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Atlas of

Glaucoma Surgery

Atlas of
Glaucoma Surgery
Editors

Tarek Shaarawy MD
Consultant and Head, Glaucoma Sector
Department of Ophthalmology
Geneva University Hospitals
University of Geneva
Geneva, Switzerland

Andr Mermoud MD
Professor and Head
Glaucoma Unit
Department of Ophthalmology
Jules Gonin Eye Hospital
University of Lausanne
Lausanne, Switzerland
Foreword

Peter G Watson

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Atlas of Glaucoma Surgery
2006, Tarek Shaarawy, Andr Mermoud
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To
Mohamed Abd El-Samad Nada, Pierre Mermoud,
Mounir Shaarawy, Alex Mermoud,
and Hussein Shaarawy.
(A grand father, two fathers, and two sons)
Acknowledging that from the more distinguished gentlemen
we have learned that real excellence and
humility are not incompatible.
We in turn will always strive to pass this
on to the two young gentlemen.

Contributors

Ahmad K Khalil MD PhD


Research Institute of Ophthalmology
Cairo, Egypt
Ahti Tarkkanen MD
Professor Emeritus of Ophthalmology
University of Helsinki
Former Director, Helsinki University Eye Hospital
Helsinki, Finland
Andr Mermoud MD
Professor, Department of Ophthalmology
Jules Gonin Hospital
University of Lausanne, Switzerland
Anthony CB Molteno FRCS
Professor, Section of Ophthalmology
Department of Medical and Surgical Sciences
University of Otago, Dunedin School of Medicine
Dunedin, New Zealand
Christian Prnte MD
Professor
University Eye Clinic, Basel, Switzerland
Daniel Elies MD PhD
Refractive Surgery Department
Instituto Oftalmolgico de Barcelona, Spain
Dilani Siriwardena FRCOphth
Glaucoma Fellow
Moorfields Eye Hospital
London, UK
Doina Gherghel MD
University Eye Clinic
Basel, Switzerland

Francesca Cordeiro PhD MRCP FRCOphth


Wellcome Trust Lecturer
Glaucoma and Optic Nerve Head Research Group
Institute of Ophthalmology (assoc. with Moorfields Eye
Hospital), London, UK
Frank Howes MBChB MMed FCS FRCS FRCOphth
Consultant Ophthalmologist
Clayton Eye Centre, Wakefield
West Yorkshire, UK
Gonzalo Munoz MD PhD FEBO
Glaucoma and Refractive Surgery Department
Instituto Oftalmolgico de Alicante, Spain
Harry Roux
Ophthalmology Resident
Department of Ophthalmology
University of Geneva, Switzerland
Hazem R El-Kholefy FRCS
Maghrabi Eye Hospital
Cairo, Egypt
Ivan O Haefliger MD
Professor
University Eye Clinic, Basel, Switzerland
Jeffrey M Liebmann MD
Professor of Ophthalmology, Manhattan Eye,
Ear and Throat Hospital, New York
New York University Medical Center, New York
Jorge Zarate MD
Department of Pathology
University of Buenos Aires, Argentina
Jose I Belda-Sanchis MD PhD FEBO
Glaucoma and Refractive Surgery Department
Instituto Oftalmolgico de Alicante, Spain

viii

Atlas of Glaucoma Surgery

Josef Flammer MD
Professor and Head
University Eye Clinic, Basel, Switzerland
Juan Jose Perez-Santonja MD PhD FEBO
Glaucoma and Refractive Surgery Department
Instituto Oftalmolgico de Alicante, Spain
Juan Roberto Sampaolesi MD
Department of Ophthalmology
School of Medicine, University of Beuenos Aires
Argentina
Kaweh Mansouri MD
Glaucoma Fellow
University Eye Clinic
Basel, Switzerland
Madhu Nagar MS Ophth FRCS Ophth
Consultant Ophthalmologist
Clayton Eye Centre
Wakefield, West Yorkshire, UK
Oscar Albis-Donado MD
Glaucoma Specialist from the Association Para Evitar
la Ceguera en Mxico
Assistant Professor, Universidad Del Norte
Chief, Glaucoma Service
Unidad Lser del Atlntico, Barranquilla, Colombia
Hospital Universidad del Norte, Barranquilla
Colombia
Pivi Puska MD
Docent of Ophthalmology, University of Helsinki
Head, Glaucoma Service
Helsinki University Eye Hospital
Helsinki, Finland
Paul J Foster PhD FRCS (Ed)
Clinical Senior Lecturer
Department of Epidemiology
Institute of Ophthalmology
University College London
and Honorary Consultant
Moonfields Eye Hospital, London

Peng Tee Khaw

PhD FRCS FRCOphth FRCP FRCPath


FIBiol FMedSci

Professor of Glaucoma and Ocular Healing


Moorfields Eye Hospital and Institute of
Ophthalmology, London
Peter Shah BSc (Hons) MB ChB FRCS FRCOphth
Consultant Ophthalmic Surgeon
Birmingham and Midland Eye Hospital and Good
Hope Hospital NHS Trust, Birmingham
Robert Ritch MD
Professor of Clinical Ophthalmology
Chief, Glaucoma Service,
Surgeon Director
The New York Eye and Ear Infirmary, New York
New York Medical College, Valhalla, New York
Roberto Sampaolesi MD
Professor Emeritus, Department of Ophthalmology
School of Medicine, University of Buenos Aires
Argentina
Selim Orgl MD
Professor
University Eye Clinic, Basel, Switzerland
Tarek Shaarawy MD
Head, Glaucoma Sector
University of Geneva
Geneva, Switzerland
Tero Kivel MD
Docent of Ophthalmology, University of Helsinki
Director; Helsinki University Eye Hospital
Helsinki, Finland
Tui H Bevin MPH
Section of Ophthalmology,
Department of Medical and Surgical Sciences
University of Otago, Dunedin School of Medicine
Dunedin, New Zealand
Wisam A Shihadeh MD
Clinical Glaucoma Fellow
Department of Ophthalmology
The New York Eye and Ear Infirmary, New York

Foreword

Glaucoma does not constitute a disease entirely but embraces congeries of pathological conditions which have the
common feature that their clinical manifestations are to a greater or lesser extent dominated by an increase in intraocular pressure.1
The concept of angle closure dates back to 1876 when two investigators, Max Knies2 and Adolf Weber,3 working
independently noted the obstruction of the angle of the anterior chamber. Priestly Smith4 used this information to
develop the theory of peripheral angle closure and changed the emphasis from over-production of aqueous to a
failure of outflow from the eye as the cause of the raised pressure. He also noted that the change in size of the lens
with age contributed to acute glaucoma. It remained then, for Otto Barkan5 in the late 1903s to further define the
diseases of the angle and to reclassify the glaucomas into open and closed angles. It was then that Currans6
suggestion of the mechanism of angle closure through pupil block became accepted and formed the basis of
modern approaches to treating acute angle closure which are almost universally successful.
Von Graefes7 amaurosis with excavation of the disc without inflammation (what was subsequently called simple
glaucoma) is far from simple. The cause and effect of primary open angle glaucoma have been the subject of
circular arguments for several decades which are still not close to resolution. So far the only intervention known to
reduce the chances of progression of this condition is the reduction of intraocular pressure. Almost every
pharmacological mechanism known to be involved in the circulation of aqueous by either the conventional trabecular
or uveo-scleral pathways has been manipulated to provide drugs to maintain a low intraocular pressure with
minimal side effects. In this medical therapy has been largely successful but the pressure of advertising has, perhaps
deliberately, obscured the value of early surgical intervention in chronic open angle glaucoma. There are some
patients, particularly those who present with advanced disease and/or high initial intraocular pressures, who all
agree require early surgery but many have developed advanced visual field loss through procrastination and
reluctance to undertake the necessary surgery. One of the worst phrases ever coined was maximum tolerated
medical therapy which implies that surgery is a course of last resort rather than a highly successful sight saving
procedure performed early in the disease. Having to use these criteria certainly biased the results of the Advanced
Glaucoma Intervention Study.8
Surgery had, and to an extent still has, a degree of morbidity which, to those used to the almost complication-free
operation of cataract, is unacceptable. An eye left inadequately treated results in eventual blindness. This means that
a certain degree of risk must be accepted. McKenzie9 rightly associated the high intraocular pressure with the march to
blindness but thought that this pressure was caused by liquid vitreous and therefore advocated the broad iris knife be
driven into the vitreous and rotated to release the fluid! It is not surprising to us now that this did not work for long and
was associated with many problems. In 1857 Critchett,10 incorporated an iris wick into the wound so first establishing
the filtering cicatrix, a term coined by de Wecker.11 This is still the principle of all successful modern surgical, and some
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Duke Elder WS. Textbook of Ophthalmol, 3 Kimpton 1940;3280-85.


Knies MV. Graefes Arch. Ophthalmol. 1876;22 (3) 163.
Weber AV. Graefes Arch Ophthalmol. 1877;23 (1) 1.
Priestly Smith T. Glaucoma, its causes, symptoms, pathology and treatment 1879.
Barkan O. Glaucoma:- Classification, causes and surgical control. Amer J Ophthalmol 1099;21 1099.
Curran. Trans Ophthalmol. Soc. 1931; 51:520
Von Graefe A. Von Graefes Arch. Ophthalmol. 1857;32: 456.
The AGIS Investigators. The advanced glaucoma intervention study 4: comparison process V. Graefes Arch Clin Exp Ophthalmol 1998;3(2): 456.
McKenzie W. A practical treatise on diseases of the eye. 703, 706 Longman Rees, Orme, Brown and Green, London.
Critchett G. Royal London Hosp. Report 1857;1, 57.
De Wecker. Ann Oculist, Paris 1896;116: 249

Atlas of Glaucoma Surgery

laser, therapies. Since the 1860s history has repeated itself. The wheel has continued to turn with different groups
developing different ways of either retracting the iris root to allow more fluid to flow through or making a hole large
enough in the eye for the fluid to drain from it. This must be achieved without permitting too much fluid to escape
under the conjunctiva so that it becomes so thin that it is liable to infection. That so many have tried to achieve this
goal means that none has entirely filled the requirements of a completely satisfactory operation. In the last 50 years
we have had anterior lip sclerectomy12, 13 iridencleisis of Holth,14 Elliott trephination,15 and Scheies operation,16 Stallards
single pillar iris inclusion,17 trabeculotomy,18 trabeculectomy19, 20 and multiple laser procedures. Many attempts were
made during the 1960s by Remond Smith.21
Cairns22 and others to isolate Schlemms canal, allowing fluid to drain through the trabecular meshwork without
opening the eye. None of these was successful over the long-term and modern attempts to do the same thing seem
to have a poor record so far. So it is that one of the many modifications of trabeculectomy remains the current
preferred option because so far this is the only procedure in which the flow of fluid from the eye can move into the
sub-Tenons space at a slow enough pace. The underlying reason for this is that the sclera heals slowly if at all. The
layer of excised sclera is covered by a second scleral flap which is capable of moving slightly in the early postoperative stages. This not only allows the aqueous to flow through the operated region into the subepiscleral and
subconjunctival space, but also responds to the pressure variations which occur postoperatively. The aqueous itself
partly controls the healing reaction of the episclera and conjunctiva.
When normal, and not affected by either long-term topical medicaments or locally applied anti-metabolites,
the conjunctiva and episclera will allow diffusion of aqueous through them. Furthermore the aqueous itself inhibits
the scarring process so that a cavity is formed in which there is an equilibrium between the intraocular pressure, the
subepiscleral tissue pressure or the episcleral venous pressure if the aqueous drains into these vessels.
Surgery and laser therapy have been accepted completely for the treatment of angle closure glaucoma and it
still remains true that early aggressive treatment of chronic open angle glaucoma in an otherwise normal eye has
the greatest possibility of success. Unfortunately if fewer and fewer surgical procedures are being undertaken the
experience and confidence of the surgeon must diminish. This makes it essential that a text such as this is available
for all to refresh their memories and to ensure that the techniques of the masters of the subject can be followed
completely.
Even though we still do not fully understand the mechanisms and genetic background to the conditions known
as glaucoma, we are able to offer palliative and sometimes curable therapies. This will continue until we can target
each individual type of the multitude of conditions which we now call glaucoma.

Peter G Watson MA MB BChir FRCS FRCOphth DO


Boerhaave Professor, University of Leiden,
Honorary Consultant, Addenbrokes Hospital, Cambridge
Honorary Consultant, Moonfield Eye Hospital, London, UK

12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Herbert H. Subconjuncival fistula formation in the treatment of primary chronic glaucoma. Trans Ophthalmol Soc UK 1903;23: 324.
La Grange F. Production of a cicatrix in chronic glaucoma. Ophthalmoscope 1907;5: 467.
Holth S. Iridencleisis cum iridotomia meridionali. Arch Ophthalmol 1930;4: 803.
Elliot RH. A preliminary note on a new operative procedure for the establishment of a filtering cicatrix in the treatment of glaucoma. Ophthalmoscope 1909;7: 804.
Scheie HG. Peripheral iridectomy with scleral cautery for glaucoma. Arch Ophthalmol 1959;61: 291.
Stallard HB.Anterior flap sclerectomy with basal iridencleisis. Eye Surgery John Wright, Bristol 4th Edition., 1965;53-665.
Burian HM, Allen L. Trabeculotomy ab externo, a new glaucoma operation Am J Ophthalmol 1962;53: 19.
Cairns JE. Trabeculectomy. Preliminary report of a new method. Am J Ophthalmol 1968;66: 673.
Watson PG. Effectiveness of trabeculectomy in glaucoma. 1975;79, 5, 831-845.
Smith R. A new technique for opening the canal of Schlemm. Preliminary report. Br J Ophthalmol 1960;44: 370.
Cairns JE. Goniospasis. Eine Methode, die zur Entlastung der Kanalblockade bei Primarem Weitwinkelglaukom Entwickelt Wurde, Klin.Monatsbl. Augenheilkd. 1974;165: 549.

Acknowledgements

We would like to express our utmost appreciation to our co-authors who showed a sincere willingness to contribute
to this scientific endeavor. Sincere thanks are also due to Mr PG Watson for accepting to write the Foreword.
Our heartfelt gratitude to Professor AB Safran, Head, Department of Ophthalmology, University of Geneva
and Professor L Zografos, Head, Department of Ophthalmology, University of Lausanne, for their continued
support of our clinical and academic activities.
We would like to graciously acknowledge Dr K Mansouri for his efforts in the coordination of this extensive
undertaking. We also find it important to mention that were it not for the patience and understanding of our
Publisher Mr JP Vij, CMD of M/s Jaypee Brothers Medical Publishers, this piece of work would not have come to
see the light. Last but not least we would like to offer our sincere thanks to Mrs G Ibrahim for her meticulous
revision of the manuscript and for offering valuable suggestions and criticism.

Tarek Shaarawy
Andr Mermoud

MD
MD

Contents

1. Reducing Intraocular Pressure: Is Surgery Better than Drugs? ............................................... 1


T Shaarawy, J Flammer, IO Haefliger
2. Trabeculectomy .................................................................................................................. 11
PT Khaw, P Shah
3. Trabeculectomy with a Scleral Tunnel Technique Combined with Mitomycin-C ................... 32
D Gherghel, S Orgel, Ch Prnte, J Flammer
4. Cyclodestruction in Glaucoma ............................................................................................ 37
A Tarkkanen, P Puska, T Kivel
5. Resurrecting the Failing Filtering Bleb ............................................................................... 45
WA Shihadeh, R Ritch, JM Liebmann
6. The Ahmed Valve ................................................................................................................ 58
O Albis-Donado
7. The Use of Molteno Implants to Treat Complex Cases of Glaucoma ..................................... 77
ACB Molteno, TH Bevin
8. Nonpenetrating Surgery .................................................................................................... 102
A Mermoud
9. Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks ..................................... 112
R Sampaolesi, JR Sampaolesi, J Zarate
10. Shortening the Learning Curve of Deep Sclerectomy ......................................................... 131
H Roux, T Shaarawy
11. Postoperative Management of Nonpenetrating Glaucoma Surgery ..................................... 140
K Mansouri, T Shaarawy
12. Trabeculotomy Ab Externo ................................................................................................ 150
AK Khalil
13. Selective Laser Trabeculoplasty ....................................................................................... 161
F Howes, M Nagar
14. Combined Cataract Glaucoma Surgery ............................................................................. 170
H Kholefy
15. Management of Angle-closure ........................................................................................... 182
P Foster

xiv

Atlas of Glaucoma Surgery

16. Modulation of Wound Healing ........................................................................................... 188


D Siriwardena, MF Cordeiro
17. Glaucomatous Complications of Refractive Surgery .......................................................... 197
G Muoz, JI Belda-Sanchs, J Prez-Santonja, D Eles
Index .................................................................................................................................................... 203

Tarek Shaarawy, Josef Flammer, Ivan O Haefliger

1 Reducing Intraocular Pressure:


Is Surgery Better than Drugs?

INTRODUCTION
Glaucoma is a progressive optic neuropathy involving
characteristic structural-pathological changes in the optic
nerve head. 1-3 Estimate of the number of patients
bilaterally blind because of glaucoma ranges between 7
and 8 million people.4-6 Glaucoma is an increasingly
important public health concern due to our aging
population demographics, and has been identified as
the second leading cause of blindness world-wide and
the first cause of irreversible blindness.
It is irreversible because it results from the
degeneration of retinal ganglion cells, and to date there
is no cure for neuronal central nervous system
degeneration, or means of regenerating lost neurons.
After more than a century of active research in the
management of glaucoma, the Holy Grail of glaucoma
treatment is still elusive and we have to be pragmatically
content with our attempts to prevent further progression
of glaucomatous damage, rather than curing the disease.
Glaucoma progression is strongly associated with a
number of risk factors.7-14 Some of these factors are
unmanageable like ethnicity and age, while others can
be manipulated, with varying degrees of success, in an
attempt to slow or arrest progression, like IOP and
possibly vascular dysregulation.
Reducing IOP is presently the evidence based, most
accepted, and most practised therapeutical approach of
glaucoma patients. 12,15 Currently topical ocular
hypotensive medications, with its different classes, as well
as filtering surgery (trabeculectomy and non-penetrating
surgery) are in the forefront of therapeutic modalities to
reduce IOP.15, 16-22
This review article looks at the potential advantages
and disadvantages of topical medications versus filtering

surgery and vice versa. It does not directly address the


question of initial treatment of glaucoma,19, 20, 23-28 or what
is the better treatment29 of glaucoma, as other review
articles had, but rather looks in a more specific fashion
on the pros and cons of each in relation to IOP reduction.
In other words this review article deals with the situation
once the decision has been made to reduce IOP.

WHAT IS THE IDEAL TREATMENT TO


REDUCE IOP?
Based on available knowledge12,15,17,22,23,27,29 an ideal
treatment to reduce IOP should achieve different
objectives. It should offer sufficient reduction in IOP,
possibly in the low teens. It should provide this reduction
on a long-term basis and not just momentarily or
sporadically. It should be associated with minimal IOP
fluctuation, IOP fluctuation being identified as a significant
and independent risk factor. It should, if possible,
encourage patient compliance or better still, be totally
independent from the compliance factor. On top of all
that the ideal treatment should offer tolerable systemic
and local side effects, or again better still be devoid of
side effects.
Last but by any means not least, in a world
exceedingly aware of the heavy medical care expenses30
an ideal treatment to reduce IOP should be economically
sound.

SUFFICIENT REDUCTION OF IOP


Although it has been suggested that IOP reduction should
be individualized to specific target pressure31 for each
specific patient, in the majority of our patients we are
mostly aiming at pressures in the low teens.32

Atlas of Glaucoma Surgery

In the Advanced Glaucoma Intervention Study


(AGIS),32 eyes were randomized to laser trabeculoplasty
or filtering surgery when medical therapy failed. In the
roughly one quarter of eyes in the study in which the
IOP was always lower than 18 mm Hg (mean IOP, 12.3
mm Hg) during 6 years of follow-up, there was no net
change in the mean visual field score. While 15 percent
of such eyes were said to have worsened by 4 AGIS
visual field units, an equal percentage improved by
the same criterion, perhaps providing an estimate of the
false-positive rate of progression. In contrast, in those
eyes in which the IOP was greater than 17 mm Hg more
than half the time (average IOP, 20.2 mm Hg), eyes lost
an average of approximately 3 AGIS units during 8 years
of follow-up. A clear dose-response relationship between
IOP and risk of progressive field loss was evidenced for
intermediate categories.
With surgery levels of IOP in the low teens, or even
lower, are technically achievable,19,20,33-36 and that is
independent of the IOP values prior to surgery. What
determines IOP levels postoperatively are mainly the
degree of surgical precision intraoperatively, the resistance
to outflow posed by the scleral flap in trabeculectomy,
at least initially. On the long run the degree of wound
scarring29 postoperatively and whether this has been
manipulated by antimetabolites,20,34 plays a role of
paramount importance.
In topical medications IOP in the low teens is less
likely to be achieved37 but never the less possible specially
with newer classes of medications18 and with the use of
combination topical medical therapies, while the level of
IOP is largely dependent on IOP values before
commencing therapy. Topical medications depending on
their mechanisms of action, whether reducing production
or increasing outflow, tend to knock down percentages
of prior levels.
It is fair though to acknowledge that not every patient
requires an IOP in the low teens in order to halt his
glaucoma progression. In the collaborative initial
glaucoma treatment study23 it would seem that patients
with mild, initial damage can do well at pressures in the
mid-to-upper teens, while those with more advanced
damage indeed do better when pressure is reduced to
the lower teens.

LONG-TERM IOP REDUCTION


In spite initial IOP reduction of some medications, the
effect seems to ware off in many cases. Watson and coworkers 38 examined the long-term efficacy of
monotherapy with topically applied beta-blocking agents.
Analysis showed that less than half the eyes initially treated
with topical beta-blockers might be expected to still be
being treated with their original medication after 5 years.
The rest required either additional medication or
trabeculectomy.
Long-term IOP reduction capabilities of other newer
classes of medications are still not fully determined.39, 40
One study 18 with a two-year follow-up found that
latanoprost significantly reduced IOP from pretreatment
values, and this reduction was maintained over the 24month treatment period with no sign of upward drift.
Surgery also shows deterioration of its results with
time. Chen and coworkers 41 studied the long-term
outcomes of primary trabeculectomies that were
successful at 1 year. This was retrospective study of
patients with various types of glaucoma who had
trabeculectomies that were successful at 1 year and who
had a follow-up of at least 10 years. Forty patients (40
eyes) were enrolled, who had primary trabeculectomies
that were successful at 1 year and who had a follow-up
range of 10 to 21 years. Control of IOP was evaluated
at 5, 10 and 15 years and at the last obtainable followup. Successful control of IOP was defined as IOP less
than 21 mm Hg or a reduction of 33 percent if
preoperative IOP was less than 21 mm Hg. These results
show that if an eye was considered successful by IOP at
1 year, the probability of successful control of IOP was
82 percent at 5 years and 67 percent at 10 and 15 years.
If an eye did not require further glaucoma surgery at 1
year, the probability that it still would not need further
surgery at 5 years was 90 percent, at 10 years 75 percent,
and at 15 years 67 percent. They concluded that loss of
IOP control and progression of glaucomatous damage
occurs over time despite initial success at 1 year.
Another study42 examined the long-term results (1
to 14 years) of trabeculectomies with 5-fluorouracil
injections that were successful at 1 year. In a retrospective
non-comparative case series the authors identified 87

Reducing Intraocular Pressure: Is Surgery Better than Drugs?


patients (87 eyes) who had trabeculectomies with 5fluorouracil injections that were successful at 1 year and
had a follow-up range of 1.0 to 14.7 years (mean, 8.1,
standard deviation of 4.4 years). All patients had
previously failed glaucoma surgery (66.7%), cataract
surgery (47.1%), or other diagnoses making them at
high risk for failure. Successful control of IOP was defined
as IOP less than 21 mm Hg or a reduction of 33 percent
if preoperative pressure was less than 21 mm Hg.
Statistical analysis was performed using Kaplan-Meier life
table analysis. If an eye is considered successful by IOP
at 1 year, the probability of successful control is 61
percent at 5 years, 44 percent at 10 years, and 41 percent
at 14 years. They concluded that despite successful IOP
control at 1 year, trabeculectomies with 5-fluorouracil
injections show a continual loss of IOP control over time.

MINIMAL IOP DIURNAL FLUCTUATIONS


Large diurnal fluctuations in intraocular pressure have
been identified as an independent risk factor in patients
with glaucoma. In a retrospective study of 114 patients
under treatment for POAG and OHT over an 11-year
period of observation. Niesel and Flammer43 described,
more than a quarter of a century ago, a highly significant
correlation between IOP and progression of visual field
defects. This correlation could be shown for the visual
field outer boundary in 81 eyes with ocular hypertension
and for typical visual field defects in 33 eyes with chronic
glaucoma. The relationship was, however, only significant
when both the standard deviation of the annual
intraocular pressure and the influence of cataract
development upon visual acuity were considered. If only
the mean IOP, not considering the standard deviation, is
considered, this correlation is rendered insignificant. In
another retrospective study44 by the same group they
described clearly a significant correlation between
concentric constriction during 11 years of observation
and the IOP fluctuation.
Asrani and coworkers45 have demonstrated that the
diurnal IOP range and the IOP range over multiple days
were significant risk factors for glaucomatous progression,
even after adjusting for office IOP, age, race, gender,
and visual field damage at baseline. This implies that we
can no longer rely on an IOP in the statistically normal

levels under treatment in office visits. Patients could still


suffer from glaucomatous progression because of high
fluctuations. What remains to be identified is the risk of
this progression in large within statistically normal
fluctuations compared to fluctuations outside of what is
statistically normal.
Migdal and coworkers37 compared the long-term
functional outcome in POAG in medically treated patients
versus surgically treated patients. Among many results
from this study they observed that patients in the surgery
treated group had the lowest mean IOPs and with fewer
peaks and troughs. The maximum mean IOP was 15.5
mm Hg and the minimum mean IOP was 13.1 mm Hg
for surgery compared with 22.1 mm Hg and 15.9 mm
Hg for medicine.
Another study46 was designed specifically to compare
the IOP fluctuations in glaucoma patients under ocular
hypotensive therapy with those of patients previously
submitted to trabeculectomy. The IOP peaks and
fluctuations for the same patients in response to the
water-drinking test (WDT) were also examined. The study
included 30 primary open-angle glaucoma (POAG)
patients using ocular hypotensive medications and with
no history of previous intraocular surgery (medical
group), and 30 POAG patients previously submitted to
one or more trabeculectomies though taking no
medication at the time of the study (surgical group). All
patients were submitted to a diurnal tension curve (DTC)
followed by the WDT. The IOP peak and IOP fluctuation
during the diurnal tension curve were significantly greater
in the medical group than in the surgical group. The
same was observed following the WDT. From an overall
baseline IOP of 10.6 mm Hg, the mean IOP change
following the WDT was 13 percent in the surgical group
and 40 percent in the medical group. The study
concluded that patients submitted to trabeculectomy have
less IOP fluctuations during the diurnal tension curve
and following a water-drinking provocative test.
This observation does constitute a definite advantage
of surgery over medical treatment in that respect, thus
potentially offering better potential chance of stabilization
or retardation of the glaucomatous disease process. One
criticism to these two studies though, was the inclusion
of patients under different classes of ocular hypotensive

Atlas of Glaucoma Surgery

medications under the medical group. Different classes


have different effects on IOP diurnal curves as has been
demonstrated by Orzalesi and coworkers. 47 They
compared the round-the-clock intraocular pressure (IOP)
reduction induced by timolol (0.5%), latanoprost
(0.005%), and dorzolamide in patients with primary
open-angle glaucoma (POAG) or ocular hypertension
(OHT). This was a crossover trial, 20 patients with POAG
or OHT were treated with timolol, latanoprost, and
dorzolamide for 1 month. The treatment sequence was
randomized. All patients underwent measurements for
four 24-hour tonometric curves: at baseline and after
each 1-month period of treatment. The between-group
differences were tested for significance by means of
parametric analysis of variance. To compare the circadian
IOP rhythms in the POAG-OHT and control groups,
the acrophases for each subject were calculated. All the
drugs significantly reduced IOP in comparison with
baseline at all times, except for timolol at 3 AM.
Latanoprost was more effective in lowering IOP than
timolol at 3, 6, and 9 AM (P = 0.03), noon (P = 0.01),
9 PM, and midnight (P = 0.05) and was more effective
than dorzolamide at 9 AM, noon (P = 0.03), and 3 and
6 PM (P = 0.04). Timolol was more effective than
dorzolamide at 3 PM (P = 0.05), whereas dorzolamide
performed better than timolol at midnight and 3 AM (P
= 0.05). In this study latanoprost seemed to lead to a
fairly uniform circadian reduction in IOP, whereas timolol
seemed to be less effective during the night-time hours.
Dorzolamide was less effective than latanoprost but led
to a significant reduction in nocturnal IOP. Although the
study compares IOP lowering effect of the medications
over a diurnal curve, the study lacks, or does not report,
information on the differences in fluctuations in the
diurnal curve between the different medications. In fact
if one compares different diurnal curves of different
medications, latanaprost seems to have its curve in the
lowest level, but if one examines the IOP diurnal curves
presented in this study, it appears that latanaprost
provides similar range of fluctuations to timolol. Another
concern in that we are judging mean IOPs and not
individual curves, theoretically single individuals might
be at higher risk of glaucomatous progression due to

high fluctuations, which would not be apparent from


mean IOP curves, this is of special concern in an era
where individualized therapeutic decisions are stressed.
Medication class specific or even medication specific
studies comparing IOP fluctuations in surgically versus
medically controlled glaucomatous patients are in dire
need, if this point is to be resolved. Though the bulk of
evidence, for the time being, seems to point to a relative
advantage of surgery over medications in that respect.

ISSUE OF COMPLIANCE AND


PERSISTENCE
Though compliance is not a real issue in surgically treated
patients, it does pose a serious challenge to the efficiency
of medical treatment.48-54
Clinically significant non-compliance with glaucoma
medications has been well documented. One study55
documented the prevalence of non-compliance in a
Greek cohort. Clinically significant non-compliance (more
than two doses missed per week) was established in 44
percent of patients examined. Men and those using
eyedrops more than 4 times a day were more likely to
default. Non-compliant patients exhibited higher mean
IOP (22.9 vs. 18.5 mm Hg; p > 0.001) and worse visual
field loss (10.8 vs. 7.0 dB; p = 0.008) compared with
compliant patients. Involuntary non-compliance was also
common in this group, with only 53 percent instilling
their eyedrops accurately.
Another study51 was designed to assess levels of
compliance in elderly glaucoma patients on timolol
eyedrops. Twenty-four percent of patients admitted to
omitting eyedrops either occasionally or frequently. Fiftyone percent were found to have had insufficient drops
dispensed to comply with treatment as prescribed. In
non-complaint patients the mean period without drops
was 85 days of the year, with a maximum of 165 days.
Compliance could theoretically, but safely be assumed
to be much worse in developing countries compared to
developed ones, for obvious reasons. It could be
assumed to improve with fewer medications and fewer
doses per day, more easily tolerated side effects, as well
as with better understanding of the nature and gravity
of the disease process.

Reducing Intraocular Pressure: Is Surgery Better than Drugs?


One study56 examined the causes of non-compliance
with drug regimens in glaucoma patients. The results
showed that forgetfulness was the number one reported
reason for non-compliance. In the literature48-56 rates of
non-compliance range between 23 percent and 51
percent, whatever the rate may be in different
communities and age groups surgery has a clear
advantage over medications in this respect.
One useful way in assessing compliance with eyedrop
medications is the miniature compliance monitor as
purposed by Kass and coworkers.57 The medication
monitor resembles commercially available 30 ml eyedrop
bottles in size, shape and weight. It electronically records
the date and time of each medication administration over
a six-week period.
Glaucoma patients persistence with long-term
pharamcotherapy is also an issue of concern when
discussing ocular hypotensive medications. Two
studies58,59 have identified persistency as a significant factor
that may influence not only health outcomes, but also
long-term costs and health planning. One study
compared persistency (time on initial therapy) of
latanoprost versus beta-blocker monotherapy. The
authors reported that patients receiving a beta-blocker
as initial therapy were 3.8 times more likely to change
therapy than those initially treated with latanoprost.

OCULAR SIDE EFFECTS AND


COMPLICATIONS
Surgery carries with it a set of serious ocular side effects
and complications, most notably endophthalmitis.60-63 The
use of antimetabolites34, 35, 42, 63-65 with trabeculectomy ups
the stakes, on one hand better success rates are achieved,
on the other higher complication rates are usually
reported. Incidence of endophthalmitis is 0.2 to 1.5
percent66,67 in trabeculectomies without antimetabolites
(this should be compared to incidence of endophthalmitis after cataract extraction which ranges between
0.07% and 0.12%),68 in trabeculectomies with 5-FU it is
3.0 percent69 and in trabeculectomies with MMC it is 2.1
percent.70
Another much dreaded, but fortunately a rare
complication is expulsive hemorrhage. One study71
reported an incidence of 0.57 percent after

trabeculectomy. Another study 72examined delayed


suprachoroidal hemorrhage (DSCH) after glaucoma
filtration procedures. Of a total of 1863 trabeculectomy
procedures, DSCH developed in 9 of 615 (1.5%)
trabeculectomies without antimetabolite, 30 of 1248
(2.4%) trabeculectomies with antimetabolite.
Other complications that do occur more commonly
include hypotonic maculopathy (8.9%), bleb leaks (8 14.6%), hyphema (24.6%), and choroidal detachment
(14.1%).73
Of special interest is cataract incidence after
trabeculectomy. This complication, apart from its
deleterious effect on vision, often necessitates another
intraoperative surgery, which could adversely affect the
initial trabeculectomy results. The cataractogenic effect
of surgery has been well documented. 23,74 Cataract
incidence post-trabeculectomy has been reported to be
as high as 20.2 percent in a follow-up of 12 months.73 It
is worth mentioning that such complication rates are not
reported with non-penetrating surgery. 75-82 The vast
majority of studies in the literature report significantly
lower early postoperative complications compared to
trabeculectomy. It also reports lower incidence of
postoperative cataract formation. It is necessary though
to acknowledge that the randomized controlled trials
reporting on cataract incidence after non-penetrating
surgery do not have the same long-term follow-ups as
in the case of trabeculectomy.
Ocular hypotensive medications are not devoid of
ocular side effects and complications. For one, the early
manifest glaucoma trial15 reported increases in clinical
nuclear lens opacity gradings with medical treatment (P
=0.002). Similar observation, but not statistically
significant was observed in the ocular hypertensive
treatment study,83 where 6.4 percent of the treatment
group had cataract surgeries compared to 4.3 percent
of the observation group (p=0.06).
It is worth mentioning that the last two studies
medication groups were under different medications. We
have no information about which ocular hypotensive
medication would put a patient under a higher risk of
cataract occurrence.
The noxious effect of ocular hypotensive medications
on the ocular surface has been long identified. One study84
reported that administration of a single topical medication

Atlas of Glaucoma Surgery

preserved with benzalkonium chloride, irrespective of type,


for 3 months or more induced a significant degree of
subclinical inflammation detected as increased expression
of HLA-DR on conjunctival epithelial cells. Another study85
reported that latanoprost treatment induces ocular surface
changes which are more evident in POAG patients who
are also affected by allergic conjunctivitis. The authors
hypothesized that these findings are probably related to
the very high latanoprost concentration of benzalkonium
chloride and to its bedtime administration, which further
amplifies the toxicity.
An increasing number of studies 23,37,86,87 both
experimental and epidemiological, have provided
evidence that filtering glaucoma surgery maybe less
effective than initially described. Of a number of risk factors
for failure, duration and number of antiglaucoma drugs
prior to surgery seem to play a critical role and highly
accumulated antiglaucoma topical treatments significantly
reduce success rates. 88 Inversely trabeculectomies
performed as a primary procedure do offer higher success
rates than trabeculctomies performed after a history of
ocular hypotensive medications.
Again very little is known about which medication, in
which patient is associated with which adverse effects,
and if that is clinically relevant.

SYSTEMIC SIDE EFFECTS AND


COMPLICATIONS
Apart from systemic side effects of general anesthesia,
which is rarely resorted to in glaucoma surgery89-91

nowadays, surgery appears to be at a clear advantage in


this respect. Ocular hypotensive medications have a long
list of potential systemic side effects (Table 1.1).92-95
Among others, pulmonary effects of beta-blockers
are exceptionally worrisome. Two drops of 0.5 percent
timolol equates to a 10 mg oral dose. This is not enough
to cause symptoms in many patients, but unfortunately
glaucoma and airways disease frequently coexist.
Glaucoma affects 5 percent of people over 65 years96
and incidence97 of asthma in elderly patients (above 65
years old) is 4 percent in males and 7 percent in females.
This should not be understood in the sense that betablockers are contraindicated in patients above 65 years,
only patients with a clinically relevant bronchial asthma
does run a risk with beta-blockers.
Attempts have been made though to offer better safety
profile ocular hypotensive medications. Betaxolol
[Betoptic] is cardioselective beta-blocker but is associated
with poorer IOP control. 98 Carbonic anhydrase
inhibitors30,47,99-105 applied topically are associated with less
serious systemic side effects, but are also less potent than
if orally administered. Prostaglandins18,40,47,95 are however
very effective at lowering intraocular pressure with, as far
as we know, minimal systemic side effects and have
become the treatment of first choice in many cases.
The advantage of beta-blockers still is that it has been
tried and tested, we know a lot about beta-blockers and
we probably do not know the same amount of
information about newer classes of ocular hypotensive
medications. This makes beta-blockers still a very valid
option.

Table 1.1: Ocular hypotensive medications and their potential systemic side effects
Medication

B Blockers

Carbonic anhydrase
inhibitors (oral and
topical)

Alpha agonists

Parasympathomimetics

Prostaglandin
analogues

Side effects

Dyspnea, bradycardia,
impotence, confusion,
depression, hypotension,
worsening of peripheral
vascular disease

Parasthesiae (systemic)
Renal stones (systemic)
Blood dyscrasias
(systemic and ? topical)
Rashes (either)
Hypokalemia (systemic)
Polyuria (systemic)
Metallic taste (topical
and systemic)

Dry mouth
GI upset
palpitations fatigue
decreased libido,
hypotension
respiratory arrest
in infants

Nausea
Vomiting
Headache
Confusion

Minimal systemic
side effects caution in
asthma?
contraindicated
in pregnancy

Reducing Intraocular Pressure: Is Surgery Better than Drugs?


ECONOMICAL BURDEN OF IOP
LOWERING STRATEGIES
The cost of surgical reduction of IOP decreases with time,
where the cost of surgery can be divided by the number
of years of life expectancy. The opposite is true for ocular
hypotensive medications where the cost increases with
time and could be multiplied by the number of years of
life expectancy.
The cost of medication106,107 for a latanaprost treated
patient per year is $ 337, while it is $ 336 and $ 288 for
betaxolol and dorzolamide, respectively. The daily cost
of latanaprost is $ 0.87, this should be put in context
with the fact that according to the United Nations and
the World Bank, more than one billion to 1.3 billion
people live on a daily income of less than $ 1 (one dollar)
a day. This makes glaucoma a surgical disease in most of
the developing countries. Developing countries have the
majority of glaucoma patents, and thus surgery is the
treatment of choice to the majority of glaucoma patients.
Unfortunately very little industry research funding is being
allocated for research in glaucoma surgery, which the
majority of glaucoma patients are poised to benefit from.
There is evident lack of studies related to economic
evaluation in glaucoma. Kobelt108 states that the genuine
lack of a useful outcome measure, and the impossibility
to calculate the absolute annual risk of vision loss at given
levels of the one parameter that is being treated, IOP,
has essentially limited the research to resource utilization.
One other limitation is that economical studies usually
take in consideration data from industrialized countries
which could be misleading if applied to developing
countries circumstances.

CONCLUSIONS
In essence, surgery has over drugs the potential to fulfill
many features of an ideal approach to reduce IOP. It
can lower IOP to low teens, achieve long-term IOP
reduction, minimize IOP fluctuations, lower cost, and
minimal systemic side effects. The major drawback
though, is the potentially devastating, but rare, ocular
side effects.
Although surgery is usually the first line treatment in
developing countries, it is still resorted to as a final attempt

to reduce IOP in developed countries. The possibility of


employing surgery as a first line treatment is limited by
the high incidence of potential ocular complications.
Beta-blockers are effective and relatively safe ocular
hypotensive medications, but have a well established list
of side effects, it has been tried and tested over longterm follow-ups. The real advantage lies in the fact that
the amount of information that we possess about betablockers is relatively large. Prostaglandins may offer
certain advantages of limited side effects and effective
IOP reduction, but longer follow-ups are in dire need to
provide evidence of efficacy and safety.
There is evidence that non-penetrating surgery could
offer a safer option to trabeculectomy, but the widespread practice is hindered by its surgical complexity,
which results in long learning curves. Being technically
demanding, it is very difficult to employ in mass surgical
treatment, specially in developing countries. The use of
implants with non-penetrating surgery is an
extraconsiderable cost. Another disadvantage is that nonpenetrating surgery does not seem to achieve its
previously defined target IOP, in a significant percentage,
without the postoperative use of goniopuncturing, which
necessitates the access to laser equipment.109
There is an urgent need to improve our surgical
options in order to reduce related ocular complications.
If possible safer and simpler surgical procedures should
be developed to tackle the bulk of our glaucoma
problem in developing countries.
Reducing IOP, is surgery better than drugs? As is the
case in many aspects of glaucoma, indeed as in life itself,
there are no easy answers to such questions. What could
be at a clear advantage for one patient could be an
absolute contraindication for another. In fact many
patients, specially in the developing world, do not have
the luxury of an option.
We look forward to the day when effectively reducing
IOP would not be such an important matter. When we
can manipulate other risk factors, as vascular
autoregulation, and neuronal damage, to the advantage
of our glaucoma patients.

Atlas of Glaucoma Surgery

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67. Ayyala RS, Bellows AR, Thomas JV, Hutchinson BT. Bleb infections:
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68. Kresloff MS, Castellarin AA, Zarbin MA. Endophthalmitis. Surv


Ophthalmol 1998;43:193-224.
69. Wolner B, Liebmann JM, Sassani JW, Ritch R, Speaker M, Marmor
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adjunctive 5-fluorouracil. Ophthalmology 1991;98:1053-60.
70. Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF, Flynn
HW, Jr. Endophthalmitis after filtering surgery with mitomycin. Arch
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71. Ishida M, Takeuchi S. Vitrectomy for the treatment of expulsive
hemorrhage. Jpn J Ophthalmol 2000;44:571.
72. Tuli SS, WuDunn D, Ciulla TA, Cantor LB. Delayed suprachoroidal
hemorrhage after glaucoma filtration procedures. Ophthalmology
2001;108:1808-11.
73. Edmunds B, Thompson JR, Salmon JF, Wormald RP. The National
Survey of Trabeculectomy. III. Early and late complications. Eye
2002;16:297-303.
74. Anderson D, Normal Tension Glaucoma Study. Collaborative normal
tension glaucoma study. Curr Opin Ophthalmol 2003;14:86-90.
75. Shaarawy T, Karlen M, Schnyder C, Achache F, Sanchez E, Mermoud
A. Five-year results of deep sclerectomy with collagen implant. J
Cataract Refract Surg 2001;27:1770-8.
76. Ambresin A, Borruat FX, Mermoud A. Recurrent transient visual
loss after deep sclerectomy. Arch Ophthalmol 2001;119:1213-5.
77. Chiselita D. Non-penetrating deep sclerectomy versus trabeculectomy
in primary open-angle glaucoma surgery. Eye 2001;15:197-201.
78. El Sayyad F, Helal M, El-Kholify H, Khalil M, El-Maghraby A.
Nonpenetrating deep sclerectomy versus trabeculectomy in bilateral
primary open-angle glaucoma. Ophthalmology 2000; 107:1671-4.
79. Gandolfi S, Cimino L. Deep sclerectomy without absorbable implants
and with unsutured scleral flap: prospective, randomized 2-year
clinical trial vs trabeculectomy with releasable sutures. 2000. Fort
Lauderdale, USA. Ref Type: Conference Proceeding.
80. Mermoud A, Schnyder CC, Sickenberg M, Chiou AG, Hediguer SE,
Faggioni R. Comparison of deep sclerectomy with collagen implant
and trabeculectomy in open-angle glaucoma. J Cataract Refract
Surg 1999;25:323-31.
81. Carassa, R. Viscocanalostomy versus trabeculectomy: a 12 months
prospective randomized study. 2000. Boston, USA. 2000.
Ref Type: Conference Proceeding
82. OBrart DP, Rowlands E, Islam N, Noury AM. A randomised,
prospective study comparing trabeculectomy augmented with
antimetabolites with a viscocanalostomy technique for the
management of open angle glaucoma uncontrolled by medical
therapy. Br J Ophthalmol 2002;86:748-54.
83. Gordon MO, Beiser JA, Brandt JD, Heuer DK, Higginbotham EJ,
Johnson CA, et al. The Ocular Hypertension Treatment Study:
baseline factors that predict the onset of primary open-angle
glaucoma. Arch Ophthalmol 2002;120:714-20.
84. Cvenkel B, Ihan A. Ocular surface changes induced by topical
antiglaucoma monotherapy. Ophthalmologica 2002;216:175-9.
85. Costagliola C, Prete AD, Incorvaia C, Fusco R, Parmeggiani F, Di
Giovanni A. Ocular surface changes induced by topical application
of latanoprost and timolol: a short-term study in glaucomatous
patients with and without allergic conjunctivitis. Graefes Arch Clin
Exp Ophthalmol 2001;239:809-14.
86. Watson PG, Jakeman C, Ozturk M. The complications of
trabeculectomy (a 20-year follow-up). Eye 1990;4:425-38.
87. Molteno A, Bosma N, Kittelson J. Otago glaucoma surgery outcome
study: long-term results of trabeculectomy1976 to 1995.
Ophthalmology 2003;106:1742-50.
88. Broadway D, Grierson I, OBrien C, Hitchings R. Adverse effects of
topical antiglaucoma medications.II. The outcome of filtration
surgery. Arch Ophthalmol 1994;112:1446-54.
89. Kansal S, Moster MR, Gomes MC, Schmidt CM Jr, Wilson RP.
Patient comfort with combined anterior sub-Tenons, topical, and

10
90.
91.
92.
93.
94.
95.
96.

97.
98.
99.

Atlas of Glaucoma Surgery

intracameral anesthesia versus retrobulbar anesthesia in


trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery.
Ophthalmic Surg Lasers 2002;33:456-62.
Sauder G, Jonas JB. Topical anesthesia for penetrating
trabeculectomy. Graefes Arch Clin Exp Ophthalmol 2002;240:73942.
Vicary D, McLennan S, Sun XY. Topical plus subconjunctival
anesthesia for phacotrabeculectomy: one year follow-up. J Cataract
Refract Surg 1998;24:1247-51.
Farrell TA. Minimizing the systemic effects of glaucoma medications.
Geriatrics 1991;46:61-4, 73.
Fraunfelder FT, Meyer SM. Systemic side effects from ophthalmic
timolol and their prevention. J Ocul.Pharmacol. 1987;3:177-84.
Bourgeois JA. Depression and topical ophthalmic beta adrenergic
blockade. J Am Optom Assoc 1991;62:403-6.
Waldock A, Snape J, Graham CM. Effects of glaucoma medications
on the cardiorespiratory and intraocular pressure status of newly
diagnosed glaucoma patients. Br J Ophthalmol 2000;84:710-3.
Leibowitz HM, Krueger DE, Maunder LR, Milton RC, Kini MM,
Kahn HA, et al. The Framingham Eye Study monograph: an
ophthalmological and epidemiological study of cataract, glaucoma,
diabetic retinopathy, macular degeneration, and visual acuity in a
general population of 2631 adults, 1973-1975. Surv Ophthalmol
1980;24:335-610.
Burrows B, Barbee RA, Cline MG, Knudson RJ, Lebowitz MD.
Characteristics of asthma among elderly adults in a sample of the
general population. Chest 1991;100:935-42.
Kaiser HJ, Flammer J, Stumpfig D, Hendrickson P. Long-term visual
field follow-up of glaucoma patients treated with beta-blockers. Surv
Ophthalmol 1994;38 Suppl:S156-9.
Orzalesi N, Rossetti I, Bottoli A, Invernizzi T, Fumagalli E, Fogagnolo
P. Comparison of latanoprost, brimonidine and a fixed combination
of timolol and dorzolamide on circadian intraocular pressure in
patients with primary open-angle glaucoma and ocular hypertension.
Acta Ophthalmol Scand Suppl 2002;236:55.

100. Arieta C, Amaral M, Matuda E, Crosta C, Carvalho Moreira FD,


Jose N. Dorzolamide Apraclonidine in the prevention of the
intraocular pressure spike after Nd : YAG laser posterior capsulotomy.
Curr Eye Res 2002;25:237-41.
101. Day DG, Schacknow PN, Wand M, Sharpe ED, Stewart JA, Leech
J, et al. Timolol 0.5 percent/dorzolamide 2 percent fixed combination
vs timolol maleate 0.5 percent and unoprostone 0.15 percent given
twice daily to patients with primary open-angle glaucoma or ocular
hypertension. Am J Ophthalmol 2003;135:138-43.
102. Honrubia FM, Larsson LI, Spiegel D. A comparison of the effects on
intraocular pressure of latanoprost 0.005 percent and the fixed
combination of dorzolamide 2 percent and timolol 0.5 percent in
patients with open-angle glaucoma. Acta Ophthalmol Scand.
2002;80:635-41.
103. Simmons ST. Efficacy of brimonidine 0.2 percent and dorzolamide
2 percent as adjunctive therapy to beta-blockers in adult patients
with glaucoma or ocular hypertension. Clin Ther. 2001;23:604-19.
104. Strohmaier K, Snyder E, DuBiner H, Adamsons I. The efficacy and
safety of the dorzolamide-timolol combination versus the
concomitant administration of its components. Dorzolamide-Timolol
Study Group. Ophthalmology 1998;105:1936-44.
105. Strahlman E, Tipping R, Vogel R. A six-week dose-response study of
the ocular hypotensive effect of dorzolamide with a one-year
extension. Dorzolamide Dose-Response Study Group.
106. Vold SD, Riggs WL, Jackimiec J. Cost analysis of glaucoma
medications: a 3-year review. J Glaucoma. 2002;11:354-8.
107. Vold SD, Wiggins DA, Jackimiec J. Cost analysis of glaucoma
medications. J Glaucoma. 2000;9:150-3.
108. Kobelt G. Health economics, economic evaluation, and glaucoma.
J Glaucoma. 2003;11:531-9.
109. Gandolfi S, Quaranta L, Cimino L, Bettelli S. Deep sclerectomy
versus trabeculectomy. Prospective Randomized Clinical trial. 4year interim analysis. 2003. Luxor, Egypt. Proceedings of the Second
International Congress on Glaucoma Surgery. Ref Type: Conference
Proceeding.

Peng Tee Khaw, Peter Shah

2 Trabeculectomy

INTRODUCTION
This chapter addresses the current techniques used in
glaucoma filtration surgery, in particular a guarded
sclerostomy procedure best known as trabeculectomy.
The decision to perform glaucoma surgery represents a
key point in the long-term management of the patients
disease, and should only be made after detailed
consultation with the patient. The timing of surgery and
selection of appropriate procedure need careful
consideration and consultation. It is important to
remember that the preoperative and postoperative
management are critical determinants of the outcome
of glaucoma surgery.
The field of glaucoma surgery is undergoing a period
of revolution with many new approaches to the traditional
methods of surgery. Like all surgery, it is essential that
surgeons have a sound understanding of the principles
involved in the modern range of surgical procedures,
and keep up to date with new procedures so that
technique can be varied depending on the surgical
circumstances. An example of new techniques that have
revolutionized glaucoma surgery and are still changing
is the use of adjuvant therapies to modify postoperative
wound healing. The identification of relative risk factors
for failure of glaucoma surgery enables the surgeon to
vary the adjuvant therapy as appropriate while
minimizing the risk.
Glaucoma filtration surgery was previously performed
when patients had uncontrolled intraocular pressures on
maximally tolerated medical treatment, or after failed
laser trabeculoplasty. The main reasons for delaying
surgery were the risk of postoperative complications
associated with standard trabeculectomy procedures and

high failure rates for operations in certain subgroups of


glaucoma patients. Technical modifications to the
trabeculectomy procedure including adjustable stitch
techniques combined with the use and techniques of
application of these powerful antimetabolites now enable
the surgeon to have much greater control of both the
operation and postoperative scarring. The identification
of patients at risk of developing postoperative hypotony
and the continuing development of surgical measures
to reduce this risk have been important advances. The
risks of surgery in each individual patient should be
balanced against the projected visual loss which will occur
from glaucomatous damage if the intraocular pressures
are not adequately controlled. The techniques described
in the following sections are continuously changing with
the aim of making glaucoma surgery as safe and
successful as possible.

ANESTHESIA
The various operations described in this chapter can be
carried out under local or general anesthetics. The
methods of anesthesia are covered in another chapter
in this book. However, there are specific points in terms
of anesthesia in glaucoma.

General Anesthesia
The lowering of intraocular pressure with anesthesia can
be used to advantage by the ophthalmic surgeon if
intraoperative pressure lowering is required. Blood
pressure and to some extent choroidal volume can be
reduced, if necessary, by varying the anesthetic in patients
at risk of choroidal hemorrhage.

12

Atlas of Glaucoma Surgery

Local Anesthesia
When performing glaucoma surgery under local
anesthesia it is important to try and avoid unnecessary
elevation of IOP. It is advisable to use a technique that
paralyzes orbicularis oculi to prevent eyelid squeezing
and increased pressure on the globe. Patients with preexisting glaucoma may have a marked elevation in their
IOP during peribulbar or retrobulbar anesthesia. This
may be particularly important in patients who have
advanced visual field loss. Reduced volumes of local
anesthetic agents with hyaluronidase should be used in
these patients if necessary, and orbital compressive
devices (e.g. mercury balloons) should be avoided, if
possible. Buphthalmic or myopic eyes often have
extremely long axial lengths and may have large posterior
staphylomas with the attendant risks of inadvertent ocular
perforation during retrobulbar or peribulbar anesthesia.
Patients occasionally notice an enlargement of their
scotoma as a retrobulbar anesthetic takes effect, this is
reversible but patients need to be warned of this. In an
only eye, this may render the patient effectively blind
for many hours. General anesthesia may be preferable
in these patients as it avoids this problem and allows
increased control of the operative conditions. Filtration
surgery can also be carried out using only
subconjunctival anesthesia. However, the patient may
experience pain when the iris is handled particularly when
an iridotomy is performed. Intracameral anesthetic may
potentially be useful in this context.

FILTRATION SURGERY
PREOPERATIVE DETAILS
The risks of any form of surgery should be explained to
the patient in advance. In particular it is vital to explain
that surgery for glaucoma is usually done to preserve
vision not to improve it. Patients should be warned that
their vision may well be blurred in the weeks after surgery
before approaching preoperative levels. Several studies
have demonstrated a loss of best-corrected visual acuity
(of about 1 line) in postoperative patients, and it is
essential that patients are aware of this. Patients with
advanced field loss should be told of the risks of loss of
their remaining field, the so called wipe out event,

although this is extremely rare. Patients who wear contact


lenses should be advised that this may not be possible
after filtration surgery.

PRE- AND INTRAOPERATIVE DROPS


Parasympathetic Agonists
Pilocarpine eyedrops are sometimes used preoperatively
to miose the pupils. In theory, this protects the cornea
from lens-corneal touch, and may reduce the chance of
inadvertently cutting an excessively large iridectomy. The
disadvantages include shallowing of the anterior chamber,
and a theoretical possibility that the blood-aqueous
barrier may be further compromised. Long-acting
anticholinesterase agents should be discontinued if
possible to reduce blood vessel congestion and leakage.

Sympathetic Agonists
Topical adrenaline can be used at the beginning of the
operation. Solutions of 0.01 percent or 0.1 percent can
be dropped on the field of surgery. This produces
conjunctival vasoconstriction and a reduction in bleeding
during the course of the procedure. Blood contains many
growth factors that promote wound healing and increase
the chance of filtration surgery failure. The disadvantage
of using adrenaline, is that it does cause some pupillary
dilatation. However, this is not usually a problem,
particularly if the operation is carried out relatively rapidly.

Povidone-iodine
It has a broad spectrum of antimicrobial action. It can
be used to prepare the skin, and drops can be applied
to the superior and inferior fornices, to kill any bacteria.
This is particularly important if the patient has pre-existing
conjunctival or lid disease, which predisposes them to
bacterial colonization.

Steroids
It has been shown that chronic preoperative topical
treatment jeopardizes filtration surgery by increasing the
number of fibroblasts and inflammatory cells in the
conjunctiva. This is particularly marked in association with
the long-term use of adrenergic agents such as adrenaline
and dipivefrin. Topical steroids such as fluoromethalone

Trabeculectomy
reverse the histological change in the conjunctiva,
although whether this conclusively increases the success
rate has not been proven.

Nonsteroidal Anti-inflammatory Drugs


The use of preoperative nonsteroidal anti-inflammatory
drugs such as indomethacin or flurbiprofen has not been
proven to alter the long-term results of glaucoma filtration
surgery. However, in patients who may require iris
manipulation and who in addition have a risk of fibrinous
uveitis (especially dark irides) our impression is that
preoperative topical steroids and nonsteroidal drops may
be useful, even for a period as short as 24 hours before
surgery.

13

increasingly popular. This is because there is no chance of


creating a superior rectus hematoma. Such a hematoma
results in the release of growth factors that trigger wound
healing. The vector force of the corneal suture is superior
to that achieved with a superior rectus suture. The
disadvantages of the corneal traction suture include the
small risk of placing the suture too deeply and penetrating
the anterior chamber (great care in buphthalmic eyes),
and the chance of placing the suture too superficially with
subsequent cheese-wiring and loss of traction. A variety
of sutures can be used, but we use a 7-0 black silk suture
on a semicircular needle (Fig. 2.1).

