Post-operative Care
Chat Highlights
October 8, 2003

Norma Devine, Editor

On Wednesday, October 8, 2003, Dr. Jeff Henderer, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Post-operative Care."

Moderator:  Welcome, Dr. Henderer.  We're glad you could fill in for Dr. Wilson tonight.  Who wants to ask the first question about postoperative care?

P:  Dr. Henderer, is all postoperative care the same or does the care after a trabeculectomy differ from the care after a shunt or after a combined cataract-trabeculectomy (trab)? 

Dr. Jeff Henderer:  For me, the antibiotic and anti-inflammatory eye drops are about the same.  Sometimes after a tube (shunt) I'll reach for a glaucoma medicine, whereas I'll try to avoid that after a trab. 

P:  What is the usual amount of time before a patient might expect to return to work after a trab, a shunt, and combined surgery, provided there are no complications? 

Dr. Jeff Henderer:  I think at least a week, if the eye has healed correctly.  Trabs, maybe two weeks.  Cataracts and tubes, perhaps one.  Kids heal fast, so waiting one week before resuming normal activity is usually okay.  

Moderator:  Is that the same for a single surgical procedure?

Dr. Jeff Henderer:  I think so, but it depends on the procedure.  Cataract surgery is less complicated than glaucoma surgery, so the drops are usually less frequent and for less time.

P:  How long is it advisable to wait before returning to aerobic exercise following combined trab-cataract surgery?

Dr. Jeff Henderer:  I like to say at least a week, but it depends on the type of exercise (riding a bike is okay) and if the IOP (intraocular pressure) is low.  I like to hold off on swimming for at least a week or two.

P:  Is there need to be concerned about the pressure around the the eyes from a swim mask, especially if you have a bleb?  

Dr. Jeff Henderer:  I have not really encountered that one, but I suspect that as long as you take care to equalize pressure, it should be okay.  Another question is whether the increased pressure of being under water raises IOP.  I don't know the answer to that one.

P:  If a doctor suggests surgery, what questions should a patient ask? 

Dr. Jeff Henderer:  The first question is "why?"  What problem will be solved by the surgery?  Will it lower IOP?  Will it help vision?  Will it reduce the need for medication?  Those are all valid reasons for the surgery.  The second question is, what is the likelihood that the surgery will help me?  The third is, what are the risks, the success rate, the post-op time course for healing?  I'd start with those questions.

P:  Can I be put to sleep for the surgery?  

Dr. Jeff Henderer:  You can always elect general anesthesia, but it is not recommended for most people.  It's an unnecessary risk for most.

P:  Is it true that the more times you have general anesthesia, the more your body responds adversely to it?  I've had a lot of surgeries, and I seem to get worse post-op nausea after each one.

Dr. Jeff Henderer:  I am not sure I would say that is a always the case, but I've noticed that, too, for some kids I've operated on.

P:  Are there any specific hygiene measures that should be taken following combined trab-cataract surgery?

Dr. Jeff Henderer:  I'm not sure that there is anything different than for a trab.  No water in the eye for a week.  Wash the face with a washcloth.  Use the antibiotics.  No lid scrubs, as you might do for blepharitis.

P:  Does blepharitis present a serious postoperative problem?  Would that be a continuing problem for someone with a bleb or shunt?  

Dr. Jeff Henderer:  I think of blepharitis as a risk factor for post-op infection.  It is not a serious problem; it's more like a chronic low-grade inflammation.  And it certainly could be a continuing problem.

P:  Are patients with a trab more likely to get blepharitis than the general population?

Dr. Jeff Henderer:  I don't think so.

P:  How long after a trab does the doctor perform laser suture lysis? Why would the doctor choose laserable sutures instead of  removable sutures?

Dr. Jeff Henderer:  That all depends on the intraocular pressure.  If it is high, then perhaps the next day.  If the pressure is okay, then perhaps never.  I like to use both releasable and laserable sutures.  Why?  It's easier to remove the releasable ones.  There's no need to use the laser.  

P:  Are the conjunctival flap sutures ever removed?

Dr. Jeff Henderer:  Not usually.  If the knots get exposed, or the suture line gets exposed, yes.  But that is not always true. Sometimes I never remove them.  If the sutures were absorbable, then you don't have to have them removed.

