many details have been left vague because every trab is different. Always follow your own doctor's instructions carefully.

Six weeks prior to surgery

Now is the time to learn about the restrictions involved in a trab. Doing so now will give you time to determine what you'll need to do to meet them, and to begin making a habit of any necessary changes. Those with a sedentary lifestyle might not notice much. Others with a more active lifestyle must make adjustments, at least temporarily. This includes those with athletic interests (dance, gymnastics, yoga, strength-training, martial arts, etc.) and those whose work involves physical effort (cleaners, childtenders, gardeners, etc.).

Most restrictions fall into one of two categories. The first category applies after any surgery, and is concerned with preventing infection. You must take care to keep the area surrounding the eye clean and dry. You'll probably have bandages only for a day or two and it's particularly important to keep them clean. Washing your hair without getting any water, much less soap, in your operated eye will be important for a longer period, so devise a method of doing this now. Also, notice how often you touch your eye with your finger, and make a habit of restraining yourself.

The second category of restrictions is concerned with preventing excessive pressure from being applied to the eye. Obviously, this can occur if you fall, or poke your eye. Two less obvious ways of increasing pressure can be summarized as 'head below heart' and 'valsalva'. Any position that results in your head being lower than your heart increases the blood pressure in your head and eye, increasing the risk of bleeding. Therefore, bending down is forbidden for at least a week after surgery. Now is the time to get in the habit of squatting instead of bending, whether you are picking something up or cleaning. With practice, you'll find that squatting is usually an acceptable alternative, and has the advantages of saving your back and strengthening your legs.

Blood pressure in the head and eyes is also increased by a valsalva maneuver. This is the act of forcefully compressing your abdomen and diaphragm, as if to exhale, while preventing the air thus compressed in your lungs from flowing out through your mouth and nose. A similar but usually less extreme action can be a natural occurrence during many biological activities such as sneezing, coughing, blowing your nose, vomiting, pushing to have a bowel movement (especially when constipated), and sex. Most of us already correctly sneeze, cough, and blow our nose (without stopping the flow of air through our mouth and nose). It can also occur during activities such as inflating balloons or playing a wind instrument. It also frequently occurs when you lift heavy weight therefore, begin to assess the weight of the object you are about to pick up. Immediately after surgery, you'll be restricted to lifting weights less than 10 pounds (a gallon of water weighs just over 8 pounds). The restriction on weight-lifting will gradually be reduced over a period of weeks.

It may take several weeks of assessing your normal activities (opening windows, vacuuming, playing golf, walking in the woods, clipping hedges, etc.) before you can readily identify which should be avoided at least temporarily after surgery. How heavy are those bags of groceries and loads of laundry? If your normal activities require that you put your head lower than your heart, lift weights, blow hard, etc., then now is the time to discover whether there is another way of obtaining the same result. If you run into difficulties, discuss them with your doctor.

Another area that might require adjustment is appearance. Those who wear contacts must give them up (at least temporarily, although many doctors recommend that contacts not be used at all as long as the bleb continues to function). Those who wear eye makeup should begin a transition to some form that will not involve the risk of getting something in the eye. Mascara and eyeliner are particular dangers, and such products should be replaced every few months.

Another task to take care of during this period is to determine if any additional tests will be required prior to surgery, such as an EKG. Then you can get them completed in good time.

One week prior to surgery

For a short period before surgery, your doctor may require you to discontinue some medications temporarily; blood thinners such as aspirin, coumadin, plavix, ibuprofen, and even large doses of vitamin E are often on this list. A few may need to start tapering off caffeine and chocolate a week before to avoid the headache that may result from the fast required in the hours before surgery. Eat, sleep, and exercise well during this period to avoid problems such as the need for laxatives after surgery. Any new practices (such as evaluating weights before lifting, squatting rather than bending, hair-washing without face wetting, and proper sneezing) should be habitual now.

Finalize your arrangements for the weeks following surgery. Your new schedule must allow plenty of time for putting drops in your eyes, and for frequent transportation to the doctor. Consider what other help you may need in meeting your obligations while your activities are restricted.

