Glaucoma

Some Glaucoma Procedures Have Higher Risk of Intraoperative Bleeding

Jessica Nye, PhD
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Trabeculectomy
Trabeculectomy. Close-up of suturing the eye of a patient after a trabeculectomy, an operation to reduce pressure in the eye caused by glaucoma. The eye is held open by a metal retractor and a needle & forceps are seen stitching the thread. Glaucoma is caused by fluid build up in the eyeball. A trabeculectomy creates an alternative outlet for this fluid, thus reducing pressure. The mucous membrane covering the front of the eyeball (the conjunctiva) is opened and a half thickness of the white of the eye (the sclera) is cut and folded forward. A connection is made into the front chamber of the eye to act as a fluid outlet. The flap is sutured shut & conjunctiva replaced.
Scleral manipulations, concomitant disease linked with events, according to researchers

Patients undergoing glaucoma operations entailing scleral manipulations and those with concomitant diseases were more likely to have severe intraoperative bleeding. These findings, from a prospective cohort study, were published in Clinical Ophthalmology.

Patients (N=89) undergoing glaucoma surgery at the University Medical Center Gottingen in Germany were recruited for this study between 2019 and 2020. Risk for intraoperative bleeding events was predicted prior to surgery using a questionnaire and observed events were evaluated on the basis of surgical procedure and patient characteristics. Bleeding severity was graded using a 5-point ordinal scale and severe bleeding was defined as a score of 3 points or more.

The study population comprised 55.1% women, aged mean 71.3±10.5 years, 66.29% had arterial hypertension, 13.48% diabetes mellitus, and 11.24% deep vein thrombosis.

During surgery, 69.7% received intubation anesthesia, 29.2% local anesthesia, and 1.1% parabulbar block. Most operations were first-time procedures (67.4%) and 50.6% of operations were performed on the right eye.

In total, there were 89 (9%) bleeding events, 8 of which were severe. Among all bleeding events, they occurred most frequently during viscocanaloplasty (22.2%) followed by trabeculectomy (13.3%) and goniotomy with Trabectome® (NeoMedix) (5.3%). Among severe events, 4 occurred during trabeculectomy, and 2 each during goniotomy with Trabectome and viscocanaloplasty.

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Among the cohort of patients who had severe bleeding events, most occurred among men (7 vs 1; P =.01) and the events correlated with deep vein thrombosis and peripheral artery occlusive disease (both P =.04). In addition, severe bleeding tended to occur after longer duration surgery (mean, 49.6 vs 33.7 min; P =.044).

The incidence of major bleeding complications was not predicted by the presurgical risk questionnaire (P =.39) nor was use of antiplatelet or anticoagulant agents associated with increased risk for severe bleeding events (P =.13).

This study was likely limited by the small number of patients who experienced a severe bleeding event, limiting the power to detect significant effects.

This study found that the presence of deep vein thrombosis and peripheral artery occlusive disease and undergoing trabeculectomy or viscocanaloplasty may be associated with increased risk for severe intraoperative bleeding among patients with glaucoma.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Lauermann P, Klingelhöfer A, Mielke D. Risk factors for severe bleeding complications in glaucoma surgery and the role of antiplatelet or anticoagulant agents. Clin Ophthalmol. 2022;16:1245-1254. doi:10.2147/OPTH.S361867

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