P:  Are the remaining sutures gradually absorbed by the body, or are they always there?

Dr. Jeff Henderer:  Nylon sutures are gradually broken down after four to five years.  

P:  Do you have general instructions that you give all your patients who have just had cutting surgery?  Are instructions for post-trab care different from those for post-shunt surgery?

Dr. Jeff Henderer:  All my patients get instructions to rest for the first few days.  No heavy lifting; no bending over.  I'm not as concerned if the IOP is normal after surgery, but if it is low, then I have people really take it easy.  Eye drops are the same, unless I need to lower IOP after the tube.

P:  There doesn't seem to be any post-op care required for laser procedures, other than follow-up visits.  Is that correct?  Should the patient rest the eyes the day of the procedure, or resume normal activities?  

Dr. Jeff Henderer:  Usually the eye will be blurred for a few hours after surgery, so I have people take it easy the rest of the day.  Not that it will cause harm, but it's odd to have one eye blurry.  Follow-up is, as you say, the main issue.

P:  I had to wear a hard eye patch after a trab.  How long should the hard patch be worn?  

Dr. Jeff Henderer:  That's a good point I forgot to mention.  I like to have people wear the shield at night for at least a week, until the conjunctiva starts to heal and to protect the eye if the IOP is low.  After about a week, I only have people use the patch if the IOP is low.

P:  If a patient is taking an NSAID (non-steroidal anti-inflammatory drug) for three days in preparation for cataract surgery, is the NSAID stopped at the time of surgery and replaced by a steroid for the post-surgery period?  If so, why?

Dr. Jeff Henderer:  I think that most surgeons are looking for a little more anti-inflammatory effect post-op, so they add the steroid.  Some continue the NSAID.  Some don't.  Some do under certain circumstances (for instance, if you were using a prostaglandin analog before surgery).

P:  If you have a bleb needling procedure done to a scarred-over bleb, will the post-op period vision be similar to that in the post-op period after the trabeculectomy?  That is, will the vision be blurred for several weeks?  

Dr. Jeff Henderer:  That's a tough question to answer.  It really depends on a couple things.  First, did you have bleeding at the time of the needling?  That's rare, but might cause blurred vision.  Second, did your IOP drop after the needling?  If it dropped a lot, you might expect blurred vision, and it might last as long as the IOP stays low. That, in my experience, is not as long as the original surgery, but can be.

P:  Does the needling hurt as much as atropine injections?  I'm very fearful about this aspect of the surgery, having had atropine injections as a child.  I remember incredible pain and discomfort.

Dr. Jeff Henderer:  I confess I have never heard of atropine injections.  Needling should not hurt.  The eye is numb from topical drops; you're not put to sleep as for surgery.  You will feel pressure and the eye moving, but there should be no pain. 

Moderator:  One time the doctor did something with a needle to my eye the day after a trab, and it was not an injection of 5-FU.  Could it have been to open up the bleb?  Do you ever needle a flat bleb the day after the surgery?

Dr. Jeff Henderer:  You can push on the eye to try to release fluid through the trab if the IOP is high.  I'll do that before removing a suture.  It would be uncommon to needle the first day.  I prefer to cut sutures.

P:  When you were in class hearing about needling the eye for the first time, didn't the class have an "eeewwwww" reaction?  I know I do!

Dr. Jeff Henderer:  I agree!

P:  What is the "blister" thing with a needle that is done to the eye on the first day after a trab?

Dr. Jeff Henderer:  Do you mean an injection of 5-FU to help prevent scarring?

P:  Maybe it was 5-FU.  I was only 17 years old.  After two trabs, I was given at least Tylenol #3 with codeine and I had a LOT of pain.  I have nystagmus.  Could that have made my eye hurt more? 

Dr. Jeff Henderer:  I'm sorry it was so painful. Perhaps it was the surgery; perhaps the sutures.  It may well have been 5-FU for the second trab.

P:  My doctor said if he has to needle my bleb in the near future he would have to do it in the operating room because of the nystagmus.  You need to be able to hold your eye still when someone is sticking a needle in it!

Dr. Jeff Henderer:  Yep.  I can understand that.

P:  Does a trabeculectomy influence the course of uveitis?