Finalize your arrangements for the day of surgery. You will require transportation to and from surgery. Select clothing and shoes to wear that are loose and comfortable, something that does not require pulling over your head or bending over to fasten. You won't be able to take anything into the operating room, so plan on leaving home everything but the essentials. One exception is your glasses case: you won't be able to wear your glasses over the patch and shield, so take a case to put them in.

Immediately Before, During, and After Surgery

Follow your doctor's instructions for the period immediately preceding surgery. Usually this includes eating and drinking nothing after midnight the evening before surgery. The sedation that will be used during your surgery dulls your natural protective reflexes that prevent food from the stomach coming back into your throat and being breathed into your lungs. Having an empty stomach minimizes this possibility. Wash your hair at the last possible moment. Dress in your prepared clothes and remember to take your insurance card, but leave nonessential valuables like jewelry at home.

Allow plenty of time to arrive at the medical center at the designated time; make allowances for traffic and parking difficulties. Once in the reception and waiting lounge, you may be required to sign additional paper work, such as an informed consent form or a living will. More tests or samples may be required.

At some point, you and your companion will be taken to the preoperative room staffed by nurses. There you may be instructed to undress (at least your upper body) and get into a gown and booties though many surgicenters just have you wear a gown over your street clothes. It's nice to be able to keep your socks on. You will climb onto an operating stretcher that will move you into the operating room and serve as your operating table unless you are scheduled for general anesthesia. You will have to leave all personal belongings here. There will be a chair for your companion, and other small niceties to help make them comfortable while they wait. At some point, an intravenous line will be placed in your lower arm, and a saline drip started. Your anesthesiologist (if you have one) or surgeon may chat briefly with you before you are led to the operating room. Remember that your job is to be calm, cooperative, and confident.

Once in the operating room, you will be made comfortable and warm laying face up with your head secured by a donut-shaped pillow. You'll be hooked up to monitors, and fitted with a nasal oxygen canula. The circulating nurse, after scrubbing the area around your eye with an anti-bacterial solution, will place a sterile drape over your face with a clear sticky window, leaving only the targeted eye exposed. The adherent drape will keep your breath from getting into the operative field.

At some point, you will start receiving a relaxant through the IV line. You will be able to hear, feel, and respond; you won't feel worried or apprehensive. You'll feel no pain; if you do, you should inform your surgeon. The relaxant may prevent any memories of the surgery from forming. (A general anesthetic is rarely used.)

At the end of the surgery, your eye will have a sterile clear plastic shield placed over it, and may have a patch as well. The entire procedure will probably take about an hour; you'll then be taken to the postoperative area. Here you will be glad to see your companion, if any. You will be observed by the staff for a short period to make sure you are doing well. During this time you will recover from the effects of the sedation and be given something to eat and drink to raise your blood sugar after your fast and to make sure you are not nauseated from the sedation. After awhile, the IV will be disconnected, and you will need to dress in your own clothes without bending over. Be careful not to fall.

Before being dismissed, you will be cautioned about restrictions and instructed in the care of your eye. A kit containing your new medications, sunglasses, and patch materials, if any, will be given to you. There may be additional formalities and you may need to sign a paper saying you understand your instructions for post-operative care. You will be released about four hours after arriving at the medical center.

Go home and relax! Take it easy; sit around and enjoy music or conversation. You can watch TV with your other eye. Do not drink any alcohol the first day. Do not fiddle with the eye patch; keep it clean. You probably will have a scratchy feeling from the tiny stitches in your eye but feel only discomfort or minor pain now, at a level that requires nothing more than Tylenol [acetaminophen]. While a shower or bath might be relaxing, be careful not to get any water, much less soap or shampoo, in your eye. Be careful not to get into any situation where your operated eye might be poked or pressed.