Hypotensive Agents
If possible aqueous suppressants particularly those that
have long-acting effects such as beta-blockers should be
stopped several days in advance with outpatient
monitoring. This will optimize aqueous flow
postoperatively, encouraging aqueous flow through the
new channel and help to prevent hypotony.

SURGICAL TECHNIQUE FOR


TRABECULECTOMY
Position of Filtration Area
Filtration surgery is most commonly performed in the
superior half of the globe. This is because the upper lid
protects the drainage area. A peripheral iridectomy
placed at 12 oclock is covered by the lid, and does not
give rise to diplopia. Drainage blebs that are not covered
by the upper lid, particularly those in the interpalpebral
fissure or the lower fornix, have a high incidence of
inflammation and endophthalmitis especially when
antimetabolites have been used. Scleritis may also be
more common, particularly with the use of antimetabolites. It is important to avoid positioning the bleb
anywhere other than the superior limbus, and other
procedures should be used if this is not possible.

Traction Suture
Superior rectus traction sutures are still commonly used.
However, the use of a corneal traction suture is becoming

Fig. 2.1: Corneal traction suture

Conjunctival Incision
The conjunctiva can be incised at the limbus (fornixbased flap) or deep in the fornix (limbus-based flap).
The advantages and disadvantages of either approach
are summarized in Table 2.1. The conjunctiva should be
handled very gently to avoid buttonholing, particularly
if antimetabolites are used. If a limbus-based flap is used,
the incision should be made far into the fornix. The
conjunctiva and Tenons should be entered in separate
layers to minimize the chance of damaging the superior
rectus muscle. An incision length of at least 10 mm is
usually necessary to provide adequate exposure. For a
fornix-based flap an incision of about 5 to 10 mm is
necessary. A relieving incision is used by many surgeons
but is not necessary and increases the trauma and risk of
wound leakage.

14

Atlas of Glaucoma Surgery


Table 2.1: Fornix versus limbal based flap
Fornix

Length of operation

Faster than limbus


based
Sclerostomy exposure Good
Large eye/small
Technically easier
eyelid fissure
Area dissected/
Smaller
damaged
Releasable suture
Simple
placement through
cornea
Conjunctival
Increased incidence
wound leaks
Rare if buried
corneal mattress
sutures used
Antimetabolite
Need multiple small
application
sponges. Great care
needed to insert
Post operative
appearance
Reoperation

More diffuse
(esp with MMC)
Technically easier

Limbus

aqueous flow. Even cystic blebs from pre-antimetabolite


days have these features.

Slower than fornix based


Reasonable
Difficult
Larger
More difficult
Less common if deep
in fornix
Fewer sponges needed
Easy to insert sponge
without touching
wound edge
More focal
(esp with MMC)
More difficult

We dissect backwards with Westcott scissors to make


a pocket of approximately 10 to 15 mm posteriorly and
wide for the antimetabolite sponges. When dissecting
over the superior rectus tendon we lift the conjunctiva
to cut attachments avoiding the tendon itself (Fig. 2.2).

Fig. 2.3: Ring of steel and anterior aqueous flow

The restricted flow from the posterior incision resulting


in more focal cystic blebs led us to change. The effects of
treatment were very focal and the cells at the edge of
the treatment area although growth arrested and can
make scar tissue and encapsulate the area resulting in
thinning and a cystic bleb. A fornix-based incision allowed
a larger area of antimetabolite treatment, without a
posteriorly placed restricting scar.
Similar blebs can be achieved with a limbus-based
flap but the incision has to be very posteriorly placed
and this result is not as consistent. This does make the
subsequent scleral flap and sutures more difficult.

Scleral Flap

Fig. 2.2: Dissection over rectus lifting conjunctiva

We always previously used a limbus-based incision


with antimetabolite as we were worried about
postoperative leaks. However, my clinical observation
of cystic blebs led me to the hypothesis that they had
two things in common. The first was restricted posterior
flow the ring of steel (Fig. 2.3). The second was anterior

There are several types of scleral flap. The two most


common types being rectangular and triangular in shape.
There is no evidence that one is superior to the other.
The scleral flap is usually outlined, and a lamellar
dissection is carried out with a blade or scleral pocket
knife. Alternatively, with a rectangular flap an incision
can be made, and a scleral pocket made (like a phaco
emulsification pocket) (Fig. 2.4) and then the two side
incisions cut at the end (Fig. 2.5).
The side incisions are not cut right to the limbus as
this encourages posterior flow reducing the incidence of
cystic blebs. We now cut the scleral flap before applying
antimetabolite. There is also evidence that treatment
under the flap increases the success rate and experimental

Trabeculectomy

Fig. 2.4: Scleral pocket being cut

15

formation of holes in the flap and cheese-wiring of the


flap sutures. All these complications allow increased
aqueous leakage and reduce flap resistance.
This is particularly important with the use of
antimetabolites, because the conjunctival resistance to
outflow may not rise for several weeks or even months
after surgery. This is also very important in eyes with
thin, less rigid sclera such as buphthalmos and myopia.
If the scleral flap does not provide adequate resistance,
the eye will be hypotonous. It is important to remember
that the limbus may be thinned after multiple surgery or
cryotherapy. If there is a large aqueous vein running
through the site of the potential scleral flap, this vein
should be avoided, as when the flap is cut, the vein will
end up as a perforating hole in the scleral flap. Scleral
flap sutures are preplaced at this stage whilst the eye is
still firm. Scleral flap sutures are more difficult to place
once the eye has been entered and is hypotonous.

Intraoperative Antimetabolite Use

Fig. 2.5: Limited side cuts to scleral flap to encourage


posterior flow

and clinical evidence to suggest this is safe. We try to cut


the largest flap possible and leave the side cuts at the
limbus incomplete (1-2 mm from limbus). This forces
the aqueous backwards over a wider area to get a diffuse
bleb. An aqueous jet at the limbus predisposes to an
anterior focal cystic bleb, whereas posteriorly directed
diffuse flow of aqueous from incompletely cut sides of a
large scleral flap results in a more diffuse noncystic bleb.
The main function of the scleral flap is to provide
resistance to aqueous outflow and prevent hypotony.
To perform these functions the flap must be sufficiently
large to cover the sclerostomy. It is important that the
scleral flap is not too thin, since this increases the chance
of flap dehiscence. Additional problems include

The full details of all antiscarring agents are too extensive


for this chapter and are covered elsewhere. However
the many potential agents are summarized in Table 2.2
and the risk factors, risks of antimetabolite complications
and regimen we use in Tables 2.3 to 2.6. If intraoperative
antimetabolites are indicated we now use them after the
half thickness scleral flap has been cut but before the
eye is entered, as there is reasonable pharmacokinetic
and clinical data to suggest this is safe. If there is any
problem with the scleral flap or scleral integrity or any
sign of aqueous leak the use of antimetabolites can be
withheld safely.
The variations in the technique used to deliver
intraoperative antimetabolites may account for some of
the variations in efficacy and complications seen in the
literature. It is very important for individual users to
maintain a consistent technique and to build up
experience with one technique.
Changes in area of treatment, conjunctival and scleral
flap construction, and adjustable sutures have led to a
dramatic difference in terms of reducing short and longterm complications (Fig. 2.6). This has led to a reduction
in cystic areas within the bleb from 90 to 29 percent.
The blebitis and endophthalmitis rate over 3 to 5 years

16

Atlas of Glaucoma Surgery

Table 2.2: Sequence of events in tissue repair and possible


types of modulation after glaucoma filtering surgery (events
and agents have overlapping time duration and action)
Modified from Khaw et al {Khaw, 1994 5819 /id}
Events

Possible modulations

Activated conjunctiva
pre-activated cells
Conjunctival/episcleral/scleral
incisions. Damage to
connective tissue
Release of plasma proteins
and blood cells
Activation of clotting and
complement. Fibrin/
fibronectin/blood cell clot
Release of growth factors
from blood

Stop medical therapy (espdrops


causing red eye). Preoperative steroids
Minimal trauma
Less invasive surgical techniques

Aqueous released from eye


Breakdown of blood
aqueous barrier
Release of growth factors
into aqueous
Aqueous begins to flow
through wound
Migration and proliferation
of polymorphonuclear
neutrophil cells, macrophages
and lymphocytes.

Activation, migration and


proliferation of fibroblasts

Wound contraction
Fibroblast synthesis of
tropocollagen
glycosaminoglycans and
fibronectin
Collagen cross-linking
and modification
Blood vessel endothelial
migration and proliferation
Resolution of healing,
apoptosis
Disappearance of fibroblasts
Fibrous subconjunctival scar

Hemostasis (Blood can reverse MMC)


Agents preventing/removing fibrin, e.g.
heparin, tissue plasminogen activator,
hirudin
Antagonists to growth factor production,
e.g. antibodies to growth factors
humanized anti-TGF-beta2 antibody
(CAT 152 TrabioR) or receptors
Anti-sense oligonucleotides, ribozymes
Less specific antagonists, e.g. tranilast,
genistein, suramin
Blood aqueous barrier stabilizing agents,
e.g. steroids
Non-steroidal anti-inflammatory agents

Anti-inflammatory agents, e.g. steroids/


cyclosporine
Anti-metabolites, e.g. 5-FU/MMC,
Antibodies to inflammatory mediators
Angiotensin converting enzyme or
chymase inhibitors
Preoperative steroids to reduce
activation
Antimetabolites MMC 5-FU
Methylxanthine derivatives, mushroom
lectins
Antiproliferative gene p21(WAF-1/Cip1)
Photodynamic therapy
Anticontraction agents, e.g. colchicine,
taxol lectins, MMP inhibitors
Interferon alpha, MMP inhibitors,
fibrostatin-c

Table 2.3: Risk factors for failure due to scarring after


glaucoma filtration surgery
Risk factors
1 Ocular
Neovascular glaucoma (active)
Previous failed filtration surgery
Previous conjunctival surgery
Chronic conjunctival inflammation
Previous cataract extraction
(conjunctival incision)
Aphakia (intracapsular extraction)
Previous intraocular surgery
Uveitis (active, persistent)
A red, injected eye
Previous topical medications
(beta-blockers + pilocarpine)
(beta-blockers+pilocarpine
+adrenaline)
New topical medications
High preoperative intraocular
pressure (higher with each
10 mm Hg rise)
Time since last surgery
(especially if within last 30 days)
Inferiorly located trabeculectomy
2 Patient
Afro-Caribbean origin
May vary, e.g. West
vs East Africans
Indian subcontinent origin
Hispanic origin
Japanese origin
Elderly (+) vs Young + (+)
(particularly children) + +

Risk 1- 3+ Comments
+++
+ + (+)
++
+ + (+)
+ + (+)
+++
++
++
++

Uncertain

Depends on type of
surgery

+ (+)
+++
+ (+)
+ (+)

Particularly if they
cause a red eye

+
+ + (+)
+
++
+ + (+)
+
+
(+)
(+)

Table 2.4: Possible risk factors for antimetabolite


related complications
Elderly patient
Primary surgery no previous medications
Poorly supportive scleral tissue prone to collapse, e.g. Myopia/
buphthalmos/Ehlers-Danlos
Thin conjunctiva or sclera
Bleb placed in interpalpebral or inferior position

Anti-cross linking agents, e.g. betaaminopropionitrile/penicillamine


Inhibitors of angiogenesis, e.g. fumagillin
analogs, heparin analogs
MMC 5-FU Death receptor ligands
Stimulants of apoptosis pathways

Fig. 2.6: Showing diffuse bleb in patients right eye using large
area of treatment vs a smaller area of treatment with mitomycin-C

17

Trabeculectomy
Table 2.5: Moorfields Eye Hospital (More flow) intraoperative
single dose antiscarring regimen v2004 (Continuously
evolving). Lower target pressures would suggest a stronger
agent was required

Table 2.6: Various intraoperative antiscarring agents applied


directly to the bleb site

Low risk patients (Nothing or intraoperative 5FU 50 mg/ml*)#


No risk factors
Topical medications (beta-blockers/pilocarpine)
Afro-Caribbean (Elderly)
Youth <40 with no other risk factors
Intermediate risk patients (Intraoperative 5FU 50 mg/ml* or MMC 0.2
mg mg/ml)#
Topical medications (adrenaline)
Previous cataract surgery without conjunctival incision (capsule
intact)
Several low risk factors
Combined glaucoma filtration surgery/cataract extraction
Previous conjunctival surgery, e.g. squint surgery/detachment surgery/
trabeculotomy
High risk patients (Intraoperative MMC 0.5 mg/ml) #
Neovascular glaucoma
Chronic persistent uveitis
Previous failed trabeculectomy/tubes
Chronic conjunctival inflammation
Multiple risk factors
Aphakic glaucoma (a tube may be more appropriate in this case)
*Intraoperative beta-radiation 1000 cGy can also be used. CAT-152
(TrabioR) or humanized anti-TGF-beta 2 antibody may be appropriate
in the low and intermediate risk groups in the future based on the results
of current studies. These groups account for the majority of patients
undergoing glaucoma surgery.
# Postoperative 5-fluorouracil injections can be given in addition to the
intraoperative applications of antimetabolite.
There have been reports of 5FU given intraoperatively directly into
the filtration site during surgery. However, the risk of intraocular
penetration is great and commercial 5FU is alkaline with a pH of almost
9.0. Injected MMC has also been occasionally reported but one case of
combined central retinal artery and vein occlusion has been reported
following MMC injection. Fifty microliters of MMC (one drop) irreversibly
damages the cornea

5FU
50 or
25 mg/ml

beta-radiation
1000 cGy

MMC
0.2-0.5 mg/ml

Delivery

2-5 minutes

2-5 min

Cost

UK1.50
10 ml vial

Availability

Good

20 sec-3 min
depending on
output rate
Approx
UK3000
for probe but
lasts 10+ years
Special
ordering and
licensing
required
Lead shielded
area

Storage

Room
temperature
ready
constituted
Duration effect Several weeks Several weeks
on fibroblast Clinical effects
proliferation several years
Primary effect Growth
arrest
Control over Moderate
area treated

Growth arrest
Precise

UK8 2 mg vial makes


5 ml of 0.4 mg/ml
Good

Powder stable at room


temp Unstable once
reconstituted
Months/permanent
cell death at higher
range concentrations
Growth arrest and cell
death
Moderate

conjunctiva and to prevent antimetabolite touch. This


clamp maintains a pocket for antimetabolite treatment
(Fig. 2.7). Our experiments have shown that the
antimetabolite affects mainly the area it touches, therefore
protecting the edge, prevents wound leaks and
dehiscence.

was 20 percent for older limbus based techniques with a


smaller treatment area versus zero percent over the same
period for the current technique.6 Falls in complication
rate have also been seen in the USA in lower risk
populations from approximately 6 to 0.5 percent to date
(Paul Palmberg personal communication). If these figures
were extrapolated to an approximate figure of 50,000
trabeculectomies with antimetabolite per year in the
United States it is possible that bleb related complications
could be avoided in many thousands of patients.

Conjunctival Clamp
We use a special conjunctival T clamp designed
(Duckworth-and-Kent.com No 2-686) to hold back the

Fig. 2.7: Conjunctival T clamp for holding tissue away from


antimetabolite

18

Atlas of Glaucoma Surgery

Type of Sponge
We use circular medical grade polyvinyl alcohol sponges
used for LASIK corneal shields rather than other sponges.
The sponges are cut in half and folded like a foldable
lens (Fig. 2.8) and they fit through the entrance to the
pocket without touching the sides (approximately 5 mm
3 and insert about 6 of these) (Fig. 2.9). We attempt
to treat as large an area as possible, including under the
scleral flap. The polyvinyl alcohol sponges maintain their
integrity and do not fragment. In contrast, methycellulose
sponges fragment relatively easily, with an increased
chance of leaving small pieces of sponge behind in the
wound. The large area of treatment results in more
diffuse non-cystic blebs clinically. Increasing the surface
area of treatment results in a much more diffuse noncystic
area clinically. A large area prevents the development of
a ring of scar tissue (the ring of steel) which restricts
flow and promotes the development of a raised cystic
avascular bleb.

Antimetabolite Treatment Duration and Washout


We treat for three minutes. If we need to vary the effect
of MMC we vary the concentration. We use only two
concentrations (0.2 and 0.5 mg/ml). For intraoperative
5FU we use 50 mg/ml, washed out with 20 ml of
balanced salt solution. Pharmacokinetic experiments we
have done show a rapid uptake over three minutes after
which there is a plateau when relatively little drug is
added for extraminutes. In the period from 1 to 3
minutes there is considerable variation in the dose
delivered.
Paracentesis
A paracentesis should be performed to allow fine control
of the anterior chamber. If the paracentesis is made
obliquely, (Fig. 2.10) parallel to the limbus, then the
blade remains in the peripheral region of the anterior
chamber with minimal chance of lens damage. Similarly,
if the anterior chamber needs to be reformed in the
intra- or postoperative period, a cannula introduced
through an oblique paracentesis has little chance of
causing lens trauma. If the entry site is placed inferiorly
this can be used to gain access to the anterior chamber
in the outpatient clinic, if necessary. An additional

Fig. 2.8: Polyvinyl alcohol sponges being folded

Fig. 2.9: PVA sponge being inserted avoiding the


cut edge of conjunctiva

advantage of a paracentesis is that it allows controlled


decompression of the anterior chamber and reformation
of the eye without using the sclerostomy entry site. As
the scleral flap sutures are tied, the resistance of the flap
to aqueous outflow can be tested by irrigating the
anterior chamber with fluid through the paracentesis
enabling the opening pressure of the valve to be set
with more precision. A technique that offers another level
of pressure control is the use of a continuous infusion.

Infusion
We use an anterior segment infusion (Lewicky, Visitec)
on a three-way tap through the paracentesis (Fig. 2.11).
This maintains the pressure and rigidity of the globe

Trabeculectomy

Fig. 2.10: Oblique paracentesis minimizing any risk to lens,


for Lewicky infusion

throughout the surgery minimizing serious complications


such as intraoperative choroidal effusions particularly in
high risk patients, e.g. high myopes, buphthalmics. The
pressure in the eye can be controlled using bottle height
increasing the accuracy of the suture closure almost
removing significant postoperative hypotony.

19

to the surface at this point enters the anterior chamber


through the anterior part of the trabecular meshwork.
The incision for filtration is best done as anterior as
possible as this reduces bleeding. Too posterior an incision
increases the risk of the ciliary body being exposed or
damaged.
If a blade and scissors are used it is difficult to cut a
sclerostomy much smaller than 3 1.5 mm. The flap is
lifted gently taking care not to cause a buttonhole. The
block is outlined to at least 50 percent depth half without
entering the anterior chamber. The eye should then be
entered, the turned blade upwards and the incision
opened like the action of a letter opener. If gentle traction
can be applied on the flap this keeps the blade away
from the iris and underlying structures. The side incisions
are then completed radially cutting backwards and the
base of the flap can be cut with the blade or Vannas
scissors.
A punch is the method of our choice, and a variety
of these are available. There is evidence that a small
sclerostomy (0.5 mm) is easily adequate and may
minimize astigmatism and the chance of limbal aqueous
flow, and maximize the chance of controlling outflow.
An anterior incision is made in a similar fashion to that
previously described, slightly larger than the diameter of
the punch head. The punch should then be inserted
ensuring that a full thickness of limbus is engaged. The
punch should then be aligned perpendicular to the eye
to ensure a clean non-shelved sclerostomy (Fig. 2.12).

Fig. 2.11: Anterior segment infusion to maintain intraocular


pressure and gauge opening pressure of sclerostomy

Block Removal (Sclerostomy)


The block removal of cornea and sclera can be achieved
in a variety of ways. It can be manually cut and removed,
with an appropriate blade and scissors, or a special punch
instrument can be used. The sclerolimbal junction is the
beginning of the blue translucent zone where the white
sclera merges into clear cornea. An incision perpendicular

Fig. 2.12: Small 0.5 mm titanium scleral punch


to maximize flow control

20

Atlas of Glaucoma Surgery

Peripheral Iridectomy

intraocular pressure until significant healing occurs, which

A peripheral iridectomy is performed through the

may be many months, if mitomycin is used. It is also

sclerostomy. The reasons for carrying out a peripheral

important when there are particular problems with the

iridectomy are to prevent iris incarceration in the

eye, e.g. an eye with angle-closure whose anterior

sclerostomy, and in some cases to relieve any element

chamber is likely to be flat postoperatively, unless there

of pupillary block. It is important that the iridectomy is

is adequate aqueous outflow resistance. In these cases

not too large, otherwise the patient may experience glare

the sutures should be tied tight to provide sufficient

and monocular diplopia. The iridectomy should be made

resistance to prevent postoperative anterior chamber

relatively broad at the base, but short in length so a

shallowing.

large iris defect is not created. Cutting the iridectomy

Several types of suture can be used, interrupted which

with the scissors parallel to the limbus helps achieve this.

can be lasered or cut, releasable which can be pulled

A more corneal, rather than scleral sclerostomy reduces

out in a variety of ways or a new type of suture which

the chance of iris incarceration and bleeding. If an infusion

we have designedthe adjustable suture. We routinely

is used, the iris can be made to present to the wound

place a suture at each posterior corner of the scleral flap,

without any intraocular manipulation, minimizing trauma

using a 10-0 nylon suture. Some sutures (e.g. 10-0 Alcon

and the need for an assistant (Fig. 2.13).

version) are better suited for use as adjustable or


releasable sutures since they tend not to break when
tension is applied to the suture during removal. Having
placed the initial two sutures, the need for further sutures
can be assessed by inflating the eye through the
paracentesis and observing the amount of aqueous flow
through the flap.
We have also developed a new type of adjustable
suture which we have now evolved for about 3 years.
These allow the tension to be adjusted postoperatively
through the conjunctiva with specially designed forceps
with very smooth edges used for this adjustment of

Fig. 2.13: Iris presenting through small sclerostomy with gentle


pressure on back edge when infusion used. No intraocular
entry necessary)

pressure. (DuckworthandKent.com DK adjustable suture


forceps No 2-502) (Fig. 2.14). The adjustable suture
system allows a gradual titration of the intraocular

Scleral Flap SuturesNew adjustable,

pressuremore gradual than that seen with suture

Releasable and Fixed

removal or massage (Fig. 2.15). We try and avoid

The function of the sutures is to secure the scleral flap


and provide adequate tension so that the flap acts as an
aqueous flow restrictor. The tension provided by the flap

completely cutting or removing sutures in the early


postoperative phase, since this can lead to insufficient
flap resistance with aqueous overdrainage and hypotony.

and sutures is particularly important when antimeta-

This is a particular problem when antimetabolite therapy

bolites are used as this is the primary regulator of the

is used.

Trabeculectomy

21

hypotony and shallowing of the anterior chamber. Many


of the sight-threatening complications of glaucoma
filtration surgery are associated with hypotony. Because
of the prolonged inhibition of subconjunctival scarring
with antimetabolite therapy (especially with MMC), it is
important to remember that hypotony can result from
suture removal even several months after surgery. Late
choroidal effusions and suprachoroidal hemorrhage have
been reported after suture removal many months after
tube drainage surgery.
Fig. 2.14: Adjustable suture forceps with special fine smooth
tips for transconjunctival suture adjustment without tearing
conjunctiva

Conjunctival Closure
The conjunctiva can be closed with a variety of sutures.
For a fornix-based flap the conjunctiva can either be
closed just with one or two sutures at either end of the
relieving incision, or more thorough closure can be
performed with interrupted mattress sutures or a
continuous suture with or without corneal grooves. We
make a series of corneal grooves (Groove closure) and
do all our closure sutures through these burying the knots
in the cornea so there is no discomfort from the nylon
sutures (Figs 2.16 to 2.19). This new technique has
virtually eliminated central conjunctival retraction, leaks
and suture discomfort.

Fig. 2.15: transconjunctival loosening of adjustable sutures


without sudden fall in intraocular pressure

If the scleral flap has been sutured with non-releasable


sutures, then these can be cut in the postoperative period
using the technique of laser suturelysis with a compression
contact lens (e.g. Hoskins lens). There is a risk of causing
a button-hole in the conjunctiva with laser suturelysis,
and this gives releasable sutures a theoretical advantage
over non-releasable sutures. The use of a releasable
suture technique has not been clearly shown to increase
the long-term success rate of trabeculectomy, but does
reduce the incidence of immediate postoperative

Fig. 2.16: Corneal groove creation (5 grooves) for closure of


fornix based conjunctival flap to minimize leakage and suture
discomfort

For a limbus-based flap, a dissolving suture (e.g. vicryl)


or nylon can be used to close conjunctiva using either
interrupted or continuous suturing. We prefer a dissolving

22

Atlas of Glaucoma Surgery


suture despite the theoretical slight increase in
inflammation with vicryl because of patient comfort and
ease of management. When suturing conjunctiva, it is
important to be able to use a round-bodied rather than
a spatulate needle if possible. This is because a spatulate
needle hole tends to tear and increase in size, and
cheesewire, whereas a round-bodied needle hole tends
to close more spontaneously and leakless. This is
particularly important if antimetabolites, such as MMC
are used. It is important to take secure bites of both
Tenons and conjunctiva if single closure is used, to ensure
a watertight wound.

Postoperative Medications
At the end of surgery a subconjunctival injection of steroid
and antibiotic should be given 180 degrees away from
the trabeculectomy site. Care should be taken to ensure
this does not directly enter the eye through the
sclerostomy. Mydriatics such as atropine are used by
many ophthalmologists. Advantages include a relaxation
of the ciliary muscle and pain relief, possible reduction
of anterior chamber shallowing and malignant glaucoma,
possible stabilization of the blood aqueous barrier
(Atropine mainly) and prevention of central posterior
synechiae. Disadvantages include a dilated pupil which
may increase the chance of lens-corneal touch if the
anterior chamber is shallow, and loss of accommodation
with blurred vision. With the use of the infusion and
tight control of postoperative flow we no longer use
mydriatics routinely.

Postoperative Antimetabolite Injections

Figs 2.17 to 2.19: Lateral purse string. Entry via corneal groove,
purse string then exit via corneal grove and tie in groove.
Repeated procedure except for the conjunctival purse string
for the 3 middle sutures

Postoperative injections of 5FU can be used


postoperatively on their own, or even after intraoperative
MMC or 5FU have been used. Subconjunctival injections
of MMC have been given, but rarely significant
complications have been reported so we do not use MMC
injections routinely. 5FU was originally used as a planned
regimen following surgery, but with the advent of
intraoperative metabolites, particularly 5FU, the
injections are now more usually used according to the
clinical situation at each postoperative visit.

Trabeculectomy
Indications
1. As part of a planned regimen in a patient with a
significant risk of scarring or requiring a low
postoperative intraocular pressure.
2. In a patient showing signs of scarring and imminent
failure of the bleb.
3. Following a needling or rexploration procedure.
4. To prevent failure of an existing bleb after a healing
stimulus, e.g. cataract extraction surgery.
5. Injections may be given up to several months after
surgery if there is a persistent healing response and
the intraocular pressure is rising.

Technique
1. The eye is anesthetized with several drops of topical
amethocaine. It may also be useful to blanch the
conjunctiva with a drop of adrenaline 0.01 percent
or phenylephrine 2.5 percent if there is no
contraindication, as this may reduce the incidence of
postinjection subconjunctival hemorrhage.
2. Quantity and concentration. The original regime
involved injections of 5 mg of 5FU diluted with 0.5
ml of saline. 5FU is now generally given in a
concentration directly from the bottle, which is either
0.1 ml of a 50 mg/ml solution or 0.2 ml of a 25 mg/
ml solution (i.e. injection dose = 5 mg).
3. A thin needle is advantageous as it reduces the reflux
of 5FU into the tear film. For convenience we use a
presterilized insulin syringe with an integral 27-gauge
needle.
4. A lid speculum is inserted to improve access.
5. Site of injection. 5FU was originally given 180 degrees
from the bleb to minimize the risk of intraocular entry
of the 5FU solution which has an alkaline pH. We
now give the injection about 90 degrees from the
bleb to maximize the effect. Occasionally the injection
can be given deep in the upper fornix away from the
drainage bleb if there is very good exposure. The
conjunctiva is gently lifted with a non-toothed forceps
and the needle inserted subconjunctivally. If the
needle is too deep there is a danger of scleral bleeding
and direct tracking into the eye. The bleb resulting
from the injection is slowly raised and watched as it
advances towards the drainage bleb area, and

23

injecting should stop just before the injection bleb


meets the drainage area. Great care should be taken,
particularly in a soft eye, as 5FU may enter the eye
much more easily in a soft eye (see Fig. 3.10).
6. The needle should be left in place for a few seconds
as this helps to seal off the entry site and reduce
leakage of 5FU into the tear film.
7. Any remnant 5FU in the tear film should be irrigated
out. If amethocaine eyedrops are used after a 5FU
injection a fine white precipitate in the tear film
indicates that there is 5FU present. Washing out the
fornix may reduce the incidence of corneal
complications.
8. We have developed a new technique of 5-FU
preceded by subconjunctival Helon GV TM. This
viscoelastic wall prevents leakage of 5FU back into
the tear film and enhances the effect of the 5-FU
(Fig. 2.20).

Fig. 2.20: VIscoelastic wall and 5FU lake

Postoperative Management of Glaucoma


Filtration Surgery
1. Topical steroids. It is important to suppress the wound
healing response in the early to intermediate
postoperative period. Steroids are initially prescribed
2 hourly for the first 2 weeks and then the dosage is
adjusted according to bleb morphology. Patients
routinely receive a reducing dose of topical steroids
for approximately 8 weeks postoperatively. We use
the strongest steroid available, at present prednisolone
acetate 1 percent.

24

Atlas of Glaucoma Surgery

2. Topical antibiotics. The patient usually receives


antibiotics for about 4 weeks postoperatively.
3. Topical mydriatic/cycloplegic agents. Use of these
agents varies between surgeons. They may be useful
in preventing postoperative synechiae, help to deepen
the anterior chamber (particularly in eyes at high risk
of developing a shallow anterior chamber or
malignant glaucoma), and reduce spasm due to ciliary
spasm. Disadvantages include increased visual blurring
and a possible increased risk of lens corneal touch if
the anterior chamber is shallow.
4. Topical nonsteroidal anti-inflammatory drugs. These
may be useful in selected patients but their efficacy is
not proven.
5. Oral steroids. The use of these powerful drugs with
potentially dangerous systemic side effects is not
routine. However, there are certain patients (e.g.
those with severe uveitic glaucoma) in whom the
benefits of use will outweigh the risks. When used,
systemic steroids should be started in the preoperative
period and there should be good communication
between the ophthalmic surgeon and the patients
family doctor and other physicians.
6. Antimetabolite therapy. Subconjunctival 5FU can be
given in the postoperative period to modulate wound
healing. It is essential that if 5FU is used, it
is given as soon as bleb failure is detected. Signs
of impending bleb failure include; changes in
bleb morphology with increased bleb vascularity,
thickening of conjunctiva and Tenons capsule,
reduction in bleb size and height, reduction of
conjunctival microcysts and progressive elevation
of the IOP. The formation of focal bleb encapsulation
may result from continued subconjunctival
fibrosis.
7. Complications. The best management of
complications is to anticipate and prevent them.

Intraoperative Complications (Glaucoma


Filtration Surgery)
Conjunctival Tear
Conjunctival tears can be a serious problem, particularly
if antimetabolites are used. The most common cause

of a conjunctival tear is surgical damage from scissors


during the dissection process. This is particularly likely if
there has been previous surgery and adhesions are
present.
Prevention
i. Slow dissection with continual reassessment of the
plane of dissection.
ii. If there is significant scarring, it is best to proceed
slowly with very small cuts, to minimize any tearing
action.
iii. Use G. adrenaline to reduce tissue vascularity and
bleeding.
iv. Inject subconjunctival saline to demarcate scar tissue
and open up tissue planes (NB very useful tip)
Management
i. If a conjunctival tear occurs, and antimetabolites
are not used, it can usually be repaired by a simple
purse-string vicryl suture, on a vascular needle.
ii. If antimetabolites are used (especially MMC), it may
be necessary to bring in tissue that has not been
exposed to the antimetabolite. This can be done by
dissecting an attached flap of Tenons capsule, from
an area distant to the treated area, and then rotating
it underneath the conjunctiva and then sewing it in
as a living patch underneath the tear.

Scleral Flap Damage


Prevention
i. Reduce handling of scleral flap to a minimum.
ii. Do not make flaps too thin as they cheese-wire and
tear very easily. The eye should not be opened until
the scleral flap has been fully completed.
Management
i. If the scleral flap is severely damaged during the
dissection, then surgery should not proceed at that
site and a new scleral flap created in an area of
undamaged sclera.
ii. If minor flap damage occurs, this may have to be
repaired with the 10/0 nylon suture. If very severe
damage has occurred and the sclerostomy cannot
be secured, then a scleral patch from another area
or a donor, or processed pericardium may have to
be sewn onto the operation site.

Trabeculectomy
Conjunctival, Scleral and iris Bleeding
Prevention
i. Bleeding can be avoided by appropriate use of
cautery. Close attention to hemostasis including clot
removal is important, because blood is a very potent
stimulus for fibrosis.
ii. Installation of G adrenaline 0.01 percent at the start
of surgery help reduce bleeding in the area.
iii. Stop aspirin and anticoagulants preoperatively, if
possible.
Management
i. If there is bleeding following the peripheral
iridectomy, it is best to wait, leaving the flap slightly
open, to allow the blood to exit the eye, rather than
collecting in the anterior chamber. In the vast
majority of cases, the bleeding stops within a minute
or two. The clot can then be irrigated out, and the
operation completed.
ii. If the bleeding continues the intraocular pressure in
the eye should be raised, with an anterior chamber
infusion if necessary.

Suprachoroidal Hemorrhage
Fortunately, this is very rare intraoperatively. The
intraocular contents will come forward and the pressure
will rise acutely.
Prevention
i. Caution in advising surgery in high risk eyes (e.g.
other eye expulsive hemorrhage).
ii. Avoid operating on inflamed eyes until quieter or
eyes with high pressures.
iii. Maintain intraoperative pressure (preplace sutures,
use an anterior chamber infusion throughout
procedure).
iv. Maintain postoperative intraocular pressure (e.g.
viscoelastic, C3F8 gas in aphakic eyes).
v. Stop aspirin and anticoagulants if possible and avoid
Valsalva maneuvres postoperatively.
vi. In nanophthalmic eyes, scleral decompression may
be required before entry into the eye. The diagnosis
will be missed unless it is looked for clinically (small
eyes) and with ultrasound (short eye and thick
ocular coat).

25

Management
i. Close all wounds rapidly.
ii. When eye is secured, assess posterior segment and
confirm diagnosis and presence of choroidal
hemorrhage. If they are peripheral and not
impinging on central vision consider leaving. If
hemorrhage is extensive then consider drainage
through one or two sclerostomies. Drainage must
be performed before the blood clots to be effective
at the time of surgery.

Vitreous Loss
Fortunately, this very rarely occurs.
Prevention
i. Keep sclerostomy as anterior as possible.
ii. Note any iridodonesis and subluxed lenses preoperativelyconsider tube surgery or filtration with
MMC if lensectomy and anterior vitrectomy
inevitable.
Management
i. Anterior vitrectomy
ii. Postoperative 5FU will be required as there is an
increased chance of filtration failure.

Wound Leak
Prevention
i. Use round vascular needle (e.g. BV needle) which
reduces conjunctival leakage and buttonholing.
ii. Place incision in limbal based flap as far away from
limbus as possible, deep in the fornix.
iii. Use extramattress suture(s) to close fornix based
conjunctival flaps.
iv. Protect cut edge of conjunctiva from drug (e.g.
special conjunctival clamp).
v. Avoid conjunctival dissection in scarred areasif
posssibleconjunctival buttonholing is more likely
in these areas due to multiple adhesions.
Management
i. Small leaks often settle spontaneously with
observation. If leaks persist then treatment options
include use of a pressure dressing, bandage contact
lens, Simmonds shell or suppression of aqueous
production with acetazolamide.

26

Atlas of Glaucoma Surgery

ii. Significant leaks with hypotony and choroidal


effusions are best managed by resuturing the wound.

Postoperative Complications
(Glaucoma Filtration Surgery)
Wipe out of Remaining Field/Vision
This is a very rare but important complication of filtration
surgery. It is thought to occur more commonly if there is
advanced field loss, particularly if the field loss is within
10 degrees of fixation, although this has not been
conclusively proven.
Prevention
i. Check intraocular pressure in the first few hours
after surgery to detect and treat any pressure spike.
ii. Take precautions to avoid peri- and postoperative
hypotony as well as acute disk swelling may also
compromise a very damaged nerve.
iii. Avoid episodes of perioperative systemic
hypotension.

Shallow/flat Anterior Chamber


Shallowing of the anterior chamber post-filtration surgery
is a common event. Certain eyes have a higher risk of
this complication, particularly hypermetropic eyes with
angle closure glaucoma. The key to successful
management of a shallow anterior chamber is to identify
the cause. If there is lens-corneal touch surgical
intervention is required immediately to prevent corneal
decompensation. Reformation of the anterior chamber
can be performed using balanced salt solution, gas or a
viscoelastic. A high density viscoelastic such as Helon GV
may be particularly useful. The procedure is safer and
easier if an oblique temporal paracentesis was performed
at the time of initial surgery. Anterior chamber
reformation can be performed at the slit lamp if an
appropriate paracentesis exists.

Hypotony: Due to Aqueous Overdrainage


The use of antimetabolites (especially MMC) has
increased the incidence of hypotony due to an over
draining bleb. In glaucoma filtration surgery some degree
of hypotony with an IOP less than 6 mm Hg is common
in the first few days following surgery, particularly if tight
suturing techniques are not used. Most cases will settle

without interventionion. If the hypotony persists and


produces a hypotonous maculopathy then surgical
treatment is indicated (see later section).
Prevention
i. Close scleral flap securely. Adjustable/releasable
sutures are very useful. Multiple sutures may be
required particularly if MMC is used.
ii. Use an infusion with a known pressure to regulate
opening pressure.
iii. Do not make scleral flap too small or thin,
particularly if MMC used, otherwise outflow cannot
be adequately restricted.
iv. Do not release sutures too early. If MMC is used
suture release (even months after surgery) may
result in hypotony. It is preferable to try to loosen
releasable sutures with massage rather than release
them.
v. Caution when using strong antimetabolites in
patients with a high risk of hypotony related
complications, particularly patients who have thin
or abnormal sclerae, e.g. myopes, buphthamics and
those with collagen abnormalities

Choroidal Effusion
Choroidal effusions are common in eyes that are
hypotonous following filtration surgery. The collection
of fluid (high protein content) in the suprachoroidal space
is produced by transudation from leaky capillaries in the
choriocapillaris.
Prevention
i. Take measures to prevent hypotony (see above).
Management
i. Cycloplegicmydriatic agents and frequent topical
steroids.
ii. Surgical intervention is rarely required, but signs
that drainage of the effusions may be is needed
include: evidence of lens-corneal touch with corneal
edema, bleb failure with increasing IOP, marked
anterior segment inflammation and apposition of
the effusions (kissing choroidals).
iii. If the IOP is normal then other causes of choroidal
effusion should be considered including scleritis, and
low serum protein levels and nanophthalmos.

Trabeculectomy
Raised Intraocular Pressure
A high IOP after filtration surgery is one of the most
common complications of filtration surgery. It is almost
always due to inadequate aqueous outflow. Treatment
depends on the site of obstruction. Sometimes
obstruction can occur in several sites at once. The sites
of obstruction are as follows.
Posterior diversion of aqueous (Malignant glaucoma)
In malignant glaucoma the aqueous is misdirected
backwards into the vitreous cavity and is prevented from
flowing anteriorly by the anterior vitreous face. The
patient usually presents with a shallow anterior chamber,
and an elevated intraocular pressure several days after
surgery. Ultrasound reveals hypoechogenic areas on
ultrasound. It has been observed that ciliary processes
are rotated anteriorly in malignant glaucoma such that
they press against the lens equator and prevent anterior
flow of aqueous. It has also been noted that the anterior
vitreous hyaloid is abnormally positioned plugging spaces
between ciliary processes. An acute pupil block or
choroidal hemorrhage can sometimes give a similar
picture but is easily excluded clinically. The eye may have
a predisposing risk factors such as hypermetropia, and
angle closure glaucoma.
i. Prevention
Identify high-risk eyes preoperatively (Ultrasonic
measurement of axial length if necessary). It is
important to identify nanophthalmic eyes, as
prophylactic sclerotomies may be required.
Ensure that there is a relatively high resistance at
the level of the scleral flap by tight closure. If
necessary manage raised intraocular pressure
medically in the early postoperative period,
releasing sutures later. Overdrainage of aqueous
in the early postoperative period must be avoided
in high risk eyes.
Use of cycloplegics especially G. atropine or
homatropine is useful.
In high risk eyes if some cataract is present a
combined procedure may debulk lens volume. A
rigid one piece implant may help prevent a flat
anterior chamber. The capsulorrhexis should be
kept relatively small to prevent lens implant/pupil
capture occurring if the anterior chamber

27

shallows. If malignant glaucoma does develop this


is easier to manage in a pseudophakic eye.
ii. Management
Ensure peripheral iridectomy is patent
Mydriatics. Atropine 1 percent and phenylephrine
10 percent (if no contraindication)
Aqueous suppressive agents with osmotics, if
necessary
If the ciliary processes are visible on gonioscopy
such as in an eye with a broad iridectomy, direct
argon laser to the ciliary processes may break the
attack. However, corneal edema and the
shallowed anterior chamber often make this very
difficult.
Disruption of peripheral anterior vitreous face
using a Nd:YAG laser. The aim of this procedure
is to create a pathway for fluid to move from the
posterior segment to the anterior chamber. To
achieve this goal it is usually necessary to disrupt
the peripheral anterior vitreous face. Disruption
of the central hyaloid often fails to produce an
adequate pathway for fluid movement. It can be
difficult to remove the anterior vitreous face
particularly in a phakic eye where the risk of
lenticular damage is high. If the patient is phakic
but has significant cataract consideration should
be given to lens extraction and this increases the
chance of successful disruption of the anterior
hyaloid face.
Good visualization and precise focusing of the
Nd:YAG laser are important. It is useful to have a
patent PI in order to achieve adequate access to
the peripheral anterior hyaloid. As soon as the
hyaloid is disrupted the anterior chamber will be
observed to deepen. In pseudophakic eyes one
must create a passage through any tissue that
intervenes between the PI and hyaloid, including
lens capsule and any cortical lens remnants. If the
eye is inflamed there may be condensations of
anterior hyaloid which are adherent to adjacent
structures, and which create restricted pockets of
misdirected aqueous.
If a surgical vitrectomy is necessary, this can be
performed through the peripheral iridectomy if

28

Atlas of Glaucoma Surgery

the patient is pseudophakic, but will required pars


plana approach if the patient is phakic.
Pupil block
If pupil block occurs after filtration surgery the peripheral
iridectomy is non-patent or may be blocked by fibrin.
The anterior chamber is shallow with some iris bombe.
i. Management
Pressure lowering treatments as necessary
Nd:YAG laser iridotomy
Pupil dilatation to break any synechiae
Steroids to reduce inflammatory exudate.
Fistula blockage
If the rise in intraocular pressure occurs in the first 1 to 2
weeks fistula obstruction is the most common cause. The
bleb is usually flat. The most common cause is scleral
flap sutures that are too tight. Other causes include fibrin
and blood at the level of the flap and subconjunctival
space. Gonioscopy will help identify those cases in which
the internal aspect of the sclerostomy is blocked by iris,
ciliary processes, vitreous or blood; or in which there
has been failure to correctly excise the corneoscleral block.
i. Prevention
Ensure adequate size and clean excision of
corneoscleral block.
Avoid a posteriorly sited sclerostomy which
increases chance of ciliary body or blood
obstruction
Create and use a paracentesis to check the
opening pressure of the scleral flap intraoperatively.
ii. Management
Gentle massage at posterior lip of sclerostomy
may loosen any adhesions and restart aqueous
flow through the fistula. This may also loosen any
mild internal sclerostomy blockage. The
application of focal pressure through the eyelids
initially may be all that is required. Otherwise,
pressure applied more focally (with a sterile plastic
ointment applicator) is more effective than diffuse
digital massage through the lids. If releasable

sutures have been used this maneuver tends to


loosen the tension in the knot and reset a lower
opening pressure at the scleral valve. One problem
with completely removing releasable sutures or
cutting a scleral flap suture with the argon laser is
that the resistance to flow at that point in the flap
drops suddenly, with loss of control and risk of
sudden aqueous overdrainage and hypotony. The
patient should be re-examined about 30 minutes
after massage to check that the IOP has not
increased again.
If massage fails to establish adequate aqueous
drainage through the scleral flap then it maybe
necessary to remove the releasable suture or
perform argon laser suturelysis.
Application of argon or Nd:YAG laser to the
internal aspect of the sclerostomy can be used to
remove any tissue blocking the opening.
Subconjunctival fibrosis
Blebs that were previously functioning may become
encysted or encapsulated during the first few months
after filtration surgery because of the wound healing
response. These blebs have an elevated, tense, domeshaped structure associated with an elevated IOP (Fig.
2.21). There is a fibrotic healing response within Tenons
capsule, particularly around the edge of the cyst, but
there may also be compression of the subconjunctival
tissues which reduces transconjunctival aqueous flow. In
addition, some blebs are lined with fibrin. Patients who
have received previous topical sympathomimetic agents
maybe at higher risk of developing bleb encapsulation.
i. Management
Intensive topical steroids
Aqueous suppressant therapy may help by
reducing the compaction of the inner layers of
the bleb, allowing increased transconjunctival
aqueous flow
Needling of encapsulated bleb. This procedure
can be performed under topical anesthesia at the

Trabeculectomy

29

performed or antimetabolites (particularly MMC) were


used at surgery. The leak can be focal and single or
diffuse with multiple sweating areas (Fig. 2.22).

Fig. 2.21: Severely encysted bleb

slit-lamp. The conjunctival vascularity is reduced


by prior instillation of G. adrenaline 0.01 percent
or G. phenylephrine 2.5 percent. Aqueous iodine
(5%) is instilled into the conjunctival sac and then
washed out after several minutes. The patient is
asked to look down and an assistant or speculum
used to retract the upper lid. A narrow gauge
needle (e.g. 29 G) is passed through the
conjunctiva several millimeters to one side of the
bleb. The needle is advanced until the tip
punctures the cyst wall. The needle is then gently
moved from side to side to enlarge the hole in
the wall of the cyst. The act of needling is likely to
reactivate the wound healing process in the region
of the bleb, and for this reason a subconjunctival
injection of 5FU (5 mg) is given away from the
bleb. Topical steroids and antibiotics are given after
the needling. It is important to be aware that
excessive needling can result in a precipitous drop
in IOP and can potentially result in all the
complications of hypotony including suprachoroidal hemorrhage.
Late bleb leak focal or diffuse
Blebs can start to leak months or years after surgery, this
is particularly so if an unguarded sclerostomy was

Fig. 2.22: Leaking bleb secondary to cystic change

i. Prevention
Avoid unguarded sclerostomies. Full thickness
sclerostomies are much more likely to result in
thin cystic blebs, even without antimetabolite use.
Avoid excessive use of antimetabolites.
ii. Management
The decision to treat depends on several factors
including; patient factors (including symptoms),
the size of the leak, bleb morphology, risk factors
for infection, and the presence of hypotony and
complications of hypotony such as macular
edema. Small leaks may settle spontaneously. The
range of treatment options include:
Large diameter contact lenses.
Bleb compression sutures. 9/0 nylon sutures are
sewn across the bleb compressing it around the
leak site. This can be combined with blood
injection. While the sutures stay in situ the patient
should continue on prophylactic antibiotics (see
Fig. 2.13).
Laser treatment to the deep scleral flap.
Trichloracetic acid painted on bleb.

30

Atlas of Glaucoma Surgery

Injections of autologous blood (1 to 2 ml). This


can be given both into and around the bleb. The
pressure may rise immediately after injection due
to blood clot obstructing outflow. However, the
pressure will fall when the fibrinolytic system is
activated. At this later stage only secondary healing
stimulated by the injection will increase the
intraocular pressure. If intrableb injection is used
the blood may enter the anterior chamber and
cause a hyphema or the vitreous cavity
(particularly in pseudo or aphakic eyes) resulting
in a vitreous hemorrhage. The use of concurrent
viscoelastic in the anterior chamber to raise
pressure and prevent blood entry. However, this
may result in a large, persistent pressure rise and
is not advised
Refashioning of the bleb. This is the most
extensive treatment but also the most effective as
the area is effectively reconstructed. The cystic
avascular area is resected and viable vascularized
conjunctiva is brought down from above. A
lamellar scleral patch is sewn onto the old
trabeculectomy site, and reduces the chance of a
recurrence of bleb thinning and leakage. If a scleral
patch is not used, then there is a very high chance
if a recurrence of the cystic area in the long-term
(see Fig. 2.14). The technique is very effective in
stopping leaks, but can be complicated by a
persistent rise in IOP
Quilting sutures can be used to tack down an
exuberant conjunctiva
Cataract surgery may produce an inflammatory
reaction which may stimulate wound healing. If a
significant cataract is present it may be appropriate
to perform cataract surgery if the bleb is only
slightly overdraining. The surgery may stimulate
enough healing to restore the bleb to an
acceptable condition. However, it is important to
remember that biometry may be different in a
hypotonous eye.
Early infectionblebitis and endophthalmitis
i. Prevention
Identify high risk patients (e.g. blepharitis) and
manage preoperatively

Preoperative aqueous iodine to lids and


conjunctival sac
Make sure that there are no lashes in the operative
field
If releasable sutures are used they should be either
buried or removed early if exposed.
Late infection
i. Prevention
Avoid overtreating patient with antimetabolite.
Avoid unguarded sclerostomy and very thin scleral
flaps, which may necrose (especially if MMC is
used).
Avoid very focal small areas of antimetabolite
exposure. Use larger areas of treatment and certain
agents (e.g. beta-irradiation) produce more diffuse
and less cystic blebs
Avoid blebs situated in the interpalpebral or
inferior area. The blebitis/scleritis and infection rate
may be 5 to 10 times in these areas compared to
blebs under upper lid. Use tubes or other
therapies rather than place blebs inferiorly.
ii. Management
Bleb infection is an emergency. Patients should be
told to seek ophthalmological attention immediately
if they develop a purulent conjunctivitis. If there is a
suggestion of endophthalmitis the patient should
be treated as an endophthalmitis and undergo
swabs, aqueous and vitreous taps. Even with bleb
associated endophthalmitis swabs and aqueous taps
may be culture negative with positive vitreous
cultures, usually if antibiotic therapy has been started
but even if it has not. The patient should then receive
intravitreal antibiotics. If there is marked vitreous
activity a vitrectomy should be considered to debulk
the infective agent and toxins. Haemophilus and
Streptococcus are the most common organisms
causing bleb related endophthalmitis and any
antibiotic regimen should cover these organisms.
Cataract
Cataract progression is a very common complication of
glaucoma filtration surgery. Several situations increase
cataract progression including lens/corneal touch, lens
trauma, inflammation, hypotony and the use of
intraoperative MMC.

Trabeculectomy
i. Prevention
Take precautions to avoid postoperative hypotony
and flat anterior chambers
Avoid direct lens traumause of an oblique
paracentesis parallel to the limbus minimizes the
possibility of any lens trauma lowers the chance
of damage when reforming the anterior chamber
and or testing the resistance of the scleral flap
Consider combined cataract and filtration surgery
in primary glaucoma if there is significant lens
opacity.
Ptosis and strabismus
i. Prevention
Use a corneal traction suture rather than a superior
rectus suture
Avoid excessive traction on the eye which stretches
levator aponeurosis
Avoid rectus muscle traction sutures when placing
tube implants where possible

31

When dissecting a limbus based flap incise the


conjunctiva and Tenons as separate layers to
prevent damage to the superior rectus muscle
Take care with posteriorly placed sponges soaked
in antimetabolite as MMC is toxic to muscle.
ii. Management
Conservative most cases settle spontaneously
Appropriate surgery (e.g. to repair a levator
dehiscence) may be required in some cases.
Astigmatism
i. Prevention
Keep actual sclerostomy and amount of tissue
removed to a minimum, particularly if scleral
rigidity is low
Keep scleral flap size to minimal size required to
achieve control of flow (but noting that relatively
larger flaps may be needed with strong antimetabolites)
Use oblique rather than radial sutures on scleral
flap where possible.

32

Atlas of Glaucoma Surgery


Doina Gherghel, Selim Orgl, Christian Prnte, Josef Flammer

3 Trabeculectomy with a Scleral Tunnel

Technique Combined with Mitomycin-C

INTRODUCTION
Since its introduction by Cairns, trabeculectomy has
become the most commonly performed approach for
surgical reduction of interocular pressure.1-3 There are,
however, two major problems in daily practice with this
surgical approach. Very often, the success in lowering
intraocular pressure is limited in time. Attempts to
overcome this limitation have included the use of
antimetabolites such as mitomycin-C. The use of this
type of antimetabolites has dramatically increased the
incidents of postsurgical ocular hypotonicity. Many
technical modifications have been developed, whether
a modified trabeculectomy using releasable sutures or
scleral tunnel techniques similar to that used in phako
emulsification; or guarded procedures with
nonpenetrating deep sclerectomy. The success rate with
these various techniques has not been able to convince
glaucoma surgeons to abandon classical trabeculectomy.
Furthermore, although trabeculectomy with the primary
use of intraoperative mitomycin-C has been reported to
be a relatively safe procedure,4-5 many surgeons still fear
potential complications due to postoperative ocular
hypotonicity. In the following, we present a surgical
approach that attempts to take advantage of the longterm benefits of mitomycin-C by applying it routinely
while avoiding the early complications often observed
with such a drug by using a scleral-tunnel technique
combined with a tight scleral wound closure using
dissolvable sutures.

SURGICAL MODIFICATIONS
We describe a modified technique that has all the
advantages of scleral tunnel architecture, concomitant

use of low-concentration MMC and tight suture closure


(Figs 3.1A to P).
The eye is stabilized by two anchorage sutures at the
corneal limbus, attached to the lid holder, without
penetration of the anterior chamber.
A limbus-based flap, including conjunctiva and
Tenons layer is prepared. Thereafter, a 5 to 10 IE per
10 to 20 ml 8-ornithine-vasopressin solution
(ornipressine, POR-8) is used as a local vasoconstrictor,
preventing excessive bleeding. In the mean time, the
sub-Tenon space is prepared.
After the preparation of the sub-Tenon space has been
finalized, hemostasis is achieved with bipolar cautery. A
surgical sponge soaked with a 0.28 mg/ml solution of
MMC is applied to the episclera, over the site of the
planned scleral wound. The conjunctiva-Tenon layers are
draped over the sponge, avoiding contact of the MMC
with the wound edge. The exposure time varies according
with the case profile and risk factors (the number of prior
surgeries, vascularity of the tissues, etc.), and lies between
1 and 6 minutes (one sponge per minute).
After removing the sponge, one carefully irrigates the
whole area with 100 ml of balanced salt solution.
Paracentesis, in clear comea, is performed in the temporal
quadrant. The conjunctiva is attached with two sutures
to the eyeholding sutures, allowing a clear view of the
sclera during the preparation of the corneoscleral tunnel.
Thereafter, a 3 mm horizontal scleral incision is created
2 mm from the corneoscleral limbus.
A crescent-shaped diamond knife is introduced
through the scleral incision, advancing 0.5 mm into the
corneal lamellae. The tunnel is widened nasally and
temporally, parallel anteriorly to the scleral incision, and

Trabeculectomy with a Scleral Tunnel Technique Combined Mitomycin-C

33

Fig. 3.1C: A limbus-based conjunctival flap is prepared

Figs 3.1A and B: The eye is stabilized by two anchorage sutures


at the corneal limbus, attached to the lid holder, without
penetration of the anterior chamber

the anterior chamber is penetrated. The trabeculectomy


is then done with a punch, which enables the creation
of a regular precalibrated cut and excision of a
semicircular relatively controlled amount of sclerocorneal
tissue. Single or multiple cuts may be performed as
needed. The peripheral iridectomy is made with Vannas
scissors.
The scleral wound is closed with a combination of
two interrupted 10-0 nylon sutures and at least two
interrupted 8-0 vicryl sutures. The tightness of the vicryl
sutures is adjusted to approximate the edges of the scleral
wound and nearly totally restrict aqueous flow, and the
anterior chamber is reformed with balanced salt solution
trough the paracentesis.

Fig. 3.1D: Sub-Tenons space is prepared

Fig. 3.1E: A surgical sponge soaked with a 0.28 mg/ml solution


of MMC is applied on the episclera, over the site of the planned
scleral wound

34

Atlas of Glaucoma Surgery

Fig. 3.1F: After removal of the sponge, the whole area is


carefully irrigated with 100 ml of balanced salt solution

Fig. 3.1I: A 3 mm horizontal scleral incision, 2 mm from the


corneoscleral limbus, is created with a diamond knife

Fig. 3.1G: The conjunctiva is attached with two sutures to the


eye-holding sutures

Fig. 3.1J: A 3 mm horizontal scleral incision, 2 mm from the


corneoscleral limbus, is created with a diamond knife

Fig. 3.1H: The conjunctiva is attached with two sutures to the


eye-holding sutures

Fig. 3.1K: The trabeculectomy is done with a punch

Trabeculectomy with a Scleral Tunnel Technique Combined Mitomycin-C

Fig. 3.1L: Peripheral iridectomy is performed with


Vannas scissors

Fig. 3.1M: The scleral wound is closed with two interrupted


10-0 nylon sutures

Fig. 3.1N: A watertight scleral closure is performed with at


least two interrupted 8-0 vicryl sutures

35

Fig. 3.1O: The Tenons layer is sutured with a


running 8-0 vicryl suture

Fig. 3.1P: The conjunctiva is sutured with a


running 8-0 vicryl suture

Tenons layer and conjunctiva are sutured separately


with a running 8-0 vicryl suture.
There are several advantages of this technique over
standard trabeculectomy:
1. The use of a specific local vasoconstrictor agent such
as POR-8 seems to be very useful in reducing the
local bleeding during surgery.
2. A low MMC concentration is used, which has been
demonstrated to be as effective as a high
concentration for good IOP control.6 lt also avoids
the potential toxicity due to a higher concentration.
The exposure time is a graded function of the risk
factors for failure (i. e. patients with more risk factors
receive higher exposure times for MMC).