Dr. Jeff Henderer:  I would say the opposite.  Uveitis can really cause trouble in that it leads to bleb failure.  I have not really seen uveitis stirred up by a trab, but I've certainly seen rapid failure. Some use tubes in this situation, even before a trab.

P:  What are the risk factors for post-trabeculectomy endophthalmitis?

Dr. Jeff Henderer:  That depends upon if you mean early or late post-op endophthalmitis.  If early, it's like any surgery.  If it's late, there's no doubt that a bleb leak is a problem.  So are inferior blebs, and conjunctival erosions.  Blepharitis may play a role, too.

P:  Is recovery time longer if you have a repeat trab or a shunt after a failed trab?  

Dr. Jeff Henderer:  For a repeat trab, I tend to be a bit more aggressive.  I mean, the IOP might be low post-op, which could  lead to a longer recovery.  For tubes, no.  The recovery time is the same as usual.

P:  Would you keep a patient who has hypotony home for a longer time?  

Dr. Jeff Henderer:  I would until the eye starts to recover.

P:  How common is post-op ocular pain and what do you generally give patients for it?

Dr. Jeff Henderer:  I have always felt that there should be no post-op pain.  That's not to say there isn't soreness or some foreign-body sensation from the sutures.  But no pain that Tylenol can't control.  More pain that that, I want to hear about it.

Moderator:  Should pets such as dogs and cats be removed from the house after combined trabeculectomy-cataract surgery?  If so, for how long?  

Dr. Jeff Henderer:  I've not heard about that.  I've not told people to stay away from pets.  Why?

Moderator:  The question was sent in by someone.   I assume she is concerned about pet hair or allergies.

Dr. Jeff Henderer:  I think that is a great question, as allergies to pets are a common causes of eye irritation.  I am not sure that I would like to see a highly allergic person with a pet after surgery, but I don't think that it's a big problem, that I'm aware of.

P:  Is it possible for an aphakic patient to continue to use contact lenses after a trab or shunt procedure?

Dr. Jeff Henderer:  I'm not a big fan of contact lenses after trabs.  I've heard of some who use soft lenses, but I'm not in favor unless the bleb is vascular.  Then, maybe.  For shunts, lenses are probably okay. 

P:  Can any ophthalmologist perform glaucoma surgery?

Dr. Jeff Henderer:  Most ophthalmologists can do trabs.  Only glaucoma specialists, by and large, perform shunt surgery.  Other more unusual procedures are really only for specialists, too.  It's not that that non-specialists can't perform them; it's just a matter of experience.  I know that Dr. Wilson can do vitrectomy.  I can't.  I could, perhaps, if pushed, but I wouldn't ever do it if I could avoid it.

P:  Is a vitrectomy a routine part of shunt surgery?

Dr. Jeff Henderer:  No.

P:  What do you recommend for cleaning lids if you have a trab?

Dr. Jeff Henderer:  I'd go for oral antibiotics and perhaps lid soaks as a treatment for blepharitis.  Maybe even some topical antibiotic cream.

P:  Could scrubbing the eyelids several times a day, part of the treatment for blepharitis, inadvertently damage a bleb or shunt?

Dr. Jeff Henderer:  Probably not a shunt, but most certainly a bleb.  I don't recommend scrubs after trabs for that reason.

P:  What causes blepharitis?

Dr. Jeff Henderer:  I'm not sure anyone really knows the answer to that one.  I sort of lump it in with dandruff, although blepharitis can take the form of plugged oil glands in the lid, as well as scruff on the lashes.

P:  Would you say that those who have chronic blepharitis, and must scrub the eyelids several times a day, should not have blebs?  If not, what what should they do if their IOP isn't controlled by eye drops?

Dr. Jeff Henderer:  I have never not done a trab because of blepharitis.  I don't think it is that much of a problem.  But I do use antibiotics more liberally and think about it a bit more.

P:  Dr. Henderer, before you leave, will you tell us your impression of the recent symposium at Wills?  

Dr. Jeff Henderer:  It was exceptional!  I must say that.  The presentations were excellent.  The meeting was great.  Hats off to the gang who put it together. 

P:  Thank you, Dr. Henderer.  

Moderator:  I hope you can join us again sometime soon.

End of highlights for October 8, 2003.

On October 15, Dr. Wilson discussed "Working with Glaucoma" in the Chat room. Click here for highlights of that meeting.

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