The first twenty-four hours after the surgery, you will feel fairly normal. However, you will still be under the effect of the anesthesia, so you should not drive or conduct other activities requiring alertness and quick responses. You will not be able to see well because you will be newly one-eyed, sometimes with a patch over the operated eye that prevents wearing your glasses. Your depth perception will be poor, so be careful around stairs and curbs.

The next day you will need transportation to and from the doctor’s office. Here, they will ask about your first night and check your visual acuity. Do not worry if it is poor at this point; often people cannot even see the big E, even with the pinhole device. Your intraocular pressures will be checked, with the usual drops given for that, and the eye examined to make sure the wound is well-closed and the trabeculectomy working well. If the pressure is higher than expected, a suture may be removed with a small sharp knife or laser to open up the trabeculectomy flap further. Your medication instructions will again be reviewed with you. Your next appointment will be set up; this is often for a week later, but sometimes it is for the next day.

First week following surgery

Not too many years ago, people were required to spend this first week in bed. That is no longer true, but your restrictions will be in full force, and should be carefully observed. You should limit yourself to non-strenuous activities: don't strain, don't bend, and don't lift anything over 10 pounds. Protect your eye with either the shield or glasses. A patch is not needed, however, some people find that wearing the patch at night helps minimize discharge and irritation. If you find that the tape supplied in the kit irritates your skin, there are alternatives such as paper tape available. If the tape is so sticky that it feels like it pulls off some of your skin each time you remove it, try sticking it to a clean spot on your clothes or a clean cloth several times to remove some of the stickum before using it on your face.

You may notice some strange particles floating in the eye, as well as a little discharge, but these are usually no problem. Follow the instructions you have been given for cleaning the eye, being as gentle as possible.

Other people may not notice anything unusual about the appearance of your eyes if they are used to you wearing glasses and no eye makeup. Upon closer inspection, your eye may appear slightly red and watery. This is because the new outflow of fluid may collect just above the lower eyelid, lifting the conjunctiva above the surface of the eye. Do not worry as this means things are working as expected, and the appearance of things will gradually improve. A “black eye”, caused by bleeding from the anesthesia needles, will fade like a bruise, first fading to brown, and then green.

Most people feel some discomfort, but not pain. Many report periods of feeling blue as well as euphoric. The vision in your trab eye will be poor but you will have your normal vision in your other eye. This is usually sufficient for many activities, including computer work. Rest your eyes whenever they feel tired. Driving may be possible, but your vision is probably worse in this regard than you realize, so be very careful.

You'll be busy medicating your eye. In addition to your regular medications for your non-trab eye, you will be using at least two different drops in your newly operated eye, and one of these is needed every few hours during the day. For most people, a chart and a timer helps keep everything on schedule. This is a good opportunity to put your eager helpers to work. Double-check the instructions for your medicine: many people miss the fact that the steroid bottle needs shaking before administering drops. Remember to wash your hands before medicating, and to allow five minutes for absorption between the different drops.

The first six weeks following surgery

Your doctor will need to check your eye frequently during this period. Weekly exams are often required for about a month, and then the period between exams is gradually lengthened. Keep track of your supply of medications; at some point you may run low and need additional prescriptions from your doctor. It is best to have someone else do your driving, especially to doctor appointments since the doctor may need to do a procedure that would impair your driving ability.

Acuity in the trab eye improves over what it was immediately post-surgery, but often remains below your pre-surgery level, at least while the new medications are continued. It may take months for your vision to stabilize, so do not be too eager to buy new glasses.

After several weeks, the medications are slowly tapered off, and similarly your restrictions are gradually lifted. The stitches closing the cut in the conjunctiva will dissolve during this period or may need to be removed. The latter is done in the office with a drop of liquid anesthesia and is pain-free. The area of conjunctiva that is raised by fluid draining from the trabeculectomy, the bleb, gradually changes shape.

After about a month, some people begin to feel that their eye has healed. However, the new scars are being remodeled as a balance is sought between the body's tendency to scar over the opening, and the pressure of the eye's fluid keeping it open. Stability may be achieved in as little as three months, but it often takes longer. Being well prepared will help you keep this period as pleasant as possible.