36

Atlas of Glaucoma Surgery

3. The scleral-tunnel technique, with diminished


dissection, avoidance of the radial incisions and less
intraoperative manipulation, may reduce bleeding
and inflammation, which promote excessive wound
healing,7 but also reduces postoperative astigmatism.
4. Because conjunctival healing may be markedly
inhibited by MMC, hypotonicity is prevented primarily
by the resistance offered by the tight scleral wound
during the early postoperative period. Multiple
combined nylon-vicryl sutures provide keep the
wound tight in the first 3 to 5 weeks; to titrate the
flow when the vicryl sutures dissolve, they allow
aqueous fluid to drain into the preformed bleb. This
mechanism is more natural than the laser suturelysis,
which possibly implies a new traumatically induced
inflammatory response, may be both expensive and
uncomfortable for a patient who has just undergone
recent eye surgery, and has an additional risk for
subconjunctival hemorrhage or bleb leaks, which may
be induced during the procedure.
We investigated the data of 91 patients operated on
in our clinic between 1995 and 1998, 46 with the scleral
tunnel technique and 45 with classic trabeculectomy. The
groups were comparable with regard to age,
preoperative and postoperative visual acuity, visual field
defects, and IOP. MMC 0.28 mg/ml was used in both
groups. The follow-up period was between 6 and 36
months.
It is noteworthy that more than 95 percent (44/46)
of the eyes had a final IOP less than 20 mm Hg in the
group operated on with the new technique, compared
to 91 percent (41/45) in the group operated on with
the Cairns technique (Table 3.1). Also, early postoperative
hypotonicity (IOP < 5 mm Hg) appeared only in one

Table 3.1: Surgical results of the new technique versus


classic trabeculectomy
No
New
technique 46
Cairns
technique 45

Age

Preoperative Months
Postoperative IOP <
Hy %
IOP (mm Hg) follow-up IOP (mm Hg) 20 mm Hg

64.39 20.52 5.56 6-36


12.66

11.38 5.08 95.65%

2.1%

60.71 21.45 5.51 6-36


14.69

12.25 4.48 91.11%

11.1%

IOP: intraocular pressure; Hy: postoperative hypotonia

case (2%) in the group treated with the scleral tunnel


technique, compared to 5 cases (11%) found in the
group operated on by classical trabeculectomy. This fact
may be attributed to having only a horizontal scleral
incision, and also to the initial tight combined suturing.
It seems that this new scleraltunnel technique, in
combination with combined nylon-vicryl tight suturing
and use of a low concentration MMC is effective, has a
lower perioperative surgical risk, less traumatic
maneuvers, and is a good alternative to classical Cairns
trabeculectomy.

REFERENCES
1. Cairns JE. Trabeculectomy: preliminary report of a new method.
Am J Ophthalmol 1968;66:673-81.
2. Drance SM, Vargas E. Trabeculectomy and thermosclerostomy: a
comparison of two procedures. Can J Ophthalmol 1973;8:413-5.
3. Watson P. Trabeculectomy. A modified ab externo technique. Ann
Ophthalmol Glaucoma 1970;2:199-205.
4. Nuijts RA, Vernimmen RCJ, Webers CA. Mitomycin C primary
trabeculectomy in primary glaucoma of white patients. J Glaucoma
1997;6:293-7.
5. Scott I, Greenfield D, Schiffman J, et al. Outcomes of primary
trabeculectomy with use of adjunctive mitomycin. Arch Ophthalmol
1998;116:286-91.
6. Agarwal H, Sood N, Sihota R, Saga L, Honavar S. Mitomycin-C in
congenital glaucoma. Ophthalm Surg Lasers 1997;28:818-22.
7. Maumenee AE. External filtering operations for glaucoma: the
mechanism of function and failure. Trans Am Ophthalmol Soc
1960;58:219-28.

Ahti Tarkkanen, Pivi Puska, Tero Kivel

4 Cyclodestruction in Glaucoma

INTRODUCTION
When all medical and surgical therapies fail to control
intraocular pressure (IOP), it may be necessary to ablate
a par t of the ciliary body. Cyclodiathermy and
cyclocryocoagulation belong to the past because of the
severe side effects such as intense postoperative pain,
abrupt rise of intraocular pressure (IOP), intraocular
hemorrhage and phthisis. The side effects of Nd:YAG
laser cyclophotocoagulation are similar but milder.
These methods are being replaced by contact
transscleral infrared 810 nm diode laser, red 647 nm
krypton or 670 nm diode laser cyclophotocoagulation.
The energy of these wave lengths is excellently absorbed
by melanin pigment of the ciliary epithelium. In order to
produce similar coagulation effect in the rabbit ciliary
body only a half as much energy is required with the
647 nm krypton laser as compared to the 1064 nm
Nd:YAG laser. The red lasers do not impair the sensitivity
of the cornea, they do not injure corneal subbasal nerves
and they do not change tear secretion. Postoperative
pain is minimal, if any. Diode laser equipment is not
costly, it is mostly portable and easy to use. Transscleral
diode laser cyclophotocoagulation is performed on an
outpatient basis. An operation room is not needed. The
procedure is simple, safe, and easy to learn (Figs 4.1
and 4.2).

EARLY CYCLODESTRUCTIVE
PROCEDURES
Cyclodiathermy
In 1925 Curran1 cauterized the sclera over the ciliary
body using a red-hot galvanocautery loop. His aim was
to lower IOP by creating an artificial staphyloma to

Fig. 4.1: Start of transscleral contact cyclophotocoagulation. A


sterile operating room is not needed. The surgeon is using
protective spectacles

Fig. 4.2: The equipment on the operating table consists mainly


of lid speculum, millimetre calliper, eyedrops and a patch

increase filtration through spongy sclera. Weve2 noted


in 1932 that IOP remained low after extensive diathermy
in the non-penetrating mode over the region of the
ciliary body. The penetrating cyclodiathermy was
introduced by Vogt3 in 1936. It remained the method of
choice until 1960s. In 1970 Walton and Grant4 reviewed

38

Atlas of Glaucoma Surgery

a series of 100 operations performed on 26 adults and


27 children. They documented only a 5 percent chance
of long-lasting, useful reduction in IOP and about the
same chance of inducing phthisis. Hence cyclodiathermy
was soon replaced by cyclocryocoagulation.

Cyclocryocoagulation
Freezing of the ciliary body to lower IOP was suggested
by Bietti5 in 1950. However, it took about 15 years before
it was accepted that this method was useful in treating
patients with advanced treatment-resistant glaucoma.
Specific indications were neovascular, inflammatory and
aphakic glaucomas. 6 Favorable results have been
reported in neovascular glaucoma.7,8 Although visual
outcome may be poor, pain relief in 90 percent of the
patients has been the main benefit.9,10 Good results have
been also obtained in the treatment of aphakic openangle glaucoma11 as well as in glaucoma after penetrating
keratoplasty.12,13
The most frequent complications of cyclocryocoagulation are postoperative, intense pain, which may
last for several days, transient elevations of IOP, hyphema
and chronic secondary uveitis. Postoperative pain may
be reduced by performing the operation after conjunctival peritomy. Still strong analgesics are often needed.
In one study14 it was reported that IOP rose to 60 to 80
mm Hg during the freezing phase, but decreased to
baseline during thawing. Postoperatively IOP rose again
to 60 mm Hg and peaked for 6 hours after the operation.
Phthisis has been described in consecutive patients in 12
percent.15 Of eyes with neovascular glaucoma 22 percent
ended up with this extreme complication.
After the advent of ingenious new methods of
cyclodestruction, mainly transscleral contact
cyclophotocoagulation, cyclocryotherapy is not preferred
any more.

Nd: YAG Cyclophotocoagulation


In 1961 Weekers and associates16 used transscleral light
energy for the first time to destroy a part of the ciliary
body in glaucoma. They applied xenon arch and
introduced the concept of cyclophotocoagulation. Since
then introduction of ruby laser17 paved the way for
Nd:YAG lasers18 which have received a wide acceptance.
For contact cyclophotocoagulation the continuous mode

is used. The probe has to be held perpendicular to the


scleral surface and pushed firmly against the sclera to
increase the localized coagulation effect. Between 30 and
40 applications are usually made with 5 to 7 J energy.19
A good response has also been obtained after only 16
applications with 2 J each.20
In one study 62 percent of the patients had their
IOPs below 21 mm Hg after treatment and 11 percent
had to be retreated. 20 In another study the mean
pretreatment IOP was very high, 38.7 mm Hg and after
treatment it had fallen to 15.8 mm Hg.21 To avoid phthisis
only a half of the original number of applications were
recommended.
The complications of transscleral Nd:YAG cyclophotocoagulation resemble those of cyclocryotherapy, but are
less severe. Most common complications reported were
postoperative anterior uveitis (42%), conjunctival
injection (36%) and pain (30%).22
There are a few reports of sympathetic ophthalmia
after Nd:YAG cyclophotocoagulation.23,24 In cases with
histopathological confirmation of the diagnosis the
exciting eye had undergone perforating incisional
surgery.25 Hence eyes without visual potential should
be treated cautiously keeping this complication in mind.

CURRENT CYCLODESTRUCTIVE
PROCEDURES
Although the intraocular pressure-lowering effects may
be similar with different cyclodestructive procedures such
as cyclocryocoagulation or Nd:YAG cyclophotocoagulation, the present trend is for various transscleral contact
diode laser techniques. The risk of transient postoperative
IOP rise, pain, conjunctival injection and iritis is
considerably less. Even repeated operations are well
accepted by the patients. Of great significance is also the
low incidence of visual loss (Figs 4.3 to 4.6).

Infrared 810 nm Diode Laser


Cyclophotocoagulation
Infrared diode lasers operate within the 780 to 850 nm
spectrum in contrast to the 1064 nm wavelength by the
Nd:YAG laser. The near infrared light has an excellent
scleral penetrance and better melanin absorption than
the longer wavelength of the Nd:YAG laser. The
histopathological effects are similar in living rabbit26 and

Cyclodestruction in Glaucoma

Fig. 4.3: Ceralas 810 nm diode laser

Fig. 4.4: Before starting the operation the power through the
fiberoptic probe is checked using Power Max Laser Fiber Power
Meter

human autopsy eyes, but the diode laser requires less


energy. Even in diode laser the contact mode is preferred
over the noncontact technique because of the smaller
amount of energy required.
The details of the standard technique is given in Tables
4.1 and 4.2. It has to be emphasized that at the beginning
27

39

Fig. 4.5: After insertion of the lid speculum the site of pars
plicata is identified by transscleral illumination. Its distance
from the limbus is measured

Fig. 4.6: When performing the operation the fiberoptic probe


has to be held perpendicular to the scleral surface and pressed
firmly. Even a slight misalignment will cause loss of energy to
the site of the operation. By the use of millimeter caliper the
correct site is secured

of the operation the pars plicata area has to be localized


using transscleral illumination and the fiberoptic probe

40

Atlas of Glaucoma Surgery

Table 4.1: Operative technique of 810 nm transscleral


contact diode laser cyclophotocoagulation
1. Instil one drop of 1% iopidine (apraclonidine) in the operative
eye and give 125 to 250 mg acetazolamide perorally 1 hour before
the procedure to avoid postlaser IOP spikes.
2. Give periocular/ sub-Tenon anesthesia.
3. Set the patient in supine position in a non-sterile room.
4. Set the lid speculum in the operative eye.
5. Patch the other eye.
6. Identify pars plicata area of the ciliary body by transscleral
illumination. Identify the surgical limbus carefully.
7. Control of the output of the contact probe.
8. Set the power to 1.5 to 2.5 W and the application time to 1.5 to
2 seconds.
9 Applicate the diode laser using the contact probe. Avoid using a
probe with sharp edges.
10. Keep the tip of the probe perpendicular to the scleral surface and
press it firmly against the sclera. (The G-probe orientates the
diode beam parallel to the visual axis). Avoid treating areas of
scleral thinning and of long posterior ciliary arteries.
11. Start the applications at 6 oclock and make 5 to 10 applications
from 6 to 9 oclock. Avoid 9 oclock position because of the long
posterior ciliary arteries and nerves.
12. Continue the procedure treating from 6 to 3 oclock
(counterclockwise). In this way the lower half will be treated.
13. Instil one drop of 1% of apraclonidine (iopidine) and
dexamethason-chloramphenicol ointment in the treated eye.
14. Close the eye with bandage.
15. To identify the possible but rare postoperative spikes of IOP measure
the IOP after 2 hours with applanation tonometer and control the
state of the cornea and the anterior chamber.
16. Put further ointment in the eye and close the eye with bandage.
17. Send the patient home.
18. Advice the patient to remove the bandage the same evening and
instil dexamethason-chloramphenicol eyedrops 4 times a day and
continue the preoperative IOP lowering medication.
19. Examine the patient in a postoperative control 2 days later.
Continue the previous antiglaucoma medication as well as
dexamethason-chloramphenicol eyedrops.
20. Examine the patient at the next postoperative control 3 to 4 weeks
later. In case the target pressure has been reached antiglaucoma
medication can be slowly tapered starting with possible oral
acetazolamide. The next topical medication to be discontinued is
the one causing local or systemic side effects.

held perpendicular and pressed against the sclera. Malalignment will markedly lessen the effect.
In treating various type of refractory glaucoma, about
70 percent achieved a final IOP of 21 mm Hg or less.28-32
The number of medications could be decreased and loss
of visual acuity was not a problem. Very favorable results
were obtained also in treating glaucomas associated with
chronic uveitis.33 After 12 months IOP was controlled in
77 percent of eyes. Repeat of the treatment was needed
in 64 percent. Reactivation of uveitis, persistent hypotonyt
and phthisis did not occur. Meta-analysis suggested that
higher total energy was associated with a higher percentage

Table 4.2: Complications of the transscleral contact 810 nm


diode laser cyclophotocoagulation
1. Frequent (> 10%)
Mild to moderate iritis (38-100%)
Loss of > 1 to 2 lines of Snellen visual acuity or a change in low
vision category (12-38%)
2. Varying frequency
Pop effects (tissue disruption; 0-70%)
Postoperative pain (0-37%)
Conjunctival burns (0-26%)
Conjunctival chemosis (2-30%)
Conjunctival hyperemia (7-100%)
Severe iritis (4-15%)
Hyphema (0.5-17%)
Cells in anterior vitreous (0-15%)
3. Infrequent ( <10% of cases)
Corneal epithelial defects (0-7%)
Corneal edema (0-9%)
Fibrinoid reaction in anterior chamber (1-7%)
Mild anterior vitreitis (0-6%)
Cystoid macular edema (0-7%)
Hypotonia (0-9.5%)
4. Rare (< 5% of cases)
Corneal decompensation (0-2%
Rejection of penetrating keratoplasty (0-2%)
Pupil distortion (0-1%)
Focal scleral thinning
Vitreous hemorrhage (0.4-2%)
Choroidal detachment (0-2%)
Macular pucker (0-0.5%)
Phthisis (0-5%)

of patients achieving an IOP of 21 mm Hg or less.36 In


pediatric refractory glaucoma the success rate is lower than
in adults and the younger patients may relapse more
rapidly.34 After repeat cyclodiode therapy 72 percent of
eyes showed clinically useful reduction of the IOP for at
least a year. Diode laser cyclophotocoagulation has been
used also as a primary treatment for primary chronic
open-angle glaucoma.35 After 13 months the drop in IOP
was still 20 percent or more in 47 percent of eyes. Target
pressure of 22 mm Hg or less was achieved in 48 percent.
The most common complication after transscleral
contact 810 nm diode laser photocoagulation is mild
and transient anterior chamber inflammation.28,29,31,51-53
Rarely, severe uveitis has been reported.28,29 Mild pain
or discomfort after the treatment occurs but responds
well to topical and systemic nonsteroidal antiinflammatory drugs and clears within a week.38,51,53
However, even very rare, severe complications such
as persistent hypotony or phthisis have to kept in mind
particularly when treating neovascular glaucoma.29,55,56

Cyclodestruction in Glaucoma

41

Red 647 nm Krypton and 670 nm Diode Laser


Cyclophotocoagulation

Table 4.3: Operative technique of transscleral contact 670


nm diode and 647 nm krypton laser cyclophotocoagulation

It has been shown experimentally that with 647 nm


krypton laser identical tissue lesions in the pars plicata of
the rabbit eye can be produced by using only a half of
the energy compared to contact Nd:YAG laser.37 Melanin
absorption of the short wavelength laser energy is
superior when compared with 1064 nm Nd:YAG laser
and even somewhat better than of the 810 nm infrared
diode laser.
In treating refractory posttraumatic glaucoma with
contact transscleral krypton laser, an almost 40 percent
drop in IOP was recorded 20 months following
treatment.39 One-third had to be treated twice, 18 percent
needed three-treatment sessions and 9 percent had to
be treated four times. Still none of the eyes developed
permanent hypotony or phthisis. Thirty eyes with
neovascular glaucoma were treated with transscleral
contact krypton laser combined with transscleral
peripheral retinal cryocoagulation. This resulted in an
IOP of 8 to 21 mm Hg or a fall of IOP 30 percent or
more in 87 percent of the eyes 17 months postoperatively.41 One eye developed permanent hypotony
and one phthisis. Contact transscleral 670 nm diode laser
did not induce any changes in subbasal corneal nerves
when studied with in vivo confocal microscopy.42 Corneal
sensitivity was found to remain normal as did also the
tear secretion.
The technique of contact transscleral 647 nm krypton
and 670 nm diode laser application is described in Table
4.3.
Our experience is based on the performance of more
than 1500 cyclophotocoagulations with transscleral
contact krypton 647 nm and diode 670 nm lasers.
Complications with krypton 647 nm and diode 670 nm
lasers are listed in Table 4.4. The patients did not report
significant pain requiring systemic analgetics. No
conjunctival burns could be seen. Mild uveitis appeared
in most patients but cleared rapidly with topical
hydrocotisone-chloramphenicol. Eyes with neovascular
glaucoma and chronic uveitis showed the most
pronounced anterior chamber reactions. Fibrinoid
reaction was seen in 0 to 5 percent of patients.

1. Instil one drop of 1% iopidine (apraclonidine) in the operative


eye and give 125 to 250 mg acetazolamide perorally one hour
before the procedure
2. Give periocular/sub-Tenon anesthesia.
3. Set the patient in supine position in non-sterile room.
4. Set the lid speculum to the operative eye.
5. Patch the other eye.
6. Identify the pars plicata area of the ciliary body by transscleral
illumination. Identify the surgical limbus carefully.
7. Control the output of the contact probe.
8. Set the power to 0.4 W and the application time to 10 seconds.
9. Applicate the diode laser using the contact probe. Avoid using a
probe with sharp edges.
10. Keep the tip of the probe perpendicular to the scleral surface and
press it firmly against the sclera. Avoid treating areas of scleral
thinning and of long posterior ciliary arteries.
11. Start the applications at 6 oclock and make 10 applications from
6 to 9 oclock. Avoid 9 oclock position because of the long posterior
ciliary artery and nerve.
12. Continue the procedure treating from 6 to 3 oclock
(counterclockwise). In this way the lower half will be treated.
13. Instil one drop of 1% apraclonidine (iopidine) and dexamethasonchloramphenicol ointment in the treated eye.
14. Close the eye with bandage.
15. To identify the possible but rare postoperative spikes of IOP measure
the IOP after 2 hours with applanation tonometer and control the
state of the cornea and the anterior chamber.
16. Put further ointment in the eye and close the eye with bandage.
17. Send the patient home.
18. Advice the patient to remove the bandage the same evening and
instill dexamethason-chloramphenicol eyedrops 4 times a day
and continue the preoperative IOP lowering medication.
19. Examine the patient in a postoperative control 2 days later.
Continue the previous antiglaucoma medication as well as
dexamethason-chloramphenicol eyedrops.
20. Examine the patient in the next postoperative control 3 to 4 weeks
later. In case the target pressure has been reached antiglaucoma
medication can be slowly tapered starting with possible oral
acetazolamide. The next topical medication to be discontinued is
the one causing local or systemic side effects.
Retreatment
In case the target pressure level has not been achieved the retreatment
may be considered 1 to 2 months after the initial procedure.
The retreatment is performed with an identical way but now the
new treatment consists of ten applications to the 9 to 12 oclock quarter
and retreatment of ten applications to the 6 to 9 oclock quarter.
Further retreatment
If new retreatments proves mandatory in the third procedure ten
applications are performed to the 9 to 12 oclock quarter as a retreatment
and ten applications to the 3 to 6 oclock quarter as a retreatment

In the treatment of refractory glaucoma in 27 eyes


of 22 young patients with the transscleral contact krypton
laser a scleral thinning developed in the treatment area
in two patients. None of the eyes developed permanent
hypotony or phthisis.40

42

Atlas of Glaucoma Surgery

Table 4.4: Complications of transscleral contact krypton 647


nm and 670 nm diode laser cyclophotocoagulation
1. Frequent (10%-40%)
Transient corneal punctate epitheliopathy or dry eye (6-20%)
Mild iritis (16-38%)
Loss of > 1 to 2 lines of Snellen visual acuity or a change in low
vision category (9.6-31%)
Progression of pre-existing cataract (14%)
2. Infrequent (<10% of cases)
Dry eye (6-9%)
Mild anterior vitreitis (0-6%)
3. Rare (< 5% of cases)
Postoperative pain not requiring systemic analgesics (0-4%)
Fibrinoid reaction (0-5%)
Corneal ulcer (3-5%)
Focal scleral thinning (0-5%)
Moderate to severe iritis (2-4%)
Hyphema (0-1%)
Transient disturbance of near vision in one young person (04.5%)
Disturbance in iris sphincter function (0-1%)
Oval pupil (0-2%)
Cystoid macular edema (0-5%)
Vitreous hemorrhage (0-1%)
Hypotony (0-5%)
Phthisis bulbi (0-5%)
4. Totally absent
Conjunctival burns
Audible pops

The treatment has been well accepted and the


patients have been willing to come for retreatment when
necessary.

MECHANISM OF INTRAOCULAR
PRESSURE REDUCTION
The mechanism of IOP reduction after cyclophotocoagulation is very much debated. The accepted
mechanism is ablation of the ciliary epithelium to
minimize aqueous production.43,46-48 Alternative theories
include damage of the ciliary vascular supply, 47
postoperative uveitis with reduced aqueous production,48
an increase of uveoscleral outflow44-46 and increased
uvescleral outflow from ciliary epithelial damage.44,46,48
An eye with treatment-resistant chamber angle recession
glaucoma was successfully treated with transscleral contact
krypton cyclophotocoagulation.50 When the eye was
examined at autopsy ten months later it was found that
effective ablation of the ciliary processes had been
achieved. Only a slight inflammatory reaction was

present. The experience supports the view that after


transscleral cyclophotocoagulation nonconventional
outflow routes are increased.51

INDICATIONS FOR PARTIAL


CYCLODESTRUCTION
Transscleral contact, near infrared 810 nm diode laser,
red 647 nm krypton laser and red 670 nm diode laser
are currently preferred over cyclocryocoagulation59 and
even to Nd:YAG laser,60 whenever available. With former
techniques the risk of severe postoperative complications
is low. Most of the units are portable, and less expensive
than Nd:YAG lasers.
Transscleral cyclophotocoagulation is indicated in
patients with therapy-resistant glaucoma who have failed
maximum tolerated medical theray, laser trabeculoplasty
and incisional pressure-lowering operations, for patients
with minimal useful vision or no visual potential and for
pain relief from intractable glaucoma.58 Eyes without
visual potential should be treated cautiously if they have
undergone previous surgery because of isolated reports
of presumed sympathetic ophthalmia after Nd:YAG
cyclophotocoagulation.25
Cyclophotocoagulation can also be useful for patients
whose general medical condition will prevent incisional
surgery and to those who refuse traditional filtering
operation or placement of a stent.

REFERENCES
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3. Vogt A. Versuche zur intraokularen Druckherabsetzung mittels
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4. Walton DS, Grant WM. Penetrating cyclodiathermy for filtration.
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Cyclodestruction in Glaucoma
9. Krupin T, Mitchell KB, Becker B. Cyclocryotherapy in neovascular
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15. Brindley G, Shields MB. Value and limitations of cyclocryotherapy.
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17. Smith RS, Stein MN. Ocular hazards of transscleral laser radiation.II.
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continuous wave neodymium:YAG laser cyclophotocoagulation.
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cyclophotocoagulation in the treatment of open-angle glaucoma.
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23. Pastor SA, Iwach A, Nozik RA, et al. Presumed sympathetic
ophthalmia following Nd:YAG transscleral cyclophotocoagulation.
J Glaucoma 1993;2:30-1.
24. Bechrakis NE, Mller-Stolzenburg NW, Helbig H, et al. Sympathetic
ophthalmia following laser cyclogoagulation. Arch Ophthalmol 1994;
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25. Minckler DS. Does Nd:YAG cyclotherapy cause sympathetic
ophthalmia? (editorial). Ophthalmic Surg 1989;20:543.
26. Schuman JS, Jacobson JJ, Pulificato C, et al. Experimental use of
semiconductor diode laser in transscleral contact cyclophotocoagulation in rabbits. Arch Ophthalmol 1990; 108:1152-57.
27. Hennis HL, Assia E, Stewaret WC, et al. Transscleral
cyclophotocoagulation using a semiconductor diode laser in cadaver
eyes. Ophthalmic Surg 1991; 21:274-9.
28. Schlote T, Derse M, Rassmann K, et al. Efficacy and safety of contact
transscleral diode laser cyclophotocoagulation for advanced
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29. Mistlberger A, Liebmann JM, Tshciderer H, et al. Diode laser
cyclophotocoagulation for refractory glaucoma. J Glaucoma
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30. Pucci V, Marcini G,Pedrotti E, et al. Transscleral diode laser
photocoagulation for refractory glaucoma. Ophthalmologica 2001;
215:263-6.
31. Threlked AB, Johnson MH. Contact transscleral diode laser
cyclophotocoagulation for refractory glaucoma. J Glaucoma 1999;
8:3-7.

43

32. Pucci V, Tappainer F, Borin S et al. Long-term follow-up after


transscleral diode laser photocoagulation in refractory glaucoma.
Ophthalmologica 2003; 217:279-83.
33. Schlote T, Derse M, Zierhut M. Transscleral diode laser
cyclophotocoagulation for the treatment of refractory glaucoma
secondary to inflammatory eye diseases. Br J Ophthalmol 2001;
84:999-1003.
34. Kirwan JF, Shah P, Khaw PT. Diode laser cyclophotocoagulation:
the role in the management of refactory pediatric glaucomas.
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35. Egbert PE, Fiadayor S, Budenz DL, et al. Diode laser transscleral
cyclophotocoagulation as primary surgical treatment for primary
open-angle glaucoma. Arch Ophthalmol 2001; 119.
36. Hauber FA, Scherer FJ. Influence of total energy delivery on successful
rate after contact diode laser transscleral cyclophotocoagulation: a
retrospective case review and meta-analysis. J Glaucoma
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37. Immonen I, Suomalainen VP, Kivel T, et al. Energy levels needed for
cyclophotocoagulation: a comparison of transscleral cw-YAG and
krypton lasers in the rabbit eye. Ophthalmic Surg 1993; 24:530-3.
38. Immonen I, Puska P, Raitta C. Transscleral contact krypton laser
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pressure control after transscleral diode cyclophotocoagulation in
eyes with intractable glaucoma. J Glaucoma 1998; 7:319-28.
40. Raivio V, Immonen I, Laatikainen LT, et al. Transscleral krypton
laser cyclophotocoagulation for treatment of posttraumatic glaucoma.
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laser cyclophotocoagulation for treatment of glaucoma in children
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43. Raivio VE, Vesaluoma MH, Tervo TMT, et al. Corneal innervation,
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transscleral cyclophotocoagulation with cryopexy. Invest Ophthalmol
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of continuous-wave neodymium:yttrium aluminium garnet laser
cyclophotocoagulation. Invest Ophthalmol Vis Sci 1992;33:221623.
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decrease after contact transscleral continuous-wave Nd:YAG laser
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48. Schubert HD, Federman JL. The role of inflammation in cw Nd:YAG
contact transscleral cyclophotocoagulation and cryopexy. Invest
Ophthalmol Vis Sci 1989;30:543-9.
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after in vitro neodymium yttrium garnet laser cyclophotocoagulation.
Invest Ophthalmol Vis Sci 1990;31:1834-8.
50. Kivel T, Puska P, Raitta C, et al. Clinically successful contact
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44

Atlas of Glaucoma Surgery

51. Duy TP, Seiler T, Wollensak J. nderungen der Abflussleichtigkeit


nach Zyklokryokoagulation bei primrem Glaukom. Klin Monatsbl
Augenheilkd 1987;190:99-102.
52. Kosoko O, Gaasterland, D, Pollack I, et al. Long-term outcome of
initial ciliary ablation with contact diode laser transscleral
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53. Brancato R, Carassa RG, Bettin P, et al. Contact transscleral
cyclophotocoagulation with diode laser in refractory glaucoma.
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54. Bloom P, Tsai J, Sharma K, et al. Cyclodiode transscleral diode laser
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55. Hawkins TA, Stewart WC. One-year results of semiconductor
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56. Murphy CC, Burnett CAM Spry PGD, et al. A two-centre study of
the dose-response relation of transscleral diode laser
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57. Walland MJ Diode laser cyclophotocoagulation: dose-standardized
therapy in end-stage glaucoma. Austr and New Zealand J Ophthalmol
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58. Pastor SA, Singh K, Lee DA, et al. Cyclophotocoagulation: a report
by the American Academy of Ophthalmology. Ophthalmology
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59. Freigassner P, Eckhardt M. Transscleral cyclophotocoagulation versus
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60. Delgado MF, Dickens CJ, Iwach AG, et al. Long-term results of
noncontact neodymium:yttrium-aluminium-garnet cyclophotocoagulation in neovascular glaucoma. Ophthalmology
2003;110:895-9.

Wisam A Shihadeh, Robert Ritch, Jeffrey M Liebmann

5 Resurrecting the Failing Filtering Bleb

INTRODUCTION
The desired goal of glaucoma filtering surgery is to
maintain indefinitely the patency of an artificially created
fistula between the inside of the eye and the extraocular
space. The key to successful management of the patient
undergoing surgery is anticipation of potential
postoperative problems, early detection and timely,
appropriate intervention to enhance filtration. Following
a patient after filtering surgery is like playing chessone
has to think several moves ahead and act, not necessarily
on what the findings are on a particular visit, but what
these findings suggest may be likely to occur at a
subsequent visit. In this chapter, we discuss the clinical
appearance and management of failing blebs following
filtering surgery.

NORMAL BLEB MATURATION AND


FUNCTION
Since Cairns1 introduced trabeculectomy in 1968, the
success of this procedure has hinged on the development
of a functioning filtering bleb, which is in turn influenced
by a number of factors including postoperative wound
healing properties.2 Successful blebs vary in appearance.
They differ in height, pallor, and extent of conjunctival
microcystic edema. Blebs may be diffuse or localized.
Different criteria have been included in the classification
of blebs; for example, the Indiana Bleb Appearance
Grading Scale selected height, extent, vascularity and
Seidel test as criteria for their classification system.3
Following surgery the bleb may assume one of the
following appearances:4
1. Type 1 bleb has a thin and polycystic appearance
due to a transconjunctival flow of aqueous and is
associated with good filtration (Fig. 5.1).

Fig. 5.1: Thin polycystic filtering bleb

2. Type 2 bleb is low-lying and diffuse with a relatively


avascular appearance in comparison with the
surrounding conjunctiva (Fig. 5.2). Conjunctival
epithelial microcysts are usually visible with high
magnification (Fig. 5.3) and indicate active filtration.
3. Type 3 bleb is a non-filtering bleb caused by
subconjunctival fibrosis. It is unassociated with
microcystic spaces and its surface often contains
engorged blood vessels (Fig. 5.4).
4. Encapsulated bleb (Tenon capsule cyst) typically
develops 2 to 8 weeks postoperatively. It is
characterized by a localized, highly elevated, domeshaped, firm, cyst-like cavity of hypertrophied
Tenons capsule with engorged conjunctival blood
vessels (Fig. 5.5). The cavity entraps aqueous humor
and prevents filtration, although in some cases IOP
may not be elevated because functional areas of
filtration may surround the bleb.
Elevated IOP can occur transiently 3 to 4 weeks after
a guarded filtering procedure, despite a large bleb. In
some cases, this rise is caused by an encapsulated bleb;
in others, temporary swelling of the sclera or collagenous

46

Atlas of Glaucoma Surgery

Fig. 5.2: Thin diffuse filtering bleb


Fig. 5.5: Encapsulated non-filtering bleb

RISK FACTORS FOR FILTRATION


FAILURE

Fig. 5.3: Conjunctival epithelial microcysts

Fig. 5.4: Vascularized non-filtering bleb

lining of the wall of the bleb limit the outflow of aqueous


humor. It is important to recognize that this so-called
high bleb phase may be transient and is not necessarily
a sign that the surgery has failed.5

Trabeculectomy is highly successful as the initial


intraocular surgery for glaucoma and has been the
standard procedure for over a generation. Although
reported success rates have ranged as high as 98 percent,
its effect is reduced over time. Risk factors for failure
include neovascular glaucoma, African descent, aphakia,
prior failed filtering procedures, and prior cataract
surgery.
Filtering surgery is less successful in younger than in
older patients. For example, Stewart et al6 reported
trabeculectomy success rates of 30 percent versus 66.6
percent at one year for patients under and over age 40.
Mills7 and Gressel et al8 reported lower success in patients
with juvenile-onset open angle glaucoma when
compared to older patients. Success in younger black
patients ranges from 50 to 57 percent (age 20 to 60
years) to 82 percent (over age 60).9 Failure of glaucoma
surgery in young individuals may be related to a thicker
Tenons capsule and a more vigorous scarring response.1013
Both of these factors may lead to more episcleral scarring
and a thicker bleb.
The presence of multiple risk factors further decreases
the likelihood of success. In addition, the prolonged
preoperative use of multiple topical antiglaucoma
medications may increase the risk of filtration failure.14,15

Resurrecting the Failing Filtering Bleb

47

For all of the above reasons, earlier trabeculectomy has


been advocated by some.16,17

SIGNS OF FILTRATION FAILURE


The filtration pathway is a dynamic system. Fibroblasts,
connective tissue elements, growth factors, cytokines,
aqueous humor and the vascular supply all influence
the course of the bleb over time. Bleb failure can occur
in the early postoperative period or months to years
later. In the past, surgeons performed trabeculectomies,
prescribed steroids, and watched while the bleb either
succeeded or flattened and failed. In cases of failure, a
second filter at the inferior limbus or an implant was
performed before trying to revise the first filter surgically.
Today, we know that active and early intervention is
needed to maximize the success of filtering surgery. We
try every way to restore failing bleb function before going
on to new surgery. Again, the analogy with chessThink
ahead!
Early recognition of the symptoms, signs, and patterns
of filtration failure allows for timely intervention to
encourage filtration. This is particularly important during
the first two weeks following surgery when the healing
process is most active. Careful attention to the depth of
the anterior chamber, appearance of the bleb,
gonioscopic appearance of the internal ostium, and the
response to digital pressure to the globe facilitate
recognition of filtration failure, which may be classified
by anatomic location (internal or external) and
temporally (early or late in the postoperative period).
Bleb appearance is the single most important
postoperative feature18 and tends to change over time
(Figs 5.6A to C).19,20 Injection and vascularization of the
bleb indicate the presence of inflammation and are poor
prognostic signs (Figs 5.7A to C).21 This is more significant
in the presence of a flattening bleb, but their presence in
the postoperative period is often the first indication that
filtration failure may occur. This typically occurs prior to
any elevation of intraocular pressure (IOP). Progressive
loculation may herald the development of bleb
encapsulation. Sacu et al22 suggested that the early
morphological appearance of blebs may correlate with
the outcome of trabeculectomy with mitomycin-C and
may help to disclose patients with increased failure risk.

C
Figs 5.6A to C: Successful bleb formation is characterized by
decreasing injection, elevation, and the presence of
conjunctival microcysts. A: 10 days. B: 1 month. C: 3 months
after surgery

Gonioscopy allows direct visualization of the internal


appearance of the outflow pathway. Gonioscopy in the

48

Atlas of Glaucoma Surgery

bleb. Partial or total occlusion of the internal ostium


maybe identified.
Digital compression, which is employed by some
ophthalmologists to promote improved long-term
filtration, is extremely important in helping to determine
the location of the obstruction to aqueous flow.23 In a
failing bleb, compression may result in either elevation
of the bleb (focal or diffuse) or resistance to elevation. If
compression fails to elevate the bleb and the internal
ostium is free of obstruction, the obstruction is typically
at the level of the external ostium. Transient bleb
formation with lowering of the IOP suggests the presence
of tight scleral flap sutures or loculation.
Once the cause of the failure has been isolated,
appropriate, active treatment may prolong the life of a
failing filter. Since repeat filtering surgery if often
unrewarding, it is best to maximize the effect of the initial
surgery. Accurate diagnosis allows the surgeon to choose
the correct therapeutic intervention.
Management of the failing filter requires therapy
directed toward the level of blockage to aqueous flow
and blocking the wound healing response to both the
initial surgery and the planned intervention. For example,
internal blockage may be treated by laser revision or
automated trephination.24 This effectively converts a
partial thickness operation to a full-thickness procedure.
Laser or therapeutic ultrasound have been purported
to be of some benefit to increase flow through episcleral
scarring,25 although immediate postoperative rises in IOP
and cataract formation may limit the latters applicability.

Filtration Failure due to Blockage of the


Internal Ostium

C
Figs 5.7A to C: A bleb that developed progressive loculation,
hyperemia, and flattening. A: 3 days. B: 3 weeks. C: 6 weeks
after surgery

postoperative period can be performed with minimal


trauma to the cornea, avoiding contact with the filtering

Early internal failure usually results from occlusion of


the intraocular portion of the sclerostomy. This is usually
related to surgical complications such as incarceration of
iris, vitreous, ciliary body, ciliary processes, or lens into
the internal ostium, or occlusion of the ostium with blood
or fibrin. Late internal blockage may result from anterior
chamber membrane proliferation over the internal
ostium such as a fibrovascular membrane in neovascular
glaucoma, fibrous tissue in fibrous ingrowth, epithelium
in epithelial downgrowth, or corneal endothelium and
Descemets membrane in the iridocorneal-endothelial

Resurrecting the Failing Filtering Bleb


syndrome. Iris or ciliary process pigment epithelium may
occasionally proliferate and block the internal ostium.
Carefully inspecting the wound intraoperatively, and
keeping the excised tissue block as far anterior as possible
will avoid most of these problems. Possible closure of
the internal sclerostomy also highlights the importance
of performing gonioscopy on all eyes manifesting
postoperative bleb failure. Unless the incarceration is
noted early and the tissue removed easily, most of these
eyes require reinstitution of medical therapy or repeat
filtering surgery.
Argon and Nd:YAG lasers have been used to
successfully open internally and externally blocked
sclerostomy sites. 26-33 In addition, a transcorneal approach
with a curved needle and a transanterior chamber
approach with a goniotomy-type of blade have also been
successful in cases where aqueous outflow is blocked
through the internal sclerostomy. These techniques,
however, are more easily described than performed; we
have had few successes with any of them.

Filtration Failure due to Blockage External to


the Ostium
Scarring at the conjunctival Tenons-episcleral interface
is considered the major cause of failure of filtering
surgery.34,35 During the first postoperative month, external
blockage results in an initial failure to establish an
adequate filtering bleb. Inadequate aqueous flow through
the fistula due to aqueous hyposecretion or tight scleral
flap sutures contributes to this process by allowing the
conjunctiva to remain in contact with the episclera.
Subsequent injection, vascularization, leukocytic
infiltration, connective tissue proliferation, and the
formation of granulation tissue limit subconjunctival
aqueous flow. The causes of inadequate bleb formation,
such as postoperative aqueous hyposecretion, whether
related to shallowing of the anterior chamber,
ciliochoroidal detachment, prolonged secretory
hypotony, or tight scleral flap sutures, should be
addressed as they arise. Tight scleral flap sutures should
be cut or released, intraocular inflammation should be
treated aggressively with topical steroids (systemic steroids
upon occasion in patients with chronic uveitis), and
chamber depth maintained and prolonged hypotony

49

avoided whenever possible. Late failure is most


commonly due to scarring at the conjunctiva-Tenonsepiscleral interface.

Bleb Encapsulation
Bleb encapsulation (Tenon cyst) develops in
approximately 10 to 28 percent of eyes following filtering
surgery,5,36-41 typically during the first 8 postoperative
weeks. Richter et al42 reported an incidence of 13.7
percent in over 400 consecutive surgeries. The incidence
was higher following filtering surgery for congenital (33%)
and juvenile glaucoma (44%). Signs of bleb
encapsulation developed a mean of 20 days following
filtration. Reported risk factors for encapsulation include
male gender,41,43 prior argon laser trabeculoplasty,36,43,44
anterior uveitis,45 prolonged preoperative topical blocker,36,44 and parasympathomimetic use,36 history of
encapsulated bleb, 36 surgical glove powder, 46 and
preoperative steroid injection over the fistula.47 The use
of adjunctive 5FU injections did not reduce the incidence
of bleb encapsulation in two prospective series.48,49
The encapsulation process consists of fibroblastic
overgrowth that results in a tense, opalescent bleb with
a thick wall in direct communication with the anterior
chamber (Fig. 5.8).39,50 Histopathology reveals dense
subconjunctival connective tissue, few cells and no cellular
lining.50,51 Bleb encapsulation may be accompanied by
progressive conjunctival hyperemia. One typically finds
loculation, thickening of the subconjunctival connective
tissue, and elevated IOP. The spectrum of appearance
ranges from incomplete loculation and mild hyperemia
to complete encapsulation. The dome-like region is firm,
although the overlying conjunctiva may be mobile, and
is in direct communication with the anterior chamber.
Complications of bleb encapsulation include uncontrolled
IOP, corneal dellen, and occasional discomfort.
The key to successful management is patience. In
most cases, the pressure will decrease within 2 to 4
months with the use of aqueous suppressants. It is
believed that the decrease in aqueous production and
IOP associated with medical therapy allows for
remodeling of the cyst wall and eventually improved
aqueous flow across it. The connective tissue remnant
remains within the subconjunctival space, but aqueous

50

Atlas of Glaucoma Surgery


Iris incarceration resulting in filtration failure,60 bleb
rupture,61 rupture of a 6-year-old keratoplasty wound,62
and subretinal hemorrhage due to rupture of Bruchs
membrane63 have been reported as complications of
digital compression.

Laser Suturelysis

Fig. 5.8: Encapsulated bleb

flow into the surrounding tissues is adequate to maintain


IOP control. Extended use of aqueous suppressant
following filtering surgery, however, may limit the extent
of bleb formation. After resolution, the antiglaucoma
therapy may be tapered. Yaramangumeli52 found that
bleb encapsulation responds well to conservative medical
treatment. Feyi-Waboso and Ejere 53 showed that
needling of encapsulated trabeculectomy blebs is not
better than medical treatment in reducing IOP.
Many encapsulated blebs, particularly those that are
only partially loculated, may resolve spontaneously or
respond to intensive topical steroid therapy or digital
compression.54 If this does not occur and a cyst is present,
the cyst can be punctured with a needle (described
later).55-58 Better, but still poor, results have been obtained
by excising the Tenons cyst in toto. If the final pressure is
not low enough to permit preservation of the remaining
visual field, or if medical therapy is insufficient to control
a pronounced, sustained IOP elevation, surgical revision
may become necessary. When filtering surgery is needed,
adjunctive antifibrosis agents are indicated.

Tight scleral flaps are known to block aqueous flow


through the fistula. For that reason, laser suturelysis
especially in the early postoperative period is considered
an effective way of encouraging flow. Laser suturelysis is
not reserved only for eyes with signs of bleb failure, but
is preplanned and used to titrate the desired filtration.

Historical Aspects
Lieberman64 initially reported on the procedure in 1983,
obtaining good success using the triangular space
between two mirrors of a four-mirror Ziess lens. Hoskins
and Migalizzo65,66 designed a special lens for the procedure.
More recently, Ritch67,68 has designed a lens that provides
excellent compression of the conjunctva, an improved
view of scleral flap sutures, and effortless retraction of
the upper lid.

Indications
Laser suturelysis is indicated when inadequate filtration
from tight closure of the scleral flap is suspected. Timing
of the procedure is of crucial importance. It is safer to
delay it until the 2nd or the 3rd postoperative day to
minimize hypotony and flat anterior chambers. The
greatest effect in lowering IOP is achieved if suturelysis is
done in the first two postoperative weeks and rarely after
four weeks unless antimetabolites are used in conjunction
with glaucoma filtering surgery.69

MANAGEMENT OF FILTRATION FAILURE

Technique

Digital Compression

Laser suturelysis should be performed with as little


conjunctival manipulation and laser energy as possible.
Care must be taken to avoid a potential conjunctival
burn or buttonhole injury. This may be accomplished
by defocusing the beam posteriorly. In the presence of a
subconjunctival hemorrhage, a diode or krypton laser
should be used rather than the argon laser, since argon
energy is absorbed by the blood and can result in a

Digital compression is used by many glaucoma surgeons


to encourage filtration, particularly in the presence of
inadequate filtration.23 Focal pressure to the edge of the
scleral flap under direct visualization with a moistened
cotton-tipped applicator59 or with the surgeons finger
through the upper lid may cause a momentary gape
between the edge of the scleral flap and the scleral bed.

Resurrecting the Failing Filtering Bleb

51

conjunctival burn and buttonhole. Settings of 0.05


second, 50 m spot size, and 200 to 400 mW power
are usually sufficient. A Hoskins or Ritch suturelysis lens
under topical anesthesia should be used to compress
the overlying conjunctiva (Figs 5.9A and B and 5.10).
Alternatively, the edge of a Zeiss gonioprism or disposable
glass pipette 70 may be used. The use of a contact
endolaser has been described.71

Fig. 5.10: Hoskins laser suturelysis lens

One suture should be cut at a time to minimize the


risk of hypotony. Cautious digital massage or pressure
to the edge of the scleral flap following suturelysis often
helps elevate the bleb if it does not do so spontaneously.
If the bleb remains flat even with massage, this is a sign
of impending bleb failure. In this case, we inject
subconjunctival saline or lidocaine to attempt to recreate
the bleb and prevent conjunctival episcleral adhesions.
Subsequent 5FU therapy may help limit postoperative
scarring. Suturelysis should be completed within 7 to 10
days for trabeculectomy without antiscarring medications,
within 14 days for 5FU trabeculectomy, and within 1
month for mitomycin trabeculectomy.

Complications

B
Figs 5.9A and B: A: Ritch laser suturelysis lens.
B: Magnified view of the suture

The most common complication after laser suturelysis is


hypotony with a shallow anterior chamber.72 The use of
antimetabolites with surgery increases the risk of
hypotony and can result in choroidal effusion in
susceptible eyes. Kapetansky73 found that delaying the
final laser suturelysis following trabeculectomy with
mitomycin-C until after the second postoperative month
may reduce the risk of hypotony without adversely
affecting the final IOP. Conjunctival perforation is another
complication that ophthalmologists may face especially
in high power settings of the laser. Other risk factors for
conjunctival perforations include conjunctival
hemorrhage, thin ischemic blebs, and the use of Nd:YAG
laser.70 In cases of conjunctival or intrableb hemorrhage,
it is safer to use krypton laser.74,75 Malignant glaucoma
has been also reported as a complication.76,77

52

Atlas of Glaucoma Surgery

Bleb Needling
Revision of trabeculectomy through a small conjunctival
incision for filtration failure was described in 1941.78
Discission with a needle-knife was first described in
1962.79 Bleb needling, as currently performed, was
described by Pederson and Smith,39 and is capable of
restoring function to clinically failed blebs which would
otherwise require reoperation.19,80-82 This procedure
allows the surgeon to create an opening(s) in the wall of
an encapsulated bleb or raise a flattened bleb at the slitlamp or in the operating room via subconjunctival
manipulation with a small gauge needle. The technique
involves elevation of the conjunctiva off the surface of
the globe with balanced salt solution or anesthetic with a
small gauge needle. The underlying episcleral/Tenons
capsule scarring is then incised with the needle. If this
does not succeed in restoring filtration, the edge of the
scleral flap may be elevated. A Hoskins lens may be used
to enhance visibility of the needle tip during the
procedure.83
Using this technique, Pederson and Smith39 achieved
successful control of IOP in 96 percent of cases with or
without more complete surgical revision. Shin et al82
reported restoration of bleb function in 80 percent of
eyes with flat, failed blebs undergoing needle revision
with supplemental 5FU. Ewing and Stamper55 reported
successful outcome in 11/12 patients without significant
surgical complications. Common complications include
conjunctival hemorrhage and transient wound leak.
Ocular hypotony may occur, and although rare,
choroidal effusion has been reported. 56 Aqueous
misdirection has been also reported following needling
of trabeculectomy bleb.84,85 Aqueous may occasionally
leak from the needle entry site for several days, but does
not usually require any intervention. The main
advantages of the procedure include its ease, minimal
anesthesia, and few complications. Reoperation, however
may often be required.39,86 potential risk factors for failure
include pre-needling IOP over 30 mm Hg, lack of
mitomycin-C use during the previous filtering surgery,
and IOP over 10 mm Hg immediately after needling.87
Adjunctive 5FU decreases the propensity towards scarring
and increases the success rate. 88-93 Fornix-based
trabeculectomies may be more likely to fail the needle

revisions compared with limbus-based trabeculectomies.94


Injected95,96 or transconjunctival97 mitomycin-C may
enhance success of the needling procedure in the failing
filtering blebs.
In addition to bleb needling, modalities used to
attempt to establish bleb function postoperatively include
use of tissue plasminogen activator 98,99 and
perfluoropropane gas.100

Trephination
Earlier attempts at ab interno filtration included
goniopuncture, 101 electrocautery puncture, 102 and
goniodiathermy.103 For various reasons, these procedures
were never widely adopted. A true ab interno sclerostomy
technique producing excision of trabecular tissue was
first devised by Brown and coworkers using an
automated trephine.104,105
More recently, laser procedures have been described
to re-establish filtration when the blockage is internal to
the bleb, including external argon,32 Nd:YAG,26 internal
argon,30 mode-locked Nd:YAG,31,106-108 and Q-switched
Nd:YAG. Success with these modalities has been limited
by the excess fibrosis associated with thermal injury.
Nevertheless, ab interno trephination was largely
abandoned. In the mid-1990s, we revived the procedure
as a tool for bleb revision in selected, mature blebs with
failure at the level of the scleral flap (Fig. 5.11). We
retrospectively evaluated the effectiveness of this
procedure and found it to be a useful effective technique
for re-establishing flow through mature filtering blebs.
In 2004, at the ARVO meeting, we presented data on
ab interno trephinations performed on 40 failing blebs
of 38 patients who were followed for a mean period of
32.3 months (range 3 to 96) between 1995 and 2003.24
We defined success as IOP 21 mm Hg and at least 20
percent reduction from baseline on the same or fewer
number of pretrephination medications, 30/40 eyes
(75%) fit the criteria for success over the course of followup. Among all 40 eyes with 3 months of follow-up
there was a significant drop in IOP from pretrephination
to 3 months. The percentage of patients requiring 2
medications declined from 90 percent at pretrephination
to 21 percent at 3 months and was stable thereafter.
Some patients were able to eliminate all medications.

Resurrecting the Failing Filtering Bleb

53

Potential disadvantages of this technique include the


potential for iatrogenic trauma to anterior segment
structures, hyphema formation, the limited availability
of the instrument, and limited access to the superotemporal limbus.

Technique

Fig. 5.11: Mature cystic bleb amenable to trephination

Patients who did not meet the criteria of success regained


successful IOP control with other modalities of
management including medical treatment and bleb
needling. One eye required a trabeculectomy revision
and two eyes required artificial drainage shunts.
Complications were few.
Ab interno automated trephination provides a viable
alternative for re-establishing filtration in these blebs with
subepiscleral fibrosis. There are several advantages of
trephination. The equipment is inexpensive and easier
to use compared to laser technology. The procedure is
rapidly performed, minimizing the risk of intraoperative
hypotony and choroidal hemorrhage. There is no
possibility of early wound leak because of the internal
approach, barring a buttonhole injury with the trephine.
Finally, patients have less discomfort with less tissue
manipulation and faster rehabilitation with less postoperative manipulation than standard revision surgery.
Trephination has a low rate of complications. The
risk of intraoperative complications is minimized by the
use of miotics and viscoelastic agents to protect the lens
and corneal endothelium, respectively. Viscoelastics also
maintain the anterior chamber depth and may
tamponade any potential bleeding. Infusion of balanced
saline solution over the trephine tip helps maintain the
anterior chamber, which minimizes the risk of choroidal
hemorrhage. In addition, we found a low rate of postoperative hypotony because the bleb walls, which were
specifically chosen if they were mature and well defined,
were not violated, effectively limiting aqueous flow to
the bleb space.

Patients receive topical tetracaine drops and intraocular


lidocaine anesthesia. An 8-0 polyglactin traction suture
is placed in the inferior clear cornea and a paracentesis
is made temporally. Acetylcholine is instilled to constrict
the pupil and the anterior chamber is filled with
viscoelastic.
An MVR blade is used to make a clear corneal incision
approximately 180 from the intended operative site. A
19-gauge automated trephine (Trek Instruments,
Mukwonago, WI) with a 0.4 mm motorized rotary (300
rpm) cutting tip and side sleeve infusion is introduced
into the eye through this incision with the infusion on,
advanced across the anterior chamber parallel to the
iris, and engaged in the opposite angle in the area of the
blocked fistula. The handpiece is controlled with a foot
pedal with separate switches for infusion and cutting (Fig.
5.12).

Fig. 5.12: Trephine handpiece

The tip is advanced through the sclera at the flap site


until it could be seen within the bleb, at which point it is
immediately withdrawn back into the anterior chamber.
In most cases two or three passes of the trephine are
performed. The viscoelastic is removed from the eye,
and a single 10-0 nylon suture is used to close the corneal

54

Atlas of Glaucoma Surgery

incision. Subconjunctival 5-fluorouracil as well as


subconjunctival steroid is administered at the end of the
case.

Laser Cautery of Bleb Vessels


The success of glaucoma filtering surgery depends on
the modification and control of postoperative
inflammation and wound healing, the natural biological
responses to surgical trauma. It was found that longterm conjunctival inflammation predisposes to a poor
outcome after filtering surgery.109 Ropy, or corkscrew,
vessels significantly increase the rate of bleb failure.22
Attention has focused on pharmacological modalities
to interfere with wound healing and maintain the patency
of sclerostomy after filtering surgery. These include the
frequent administration of postoperative steroids to retard
inflammation and scarring, the local intraoperative and
postoperative use of antimetabolites to reduce fibroblast
proliferation and the use of agents that interfere with
the synthesis of normal collagen such as penicillamine.110
The pharmacological agents, however, will not help
in regressing the ropy bleb vessels once they are formed.
Those ropy vessels are largely responsible for bringing
the inflammatory cells and mediators to the filtration site
leading to subsequent inflammation, healing, scarring
and eventually possible failure of the filtering surgery.
We used the argon laser (parameters: 0.3 second contact
time, 200 microns spot size and a power of 240
milliwatts) to photocoagulate those bleb vessels. Blebs
that were lasered look clinically quieter and respond
better to subsequent needling (Figs 5.13A and B). Data
regarding the efficacy of this technique is not yet available.

Bleb Reconstruction
When attempts at salvaging a failing bleb are ineffective,
bleb reconstruction at the same site can be performed.
Advancement of the conjunctiva with excision of the preexisting bleb may be successful.111,112 Failed blebs may
be reconstructed with free conjunctival autografts.113-115
Amniotic membrane transplantation has also been
described.116

B
Figs 5.13A and B: A: Pre-laser cautery of bleb vessels. B:
Post laser cautery of bleb vessels

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23. Wieland M, Spaeth GL. Use of digital compression following
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24. Shihadeh W, Ritch R, Liebmann JM. Ab interno automated
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27. Rankin GA, Latina MA. Transconjunctival Nd:YAG laser revision of
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28. Ticho U, Ivry M. Reopening of occluded filtering blebs by argon laser
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29. van Buskirk EM. Reopening filtration fistulas with the argon laser.
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30. Budenz DL, et al: Laser therapy for internally failing glaucoma
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31. Cohn HC, Whalen WR, Aron-Rosa D. YAG laser treatment in a
series of failed trabeculectomies. Am J Ophthalmol 1989; 108: 395403.
32. Kurata F, Krupin T, Kolker AE. Reopening filtration fistulas with
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1984; 98:340.

55

33. Weber PA, Jones JH, Kapetansky F. Neodymium:YAG


transconjunctival laser revision of late-failing filtering blebs.
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34. Costa VP, et al. Wound healing modulation in glaucoma filtraion
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35. Skuta GL Parrish RK II: Wound healing in glaucoma filtering surgery.
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36. Feldman RM, et al. Risk factors for the development of Tenons
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37. Ophir A. Encapsulated filtering bleb. A selective reviewnew
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38. Ophir A, Ticho U. Encapsulated filtering bleb and subconjunctival
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40. Sherwood MB, et al. Cysts of Tenons capsule following filtration
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42. Ritcher CUS, et al. The development of encapsulated filtering blebs.
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45. Ophir A, Ticho U. Filtering surgery with 5-fluorouracil: a second
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46. Oh Y, Katz LJ, Spaeth FL, Wilson RP. Risk factors for the development
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47. Loftfield K, Ball SF. Filtering bleb encapsulation increased by steroid
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48. Goldenfeld M, et al. 5-fluorouracil in initial trabeculectomy, a
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117: 149-54.
49. Ophir A, Ticho U. Subconjunctival 5-fluorouracil and herpes simplex
keratitis. Ophthalmic Surg 1991; 22: 109-10.
50. van Buskirk EM. Cysts of Tenons capsule following filtration surgery.
Am J Ophthalmol 1982; 94: 522-7.
51. Addicks EM, et al. Histologic characteristics of filtering blebs in
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52. Yarangumeli A, Koz OG, Kural G. Encapsulated blebs following
primary standard trabeculectomy: course and treatment. J
Glaucoma 2004; 13: 251-5.
53. Feyi-Waboso A, Ejere H. Needling for encapsulated trabeculectomy
filtering blebs. Cochrane Database Syst Rev 2004; 2: CD003658.
54. Costa VP, Correa MM, Kara-Jose N. Needling versus medical
treatment in encapsulated blebs. A randomized, prospective study.
Ophthalmology 1997; 104: 1215-20.

56

Atlas of Glaucoma Surgery

55. Ewing RH, Stamper RL. Needle revision with and without 5fluorouracil for the treatment of failed filtering blebs. Am J Ophthalmol
1990; 110: 254-9.
56. Potash SD, Ritch R, Liebmann J. Ocular hypotony and choroidal
effusion following bleb needling. Ophthalmic Surg 1993; 24: 279.
57. Durcan FJ, Cioffi GA, van Buskirk EM. Same-site revision of failed
filtering blebs. J Glaucoma 1992; 1: 2-6.
58. Greenfield DS, Miller MP, Suner IJ, Palmberg PP. Needle elevation of
the scleral flap for failing filtration blebs after trabeculectomy with
mitomycin C. Am J Ophthalmol 1996; 122: 195-204.
59. Traverso CE, Tomey KF, Antonios S. Limbal- vs fornix-based
conjunctival trabeculectomy flaps. Am J Ophthalmol 1987; 104: 28.
60. Segrest DR, Ellis PP. Iris incarceration associated with digital ocular
massage. Ophthalmic Surg 1981; 12: 349-51.
61. Miller GR, Krustin J. Ruptured filtering bleb after ocular massage.
Arch Ophthalmol 1966; 76: 363.
62. MacRae SM, et al. The effects of sodium hyaluronate, chondroitin
sulfate and methylcellulose on the corneal endothelium and intraocular
pressure. Am J Ophthalmol 1983; 95: 332-41.
63. Ruderman JM, Jampol LM, Krueger DM. Visual loss caused by
subretinal hemorrhage and rupture of Bruchs membrane after digital
ocular massage. Am J Ophthalmol 1988; 106: 493-4.
64. Lieberman Mf. Suture lysis by laser and goniolens. Am J Ophthalmol
1983; 95:257.
65. Hoskins D, Migaliazzo CV. Argon laser treatment of filtering bleb
insufficiency. Klin Monatsbl Augenheilkd 1989; 195: 328.
66. Hoskins HD Jr, Migaliazzo C. Management of failing filtering blebs
with argon laser. Ophthalmic Surg 1984; 15: 731.
67. Ritch R, Potash Sd, Liebmann JM. A new lens for argon laser suture
lysis. Ophthalmic Surg 1994; 25: 126.
68. Lai JS, Tham CC, Lam DS. Argon laser suture lysis using Ritch lens
following cataract surgery. Indian J Ophthalmol 2002; 50: 131-2.
69. Savage JA, Condon GP, Lyth RA, et al. Laser suture lysis after
trabeculectomy. Ophthalmology 1998; 95: 1631-8.
70. Tomey KF. A simple device for laser suture lysis after trabeculectomy.
Arch Ophthalmol 1991; 109: 14-5.
71. Salamon SM. Trabeculectomy flap suture lysis with endolaser probe.
Ophthalmic Surg 1987; 18: 506-7.
72. Benson WE, Coscas G, Katz LJ. Revision of failing filtering blebs. In
Current Techniques in Ophthalmic Laser Surgery. Philadelphia:
Current Medicine 1994: 200-4.
73. Kapetansky FM. Laser suture lysis after trabeculectomy. J Glaucoma
2003; 12: 316-20.
74. Mudgil AV, To KW, Balachandran RM, Janigian RH, Tsiaras WG.
Relative efficacy of the argon green, argon blue-green, and krypton
red lasers for 10-0 nylon subconjunctival laser suture lysis. Ophthalmic
Surg Lasers 1999; 30: 560-4.
75. Aktan SG, Mandelkorn RM. Krypton laser suture lysis. Ophthalmic
Surg Lasers 1998; 29: 635-8.
76. Macken P, Buys Y, Trope GE. Glaucoma laser suture lysis. Br J
Ophthalmol 2000; 80: 398-401.
77. DiSclafani M, Liebmann JM, Ritch R. Malignant glaucoma following
argon laser release of scleral flap sutures after trabeculectomy. Am J
Ophthalmol 1989; 108: 597-8.
78. Ferrer H. Conjunctival dialysis in the treatment of glaucoma recurrent
after sclerectomy. Am J Ophthalmol 1941; 24: 788-90.

79. Fitzgerald JR, McCarthy JL. Surgery of the filtering bleb. Arch
Ophthalmol 1962; 68: 453.
80. Gillies WE, Brooks AMV. Restoring the function of the failed bleb.
Aust NZ J Ophthalmol 1991; 19: 49-51.
81. Morales J, Ritch R. Treatment of failing filtering blebs. Clin Decisions
Ophthalmol 1987; 11: 4-11.
82. Shin DH, et al. Needling revision of failed filtering blebs with adjunctive
5-fluorouracil. Ophthalmic Surg 1993; 24: 242.
83. Hayashi M. Use of the Hoskins lens in needle revision of a failed bleb
after filtration surgery. Am J Ophthalmol 1995; 119: 232-3.
84. Mathur R, Gazzard G, Oen F. Malignant glaucoma following needling
of a trabeculectomy bleb. Eye 2002; 16: 667-9.
85. Ramanathan US, Kumar V, ONeill E, Shah P. Aqueous misdirection
following needling of trabeculectomy bleb. Eye 2003; 17: 441-2.
86. Shingleton BJ, et al. Management of encapsulated filtration blebs.
Ophthalmology 1990; 97: 63-8.
87. Shin DH, Kim YY, Ginde SY, Kim PH, Eliassi-Rad B, Khatana AK,
Keole NS. Risk factors for failure of 5-fluorouracil needling revision
for failed conjunctival filtration blebs. Am J Ophthalmol 2001; 132:
875-80.
88. Liebmann JM, Ritch R. 5-fluorouracil in glaucoma filtration surgery.
Ophthalmol Clin NA 1988; 1: 125-31.
89. Broadway DC, Bloom PA, Bunce C, Thiagarajan M, Khaw PT.
Needle revision of failing and failed trabeculectomy blebs with
adjunctive 5-fluorouracil: survival analysis. Ophthalmology 2004;
111: 665-73.
90. Ophir A, Wasserman D. 5-fluorouracil-needling and paracentesis
through the failing filtering bleb. Ophthalmic Surg Lasers 2002; 33:
109-16.
91. Ophir A, Porges Y. Needling with intra-bleb 5 fluorouracil for
intractable neovascular glaucoma. Ophthalmic Surg Lasers 2000;
31: 38-42.
92. Durak I, Ozbek Z, Yaman A, Soylev M, Cingil G. The role of needle
revision and 5-fluorouracil application over the filtration site in the
management of bleb failure after trabeculectomy: a prospective
study. Doc Ophthalmol 2003; 106: 189-93.
93. Hodge W, Saheb N, Balazsi G, Kasner O. Treatment of encapsulated
blebs with 30-gauge needling and injection of low-dose 5-fluorouracil.
Can J Ophthalmol 1992;27:233-6.
94. Hawkins AS, Flanagan JK, Brown SVL. Predictors for success of
needle revision of failing filtration blebs. Ophthalmology 2002; 109:
781-5.
95. Ben-Simon GJ, Glovinsky Y. Needle revision of failed filtering blebs
augmented with subconjunctival injection of mitomycin C.
Ophthalmic Surg Lasers 2003; 34: 94-9.
96. Mardelli PG, Lederer CM Jr, Murray PL, Pastor SA, Hassanein KM.
Slit-lamp needle revision of failed filtering blebs using mitomycin C.
Ophthalmology 1996; 103: 1946-55.
97. Iwach AG, Delgado MF, Novack GD, Nguyen N, Wong PC.
Transconjunctival mitomycin-C in needle revisions of failing filtering
blebs. Ophthalmology 2003; 110: 734-42.
98. Smith MF, Doyle JW. Use of tissue plasminogen activator to revive
blebs following intraocular surgery. Arch Ophthalmol 2001; 119:
809-12.
99. Szymanski A. Promotion of glaucoma filter bleb with tissue
plasminogen activator after sclerectomy under a clot. Int Ophthalmol
1992; 16: 387-90.
100. Tym WH, Seah SKL. Augmentation of filtering blebs with
perfluoropropane gas bubble. An experimental and pilot clinical
study. Ophthalmology 1999; 106: 545-9.

Resurrecting the Failing Filtering Bleb


101. Scheie HG. Goniopuncturea new filtering operation for glaucoma,
a preliminary report. Arch Ophthalmol 1950; 44: 761-82.
102. Moses, RA. Electrocautery puncture of the trabecular meshwork in
enucleated human eyes. Am J Ophthalmol 1971; 72: 1094.
103. Kozart DM, Cameron JD. Goniodiathermy: experimental studies
on ab interno filtration. Ann Ophthalmol 1978; 10: 1597.
104. Brown RM, et al. Internal sclerectomy for glaucoma filtering surgery
with automated trephine. Arch Ophthalmol 1987; 105:133-6.
105. Brown RH, et al. Internal sclerectomy with an automated trephine
for advanced glaucoma. Ophthalmology 1988; 95: 728.
106. Cohn HC, Aron-Rosa D. Reopening blocked trabeculectomy sites
with the YAG laser. Am J Ophthalmol 1983; 95: 293.
107. Praeger DL. The reopening of closed filtering blebs using the
neodymium:YAG laser. Ophthalmology 1984; 91: 373.
108. Dailey RA, Samples JR, van Buskirk EM. Reopening filtration fistulas
with the Nd:YAG laser. Am J Ophthalmol 1986; 102: 491-5.
109. Rockwood EJ, et al. Glaucoma filtration surgery with 5-fluorouracil.
Ophthalmology 1987; 94: 1071.
110. McGuigan LJB, et al. Effects of D-penicillamine and daunorubicin
on conjunctival fibroblast proliferation and collagen synthesis. Invest
Ophthalmol Vis Sci 1988; 29: 112.

57

111. Catoira Y, Wudunn D, Cantor LB. Revision of dysfunctional filtering


blebs by conjunctival advancement with bleb preservation. Am J
Ophthalmol 2000; 130: 574-9.
112. Mandal AK. Results of medical management and mitomycin Caugmented excisional bleb revision in encapsulated filtering blebs.
Ophthalmic Surg Lasers 1999; 30: 276-84.
113. Buxton JN, Lavery KT, Liebmann JM, Buxton DF, Ritch R.
Reconstruction of filtering blebs with free conjunctival autografts.
Ophthalmology 1994; 101: 635-9.
114. Honjo M, Tanihara H, Inatani I, Honda Y. Removal of a large nonfunctional bleb and reconstruction with free conjunctival autograft
after trabeculectomy. Acta 2001; 79: 326-7.
115. Schnyder CC, Shaarawy T, Ravinet E, et al. Free conjunctival
autologous graft for bleb repair and bleb reduction after
trabeculectomy and non-penetrating filtering surgery. J Glaucoma
2002; 11: 10-6.
116. Barton K, Budenz DL, Khaw PT, Tseng SCG. Glaucoma filtration
surgery using amniotic membrane transplantation. IOVS 2001; 42:
1762-8.

58

Atlas of Glaucoma Surgery


Oscar Albis-Donado

6 The Ahmed Valve

INTRODUCTION
Modern implant glaucoma surgery has been influenced
by the invention of Dr Mateen Ahmed and the
introduction of his glaucoma valved implant in 1990.
The Ahmed valve was the first restrictive glaucoma
implant with a true valve mechanism developed. It was
designed to address the need to control intraocular
pressure (IOP) during the first day after surgery, reducing
at the same time the risk of hypotony and choroidal
detachment; a task hard to achieve with pre-existing nonrestricted implants.
Four different models are available for implantation
nowadays:
AGV S2: Three-piece design, polypropylene body,
silicone tube, 184 mm2 total area, intended for adult
eyes, axial length 20.5 mm or more
AGV S3: Three-piece design, polypropylene body,
silicone tube, 92 mm2 total area, for pediatric or
nanophthalmic eyes
AGV B1: Double plate design, polypropylene
body, silicone tube, 368 mm2 total area, second
plate can be fixed at either side of primary plate
AGV FP7: Flexible plate, silicone body, silicone
tube, 184 mm2 total area. The valved mechanism
is made of polypropylene protected by silicone to
avoid its contact with inflammatory cells. Its plate
also has new holes intended to limit the size of the
bleb and decrease chances of extrusion and/or
migration.
The tube is inserted into the anterior chamber or
into the vitreous cavity via pars plana in vitrectomized
eyes. The aqueous is transported to the valves body,
where it has to pass between two silicone elastomer foils,

Fig. 6.1: Ahmed valves three-piece design. F: Elastomer foils


that regulate one-way flow. TC: Tapered chamber creates
ventury flow towards the valves body. B: Body. E: Fixating
Eyelets. AB: Assembly bolts help tighten the elastomer foils to
the proper tension for flow regulation

held in place by the polypropylene piece at a certain


tension (Fig. 6.1). The initial pressure needed to break
the adherence of these membranes often exceeds 100
mm Hg, but afterwards they separate whenever the
pressure is over 12 mm Hg, and close when the pressure
falls to 8 or less: this mechanism permits one-way flow
only.
Aqueous passage is facilitated by the design of the
chamber that first receives it. Taking advantage of
Bernoullis law, a tapered chamber makes aqueous drain
from a high pressure, low velocity, greater diameter site

The Ahmed Valve


to a lower pressure, higher velocity and smaller diameter
site, helping maintain flow through the foils.
The filtering area varies according to the model, and
this area seems to be critical for long-term IOP control,
at least with other implants.1 Experience with models B1
and FP7 is still limited and no studies to date have
reported results with them. Our experience is limited to
a few cases and has been of variable success so far.

INDICATIONS
The valve should be considered for any multioperated,
unresponsive glaucoma. It can also be a first line
procedure in phakic, aphakic, post-keratoplasty or
neovascular glaucoma, in eyes with previous retinal and/
or vitreous surgery, and in any eye with scarred
conjunctiva.
Children with glaucoma and eyes that have not
reached an axial length over 20.5 mm should receive
the AGVS3 model. Children with congenital or
secondary glaucomas and adult-size or buphthlamic eyes
should receive either model AGVS2 or FP7.

59

by Dr. Palmberg (personal communication) could


potentially be better for cases where silicone oil is present
and concerns of its exit through the tube may be critical.
Whenever the nasal quadrant must be used the plate
should be secured closer to the limbus (6 to 8 mm) in
order to avoid its posterior end to come in contact with
the optic nerve.3
A fornix-based conjunctival flap is constructed, taking
care to avoid conjunctival perforations or lacerations and
also to avoid accidental dissection of the scleral stroma.
Radial relaxing cuts are made 90 apart to facilitate
Tenons manipulation. Tenons capsule is also lifted at
the same time, making sure it is completely adhered to
the conjunctival flap (Fig. 6.2). Any piece of Tenons left
on the sclera has to be removed in order to diminish the
risk of valve migration. In case of encountering old
filtration sites, staphylomas or sclerostomies, it may be
preferable to remove any epithelial tissue they may have,

SURGICAL TECHNIQUE
Several modifications to the usual technique were
developed by Dr. Gil-Carrasco, at the Hospital de la
Asociacin Para Evitar La Ceguera en Mxico, Dr Luis
Snchez Bulnes or APEC. These include the use of 7-0
silk, the scleral tunnel technique and no-patch technique
as described previously.2
The eye is usually operated under peribulbar or
retrobulbar anesthesia, but in special cases where the risk
of perforation is too great, a combination of topical and
sub-Tenons can be used safely. General anesthesia can
be left for children and other uncooperative patients. A
bolus of mannitol and/or Honans balloon may be
necessary whenever the anterior chamber will have a large
incision due to combined cataract, IOL, or corneal surgery.
The preferred quadrant for valve implantation is the
superotemporal because of its easier access, less chances
of muscular restriction and a better-looking postoperative
aspect. Only in cases with marked scleral thinning,
dehiscent conjunctiva or when a second or third implant
is needed should the other quadrants be considered.
The inferotemporal or inferonasal quardant, as proposed

Fig. 6.2: Tenons capsule is lifted together with the conjunctiva.


Dissection is prolonged as far as the intermuscular septum
and beyond. T: Tenons capsule. C: Conjunctiva. S: Sclera

and then cut the conjunctiva around them if necessary,


so they can be safely covered when closing the
conjunctiva at the end of the procedure.
Dissection under Tenons capsule is continued
posteriorly, going beyond the intermuscular septum with
closed Westcott or Stevenss scissors, and retiring them

60

Atlas of Glaucoma Surgery

open to widen the space for the valve. Care must be


taken not to rupture Tenons capsule and expose either
the intraconal or extraconal fat pads, as this will increase
chances of fibrosis, and especially of postoperative
restrictive strabismus, as has been described with inferior
oblique surgeries.4 Cauterization of any bleeding vessels
may be performed to reduce chances of bleb fibrosis
and facilitate visualization of subsequent steps.
Partial Tenons capsule resection may be indicated in
some patients in whom we need to delay or blunt the
hypertensive phase, as described by Sussana.5 The use
of mitomycin-C (MMC) as an adjunctive therapy is of
use only to diminish the aggressiveness of the
hypertensive phase and shows almost no long-term effect,
even in 1 percent concentrations. This partial Tenons
capsule resection can also be made posteriorly, without
removing the portion closest to the limbus, in order to
lower the chances of bleb leak.
Ahmeds valve must be primed before insertion; we
inject BSS with a 27G cannula inserted 3 to 5 mm into
the tube and often a small popping sound is heard
while the BSS separates the silicone foils. The valve must
be held firmly as the pressure we are exerting may make
it fly away suddenly (Fig. 6.3).
We fix the valves body with a preplaced 7-0 silk suture
(Ethicons TG140-9 plus or Alcons C-3 3/8 needle);
this type of suture has several advantages: it is flexible,
well tolerated, does not tend to cut loose from the sclera,
and promotes a fibrous response anterior to the plate,
reducing chances of migration. This preplacement can
be done whether we are planning a one-stitch or twostitch technique. For the one-stitch technique, both
needles of a preplaced double mounted 7-0 silk suture
are passed from above through the fixating eyelets. The
trailing loop that is formed is then passed under the tube
to avoid exerting pressure over it (Fig. 6.4). For the twostitch technique the silk is placed in a similar manner
and the loop can be cut after the valve is in place and
the episcleral bites have been made.
The usual technique for inserting the valves body
involves using forceps. This technique has the disadvantage
of potentially damaging the valves mechanism by pinching
it and also damaging its surface, which probably increases
chances of fibrosis. We prefer to partially insert it with two

fingers under abundant BSS irrigation by the assistant


and then sliding it backwards into sub-Tenons space by
using a closed needle holder or forceps pushed against
the solid inferior plate. Care must be taken not to put
pressure on the union between the two polypropylene
pieces, as this may crack open the valve in two if there is
too much resistance. Fibrous tissue may grow and
compromise the mechanism if this happens.6
The valve is fixated 8 to 10 mm behind the limbus
on the temporal quadrants, and 6 to 8 mm on the nasal
quadrants. Another useful landmark is the ramification
of the long anterior ciliary vessels; the sclera is usually
vessel-free behind this area. This is especially useful in
patients in whom the limbus is ill defined (sclerocornea,
congenital glaucomas, post-traumatic leucomas, etc.).
For the one-stitch technique the first needle is passed
parallel to the limbus from the side of the valve towards
the tube. The needle must pass episcleral or through
partial scleral thickness with care to avoid perforations.
The second needle is passed in a similar way, towards
the exit site of the first needle (Fig. 6.5). Next, both ends
are pulled tight to bring the valve forward and avoid
any slack suture which may permit displacement or
movement of the valve. One of the ends is cut and then
both ends are tied together under the tube with three
loops, cutting loose the other needle at the end (Fig.
6.6).
In case separate knots are preferred or in case of
accidentally cutting the loop under the tube the episcleral
bites are made shorter, near the eyelets, so the chances
of valve movement are minimized.
Whenever scleral buckling is present, surgery is better
planned to place the valve over the band, sponge or
tire. If the band is too anterior the capsule surrounding
the band must be dissected in order to fix the valve
through the band to the sclera or, alternatively, to the
band (Fig. 6.7).
A 23 G (22 G can be used for the first cases) needle
is used to make the tunnel into the anterior chamber.
The needle is prepared bending it in such a way that it
will let us manipulate it without interference from the
eyelids, brow or lid speculum. The first bend is made
backwards on the upper side and 5 mm behind of the
beveled tip, leaving it in a 70 angle with respect to the

The Ahmed Valve

Fig. 6.3: Priming: Ahmeds valve must be primed before use. A


27-gauge cannula is inserted 2 to 3 mm into the tube and
balanced salt solution is injected until it separates the elastomer
foils and exits towards the body

Fig. 6.4: Preplacement of silk suture. Both needles of a double


mounted 7-0 silk suture are passed through the fixating eyelets,
leaving the trailing loop under the tube

rest of the needle. The second bend is made near the


plastic shaft in the opposite direction, leaving it 90 away
from the original shape (Fig. 6.8). This Z shape will let
us manipulate the needle inside the eye, avoiding
pressure against or interference from the lids.

61

Fig. 6.5: One-stitch technique. The needles are passed through


episclera, towards the tube, fixing the valve 8 to 10 mm parallel
to the limbus

Fig. 6.6: One-stitch technique. Both ends of the suture are tied
under the tube. The suture must be tightened to avoid
displacements

In the usual technique where a scleral patch is


needed, a limbal entry with the needle directed parallel
to the iris is first made, and then the tube is trimmed in a

62

Atlas of Glaucoma Surgery

Fig. 6.7: Fixing through a scleral sponge. Whenever the ideal


position for the valve coincides with a retinopexy band or
sponge, one of the options is to pass the sutures through the
band, finally fixing them to the episclera under the band

Fig. 6.8: Bending the needle. A 23-gauge, 1 needle is bent


twice, forming first a 70o angle (1) and then a 90 to 110o angle
for the second bend (2). The bevel is left facing upwards at all
times

beveled manner and inserted into the anterior chamber.


The portion of the tube that is outside the anterior

Fig. 6.9: Making the tunnel. The tunnel is begun 3 to 4 mm from


the limbus, maintaining the needle visible under the episclera
at all times. At the limbus the point is made parallel to the iris

chamber is then covered with a scleral, corneal,


pericardium or fascia lata patch.
In our technique we avoid using a patch by making
a long episcleral tunnel, starting 4 mm behind the limbus
(Fig. 6.9). This has the advantage of having a long, tight
tunnel that minimizes lateral tube movements and
therefore erosions. It also shortens operative time by a
considerable amount and permits implantation without
the need for extraneous tissue, which is usually completely
reabsorbed within 1 or 2 years.
The bent needle is mounted on a syringe filled with
BSS or viscoelastic and used bevel-up to make the tunnel,
starting 4 mm behind the limbus. The point of the needle
is initially directed under the episclera, making a tangent
movement almost on the verge of leaving the eye until
the limbus is reached (Fig. 6.10). At this point the
direction of the needle is changed and made parallel to
the iris (Fig. 6.11).
Depending on the direction change, the entrance to
the anterior chamber can be made through the
trabeculum or alternatively over Schwalbes line if the
intention is to avoid any corneal touch, especially in
corneal transplant cases or whenever peripheral anterior

The Ahmed Valve

Fig. 6.10: Making the tunnelstep 1, side view. The 23 gauge


needle if first passed tangent to the sclera, on the verge of
perforating the episclera

Fig. 6.11: Making the tunnelstep 2, side view. At the limbus


the dissection is changed so the needle is directed parallel to
the iris

synechia are present. When removing the needle, care


must be taken not to touch the lens or cornea, and the
removal is stopped when the bevel is at the limbus. At
this point slow side-to-side and rotational movements

63

Fig. 6.12: Widening the inner portion of the tunnel. Small side
to side movements are made using the cutting edge of the
needle to widen the tunnels inner opening

are made to widen the inner mouth of the tunnel, and


reduce resistance to the tubes entrance (Fig. 6.12).
The first cases can be hard to get just right; in case a
first tunnel does not seem to be working, as much as 6
additional tunnels can be tried next to the first one, using
the same quadrant. If this is the case the tube might
need to be longer than originally planned, accounting
for the bend it must now have.
When planning a pars plana approach the valve is
placed farther behind, closer to 10 mm from the limbus,
and the tunnel is started 5 to 6 mm behind the limbus
(Fig. 6.13). The change of direction is made 3 to 4 mm
from the limbus, going through pars plana (Figs 6.14
and 6.15). This strategy should be reserved for aphakic
patients or those with an IOL and direct communication
between the vitreous cavity and the anterior segment.
In phakic patients or those with an intact barrier between
the anterior and posterior segments the tube is best suited
for an anterior chamber approach.
Whenever there are extensive anterior synechia in
our quadrant of choice and there is little chance of
making a successful synechiolysis or great risk of tube
occlusion, the needle can be advanced through the uveal
tissue, be it iris and/or ciliary body. This has the

64

Atlas of Glaucoma Surgery

Fig. 6.13: Tunnel for pars plana insertion. The tunnel is started
5 to 6 mm from the limbus and at the 3 to 4 mm mark the needle
is directed posteriorly, behind the iris

Fig. 6.14: Pars plana tunnelstep 1. The needle is first


directed parallel to the sclera

disadvantage of a greater chance of bleeding, which can


be controlled using viscoelastic and/or an air bubble.
The final position of the tube will be in the posterior
chamber, anterior to the IOL or lens.

Fig. 6.15: Pars plana tunnelstep 2. The needle is rotated


posteriorly, directing it behind the iris and going through pars
plana. This technique should be reserved for aphakic or
pseudophakic vitrectomized eyes

Tube trimming is done in a beveled manner,


calculating the desired length by placing the tube over
the cornea, and cutting about 1 mm behind the intended
place for the tip. The tube will reach the desired length
because it will no longer be affected by the corneal
curvature (Fig. 6.16). The ideal length is usually just at
the partially dilated pupillary margin, and at least 1.5
mm into the anterior chamber. The bevel should have a
45 angle; if it is closer to 0 the chances of obstruction
will be greater due to a reduced lumen area and there
will also be a greater difficulty for its insertion through
the tunnel; if it is closer to 90 the tip will be too malleable
and tend to get entangled with the tunnels mouth or
any irregularity in its inner path.
Whenever the tube is placed through pars plana the
length is calculated almost 2 mm behind, due to a greater
effect on the apparent position from the corneal
curvature. In all cases it may be preferable to leave it
longer and have it trimmed if necessary, instead of leaving
it too short and amenable to retraction.
Tube insertion itself is accomplished grasping the tube
1 to 2 mm behind its tip with a needle holder or using
New World Medicals special tube forceps. The tip is

The Ahmed Valve

Fig. 6.16: Effect of corneal curvature on final length of the tube.


A: Apparent position of the tip before insertion. B: Actual position
of the tube inside anterior chamber. Notice the tube closer to
the pupillary margin than anticipated. C: Actual position of a
pars plana inserted tube. Despite a more posteriorly fixated
valve the tube is still longer than what it seems from the outside

inserted and guided through the outer mouth of the


tunnel, and then it is pushed forward towards the cornea,
making sure the pushing force is directed parallel to the
sclera. Resistance will be greater when the tip reaches
the limbus, due to the change of direction. This can be
overcome by using a blunt instrument (the back of a
forceps will do) to massage the limbus right over the
tube, making it change direction enough to unbutton
the tip from the previous direction and leaving it in the
anterior chamber (Figs 6.17 and 6.18).
Occasionally there is simply too much resistance and
in those cases viscoelastic injected with a 26 or 27 G
cannula through the tunnel can help lubricate the tubes
passage. If the tubes final length is too long, it can be
pulled out of the eye, trimmed and reinserted; this may
cause some hypotony due to aqueous exit, so BSS or
viscoelastic injected through the tunnel or, alternatively,
through a paracentesis, can be used to raise the pressure
again and facilitate insertion.
If you find the tube too close to the cornea or iris,
the simplest solution is to raise the IOP again and make

65

Fig. 6.17: Overcoming limbus resistance. A blunt instrument is


used to depress the limbus, widening the tunnels inner opening

Fig. 6.18: Overcoming limbus resistance. Limbus depression


untangles the tip of the tube, which now easily slides into the
anterior chamber

another tunnel, next to the original. The only problem


with this approach is that the effective length of the tube
may shorten due to the curve that the tube will have to
take to enter the new tunnel away from the original.

66

Atlas of Glaucoma Surgery

Whenever there is risk of a too rapid IOP lowering or


concerns of choroidal detachment or suprachoroidal
hemorrhage, 1 percent sodium hyalorunate can be
injected and left in the anterior chamber. This can be
done through a paracentesis or by inserting a 27 G
needle, connected to the viscoelastic, through the limbus,
into the anterior chamber. The substance will slowly leave
the eye and drain into the reservoir where it will be
metabolized without affecting final outcome.
After the tube is in place, closure of the conjunctiva
and Tenons is achieved using one of the ends of the 70 silk suture. The suture is passed from the conjunctiva
and episclera still attached to the limbus, towards the
mobile conjunctiva, grasping Tenons capsule in order
to bring it forward towards the limbus. The needle is
passed again, this time from the conjunctival flap towards
the previous bite, also fixing it to the episclera and tying
the knot over the conjunctiva (Fig. 6.19). The other end
of the conjunctiva is closed in a similar manner in such a
way that a line of tensioned Tenons capsule is built against
the limbus, making this end water-tight (Fig. 6.20). Radial

Fig. 6.19: Closing conjunctiva and Tenons capsule. Sutures at


the limbus must be fixed to episclera and bring Tenons capsule
forward towards the limbus

Fig. 6.20: Water-tight conjunctival closure. Tenons capsule is


tensioned in such a way that a tight tension line is formed
against the limbus, avoiding leaks

relaxing cuts can be closed if necessary with or without


fixing the suture to episclera.

TECHNIQUE FOR DOUBLE PLATE


AHMED
A similar technique for inserting the primary plate is used
in cases where a B1 model is indicated. This implant is
usually reserved for patients with very aggressive
glaucomas, multioperated in whom we need a greater
area of filtration.
The biggest difference lays in a greater conjunctival
dissection, as two adjacent quadrants must be prepared.
The second plate is not valved and can be attached to
either side of the primary implant, which has a hook
that grasps the interconnecting tube (Fig. 6.21). This
tube can be attached to the primary valve before fixing
it to the eye, leaving it over the intervening rectus muscle
or, alternatively, it can be attached afterwards if the
intention is to pass it under the muscle. This last option
can be harder to achieve, since there is the need to dissect
and isolate the rectus muscle with a muscle hook and
then attach the tube using forceps or placing a cannula
inside the connecting tube to manipulate it.

The Ahmed Valve

67

improve their remaining vision. The same pathologies


responsible for their eye problems are, on many cases,
responsible for systemic troubles that may not let us have
a second chance to complete their visual rehabilitation.
The Ahmed valve can let us avoid loss of IOP control
due to any of these surgeries, their complications or the
necessary steroids. Its one-way flow mechanism, firstday IOP control, simple implantation and low incidence
of hypotony opens the possibility of a one-step
procedure for glaucoma control combined with almost
any other surgery, regardless of the status of the
conjunctiva.

PENETRATING KERATOPLASTY AND


AHMED VALVE IMPLANTATION
Fig. 6.21: Double plate Ahmed valve. The second plate can be
attached to either side of the primary valve. The interconnecting
tube is not restricted and permits two-way communication. Small
pools (P) are near the tips of the tube to reduce chances of
obstruction from surrounding tissue

The second plate is fixed to the eye using separated


7-0 silk sutures after the interconnecting tube is in place.
Conjunctiva is closed in a similar manner as previously
described, using an extra-suture in the middle of the
180 conjunctival flap to create the Tenons capsule
water-tight barrier.

AHMED VALVE IN COMBINED


PROCEDURES
Many times a difficult glaucoma case is further
complicated by accompanying maladies: Corneal
opacities may preclude adequate tube placement;
presence of cataracts may impede posterior segment
visualization or may simply need to be removed due to
visual impairment, high risk of malignant glaucoma,
concerns of flat anterior chamber or the need for retinal
photocoagulation. Concurrent retinal detachment, retinal
neovascularization, vitreous hemorrhage and other retinal
surgical indications may increase the need for tight IOP
control, despite the frequent and almost unavoidable
mistreatment of the conjunctiva in these patients.
Some patients may need to have multiple anterior
and posterior segments procedures, to retain and/or

Most of the reported failures in implant surgery and


penetrating keratoplasty have shown an increased rate
of graft failure, making this the most dreaded and
frequent complication.7, 8 In our own initial series of 23
patients with concurrent Ahmed valve implantation and
penetrating keratoplasty our cumulative life-table analysis
success rate was 80 percent at 6 months and 54 percent
at 12 months.9 Further follow-up will probably tend to
increase the 12 month success rate. Our current
guidelines for successful combined surgery are presented.
First, Ahmed valve must be implanted and secured
in place, preferably in the superotemporal quadrant
If possible to view anterior segment structures, the
tunnel with a 23 or 22 G needle should be done
prior to penetrating keratoplasty. Viscoelastic may
be injected at this time if previously mounted with
the bent needle
The tunnel should also be done first if the patient is
aphakic and we are planning to do a pars plana
approach
The change of direction at the limbus is made as
anterior as possible, partially through recipients
corneal stroma; this will direct the tube posteriorly,
away from the cornea
The tube may be inserted into the anterior chamber
if IOP is too high. After it has been in place for a
while, IOP will have lowered at a slower pace to a
safer level for the rest of the surgery, avoiding
sudden decompression

68

Atlas of Glaucoma Surgery

Flieringas ring should be secured in place using 3


stitches, avoiding the quadrant corresponding to the
valves position
Penetrating keratoplasty is performed; a 0.5 mm.
difference between the donor and recipient
diameters is recommended to increase chances of
a deeper anterior chamber
Make sure abundant viscoelastic is placed into the
anterior chamber
Separated corneal radial sutures are preferable due
to high risk of rejection in most of these patients
After the donor cornea is in place and sutures are
buried, the AC is again filled with viscoelastic to raise
the pressure and deepen the chamber
The tunnel is made, if it was not previously made,
and the tube is inserted as previously described
Conjunctiva is closed as usual.
Making the entrance of the tunnel more anterior has
made the tubes inclination greater in a posterior
direction. This should reduce the rate of corneal
decompensation due to prolonged tube-corneal touch.
It also increases the chances of tube-iris touch, but tube
occlusion from this situation is less frequent and easier
to manage; iris atrophy is less worrisome and only
persistent iritis could potentially be more troublesome,
but not as common.
A useful technique to reduce the risk of expulsive
hemorrhage is the combination of a lamellar keratoplasty
and phacoemulsification whenever cataract extraction
must be made, in a similar way as described by Malbran
et al.10 Partial thickness trephination is made after the
valve is in place and the tunnel has been made. Lamellar
removal of the anterior two-thirds of the stroma is
performed with the aid of air, viscoelastic, crescent blade
or a microkeratome. A corneal or scleral incision is made
and phacoemulsification is performed with the aid of
viscoelastic on the stromal bed to improve visualization.
The IOL is implanted in the usual manner and the incision
closed. Corneal trephination is completed to full thickness
and the donor cornea secured in place. The amount of
time the eye is left in a high risk condition is minimized
and the many advantages of a closed-system cataract
extraction maximized. The tube is inserted after the
cornea is in place, unless it was needed in place from the
beginning.

CATARACT EXTRACTION AND AHMED


VALVE IMPLANTATION
This is probably the most frequent combined procedure
with the Ahmed valve. Many of the conditions that
originally complicated the glaucoma also produce and/
or accelerate cataracts. On other occasions the cataract
itself may be responsible for the glaucoma or may prevent
further treatment of posterior segment complications.
Important points to remember during this surgery are
presented below.
Ahmed valve must be implanted and secured in
place as a first step, preferably in the superotemporal quadrant, as previously described
The tunnel for the tube is made using a bent 23 G
needle, but it has to be planned in such a way that
it will not coincide with the cataract incision
In cases where the cataract extraction is to be made
by a phaco technique with a corneal incision in the
same quadrant as the valve (right eyes for right
handed surgeons and vice versa) the tunnel is made
more temporal or alternatively directed tangent to
the pupil (Fig. 6.22)

Fig. 6.22: Phaco and Ahmed valve combined procedure. Care


must be taken to avoid the tunnel and cataract incision to
coincide. Tubes direction may be planned more temporal for a
superior cataract incision

The Ahmed Valve


Cataract incision is made nasal to the tunnel; this is
also true for scleral incisions, except for the fact that
the conjunctiva may need to be further dissected to
make room for the incision, especially when using
a rigid, single-piece IOL
For extracapsular extraction the conjunctiva is
dissected nasally according to the size of the incision
normally used by the surgeon; the temporal
dissection is only extended as far as the horizontal
meridian as usual for valve implantation
Tenons dissection is extended posteriorly only in
the quadrant where the valve is to be placed; the
nasal quadrants conjunctiva can be dissected away
from the limbus without dissecting Tenons capsule
from its anterior insertion
The tunnel and the cataract incision should always
be separated
Trim the tube to the desired size, but leave it a bit
long
The tube can be placed before entering the anterior
chamber if IOP is too high and then be left in place,
or preferably be partially removed to avoid filtration
during surgery and likelihood of surge or other
problems, in particular in phaco cases
In most cases the tube may be tucked under the
conjunctival flap until finishing cataract extraction.
Cataract surgery is performed using our technique
of choice for each case; we prefer phacoemulsification in most cases
After the IOL is in, viscoelastic is left in place: it will
exit the eye through the tube and reduce the risk of
hypotony/flat anterior chamber
A peripheral iridectomy is recommended and should
be made in cases of uveitic and closed-angle
glaucomas
Closing the incision, even in patients with a self
sealing incision, is recommended to avoid leakage
of viscoelastic during tube insertion
The tube is inserted through the previously made
tunnel; if the tubes final position is unsatisfactory, a
new tunnel temporal to the first can be made. If
only the nasal sclera is available the tunnel can be
constructed under the cataract incision, but tube
insertion will be more difficult

69

Close conjunctiva as usual; if a large scleral incision


was made it may be necessary to put additional
sutures on the nasal side.
Results with this procedure have been very
encouraging, since patients from our initial series of
primary cases are getting better IOP control than expected.
These patients with intact conjunctiva and indication for
combined surgery were divided in two groups: those with
phacoemulsification cataract extraction (17 eyes, mean
age 74) and those with extracapsular cataract extraction
(23 patients, mean age 69.3). Success rate in eyes with
extracapsular extraction (mean follow-up 7.4 months) was
95.6 percent (86.9% on no medications, 8.7% with
medications); mean IOP was reduced from 23.6 mm Hg
on 3 drugs to 13.1 mm Hg on 0.1 drugs. In eyes with
phaco cataract extraction and 6 months of mean follow
up success rate was 100 percent, 88.2 percent with no
medications, and 11.8 percent with medications; mean
IOP was reduced from 21.2 mm Hg on 3 drugs to 13
mm Hg with 0.1 drugs.
This technique is faster than combined procedures
with a normal filtering procedure, and will also control
IOP from day one. There is less chance of hypotony
and aqueous leaks. Recovery is faster, due to greater
preservation of the scleral structure and also to less
chance of induced astigmatism, especially in phaco
procedures. Among its disadvantages its greater cost
must be considered and, of course, long-term IOP control
is unknown, but may be similar to results with its use as
primary procedure.11

AHMED VALVE COMBINED WITH


SECONDARY AND SUTURED
INTRAOCULAR LENS IMPLANTATION
Aphakia related glaucomas and traumatic glaucomas with
lens subluxation are among the most difficult to manage
using conventional filtering techniques. The conjunctiva
is usually compromised and the iris, angle and even the
sclera have been at many times disturbed due to previous
surgical or other trauma. It is not uncommon to find
vitreous in the anterior chamber of these eyes. Scleralfixated and anterior chamber intraocular lenses are the
two most common ways of dealing with these cases.

70

Atlas of Glaucoma Surgery

Conjunctival dissection is performed as usual for


Ahmed valve implantation; the portion that will
coincide with the scleral IOL incision is dissected only
anterior to Tenons capsule limbal insertion
The valve is fixated as usual at the superotemporal
quadrant
Conjunctival flaps are made as necessary for the
scleral pockets where the IOL sutures will be
secured. A radial corneal marker is recommended
for planning these incisions 180 apart
One of the flaps may coincide with the valves
quadrant, especially on the left eye for right-handed
surgeons. It is recommended to be made closer to
the 1 oclock position, so the temporal portion can
be used for the tube
The tunnel for tube insertion is made temporally
with a 23 G needle, avoiding the scleral flap for left
eyes and the scleral IOL incision for right eyes when
the surgeon is right-handed and vice versa
The scleral incision for IOL insertion is made at this
point. The polypropylene sutures may be preplaced on the IOL (if applicable) before entering
the anterior chamber, depending on the suturing
technique of choice. We prefer to make a beveled
incision to better control astigmatism
The tube is not immediately inserted, unless IOP is
considered to be extremely high
Automated anterior vitrectomy is made; if indicated
we prefer to make it as wide as possible, particularly
in the superiortemporal area to prevent vitreous
occluding the tube
Viscoelastic is injected and the IOL is placed on the
iris, on remaining capsular flaps or sutured in place.
Raise the pressure and close the wound before
securing the sutures definitively
After the IOL is in proper position and the wound
closed the tube is trimmed and inserted through
the previously made tunnel into the anterior
chamber
The conjunctiva is closed as usual; extra-sutures may
be placed on the nasal side, if necessary.
Although an analysis of results among sutured and
anterior chamber IOL has not been made, in our initial
series of 95 aphakic/pseudophakic eyes global cumulative

life-table analysis success was 89.8 percent at 12 months


and 84.2 percent at 18 months. Mean IOP was reduced
from 22.5 mm Hg with 2.8 drugs to 13.1 mm Hg with
0.5 medications. Many times final visual result is
surprisingly good. Potential visual acuity can be inferred
from spectacle or contact lens-corrected vision, but the
visual field usually improves due to lowering of spherical
aberrations and frame related artifacts.

AHMED VALVE IMPLANTATION AND VITREORETINAL SURGICAL PROCEDURES


Prior to tube shunt surgeries it was very difficult to control
glaucomas related to vitreoretinal surgery with poor
response to medical therapy. Sometimes the problems
are so severe that a one-step procedure is preferable,
controlling IOP and at the same time correcting the
vitreous and/or retinal pathologies. Corneal edema due
to high IOP precludes good visualization of the posterior
segment.
The most common indication for posterior vitrectomy
and Ahmed valve implantation in our experience is
neovascular glaucoma due to proliferative diabetic
retinopathy, with or without concurrent vitreous
hemorrhage and tractional retinal detachment. It is also
common in retinal vascular occlusive disease.
Conjunctival dissection is made as needed for the
vitreoretinal surgery; make sure radial cuts are made
90 apart in the superiortemporal quadrant
If silicone oil is to be left in the eye consider using
the inferior quadrant or using a very long tube that
crosses the temporal side of the iris to the inferior
angle; this last option can be hard to achieve safely,
as the tube may tend to move towards the cornea,
it may also cross the visual axis or be occluded by
the inferior iris
If an scleral band or buckle is going to be placed it
must be secured before inserting the valve (see Fig.
6.7)
The valve is fixed anterior to the band or buckle. On
the rare occasions when the band has to be placed
more anteriorly than usual the valve can be sutured
to the band or to the episclera through the band

71

The Ahmed Valve


Make the scleral tunnel for the tube before making
the sclerostomies or any other intraocular
procedure. The tube can be placed initially if IOP is
deemed too high for a safe vitreoretinal procedure
Perform the necessary vitreoretinal surgeries or even
better, let the retina specialist do his/her work
Make sure there is no vitreous left that may
potentially occlude the tube in the valves area
After closing the sclerostomies raise IOP using BSS
or viscoelastic as needed and insert the tube into
the anterior chamber through the previously made
tunnel
Closure of the conjunctiva is also critical. Tenons
capsule in the quadrant of the valve must be brought
forward to the limbus and secured in place to
minimize risk of postoperative leak. All sutures must
be anchored to episclera to ascertain this.
Results in 81 eyes with previous or concurrent
vitreoretinal surgery in our series are encouraging. Mean
follow-up has been 6.6 months (range 0.5 to 39), global
success is 72.72 percent at 12 months (life-table analysis,
57% with no medications). Mean IOP was reduced from
31.8 mm Hg on 3.19 drugs to 15 mm Hg on 0.3 drugs.
Visual acuity improved in 22 percent, remained
unchanged in 39.5 percent and worsened in the rest.
Failures were 17.28 percent of the eyes (14 eyes); ten
eyes (12.3%) failed due to loss of light perception. Loss
of light perception was IOP related in 2 eyes, due to retinal
detachment in 5 and due to retinal injury in the other 3.
Many of the mentioned procedures can be further
combined to manage even more complicated cases. For
instance, it may be necessary to make a corneal
transplant and Ahmed valve implantation in a patient
who also needs cataract extraction and posterior
vitrectomy for a vitreous hemorrhage. In these cases we
first fix the valve in place and then perform an open-sky
extracapsular cataract extraction or a lamellar keratoplasty
and phaco cataract extraction, place a temporary
keratoprosthesis, do the vitrectomy, endophotocoagulation, etc. and then remove the keratoprosthesis,
put in the IOL, suture the corneal transplant and at the
end put in the tube and close the conjunctiva.

COMPLICATIONS AND THEIR


MANAGEMENT
Many problems may arise while performing Ahmed valve
implantation or during both its early and late
postoperative periods (Table 6.1). They occur more
frequently on more troubled eyes and those with the
greatest number of previous surgeries and associated
pathologic conditions. Most of these tribulations may be
prevented by doing a careful technique and following
the previously mentioned recommendations for each
step of the surgery.
Table 6.1: Complications of Ahmed valve
Intraoperative
complications

Early postoperative

Late postoperative

Related to
conjunctival:
dissection/closure/
buttonholes
Ocular perforation
Related to tube
insertion/position/
cutting
Valves body
placement
Hyphema
Flat/shallow AC
Choroidal
detachment/
Expulsive
Hemorrhage
Vitreous loss/
malignant glaucoma
Traumatic cataract/
Lens trauma

Conjunctival
dehiscence/Seidel

Tube exposure

Tube corneal/iris touch Tube retraction


Tube occlusion
Cystic/Fibrotic/
Encapsulated bleb
Valves body
displacement
Hyphema
Flat/shallow AC
Choroidal
detachment
Serous/hemorrhagic

Valves body
displacement
Restrictive strabismus
Sub-acute choroidal
detachment

Malignant glaucoma
Cataract

Cataract

Intraoperative Complications
All intraoperative complications should be treated as soon
as they appear, except for lens trauma, which may be
observed if the capsular rupture is small; fibrosis may
form over the capsular rupture and the opacity may be
localized and not interfere with the visual axis. If the
rupture is too big or compromises the pupillary axis the
cataract may be extracted, preferably by phaco, and the
IOL implanted as a secondary procedure when the
biometry becomes available.
Most troubles related to conjunctival and scleral
dissection happen in eyes with previous retinal surgeries,
scleromalacia, scleral staphylomas, or previous ocular

72

Atlas of Glaucoma Surgery

trauma. The conjunctiva becomes firmly adhered to the


sclera and this fibrosis can be so strong that the usual
blunt dissection separating conjunctiva and Tenons from
sclera, may actually become an intrastromal dissection
that will further thin the scleral wall. Prompt identification
of the complication, heralded by abundant, dark
bleeding, and a change of the direction of the dissection
in a posterior way, may leave enough suitable sclera for
making the tubes tunnel. If a perforation occurs it should
be closed using 7-0 vicryl and cryotherapy performed
around the site if it is too posterior.
Tube insertion can be a difficult task. On occasion it
entangles with the iris or the ciliary body and has to be
reinserted and redirected. Injection of viscoelastic material
into the anterior chamber may facilitate the insertion by
pushing the iris and/or lens posteriorly. The change of
direction at the limbus can be overcome by doing the
previously described massage (see Figs 6.17 and 6.18),
but sometimes the tube has to be aided with a 27 G
cannula, inserted under the tube inside the tunnel or in
desperate cases by making a slit incision near the proximal
end of the tube, use the cannula as a guide inside the
tube, insert it into the anterior chamber, then slide the
tube around the cannula into the eye and remove the
cannula (Fig. 6.23). An inconvenience of this procedure
is the possibility of making a secondary anterior bleb
near the slit when and if eye massage is initiated.
A small hyphema can be left without trouble in the
eye unless it forms a clot near the tip of the tube. If
abundant bleeding occurs one or two paracentesis must
be made in order to allow for blood and clot aspiration.
At times the clot becomes so thick that it must be
removed by using the vitrectomy unit. If bleeding recurs
viscoelastic and/or air may be left in the anterior chamber
to raise the pressure and promote vessel collapse and
bleeding control.
Whenever excessive manipulation results in an
intraoperative flat or shallow anterior chamber, the risk
of choroidal detachment and other hypotony-related
complications is higher. Viscoelastic material is also left in
the AC to diminish this risk and slow down IOP reduction.
If there is difficulty in maintaining the viscous material
inside the anterior chamber and it seems to be expelled
from the eye, an expulsive hemorrhage or suprachoroidal

Fig. 6.23: Aiding tube insertion with a cannula. A slit incision is


made close to the valves body. The cannula is passed through
its lumen and then passed through the tunnel into the anterior
chamber. Afterwards the tube is guided over the cannula into
the anterior chamber and the cannula is removed

hemorrhage should be suspected. The eye is closed as


fast as possible if there are any other incisions and, after
confirming the diagnosis by indirect ophthalmoscopy or
simply by the loss of the retinal reflex, several sclerostomies
should be made, one per quadrant at 5 to 6 mm from
the limbus, to drain the blood.
If this complication is encountered during a
penetrating keratoplasty in an open-sky situation the top
priority is to stop the expulsion of the retina and choroid,
blocking them by using donors cornea (previously cut
and left with viscoelastic on its endothelial face), the IOL
or a finger with sufficient pressure to withstand it. A large
bore (19 or 20 G) needle is passed through conjunctiva
and sclera 5 to 6 mm from the limbus, obtaining
abundant blood drainage (Figs 6.24A and B). This will
stop the expulsion temporarily and give enough time to
pass the first 1 to 2 sutures securing the cornea in place
before it is occluded by clot formation. A second needle
is passed in another quadrant while holding the donor
cornea in place and further drainage is obtained,
permitting extra 2 to 4 sutures to be secured in place,
removal of the first needle and its purging. When the

The Ahmed Valve

73

will lower and a new hemorrhagic choroidal detachment


may present. After a week or so, any remaining blood
may be drained, accompanied by vitrectomy and siliconoil and/or gas as necessary, and the tube may be inserted
at this time. Failure to reoperate on time usually ends in
a phthisic eye.
Malignant glaucoma may present during surgery and
is often difficult to diagnose; regardless, it must be
recognized and treated immediately. It more often occurs
in phakic patients with chronic or acute angle-closure
glaucomas and is heralded by intraoperative flat anterior
chamber, unresponsive to reformation with BSS, air or
viscoelastic. If diagnosis is certain, Chandlers maneuver
is indicated (see below).

Early Postoperative Complications

Figs 6.24A and B: Suprachoroidal hemorrhage during


penetrating keratoplasty: Two choroidal detachments can be
seen protruding through the trephination; bleeding starts when
the ora serrata is brusquely separated from pars plana. Donor
cornea is held in place by an assistant while a large-bore
needle is passed transconjunctivally 5 to 6 mm behind the
limbus, obtaining enough choroidal drainage to stop expulsion
of intraocular contents, which in turn permits closure

pressure rises again the first needle is put back in place


and the second removed. This can be made as many
times as necessary until the donor cornea is locked in
place and a better conjunctival and scleral dissection can
be made to leave sclerostomies open. Another
sclerostomy should be made in the remaining quadrant
and even on the same quadrant of the valve if deemed
necessary.
At the end of the procedure the tube should be left
under the conjunctiva. If left draining in place the IOP

Aqueous leakage is rare during the early postoperative


period by using our technique. It may appear whenever
the limbus is deformed by another incision or scleral
patch that avoids an adequate apposition between
Tenons capsule and sclera.
It is not uncommon to encounter a flat or shallow
anterior chamber that may spontaneously resolve
without surgical intervention. Conventional medical
management includes the use of mydriatics and
cycloplegics that help deepen the AC, and avoiding the
use of systemic hypotensive drugs, including the
temporary discontinuation of contralateral timolol
maleate and brimonidine, which have greater systemic
absorption. Unless development of corneal decompensation, imminent cataract or choroidal detachment with
choroidal kiss is present, medical therapy is adequate.
If any of these complications are present reformation
of the anterior chamber can be made with the use of
viscoelastic through a patent paracentesis or with a 27 G
needle. Again, if this maneuver is difficult and the anterior
chamber refuses to reform by expelling the viscous
substance through the tube and/or paracentesis a
malignant glaucoma should be suspected and a vitreous
tap may be performed by using a modified Chandlers
maneuver. When this is not enough pars plana vitrectomy
with removal of the hyaloid face and even cataract
extraction, combined with posterior capsulorhexis and
anterior vitrectomy, may be necessary occasionally, in

74

Atlas of Glaucoma Surgery

order to communicate the posterior and anterior


segments and avoid forward displacement of the iris and
lens. If the patient is already pseudophakic a hyaloid
disruption with the YAG laser is performed, combined
with an eccentric posterior capsulotomy, as far away as
possible from the tubes position to avoid possible vitreous
bolus to occlude it, letting the trapped aqueous pass into
the anterior segment (Fig. 6.25).
Clots and fibrin may be removed by tPA (tissue
plasminogen activator) infusion (0.2 ml of 125 mcg/ml),
if available. They may also be partially removed from
around the tube by lysing them with a YAG laser. A
similar approach can be used when trying to dislodge a
vitreous strand occluding the tube. The laser is directed
about 1 mm around the tip of the tube, cutting the
vitreous in such a manner that small pieces will exit the
eye through the tube. If a lot of vitreous is present or if it
occludes the tube again a better approach is to perform
an anterior vitrectomy.

Fig. 6.25: YAG laser capsulotomy and hyaloidotomy for


malignant glaucoma. Several laser shots are made behind the
intraocular lens (IOL) on the hyaloid face, aiming to
communicate several of the lacunae. Afterwards a capsulotomy
is performed either through a previous iridectomy or near the
border of the IOL, as far away from the tube as possible to
prevent tube occlusion

If the shallow anterior chamber is resolved and the


tube remains in contact with the cornea, lens or iris, the
conjunctiva should be lifted again, a new tunnel made
and the tube removed from the original site and placed
through the new entry site. On occasion the old tunnel
remains filtering for a while and if this is the case it can
be collapsed by placing a 10-0 nylon suture through its
posterior opening.

Late Postoperative Complications


By far, the most frequent late postoperative complication
is bleb fibrosis and loss of IOP control. Initial treatment
and prevention begins around the second to third week,
when eye massage is initiated to lower IOP and try to
obtain a bigger, more diffuse filtering bleb. This exercise
is explained to the patients so they can do it themselves
at home.
Pressure is directed towards the eyeball in the
inferonasal quadrant, opposite the position of the valve.
The pressure is kept constant for 30 seconds, allowing a
bolus of aqueous to exit the eye into the bleb, lowering
IOP, and taking advantage of the valves one-way
mechanism. It should be repeated 3 to 4 times a day in
the same manner.
Most of the times some pain is referred by the patient,
if they are doing the exercise right, due to distention of
the collagen fibers making up the bleb. The role of this
massage is not very well defined. In some patients it seems
to work perfectly well; in others it seems to increase
fibrosis due to a chronic and repetitive traumatic breakup of the collagen fibers. Signs of a successful massage
are to demonstrate a significant reduction in IOP, an
increase in bleb size and a preservation of both effects
for a significant amount of time.
Concomitant hypotensive drugs are preferable if the
patient does not tolerate the massage, if the tube touches
the cornea or any other intraocular structure while doing
the massage or if IOP does not diminish well enough or
for long enough. Low-dose colchicine use may be helpful
in some patients, as proposed by Molteno.
Fibrosis dissection can be performed using topical plus
sub-Tenons anesthesia or with a peribulbar or retrobulbar
block. A radial conjunctival incision is made parallel to the

The Ahmed Valve

75

valves body, starting on its most anterior aspect; Westcotts


scissors are used to make a blunt dissection separating
conjunctiva from subjacent Tenons and fibrosis in a
posterior direction over the valves body (Fig. 6.26). Any
bleeding vessels may be cauterized as needed. Next a
stab incision is made into the fibrotic bleb, briskly obtaining
aqueous. Westcotts scissors are placed in such a way that
one of the blades is placed inside the fibrous bleb and the
other over it, under the conjunctiva (Fig. 6.27). A piece
of the fibrotic tissue is removed; the size of this fragment
should be close to the total size of the valves body. Closure
of conjunctiva is made with 7-0 vicryl with a running
horizontal mattress suture to make it water-tight and
periocular steroids injected. Postoperative care is similar
to the primary procedure.

Fig. 6.27: Removal of fibrous tissue. A slit incision is made with


a sharp blade, obtaining abundant aqueous. The capsule is
cut with one of the scissors arms inside the bleb and the other
under the conjunctiva, removing as much tissue over the valve
as possible, leaving a window over the valve. Conjunctiva and
Tenons are closed with a running mattress suture

Fig. 6.26: Removal of fibrous tissue. First blunt dissection is


performed undermining under the conjunctiva. A fibrous
capsule is seen covering the valve, distended by aqueous if
the tube is not occluded. At this moment antiscarring agents
may be applied

Alternatively, conjunctival dissection may be performed


as for the primary implantation. This approach is especially
useful whenever tube manipulation is necessary or the
fornices are shallow due to multiple previous surgeries,
excessive fibrosis and/or symblepharon. The conjunctiva
is again lifted, fornix-based, in the 90 where the valve is
located. If the tube needs repositioning it is best to first do

the new tunnel, carefully dissecting out the tube from the
old tunnel aided by a sharp needle and place the tube
through the new tunnel before opening the capsule, so
the eye does not get too hypotonous. Care must be taken
not to accidentally cut the tube if dissecting with excessive
bleeding and poor visualization. After the tube is back in
place capsule dissection is performed as described
previously and conjunctival closure as for the primary
procedure.
Tube related late complications can be managed in
several ways. Tube retraction may need repositioning of
the tube through a new and more posterior tunnel, but
occasionally may need repositioning the valves body
more anteriorly. A more conservative but not always
available approach is to use New World Medicals tube
extender, avoiding making another tunnel, unless the
tube has been exposed.12
Tube exposure is a rare complication with the present
episcleral tunnel technique. Exposure can lead to
infection and even to endophthalmitis. Primary suturing
of the conjunctiva may work, but occasionally scleral,

76

Atlas of Glaucoma Surgery

corneal, pericardium, dermic or amniotic membrane


patches will need to be used to help provide stroma for
integration of the conjunctiva over the tube. Prompt
primary covering of the defect rarely works in the long
term. One of the most effective methods to solve this
problem is to lift again the conjunctiva and create a new
tunnel for the tube. If there is an infection this may not
be an option and the valve may need to be removed
and a new one placed in another quadrant.

CONCLUSIONS
The Ahmed valve has been the mainstay for immediate
control of IOP in difficult and complicated glaucoma
cases. Its properties have made it a reliable means of
managing simultaneously many tribulations in
problematic eyes. Regardless of its benefits, its use is not
always trouble-free or remedial. Many complications
during both the early and late postoperative periods can
be sight-threatening, and difficult to manage, not least
of all loss of long-term IOP control.
New materials, coatings, surgical techniques, antiscarring agents and drugs may improve the clinical
management of the postoperative period in eyes that
need an Ahmed valve. The role of eye massage to
increase the size of the filtering bleb has to be studied
further in order to determine if it is beneficial or
detrimental in the long run. Possible future risk factor
analysis and genetic tests may be able to predict which
patients, or at least which indications, will do better with

each available model. The future looks promising, but a


great deal of research has still to be done regarding the
management and evaluation of difficult glaucoma cases.

REFERENCES
1. Britt MT, LaBree LD, Lloyd MA, et al. Randomized clinical trial of
the 350 mm2 versus the 500 mm2 Baerveldt implant: longer term
results: is bigger better? Ophthalmology 1999; 106: 2312-8.
2. Gil-Carrasco F, Salinas-VanOrman E, Recillas-Gispert C, Paczka JA,
Gilbert ME, Arellanes-Garcia L. Ahmed valve implant for uncontrolled
uveitic glaucoma. Ocul Immunol Inflamm 1998;6:27-37.
3. Ayyala RS, Layden WE, Slonim CB, Margo CE. Anatomic and
histopathologic findings following a failed Ahmed glaucoma valve
device. Ophthalmic Surg Lasers 2001; 32: 248-9.
4. Parks MM. Causes of the adhesive syndrome. In Symposium on
Strabismus. St. Louis, CV Mosby, 1978.
5. Susanna R Jr. Latin American Glaucoma Society Investigators.
Partial Tenons capsule resection with adjunctive mitomycin C in
Ahmed glaucoma valve implant. Br J Ophthalmol 2003; 87:994-8.
6. Hill RA, Pirouzian A, Liaw L. Pathophysiology of and prophylaxis
against late Ahmed glaucoma valve occlusion. Am J Ophthalmol
2000; 129: 608-12.
7. Coleman AL, Mondino BJ, Wilson MR, et al. Clinical experience
with the Ahmed glaucoma valve implant in eyes with prior or
concurrent penetrating keratoplasties. Am J Ophthalmol
1997;123:54-61.
8. Al-Torbak A. Graft sur vival and glaucoma outcome after
simultaneous penetrating keratoplasty and ahmed glaucoma valve
implant. Cornea. 2003;22:194-7
9. Gil-Carrasco F, Paczka JA, Jimnez Romn J, et al. Experiencia
clnica inicial con la vlvula de Ahmed: reporte de 278 casos con
glaucoma incontrolable. St. Ophthal 1997;16:117-22
10. Malbran ES, Malbran E, Buonsanti J, Adrogue E. Closed-system
phacoemulsification and posterior chamber implant combined with
penetrating keratoplasty. Ophthalmic Surg 1993; 24(6):403-6.
11. Wilson MR, Mendis U, Paliwal A, Haynatzka V. Long-term follow-up
of primary glaucoma surgery with Ahmed glaucoma valve implant
versus trabeculectomy. Am J Ophthalmol 2003;136:464-70.
12. Rebolleda G, Munoz-Negrete FJ. Extender-tube for Ahmed glaucoma
valve implant. Arch Soc Esp Oftalmol. 2003;78:513-6.

Anthony CB Molteno, Tui H Bevin

The Use of Molteno Implants to

7 Treat Complex Cases of Glaucoma

INTRODUCTION

HISTORICAL BACKGROUND

The discovery of synthetic polymers that are inert and


compatible with the tissues has made it possible to
engineer a variety of drainage devices that can be used
to advantage in the treatment of more severe and
complex cases of glaucoma. The device developed by
the senior author, the Molteno implant (Molteno
Ophthalmic Ltd., Dunedin, New Zealand), consists of a
fine bore silicone tube opening onto the upper surface
of one or two episcleral plate(s) (Figs 7.1A to C). The
function of the silicone tube is to deliver aqueous from
within the eye onto the surface of the episcleral plate.
This plate is firmly sutured to the sclera and covered by
a thick flap of Tenons tissue and conjunctiva. The
function of the plate is to initiate and maintain a large
circular unilocular bleb. The bleb develops a specialized
fibrovascular lining, the bleb capsule, which becomes
distended by aqueous. It is this fibrovascular bleb capsule
that is responsible for regulating the escape of aqueous
from the eye and determines the final level of intraocular
pressure (IOP) that is achieved after insertion of the
draining implant (Figs 7.2 to 7.4).1
While the surgical trainee may be most concerned
with the indications for operation and technical details
of the surgical procedure for insertion of the drainage
device, the surgery itself is only one factor determining
the long-term success or failure of the operation. Equally
important is an understanding of Tenons tissues
response to aqueous and the episcleral plate of the
implant and how to use these responses to prevent
postoperative hypotony and obtain a thin permeable
bleb capsule that provides good long-term control of
IOP.1

Process of Bleb Formation (Immediate


Drainage of Aqueous)
When Molteno implants were first used they were
inserted at a single operation with immediate drainage
of aqueous into the tissues overlying the plates of the
implant.2 These cases showed a remarkably consistent
postoperative pattern of an early short period of low
IOP followed by temporary elevation of IOP before longterm stabilization of IOP (Fig. 7.5). It was also noted that
the permeability of the bleb capsule formed around a
draining implant depended mainly on the age of the
patient and, to a lesser degree, on the severity of the
glaucoma. Infants, even those with severe buphthalmos,
aged <18 months and elderly and frail patients, formed
thin walled blebs which drained well. However, in older
children and fit adults, insertion of an implant resulted
in a striking sequence of changes in the surrounding
tissues, which in some cases resulted in the formation of
a heavily fibrosed bleb capsule and inadequate lowering
of IOP.
The changes that accompany formation of a bleb
around an implant were most prominent when a single
plate implant was used to drain severe and advanced
glaucoma in a young adult. These stages were named
according to the behavior of the IOP at the time.
1. Hypotensive stage: This first stage lasted for 7 to
10 days after operation and was characterized by a
low IOP with diffuse edema and congestion of blood
vessels in the tissues covering the episcleral plate of
the implant (Fig. 7.6).
2. Hypertensive stage: During the first 3 to 4 weeks of
the hypertensive stage the blood vessels covering

78

Atlas of Glaucoma Surgery

Fig. 7.1A: Pressure ridge single


plate Molteno implant

Fig. 7.1C: Pressure ridge double plate


Molteno implantleft eye

Fig. 7.1B: Pressure ridge double plate Molteno implant


right eye

the bleb wall remained dilated and the IOP rose


steadily to a peak of 30 to 50 mm Hg, 4 to 5 weeks
after operation (in untreated cases). During this time
the edema disappeared, a definite layer of fibrous
tissue appeared in the deepest layers of the bleb
capsule and the bleb became distended with
aqueous. However, once the congestion of the bleb
blood vessels resolved, the IOP started to fall, rapidly

Fig. 7.2: Section of eye 8 years after insertion of Molteno implant


showing fibrovascular capsule (implant has been removed
before processing) (Massons trichrome stain)

The Use of Molteno Implants to Treat Complex Cases of Glaucoma

79

Fig. 7.3: Diagram showing translimbal tube draining


aqueous from the AC to the upper surface of episcleral plate

Fig. 7.6: Eight days after insertion of a Molteno implant when


the IOP was 10 mm Hg showing diffuse edema and congestion
of blood vessels in the tissues covering the episcleral plate

Fig. 7.4: A case of aphakic glaucoma with two failed


trabeculectomies at 10 oclock and 2 oclock showing position
of tube in AC

Fig. 7.7: Four weeks after insertion of a Molteno implant when


the IOP was 34 mm Hg showing congested blood vessels and
deposition of fibrous tissue in the bleb capsule

Fig. 7.5: IOP after drainage by Molteno implant in a 47-yearold male with advanced traumatic glaucoma in a quiet eye.
Note hypotensive stage, hypertensive stage, and late stable
stage

at first and then more gradually to reach a stable


plateau 3 to 6 months after operation (Fig. 7.7).
3. Stable stage: Once the bleb vasculature had
assumed its normal caliber and the IOP stabilized,

the eye was in the stable stage. This was


characterized by a well-circumscribed bleb with a
moderately vascular fibrous bleb capsule with a
capillary circulation apparently identical to that
elsewhere in the conjunctiva. After several months,
fluid filled channels appeared in the margin of the
bleb and increased in number and prominence with
time. Apart from the development of these
channels, and in some cases a definite stretch and
extension of bleb beyond the edges of the episcleral
plate, the stable stage bleb remained unchanged
for the remainder of the patients life (Fig. 7.8).
Observation has shown that the thickness of the stable
stage bleb capsule was controlled by the intensity and

80

Atlas of Glaucoma Surgery

Fig. 7.8: Twelve weeks after insertion of a Molteno implant


when the IOP was 20 mm Hg showing distended bleb and
normal caliber blood vessels resembling those elsewhere in
the conjunctiva

Fig. 7.9: Thick fibrovascular capsule 3.5 years after direct


insertion of a Molteno implant with immediate drainage of
aqueous (hematoxylin and eosin stain, x100)

duration of bleb inflammation during the hypertensive


stage. The obvious corollary to this was that if bleb
inflammation could be controlled through the temporary
administration of appropriate medication, then the stable
stage bleb capsule would be thin and being exposed to
the degenerative action of aqueous give life-long control
of IOP (Figs 7.9 and 7.10).

Control of Bleb Fibrosis by Anti-inflammatory Agents


Initial trials of anti-inflammatory agents demonstrated
that their effects could be detected by the fall in IOP that
they caused, when given during the hypertensive stage
of bleb inflammation. It was therefore a relatively simple
matter to identify active drugs and test combinations of
drugs for synergistic action. Significant anti-inflammatory
effect was demonstrated by orally administered
glucocorticoids, some non-steroidal anti-inflammatory
agents and colchicine. Topically administered adrenaline
and atropine were also shown to cause lowering of IOP
at this time. When given singly, none of these agents
produced a marked effect. However, when given in
combination, these agents reduced postoperative bleb
inflammation with its accompanying elevation of IOP
and produced a thin-walled stable stage bleb, which gave
excellent long-term control of IOP.

Fig. 7.10: Thin permeable fibrovascular capsule 6 years after


direct insertion of a Molteno implant with immediate drainage
of aqueous combined with the administration of prednisone,
diclofenac and colchicine for 6 weeks after operation
(hematoxylin and eosin stain, x100)

The most effective combination of drugs identified


so far is oral prednisone 10 mg tds, diclofenac 50 mg tds
and colchicine 0.3 mg tds together with topical adrenaline
1% or 2% and topical atropine 1% all given 3 times a
day for 5 to 6 weeks after operation (dosage as for a 70
kg healthy adult).3-5
When given from the time of operation to the end of
the hypertensive stage this regime produces a thin-walled
stable stage bleb with good long-term control of IOP
(Fig. 7.11). However, the development of surgical
techniques for delayed drainage of aqueous has greatly
reduced the need for this regime.

The Use of Molteno Implants to Treat Complex Cases of Glaucoma

Fig. 7.11: Diagramatic IOP graphs to illustrate effects of antiinflammatory drugs on IOP and final thickness and permeability
of final bleb capsule after insertion of Molteno implants with
immediate drainage of aqueous

Control of Bleb Fibrosis by Delayed


Drainage of Aqueous
At the present time the main method used to control
bleb fibrosis is the two-stage operation. Originally this
involved two separate operations.6 In the first stage
operation, the plate of the implant was sutured to the
sclera and the free end of the connecting tube tucked
under the rectus muscle, instead of being inserted into
the anterior chamber (AC). Six to eight weeks later, when
the plate of the implant had become enclosed in a thin
envelope of dense connective tissue (Fig. 7.12) the free
end of the connecting tube was withdrawn from beneath
the muscle and inserted into the AC under cover of a
watertight scleral flap.
This technique allowed the area of drainage to be
increased by linking plate(s) together and the best
compromise between avoidance of postoperative
hypotony and good long-term drainage was found to
be a double plate implant having an area of 265 mm2.
Despite this increase in area, it was found that a
hypertensive stage of bleb inflammation and deposition
of further fibrous tissue still occurred after the second
stage operation.
The two separate operation technique has now been
replaced by the vicryl tie technique.7, 8 In this operation
the plate of the implant is sutured to sclera and covered

81

Fig. 7.12: Thin envelope of dense connective tissue 60 m


thick formed around the episcleral plate of a Molteno implant
in the absence of aqueous (hematoxylin and eosin stain,
x 100). Note this layer takes 3 weeks to form and remains
unchanged thereafter

by the overlying Tenons tissue at the same time as the


tube is inserted into the AC, after being occluded by a
5.0 vicryl suture tied firmly around the tube. The tube is
inserted into the AC via a puncture wound that is selfsealing. Thus the IOP remains at its preoperative level
until the connecting tube opens spontaneously 3 to 5
weeks after operation when the vicryl suture dissolves
allowing aqueous to flow into a preformed bleb capsule
lined by a thin layer of fibrous tissue 20 to 60 m thick
(Figs 7.13 to 7.17).
The gradual and completely atraumatic opening of
the tube as the vicryl suture dissolves demonstrates what
happens when aqueous from a severely glaucomatous
eye drains into the episcleral tissues through the
preformed bleb capsule. As is the case with immediate
drainage of aqueous the timing and intensity of the
reaction depends on the age of the patient and the
severity of the glaucoma.

Effects of Patients Age and Severity of Glaucoma


In infants (<18 months of age), elderly patients and
patients in whom the glaucoma is not too severe, the
opening of the tube is followed by a period of <3 weeks
of low normal IOP (10 to 15 mm Hg) after which there
is a moderate elevation of IOP to 25 to 30 mm Hg lasting
3 to 4 weeks before the IOP falls to normal levels.
In more severe cases of glaucoma, especially in young
patients, the same sequence of events occurs except that
the IOP rises sooner and the bleb vessels become visibly

82

Atlas of Glaucoma Surgery

Fig. 7.13: Diagram to illustrate vicryl tie technique for delayed


drainage of aqueous showing implant in position with drainage
tube occluded by vicryl
Fig. 7.16: Tissues covering second plate of double plate
Molteno implant before opening of tube 28 days after operation

Fig. 7.14: Diagram to illustrate vicryl tie technique showing


distended bleb after spontaneous opening of tube

Fig. 7.17: Distended bleb of Figure 7.16 1 day later after


spontaneous opening of tube

Fig. 7.15: Operative photograph showing position of vicryl tie

dilated with elevation of IOP to 35 to 40 mm Hg for 3 to


4 weeks before the bleb becomes pale and the IOP falls
to a normal level (with the use of hypotensive medication
in some cases).*
* This hypertensive stage of bleb inflammation and fibrosis, which
occurs when aqueous is drained into a preformed bleb, can be suppressed
by the same combination of systemic prednisone, diclofenac and colchicine
that is used after single stage insertion of implants. However there is less
need for this medication and when it is given the results are correspondingly
better

This milder hypertensive stage of bleb inflammation


and fibrosis, which occurs when aqueous is drained into
the episcleral tissue through a preformed bleb capsule,
can be suppressed by the same combination of systemic
prednisone, diclofenac and colchicine that is used after
single stage insertion of implants. However this regime is
seldom needed with the current surgical technique (Fig.
7.18).

Indirect Control of Bleb Fibrosis by Perioperative


Control of Intraocular Pressure
Bleb capsule fibrosis may also be reduced by adjusting
the dosage of hypotensive medication to maintain the
IOP at normal levels from the time of operation until 6
to 8 weeks after the onset of drainage. This technique

The Use of Molteno Implants to Treat Complex Cases of Glaucoma

Fig. 7.18: Diagramatic IOP graphs to illustrate effect of antiinflammatory drugs in reducing the hypertensive stage
inflammation and increasing the permeability of the fibrous
bleb capsule after insertion of Molteno implants with delayed
drainage of aqueous (vicryl tie technique)

83

Fig. 7.19: Diagramatic IOP graphs to illustrate the effect of


postoperative hypotensive medication in reducing the intensity
of the hypertensive stage of bleb inflammation and lowering
the stable stage IOP (increasing the permeability of the
fibrovascular bleb capsule)

has largely replaced the use of anti-inflammatory agents


for reducing the thickness and increasing the permeability
of the fibrous bleb capsule (Figs 7.19 and 7.20).

CURRENT SURGICAL TECHNIQUE


Indications
Molteno implants are considered in cases where simple
drainage operations such as trabeculectomy are unlikely
to give safe long-term control of IOP. Current indications
for using implants include:
1. Infantile and juvenile glaucoma.9, 10
2. Aphakic or pseudophakic glaucoma.11
3. Traumatic glaucoma.12
4. Uveitic glaucoma.13
5. Glaucoma secondary to previous intraocular
surgery.7
6. Primary glaucoma with additional ocular or general
risk factors, e.g. cataract and glaucoma.14
7. Neovascular glaucoma.15,16

Selection of Implant Area


The area of plate (133 mm2 in the case of single plate
and 265 mm2 in the case of double plate implants)
necessary for control of IOP depends on the patients
age and general state and the severity of the glaucoma,

Fig. 7.20: Thin permeable fibrovascular bleb capsule 12 years


after insertion of Molteno implant with delayed drainage of
aqueous and perioperative control of IOP (hematoxylin and
eosin stain, x100)

both of which are modified by the past history of the


eye.

Age
Infants less than 18 months old, irrespective of the
severity of the glaucoma, produce thin bleb capsules
and thus require only single plate implants. Older children
and adults produce thicker and less permeable bleb
capsules even in less severe cases of glaucoma and usually
require double plate implants. Old (>70 years) and frail

84

Atlas of Glaucoma Surgery

individuals, particularly those who have been on longterm systemic steroids, produce less fibrous bleb capsules
so that single plate implants provide adequate drainage
in the less severe cases.

Severity of Glaucoma
Mild cases in which the IOP can be reduced to normal
levels with hypotensive medication require single plate
implants while eyes with a preoperative IOP >25 mm
Hg on two or more hypotensive agents require double
plate implants even in older patients.

Past History of the Eye


Cases in which previous drainage operations have failed
or which have undergone several intraocular procedures
tend to produce more heavily fibrosed bleb capsules
and usually require double plate implants at all ages.
However this is not always the case since eyes with very
advanced glaucoma and poor vision that have undergone
several previous operations may have reduced aqueous
secretion from the ciliary body and become phthisical if
drained by double plate implants! Therefore in cases
where several previous operations have been carried
out it is generally wiser to insert a single plate implant
and if necessary add a second plate at a later date (See
below).

Preoperative Management
Preoperative management involves reviewing and if
necessary increasing the patients hypotensive medication
to reduce the IOP to as near the normal range as possible.
If the IOP can be kept low even for a short time, this will
reduce the final thickness and increase the long-term
permeability of the fibrovascular bleb lining (with
correspondingly better control of IOP).

Choice of Surgical Technique


The advantages of techniques which delay drainage of
aqueous into a preformed bleb are such that this
approach is always used in quiet or reasonably quiet
eyes. However, cases of neovascular glaucoma and
actively inflamed eyes which require urgent reduction
of IOP require insertion of implants with immediate
drainage of aqueous. This results in a marked

hypertensive stage of bleb congestion and fibrosis which


is minimized by photocoagulation of the underlying
retinal disease in the case of neovascular glaucoma and/
or the administration of prednisone, diclofenac and
colchicine.

Surgical Technique for Delayed


Drainage of Aqueous
While the details of operative technique must take
account of the circumstances of each case, the basic steps
by which an implant is inserted can be applied in all
cases.
1. Exposure: In most cases the implants are placed
on either the superior nasal or temporal quadrants.
It is important to raise a sufficiently large fornix based
flap so that the plate(s) of the implant are covered
by a thick layer of Tenons tissue and conjunctiva
which extends well beyond the limits of the plate.
Therefore, when raising a flap to place a single plate
implant in the superotemporal quadrant, the incision
around the limbus should extend from beneath the
lateral rectus muscle insertion to a point medial to
the superior rectus muscle insertion. Similarly, when
placing a double plate implant, the usual incision
should extend from beneath the lateral rectus
insertion around the superior limbus to beneath the
medial rectus insertion. While this dissection may
be straightforward in eyes that have not had many
previous operations, it can be delicate and time
consuming and it is sometimes necessary to take
the incision around previous failed drainage
operation sites, to avoid raising the scarred
conjunctiva and prematurely releasing aqueous
(Fig. 7.21).
2. Raising a lamellar scleral flap: A limbus based lamellar
scleral flap is used where the sclera is of adequate
thickness. The advantages of raising a lamellar scleral
flap in cases where the drainage angle remains open
and relatively intact is that it shows the landmarks
for watertight insertion of the tube into the AC. A
half thickness lamellar scleral flap extending into clear
cornea will show opaque white sclera then a subtly

The Use of Molteno Implants to Treat Complex Cases of Glaucoma

Fig. 7.21: Extended incision for double plate Molteno


implantleft eye

translucent area which marks the position of


Schlemms canal followed by an opaque white line
indicating the edge of Descemets membrane. This
facilitates accurate placement of the tube at the
correct angle and position in the AC and also covers
the tube and protects it in its course from the
episcleral plate to the limbal tissue. Where the scleral
tissues are so scarred or ectatic that a lamellar scleral
flap cannot be raised a piece of donor sclera is placed
over the tube in this part of its course (Fig. 7.22).

Fig. 7.22: Raising the half thickness flap and dissecting


1 mm into clear cornea

3. Placement of the implant: The episcleral plates of


the implant are designed to fit between the adjacent
rectus muscles. The suture holes are placed so that a
7.0 silk suture may be passed through the tough
sclera at the muscle insertion, up through the suture
hole and then back through the muscle insertion with
the knot tied just anterior to the insertion. This holds

85

the plate in the correct position snugly up against the


muscle insertions. The first plate which supports the
outer end of the translimbal tube requires two sutures
but a single suture is adequate for the second plate
of a double plate implant provided that the plate is
placed so that the connecting tube is not kinked. Once
the plates of the implant are fixed in position on the
sclera any blood clot in the connecting tube or on
the surface of the plates is washed away and the
second plates position checked to ensure there is no
chance of it moving and kinking the connecting tube
(Figs 7.23 to 7.27).
4. Occlusion of translimbal tube: The drainage tube is
occluded by a 5.0 vicryl suture tied around the tube
at its attachment to the episceral plate. This suture
is tied with two half hitches that form a slipknot and
allow the ligature to be pulled up tight. A 2 cc syringe
is then used to inject saline down the tube using a
Rycroft cannula. If this shows that the tube is
occluded a second throw is added to lock the knot
and the patency of the tube tested once more. If
completely occluded the suture is cut leaving the
ends 3 to 4 mm long to prevent the knot untying
itself (Fig. 7.28).
5. Trimming the end of the tube: In order to trim the
tube to the correct length, the lamellar scleral flap
should be replaced and the tube laid over it to
overlap the cornea. The end of the tube should
then be trimmed at an angle of 40 to 45o with the
bevel facing forward. This cut should be made with
a pair of spring scissors at a point 2 mm from the
limbus taking great care not to stretch the tube. If
the tube is cut off 2 mm beyond the point where it
crosses the limbus on the outside of the eye it will
extend into the AC to the correct distance of 3 mm
after insertion beneath the scleral flap.
Surgical technique for combined operation: When
insertion of an implant with delayed drainage of
aqueous is combined with cataract extraction or a
penetrating corneal graft, the operation for the
insertion of the implant should be carried out to
the stage where the tube is ready for insertion into
the AC before completing the intraocular part of

86

Atlas of Glaucoma Surgery

Fig. 7.23: Passing the second plate of a double plate Molteno


implant between the superior rectus muscle and the superior
oblique muscle tendonleft eye

Fig. 7.24: Pulling the second plate of a double plate Molteno


implant anteriorly to free it from under the superior oblique
tendon

Fig. 7.26: Suturing the episcleral plate of the Molteno implant

Fig. 7.27: Pressure ridge double plate Molteno implantleft


eye-sutured in position on the sclera with the episcleral plates
correctly placed with their anterior edges in line with the
insertions of the rectus muscles

Fig. 7.28: Making a relieving slit in one wall of the


translimbal tube

Fig. 7.25: Positioning the Molteno implant when the tube is


passed over the superior rectus muscle

the procedure and only then inserting the tube into


the AC.

6. Insertion of tube into the anterior chamber: The


AC must have sufficient depth to allow placement
of the tube without compromising the corneal
endothelium (If it does not, the tube should be
placed into the posterior chamber). The entry track

The Use of Molteno Implants to Treat Complex Cases of Glaucoma


into the AC is made by a 22-gauge needle which
has the distal 2/3rd of its bevel bent forwards at
30o. This produces a microkeratome with a hollow
blade. The act of bending flattens the needle slightly
so that its diameter is greater than the tube. The
surgeon holds the microkeratome blade parallel to
the plane of the iris and inserts it into opaque sclera
1 to 1.5 mm posterior to the translucent zone that
marks the position of Schlemms canal. The needle
point is advanced until aqueous appears on its
hollow surface and is then withdrawn. A Rycroft
cannula is slipped through the incision to check that
it is correctly placed in the AC and then the beveled
free end of the occluded tube is inserted down the
track. It should enter easily at first and show slight
resistance as it is pushed into the AC (If difficulties
are encountered the needle point can be reinserted
and pushed in a little further to enlarge the tapered
track). The tube is then advanced into the AC and
moved slightly to check that the transparent free
end is appropriately positioned. If the tube is too
far anterior it can be withdrawn and a slightly more
posterior incision made immediately behind the first
incision. Inserting the tube through this more
posterior incision closes the anterior track (Figs 7.29
to 7.32).
7. Insertion of the tube into the posterior chamber:
Where the AC is too shallow or non-existent the
tube should be placed in the posterior chamber. In
cases where the tube is inserted into the posterior
chamber via the pars plana it is unnecessary to raise
a lamellar scleral flap and the tube is inserted through
full thickness sclera. However, a tight needle track
entry cannot be used because if it is, there is a danger
that the very soft tube will be inserted into the
superchoroidal space where it will curl up without
achieving drainage! The tube is trimmed so its
beveled end will extend to a point near the visual
axis where it is accessible to slit lamp examination
and laser disruption of any vitreous that may occlude
it. The first plate of the implant to which the tube is
attached should be sutured in the chosen position
on the sclera with 7.0 silk mattress sutures that are

87

Fig. 7.29: The track of the 22-gauge needle tip through the
tissues into the anterior chamber

Fig. 7.30: Inserting the tube into the needle track

Fig. 7.31: Feeding the tube down the needle track into the AC

left untied. After choosing the point of entry through


the pars plana the drainage tube is occluded with
5.0 vicryl and tested in the usual manner. A 30o
micropoint blade is used to make a 3 mm long
incision through the sclera and ciliary body tangential
to the limbus. All vitreous from the anterior part of

88

Atlas of Glaucoma Surgery

Fig. 7.32: Tube correctly placed in the AC

the vitreous cavity is removed by a vitrector with


sleeve and two 7.0 silk sutures are placed in the
scleral incision before inserting the tube. These
sutures are then tied tightly to form a watertight
seal around the tube and the tube advanced until
the vicryl tie lies up against the outer sclera. The
angle of the tube is then adjusted by tying the
preplaced mattress sutures holding the plate in
position. Tying these tightly slides the plate forward
and increases the angle of the tube and vice versa.
8. Sherwood slit: The Sherwood or venting slit is used
in cases where the preoperative IOP cannot be
reduced to near normal levels by intensive
hypotensive medication. A linear slit in the tube next
to the vicryl tie allows aqueous to escape beneath
the lamellar scleral flap for several weeks until scar
tissue around the tube stops aqueous drainage
through the slit. By this time the vicryl will have
broken down and drainage into the preformed bleb
established. The Sherwood slit is made by passing a
30o micropoint blade into the side of the tube
parallel to the surface of the sclera after the tube is
placed in the AC. The blade is advanced to make a
linear slit that should be as long as the tube is wide.
This short slit allows aqueous to escape from the
tube when the IOP reaches 20 to 25 mm Hg (Figs
7.28 to 7.33).
9. Closure: It is important to ensure that Tenons tissue
has not been caught behind the posterior edges of
the plate and that it lies freely over the limbus of
the eye. Once satisfied that the tissues are easily
opposed the lamellar scleral flap is loosely sutured

Fig. 7.33: Cross-section of the episcleral plate with tube


showing the slit in one side wall of the translimbal tube

in position using the tension of these sutures if


necessary to adjust the angle of the tube. If used a
piece of glycerin preserved donor sclera may be
placed either beneath or above the lamellar scleral
flap. Where donor sclera is used it is very important
to ensure at least 1 mm of bare host sclera covered
by Tenons tissue separates the donor sclera from
the edge of the corneal epithelium (Fig. 7.34) and
that the donor sclera should not extend to make
contact with the anterior edge of the episcleral plate.
If the donor sclera should overlap the corneal
epithelium this layer may grow between host tissues
and donor sclera and prevent it being incorporated
into the tissues (Figs 7.34, 7.35A and B, and 7.36).

Tenons Access to Vicryl Tie


It is important to make sure that the vicryl suture placed
around the tube is in contact with vascular Tenons
connective tissue. If the scleral flap covers the vicryl suture
and separates it from Tenons tissue there will be
considerable delay before the vicryl breaks down. If the
flap covers the tie it is not necessary to shift the plate. All
that has to be done is to cut a small V-shaped piece out
of the posterior edge of the lamellar flap to expose the
tie to vascular Tenons tissue.**

Surgical Technique for Immediate


Drainage of Aqueous
The surgical technique for immediate drainage of
aqueous includes the step of stretching Tenons tissue
**The vicryl tie can be released at any stage by using argon laser suturelysis. Suturelysis results in immediate distention of the bleb with a reduction
of IOP to 1 to 2 mm Hg followed by an elevation of IOP to 10 mm Hg over
the next 3 to 4 hours

The Use of Molteno Implants to Treat Complex Cases of Glaucoma

89

and prevents hypotony in the early postoperative period


(Figs 7.37 to 7. 43).

Fig. 7.34: The tube buried under the lamellar scleral flap and
covered by a patch of donor sclera

Fig. 7.37: Lifting Tenons tissue and conjunctiva to expose


the undersurface of Tenons tissue

B
Fig. 7.35: Sectional diagrams to show: (A) a fold of Tenons
tissue caught behind the episcleral plate, and (B) Tenons tissue
freed

Fig. 7.38: Suturing Tenons tissue in front of the plate

Fig. 7.39: Tenons tissue sutured in front of the plate


Fig. 7.36: The conjunctiva sutured over the limbus

over the pressure ridge of the episcleral plate of the


implant and suturing it into position before inserting the
tube into the AC. This step limits the escape of aqueous

Surgical Technique for Neovascular Glaucoma


The first three steps are identical to those described above.
However, the drainage tube is not occluded instead
Tenons capsule is tightly sutured over the pressure ridge

90

Atlas of Glaucoma Surgery

Fig. 7.40: The tube trimmed at 45o so that its point overlaps
the limbus by 2.5 to 3 mm

Fig. 7.41: Stretched and edmatous Tenons tissue preventing


the escape of aqueous into the main bleb cavity for the first 7 to
10 days after operation

Fig. 7.42: Tenons tissue starting to lift off the pressure ridge
10 to 14 days after operation

of the implant to form a pressure sensitive biological


valve. After insertion of the tube of the implant into the
AC, aqueous drains through the tube into the small
chamber formed by the pressure ridge. This limits the
escape of aqueous from the eye and prevents
postoperative hypotony. When the IOP reaches 10 to
15 mm Hg the stretched Tenons tissue lifts off the
pressure ridge to allow a small amount of aqueous to
escape into the main bleb cavity. This reduces the IOP
slightly, and the tissue valve closes until the IOP rises
again and more aqueous escapes. This process continues
for 7 to 14 days until sufficient aqueous accumulates in
the main bleb cavity to distend it and lift the tissues off
the pressure ridge. At this point the tissue valve offers no
further resistance to the passage of aqueous and the
prevailing level of IOP is determined by the drainage
area and permeability of the fibrous bleb lining.
Cases presenting with neovascular glaucoma can be
divided into those with potentially useful vision (visual
acuity >3/60) in whom the aim is to control the IOP in
the normal range, and those with minimal vision in
whom the main aim of treatment is to maintain a white
pain free eye without necessarily normalizing the IOP.
Double plate implants are indicated in cases of
neovascular glaucoma with some visual potential and
markedly elevated IOP. In these cases the connecting
tube between the first and second plates should be
occluded at the time of operation with a 5.0 vicryl ligature.
This provides temporary drainage through the bleb that
forms around the first plate until the vicryl tie breaks
down allowing aqueous to drain into the second bleb. If
the underlying ocular and general state of the patient
can be improved in the interval between insertion of the
implant and opening of the vicryl tie, the preformed
bleb lining of the second plate receives relatively healthy
aqueous and forms a thin permeable fibrovascular lining
which gives good control of IOP without the need for
supplementary hypotensive medication in most cases.

Postoperative Management in Eyes Drained


by Delayed Drainage of Aqueous (Vicryl Tie
Technique)
Fig. 7.43: The fibrous bleb lining distended by aqueous and
the biological valve no longer active

Postoperative management consists of adding a topical


antibiotic (and in some cases a steroid) to the preoperative

The Use of Molteno Implants to Treat Complex Cases of Glaucoma


hypotensive medication which is continued for 4 to 5
weeks until absorption of the suture leads to spontaneous
opening of the tube. The onset of drainage usually
produces no symptoms and is noted at routine weekly
follow-up. Examination shows low IOP and distension
of the blebs. Hypotensive medication is reduced to raise
the IOP to >15 mm Hg. The IOP remains low for 1 to 3
weeks before the distended bleb shows signs of vascular
congestion and in the absence of treatment the IOP rises
over 3 to 4 weeks to 25 to 35 mm Hg before the vascular
congestion ceases and the IOP falls back towards normal
levels. The intensity of inflammation and the amount of
connective tissue laid down during this hypertensive
stage of bleb formation are reduced by appropriate
use of hypotensive medication over this period.
Appropriate medication includes topical beta blockers,
and topical or systemic carbonic anhydrase inhibitors.
Miotics, prostaglandin analogues and adrenergic agents
that may be proinflammatory should not be used during
this period.

Indirect Control of Bleb Fibrosis by


Hypotensive Agents
At the first signs of bleb inflammation or if the IOP rises
to >20 mm Hg timolol or an equivalent beta blocker is
prescribed. If necessary a carbonic anhydrase inhibitor
is added and the dosage adjusted to keep the IOP from
rising to >30 mm Hg. Once the vascular congestion of
the hypertensive stage has passed (6 to 7 weeks after
the onset of drainage) the IOP falls back to normal. Very
occasionally it does not do so in patients who are steroid
responders. In these cases topical steroids should be
discontinued and the IOP will fall to normal within 1 to
2 weeks.

Direct Control of Bleb Fibrosis by


Systemic Anti-inflammatory Agents
Occasionally, in the most severe cases, e.g. where active
inflammation is present in the eye, it may be
advantageous to administer a combination of systemic
prednisone, a non-steroidal anti-inflammatory agent and
colchicine as an additional measure to suppress bleb
inflammation for 6 weeks after the beginning of drainage
of aqueous.3-5 NB When using implants this regime should

91

not be given before the onset of drainage of aqueous as


it will prevent the formation of a preformed bleb lining,
delay the opening of the tube and increase the incidence
of hypotony after the tube opens!

Cytostatic Agents
The perioperative or postoperative use of mitomycin-C
or 5-fluorouracil with implants does not improve control
of IOP. Both agents inhibit wound healing and may cause
exposure of implants due to breakdown of the overlying
tissues, therefore they should not be used.17

Postoperative Management of Cases with


Immediate Drainage of Aqueous (A Vicryl Tie is
Not Used on the Drainage Tube)
The majority of eyes drained using this technique are
cases of neovascular glaucoma or rare cases of active
uveitis with secondary glaucoma whose postoperative
management consists of topical steroids and cycloplegic
agents which are continued for several weeks until the
eye is quiet. In cases of neovascular glaucoma early
photocoagulation of the underlying retinal lesions should
be combined with optimal management of the
underlying general vascular disease in order to minimize
the vasoformative activity of the draining aqueous. Bleb
inflammation and fibrosis may be limited in less severe
cases by prescribing hypotensive agents while more
severe cases with potential for useful vision should receive
oral prednisone, a non-steroidal anti-inflammatory agent
and colchicine during this period.3-5

Long-term Management (All Cases)


It is important that the surgeon should appreciate how
the fibrovascular capsule which regulates the IOP after
the insertion of implants responds to different groups of
hypotensive agents. Timolol, other beta blockers and
topical or systemic carbonic anhydrase inhibitors are
highly effective in reducing IOP, show marked synergism
and have a favorable long-term effect on bleb
permeability. Miotics and prostaglandin analogues are
variable in their action and may be ineffective or even
raise the IOP due to their proinflammatory side effects.
Adrenergic agents are sometimes useful but rebound
vasodilatation makes their action less certain. The need

92

Atlas of Glaucoma Surgery

for hypotensive medication decreases slowly with time.


Severely damaged eyes in which a single topical
medication produces hypotony while the IOP is too high
without medication can be managed by adjusting the
dose of oral acetazolemide to produce the IOP required.

Early Complications
The postoperative complications after insertion of
implants are very similar to those that occur after
conventional drainage surgery and their management is
broadly the same.
1. Hyphema: Hyphemas are common given the type
of case being drained by implant and require no
special treatment.
2. Choroidal detachment: Choroidal detachments are
uncommon and tend to occur in terminally
advanced cases where thin sclera prevents watertight
insertion of the tube into the AC. They are managed
conservatively.
3. Leakage through tube: This should be prevented
by careful surgical technique but when it does occur
the eye is managed conservatively using topical
steroids and cycloplegic agents and relying on the
biological valve formed by the pressure ridge to
prevent hypotony.
4. Hypotony: Despite good surgical technique
hypotony may occur in terminal eyes as a result of
temporary suppression of aqueous secretion by the
ciliary body. These cases are best managed
conservatively. Very occasionally hypotony occurs
when a double plate implant is inserted in a case
where, in retrospect, a single plate implant should
have been used. These cases are initially managed
conservatively, however if the IOP does not rise
sufficiently within 2 to 3 weeks the second plate
should be removed. This is easily done as an
outpatient procedure. Using topical anesthesia the
conjunctiva is incised over the anterior edge of the
second episcleral plate. The plate is then grasped
with a pair of toothed forceps and pulled forwards
out of the bleb cavity. The connecting tube is
stretched and cut as short as possible so that it retracts
into the tissues. After this procedure connective tissue

encloses the cut end of the connecting tube and


the IOP rises to normal levels within 3 to 4 days.

Late Complications
1. Raised intraocular pressure: In cases where a single
plate has not given adequate control of IOP a second
plate can be added without direct intraocular
intervention. A single plate implant is placed in an
adjacent quadrant to the existing bleb. After suturing
the plate in position on the sclera and occluding its
drainage tube by a 5.0 vicryl ligature the tube is
trimmed to a length where it extends to the centre
of the existing first plate. The end of the tube is
beveled with the bevel facing down towards the
surface of the plate to prevent the end of the tube
from being occluded by contact with the inner
surface of the bleb capsule. A 22 gauge needle is
used to form a microkeratome as previously
described and a tapered incision made in the
fibrovascular bleb capsule to allow the tube to be
pushed into the cavity. Following this procedure a
preformed bleb lining forms around the second
plate and additional drainage of aqueous starts
automatically when the vicryl suture dissolves.
2. Thinning of the tissues over the tube: Late thinning
of the conjunctival tissues covering the drainage tube
is managed by raising a flap of conjunctiva and
placing a piece of donor sclera over the tube.
3. Late migration of the tube in the anterior chamber:
The tissues of growing eyes of young infants and
eyes with chronic uveitis are unusually soft and may
allow slow displacement of the tube from its original
position in the AC. The tubes position should be
routinely noted and any slow displacement in a
direction that threatens contact between the free
end of the tube and the cornea should be addressed.
The technique for re-siting the tube consists of raising
a fornix based flap of conjunctiva and Tenons tissue
to give access to the tube between the episcleral
plate and the limbus. A careful longitudinal incision
of the connective tissue sheath around the tube is
made. This allows the tube to be grasped by a fine
pair of forceps and withdrawn from the AC. A

The Use of Molteno Implants to Treat Complex Cases of Glaucoma


mattress suture of 7.0 silk is placed and tied tightly
to occlude the tube track into the AC. After
reforming the AC a suitable lamellar scleral flap is
raised and the tube re-inserted into the AC via an
appropriately placed self-sealing incision. The tube
is then covered with donor sclera and the
conjunctival flap replaced.

93

postoperative course was uneventful and all


hypotensive medication discontinued within 6
months of operation. During the 10 years since
operation the IOP has remained within normal limits
and the visual acuity has recovered to 6/6 (Figs 7.44
to 7.46).

ILLUSTRATIVE CASES
Special Considerations for
Certain Groups of Cases
Buphthalmos
Implants give outstanding results when used as a primary
procedure in cases of buphthalmos associated with
Sturge-Weber syndrome, neurofibromatosis, congenital
cataract surgery and severe cases of primary
hydrophthalmia.10 Similar short-term results can be
obtained in cases that have undergone many previous
procedures however, the long-term consequences of
multiple operations such as low grade inflammation,
retinal detachment, band keratopathy and corneal
decompensation sooner or later destroy the patients
vision despite adequate control of IOP. Thus implants
should be used where alternative procedures do not carry
a good long-term prognosis. With children donor sclera
is used to provide long-term cover for the tube and
constant vigilance is required to prevent the development
of amblyopia in otherwise successful cases. When
implants are used in cases of Sturge-Weber syndrome
the aqueous is absorbed into abnormal angiomatous
vessels that have a higher intravascular pressure than
normal capillaries causing the IOP to stabilize at 20 mm
Hg. Attempts to lower this pressure by adrenergic agents
give erratic results and such cases are best managed by
accepting an IOP at the upper limit of the normal range.
Illustrative case of simple buphthalmos: Case 1:
An 11-year-old girl with simple buphthalmos,
presented with an IOP of 60 mm Hg, advanced
cupping and a visual acuity of 6/60! She was
commenced on 3 hypotensive medications which
reduced the IOP to 30 mm Hg. Eleven weeks later
a double plate Molteno implant was inserted using
the vicryl tie technique and donor sclera. The

Fig. 7.44: Right eye of case 1 showing blebs over double plate
Molteno implant and donor sclera 9 years after insertion

Fig. 7.45: Right eye of case 1 showing increased size of


draining bleb 9 years after insertion

Illustrative case of buphthalmos associated with


Sturge-Weber syndrome: Case 2: An 8-month-old
infant, presented with bilateral buphthalmos
associated with bilateral Sturge-Weber syndrome and
cerebral involvement causing epilepsy. Preoperatively
the IOPs were 32 and 37 mm Hg and the horizontal
corneal diameters 14 and 13 mm respectively. Single
plate Molteno implants were inserted using the vicryl
tie technique and donor sclera. The postoperative
courses were smooth although examination under

94

Atlas of Glaucoma Surgery


The visual function of Case 2 is limited as a result of
cerebral involvement by the hemangiomas. Interestingly
both eyes, 8 diopters myopic at the time of operation,
had become emmetropic by the time he was 2.5 years
old (Figs 7.47 and 7.48A and B).

Fig. 7.46: Graph of IOP of case 1 over 10 years since


insertion of double plate Molteno implant

anesthetic showed diffuse peripheral choroidal


detachments in both eyes. These resolved
spontaneously and the IOPs remained in the normal
range without medication, although rising slowly for
the next 7 years until recorded at 27 and 24 mm Hg
after hospitalization for control of epileptic seizures.
Over the next 3 months the IOPs varied between 18
and 25 mm Hg on topical adrenaline. Additional
single plate Molteno implants were added to the
existing plates using a vicryl tie to occlude the tube
and delay drainage of aqueous from the existing
bleb into the preformed bleb around the additional
plates as previously described. These operations were
uncomplicated and the IOPs returned to 16 to 19
mm Hg where they have remained on no treatment.
After this episode his mother mentioned that he was
being treated for sinusitis during the time he was
hospitalized for control of his epilepsy when the IOP
was raised. The possible significance of this only
became apparent when a similar history of increase
in IOP associated with sinusitis was later obtained
from another case of buphthalmos associated with
Sturge-Weber syndrome. These histories suggest that
before treating any elevation of IOP in patients with
Sturge-Weber syndrome after drainage by implant it
is prudent to investigate the presence of any local
process that might be causing elevation of the venous
pressure in the angiomatous tissue.

Fig. 7.47: Case 2-6 months after insertion of single plate


Molteno implants for bilateral Sturge- Weber syndrome

B
Figs 7.48A and B: IOP curves of case 2 (A) right (b) left

Combined Cataract and Glaucoma Surgery


It is very important to perform this operation in the correct
sequence, which is:

The Use of Molteno Implants to Treat Complex Cases of Glaucoma


a. The Molteno implant is sutured to the sclera, the
tube occluded, trimmed and tucked away under
the lamellar scleral flap.
b. The cataract is extracted and the intraocular lens
placed.
c. When the cataract operation is complete the tube is
inserted into the AC and the scleral and conjunctival
flaps replaced.
Illustrative case of combined cataract and glaucoma
surgery: Case 3: A 72-year-old male, had primary
open angle glaucoma in his right only eye (the left
eye having been lost to neovascular glaucoma) with
preoperative IOPs of 20 to 31 mm Hg on 2
hypotensive medications, a cup-disk ratio of 0.9
and a superior arcuate scotoma extending to within
3o of fixation. His visual acuity was reduced to 6/18
due to lens opacities. A double plate Molteno
implant was inserted using the vicryl tie technique
combined with an extracapsular cataract extraction
with posterior chamber intraocular lens. The
postoperative course was smooth. He received
reducing doses of acetazolamide and timolol for the
first year after which the acetazolamide was
continued until the IOP stabilized at 10 to 12 mm
Hg 7 years after the operation. Fifteen years after
operation he has an IOP of 12 mm Hg on no
treatment, a visual acuity of 6/12 and his visual field
shows no significant deterioration since operation
(Figs 7.49 and 7.50).

Fig. 7.49: Right eye of case 315 years after combined


operation for cataract extraction and insertion of Molteno
implant when the IOP was 12 mm Hg on no treatment

95

Fig. 7.50: IOP curve of case 3

Neovascular Glaucoma
It is possible to salvage useful vision in cases of acute
neovascular glaucoma by immediate reduction of IOP.
This involves the insertion of an implant with immediate
drainage of aqueous to reduce the IOP to normal levels
to clear the ocular media and restore circulation through
the diseased retinal vessels. The operation is followed by
urgent photocoagulation of the underlying retinal disease
combined with active treatment of the underlying vascular
and general disease states. In cases where a double plate
implant is used the connecting tube between the plates
is occluded by a 5.0 vicryl ligature.
Illustrative case of neovascular glaucoma: Case 4:
A 59-year-old male with type 2 diabetes treated by
diet and glibenclamide who had recently undergone
cataract extraction in both eyes, presented with an
elevated IOP in his right eye due to iris
neovascularization. This was treated by argon laser
photocoagulation and trabeculectomy. His left eye
was treated by argon laser photocoagulation at the
same time. Two months later his IOPs were 46 and
34 mm Hg respectively with iris new vessels
bilaterally. Both eyes were treated by insertion of
single plate Molteno implants with immediate
drainage of aqueous. The postoperative courses
were uneventful. The left visual acuity was 6/24.
He was prescribed oral prednisone, flufenamic acid
200 mg*** and colchicine for 6 weeks after
operation to reduce intraocular inflammation and
bleb fibrosis. These procedures were followed by
photocoagulation to the left eye. The IOP was well
***Flufenamic acid 200 mg tds is equivalent to diclofenac 50 mg tds

96

Atlas of Glaucoma Surgery

controlled in the right eye but the eye had only


light perception, remained uncomfortable and
became phthisical 15 months after operation. The
vision in the left eye gradually improved to reach 6/
18 2 years after operation. His IOP was controlled
with timolol and a small dose (125 mg bd) of
acetazolamide for 3 years until a spontaneous
vitreous hemorrhage occurred. This was associated
with elevation of the IOP to 25 mm Hg which fell
again to 16 to 17 mm Hg with further photocoagulation and clearing of the vitreous hemorrhage. The
vision was maintained at 6/18 with good control of
IOP until he suffered a cerebrovascular accident
which produced a right sided hemianopia and
reduced his vision to 3/60 six weeks before death.
This case demonstrates that immediate drainage of
cases of neovascular glaucoma, combined with
photocoagulation and general medical measures,
can give surprisingly good visual results (Figs 7.51
to 7.54).

Fig. 7.52: Left eye of case 4 showing white quiet eye 6.5
years after insertion of implant

Fig. 7.53: Fundus of left eye of case 4 showing temporal half of


the pale optic disk and extensive photocoagulation 6 years
after insertion of implant

Fig. 7.51: Operative view of insertion of single plate Molteno


implant into a case of acute neovascular glaucoma

Illustrative case of uveitic glaucoma: Case 5: A 27year-old pregnant woman with Stills disease,
presented with an elevated IOP in her right aphakic
only eye. She had developed uveitis in both eyes at
5 years of age and had lost her left eye. Although
the uveitis was only minimally active her right eye
had been treated by three drainage operations, two
cataract extractions and one 180o cyclocryotherapy.
Preoperatively her IOP varied between 24 and 50

Fig. 7.54: Phthisical right eye of case 415 months after


trabeculectomy 2 months later followed by implant and left eye
treated by primary implant

mm Hg on 3 medications and oral glycerol and the


cup-disk ratio was 0.9. She was treated by insertion
of a double plate Molteno implant without

The Use of Molteno Implants to Treat Complex Cases of Glaucoma


connecting the tube to the AC combined with
temporary control of IOP by reopening one of the
old trabeculectomy sites (This was before the
introduction of the vicryl tie/Sherwood slit
technique). Four months later the IOP was 29 mm
Hg on full treatment and the drainage tube was
inserted into the AC. The postoperative course was
uncomplicated and she was treated by systemic
prednisone, a non-steroidal anti-inflammatory agent
and colchicine for 4 weeks to reduce intraocular
inflammation and bleb fibrosis. Her IOP on
acetazolamide 125 mg bd was 10 mm Hg, and 24
mm Hg on no treatment. She has been maintained
on 30 to 60 mg bd acetazolamide for the last 23
years. The tendency to intraocular inflammation has
decreased over this period. Her visual acuity at
operation was 6/9, falling to 6/18 shortly after
operation and then gradually declined to 6/36 at
23 years. Her visual field has shown no change over
this time (Figs 7.55 and 7.56).
Illustrative case of traumatic glaucoma: Case 6: A
57-year-old man, presented after being hit in the
left eye by a cricket ball. Examination revealed a
posteriorly dislocated lens, edematous cornea and
an IOP of 33 mm Hg. He refused admission for a
week. After admission a double plate Molteno
implant was inserted, his lens extracted, a vitrectomy
performed and the tube inserted into the posterior
chamber. Postoperatively he developed a 1/4
hyphema which resolved spontaneously but
otherwise the course was smooth. His cornea
remained opaque, eventually calcified, became
uncomfortable 15 years later and was treated by a
penetrating keratoplasty. The subsequent course
was smooth and 23 years after operation; he has
an IOP of 8 mm Hg on no treatment with a normal
disk and retina but reduced visual acuity of 2/60 as
a result of traumatic macular scarring (Fig. 7.57).

RESULTS
Primary Open Angle Glaucoma
The introduction of the delayed drainage technique for
inserting Molteno implants has led to their being used in
less severe cases of primary open angle glaucoma where
there are additional local and general risk factors. It is of

97

Fig. 7.55: Aphakic right eye of case 523 years after insertion
of double plate Molteno implant in a case uveitis associated
with juvenile rheumatoid arthritis

Fig. 7.56: IOP curve of case 5

Fig. 7.57: Left eye of case 623 years after insertion of double
plate Molteno implant showing clear corneal graft and end of
tube visible at 11 oclock. This tube was inserted via the pars
plana

interest to compare the results obtained from cases


drained by Molteno implants with those of similar cases
(but fewer risk factors) drained by trabeculectomy over
the same period at Dunedin Hospital.

98

Atlas of Glaucoma Surgery

Control of Intraocular Pressure


Overall results of trabeculectomy compared to implants
for primary glaucoma are as follows:
1. All trabeculectomies compared with all implant
operations: Between 1986 and 2003 754 drainage
operations were carried out on cases of primary
glaucoma at Dunedin Hospital. Five hundred and
thirty-one were trabeculectomies carried out on
relatively uncomplicated cases and 223 were
insertion of Molteno implants in eyes with additional
risk factors. The two groups were comparable with
regard to preoperative IOP and hypotensive
medication use. The mean postoperative IOP was
slightly lower in the implant group throughout
follow-up compared with the trabeculectomy group.
The proportion on hypotensive medication was
higher 1 year after operation in the implant group
but this fell progressively with increasing follow-up.
In the case of trabeculectomies the proportion on
hypotensive medication was low 1 year after
operation but increased progressively to approach
that of the implants at 5 and 10 years after
operation. The IOP of all cases in the implant group
remains controlled whereas 40 (8%) of
trabeculectomy cases have failed so far. It is
informative to consider the results of trabeculectomy
and Molteno implants in selected subgroups of
primary glaucoma (Tables 7.1 and 7.2).
2. Trabeculectomy as first operation compared to
implant as first operation: The mean postoperative
IOP was slightly lower in the case of Molteno
implants at 1 year after operation while the
proportion of cases on hypotensive medication was
slightly higher in the case of implants. However, with
ongoing follow-up the mean IOP of the implant
group remained slightly below that of the
trabeculectomies and the proportion of cases on
hypotensive medication equalized by 5 years after
operation and was slightly lower in the case of
implants at 10 years. The IOP of all cases of the
implant group remains controlled whereas 32/510
(6%) of the trabeculectomy group failed (Tables 7.1
and 7.2).

3. Trabeculectomy af ter failed trabeculectomy


compared to implant after failed trabeculectomy:
The mean postoperative IOP after Molteno implants
was substantially lower than that after trabeculectomy
and this difference was maintained. There were no
failures in the implant group compared with 8/21
(38%) of the trabeculectomy group (Tables 7.1 and
7.2).
4. Phacotrabeculectomy compared with implant
combined with cataract extraction: The mean
postoperative IOP after Molteno implants was
substantially lower and this difference was
maintained. There were no failures in the implant
group compared with 7/109 (6%) of the
trabeculectomy group (Tables 7.1 and 7.2).
5. Trabeculectomy and later cataract extraction
compared with implant and later cataract extraction:
The mean postoperative IOP was similar in the two
groups. There were no failures in the implant group
compared with 22/122 (18%) of the trabeculectomy
group (Tables 7.1 and 7.2).
Overall the long-term results of Molteno implants in
these cases with primary glaucoma are superior to those
of trabeculectomy. The differences are particularly
marked where previous trabeculectomies have failed, in
combined operations and after subsequent cataract
extraction.

Secondary Glaucomas
In all groups the overall prognosis for control of IOP in
visually useful eyes is generally good with failure occurring
in terminal eyes, eyes that have undergone multiple
previous operations and cases of uveitis in which the
underlying disease cannot be controlled. The outcomes
of cases of buphthalmos, juvenile glaucoma, traumatic
glaucoma, uveitic glaucoma, secondary glaucoma
following previous intraocular surgery and neovascular
glaucoma treated by insertion of Molteno implants with
respect to IOP control and hypotensive medication use
are presented in Tables 7.3 and 7.4.

99

The Use of Molteno Implants to Treat Complex Cases of Glaucoma

Table 7.1: Status of cases of primary open angle glaucoma treated by a trabeculectomy or Molteno implant at Dunedin
Hospital between 1986 and 2003 as of January 2004
Number

IOP control
(IOP = 5 - 21 mm Hg)
No medication

Trabeculectomy as first or subsequent operation*


Implant as first operation or following trabeculectomy*
Trabeculectomy as first operation
Implant as first operation
Trabeculectomy after failed trabeculectomy
Implant after failed trabeculectomy
Phacotrabeculectomy
Phaco/implant
Trabeculectomy and later cataract extraction
Implant and later cataract extraction

531
223
510
182
21
41
109
51
122
48

366 (69%)
153 (69%)
357 (70%)
135 (74%)
10 (48%)
20 (49%)
64 (59%)
39 (77%)
74 (61%)
34 (71%)

Fail

With medication
125 (24%)
70 (31%)
122 (24%)
47 (26%)
3 (14%)
21 (51%)
38 (35%)
12 (24%)
26 (21%)
(%)

40 (8%)
0
32 (6%)
0
8 (38%)
0
7 (6%)
0
22 (18%)
0

* Includes cases in the respective subsets below

Table 7.2: Mean IOP and hypotensive medication use of cases of primary open angle glaucoma treated by trabeculectomy
or Molteno implant at Dunedin Hospital between 1986 and 2003
Number
Mean IOP (standard deviation) in mm Hg
Mean number of Hypotensive Medications
Preoperative
Trabeculectomy as first or subsequent operation*
Implant as first operation or following trabeculectomy*
Trabeculectomy as first operation
Implant as first operation
Trabeculectomy after trabeculectomy failure
Implant after failed trabeculectomy
Phacotrabeculectomy
Phaco/implant
Trabeculectomy and later cataract extraction
Implant and later cataract extraction

* Includes cases in the respective subsets below

N=531
23.7 (6.6)
1.90
N=223
24.0 (6.5)
1.98
N=510
23.7 (6.5)
1.89
N= 182
23.9 (6.6)
1.96
N= 21
25.9 (8.7)
2.10
N= 41
24.6 (6.0)
2.07
N = 109
21.0 (6.0)
1.66
N= 51
21.7 (6.2)
1.87
N = 122
24.9 (5.6)
1.95
N = 48
23.8 (7.2)
1.75

Years postoperatively
1

10

15

N=445
15.0 (3.5)
0.23
N=182
14.4 (2.9)
0.59
N=431
15.0 (3.5)
0.21
N= 147
14.4 (2.8)
0.57
N=14
18.4 (4.7)
0.72
N= 35
14.7 (3.3)
0.73
N= 89
16.2 (3.2)
0.3
N= 47
14.0 (2.3)
0.51
N= 117
14.5 (3.7)
0.21
N= 46
14.8 (2.7)
0.48

N=377
15.0 (3.4)
0.29
N=160
14.2 (3.2)
0.54
N=365
15.0 (3.3)
0.27
N= 126
14.0 (2.8)
0.49
N=11
16.2 (5.4)
0.97
N= 34
14.8 (4.3)
0.72
N= 64
16.2 (3.6)
0.42
N= 38
13.5 (2.6)
0.48
N= 115
14.9 (3.8)
0.24
N= 43
14.6 (3.0)
0.39

N=224
14.9 (3.2)
0.42
N=87
14.2 (3.1)
0.48
N=216
14.8 (3.1)
0.38
N= 63
14.2 (2.9)
0.35
N= 9
16.7 (4.7)
1.22
N= 24
14.4 (3.7)
0.81
N= 28
15.2 (3.6)
0.57
N= 21
13.1 (2.9)
0.52
N= 86
15.3 (3.11)
0.43
N= 27
14.6 (3.6)
0.52

N=90
15.4 (4.2)
0.45
N=27
13.1 (3.3)
0.50
N=87
15.3 (4.3)
0.45
N=16
12.2 (2.5)
0.40
N= 5
15.7 (1.0)
0.80
N=11
14.3 (4.0)
0.66
N= 6
19.5 (7.0)
0.85
N=11
12.0 (2.3)
0.36
N= 47
14.8 (3.4)
0.30
N= 8
14.9 (4.6)
0.68

N=14
14.5 (4.1)
0.96
N=2
10.3 (0.4)
1.00
N=12
14.1 (4.3)
0.87

N=5
16.1 (2.4)
0.80
N=2
10.3 (0.4)
1.00

N=18
14.2 (3.2)
0.37

100

Atlas of Glaucoma Surgery

Table 7.3: Status of cases of buphthalmos, juvenile glaucoma, traumatic glaucoma, uveitic glaucoma, secondary glaucoma
and neovascular glaucoma treated by Molteno implant at Dunedin Hospital between 1977 and 2003 as of January 2004
Number

Buphthalmos
Juvenile glaucoma
Traumatic glaucoma
Uveitic glaucoma
Secondary glaucoma
Neovascular glaucoma

IOP control
(IOP = 5-21 mm Hg)

49
24
43
49
74
148

Fail

No medication

With medication

26 (53%)
9 (38%)
31 (72%)
33 (67%)
44 (60%)
40 (27%)

16 (33%)
11 (46%)
7 (16%)
11 (23%)
21 (28%)
39 (26%)

7 (14%)
4 (17%)
5 (12%)
5 (10%)
9 (12%)
69 (47%)

Table 7.4: Mean IOP and hypotensive medication use of cases of buphthalmos, juvenile glaucoma, traumatic glaucoma,
uveitic glaucoma, secondary glaucoma and neovascular glaucoma treated by Molteno implant at Dunedin Hospital between
1977 and 2003
Number
Mean IOP (standard deviation) in mm Hg
Mean number of Hypotensive Medications
Preoperative
Buphthalmos
Juvenile glaucoma
Traumatic glaucoma
Uveitic glaucoma
Secondary glaucoma
Neovascular glaucoma

N=49
32.9 (12.5)
1.67
N=24
27.8 (9.7)
2.00
N=43
32.7 (13.6)
1.86
N=49
31.4 (13.4)
1.87
N=74
31.2 (10.9)
2.02
N=148
40.0 (12.8)
1.30

Years postoperatively
1

10

15

20

N=43
15.0 (4.3)
0.40
N=20
17.1 (4.8)
0.81
N=35
15.9 (3.3)
0.44
N=43
15.9 (5.2)
0.58
N=65
16.4 (5.5)
0.68
N=100
19.6 (9.3)
0.77

N=42
15.2 (4.4)
0.38
N=19
17.1 (4.7)
0.58
N=34
15.4 (3.9)
0.31
N=39
15.5 (6.1)
0.46
N=60
15.9 (5.5)
0.53
N=75
19.1 (10.0)
0.72

N=36
15.5 (4.1)
0.39
N=18
16.3 (4.3)
0.77
N=29
15.5 (3.5)
0.36
N=29
14.8 (4.4)
0.52
N=37
17.4 (7.6)
0.65
N= 29
21.9 (11.0)
0.78

N=27
16.6 (3.5)
0.68
N=13
16.2 (2.6)
0.99
N=19
15.0 (4.4)
0.14
N=17
15.4 (4.6)
0.47
N=21
16.5 (4.1)
0.50
N=9
26.8 (10.7)
0.52

N=19
17.3 (3.7)
0.76
N=9
18.4 (8.8)
1.11
N=12
15.4 (3.8)
0.08
N=7
13.4 (5.5)
0.14
N=13
18.6 (6.9)
0.98
N=2
12.0 (5.7)
0.25

N=8
16.7 (3.0)
0.87
N=4
N=4
1.07
N=9
13.8 (4.4)
0.33
N=3
10.5 (4.9)
0.33
N=3
18.8 (13.3)
0.16

CONCLUSIONS
The current surgical techniques for inserting Molteno
implants provide very safe and highly effective ways of
preventing postoperative hypotony and reducing the IOP
to normal levels in most types of glaucoma. The only
groups in which results are uncertain are very advanced
cases that have undergone many previous operations,
cases of chronic uveitis that remain active despite
treatment and cases of neovascular glaucoma in which
the underlying vascular disease is not amenable to
treatment.

REFERENCES
1. Molteno ACB, Fucik M, Dempster AG, Bevin TH. Otago glaucoma
surgery outcome study. Factors controlling capsule fibrosis around
Molteno implants with histopathological correlation. Ophthalmology
2003;110:2196-2210.
2. Molteno ACB. New implant for drainage in glaucoma. Clinical
trial. Br J Ophthalmol 1969;53:606-15.
3. Molteno ACB, Dempster AG. Methods of controlling bleb fibrosis
around draining implants. In. Mills KB (Ed): Fourth International
Symposium of the Northern Eye Institute. Manchester: Pergammon
Press, 1988.
4. Vote B, Fuller JR, Bevin TH, Molteno ACB. Systemic antiinflammatory fibrosis suppression in threatened trabeculectomy
failure. Clin Exp Ophthalmol 2004;32:81-6.
5. Fuller JR, Bevin TH, Molteno ACB, et al. Anti-inflammatory fibrosis
suppression in threatened trabeculectomy bleb failure produces good

The Use of Molteno Implants to Treat Complex Cases of Glaucoma


6.
7.
8.
9.
10.
11.

long-term control of intraocular pressure without risk of sight


threatening complications. Br J Ophthalmol 2002;86:1352-5.
Molteno ACB, van Biljon G, Ancker E. Two-stage insertion of
glaucoma drainage implants. Trans Ophthalmol Soc N Z 1979;31:1726.
Molteno ACB, Polkinghorne PJ, Bowbyes JA. The vicryl tie technique
for inserting a draining implant in the treatment of secondary
glaucoma. Aust NZJ Ophthalmol 1986;14:343-54.
Sherwood MB, Smith MF. Prevention of early hypotony associated
with Molteno implants by a new occluding stent technique.
Ophthalmology 1993;100:85-90.
Molteno ACB, Ancker E, Van Biljon G. Surgical technique for
advanced juvenile glaucoma. Arch Ophthalmol 1984;102:51-7.
Cunliffe IA, Molteno ACB. Long-term follow-up of Molteno drains
used in the treatment of glaucoma presenting in childhood. Eye
1998;12:379-85.
Molteno ACB, Whittaker KW, Bevin TH, Herbison P. Otago glaucoma
surgery outcome study. Long-term results of cataract extraction

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combined with Molteno implant insertion or trabeculectomy in


primary glaucoma. Br J Ophthalmol 2004;88:32-5.
Fuller JR, Bevin TH, Molteno ACB. Long-term follow-up of traumatic
glaucoma treated with Molteno implants. Ophthalmology
2001;108:1796-1800.
Molteno ACB, Sayawat N, Herbison P. Otago glaucoma surgery
outcome study. Long-term results of uveitis with secondary glaucoma
drained by Molteno implants. Ophthalmology 2001;108:605-13.
Molteno ACB, Bevin TH, Herbison P, Houliston MJ. Otago glaucoma
surgery outcome study. Long-term follow-up of cases of primary
glaucoma with additional risk factors drained by Molteno implants.
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Molteno ACB. The dual chamber single plate implantits use in
neovascular glaucoma. Aust NZJ Ophthmol 1990;18:431-6.
Molteno ACB, Haddad PJ. The visual outcome in cases of
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102

Atlas of Glaucoma Surgery


Andr Mermoud

8 Nonpenetrating Surgery

INTRODUCTION
In order to obtain a physiological per- and postoperative
IOP, the idea of nonpenetrating glaucoma surgery
(NPGS) was to create a reproducible postoperative
outflow resistance with the trabeculo-Descemets
membrane.
Several techniques of nonpenetrating filtering
surgeries based on the pioneer work of Krasnovs
sinusotomy have been described (Figs 8.1 and 8.2). In
primary and most cases of secondary open-angle
glaucoma, the main aqueous outflow resistance is thought
to be located at the level of the juxtacanalicular
trabeculum and the inner wall of Schlemms canal. These
two anatomical structures can be removed. This
technique has been called ab externo trabeculectomy. It
was first proposed by Delage in 1978, and later by
Zimmermann in 1984 and Arenas in 1991 (Fig. 8.3).
Another way to increase the aqueous outflow in a patient
with restricted posterior trabeculum outflow is to remove
the corneal stroma behind the anterior trabeculum and
Descemets membrane (Fig. 8.4). This has been called
deep sclerectomy and was first described by Fyodorov
and Kozlov and later by Stegmann (viscocanalostomy).
The most common techniques used today are deep
sclerectomy and viscocanalostomy. This chapter will
describe these two techniques.

DEEP SCLERECTOMY
In deep sclerectomy, the main aqueous outflow occurs
at the level of the anterior trabeculum and the Descemets
membrane (Fig. 8.4). This has been shown by Vaudaux
et al in an ex vivo model of deep sclerectomy (Vaudaux).
They have also reported that the outflow facility increased
from 0.19 0.03 to 24.5 12.6 l/min/mm Hg. To

enhance further the filtration after a deep sclerectomy,


the removal of the inner wall of the Schlemms canal
can be performed to increase the filtration through the
posterior trabeculum.
To keep the intrascleral space created patent, an
implant may be used. Kozlov proposed a collagen
implant which resorbs itself within 6 to 9 months (Chiou).
Stegmann uses high viscosity hyaluronic acid; Sourdille
and Dahan are using reticulated hyaluronic acid and
Hema implants respectively.
Kozlov et al have reported an 85 percent success
rate, but no information regarding success criteria or
follow-up is available (Kozlov). Long-term results of deep
sclerectomy with collagen implant are encouraging. With
a mean follow up of 64 20 months, Shaarawy et al
reported a mean IOP of 11 mm Hg with a complete
success rate of 57 percent and a qualified success rate of
91 percent (Shaarawy).

VISCOCANALOSTOMY
The hypothetic mechanism of filtration in viscocanalostomy is different from those described in other nonpenetrating filtering surgeries. Stegmann thinks that the
aqueous humor filters trough the trabeculo-Descemets
membrane to the scleral space like in deep sclerectomy,
but that it does not form a subconjunctival filtering bleb
since the superficial scleral flap is tightly closed with
numerous nylon 10/0 sutures. From the scleral space,
the aqueous humor is supposed to reach the Schlemms
canal which is opened on either side of the deep
sclerectomy, and then flows into the aqueous episcleral
veins. Until now no scientific study has been able to
confirm this hypothesis, and in our hands, patients who
underwent viscocanalostomy presented in 50 percent
of the cases a subconjunctival filtering bleb. The long-

Nonpenetrating Surgery

103

Fig. 8.3: Schematic representation of abexterno


trabeculectomy. A deep sclerectomy unroofing Schlemms
canal is covered by a superficial scleral flap. The Schlemms
canal inner wall and juxtacanalicular trabeculum are removed

Fig. 8.4: Schematic representation of deep sclerectomy. Under


a superficial scleral flap, a deep corneosclerectomy unroofing
Schlemms canal is performed. Corneal tissues behind the
anterior trabeculum and Descemets membrane are removed.
Removing of the inner wall of the Schlemms canal can also
be performed, but is not represented on the Figure

Figs 8.1 and 8.2: Schematic representations of sinusotomy.


Schlemms canal is unroofed. There is no superficial scleral
flap to cover the sclerectomy. Inner wall of Schlemms canal is
untouched

term follow-up study of viscocanalostomy is reported to


be satisfactory (Stegmann).
All types of nonpenetrating glaucoma surgeries present
in common a more predictable postoperative IOP
(between 5 and 10 mm Hg on the first postoperative

104

Atlas of Glaucoma Surgery

day). This is due to the outflow resistance membrane left


in situ peroperatively (posterior trabeculum after ab
externo trabeculectomy, trabeculo-Descemets membrane
after deep sclerectomy and viscocanalostomy). The
nonperforation of the globe offers several advantages
which are enlisted in Table 8.1. The mechanisms of
aqueous resorption are probably multiple.
Table 8.1: Advantages and disadvantages of nonpenetrating
glaucoma surgeries
Advantages

Disadvantages

Predictable postoperative IOP


More difficult surgery
Low rate of postoperative
Prolonged surgery time during
complications
learning phase
Easy ambulatory care
Need Nd-Yag goniopuncture
Rapid visual acuity recovery
Increased cost (implant)
No postoperative inflammation
Not applicable in closed angle
No cataract induced
Glaucoma
More diffused and shallow
filtering blebs
Limited risk for secondary
endophthalmitis
Safe surgery for end-stage glaucoma
Easy postoperative follow-up
Closed globe surgery
Decreased risk for malignant glaucoma

1. There is in 50 percent of cases a subconjunctival


filtering bleb which appears usually more diffuse
and shallower than after trabeculectomy.
2. There is probably an increased uveoscleral outflow
through the thin remaining scleral layer in the bed
of the deep sclerectomy (Kazakova).
3. Stegmann believes that the aqueous humor reaches
from the scleral space the Schlemms canal and
subsequently the aqueous veins.
4. There are evidence in animal models that there is a
production of new aqueous drainage veins in the
scleral space months after deep sclerectomy
(Delarive). This intrascleral filtering bleb has also been
showed by Kazakova using an UBM in successful
human deep sclerectomy (Kazakova).

SURGICAL TECHNIQUE
When performing nonpenetrating glaucoma surgery the
surgeon looks at two aims: one to create the trabeculoDescemets membrane which will allow a reproducible
postoperative outflow resistance, thus decreasing the
immediate postoperative complication rate, and two, to

create an intrascleral filtering bleb to decrease the amount


of subconjunctival bleb and therefore the potential risk
of late hypotony and bleb-related endophthalmitis.
According to medium and long-term studies of NPGS,
more than 50 percent of patients need a Nd-Yag laser
goniopuncture, it is therefore of paramount importance
to create a thin and large Descemets window. To create
a functional intrascleral filtering bleb, a large and deep
sclerectomy should be perfomed. Furthermore, to enable
the maintenance of the intrascleral space, several implants
have been proposed to avoid the collapse of the created
space.
This chapter will help the reader to understand how
to dissect the different tissues in order to create a big
intrascleral filtering bleb, to find Schlemms canal, to
dissect a correct trabeculo-Descemets window, to place
an intrascleral space maintainer using an implant and to
use antimetabilites when needed.
All types of anesthesia have been used successfully
for NPGS. We recommend injecting the smallest amount
of peri-or retrobulbar anesthesia in order to adequately
rotate the glob for the deep sclerectomy dissection. Three
to 4 ml of a solution of bupivacaine 0.75 percent,
xilocaine 4 percent and hyaluronidase 50 U are usually
sufficient for a successful local anesthesia. Topical and
subconjunctival anesthesia are also possible and have
been performed successfully in selected cases.
A superior rectus muscle or an intracorneal traction
suture is placed and the eyeball is rotated to expose the
site of the deep sclerectomy (usually the superior
quadrant). The conjunctiva is opened either at the limbus
or in the fornix. The sclera is exposed and moderate
hemostasis is performed using a wet field
electrocoagulation cautery. A superficial scleral flap
measuring 5 by 5 mm is dissected including 1/3rd of the
sclera thickness (about 300 mm) (Fig. 8.5).
This scleral flap is dissected 1 to 1.5 mm into clear
cornea (Fig. 8.6). In patients with high risk of
scleroconjonctival scar formation, a sponge soaked in
mitomycin-C 0.2 percent is placed for 45 to 60 seconds
in the scleral bed and subconjunctival space (Fig. 8.7).
After removal of the sponge, the site is washed with
balanced salt solution (20 to 30 ml).

Nonpenetrating Surgery

Fig. 8.5: Creation of a superficial 5 5 mm scleral flap

Fig. 8.6: The superficial scleral flap is 1/3rd of the scleral


thickness and is prolonged 1 to 1.5 mm into clear cornea

Fig. 8.7: In patients at risk for post-operative fibrosis, a sponge


soked in mitomycin-C is placed in the surgical site and then
washed with balanced salt solution

105

At that stage of the operation, the microscope


magnification is increased. Simultaneously, the
microscope light is switch on maximum illumination
which is essential for the fine dissection. The two lateral
and the posterior deep scleral incisions are made using a
diamond blade (0.5 3 mm, Huco vision, St-Blaise,
Switzerland). The sclera is cut almost 95 percent of his
thickness (Fig. 8.8). Complete perforation of sclera in
some part of the incision offers the view of the ciliary
body in the anterior part, or the choroid in the posterior
part of the scleral dissection (Fig. 8.9). This is a good
landmark to assess the total scleral thickness. This
maneuver has never been followed by any complication
in our experience. The deep scleral flap is then
horizontally dissected using a crescent ruby blade (2 mm
bevelled up angled, Huco vision, St-Blaise, Switzerland)
(Fig. 8.10). The remaining scleral layer should be as thin
as possible (Fig. 8.11). Deep sclerectomy is preferably
started in the posterior part of the deep scleral flap. This
helps avoiding anterior chamber perforation. In the
posterior part of the deep flap, the scleral fibers are layed
in multiple directions. More anteriorly, the scleral fibers
are more regular forming a ligament parallel to the
limbus, corresponding to the scleral spur. Schlemms
canal is then just anterior to this structure. The scleral
spur is an excellent landmark for Schlemms canal
identification (Fig. 8.12). Schlemms canal is opened (Fig.
8.13) and the sclerocorneal dissection is prolonged
anteriorly for 1 to 1.5 mm in order to remove the
sclerocorneal tissue behind anterior trabeculum and
Descemets membrane. This part of the surgery is difficult
because there is a high risk of anterior chamber
perforation. To avoid a perforation, the anterior
tabeculum and Descemets membrane can be gently
detached using a sponge, a spatula or a blunt metallic
blade (Fig. 8.14). Once the Descemets membrane
detached, two lateral radial cut are made to expose the
Descemets window (Fig. 8.15). When the anterior
dissection is completed, the deep scleral flap is removed
by cutting anteriorly first with the diamond blade (Fig.
8.16) and then using a Galan scissor (Fig. 8.17) (length
55 mm, curved and blunt blade). At that stage of the
procedure, there should be a nice percolation of aqueous
through the remaining trabeculo-Descemets membrane.

106

Atlas of Glaucoma Surgery

Fig. 8.8: The deep sclerctomy is delineated with a diamon


blade. The deep sclerectomy measures 4 4 mm and the
sclera is dissected leaving about 5 percent of sclera over the
chorriod and ciliary body

Fig. 8.10: The horizontal dissection is performed using a


ruby blade

Fig. 8.11: The remaining scleral layer is very thin


Fig. 8.9: Choroid or ciliary body view is a good landmark for
the total scleral thickness and allow the surgeon to start the
horizontal cut at he correct site

Since the main site of aqueous outflow resistance, in


primary and probably other type of secondary openangle glaucoma, is thought to be at the juxtacanalicular
trabeculum and Schlemms endothelium level this
structure should be removed using a small blunt forceps
(Fig. 8.18)(deep sclerectomy forceps 13,0 mm gaws,
Huco vision SA, St-Blaise, Switzerland). This additional
procedure has been called ab externo trabeculectomy.
To peel the thin Schlemms endothelium and

juxtacanalicular trabeculum membrane, it is crucial to


dry the exposed inner wall of Schlemms canal. When
dried, the inner wall of Schlemms canal can be grabbed
with the forceps (Fig. 8.19) and peeled easily by pulling
on it. This maneuver is followed by another important
percolation of aqueous through the posterior
trabeculum. To avoid secondary collapse of the superficial
flap, a space maintainer implant is placed in the scleral
bed and secured with a single 10/0 nylon suture (Fig.
8.20). The superficial scleral flap is then closed and
secured with two untied 10/0 nylon sutures (Fig. 8.21).

Nonpenetrating Surgery

Fig. 8.12: In the anterior part of the scleral bed, the scleral
fibers are parralel to the limbus and represent the scleral spure.
This is an excellent landmark to find Schlemms canal which
is located just anterior to the scleral spure

Fig. 8.13: Opening of Schlemms canal. The canal is dark


and contrast with the white scleral spure

The conjunctiva and Tenons capsule are closed with


running 8/0 vicryl sutures (Fig. 8.22).
The space maintainer implant may be in collagen
and is processed from porcine scleral collagen as shown
on Figure 8.20. It is increasing in volume after contact
with aqueous and is slowly resorbed within 6 to 9 months
leaving a scleral space for aqueous filtration (Chiou).
The implant may also be done with high viscosity
hyaluronic acid (Healon GV, Pharmacia, Upsalla,

107

Fig. 8.14: Detachment of the anterior trabeculum and


Descemets membrane using a sponge, a spatula or a blunt
metalic blade

Fig. 8.15: Radial anterior deep sclerocorneal cut. This is


performed either with a diamond blade or with the 11metalic
blade turned upside-down to avoid a perforation of the
Descemets membrane

Sweeden, corresponding to Stegmanns technique also


called viscocanalostomy). Reticulated hyaluronic acid
may also be used (SK-gel implant, Corneal, Paris, France.
This material will stay longer in the scleral dissection and
may provide a better space formation. More recently, a
Hema, nonresorbable implant is available (T-flux,
IOLtech, La Rochelle, France) (Dahan).

108

Atlas of Glaucoma Surgery

Fig. 8.16: The deep sclerocorneal flap is removed by first


delineating the anterior cut with the diamond blade. This cut is
performed as anterior as possible to create the bigest
Descemets window as possible

Fig. 8.17: The flap is finally removed using Galan scissors

Fig. 8.18: Pealing off the inner endothelium of Schlemms


canal and the juxtacanalicular trabeculum

Fig. 8.19: To better view the inner wall of Schlemms canal, a


sponge is used to dry the site and to expose the anterior edge
of the endothelium

Trabeculo-Descemets Perforation
In the learning phase of NPGS, the surgeon may
perforate quite often the thin membrane. It is important
when the iris prolapsed through the perforation, to
perform a peripheral iridectomy, followed by a tight
superficial scleral flap closure with 6 to 8 nylon 10/0
suture (Fig. 8.23) the scleral space should be filled with
high viscosity hyaluronic acid in order to reduce the
aqueous humor outflow (Fig. 8.24). When the anterior
chamber is shallow, viscoelastic may also be injected into
the anterior chamber through a paracentesis. This

Fig. 8.20: A collagen implant is sutured in the scleral bed. This


implant will serve as a space maintainer to create an intrascleral space for aqueous humor to filter

Nonpenetrating Surgery

Fig. 8.21: The superficial scleral flap is repositioned and


sutured with two untied 10/0 nylon sutures

109

Fig. 8.23: Tight superficial scleral flap closure with 8 nylon 10/
0 sutures to increase the aqueous humor outflow resistance

Fig. 8.24: High viscosity hyaluronic acid may be injected into


the scleral space to increase the aqueous humor outflow
resistance
Fig. 8.22: Closure of the Thenons capsule and the
conjunctiva with a running 8/0 vicryl suture

injection should however be done carefully to avoid


postoperative ocular hypertension.
Combined surgery including phacoemulsification and
NPGS are possible and are usually performed in two
different sites. The deep sclerectomy is usually performed
at the 12 oclock position and the lens extraction is
performed through a clear corneal temporal incision

POSTOPERATIVE MEDICATIONS
Patients are treated first with topical corticosteroid and
antibiotic for 2 to 3 weeks using 3 to 5 drops a day. This

is followed by nonsteroidal anti-inflammatory drugs for


up to three months postoperatively using 3 drops a day.
Goniopuncture with the Nd:YAG laser may be
performed when there is an insufficient percolation of
aqueous humor through the trabeculo-Descemets
membrane. This is probably due to the lack of surgical
dissection when the IOP rises early after the surgery.
When goniopuncture is required at a later time (more
than 9 months after initial surgery), low filtration is
probably the result of fibrosis of the trabeculo-Descemets
membrane, since goniopuncture resulted in increased
filtration of aqueous humor and decreased IOP. The
success rate of Nd: YAG laser goniopuncture is

110

Atlas of Glaucoma Surgery

satisfactory, with an immediate reduction in mean IOP


of 43.7 percent (from 22.2 7.0 to 12.5 5.8 mm
Hg) (Mermoud). By opening the trabeculo-Descemets
membrane, however, goniopuncture transformed a nonperforating filtration procedure into a perforating one.

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112

Atlas of Glaucoma Surgery


Roberto Sampaolesi, Juan Roberto Sampaolesi, Jorge Zarate

9 Nonpenetrating Deep Sclerectomy (NPDS):


Anatomic Landmarks

INTRODUCTION
It was Krasnov, in 1966,1,2 who originally proposed the
removal of the external wall of the Schlemms canal and
coined the word sinusotomy for the procedure by which
he removed the external wall of Schlemms canal from
10 to 20 oclock over 120; the inner wall of Schlemms
canal was left untouched and then the conjunctiva was
closed. Alkseev, in 1978,3 proposed the removal of the
endothelium of the inner wall of Schlemms canal and
of the juxtacanalicular tissue in sinusotomy in order to
increase the permeability of the inner wall of the chamber
angle.
Zimmerman et al (1984)4 introduced nonpenetrating
trabeculectomy; Fyodorov et al (1984)5-6 proposed deep
sclerectomy and later, and together with Kozlov and
others (1989), nonpenetrating deep sclerectomy; Kozlov
et al (1990)7 perfected the method with the addition of
a cylindric collagen implant and later developed laser
goniopuncture, methods which were further developed
by Kozlov and Kozlova (1996)8 and by Kozlova (19962000).9-10 According to Kozlovs technique, in addition
to the resection of the external wall of Schlemms canal,
the inner wall of Schlemms canal with the endothelium,
together with the juxtacanalicular tissue and external
corneoscleral trabecular meshwork are removed. In
(1991), Arenas Archila11 proposed trabeculotomy ab
externo, by which the same tissues were removed, after
removal of the external wall of Schlemms canal, but
using a microtrephine working at a speed of 800 rpm.
In 1999 Stegman 12 reported his results with viscocanalostomy in black African patients. Sourdille et al.
(1999)13 used a triangular reticulated hyaluronic acid
implant of the same size as that of the second triangular

scleral flap. We have successfully tested this technique,


which, as it is currently known, is also successfully used
by Demailly (1996).14 Moreover, a very complete book
has been edited recently by Andre Mermoud,15 who has
extensive experience in nonpenetrating surgery.
The main advantage of nonpenetrating deep
sclerectomy (NPDS) lies with the high percentage of cases
in which it prevents the three most severe complications
of trabeculectomy: flat chamber, hyphema and choroidal
detachment. Furthermore, since neither anterior
chamber opening nor iridectomy nor atropine instillation
into the anterior chamber is required, the postoperative
period is good, with the patient preserving the
preoperative visual acuity, in contrast to our experience
with trabeculectomy, which has a difficult postoperative
course, independently of the success of the procedure.
Moreover, the mild postoperative period, as well as
the low percentage of complications has encouraged
surgeons to safely recommend this technique as early as
in the preperimetric period, when damage to the optic
nerve has already occurred and pharmacotherapy has
failed to regulate IOP, though visual acuity and visual
field are still normal. This technique is thus pretty close
to the ideal therapy for the prevention of serious
anatomic and functional damage caused by the disease.

EARLY INDICATION OF NPDS IN OPENANGLE GLAUCOMAS


Effective detection by non-conventional perimetry, i.e.
by Frequency Doubling Technology (FDT), of visual field
defects correlated with optic nerve damage revealed by
confocal tomography, which in almost 50 percent of cases
go undetected by conventional perimetry (SAP), has

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks


shortened the preperimetric period of glaucoma thereby
enabling earlier detection of visual field loss in ocular
hypertension. This is vital for the indication of surgical
therapy in patients under these conditions failing to
control their intraocular pressure with maximum medical
therapy. Very favorable results can therefore be achieved
with novel less invasive surgical techniques, such as
nonpenetrating deep sclerectomy.
Frequency Doubling Technology (FDT) thus enables
the detection of glaucomatous visual field changes earlier
than SAP. Therefore, it is a valuable tool for patients
who used to be considered as ocular hypertensives and
who can now be correctly diagnosed with glaucoma.16
We will now describe some examples (Figs 9.1 to
9.3).

CONTRAINDICATION
The NPDS is contraindicated in narrow-angle or angleclosure glaucoma, congenital glaucoma and late
congenital glaucoma when the mesodermal remnants
reach Schwalbes line.

NPDS: ANATOMIC LANDMARKS


Anatomic landmarks of NPDs are being expressed in
Figures 9.4 to 9.7.

NPDS: SURGICAL TECHNIQUE


After retrobulbar anesthesia with 2 to 4 ml of a solution
of xylocaine 4 percent, the conjunctiva and Tenons
capsule are opened at the upper fornix or at the limbus.
With the sclera thus exposed careful hemostasis is
performed with the use of a bipolar cautery manufactured by Mira.
A nylon suture is placed on the cornea 1 mm away
from the limbus, at 12 hours, to move the eye.
Step 1: A rectangular one-third scleral thickness
limbal-based scleral flap, the same as that created
for trabeculectomy is dissected. One side of this
rectangle, of 5 mm, is parallel to the limbus, while
another one is perpendicular to it and 6 mm in
length. Anteriorly, the scleral flap is dissected closer
to the cornea than usual in trabeculectomy
procedures. Corneal lamellae are dissected along
1.5 mm (Fig. 9.8).

113

Step 2: A second limbal-based triangular scleral flap


is then created by penetrating 1. 5 mm along the
corneal tissue. A useful landmark for this dissection,
which must be performed carefully, is the orientation
of the scleral fibers, which though arranged in
multiple directions at the scleral level, behind this
flap, they become neatly parallel and circular at the
level of the scleral spur, thus adopting a more whitish
and nacreous appearance. Aqueous humor
percolation at this stage, with the anterior chamber
closed, when the dissection goes from the scleral
spur towards the cornea, is indicative of placement
of the incision at the proper plane. The triangular
flap, containing the external wall of the Schlemms
canal, including its endothelium, is then resected.
Anteriorly, the dissection should be made down to
the deep corneal lamellae so that only the corneal
endothelium remains. Descemets membrane and
a small layer of corneal lamellae are left. The
dissection plane can generally be easily created at
this final stage by pulling the vertex of the triangular
flap towards the cornea with a clamp (Figs 9.8 and
9.9).
Figures 9.10A to C show the pathological anatomy
of the external wall of Schlemms canal.
Step 3: The most important step of NPDS involves
the removal of the internal elements of resistance.
If this membrane is not removed the intraocular
pressure will fail to be regulated (Fig. 9.11).
Step 4: At this step the implant is secured to the
sclera with a nylon 10-0 suture.
Implants may be made of different materials. In our
first 60 patients we used the implant manufactured by
Staar Surgical AG (Nidau, Switzerland). It is a cylindrical
collagen implant measuring 2.5 mm in length and 1 mm
in diameter processed from lyophilized American porcine
scleral collagen, which is sterilized by a radiation
procedure. The water content of the hydrated device is
99 percent. This implant, is resorbed within 6 to 9 months
after surgery, as demonstrated by UBM (ultrasound
biomicroscopy) (Fig. 9.12). In the last 22 cases we used
the corneal implant (France). This implant is triangular
and it is made of sodium hyaluronate.

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Atlas of Glaucoma Surgery

Fig. 9.1: Optic nerve fiber defect at the inferotemporal quadrant with rim notch. Visual field: normal according to SAP and Bebie
curve while Frequency Doubling Technology reveals a visual field defect topographically correlated with optic nerve and fiber
layer defects. It is not a hypertension, it is really a glaucoma. The intraocular pressure fails to be regulated with maximum therapy.
We indicated NPDS

Fig. 9.2: Damage at the inferotemporal quadrant of the optic nerve (rim volume: 0.14 mm3: phase IV). For conventional perimetry
(SAP), the visual field is normal. FDT: Visual field defect correlated topographically with the optic nerve damage. Since it is not
hypertension but a glaucoma in which the IOP is not regulated with maximum therapy, the indication is NPDS.

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

115

Fig . 9.3: Advanced optic nerve damage with a rim volume of 0.17 mm3 (phase IV). Moorfield regression analysis shows a
marked optic nerve damage at the superotemporal quadrant (in red) and a smaller defect at the temporal, inferotemporal,
superonasal and nasal quadrants (in yellow). SAP: normal, FDT: visual field defect correlated topographically with the damage
of the optic nerve. Brusinis GSS for SAP (bottom) and normal visual field on the left. On the right, FDT revealed that the visual
field is in stage 1. Intraocular pressure was not regulated with maximum therapy and NPDS was therefore indicated.

COMPLICATIONS OF SURGERY
Triangular Flap Dissected too Superficially
The dissection of the triangular flap is not deep enough
for the resection of the external wall of the Schlemms
canal. The graphic at the center of the figure shows the
key element for the surgeon to find the Schlemms canal.
The most posterior darker blue sector (between 3 and 4
of the blue area) indicates the location of the Schlemms
canal (Fig. 9.13).
The external wall of Schlemms canal must be
dissected with a cutting round spatula specially designed
for this purpose by Grieshaber (Fig. 9.14). This dissection
can be made with direct illumination or under
transillumination (Fig. 9.15A and B).
For the finding of the Schlemms canal it is very
important to view the surgical area with direct
illumination and with transillumination (Minskys

maneuver). The area is transilluminated by means of


the optical fiber of the microscope supported by the
cornea, and separated from it by one of the white
triangles used for drying, but embedded in physiological
solution to prevent the cornea from overheating (Figs
9.16A and B). (In Figure 9.16A under direct illumination
and in Figure 9.16B, under transillumination).
Transillumination (Fig. 9.16B) clearly reveals the location
of the Schlemms canal (white arrows).
In Figs 9.17A to C the external wall of the Schlemms
canal of the same case has been completely removed.

Triangular Flap Dissected too Deeply


In this case when the surgeon tries to remove part of the
second flap, the iris prolapses because a perforation of
the internal wall has been made (Figs 9.18A to C). If this
happens, the surgical procedure should invariably be
turned into a trabeculectomy (Figs 9.19A to C).

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Atlas of Glaucoma Surgery

Fig. 9.4: Resistance on the conventional outflow pathway, which was removed by trabeculectomy (vertical red line). With NPDS
(vertical green line) we removed the external wall of Schlemms canal with collectors upon removing the triangular flap.
Removal of the internal tissues includes: internal wall of Schlemms canal, the juxtacanalicular tissue, the external part of the
corneoscleral trabecular meshwork. The internal part of the corneoscleral trabecular meshwork and the uveal trabecular
meshwork, which, together with Descemets membrane form the trabeculo-Descemets membrane, remain unmoved.

Fig. 9.5: Trabeculectomy:


All tissues of the internal
and external places of
resistance are removed
when the deep scleral flap
is created

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

117

Fig. 9.6: In NPDS, the external wall of the Schlemms canal is removed with the second triangular scleral flap and with
Mermouds forceps, a membrane made up by the inner wall of the Schlemms canal, the juxtacanalicular tissue and the external
part of the corneoscleral trabecular meshwork are also removed. The tissues which are left in their place are: trabeculoDescemets membrane, made up by the internal part of the corneoscleral meshwork and the uveal meshwork. As stated by Dr
Mermoud, this membrane is strong enough to support the anterior chamber and also permeable enough to improve aqueous
humor outflow with the consequent intraocular pressure reduction.

Fig. 9.7: Chamber angle: Section of the chamber angle 5: Ciliary


muscle, 6: Ciliary body, 7: Sclera, 8: Limbus, 9: Scleral septum
and Schwalbes line, 11: Iris, 12: Cornea, 13: Schlemms canal,
14: Lens. Gonioscopic image S. SPUR: Scleral spur, TR:
Trabecular meshwork, TRSHL: Trabecular meshwork of
Schlemms canal, LSCHW: Schwalbes line, CB: Ciliary body
band, LRI: Last fold of the iris, I. PR: Iris process. Optical cut 1:
Profile line at the posterior corneal surface, 2: Profile line at the
anterior corneal surface, 3: Profile line at the anterior iris surface

Fig. 9.8: The dissection has been correctly performed if three


clear areas are visualized. Dark area (limbal area). Blue area 2
(more posterior), with its anterior limit corresponding to Schwalbes
line, and its posterior limit, to the scleral spur and the open
Schlemms canal. White-grayish area 3 (behind the blue area),
triangular, made up of scleral tissue and covering the external
surface of the ciliary muscle. On the right side of this Figure the
correspondence of the surgical appearance of the three areas
with the anatomic elements of the chamber angle can be seen

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Atlas of Glaucoma Surgery

Fig. 9.9: Removal of the second triangular scleral flap (Left), on which the external wall of Schlemms canal, identified by its
hazel- or brown-colored granulous appearance, can be seen. Center and right: Correlation of this photograph with the landmarks

Figs 9.10A to C: A: Anatomopathologic examination of the


triangular flap showing some
corneal lamellae and the endothelium of the external wall of
Schlemms canal. B: Endothelial
nuclei of the external wall of
Schlemms canal (flat preparation)
C: Collector of the external wall of
Schlemms canal

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

119

Fig. 9.11: Dissection of the inner wall of Schlemms canal with its endothelium, juxtacanalicular tissue and the external corneoscleral
trabecular meshwork (Left). Schematic representation of the tissue removed and of its previous locations (Center), where only
the internal corneoscleral trabecular meshwork and the uveal trabecular meshwork, which, together with Descemets membrane
form the trabeculo-Descemets membrane, are left (Bottom-right).

Fig. 9.12: Correctly placed


implant (Staar). After the
placement the implant
which is secured with a
nylon suture, the scleral flap
is closed with two nylon
sutures. The photograph
shows the implant manufactured by Staar (Switzerland).
In our last 22 cases, we have
used the Corneal implant
(France), a triangular
implant made of sodium
hyaluronate

120

Atlas of Glaucoma Surgery

Fig. 9.13: Image visualized if the dissection has failed to be done at the correct plane and it is not deep enough for the resection
of the external wall of the Schlemms canal by means of the triangular flap. All three areas are visible but the open Schlemms
canal is not (Left). The schematic representation at the center shows the key element for the surgeon to find the Schlemms
canal: the most posterior darker blue sector (between 3 and 4) of the blue area corresponds to the Schlemms canal

Fig. 9.14: The most important


surgical step is to open the
Schlemms canal, located at the
posterior part of the blue area,
adjacent to the scleral spur

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

121

Figs 9.15A and B: Dissection of the external wall of the Schlemms canal (A) under direct illumination and (B) under
transillumination, done with an instrument specially designed for this purpose by Grieshaber

Figs 9.16A and B: Minskys maneuver (see text). In (A) under direct illumination of the Schlemms canal area, the location of
the Schlemms canal cannot be seen, which under transillumination (B) this can be seen very clearly (white arrows)

NPDS PEARLS
The goal of step number 1 (unroofing of the Schlemms
canal) is to remove the external wall in order to achieve
a good exposure of the canal. This step is perfectly shown
in Figure 9.20.
The second critical step is number 2, in which the
surgeon removes the external elements with Mermouds

forceps, as shown in Figure 9.21A. When this step is


perfectly done, the space between the scleral spur and
the Schwalbes line is enlarged, and aqueous humor
percolation is observed (Figs 9.21B and C).

LEARNING CURVE
See Figures 9.22A to H and 9.23A to C.

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Atlas of Glaucoma Surgery

Figs 9.17A to C: The dissection of the external wall of the same case is shown in A, B and C. The external wall of Schlemms
canal is completely removed

A
B
C
Figs 9.18A to C: In this case when the surgeon tried to remove part of the second flap, the iris prolapsed because a perforation
of the internal wall had taken place (A, B and C). When this happens, the surgical procedure must invariably be turned into a
trabeculectomy

GONIOSCOPY AFTER NPDS


Figures 11.24A to C illustrate the typical appearance of
the chamber angle after NPDS. The dark area (A) on
the external wall of the chamber angle is the scleral lake
(1 in the figure), which can be clearly seen full of liquid
with a fine slit cut (B).

Both Figures 9.24A and B show Schlemms canal


and the trabecular meshwork which have become
convex, raised towards the interior of the anterior
chamber, because they have been displaced, and
therefore, deformed by the cylindrical implant.

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

123

Figs 9.19A to C: The triangle flap whit the external wall of Schlemms canal
and the internal wall in place

Fig. 9.20: The goal of step 1 (unroofing of the Schlemms canal)


is to remove the external wall of Schlemms canal

Figures 9.25A and B show another appearance of


the chamber angle after this procedure. In (A) it looks as
if the procedure has been penetrating, however, if viewed
in a fine slit cut (B), a very thin trabeculo-Descemets
membrane is seen.

ND: YAG LASER GONIOPUNCTURE17


In 20 percent of cases, YAG goniopuncture was required
between months 1 to 5 postoperatively for IOP

regulation in cases reaching as high as 20 mm Hg or


more according to a single-spot check, or in the presence
of pathologic results revealed by a daily pressure curve.
The lens designed by Rousell and Fankhauser and
manufactured by Haag Streit was used for this
procedure, with an aim to perforate the resistance zone
if surgery had failed to remove part of the corresponding
tissue, and thereby communicate the anterior chamber
with the scleral lake or the subconjunctival space. The
aiming beam is focused on the trabeculo-Descemets
membrane with a power of 2 to 3.5 mJ; however,
sometimes, higher power, 4 to 5 mJ is required, but it
should be kept in mind that a power above 4 mJ may
cause small hemorrhages which can be stopped by
strongly pressing the lens against the eye. A total of 5 to
20 shots should be made at the level of Schwalbes line,
as well as above and below it. Digital massage, which is
usually indicated after trabeculectomy, is wholly
contraindicated in these cases. However, more
experienced surgeons have now concluded this YAG
goniopuncture to be necessary in 48 percent of cases
(Mermoud 2001) (Figs 9.26 and 9.27A to C).

124

Atlas of Glaucoma Surgery

Figs 9.21A to C: The second critical step is number 2. It is necessary to remove the internal elements, internal wall of Schlemms
canal, juxtacanalicular tissue and external part of the corneoscleral trabecular meshwork in order to regulate the intraocular
pressure. It should be kept in mind that between the internal and external part of the corneoscleral trabecular meshwork there
is a natural cleavage pane

In our experience of 375 NPDS Yag goniopuncture


was required in 20 percent of cases.
Yag laser also becomes useful in the postoperative
period, when there are microperforations during the
surgical procedure, and these are no noticed by the
surgeon. After surgery, the signs of iris incarceration are
dyscoria with ocular hypertension (Fig. 9.28). Iris
incarceration must be treated first with pilocarpine, and
then with laser goniosynechialysis, as shown in Figures
9.29A and B.
In Figure 9.30, the UBM shows the collagen device
after surgery and seven months later the device has been
resorbed and there is a good scleral lake and a thin
trabeculo-Descemets membrane.

Follow-up
All patients were examined at six-month intervals:
1. With a single IOP spot check.
2. With a diurnal curve. The IOP was measured at 6
am, 9 am, noon, 3 pm, 6 pm and 9 pm always
with applanation tonometry: at 6 am with the
patient in bed using a hand applanation tonometer,

the other measurements are made with the patient


seating at the slit lamp. In other to estimate de DPC
we used the following method:18 in each curve two
factors were analyzed:
a. Diurnal average: Arithmetic mean of the readings
obtained during the course of the curve.
b. Diurnal variability: The standard deviation of those
pressures.
With a mean over 19 mm Hg or a variability over
a 2.1 mm Hg, the DPC is considered pathological.
3. Visual field: evaluated with conventional perimetry
(Octopus 101 program G2) and with nonconventional perimetry (Frequency Doubling
Technology, threshold program).
4. With confocal tomography of the optic nerve (HRT).
5. With confocal flowmeter (HRF) for the measurement
of the retinal and optic nerve flow.
6. Gonioscopy.
7. Ophthalmoscopy.
Surgery was considered a complete success when IOP
was 21 mm Hg under no antiglaucomatous medication,
qualified success when IOP was 21 mm Hg under

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

125

Figs 9.22A to H: Step of the surgery when the triangle flap is remove and UBM of the same cases a different stage of the learning
curve, in the first 100 eyes, made in one year, in the first 3 months (A, B), at the 6 months (C, D) at the 9 months (E, F) and at 1
year (G, H).

antiglaucomatous therapy associated with a regulated


diurnal pressure curve (mean below 19 mm Hg and
variability below 2.1 mm Hg) and visual field and optic
disk with now evidences of damage progression.

1. Results of NPDS with an implant after 7 years of


follow up in 60 eyes. (40 with the Staar implant, 20
with the Corneal implant) 60 eyes, 50 glaucomas,
10 glaucomas with cataract (combined surgery)

126

Atlas of Glaucoma Surgery

Figs 9.23A to C: Typical


appearance of the chamber
angle after NPDS. The
Schlemms canal and the
trabecular meshwork have
become convex, raised
towards the interior of the
anterior chamber, because
they have been displaced by
the cylindrical implant, which
deforms them. In (A) the dark
area seen by diffuse illumination on the external wall of
the chamber angle is the
scleral lake, which, in (B), is
seen full of liquid with a fine
slit cut. (C) UBM of the same
case

Figs 9.24A to C: Another


appearance of the chamber
angle after this procedure. In
(A) it looks as if the procedure
has
been
penetrating,
however, if viewed in a fine slit
cut (B), a very thin trabeculoDescemets membrane is
seen. (C) the UBM does not
have enough resolution and it
seems as if the trabeculoDescemets membrane has
been broken down

IOP< 17 mm Hg: 86 percent (10 with Yag-laser


goniopuncture): complete success IOP< 20 mm Hg:
10 percent with antiglaucomatous medication:
qualified success (when IOP was regulated with
glaucoma medication) 4 percent failure (reoperation)

Single IOP spot check before surgery (Mean): 29.8


mm Hg; after surgery: 14.7 mm Hg.
Diurnal pressure curve before surgery: Mean 24.4
mm Hg, Standard deviation: 4.6 mm Hg, after
surgery: Mean 15.3 mm Hg, Standard deviation:
2.1 mm Hg

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

127

Figs 9.25A and B: (A) chamber angle before NPDS; (B) chamber angle after NPDS. The chamber angle studied
with an optical cut made by the slit lamp, shows that after NPDS that half of the Schwalbes line and scleral spur
where removed, and the optical cut between this two element is concave because this is the place of the scleral
lake filled with humor aqueous

Fig. 9.26: Nd: Yag laser goniopuncture: at the left the right place to performed goniopuncture:
at the Schwalbes line, at the posterior corneal surface and in the trabecular meshwork. At
the right there is a goniophotograph showing Schwalbes line, the scleral spur and blood
coming of the Schlemms canal, after goniopuncture

128

Atlas of Glaucoma Surgery

Figs 9.27A to C: (A) Microperforation during surgery, (B) Ocular hypertension due to dyscoria, (C) Iris incarceration

Fig. 9.28: Goniosynechialysis with Yag laser after iris incarceration

Nonpenetrating Deep Sclerectomy (NPDS): Anatomic Landmarks

129

Figs 9.29A and B: (A) Ultrasound biomicroscopy showing, from left to right: conjunctival tissue whit
aqueous humor, separating it from the cuadrangular scleral flap and two parallel lines behind it
corresponding to the implant, where the nylon suture securing it can be seen. The implant is
surrounded by aqueous humor and the scleral lake is seen behind it. (B) The intraescleral lake and
the trabeculo-Descemets membrane, 8 months later. The implant is reabsorbed

Fig. 9.30: Results: 112 consecutive cases with NPDS without


collagen implant: 1. IOP red points at Maximal Medical therapy
(MTMT), 2. IOP orange and green points after NPDS, 3. IOP
yellow and green points after Yag laser, 4. IOP green points
after Medical therapy

2. Results of NPDS without an implant in 315 eyes


after 2 years of follow up: IOP <18 mm Hg: 85.5
percent complete success 85 percent; qualified
success 10 percent (when IOP was regulated with
glaucoma medication); failure 5 percent
(reoperation)
3. Results of trabeculectomy over 40 years with 15
years of follow up in 22180 eyes
Complete success 80 percent
Qualified success 15 percent (when IOP was
regulated with glaucoma medication)
Failure 5 percent (reoperation).
All these results of NPDS, both with and without
the use of an implant, have been obtained without
the use of antimetabolites: Mitomycin-C.

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with collagen implant. Ophthalmic Surgery and Lasers, 1990.
18. Sampaolesi R, Calixto N, Carvalho CA, et al. Diurnal variation of
intraocular pressure in healthy, suspected and glaucomatous eyes.
1st South. Amer. Symp. Glaucoma, Bariloche, Mod. Probl. Ophthal.,
1966, vol. 6, pp. 1-23. (Karger, Basel/New York), 1966.

H Roux, T Shaarawy

Shortening the Learning Curve of

10 Deep Sclerectomy

INTRODUCTION

Anesthesia: Cocaine eyedrops are an excellent choice

The main disadvantage of both deep sclerectomy and


viscocanalostomy is the fact that they are associated with
a long and demanding learning curve. This fact
discourages surgeons from converting to this procedure,
which although has major advantages, falls short on the
ease of mastering it.
The main aim of this chapter is to discuss, in full
detail, all aspects of these techniques, providing specific
step by step instructions with the aim of shortening the
learning period required to successfully carry out the
operation.

for topical anesthesia, if available, otherwise subconjunctival anesthesia could be employed.


Table 10.2: Indispensable instruments used

Fine tipped Colibri forceps


Scalpel and No.11 stainless steel blade
Fine tying forceps to peel the inner wall of Schlemms canal
Microscissors for excising the deep flap.

Conjunctiva should be opened 2 mm at the limbus


lateral to the planned site of the procedure, and should

SURGICAL STEPS

continue 2 mm further from the site; considering that

The procedures is comprised of certain important steps


(Table 10.1). There is no need for an extensive list of
special and expensive instruments, instead, certain good
quality standard instruments are indispensable (Table
10.2).

the superficial scleral flap is 5 mm in width, the conjunctiva

Table 10.1: Important steps of the procedure


1. Corneal tractions suture, in clear cornea and lateral to dissection
site.
2. Fornix based conjuctival incision.
3. 5 5 mm superficial flap, extended 1 to 2 mm into clear cornea.
4. 4 4 mm deep flap scratch incision.
5. Starting the dissection flap with Choroid exposure and dissecting
slightly superficial to that.
6. Gentle pressure on the floor of Schlemms canal to detach the
Descemets membrane from corneal stroma.
7. Extending the deep flap anteriorly by using the bevel side up of a No.
11 stainless steel blade.

should be opened about 9 mm. Conjunctival incision


should be an inverted L- shaped, with the long limb of
the L parallel to the limbus. This allows for better visibility,
compared to limbal based flaps (i.e. opening the
conjunctiva away from the limbus). Another possibility
is to have an inverted C-shape, which allows for an even
better visibility of the surgical field, but takes slightly longer
time to close.
The following figures (Figs 10.1 to 10.15) are
accompanied by detailed explanatory notes on further
steps of the procedures.

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Atlas of Glaucoma Surgery

Fig. 10.1: Five by five superficial scleral flap dissection. A calliper


should be used to make sure that proper dimensions are taken,
and optionally, different sized and different shaped markers
are available

Fig. 10.2: The scratch incision aims at roughly one-third of


the scleral thickness

Figs 10.3A to C: The superficial flap is dissected using a


Scleral pocket minicrescent knife, 1.0 mm width blade, bevelled
up (GR 681.26, Alcon Grieshaber). The dissection is extended
1 to 2 mm into clear cornea. This will later facilitate the creation
of the trabeculo-Descemets membrane (TDM).
Coagulating bleeding vessels should be minimal in order
to avoid too much scarring. Most bleeding vessels can be
controlled by gentle pressure using a microsponge, and
optionally vasoconstrictor eyedrops could be used

Shortening the Learning Curve of Deep Sclerectomy

133

C
Figs 10.4A to C: A further 4 by 4 scratch incision is done in order to fashion a deeper flap using a diamond blade or a No. 11
stainless steel blade. The incision commences close to the cornea, and should be started superficially and gradually increasing
the depth as the incision is extended towards the margins of the superficial dissection

Fig. 10.5: Starting to dissect the deep flap, it is always important to expose the choroid. Exposing the choroid gives a clear
indication on the dissection depth. Choroid exposition should be done in one of the two posterior corners of the deep flap (rightsided, with a right-handed surgeon), and as mentioned before, is done only to comprehend the dissection depth. As soon as the
choroid is exposed, dissection should be started anteriorly a few microns superficial to the choroid. Blind dissection without
observing the choroids, often enough, results in superficial dissection, missing Schlemms canal and subsequent failure

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Atlas of Glaucoma Surgery

Figs 10.6A and B: Dissecting the deep flap entails at all times, the proper stretching of the grasped scleral tissue. In this way a
clear line of dissection is obvious.
Dissecting at this line allows for same level of dissection, going above the line will superficialise the plane of dissection, and
going below the line will, obviously, deepen the plan

Figs 10.7A and B: Continuing on the same plane after observing the choroid, will result in the opening of Schlemms canal,
dividing it into two parts; a superficial part within the dissected deep flap, and a deeper part (floor) in the dissection bed

Shortening the Learning Curve of Deep Sclerectomy

135

Fig. 10.8: After opening Schlemms canal, gentle pressure using a


microsponge would result in detaching Descemets membrane from
the overlying corneal stroma. It is advisable to dissect the flap using
a wet microsponge, as a dry one might perforate the fine membrane

Figs 10.9A and B: Further lateral dissection on both sides with a diamond knife or preferably with a No. 11 steel blade will offer
an extension of the dissection into clear cornea. The blade should be bevel up and angled laterally to avoid perforation. This is
probably the most sensitive part of dissection and assuring the up and lateral direction of the blades bevel is probably the safest
method to dissect. Dissection should be done in as a dry field as possible and under high magnification

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Atlas of Glaucoma Surgery

Fig. 10.10: Now a clear membrane can be seen, this constitutes


the floor of Schlemms canal (opaque band) and Descemets
membrane (transparent segment).
The Descemets membrane is extremely transparent, and
the surgeon should be able to clearly see the iris through it. If
the membrane is opaque, it is an almost sure sign that
dissection was too superficial.
Proper dissection of the membrane is a key step in both
the short and long-term success of the procedure. In the short
term, success depends on opening Schlemms canal and
peeling its floor with the juxtacanalicular trabeculum. While on
the long-term goniopuncture is needed in up to 50 percent of
cases in the first 8 years. Goniopuncture is done through the
Descemets membrane and this entails a proper dissection of
the Descemets membrane to allow for easy perforation with
the Nd:YAG laser

Fig. 10.11: The deeper flap is totally excised. This could be


done directly using microscissors or the incision could be
delineated with a diamond blade followed by excision with
microscissors. Care should be taken to excise the deep flap as
close as possible to the cornea; otherwise the remnants of the
deep flap will fall back and block the membrane

10.12

10.13

Figs 10.12 and 10.13: The inner wall of the Schlemms canal and the Juxtacanalicular trabeculum is peeled off using fine
forceps. One option is the use of the Mermoud forceps (Hucovision, AG), or fine tying forceps. It is a fact that major obstruction
to aqueous outflow is, in primary and secondary open angle glaucoma, the inner wall of Schlemms canal and the juxtacanalicular
trabeculeum, and proper peeling off this portion is key to success

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Shortening the Learning Curve of Deep Sclerectomy

137

Figs 10.14A and B: An implant inserted in the scleral dissection seems to act as a space occupier; bridging the period of
maximal wound healing activity, and is associated, in randomised controlled trials, with improvement in success rates

Fig. 10.15: The superficial flap is loosely sutured by two 10/0


stitches, and the conjunctiva is tightly sutured to avoid a
conjuctival leak (Seidel positive)

Perforation of TrabeculoDescemets Membrane (TDM)


Probably the most common intraoperative complication
of non-penetrating surgery is perforation of the TDM.
In the published reports of experienced surgeons,
perforations occurred in about 30 percent of the first 10
to 20 cases. After the initial learning phase, the surgeon
should expect a perforation in about 2 to 3 percent of
cases.

Different types of perforations include:


1. Transverse tear: Occurs at the junction of the anterior
trabeculum and Descemets membrane, probably the
weakest point of the TDM and corresponds to
Schwalbes line on gonioscopy. A perforation at this
level will usually lead to the formation of a long tear,
followed by immediate iris prolapse.
2. TDM holes: Holes may occur in the TDM during the
anterior deep dissection with the knife. Holes may

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Atlas of Glaucoma Surgery

be either small with no loss of depth of the anterior


chamber, or large and accompanied by shallow or
flat anterior chamber, and/or iris prolapse.

Management
The two factors that determine the management of a
TDM perforation are the depth of the anterior chamber,
as well as the presence of an iris prolapse.
Small holes with no iris prolapse or loss of AC depth
could be ignored and the surgery continued normally.
Small or large perforations with shallow or flat AC and
no iris prolapse should be dealt with in order to prevent
subsequent iris prolapse or peripheral anterior synechia
formations. Viscoelastic material should be injected,
through a paracentesis, into the AC under the TDM
window to reposition the iris. The smallest possible
amount of viscoelastic material should be used to avoid
a postoperative ocular pressure spike. In addition, an
implant resting on the perforation site may be used to
tamponade the hole. The superficial scleral flap should
also be tightly sutured with 6 to 8 10/0 nylon sutures.
Iris prolapse accompanying a long tear or a large
hole calls for a peripheral iridectomy, the superficial flap
should be tightly closed and viscoelastic material injected
in the surgically created scleral space to increase the
outflow resistance.
Any perforation of the TDM during deep sclerectomy
transforms a non-penetrating filtering surgery into a
penetrating one. Because the scleral space left after deep
sclerectomy decreases the aqueous-humor outflow
resistance, a very tight superficial scleral-flap closure is then
of great importance. This operation can be compared to
a trabeculectomy with an additional deep sclerectomy.

Nd:YAG Goniopuncture after NPGS


When filtration through TDM is considered to be
insufficient because of elevated IOP, Nd:YAG goniopuncture can be performed. Using a gonioscopy contact
lens, the aiming beam is focused on the semi-transparent
TDM. Using the free running Q switched mode, with a
power of 4 to 5 mJ, 2 to 15 shots are applied. This
should result in the formation of microscopic holes
through the TDM allowing a direct passage of aqueous

Fig. 10.16: Nd:YAG Goniopuncture after NPGS

from the anterior chamber to the subconjunctival space


(Fig. 10.16). The success rate of Nd:YAG laser
goniopuncture is satisfactory, with an immediate reduction
in IOP of about 50 percent. The success of
goniopuncture depends mainly on the thickness of the
TDM, hence the importance of sufficiently deep
intraoperative dissection.
By opening the TDM, however, goniopuncture
transformed a non-perforating filtration procedure into
a perforating one. Nevertheless the combined complication rates of deep sclerectomy and goniopuncture is
still significantly lower than the complication rates
associated with trabeculectomy.

Results of NPGS
Prospective non-randomized trials of deep sclerectomy
and viscocanalostomy provide sufficient evidence that
the procedure can reduce IOP to acceptable levels.
Randomized controlled trials comparing NPGS to
trabeculectomy are at a consensus on the superior safety
profile of NPGS. On efficacy there are controversial
reports. This disparity in results can be attributed to a
number of factors; namely the fundamental differences
between various NPGS techniques, the long-learning
curves, and the use of gniopunctures to achieve target
IOPs. However, one should keep in mind, when browsing
through results that it is all about technique. Issues related

Shortening the Learning Curve of Deep Sclerectomy


to which technique is superior to which in the wide
spectrum of NPGS is of paramount importance. The
fact of an existing long learning curve could not be over
stated. It is neither meaningful nor scientifically sound to
compare ones last twenty cases of trabeculectomy to
ones first twenty deep sclerectomies.
What is valid is that with its apparent mechanisms of
function that seem to target specific pathological structure
in glaucoma, NPGS is quite promising.
It would be prudent to remember that from the
weight of evidence that we have available, it is of absolute
importance to achieve proper depth of dissection, to
use implants, and to perform goniopuncture whenever
target IOPs are not achieved.

139

FURTHER READING
1. Mermoud A, Schnyder CC, Sickenberg M, et al. Comparison of
deep sclerectomy with collagen implant and trabeculectomy in openangle glaucoma. J Cataract Refract Surg 1999;25:323-31.
2. Mermoud A. Sinusotomy and deep sclerectomy. Eye 2000;14:
531-5.
3. Shaarawy T, Karlen M, Schnyder C, Achache F, Sanchez E, Mermoud
A. Five-year results of deep sclerectomy with collagen implant. J
Cataract Refract Surg 2001;27:1770-8.
4. Shaarawy T, Mermoud A. Deep sclerectomy in one eye vs deep
sclerectomy with collagen implant in the contralateral eye of the
same patient: long-term follow-up. Eye 2005;19(3):298-302.
5. Shaarawy T, Mansouri K, Schnyder C, Ravinet E, Achache F,
Mermoud A.Long-term results of deep sclerectomy with collagen
implant. J Cataract Refract Surg 2004;30(6):1225-31.
6. Shaarawy T, Flammer J, Smits G, Mermoud A. Low first postoperative
day intraocular pressure as a positive prognostic indicator in deep
sclerectomy. Br J Ophthalmol 2004;88(5):658-61.

140

Atlas of Glaucoma Surgery


Kaweh Mansouri, Tarek M Shaarawy

11 Postoperative Management of Nonpenetrating


Glaucoma Surgery

INTRODUCTION
To control the intraocular pressure safely by a surgical
procedure is the philosophers stone of glaucoma. Cairns
trabeculectomy 1 has been associated with a high
incidence of immediate postoperative complications
linked to the opening of the anterior chamber. The new
techniques of nonpenetrating glaucoma surgery
(NPGS), such as deep sclerectomy2 and viscocanalostomy 3 were developed in order to prevent those
problems and have recently gained popularity as a safe
and efficient alternative to conventional penetrating
glaucoma surgery. There is unanimous agreement that
in NPGS postoperative rehabilitation is faster and is not
considered to require the same precautions as following
trabeculectomy.
Nevertheless, the first postoperative weeks are crucial
for the success of NPGS. Experience has shown that
appropriate postoperative management (especially within
the first 2 weeks) can have the same magnitude of
influence on surgical outcome as surgery itself.

ROUTINE EVALUATION REGIMEN AND


MANAGEMENT
The first two postoperative days are essential for judging
the further outcome of surgery.
The following regimen is recommended as a guideline:
the patient is seen on the first postoperative day, where
a complete anterior and posterior examination is
performed, with particular attention given to the
appearance of the bleb and the AC depth.
After that, the patient is seen weekly for the first
month. He is then examined at months 2nd, 3rd and
6th, and, finally every 6 months with visual field

examinations once a year. In high-risk patients and other


complicated cases, additional visits may be required. The
patient is instructed to avoid full physical activity (heavy
lifting or straining).

POSTOPERATIVE MEDICATION
Routine medications used in the immediate
postoperative period (first 2 to 3 weeks) include a topical
regimen of corticosteriods and antibiotics.
Corticosteroids are used to inhibit postoperative
inflammation in the anterior segment by reducing the
rate of conjunctival epithelialization and angiogenesis. It
has been shown that these agents significantly improve
the outcome of filtering surgery. 4 The effect of steroids is
dose-dependent and greatest in the first three days after
surgery.
Prednisolone acetate 1.0 percent is administered
beginning on the first postoperative day. Drops are given
every 4 hours during waking hours for at least two weeks
and then generally tapered over the next 2 to 4 weeks.
If used longer, they may lead to a steroid-induced IOP
rise.
A broad-spectrum antibiotic (e.g. fluochinolone) is
recommended as a prophylaxis for postoperative bleb
infection and endophthalmitis.5 We prescribe antibiotics
for 1 to 3 weeks. There is, however, no consensus among
surgeons for the ideal duration of their use.
Several studies have shown the beneficiary effect of
non-steroidal anti-inflammatory drugs (NSAIDs) such as
indomethacin and diclofenac on postoperative
inflammation and pain. 6,7 In recent years, new
combinations of antibiotics/NSAID have entered the
market that facilitate the surgeons treatment regimen.

Postoperative Management of Nonpenetrating Glaucoma Surgery


Bleb
As after trabeculectomy, almost all patients undergoing
NPGS have a diffuse conjunctival bleb on the first
postoperative day.1
The patient should be examined regularly throughout
the first postoperative period in order to judge the
appearance of the bleb. The desired bleb should appear
diffuse, slightly raised and avascular. Conjunctival
subepithelial microcysts are also associated with successful
blebs.
Failing blebs are often surrounded by a fibrous
capsule that can impede the reabsorption of aqueous
humor. They are characteristically strongly elevated,
vascularized, and localized. Visible corkscrew vessels of
the conjunctiva are a sign of an impending failure.

Management
Failed-filtering blebs should be treated with needling
procedures with or without adjunctive antimetabolite
injection. The needling revision attempts to create an
opening in the thickened wall of a bleb or to elevate the
scleral flap in order to re-establish filtration.
Under the slit lamp, after a 30-gauge needle is
introduced beneath the conjunctiva, the conjunctiva is
ballooned at the site with the injection of a topical
anesthetic. The tip of the needle is then moved into the
fibrous cyst and several tears are made in the capsule. It
could also be moved in sweeping motion to mechanically
separate adhesions at the edges of the flap. Tonometry
and Seidel testing should be done 15 minutes after this
procedure. The procedure can also be performed in the
operating room to ensure a safer environment. Reported
success rates vary between 68 to 93 percent. 9-11
Complications of needle revision are conjunctival
hemorrhage, transient wound leak, hyphema, choroidal
effusion, and hypotony. In general they are minor and
resolve without sequelae.

Digital Ocular Massage


Contrary to trabeculectomy, where the stimulating effect
of applying digital pressure (massage) plays a role in
salvaging failing filtering blebs, it is contraindicated in
NPGS. This is because of the fragile trabeculo-Descemets
membrane that separates the surgically created intrascleral

141

space from the AC. By applying physical force, this


membrane could rupture and cause hypotony or an iris
prolapse with adverse effects.

Nd:YAG Goniopuncture
When percolation of aqueous humor through the
trabeculo-Descemets membrane (TDM) is considered
to be insufficient, a goniopuncture can be performed in
the membrane using a neodymium:yttrium-aluminium
(Figs 11.3 and 11.4) garnet laser shortly after surgery. 12
A lack of surgical dissection can be the reason for a
mounting IOP in the first postoperative period. If
goniopuncture is required later than approximately 9
months after surgery, it may be due to fibrosis of the
TDM. It may be needed in up to 51 percent of
nonpenetrating procedures over a period of eight years
and is successful in lowering postoperative IOP in 80
percent of cases as reported by Shaarawy and coworkers. 13
Complications associated with goniopuncture are rare.
Mermoud et al have reported two cases of choroidal
detachment. There is one reported case of peripheral
iris synechiae to the TDM.14 More recently, Vuori15
reported three cases of spontaneous iris prolapse in her
series of 31 patients. The extent of IOP increase after iris
prolapse (39 mm Hg, 59 mm Hg, and 71 mm Hg in the
3 cases) required surgical intervention, which transformed
the procedure to a trabeculectomy. These reports show
that there are potentially sight-threatening complications
to Nd:YAG goniopuncture.
Gonioponcture with the Nd:YAG laser should be
considered as an useful adjunctive procedure that
converts a nonpenetrating procedure into a microperforating one and can sometimes by the key to successful
surgery.

Antimetabolites
The goal of glaucoma filtering surgery is to maintain an
intrascleral fistula by reducing the wound-healing process
and thereby to keep the IOP in the low teens.
One of the most frequent causes of failure of NPGS is
fibrosis of the conjunctiva and episclera associated with
bleb fibrosis. The use of topical antifibrotic agents such as
Mitomycin-C (MMC) and 5-fluorouracil (5-FU) for wound

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Atlas of Glaucoma Surgery

healing modulation has significantly improved the


prognostic of surgery for high risk cases (i.e. African race,
young age, neovascular and inflammatory glaucoma,
previous failed surgery, and aphakic, or pseudophakic
eyes). Yet despite the benefit of antimetabolites, they also
have some serious potential for harm. In general, they
tend to increase the complications of NPGS, which are
described in the next section.

Mitomycin-C
The MMC is an antibiotic that is isolated from
Streptomyces caespitosus. It has antineoplastic and
cytotoxic properties which have made it popular for
patients with a high risk of filtration failure. MMC has
been shown to be more potent than 5-FU in inhibiting
fibroblast synthesis and proliferation. 16 Several studies
have demonstrated that the use of intraoperative MMC
significantly reduces the postoperative IOP and increases
the success rate of deep sclerectomy. 17,18 It is the single
most important parameter for obtaining desired bleb
morphology.
An MMC is usually applied intraoperatively on a
cellulose sponge to the episclera or the conjunctiva.
Concentrations range from 0.2 to 0.5 mg/ml, for 2 to 5
minutes (some surgeons prefer shorter application times
for patients with thinner structures). Mitomycin-C can
also be administered in the framework of a postoperative
needling revision for failing blebs.
Adverse side effects of MMC use are the toxicity to
corneal endothelium and blood vessels. MMC-associated
blebs have a cystic and avascular aspect. The thin wall
can lead to wound leaks (positive Seidel test). It might
also increase the risk of scleral ectasia and iris prolapse
and should be used cautiously.

5-Fluorouracil
5-FU is a fluorinated pyrimidine antagonist that selectively
inhibits the fibroblast cell cycle, thereby decreasing
fibroblast proliferation. It was the first antimetabolite that
was used by glaucoma surgeons. It reduces scar formation
at the surgical site by reducing the proliferation of Tenons
capsule fibroblasts. Intraoperative application has been
shown to reduce postoperative IOP and the need for
postoperative glaucoma medication. 19,20

For intraoperative application, 5-FU (50 mg per ml)


is soaked on a sponge and placed for 3 to 5 minutes
beneath the conjunctiva and Tenons capsule. Before
resuming surgery, the tissues should be irrigated with
BSS.
Needling with 5-FU can also be recommended for
postoperative injections in eyes with failing filtering blebs.
Injections can be performed as a slit-lamp procedure
directly into the filtering bleb and can be repeated if
required. Karlen and co-workers21 reported about the
use of postoperative subconjunctival iinjections of 5-FU
in failing blebs after deep sclerectomy with collagen
implants. Twenty three percent of their patients received
0.1 ml of a 50 mg/ml solution of 5-FU. The mean
number of injection per patient was 2.9 (SD 2.1).
Most side effects of 5-FU use are transient and less
severe than MMC. They include hypotony, bleb leaks,
corneal epitheliopathy, and endophthalmitis.

COMPLICATIONS AND MANAGEMENT


Early Postoperative Complications
Early postoperative complications are defined as
complications, which occur within the first month after
surgery.
NPGS is associated with significant reduction of early
postoperative complications compared to standard
trabeculectomy. 21,22 The sclerectomy performed in
nonpenetrating glaucoma surgery passes deeply into the
sclera, but it is designed to avoid full-thickness penetration
into the anterior chamber (AC). The remaining thin
trabeculo-Descemets membrane (TDM) offers resistance
to aqueous humor outflow that permits a slow decrease
in IOP and accounts for the reliable and reproducible
IOP on the first postoperative day. It also protects against
abrupt lowering of IOP, thereby minimizing the immediate
postoperative complications due to overfiltration such as
hypotony, choroidal detachments, flat anterior chamber,
and induced cataract.
Despite the apparent safety, the surgeon should be
aware of the existence of postoperative complications
and know how to deal with them appropriately.

Postoperative Management of Nonpenetrating Glaucoma Surgery

143

Ocular Hypertension

Hypotony

Increased IOP is the most common complication after


NPGS that can have different origins and should be
treated accordingly. Fibrosis and loss of permeability of
the TDMs window, which is the main site of aqueous
outflow resistance, are well-described causes of
postoperative elevation in IOP. Insufficient dissection of
the deep scleral flap is a common mistake by a novice to
NPGS. Steroid-responders can show a IOP spike within
the first postoperative weeks. A hemorrhage in the scleral
bed can occur but usually disappears after a few days
and with it the IOP rise. With viscocanalostomy, excess
viscoelastic material that remains in the AC can result in
an IOP increase.
Peripheral anterior synechiae (described below),
malignant glaucoma and postoperative rupture with iris
prolapse are other provocating factors for an uncontrolled
IOP.

We define hypotony as an persistent IOP less than 5


mm Hg. Shaarawy and co-workers23 reported a mean
postoperative IOP of 5.1 (3.3) mm Hg at day 1 after
NPGS. They showed that early postoperative hypotony
was a good indicator of proper surgical dissection and a
prognostic factor for long-terms IOP reduction. IOP
usually increases over the first postoperative days with
topical steroids.
A shallow or flat AC with a low IOP point either to a
wound leak or excessive filtration and would require
surgical intervention to re-establish the AC and reform
any accompanying choroidal effusion. To the best of our
knowledge, there is no reported case of flat anterior
chamber after NPGS in the literature. Therefore,
hypotony after NPGS is common for the first postoperative week, but complications associated with
hypotony are significantly less than with conventional
trabeculectomy. The patient should be informed that
their visual acuity might transiently suffer during this
period.

Management: Treatment should be oriented according


to each specific cause.

Shallow Anterior Chamber


To date no case of completely flat or shallow anterior
chamber has been reported after NPGS. This is probably
due to the lack of abrupt IOP decrease during nonpenetrating procedures. Other risk factors for a shallow
anterior chamber are a leaking bleb, excessive outflow
associated with an overfiltarting bleb, suprachoroidal
hemorrhage, a papillary block, choroidal detachmant,
and malignant glaucoma.
We differentiate three grades of flat anterior chamber:
1. Peripheral iridocorneal touch.
2. Pupillary border iridocorneal touch.
3. Corneal-lenticular touch.
Management: If the shallow AC is secondary to a
choroidal detachment (usually grade 1) it usually resolves
with the resorption of the choroids (often within 2 weeks).
Patients presenting a corneal-lenticular touch should
rapidly undergo a AC reformation in order to avoid
corneal edema, formation of anterior or posterior
synechiae, cataract, or bleb failure. Reformation can be
done by injection of viscoelastic material, air, or BSS.

Management: We hypothesize that the remaining thin


trabeculo-Descemets membrane offers enough
resistance to avoid a collapse of the AC and subsequent
complications such as hypotony maculopathy with
significant loss of vision. Only these cases would require
treatment which is focused on increasing IOP within the
first 6 months.

Bleb Leak
Conjunctival bleb leaks can occur early after surgery and
are the most frequent cause of a flat anterior chamber.
We regularly perform a Seidel test during the early
postoperative period.24 However, wound leaks can also
occur with normal IOP. For this reason, routine Seidel
testing should be performed during the weeks following
surgery, especially for eyes which received antimetabolites
and for blebs with a thin, avascular appearance. Late
spontaneous bleb leaks in-patients with severe coughing
have been reported in trabeculectomy cases. 25 Although
no such case has been described in NPGS, surgeons
should be aware of these potential in-patients with chronic
obstructive pulmonary disease.

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Atlas of Glaucoma Surgery

Management: Most leaks close spontaneously after


discontinuation of steroid therapy. If the leak does not
stop by itself, the application of topical antibiotics (i.e.
gentamicin) can induce conjunctival fibrosis and resolve
a great percentage of bleb leaks. This process can take
as long as four months. Rare resistant bleb leaks can be
surgically managed by intrableb injection of autologous
blood. However, these procedures often do not work
after using antimetabolites because the tissues are
avascular and unresponsive.
The incidence of wound leaks in NPGS is comparable
to penetrating filtering surgery. 26

Hyphema
Hyphema is a complication with a low incidence after
NPGS. 21,27 Anterior chamber bleeding usually originates
from a rupture of small iris vessels, ciliary processes, or
from leakage of red blood cells through the TDM.
Management: In case of levelled hyphema no particular
treatment (i.e. surgical washout) is required since the
AC usually clears itself from present erythrocytes.

Inflammation
The low incidence of inflammation is one major
advantage of nonpenetrating over penetrating filtering
surgeries. The very nature of NPGS being an
extraocular intervention without the need for an
iridectomy explains why anterior chamber inflammation
is mild in the initial postoperative phase and practically
non-existent thereafter. 28
We have observed a higher rate of inflammation inpatients with more complicated diagnosis (pseudoexfoliative, pigmentary, and uveitic glaucoma). There also
seems to be a tendency for increased rates of inflammation in combined phacoemulsification-deep
sclerectomy procedures.29
Management: Topical steroids are given over a six week
period.

Choroidal Detachment
When fluid accumulates between sclera and choroid, an
elevation of the choroids resulting in choroidal
detachment occurs. This complication is often observed

postoperatively when the eye is hypotonic (IOP below 4


to 5 mm Hg). However, by producing a ciliary block
detachment, it can also reduce aqueous humor
production and thereby contribute to prolonged
hypotony. Clinically, a whitish elevation of the retinachoroid is seen in fundoscopy. It can be accompanied
by visual field defects in the periphery. B-scan reveals a
hollow elevation.
Important risk factors include systemic hypertension
(small eyes with thick sclera), hyperopia, age, ocular
inflammation, and atherosclerosis.
Choroidal detachment is a rare complication after
NPGS. Contrary to trabeculectomy eyes with an almost
20 percent incidence28, available literature21,30-33 reports
an incidence rate of 2 to 5 percent after NPGS.
Chiou and co-workers 34 could observe discrete
peripheral choroidal and ciliary body detachments in
40 percent of eyes.
Management: Small and mid-sized choroidal
detachments do not require any specific treatment and
normally resolve with increasing IOP. Severe cases with
persistent corneal-lenticular touch and/or retinal
apposition (kissing choroids), potentially leading to
amaurosis (and corneal damage), require cycloplegic and
anti-inflammatory agents followed by surgical
intervention. In these eyes, surgical drainage of the
suprachoroidal space and anterior chamber reformation
with viscoelastic material is indicated.

Suprachoroidal Hemorrhage
It is a serious but fortunately extremely rare complication
that can lead to permanent loss of vision. There is one
published report in the literature of this complication
occurring after deep sclerectomy.35 In this case, the
suprachoroidal hemorrhage resolved spontaneously by
three weeks. Hemorrhage into the suprachoroidal space
can occur during surgery or in the immediate postoperative period, but generally within the first 48 hours.
The patient experiences severe, uncontrollable pain, loss
of vision and a high IOP. Prolonged hypotony has been
clearly identified as the main risk factor in trabeculectomy
eyes. 36 Another risk factor is aphakia. Since visualization
is normally poor, echography can be useful to detect a
hemorrhage.

Postoperative Management of Nonpenetrating Glaucoma Surgery


Management: If the bleeding does not resolve
spontaneously within a few days, drainage should be
performed through scleral incisions with a constant
infusion of BSS into the anterior chamber. Drainage can
only be done when blood clots have been lysed.

Bleeding during Gonioscopy


Bleeding during gonioscopy after combined
phacoemulsification and deep sclerectomy with SK-gel
implantation has recently been reported in two patients.
Moreno-Montanes and co-worker37 described two cases
who underwent DS and then had moderate bleeding of
the TDM during gonioscopy. The events happened in
both eyes 7 and 8 months postoperatively. In both cases,
the operation had been uneventful and IOP was normal,
goniopuncture had been performed in one case. The
hyphemas had probably occurred from new drainage
vessels around the Descemets window. There is evidence
in animal models that new aqueous drainage veins are
produced in the scleral space after deep sclerectomy. 38
Ambresin et al39 reported one case of recurrent
transitory visual loss 6 years after DS with a collagen
implant. The patient was a 75-year-old female who had
recurrent bleeding through a microperforation of the
trabeculo-Descemets membrane with a 2 mm hyphema.
As rare as it is, this findings suggest that postoperative
gonioscopy should be conducted gently, particularly in
patients under anticoagulation medication.
Management: After application of moderate pressure to
the goniolens the bleeding stops.

TDM Rupture
The thin remaining trabeculo-Descemets membrane can
rupture at any point of time after surgery. Patients should
be warned not to rub their eyes too vigorously and to
avoid Valsalva maneuvers. But the risk of this
complication, normally decreases with time due to
increasing post-membrane outflow resistance. Clinically,
often an accompanying iris prolapse with a decentralized
pupil and darkening of the subconjunctival space can
be seen.
Management: No treatment is needed when IOP remains
stable. If, however, the concomitant iris prolapse impedes

145

the outflow of aqueous humor, producing a IOP rise,


surgical intervention is needed. In these cases, viscoelastic
should be administered to reposition the iris back. A
collagen implant could further tamponade the hole by
swelling up, and the superficial flap should be closed
with 6 to 8 10/0 nylon sutures. If the rupture is more
prominent, the operation should be converted into a
conventional trabeculectomy.

Cataract Formation
Surgery-induced cataract is a common complication of
trabeculectomy, 40 whereas nonpenetrating glaucoma
surgery is associated with very low incidence of cataract.
Aside from the vision impairing effect of cataract
development, cataract extraction in a previously
operated eye may be accompanied by a surgically
induced malfunction of the filtering bleb. 41

Malignant Glaucoma
Malignant glaucoma was first described by von Graefe42
as a form of postoperative glaucoma that often led to
blindness. It is usually characterized by a shallow anterior
chamber and an increase in IOP. Predisposing factors
resulting in malignant glaucoma are (intra)ocular surgery
(e.g. trabeculectomy and cataract surgery) and anterior
segment laser procedures. Due to the property of NPGS
being extraocular, this complication is quite infrequent.
Chiou and co-workers43 reported one case with narrowangle glaucoma who developed malignant glaucoma after
deep sclerectomy.

Late Postoperative Complications


Iris Prolapse
After NPGS, the sclerectomy site becomes the weakest
part of the globe. Intra- or postoperative rupture of the
thin remaining TDM could cause an iris prolapse (Fig.
11.1). Hyams and Geyer44 recently reported two cases
of iris prolapse in their series of 74 patients who
underwent NPGS. The first case was a 72 year-old
woman with PEX glaucoma who developed an iris
prolapse ten months after deep sclerectomy. The second
case was a 77-year-old man with absolute neovascluar
glaucoma, who showed iris incarceration and scleral
ectasia eight months after viscocanalostomy. Both patients

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Atlas of Glaucoma Surgery

developed this complication after IOP increase without


trauma. They did not require any particular intervention,
but needed medical therapy to control their IOP. The
fact that only one suture rather than two or more was
used to close the scleral flap, might explain this
occurrence.
Management: If the iris prolapse is due to a large
perforation, an peripheral iridectomy should be done.
Viscoelastic should be injected in intracameral plus scleral
space to increase outflow resistance accompanied by 6
to 8 nylon sutures to avoid hypotony.

Bleb Fibrosis
A frequent cause of an increasing IOP is bleb failure due
to conjunctival or episcleral fibrosis which is slightly more
frequent after NPGS than after trabeculecomy . Signs of
an early bleb fibrosis are an in elevated IOP, diffuse
conjunctival injection, and the presence of large vessels.
Predisposing factors are inflammation in the anterior
chamber and subconjunctival hemorrhage.
Management: If despite the presence of a fibrotic bleb
IOP remains normal, no treatment is needed. In case of
increasing IOP, subconjunctival injections of an
antimetabolite are required to stop the scarring process.

Encapsulated bleb (Tenons Cyst)


An encapsulated bleb or Tenons cyst develops through
a fibroblastic overgrowth that results in a tight-appearing,
opalescent bleb with a thick wall and vessels of the surface.
This wall entraps the aqueous humor in the
subconjunctival space. In slit-lamp examination, it is
characterized by a large, dome-shaped, pseudocyst and
ring-shaped scarred borders. The conjunctival pseudocyst
is often accompanied by progressive hyperemic
conjunctiva and consequently elevated IOP. Encapsulated
blebs usually appear few weeks (1 to 6 weeks) after surgery.
Encapsulated blebs occur more often when
antimetabolites are used. The incidence of Tenons cysts
after NPGS is comparable to trabeculectomy. Risk factors
include male gender, previous ALT or other ocular
surgery, previous use of topical betablockers or
sympathomimetics.

Management: If the IOP is controlled despite early signs


of scars, the bleb can be simply observed or treated with
anti-inflammatory and/or antiglaucomatous agents (e.g.
beta-adrenergic antagonists). If the IOP becomes
uncontrolled, needling should be done with or without
5-FU or mitomycin-C subconjunctival injections. Despite
successful needling, some blebs have a tendency for
recurrence in which case needling should be repeated.
In these cases, excision of the pseudocyst can also be
attempted.

Peripheral Anterior Synechiae


We speak of peripheral anterior synechia (PAS) when
the iris adheres to the trabeculo-Descemets window (Fig.
11.2). This may occur in the site of filtration with or
without an iris prolapse after rupture (Valsalva or trauma),
intraoperative microperforations of TDM, or iris
entrapment after goniopuncture. They can inhibit
aqueous flow and cause an associated increase in IOP.
Management: Nd:YAG laser lysis can be done to detach
the iris from the osteum. In refractory cases, medical or
surgical intervention (reoperation on another site) should
be attempted.

Cataract Progression
It was reported that cataract progression is not influenced
by deep sclerectomy contrary to trabeculectomy.45 This
lack of progression is probably due to the absence of
postoperative hypotony and the integrity of the anterior
chamber and the globe as a whole.
Shaarawy and co-workers46 followed 104 patients for
up to 48 months and showed progression of existing
senile cataract in 21 percent of eyes.

Descemets Membrane Detachment


This is an unusual complication after NPGS, occurring in
about 1 out of 250 to 300 operated cases.47 Descemets
detachment can occur after deep sclerectomy when
aqueous humor is forced from the scleral space to the
sub-Descemets space, secondary to trauma, needling for
an encysted bleb, or heavy ocular massage. In
viscocanalostomy, the pathogenesis can be attributed to
a misdirection of viscoelastic material (Figs 11.5 and 11.6).

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Postoperative Management of Nonpenetrating Glaucoma Surgery

147

Fig. 11.3: Ultrasonic biomicroscopy image of TDM after deep


sclerectomy

Fig. 11.1: Iris prolapse

Fig. 11.4: Goniopuncture following a flat bleb and elevated


IOP

Scleral Ectasia
Fig. 11.2: Anterior peripheral synechiae on TDM

Clinically, this complication can be seen on the slit


lamp as separation of Descemets membrane from its
overlying stroma with or without a concomitant corneal
edema and blood in the retro-Descemets space.
Management: Although this is generally a transient and
self-resolving complication, it can become prolonged and
affect visual acuity. In severe cases, descemetopexy can
be done with injection of a viscoelastic or air to put the
detached scroll back into place.

Ectasia is a thinning of sclera, usually with bulging; it is in


itself not harmful. Scleral ectasia is an extremely rare
complication that may occur in-patients with thin sclera
and/or abnormal wound healing. Since the scleral flap
(one-third thickness) is weaker than in trabeculectomy
and the deep scleral flap creates a zone of weakness, a
thinner than usual sclera as seen in patients with high
myopia, associated rheumatoid arthritis, or chronic
uveitiscan lead to this condition. Milazzo and coworkers48 reported one case of a 12-year-old girl with
chronic juvenile oligoarticular arthritis who had a rise in

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Atlas of Glaucoma Surgery

Fig. 11.5: Detachment of Descemets membrane after deep


sclerectomy with collagen implant

Fig. 11.6: Detachment of Descemets membrane. Separation


of the membrane from its stroma with corneal edema and
reduction of visual acuity

IOP and developed scleral ectasia with iris hernia. Due


to the anatomical vulnerability, the use of antimetabolites
in these subjects requires careful consideration.

REFERENCES
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2. Kozlov VI, et al. Nonpenetrating deep sclerectomy with collagen.
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3. Stegmann R, Pienaar A, Miller D. Viscocanalostomy for open-angle
glaucoma in black African patients. J Cataract Refract Surg.
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4. Roth SM, Spaeth GL, Starita RJ, et al. The effects of postoperative
corticosteroids on trabeculectomy and the clinical course of glaucoma:
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7. Sun R, Gimbel HV. Effects of topical ketorolac and diclofenac on
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viscocanalostomy versus trabeculectomy in white patients with openangle glaucoma: a randomized clinical trial. Ophthalmology
2001;108(2):254-8.
9. Pederson JE, Smith SG. Surgical management of encapsulated
filtering blebs. Ophthalmology 1985;92(7):955-8.
10. Shin DH, Juzych MS, Khatana AK, Swendris RP, Parrow KA. Needling
revision of failed filtering blebs with adjunctive 5-fluorouracil.
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11. Ewing RH, Stamper RL. Needle revision with and without 5fluorouracil for the treatment of failed filtering blebs. Am J Ophthalmol
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12. Demailly P, Jeanteur-Lunel MN, Berkani M, Ecoffet M, Kopel J,
Kretz G, Lavat P. Non-penetrating deep sclerectomy combined with
a collagen implant in primary open-angle glaucoma. Medium-term
retrospective results. J Fr Ophtalmol 1996;19(11):659-66.
13. Shaarawy T, Mansouri K, Schnyder C, Ravinet E, Achache F,
Mermoud A. Long-term results of deep sclerectomy with collagen
implant. J Cataract Refract Surg 2004;30(6):1225-31.
14. Kim CY, Hong YJ, Seong GJ, Koh HJ, Kim SS. Iris synechia after
laser goniopuncture in a patient having deep sclerectomy with a
collagen implant. J Cataract Refract Surg 2002;28(5):900-2.
15. Vuori ML. Complications of neodymium:YAG laser goniopuncture
after deep sclerectomy. Acta Ophthalmol Scand 2003;81:573-76.
16. Mattox C. Glaucoma filtration surgery and antimetabolites.
Ophthalmic Surg Lasers 1995;26:473-80.
17. Kozobolis VP, Christodoulakis EV, Tzanakis N, Zacharopoulos I,
Pallikaris IG. Primary deep sclerectomy versus primary deep
sclerectomy with the use of mitomycin C in primary open-angle
glaucoma. J Glaucoma. 2002;11(4):287-93.
18. Neudorfer M, Sadetzki S, Anisimova S, Geyer O. Nonpenetrating
deep sclerectomy with the use of adjunctive mitomycin C.
Ophthalmic Surg Lasers Imaging. 2004;35(1):6-12.
19. Ophir A, Ticho U. Encapsulated filtering bleb and subconjunctival
5-fluorouracil. Ophthalmic Surg 1992;23:339-41.
20. Wilson RP, Steinmann WC. Use of trabeculectomy with postoperative
5-fluorouracil in patients requiring extremely low intraocular pressure
levels to limit further glaucoma progression. Ophthalmology
1991;98:1047-52.
21. Karlen ME, Sanchez E, Schnyder CC, Sickenberg M, Mermoud A.
Deep sclerectomy with collagen implant: medium term results. Br J
Ophthalmol. 1999 ;83(1):6-11.
22. Watson PG, Jakeman C, Ozturk M, et al. The complications of
trabeculectomy: a 20-year follow-up. Eye 1990;4:425-38.
23. Shaarawy T, Flammer J, Smits G, Mermoud A. Low first
postoperative day intraocular pressure as a positive prognostic
indicator in deep sclerectomy. Br J Ophthalmol, 2004;88(5):65861.
24. Cain W Jr, Sinskey RM. Detection of anterior chamber leakage with
Seidels test. Arch Ophthalmol, 1981;99(11):2013.
25. Shaikh A, Ahmado A, James B. Severe cough: a cause of late bleb
leak. Glaucoma. 2003;12(2):181-3.
26. Mermoud A, Schnyder CC, Sickenberg M, Chiou AG, Hediguer SE,
Faggioni R. Comparison of deep sclerectomy with collagen implant
and trabeculectomy in open-angle glaucoma. J Cataract Refract
Surg. 1999;25(3):323-31.
27. Lachkar Y, Neverauskiene J, Jeanteur-Lunel MN, Gracies H, Berkani
M, Ecoffet M, et al. Nonpenetrating deep sclerectomy: a 6-year
retrospective study. Eur J Ophthalmol. 2004;14(1):26-36.

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28. Chiou AG, Mermoud A, Jewelewicz DA. Postoperative inflammation
following deep sclerectomy with collagen implant versus standard
trabeculectomy. Graefes Arch Clin Exp Ophthalmol
1998;236(8):593-6.
29. Gianoli F, Schnyder CC, Bovey E, Mermoud A. Combined surgery
for cataract and glaucoma: phacoemulsification and deep
sclerectomy compared with phacoemulsification and trabeculectomy.
J Cataract Refract Surg. 1999;25(3):340-6.
30. Mermoud-Sickenberg, Zimmerman TJ, Kooner KS, Ford VJ, et al.
Effectiveness of nonpenetrating trabeculectomy in aphakic patients
with glaucoma. Ophthalmic Surg 1984;15:44-50.
31. Zimmerman TJ, Kooner KS, Ford VJ, et al. Trabeculectomy vs. nonpenetrating trabeculectomy: a retrospective study of two procedures in
phakic patients with glaucoma. Ophthamic Surg. 1984;15:734-40.
32. Stegmann RC. Visco-canalostomy: a new surgical technique for
open angle glaucoma. An Inst Barraquer Spain 1995;25:229-32.
33. Kozlov VI, Bagrov SN, Anisimova SY, et al. Non-penetrating deep
sclerectomy with collagen. Eye Microsurg (Russian) 1995;3:44-6.
34. Chiou AG, Mermoud A, Hdiguer SE, et al. Ultrasound
biomicroscopy of eyes undergoing deep sclerectomy with collagen
implant. Br J Ophthalmol 1996;80:541-4.
35. Neudorfer M, Sadetzki S, Anisimova S, et al. Nonpenetrating deep
sclerectomy with the use of adjunctive mitomycin C. Ophthalmic
Surg Lasers Imaging. 2004;35(1):6-12.
36. Canning CR, Lavin M, McCartney AC. Delayed suprachoroidal
haemorrhage after glaucoma operations. Eye. 1989;3( Pt 3):327-31.
37. Moreno-Montanes J, Rodriguez-Conde R, Bleeding during
gonioscopy after deep sclerectomy. J Glaucoma. 2003;12(5):4279.
38. Delarive T, Rossier A, Rossier S, Ravinet E, Shaarawy T, Mermoud
A. Aqueous dynamic and histological findings after deep sclerectomy

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with collagen implant in an animal model. Br J Ophthalmol.


2003;87(11):1340-4.
Ambresin A, Borruat FX, Mermoud A. Recurrent transient visual
loss after deep sclerectomy. Arch Ophthalmol, 2001;119(8):1213-5.
Collaborative Normal-Tension Glaucoma Study Group. Comparison
of glaucomatous progression between untreated patients with normal
tension glaucoma and patients with therapeutically reduced
intraocular pressures. Am J Ophthalmol, 1998;126:487-97.
Haynes WL, Alward WM. Control of intraocular pressure after
trabeculectomy. Surv Ophthalmol. 1999;43(4):345-55.
von Graefe A. Beitrge zur Pathologie und Therapie des Glaukoms.
Arch Ophthamol. 1869;15:108-52.
Chiou AG, Mermoud A, Hediguer SE. Malignant ciliary block
glaucoma after deep sclerectomy ultrasound biomicroscopy
imaging. Klin Monatsbl Augenheilkd 1996;208:279-81.
Hyams M, Geyer O. Iris prolapse at the surgical site: a late
complication of nonpenetrating deep sclerectomy. Ophthalmic Surg
Lasers Imaging. 2003;34(2):132-5.
Henchoz L, Schnyder C, Shaarawy T, et al. Surgery-induced cataract
and cataract progression following deep sclerectomy with collagen
implant compared to trabeculectomy. Ophthalmology
2000;107:205.
Shaarawy T, Nguyen C, Schnyder C, Mermoud A. Comparative
study between deep sclerectomy with and without collagen implant:
long term follow-up. Br J Ophthalmol. 2004;88:95-8.
Ravinet E, Tritten JJ, Roy S, Gianoli F, Wolfensberger T, Schnyder
C, Mermoud A. Descemet membrane detachment after
nonpenetrating filtering surgery. J Glaucoma. 2002;11(3):244-52.
Milazzo S, Turut P, Malthieu D, Leviel MA. Scleral ectasia as a
complication of deep sclerectomy. J Cat Refract Surg 2000;26:7857.

150

Atlas of Glaucoma Surgery


Ahmad K Khalil

12 Trabeculotomy Ab Externo

INTRODUCTION
Trabeculotomy is receiving increased interest as a
glaucoma procedure not only in developmental, but also
in adult-onset open-angle glaucoma. Together with
goniotomy, it occupies the forefront in the management
of developmental glaucoma. Except for cases with
anterior segment dysgenesis, trabeculotomy has the
advantages of being possible to perform in virtually all
cases, regardless the presence or absence of corneal
opacity. There is less need for repeated surgeries. Recent
reports have reported success even in conditions it was
thought previously unsuccessful as aniridia and SturgeWeber associated glaucoma.1,2 In recent years, it has been
increasingly performed in adult POAG cases3 with good
results and less complications as compared with
trabeculectomy. It has been also reported in many series
of combined phacotrabeculotomy, with good results.4-6
In these eyes, it is associated, not only with a high success
rate, but also with much fewer complications as
compared with phacotrabeculectomy.
The idea was first introduced in the late sixties and
early seventies,7,8 and is simply to approach the canal of
Schlemm from outside the eye (ab externo), introduce
specially designed probes into them, rotating these into
the anterior chamber. In doing so the inner wall of the
canal, the trabeculum, usually offering the most resistance
to aqueous outflow, and any associated developmental
anomaly, are severed. In eyes with no previous surgical
intervention, it is possible to probe the canal of Schlemm
along the full length of the trabeculotome in virtually all
cases. The often acclaimed branching canal is not met

surgically that often. In an interesting histopathological


study of trabecular meshwork one year after
trabeculotomy in monkeys,9 the chamber angle was
almost completely repaired by newly-formed trabecular
tissue which was identical to the normal trabecular tissue.
Trabeculotomy is a first choice for surgery in all cases
of developmental glaucoma, regardless of any previous
surgery, as long as there is a sound non-scarred 120
degrees of limbic circumference. Bad prognostic signs
include eyes with corneal diameter 14.5 mm or more,
advanced congenital cases, and multiple previous
surgeries.
Several techniques have been described for
performing trabeculotomy. I prefer the use of three sets
of variable curvature handle-less probes. I find them very
advantageous in the following points:
They adapt to varying corneal diameters. Coming
with different curvatures helps in gentle and accurate
probing of the canal. An unsuitable curvature used
might not pass the whole length, and gives a false
block impression.
They are very light weight with no handle to directly
transmit force to them, rendering it difficult to spoil
the two core steps in the procedure; by either
forceful faulty insertion of the trabeculotome, or
traumatic forceful rotation into the AC if it is not
correctly inserted.
On the other hand, this light-weightiness renders the
probes much more difficult for handling and
maneuvering. As with any surgical difficulty, this can be
overcome by practice (Figs 12.1 to 12.35).

Trabeculotomy Ab Externo

151

Fig. 12.1: A previously non-operated eye. Trabeculotomy is


performed at the 12 oclock position

Fig. 12.2: A scarred superior limbus caused by previous


trabeculectomy. A successful trabeculotomy was performed in
the nasal limbus (right side of the picture)

Fig. 12.3: Different curvature trabeculotomy probes. Each set


suits its equivalent corneal diameter and limbal curvature.
Being without a handle renders them mechanically weak
enough not to force a false intrascleral passage, yet very
sensitive to the appropriate limbal curvature, and strong enough
to do their job in severing the delicate trabecular meshwork.

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Atlas of Glaucoma Surgery

Figs 12.4A and B: Diagrammatic representation of the layout of surgery: Surgery is usually carried out at the 12 oclock position,
unless this site is jeopardized by previous surgery, in which case a lateral (or even inferior) approach can be used. Trabeculotomy
probes are introduced into both sides of the cut ends of Schlemms canal. Both probes should be introduced before rotating the
first probe to reduce the difficulty of inserting the second probe in a collapsed canal

Figs 12.4C and D: Probes are then rotated, one after another into the anterior chamber. In doing so, the trabecular meshwork
is cut along the length of the probes connecting the Schlemms canal directly to the anterior chamber

Trabeculotomy Ab Externo

Fig. 12.5: A 6-0 corneal traction (arrow), or a superior rectus


bridle suture helps expose the surgical field. A limbal based
conjunctival incision is made 6 to 8 mm from the limbus. Two 80 retraction sutures are taken in the limbal side of the
conjunctival incision. These not only retract the conjunctiva,
but they also exert gentle traction on the globe, further helping
exposure in these usually large globes in small palpebral
fissures

Fig. 12.6: A superficial scleral flap similar to that done during


trabeculectomy is made

153

Fig. 12.7: Intrascleral dissection is carried out well into the


clear cornea. Position of the canal is so variable in buphthalmic
eyes

Fig. 12.8: A radial incision is started, gradually deepening


over the presumed location of the canal of Schlemm. This differs
greatly between adult and infant eyes, and still there is
considerable variation in its location among newborn-infant
eyes with different globe sizes. Though it is not a rule of thumb,
it is usually located more posteriorly in larger globes. In very
large eyes, it can often be found well underneath the white of
sclera

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Atlas of Glaucoma Surgery

Fig. 12.9: The radial incision is very gradually deepened, extending anteriorly or posteriorly if the need arises, till the canal is
reached. Opening of the canal is recognized by one or more of the following:
Gentle egress of aqueous; a gush or an efflux of aqueous denotes opening the anterior chamber rather than the canal
Direct (dry) visualization of the canal; most commonly in stretched out buphthalmic eyes. This is usually associated afterwards
by the exudation of aqueous
Rarely; in congested eyes, egress of blood from the canal site can be the main sign of its opening

Fig. 12.10: Direct (dry) visualization of the canal


Fig. 12.11: Gentle egress of aqueous is a good indication of
opening the canal

Trabeculotomy Ab Externo

155

Fig. 12.12: A gush of aqueous during dissection signifies


opening the AC rather than the canal. Finding the canal
becomes more demanding, but should be tried

Fig. 12.13: The lip of the radial incision is held by the nondominant hand, while the trabeculotomy probe is held by the
dominant hand and gently directed towards the cut end of the
canal.

Fig. 12.14: The probe is gently introduced into the canal; the lip
of the incision is released. Depending on the depth of dissected
scleral flap, the internal probe can usually be visualized in its
tight path in the canal (arrows). The external probe is always
there to assess the conformity of the trabeculotome to the limbic
circumference, and that it has not gone astray. A correctly places
trabeculotome only moves along its axis. If correctly placed, it
should not rotate. It is a blunt pin in a conforming tube!

Fig. 12.15: Gentle knocking on the back of the trabeculotome


safely guides it along its path to its full length in the canal of
Schlemm. There should be minimal resistance; significant
resistance means either the probe is in the wrong place or if
the probe is surely in the canal, that the probe curvature is not
the ideal one for the that eye.
A smooth passage blocked in the middle of the way can
occur if the probe hits a scarred limbic area caused by a
previous surgery. In primary trabeculotomy, this is very rare.

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Fig. 12.16

Fig. 12.18: Pulling the conjunctiva occasionally is necessary


to assess the conformity of the outer probe to the limbic
circumference

Figs 12.16 and 12.17: The same is repeated with the second
probe

Fig. 12.19: The two probes nicely in place; the outer probes
are parallel to the limbus. They are not freely mobile either
anteriorly into the AC, or posteriorly into the supraciliary space

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157

Fig. 12.20: An example of an extremely stretched-out slit like


canal in a case with advanced buphthalmos. Despite the
apparent difference in the level of right and left trabeculotomes,
both are correctly in the canal (the tube is a bit loose). Note the
relation of the outer probes to the limbal circumference, and
the visibility of the inner probes anterior to the scleral white.

Fig. 12.21: The outer probe betrays a faulty insertion into the
supraciliary space; the trabeculotome is freely mobile
anteroposteriorly. This has to be removed completely, and
reinserted carefully (temporal secondary trabeculotomy in an
eye with previous trabeculectomy at 12 oclock position)

Fig. 12.22: Same case of Figure 12.21 after proper insertion


of the trabeculotome

Fig. 12.23: Faulty insertion into the AC, aqueous gushes to


the surgical field, and the probe is freely mobile anteriorly

Fig. 12.24: Same as Figure 12.23 after proper insertion

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Atlas of Glaucoma Surgery

Fig. 12.25

Fig. 12.26

Figs 12.25 and 12.26: The trabecular meshwork to be cut during trabeculotomy is a soft structure. Cutting it does not involve any
force. On rotating the trabeculotome into the AC, the tip makes the first cut, and appearance in the AC (arrows), then follows the
rest of the internal probe (inset). This tactile lag between appearance of only the tip first, with no limbal or corneal distortion, and
then the rest of the probe (Khalils sign), is an important sign of success. The need for force, with corneal or limbal distortion
(Fig.12.8) simply means that the trabeculotome is not properly placed. On the other hand, if rotation meets no resistance at all,
with simultaneous appearance of the whole length of the internal probe in the AC means that it was lodged in the anterior
chamber angle rather than in the canal

Fig. 12.27: After rotating of the full length of the probe into the
AC, the probe is gently withdrawn, paying care not to touch the
iris-lens. This is especially important with the second probe
when the anterior chamber gets shallower

Fig. 12.28: Corneal wrinkles on rotating the trabeculotome


imply its faulty insertion in scleral lamellae or into the
supraciliary space

Trabeculotomy Ab Externo

159

Fig. 12.29
Fig. 12.30
Figs 12.29 and 12.30: Hyphema on rotating the trabeculotome is not uncommon. It is usually self-limited, and absorbed by the
second postoperative day. Injection of air into the AC helps control a more active bleeding

Fig. 12.31: Scleral flap is closed tightly by interrupted 10/0 monofilament

Fig. 12.32

Fig. 12.33

Figs 12.32 and 12.33: The conjunctiva is then closed by running 8/0 vicryl

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Fig. 12.34

Fig. 12.35

Figs 12.34 and 12.35 (optional addition): In the rare event of inability to locate the canal, the procedure can be easily
converted to a trabeculectomy.

REFERENCES
1. Adachi M, Dickens CJ, Hetherington J Jr et al. Clinical experience
of trabeculotomy for the surgical treatment of aniridic glaucoma.
Ophthalmology 1997;104(12):2121-5.
2. Irkec M, Kiratli H, Bilgic S. Results of trabeculotomy and guarded
filtration procedure for glaucoma associated with Sturge-Weber
syndrome. Eur J Ophthalmol 1999;9(2):99-102.
3. Chihara E, Nishida A, Kodo M et al. Trabeculotomy ab externo: An
alternative treatment in adult patients with primary open-angle
glaucoma. Ophthalmic Surg 1993;24(11):735-9.
4. Gimbel HV, Meyer D. Small incision trabeculotomy combined with
phacoemulsification and intraocular lens implantation. J Cataract
Refract Surg 1993;19(1):92-6.

5. Kubota T, Touguri I, Onizuka N et al. Phacoemulsification and


intraocular lens implantation combined with trabeculotomy for
open-angle glaucoma and coexisting cataract. Ophthalmologica
2003;217(3):204-7.
6. Tanito M, Ohira A, Chihara E. Surgical outcome of combined
trabeculotomy and cataract surgery. J Glaucoma 2001;10(4):302-8.
7. Paufique L, Sourdille P, Ortiz-Olmedo A. Technic and results of
trabeculotomy ab externo in the treatment of congenital glaucoma.
Bull Mem Soc Fr Ophtalmol 1969;82:54-65.
8. Harms H, Dannheim R. Epicritical consideration of 300 cases of
trabeculotomy ab externo. Trans Ophthalmol Soc U K 1970;89:4919.
9. Ito S, Nishikawa M, Tokura T et al. Histopathological study of
trabecular meshwork after trabeculotomy in monkeys. Nippon Ganka
Gakkai Zasshi 1994;98(9):811-9.

Frank Howes, Madhu Nagar

13 Selective Laser Trabeculoplasty

INTRODUCTION
Laser Trabeculoplasty (LTP)
The first pilot study using laser energy on the trabecular
meshwork (TM) to reduce intraocular pressure was
described by Wise and Witter in 1979.1 Many articles
have since been published on the evidence base of the
clinical effectiveness of laser trabeculoplasty using argon
lasers, Dye lasers and Diode lasers. The laser wavelengths
used in the majority have been those provided by the
continuous wave argon lasers traculoplasty (ALT), with
wavelengths between 450 nm (blue) and 520 nm
(green), and with a spot size of 50 m at a pulse duration
of 200 msec, producing powers between 700 and 1000
mW titrated by expected visible reaction on the TM. This
energy absorption at TM produced thermal coagulation
effects detectable by most histopathology techniques.
Clinically this energy absorption produced a drop in
intraocular pressure in approximately 90 percent of
patients treated through 360o (first year, with decreasing
efficiency of 5 to 10% per year)2 and inflammatory
changes sufficient to induce peripheral anterior synechiae
and trabecular scarring. The mechanism of action of LTP/
ALT has been unknown to date with scientific speculation
indicating the likely mechanisms being either mechanical,
by postcoagulative collagenous contracture stretching the
TM open, or ultra-structural, by TM endothelial renewal
following laser induced TM endothelial loss. Later in
vitro studies have confirmed coagulative damage at the
edge and base of ALT craters as well as disruption of
collagen beams, associated fibrinous exudates, lysis of
endothelial cells, and nuclear and cytoplasmic debris.3
In view of the great potential benefit of this form of
treatment, in terms of effectivity, compliance and quality

of life, ALT/LTP has been considered useful as a primary


treatment4-8 for both open-angle glaucoma and ocular
hypertension. However following the early conclusions
of the Glaucoma Laser Trial, the later results9,10 of which
were very positive, many glaucoma specialists felt that,
in view of the damage to the TM from ALT,11 the use of
this treatment modality was best restricted to an
intermediary role between failed medical treatment and
surgery, and certainly repeat treatment (repeat treatment
over previously treated TM, i.e. more than 360 o
treatment) should be entertained only if surgery is
delayed for a short period of time after determination
that medical therapy has failed.

Place of SLT in Relation of ALT


In the search for a less invasive form of laser treatment
for the trabecular meshwork, Mark Latina and coworkers
in 1995 defined a new means for delivering exactly this.12
The group studied the effect of delivering different
forms of laser energy to selective targets in the TM (the
pigmented cells). They noted that by irradiating cell
cultures of pigmented and nonpigmented TM cells with
laser parameters confining the energy absorption to the
pigmented cells only, using pulse durations between 10
nanosec and 1 microsec, coagulative damage was
avoided, hence potentially preserving the structural
integrity of the meshwork while still having the biological
effect of intraocular pressure reduction (Fig. 13.1).
The conclusions drawn from this study lead to the
development of a commercial laser system, the Selecta
7000 for selective irradiation of the pigmented TM cells
(Selective Laser Trabeculoplasty - SLT), initially produced
by coherent and later Lumenis. A number of clinical
studies13-22 have demonstrated SLT to be a safe alternative
to argon laser trabeculoplasty.

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Lumenis has since designed and built two other lasers
for the delivery of Selective Laser Trabeculoplasty.

Fig. 13.1: Schematic drawing of the laser irradiation passing


through a mixed cell culture of pigmented and non-pigmented
TM cells12

The studies have shown that SLT provides effective


reduction in intraocular pressure also in eyes that had
previous argon laser trabeculoplasty (ALT) treatment. It
is less traumatic to the eye than ALT,15 which has been
the standard laser procedure. The ALT can cause tissue
destruction and scarring of the trabecular meshwork
structures. The SLT reduces intraocular pressure without
this risk.

SLT LASER
Lumenis (Coherent) has designed a laser that provides
the necessary energy. The first of these lasers is the Selecta
7000 pictured in Figure 13.2.

Fig. 13.2: The Selecta 7000 SLT Laser. The first produced by
Lumenis (Coherent)

Fig. 13.3: The Selecta Duet which delivers both Q-switched


1064 nm Nd:YAG laser for photodisruption and Q-switched
532 nm frequency doubled laser for SLT

Lumenis has also made an attachment for the


tonometry pole of a Haag Streit type slit lamp that will
deliver the Q-switched 532 nm laser for SLT (Fig. 13.3).
The SLT laser operates by the process of selective
photothermolysis, which is based on three principles:
1. The absorption of laser energy by intracellular targets
that must be greater than that of the surrounding
tissues.
2. The wavelength must match the absorption
wavelength of the target.
3. The pulse duration must be extremely short to
generate and confine heat to the pigmented targets
(the heat should however be sufficient to generate
a biologic response, while minimizing collateral
damage).
With all these parameters met, energy delivery is
independent of focusing (Figs 13.4 and 13.5).

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163

biologic response in the area of energy absorption,


causing the release of cytokines that trigger macrophage
recruitment and other changes leading to IOP
reduction.24

Fig. 13.4
Fig. 13.6: Melanin laden pigmented TM endothelial cells

Fig. 13.7: Photomicrograph of the TM using fluorescent viability/


cytotoxicity assay after irradiation with SLT. Only the pigmented
trabecular cells exhibit nuclear staining (orange fluorescence
which indicates cell death) and absence of green cytoplasmic
staining (green fluorescence). The non-pigmented TM cells
were not affected by the SLT energy, as shown by the
cytoplasmic staining and absence of nuclear staining

Figs 13.4 and 13.5: The Selecta II by Lumenis

Selective laser trabeculoplasty as the name suggests


selectively targets the melanin laden pigmented cells of
the trabecular meshwork (Figs 13.6 and 13.7). It is these
cells that absorb the laser energy, inducing, primarily,

As depicted in Figure 13.7, the selective nature of this


therapeutic form of energy delivery can be seen by the
way in which the non-pigmented cells and connective tissues
are unaffected following the energy delivery. It is these
observations that allow us to conclude that SLT is safe and
effective, and can be employed as a minimal follow-up out
patient procedure (see subsection on complications below).

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The following electron micrographs (Figs 13.8 and 13.9)


further illustrate this point, demonstrating the paucity of
structural damage following SLT.

Fig. 13.8: Electron micrograph of the TM after SLT demonstrating


minimal damage to the trabecular beams (SLT works by using
a specific wavelength to irradiate and target only the melanincontaining cells in the trabecular meshwork, without incurring
collateral thermal damage to adjacent non-pigmented
trabecular meshwork cells and underlying trabecular beams).
As quoted by Theresa R. Kramer M.D., Associate Professor of
Ophthalmology, Emory University, Atlanta, Georgia: SLT
appears to cause no coagulative damage to the human TM,
and less structural damage to the TM compared with ALT

This should be contrasted with the effects on the


trabecular meshwork after Argon Laser Trabeculoplasty
as demonstrated below.

SLT LASER DELIVERY PARAMETERS


1. Solid state Nd:YAG laser (1064 nm), frequency
doubled, producing a wavelength of 532 nm.
2. The laser is Q-switched producing short pulse energy
(3 nanoseconds).
3. The spot size of 400 m diameter.
4. Around 40 to 50 contiguous applications per 180o.
5. Power range 0.4 mJ to 1.2 mJ (end point visual
no reaction seen).

Fig. 13.10: A schematic of the relative size of a 400 m spot


size on the trabecular meshwork (Note that an eye with White
to White measurement of 12 mm has a trabecular distance of
approximately 39 mm, permitting a maximum of 98 contiguous
applications, or 49 applications per 180o)

Figure 13.10 demonstrates the size of the SLT laser


spot on the TM. Note the extension across both Schwalbes
line and the scleral spur, designed to maximize the laser
energy exposure to the target cells. This is contrasted with
the 50 m spot size used in ALT which is aimed at the
anterior nonfunctional third of the TM (Figs 13.11 and
13.12). In spite of the difference in spot size, SLT delivers
approximately 10,000 times less energy than ALT.

EFFECTIVITY OF SLT

Fig. 13.9: Electron micrograph of the trabecular meshwork


following argon laser trabeculoplasty. The damage to the
trabecular beams in considerably more than the damage
following selective laser trabeculoplasty

Numerous authors have demonstrated the effectivity of


SLT. The clinical trials to date have invariably, initially,
examined the response to SLT at the point where they
would otherwise have used ALT, i.e. between failed
medical therapy and surgical intervention. The larger
numbers have been in the groups of primary open-angle

Selective Laser Trabeculoplasty

165

reduction in both patient response rate as well as effect,


when compared to SLT in the failed medical group.16

Fig. 13.11: Schematic of the relative TM coverage of the 400


m spot size of the SLT laser and the 50 m spot size of the
ALT laser

Fig. 13.13: Therapeutic effect of SLT in patients with POAG


and OHT, poorly controlled on maximally tolerated medical
therapy (mtmt) that have had 180 degree SLT (Howes and
Nagar Jan 2003)

Fig. 13.12: Gonioscopic view of the SLT and ALT aiming


spots on the angle

glaucoma (POAG) and ocular hypertension (OHT). Most


of theses studies demonstrate patient response rate of
approximately 80 to 90 percent (first year) with less than
a 5 percent loss of effect in the second year. The success
of these treatments reopened the clinical question as to
whether primary treatment with SLT would be a
satisfactory form of therapy with the obvious benefits of
improved compliance, improved quality of life, reduced
side effects from topical medication and reduced
conjunctival scarring from the reduction in the chronic
use of topical medication, preserving conjunctiva for
potential future filtering surgery. A number of studies
then followed examining the clinical outcomes of primary
SLT in newly diagnosed POAG and OHT. These two
groups showed slightly better intraocular pressure

Fig. 13.14: Therapeutic effect of SLT in patients treated primarily.


Note a slightly better effect than those treated secondarily (see
Fig. 13.13) (Howes and Nagar Jan 2003)

Following the above studies (Figs 13.13 to 13.15), it


was noted that 4 percent of patients responded well to
180o SLT but did not reach target IOP, requiring topical
adjunctive agents, and 5 percent of patients responded
adequately in spite of under treatment due to inadequate
access to the angle due either to segmental narrow angles
or the presence of peripheral anterior synechiae.
Noticing the above factors, and with the knowledge
that a biological response with release of cytokines and
tissue growth factors, intraocular pressure modifying
factors, are likely mediators of the intraocular pressure

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Fig. 13.15: Patient response/nonresponse rates in both groups


(POAG and OHT) that have had 180o SLT both as primary
treatment (pri) and following failed maximally tolerated medical
therapy (sec). The percentage response indicated with the
turquoise bars with numbers of patients indicated alongside.
The red bars indicate the non-response rates (Howes and
Nagar Jan 2003)

reduction, 24 additional studies were performed to


determine whether a dose related response would be
present (Fig. 13.16).
The additional studies were done by performing 90o,
180o and 360o SLT, expecting to find an optimal area
treated for optimal effect, with the hope of defining the
optimal area of tissue to be irradiated for adequate effect
while saving tissue potentially for further treatment if
necessary (Figs 13.17 and 13.18). In addition studies
were done to examine whether a crossover effect was
present, induced by systemically absorbed and circulating
intraocular pressure modifying factors (Fig. 13.19).
As can be seen from the data in Figure 13.15, the
more the area of TM treated by SLT, the greater the
effect. However, the side effects such as discomfort,
anterior chamber activity and intraocular pressure rise
after treatment (see subsection on complications)
Observing the effects of SLT on intraocular pressure
over the three-year duration of the Howes and Nagar
study has lead to a few other observations. Notably there
have been a number of cases that have demonstrated
late response to SLT (8.4% of the POAG group on mtmt
with 180o treatment). Typically, this effect was seen some
8 to 14 weeks after the delivery of the laser.

Fig. 13.16: Artistic impression of the release of cytokines and


activated macrophages over the TM following SLT.24 The
energy absorbtion following SLT causes the release of
cytokines and tissue growth factors, which influence the
migration of monocytes to the injury site. The monocytes are
transformed into activated macrophages, which then return to
the spleen. The spleen becomes a depot site for macrophage
recirculation. These macrophages then return back to the eyes
strictly localizing to the TM, and hence the cross-circulation to
the contralateral eye. (Ref: Dr J Alvarado speaking at
International Glaucoma Society, 4th International Glaucoma
Symposium. Published in Ocular Surgery News Nov 2003)

Fig. 13.17: Therapeutic effect of three different doses of SLT


(intraocular pressure modifying factors) using 90o, 180o and
360o treatment on newly diagnosed OAG and OHT patients.
(Nagar & Howes 2003)22

DELIVERY OF SLT
The SLT on all studies has demonstrated ease of delivery,
minimal discomfort for the patient during delivery of

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TM color change or bubble formation, then reducing


the power slightly, hence the importance of land marking
during delivery as discussed above because positioning
can be lost during delivery if attention is not paid to this
detail.
Topical anesthetic should always be used for the
application of the lens and the delivery of the laser.
Proxymetacaine 1 percent is the most useful agent for
this as the burning sensation after instillation is minimal.

COMPLICATIONS OF SLT

Fig. 13.18: Patient response rates in the three groups treated


with 90o, 180o, and 360o SLT (Nagar & Howes 2003)22

The complication rate following the delivery of SLT is


minimal. The complications appear to be restricted to
mild physical discomfort, anterior chamber activity and
postlaser pressure rises which to date have not exceeded
10 mm Hg. The anterior chamber activity is manageable
with nonsteroidal anti-inflammatory agents, negating the
need for steroidal agents which have other risks in
glaucoma (Fig. 13.20).

Fig. 13.19: Cross-over effect from systemic absorption of


intraocular pressure modifying factors reaching target sites
in the contralateral untreated eye (Howes and Nagar Sept
2003)

the laser with minimal side effects and complications


following the delivery of the laser. The delivery is simple
for any ophthalmologist accomplished in the use and
technique of gonioscopy. Some experience is valuable
in the consistent and even delivery of the laser through
the gonioscope as land markings are important during
the rotation of the device to avoid missing treatment
areas or repeating laser applications over already treated
areas. The application and rotation pressures should be
minimal to avoid patient discomfort. In most respects
the delivery is the same as for ALT with the exception of
the visual end point, which with SLT means increasing
power to the threshold of visible reaction which is any

Fig. 13.20: The adverse effects of SLT in the three groups


90o, 180o, 360o.22 The colour bars indicate the three adverse
events noted following treatment in the three modalities. The
numbers adjacent to each bar indicate the percentage of the
patients affected. Note that the adverse events increase with
the area treated (Howes and Nagar 2003)

Not all the pressure spikes that occur require


management and where the risks are identified for a
particular patient, these are easily managed. Only when
angle pigmentation is dense (e.g. pigment dispersion
syndrome or pseudoexfoliation) is precaution of
particular importance, as excessive heat absorbtion may
cause higher pressure rises, suggesting that these patients

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Atlas of Glaucoma Surgery

may be better treated with low powers and less area of


treatment.

SUMMARY
Selective Laser Trabeculoplasty is a safe and effective
procedure for the treatment of POAG, OHT, and some
of the secondary open-angle glaucomas such as
pigmentary and pseudoexfoliative glaucoma. The
treatment can be applied as both a secondary treatment
profile following poor control on MTMT and as a primary
treatment on the diagnosis of the onset or potential onset
of a glaucomatous optic neuropathy.
Primary treatment offers patients significant
advantages by reduction of medication and possibly no
medication requirement, which is particularly useful in
the elderly or infirm, or in those who are often in the
prime of their lives where inadvertent poor compliance
can be a problem. In addition the effect of the treatment
seems to be better when the treatment is offered when
the intraocular pressures are high and the eye is untreated
by medication.
The modern treatment of glaucoma, which has
involved many new medical agents as well as SLT, has
reduced the need for filtering surgery in many ophthalmic
units. The part SLT plays in this reduction in those units
having this device is difficult to estimate.
The patients who have had SLT are happy but the
need for follow-up in these patients needs to be stressed
as the apparent decrease in the need for medication can
be misconstrued as a cure, careful discussion with the
patients receiving this treatment, particularly as a primary
treatment will avoid this happening.

ACKNOWLEDGEMENT
Thanks and appreciations go to George Marcellino and
his Lumenis company colleagues for their assistance in
the provision of graphic material.

REFERENCES
1. Wise JB, Witter SL. Argon Laser therapy for open-angle glaucoma:
A Pilot study. Arch Ophthalmol 1979; 97(2):319-22.
2. Lund OE, Zink H. Long-term results following argon laser
trabeculoplasty. Klin Monatsbl Augenheilkd. 1988;193(6):572-8
German.

3. Kramer TR, Noecker RJ. Comparison of the morphologic changes


after selective laser trabeculoplasty and argon laser trabeculoplasty
in human eye bank eyes. Ophthalmology. 2001;108(4)773-9.
4. Tuulonen A, Niva A, Alanko H. A controlled five-year follow-up
study of laser trabeculoplasty as a primary therapy for open angle
glaucoma. Am J Ophtalmol. 1987;104(4)334-8.
5. Tuulonen A, Koponen J, Alanko H, Araksinen P. Laser trabeculoplasty
versus medication treatment as primary therapy for glaucoma. Acta
Ophtalmol (Copenh) 1989;67(3)275-80.
6. Bergea B, Bodin L, Svedbergh B. Primary argon laser trabeculoplasty
vs pilocarpine. IV. Long-term effects on optic nerve. Acta Ophthalmol
Scand 1995;73(3):216-21.
7. Bergea B, Bodin L, Svedbergh B. Primary argon laser trabeculoplasty
vs pilocarpine. III. Long-term effects on visual fields. Acta Ophthalmol
Scand. 1995;73(3):207-15.
8. Bergea B, Bodin L, Svedbergh B. Primary argon laser trabeculoplasty
vs pilocarpine. II. Long term effects on intraocular pressure and
facility of outflow. Study design and additional therapy. Acta
Ophthalmol (Copenh) 1994;72(2):145-54.
9. Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial
(GLT) and glaucoma laser trial follow-up study: 7. Results. Am J
Ophthalmol 1995;120(6):718-31.
10. Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial
(GLT) and glaucoma laser trial follow-up study: 6. Results. Am J
Ophthalmol. 1995;120(1):10-22.
11. Howes FW, Trope G. Argon Laser Trabeculoplasty as a Primary
Treatment published Ophthalmic Practice (Canada), 1992;10(3).
12. Latina MA, Park C. Selective targeting of trabecular meshwork cells:
In vitro studies of pulsed and CW laser interactions. Exp Eye Res
1995;60(4):359-71.
13. Latina MA, Sibayan SA, Shin DH, Noecker RJ, Marcellino G. Qswitched 532 nm Nd:YAG laser trabeculoplasty (selective laser
trabeculoplasty): a multicentre, pilot, clinical study. Ophthalmology
1998;105 (11): 2082-8; discussion 2089-90.
14. Latina MA, Tumbocon JA. Selective laser trabeculoplasty: a new
treatment for open angle glaucoma. Curr Opin Ophthalmol.
2002;13(2):94-6.
15. Damji K, Shah KC, Rock WJ, Bains HS, Hodge WG. Selective laser
trabeculoplasty v argon laser trabeculoplasty: a prospective
randomised clinical trial. Br J Ophthalmol 1999;83(6): 718-22.
16. Melamed S, Ben Simon GJ, Levkovitch-Verbin H. Selective laser
trabeculoplasty as a primary treatment for open-angle glaucoma: a
prospective, nonrandomised pilot study. Arch Ophthalmol 2003;
121(7): 957-60.
17. Howes FW, Nagar M. Selective Laser Trabeculoplasty A New
Treatment for Glaucomapresented at the conference of the
International Glaucoma Symposium, Prague 2001.
18. Howes FW, Nagar M. Selective Laser TrabeculoplastyA New
Treatment for Glaucoma: Published Ocular Surgery news September
2001.
19. Nagar M, Howes FW. Selective Laser TrabeculoplastyA New
Treatment for Glaucomapresented American Academy of
Ophthalmology, Orlando 2002.
20. Nagar M, Howes FW. Long-term SLT results promise valuable
primary treatment: published in ESCRS Euro Times January 2003.

Selective Laser Trabeculoplasty


21. Nagar M, Howes FW. Selective Laser TrabeculoplastyA New
Treatment for Glaucoma for Open Angle Glaucoma Management
presented at the conference of the International Glaucoma
Symposium, Barcelona 2003.
22. Nagar M, Howes FW. Selective Laser TrabeculoplastyA
Randomized Control Trialpresented American Academy of
Ophthalmology, Anaheim 2003.

169

23. Cvenkel B, Hvala A, Drnovsek-Olup B, Gale N. Acute ultrastructural


changes of the trabecular meshwork after selective laser
trabeculoplasty and low power argon laser trabeculoplasty. Lasers
Surg Med. 2003;33(3)204-8.
24. Alvarado JA. Selective Laser Trabeculoplasty: Underlying
mechanism. Ophthalmology Management (Supp) 2002; 3-5.

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Atlas of Glaucoma Surgery


Hazem Kholefy

14 Combined Cataract Glaucoma Surgery

A commonly encountered problem is the coexistence of


cataract and glaucoma, especially in the elderly, the
management of either requires consideration of both.
As the degree of visual handicapping caused by the
cataract along with the urgency to control the intraocular
pressure.11
The two conditions are so much interrelated as
progressive lens changes in cataract can mimic
progressive visual field loss, reduce the visual acuity and
narrow the drainage angle. Meiotics can aggrevate visual
impairment from cataract, also previous glaucoma
surgery along with some antiglaucoma drugs can
accelerate the development of cataract, thus each of these
conditions should be considered when treating the other.
40

There have been recent advances that allowed the


combined surgery to promote its success along the last
decade, they include the promotion of the small incision
cataract surgery phacoemulsification and the alternatives
in combining it with glaucoma through a separate incision
surgery or same incision surgery, this along with the
development of the antimetabolites in glaucoma surgery
that added in its success.1-4
Cataract surgery is considered when the patient
complains of deterioration of vision to a point that
interferes with the ability to read, write and perform other
activities of daily living and when his complaints are
harmonious with the examination of his anterior segment
and the degree of cataract putting in mind that the
degree of cataract is perceived more with glaucoma
especially with the compromised fields.11
A thorough examination of the cataract should take
place including the ability to see inside the eye using the

direct ophthalmoscope, also testing of the visual acuity


in high and low contrast, potential acuity testing, pupil,
gonioscopy and routing anterior segment and fundus
examination.
Glaucoma subtypes, IOP control, current medications
used and severity of damage to the optic nerve can affect
the decision. Also previous glaucoma surgeries or laser
iridotomy or trabeculoplasty should be looked for.

SPECIAL CONSIDERATIONS
Conjunctival scarring from previous surgery makes
dissection difficult and increases the failure rate of
glaucoma surgery, as well as increasing the risk of
conjunctival tear and buttonhole. Long use of meiotics
makes the pupil difficult to dilate and makes cataract
surgery difficult specially capsulorrhexis and
phacoemulsification.11
Patients with pseudoexfoliation syndrome are more
prone to develop cataracts, and a higher association of
glaucoma . The management of such a case is challenging
because 1. A tendency towards incomplete mydriasis
with a subsequent small pupil that can complicate cataract
extraction. 2. weak zonules that increases the risk of
zonular dialysis with vitreous loss and lens dislocation
during cataract surgery and again this increases the failure
rate of the glaucoma procedure.17 3. A cornea that might
be more prone to endothelial damage. 4. A tendency
towards hyphaema during surgery. 5. A tendency
towards total zonular loss that will cause even in the bag
lens to fall into the vitreous. If zonular dialysis and lens
subluxation is noted preoperative by phacodenesis this
necessitates a special preparation of either capsular
tension rings with careful Phacoemulsification, or if it is

Combined Cataract Glaucoma Surgery


extreme intracapsular method for cataract extraction is
used along with either sulcus fixation intraocular lens or
anterior chamber lens but with good anterior vitrectomy
in either case. The increased frequency of intraoperative
complications during cataract extraction in pseudoexfoliation syndrome patients stemmed from zonular
weakness rather than capsule tears. Postoperative IOP
declines were greater in group even 2 years after cataract
extraction, suggesting the potential for long-term
improvement in outflow facility in patients with coexisting
cataract and glaucoma.47,51,52
Although cataract and intraocular lens surgery can
go without complications in Fuchs heterochromic uvietis,
however there many patients developed postoperative
persistent inflammation, peripheral anterior synaechia,
rubeosis of the iris and angle, pupillary block and
recurrent hyphaema. Regular glaucoma surgeries usually
failed in such patients without using antimetabolites, the
same as with patients of persistent uveitis and secondary
glaucomas.53-55
The risk of rubeosis in diabetic patients is much
increased after surery especially if the capsule is opened,
the rate of neovascular glaucoma is reported to be 9
percent after intracapsular cataract extraction and 11
percent in cases of extracapsular cataract extraction with
opened capsule, this is in contrast to the much lower
values in case of the intact capsule, however violation of
the capsule during cataract extraction is unavoidable
either intraoperative or postoperative in case of
opacification.56,57

SURGICAL OPTIONS
The coexistence of cataract and glaucoma in the same
patient gives one of three options for management either
doing both procedures in the same time, starting with
the cataract procedure or starting with the glaucoma
procedure.

Combined Cataract and Glaucoma Procedure


It is considered in those eyes with significant cataract and
intolerance to glaucoma medications or bad control of
the glaucoma using two or more medications, it is also
helpful to avoid the spike of intraocular pressure in cases
of compromised optic nerves.

171

Although one procedure is usually better than two


separate procedures, it is associated with less long-term
IOP reduction compared with trabeculectomy alone,
despite identical trabeculectomy techniques in both
procedures.
Nevertheless, combined surgery effectively lowers IOP
and reduces the long-term requirement for antiglaucoma
medications without additional complications. Also in the
absence of pre-existing retinal disease, there is every
expectation that excellent visual acuity will be obtained
in the overwhelming majority of patients along with longterm lower IOPs than when cataract surgery is performed
in a glaucomatous eye without filtration.
Combined surgery also guards against the pressure
spikes that follow cataract extraction in glaucomatous
eye which was reported to be 2.5 times higher than when
combined procedures are done.

Cataract Surgery Alone


Glaucomatous eyes with visually significant cataract in
which the IOP is well-controlled on one or two
medications with minimal disc and field changes, can be
considered for cataract extraction alone, especially in
patients unable to use meiotics because of their lens
opacity. Eyes dependant on adrenergic agents should
not be considered in this category; as cystoid macular
oedema is a significant risk in pseudophakic eyes treated
with epinephrine. There might be no need for
Trabeculectomy, as control of glaucoma is not lost by
the cataract surgery alone, and Trabeculectomy can be
postponed to a later time if needed, in this instance
Phacoemulsification is the method of choice, as it leaves
the eye as a virgin eye and the conjunctiva responds to
trabeculectomy as virgin eyes do. Postoperative the
patient should continue using the glaucoma medications,
in the same rate as preoperative.
Laser trabeculoplasty can be considered prior to
cataract extraction in eyes with border line control of
IOP undergoing cataract surgery alone. The efficacy of
the procedure in pseudophakic eyes is as phakic ones,
however it has less effect in aphakics.
Cataract surgery alone cant be expected to provide
meaningful
IOP
control
whether
using
phacoemulsification or extracapsular method, the long

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172

Atlas of Glaucoma Surgery

term pressure reduction is in the order of 1.5-2.5 mm


Hg at best with the great majority of eyes requiring the
same or increased glaucoma medications after one year.
Cataract surgery alone is technically simpler than the
combined procedure and sometimes cataract surgery
alone resolves the condition completely in cases such as
phacomorphic and phacolytic gllaucoma, but it will never
resolve primary open-angle glaucoma completely.

Glaucoma Surgery First


In eyes with advanced glaucomatous damage with
profound cupping of the optic nerve and dramatic visual
field loss, where the IOP is poorly controlled despite
maximum tolerated medical treatment, where there is
urgent need to control the IOP, filtering surgery then is
the fast option followed later by cataract extraction. In
this case antimetabolites is a must to increase the success
rate, and specially in cases of high risk of failure such as
prior intraocular surgery, eyes with neovascular or
inflammatory glaucoma, the youngs, and african
americans.
In the option of the glaucoma surgery preceding the
cataract surgery, most studies reported a high likelihood
of cataract surgery to compromise a successful filter in
the rate of 30 to 40 percent. This is true even in the case
of clear corneal wound avoiding the conjunctiva. This
suggests that the inflammation caused by lens extraction
is detrimental to long term bleb survivalalthough the
presence of a bleb is helpful in blunting the post-cataract
IOP spike.It is reasonable to anticipate loss of some of
IOP control from a pre existing bleb, to a greater or
lesser extent, if the eye later undergoes cataract surgery
by either ECCE or phacoemulsification. This is
unavoidable as glaucoma surgery worsens the cataract
already existing or initiates cataract in a clear lens and
will make cataract surgery later on inevitable.36, 38,39, 40
The disadvantages of the two-stage approach is that
it subjects the patient to two surgeries with two recovery
periods, each requiring frequent office visits. The patient
also has to withstand poor vision for long on waiting for
the cataract procedure, and eventualy after the cataract
procedure is done it might lead to failure of the filter.
Filtering surgery alone can also obviate the need for
cataract surgery if the worsening of vision is due to the

use of meiotics which can be gotter rid of postoperative.


In short combined surgery is indicated in the following :
Marginal or inadequate IOP control with respect to
the target pressure.
Vulnerability to IOP spike postoperative either
because of advanced visual field loss, or because of
marginal IOP control on maximum regimen which
permits less options postoperatively to lower the IOP.
The need to eliminate medications either because
of lack of compliance, allergy to drugs, side effects,
or high cost of the drugs.

CHOICE OF THE PROCEDURE


The procedure of choice is usually phacoemulsification
and trabeculectomy which gained much superior results
through the history in comparison to extracapsular
method with trabeculectomy. 5, 8 The first procedure
achieved better visual acuity and lower intraocular
pressure with fewer medications , and fewer postoperative
complications.
Again
the
separate
site
phacotrabeculectomy gained more success than same
site. 9, 19, 23, 24, 37 The less manipulations taking place in the
trabeculectomy site the more the success rate of the
trabeculectomy.22
This procedure is also the best approach in chronic
angle closure glaucoma as deepening of the anterior
chamber angle associated with the trabeculectomy usually
resolves the condition and improves the aqueous
drainage along with protection against malignant
glaucoma eminent to happen post filter surgery of the
angle closure type.45
When antimetabolites were used a much superior
success rate was again achieved, and in combining that
to separate site phacotrabeculectomy this appeared to
be the best combination of all. 7, 25
In the literature on surgical techniques and adjuvants
used in the management of coexisting cataract and
glaucoma, the strongest evidence of efficacy exists for
using MMC, separating the incisions for cataract and
glaucoma surgery, and removing the nucleus by phacoemulsification.25
Advanced age is a favorable prognostic factor for
successful control of IOP after combined trabeculotomy
and cataract surgery. Older patients with POAG and

Combined Cataract Glaucoma Surgery


visually significant cataract are good candidates for
combined trabeculotomy and cataract surgery.43
Cataract surgery in glaucoma patients remains a
controversial subjects. Indication of surgery depends on
a lot of clinical parameters: diagnosis, state, evolution of
glaucoma as well as compliance with medical treatment
surgical procedures of cataract and glaucomasites of
the surgeryuse of antifibrosis agents and surgeons
experience. As cataract extraction alone decreases the
intraocular pressure in open-angle glaucoma and mainly
in uncomplicated closed-angle glaucoma and
trabeculectomy alone reduces the intraocular pressure
more than combined surgery with less complications we
recommended the following surgical options: Cataract
extraction alone in patients with controlled open-angle
glaucoma and in patients with closed-angle glaucoma.
A two step procedure: filtering surgery followed by
cataract extraction in patients with poorly controlled
open-angle glaucoma or mixed closed-angle glaucoma.
Ambulatory surgery and topical anesthesia permit a two
stages surgery with less inconveniences. A combined
procedure in patients with a chronic closed-angle
glaucoma where filtering procedure alone is associated
with important complications. Actually, the best surgical
cataract procedure is phacoemulsification with a small
supero-corneal incision and implantation of a foldable
intraocular lens. The best filtering procedure remains
trabeculectomy, or the new non penetrating trabecular
surgery for experimented surgeons, in the superior
quadrant. In the future new surgical procedures and new
safe and non-toxic pharmacologic drugs which modulate
wound healing could be found in order to increase the
efficacity and indications of combined surgery.42, 43, 44, 46
In exfoliative eyes, trabecular aspiration in
combination with phacoemulsification and IOL
implantation is less effective in reducing postoperative
IOP and number of glaucoma medications than the
standard filtering glaucoma triple procedure. The risk
profile, however, appears to be more favorable in the
phaco-aspiration-treated eyes than in the phaco-trab
group. Trabecular aspiration in glaucoma triple
procedure could serve as a possible treatment of choice
for exfoliative eyes with coexisting cataract and glaucoma.
21, 17

173

In African American race, more than 2 preoperative


medications, and intraocular pressure greater than 14
mm Hg in the first postoperative week are major
independent risk factors for initial filtration failure
requiring suture release during the first month after
primary glaucoma triple procedure. Presence of the risk
factors may warrant a more aggressive antiproliferative
regimen and/or earlier suture release.27
With phacotrabeculectomy, limbus-based and fornixbased conjunctival flaps are equally effective in improving
visual acuity and lowering intraocular pressure. This
variation in conjunctival flap orientation was equally
effective in fellow eyes of the same patients, with no
difference in postoperative complications or outcomes.35
Deep sclerectomy combined with cataract surgery
resulted in an IOP reduction similar to that with
phacotrabeculectomy with the same visual outcome, but
the lower complication rate makes ambulatory care
easier.14
Previously failed glaucoma filtration surgery is a
significant risk factor for the filtration failure of combined
surgery. Intraoperative use of adjunctive MMC
significantly improves the filtration success rate of SGTP.34
In a previously operated eye for glaucoma with
hypotony, phacoemulsification might be the procedure
of choice as it causes significant elevation in IOP, resulting
in resolution of hypotony in some of these challenging
cases.20

SURGICAL PROCEDURE
Preoperatively meiotics should be discontinued a few
days prior to surgery to allow for pupillary dilatation if
the IOP is still high other medical options should be used
till the surgery date.
Preoprative the pupil is dilated using phenylephrine,
cyclopentolate and tropicamide and flurbiprofen.
Anaesthesia can be topical, local or general. Local
anaesthesia with sedation is the best option. In this
procedure a 1:1 mixture of 2 percent lidocaine with
bupivacaine, together with 150 units of hyaluronidase
in 10 cc of this mixture, are injected. This same mixture
is used for the facial block either with the van Lint or the
OBrien block. Gentle massage of the lids is used to
soften the globe, intermittently for 5 minutes following

174

Atlas of Glaucoma Surgery

After insertion of the Barraquer open loop wire


speculum provide adequate exposure of the eye
together with allowing passage of the phacoemulsification
handpiece without impedence.
A 7-0 silk suture on a tapered needle is used as a
traction suture through the superior clear cornea, a long
deep sweep through the perilimbal cornea is required
to prevent tearing of the suture through the cornea, a
cotton tipped swab is used to oppose the needle during
insertion.

leak and may provide more long-term control of IOP.


The flap is created in the superotemporal or the
superonasal quadrant, leaving the other quadrant free
for future filtering surgery, if needed.35
In a fornix-based flap, five to seven mm peritomy is
performed at the limbus, and Tenons fascia is incised
free at its insertion and dissected free, only Tenons is
grasped during dissection of the conjunctival-Tenons flap.
Conjunctiva is handled using non toothed, non-serrated
forceps, such as Max fine forceps, to avoid tearing of the
conjunctiva. The sub Tenons dissection is extended
posteriorly and laterally using a spreading action of the
Wescott scissors. The limbus is treated with diathermy
pencil to cauterize the bleerers as well as denuding the
corneal epithelium at the area of the peritomy, and the
coagulum is removed with a weck-Cel.
For a limbus-based flap, a conjunctival incision of
approximately two to three clock hours is made 10 mm
posterior to the limbus. The incision is carried through
Tenons fascia, and meticulous dissection is extended to
the limbus, through Tenons insertion, using rounded tip
Wescott scissors. Similar to the fornix-based flap, the
conjunctiva is handled with non toothed, non serrated
forceps to minimize trauma and avoid tearing of the tissue.

Fig. 14.1: A 7-0 silk suture on a tapered needle is used as a


traction suture through the superior clear cornea

Fig. 14.2: Five to seven mm. Peritomy is performed at the limbus,


and Tenons fascia is incised free at its insertion and dissected free

Conjunctival Flap

Hemostasis

Either a limbus-based or fornix-based conjunctival flap


can be used, however a limbus based flap is less likely to

Excellent haemostasis is achieved with underwater


daithermy (MIRA, Waltham, MA). This is preferable to

the injection. Honan balloon can be used to do the same


effect as the digital massage however in jeopardised optic
nerves it might be dangerous. If the IOP is extremely
high preoperative 25 percent mannitol is used in 250
500 cc saline is given intravenous to guard against
suprachoroidal haemorrhage on sudden decompression
of the globe.
The eye is sterilized with a single drop of 5 percent
povidone iodine, followed by cleaning of the lids, lashes
and surface of the surrounding facial quadrant with 10
percent povidone iodine. Irrigation of the face or eye
with water or saline is not necessary.

Traction Suture

Combined Cataract Glaucoma Surgery

175

bipolar cautery, as diathermy causes less tissue shrinkage


and charring. Diathermy is applied selectively because
not all vessels require closure. Prior to scleral flap
construction the scleral flap area is outlined by cautery.

Fig. 14.4: A mitomycin-C 0.3 mg/cc soaked Weck-Cel is


inserted underneath the conjunctiva

Fig. 14.3: Excellent hemostasis is achieved with underwater


diathermy

Maumenee-Calibri, is used to gold the corner of the


scleral flap and the dissection is carried forward in Half
thickness till clear cornea.

Mitomycin-C
After dissection of the conjunctiva and Tenons capsule a
mitomycin-C 0.3 mg/cc soaked Weck-Cel is inserted
underneath the conjunctiva, the cut edje of the
conjunctiva is not allowed to touch the pledget. It is left
in place for 2 to 3 minutes, depending on the race of
the patient, age and whether or not he underwent
previous surgery. The pledget is then removed and the
whole area is thouroughly irrigated with 15 cc of balanced
salt solution. It is important to avoid accidental inoculation
of MMC into the eye. To avoid this no entry into the
anterior chamber is allowed prior to the application of
MMC, and no instrument is allowed to touch MMC and
if this happens it is soaked well before use.

Scleral Flap
A half thickness triangular or rectangular scleral flap is
fashioned, with dimensions equivalent to the width of
the intraocular lens to be inserted if a one site
phacotrabeculectomy procedure is planned, usually a
3.2 mm is adequate for a foldable IOL and a bigger one
is for rigid IOLs. The scleral flap is outlined by a Grieshaber
681.01 blade or a Beaver 69 blade or an Alcon
superblade 30 degrees. A 0.12 toothed forceps as a

Fig. 14.5: A half thickness triangular or rectangular scleral


flap is fashioned

Care is taken to maintain the same thickness all


through, to avoid early premature entering into the
anterior chamber or amputation of the flap, the dissection
is completed on reaching into the clear cornea. This is
followed by paracentesis.

Phacoemulsification
Entry into the Anterior Chamber
A 3.0 mm Keratome is used to enter the eye at the
anterior most point beneath the scleral flap, the keratome

176

Atlas of Glaucoma Surgery


Capsular Stain
In case of mature cataract after injecting the viscoelastic
material capsular stain is used to stain the anterior capsule
and make capsulorrhexis easy, it is injected underneath
the viscoelastic and after staining the capsule it is then
washed with BSS and viscoelastic is injected again for
capsulorrhexis.

Fig. 14.6: Care is taken to maintain the same thickness all


through

is positioned parallel to the iris plane to avoid dissection


into the corneal stroma or stripping of Descemets
membrane.

Fig. 14.8: After injecting the viscoelastic the capsular stain is


injected underneath the viscoelastic

Fig. 14.7: A 3 mm. keratome is used to make the clear


corneal tunnel for phaco 90 degrees from the scleral flap

In case of separate site phacotrabeculectomy either


the 11 oclock and 1 oclock positions are used for phaco
and the flap or a superior scleral flap and a temporal
clear corneal phaco, in this case after finishing the scleral
flap the microscope is turned 90 degrees to be temporal
and start the steps of phacoemulsification.
Viscoelastic material is injected into the anterior
chamber following construction of the phaco wound by
the keratome.

Fig. 14.9: After injecting the capsular stain onto the capsule
viscoelastic is again injected after washing the stain and rhexis
performed

Management of the Pupil


In case of narrow pupil either because of posterior
synaechia or long use of pilocarpine management differs

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Combined Cataract Glaucoma Surgery


according to the degree of response. First simple
stretching is tried using a Kuglen, Sinskey or Hunkler
hook through the paracentesis and a collar button hook
is inserted through the keratome incision. The pupill is
stretched limbus to limbus with the two hooks at each
clock hour, the hooks are removed and the anterior
chamber filled with viscoelastic, further enlarging the
pupil. This procedure is usually efficient in most cases
and the pupil regains its normal size postoperatively.
Another technique is using multiple small
sphincterotomies performed using long Gills-Vannus
scissors or Rappozzo scissors, the sphincterotomies are
each 1 mm. in length.
The pupil can be opened also using iris hooks 4 of
the disposable hooks are used, they are formed of prolens
and silicone sleeves. They are inserted through stab
corneal incisions at the four quadrants, they catch the
edge of the pupil, and are then drawn towards the
limbus, in the end the result is a square large pupil.

Capsulorrhexis
It is started with the cystotome and continued with it or
with the Utrata forceps. The capsule is then brought out
using the forceps, and then hydrodissection is done with
balanced salt solution using a 27-gauge cannula,
hydrodissection (injecting the BSS between the capsule
and cortex) and hydrodelineation (injecting BSS between
the cortex and nucleus) is done, sometimes the golden
ring is apparent denoting complete hydrodelineation.

177

Phacoemulsification
The normal steps of phaco are carried out either crack
and conquor or chip and flip method.

Fig. 14.11: The crack and conquer technique of phaco


separating the nucleus into 4 quadrants

The nucleus might be cracked into quadrants and


then emulsified and the epinucleus aspirated and then
the cortex is aspirated using the automated irrigation
aspiration or the simcoe, some of the cortex might be
left after insertion of the posterior chamber IOL to protect
the posterior capsule.

Fig. 14.12: The last piece of the nucleus being emulsified


and removed out of the anterior chamber

IOL Insertion
Fig. 14.10: Hydrodissection is performed underneath the
rhexis to envelop the nucleus

The capsular bag is then inflated with viscoelstic such as


Healon and the anterior chamber is inflated with a heavier

178

Atlas of Glaucoma Surgery

viscoelastic, the scleral incision is enlarged to


accommodate the IOL. The IOL is inserted in the capsular
bag with minimal manipulation and trying of non
touching the iris and disperse pigment.

If capsular support is not sufficient anterior chamber


lens is used and a good anterior vitrectomy to remove
all remnants of vitreous in the anterior chamber is done,
the IOL is inserted so that the haptic is put away from
the sclerostomy site at least one clock hour away.

Fig. 14.13: The fldable IOL inserted through the corneal


tunnel using the McDolanld forceps

Fig. 14.15: Final adjustment of the IOL into the capsular bag

If capsular rent is noticed and still possible to insert


the IOL in the bag this is the best thing, if not the lens
might be inserted on the anterior capsule still in the
posterior chamber in the ciliary sulcus, in this case a
PMMA haptics lens is used to lessen postoperative
inflammation, prolene haptics lens are not used in the
sulcus.

Sclerectomy
Following IOL placement, viscoelastic is aspirated from
the eye, carbachol is injected into the eye to constrict
the pupil, then viscoelastic is injected again into the
anterior chamber and specially in the site of the
sclerostomy. The assistant then retracts the flap and a
rectangular sclerectomy is done using the super blade
or the Kelly-Descemets punch.

Fig. 14.14: IOL rotated to fit into the capsular bag

Fig. 14.16: The assistant then retracts the flap and a


rectangular sclerectomy is done using the super blade

Combined Cataract Glaucoma Surgery


Iridectomy
As the assistant continues to retract the scleral flap, the
iris is grasped using a non toothed forceps to avoid
damage to the zonules, lens haptics and ciliary processes,
and the peripheral iris is gently withdrawn from the eye
and by putting the VANNUS scissors horizontally the iris
is drawn towards the scissors and cut giving a wide base
iridectomy.

Fig. 14.17: The iris is grasped using a non-toothed forceps


to avoid damage to the zonules

Closure of the Scleral Flap


The scleral flap is closed tightly with 10-0 nylon sutures,
two sutures at the angles of the rectangular flap are used.
The flow rate is tested through the paracentesis while
holding the Weck-Cel sponge on the flap.

179

Closure of the Conjunctiva


Fornix-based Flap
The conjunctiva is closed with 10-0 nylon sutures
attaching it to the clear cornea at the limbus the sutures
run horizontally from the cornea towards the conjunctiva
through the episclera and cornea then the edge of the
conjunctiva then tightened.

Fig. 14.19: The conjunctiva is closed with 10-0 nylon sutures


attaching it to the clear cornea at the limbus

Limbus-based Flap
The conjunctiva is closed with a 9-0 monofilament vicryl
in a continuous locking sutures and a bite of the posterior
Tenons is taken every 2 or 3 sutures.
Tenonectomy is performed with either technique
especially if there is a thick Tenon obscuring view of the
scleral flap for suture lysis later on.
After closure of the conjunctiva the viscoelastic is
washed from the eye and the phaco wound is hydrated
and taken one suture in for tight closure and if massage
is needed postoprative leak is guarded from.

Extracapsular Method for Combined Surgery

Fig. 14.18: The scleral flap is closed tightly with


10-0 nylon sutures

In the extracapsular method after fashioning of the flap


a scleral incision is made to the right and left of the flap
and then the operation is taken over in the same way as
the plain extracapsular cataract extraction till after insertion
of the lens then the sclerectomy is done and peripheral
iridectomy, and the wound closed with 6 sutures, two
on each side of the flap, and two in the angles of the
scleral flap. The conjunctiva is then closed in the same
manner covering tightly the whole wound.

180

Atlas of Glaucoma Surgery

Postoperative Care
The patient is put on frequent antibiotic steroid
combination for 4 wees with a decreasing rate through
the time and followed up every three days in the first
two weeks then weekly after that.
The need for laser suturelysis is when the pressure
gets high accoring to the condition of the optic nerve
and the target pressure needed, in that case a Hoskins
lens is used with the argon laser adjusted on 50 Mm
spot size 700 MJ and 0.1 sec time usually through a
clear conjunctiva one shot is enough to cut the suture,
mild massage can be done after the suturelysis to
maintain an aqueous drainage.

15.
16.

17.

18.
19.

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and visual acuity follow-up] Ophthalmologe. 2000 Feb;97(2):10812.
Honjo M, Tanihara H, Inatani M, Honda Y, Ogino N, Ueno S, Negi
A, Ichioka H, Mizoguchi T,. Matsumura M, Nagata
M.Phacoemulsification, intraocular lens implantation, and
trabeculotomy to treat pseudoexfoliation syndrome. J Cataract
Refract Surg. 1998 Jun;24(6):781-6.
Hopkins JJ, Apel A, Trope GE, Rootman DS.Early intraocular
pressure after phacoemulsification combined with trabeculectomy.
Ophthalmic Surg Lasers. 1998 Apr;29(4):273-9
Isasi-Saseta MB, Urcelay-Segura JL, Zamora-Barrios J, OrtegaUsobiaga J, Moreno Garcia-Rubio B, Cortes-Valdes C.
[Trabeculectomy and phacoemulsification. One site vs. two site
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Phacoemulsification Surgery on Hypotony Following Trabeculectomy
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Jacobi PC, Dietlein TS, Krieglstein GK. The risk profile of trabecular
aspiration versus trabeculectomy in glaucoma triple procedure.
Graefes Arch Clin Exp Ophthalmol. 2000 Jul;238(7):545-51.
Jampel HD, Friedman DS, Lubomski LH, Kempen JH, Quigley H,
Congdon N, Levkovitch-Verbin H, Robinson KA, Bass EB.. Effect of
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glaucoma surgery: An evidence-based review. Ophthalmology. 2002
Dec;109(12):2215-24; quiz 2225, 2231
Kosmin AS, Wishart PK, Ridges PJ. Long-term intraocular pressure
control after cataract extraction with trabeculectomy:
phacoemulsification versus extracapsular technique. J Cataract
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Kubota T, Touguri I, Onizuka N, Matsuura T. Phacoemulsification
and intraocular lens implantation combined with trabeculotomy for
open-angle glaucoma and coexisting cataract. Ophthalmologica.
2003 May-Jun;217(3):204-7.
Liu CJ, Su HC, Chou JC, Hsu WM, Liu JH. Effect of mitomycin C
for combined trabeculectomy and phacoemulsification. Zhonghua
Yi Xue Za Zhi (Taipei). 2000 Jan;63(1):28-36.
Mamalis N, Lohner S, Rand AN, Crandall AS Combined
phacoemulsification, intraocular lens implantation, and
trabeculectomy. J Cataract Refract Surg. 1996 May;22(4):467-73.
Morris DA, Peracha MO, Shin DH, Kim C, Cha SC, Kim YY. Risk
factors for early filtration failure requiring suture release after primary
glaucoma triple procedure with adjunctive mitomycin Arch
Ophthalmol. 1999 Sep;117(9):1149-54
Noben KJ, Linsen MC, Zeyen TG. Is combined phacoemulsification
and trabeculectomy as effective as trabeculectomy alone. Bull Soc
Belge Ophthalmol. 1998; 270: 85-90
Perasalo R, Flink T, Lehtosalo J, Ralli R, Sulonen J. Surgical outcome
of phaco-emulsification combined with trabeculectomy in 243 eyes.
Acta Ophthalmol Scand. 1997 Oct;75(5):581-3.
Ritch, robert, Sheilds Bruce M, Krupin Theodore. The glaucomas,
second edition. Mosby, 1996.
Ruderman JM, Fundingsland B, Meyer MA. Combined
phacoemulsification and trabeculectomy with mitomycin-C. J
Cataract Refract Surg 1996 Oct;22(8):1085-90.
Samuelson TW. Management of coincident cataract and glaucoma.
Curr Opin Ophthalmol. 1998 Feb;9(1):33-8.

Combined Cataract Glaucoma Surgery


33. Samuelson TW. Management of coincident glaucoma and cataract.
Curr Opin Ophthalmol. 1999 Feb;10(1):66-72.
34. Shin DH, Kim YY, Sheth N, Ren J, Shah M, Kim C, Yang KJ. The
role of adjunctive mitomycin C in secondary glaucoma triple
procedure as compared to primary glaucoma triple procedure.
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35. Shingleton BJ, Chaudhry IM, ODonoghue MW, Baylus SL, King RJ,
C nmohmed nmo Phacotrabeculectomy: limbus-based versus fornixbased conjunctival flaps in fellow eyes. Ophthalmology. 1999
Jun;106(6):1152-5.
36. Shingleton BJ, Heltzer J, ODonoghue MW. Outcomes of
phacoemulsification in patients with and without pseudoexfoliation
syndrome. J Cataract Refract Surg. 2003 Jun;29(6):1080-6.
37. Shingleton BJ, Jacobson LM, Kuperwaser MC. Comparison of
combined cataract and glaucoma surgery using planned extracapsular
and phacoemulsification techniques.Ophthalmic Surg Lasers. 1995
Sep-Oct;26(5):414-9.
38. Song X, Wang W, Yang G. Trabeculectomy combined with
phacoemulsification for treatment of glaucoma complicated with
cataract] Zhonghua Yan Ke Za Zhi. 2000 Nov;36(6):431-4.
39. Stewart WC, Crinkley CM, Carlson AN. Prognostic factors in longterm intraocular pressure control following combined
phacoemulsification and trabeculectomy. Acta Ophthalmol Scand.
1996 Apr;74(2):145-50.
40. Stamper Robert L, Leiberman Marc F, Drake Michael V. Becker
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A, Ichioka H, Mizoguchi T, Matsumura M, Nagata M. Trabeculotomy
combined with phacoemulsification and implantation of an
intraocular lens for the treatment of primary open-angle glaucoma
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42. Tanito M, Ohira A, Chihara A Surgical outcome of combined
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44. Tezel G, Kolker AE, Kass MA, Wax MB. Comparative results of
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45. Tow SL, Aung T, Oen FT, Seah SK. Combined phacoemulsification,
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ophthalmologyebooks.com

182

Atlas of Glaucoma Surgery


Paul Foster

15 Management of Angle-closure

INTRODUCTION
Angle-closure is an anterior segment disease caused by
anatomical disproportion. The defining characteristic is
contact between iris and trabecular meshwork sufficient
to cause a significant reduction of aqueous outflow
(whether permanent or transient). Angle-closure is a risk
factor for glaucomatous optic neuropathy, which is
rapidly progressive in comparison with primary openangle glaucoma (POAG). Population surveys suggest that
untreated angle-closure glaucoma blind about half of
those affected. Most cases are not symptomatic.
However, cases of primary angle-closure (PAC)
encountered in hospital practice characteristically present
with a symptomatic rise in intraocular pressure (IOP) or
relatively advanced optic disk damage and visual field
loss. The management of these cases must be tailored
to the individual case. However, there are three basic
principles of managing people with angle-closure:
1. Immediate control of symptoms and raised IOP.
2. Change angle configuration, preventing further
closure.
3. Detect and control continuing optic disk and visual
field damage.

IMMEDIATE CONTROL OF SYMPTOMS


AND RAISED IOP
For patients presenting with symptomatic primary angleclosure, alleviating discomfort and ensuring the systemic
wellbeing of the patient is the first priority. Reducing the
IOP almost invariably gives symptomatic relief. The
degree and duration of IOP elevation is related to the
tissue damage sustained. Experimental data on primates
suggest that an IOP around 50 to 55 mm Hg (15 mm

Hg below perfusion pressure) sustained for 8 hours results


in patchy necrosis of the iris and ciliary body, while an
IOP around 65 mm Hg would cause ischemic changes
in the optic nerve head.1
An unreactive pupil in the presence of complete
angle-closure suggests there is anterior segment ischemia.
This is an indication for intravenous acetazolamide, which
will have an onset of action at around 15 minutes, peaking
at 30 minutes. The oral route of administration may be
used, but does not reach maximal efficacy until around
2 hours. Vomiting is another indication for use of
intravenous therapy. Applanation tonometry on an
edematous cornea will give a significant underestimate
of true IOP at higher pressures.2 Deciding management
policy solely on the basis of tonometry may be
confounded by this measurement error. However, the
finding of a fall in the IOP following treatment is probably
a reliable sign of improvement.
Pilocarpine is the second line agent. High dose
regimes (for example every 5 minutes) should not be
used, as there is a risk of pilocarpine toxicity mimicking
the features of persistently raised IOP. It has been
calculated that a dose of 100 mg of pilocarpine would
be necessary to reach toxic levels. Paradoxical shallowing
of the anterior chamber, aggravating angle-closure, is
another potential complication, although it probably
does not occur in cases of primary pupil-block angleclosure.3 Pilocarpine 2 percent is probably sufficient for
individuals with blue, green or hazel irides. Anecdotal
reports suggest the dose/response relationship is different
for patients with dark brown eyes, meaning that the 4
percent preparation is probably indicated for Asians and
Africans.

Management of Angle-closure
Once intraocular pressure is controlled, the primary
aims of management are to open the drainage angle,
and to identify and monitor if glaucomatous optic
neuropathy is present and likely to progress.
Most cases (75%) of angle-closure are the result of
primary pupil block. This is dealt with by laser iridotomy
or surgical iridectomy. In about 10 to 12 percent of cases,
the primary mechanism is anterior non-pupil block
closure. This includes people with plateau iris syndrome,
in whom an anteriorly-rotated ciliary body causes a
pronounced angulation in the peripheral third of the iris
that brings the iris close to the trabecular meshwork.
Another anterior non-pupilblock mechanism is
peripheral iris crowding. In these cases, a thick, bulky iris
with prominent circumferential rolls inserts into the
anterior edge of the ciliary body. Dilation of the pupil
exaggerates the peripheral rolls, and leads to
iridotrabecular apposition.

CHANGE ANGLE CONFIGURATION AND


PREVENT FURTHER CLOSURE
Laser Iridotomy
The aim of laser iridotomy is to alleviate pupil block.
One adequately sized iridotomy is sufficient. The
procedure is the essential first step in effectively managing
angle-closure. Generally, it is a very low risk procedure.
The most common adverse event is a transient pressure
rise. Among a group of 200 patients undergoing YAG
iridotomy, an IOP rise (> 10 mm Hg) was reported in
30 percent. Hemorrhage from the iridotomy and
transient blurring of vision occurring in about 20 percent.
Patients taking warfarin should have had a recent
coagulation test (within 1 week) confirming INR< 3.0.
Iritis (11%), posterior synechiae (7%) and corneal changes
(4%) are also recorded complications. 4 Cataract is
considered a potential long-term complication although
one study found visual acuity was the same or improved
in 85 percent of eyes at an average of 1.8 years after
treatment. Cataract progression was responsible for eyes
with decreased acuity; the rate of progression was the
same as that in similarly aged persons treated by surgical
iridectomy.5 Anecdotally, a small numbers of patients
notice a change in their vision related to glare. Symptoms

183

are most common and pronounced if the iridotomy is


positioned at the level of the lid margin, probably because
of the prismatic effect of the marginal tear strip. PIs
should be positioned underneath the upper lid, and
never at the level of the lid margin.
In all patients with thick brown irides (where the radial
fibers of the peripheral iris cannot be seen because of a
thick iris stroma), continuous wave laser (CWL) (i.e. the
argon class of lasers) should be used to pretreat at the
site of the iridotomy. However, retinal burns have been
reported following iridotomy by argon laser alone, and
macular burns are possible. 6,7 People having CWL
pretreatment should be warned of this, although they
can be reassured that the combined argon-YAG approach
minimizes the possibility of this occurrence. 8 The
sequential argon-YAG approach is the technique of
choice in thick brown irides.

Preparation and Premedication


Topical alpha adrenoceptor agonist (apraclonidine or
brimonidine) and pilocarpine (blue eyes: 2%, brown
eyes: 4%) should be used at least 30 minutes before,
with a second dose immediately before starting treatment.
The alpha agonists should be used with caution if there
is history of ischemic heart disease.

Procedure
Anesthetize the eye with amethocaine and apply a Wise
or Abrahams iridotomy contact lens. Check the defocus
is set to zero. Look for iris crypts or thin areas, and treat
an area as peripheral as possible between 11 and 1
oclock. Blue eyes usually require single 1 to 2 mJ shots.
Total power consumption should be less than 30 mJ.
For green and brown eyes where radial fibers are visible
(i.e. thin iris) use single 2 to 3 mJ shots, expecting a
maximum total power of around 50 mJ. For thick brown
irides that have had CWL pretreatment, settings and
power consumption should be similar. If any hemorrhage
is encountered, gentle pressure will help this to stop.
Enlarge the iridotomy circumferentially up to 200
microns diameter.9 Verify by direct inspection that the
iridotomy extends through the iris-pigment epithelium.

184

Atlas of Glaucoma Surgery

CWL Pretreatment for Thick Brown Irides

Laser Iridoplasty

This is mandatory for all Chinese and African. It is very


useful in other Asian and Caucasians with a thick iris. All
classes of continuous wave laser used for retinal
photocoagulation can be usedargon, diode or
frequency doubled YAG lasers for this. Again use a Wise
or Abrahams contact lens. The treatment is given in
two phases, starting with low power shots (80 to 130
mW, 0.05s, 50 microns) to treat a rosette area on the iris
stoma, to produce a soft pitting or a tiny adherent
bubble. About 15 to 20 shots should be needed to do
this. The aim is to prevent large, adherent bubbles
forming in the next phase when the power is increased
(700 to 750 mW, 0.1s, 50 microns), and another 10 to
20 shots are applied to produce a punched out crater
down to the radial muscle fibers and vasculature. If there
is any charring or popping, reduce the power. Complete
the iridotomy with a few shots of YAG. In difficult cases
(typically African patients, and those who need more
than 50 shots) consider aborting the procedure and
opting for a surgical iridectomy.

The aim of iridoplasty is to induce contraction and


compaction of the peripheral iris, drawing the iris away
from the trabecular meshwork, and creating more space
in the peripheral anterior chamber. Iridoplasty can be
used in the management of symptomatic and
asymptomatic cases (i.e. acute and chronic angleclosure). 11,12 Generally iridoplasty is a very low-risk
procedure, with a lower side effect profile than PI.
Transient pressure rises occur occasionally, as does a dullache which may persist for up to one week. A small
number of patients notice a subjective change in their
vision. Corneal burns are possible, and more often occur
when treating acute, symptomatic cases. They are very
rare in elective treatment.

Aftercare
Intraocular pressure should be measured at one to two
hours after treatment. If the IOP is high, oral
acetazolamide plus or minus additional topical agents
should be used as required. All patients should receive a
strong topical steroid (prednisolone 1% or
dexamethasone 0.1%) hourly for 24 hours (taking a
break through the night), and then 4 times a day. All
patients should be seen 1 week later in clinic and regonioscoped. Stop steroid unless there is evidence of
continued inflammation. If the IOP is raised and there is
anterior segment inflammation, swap to a topical NSAID.

Surgical Iridectomy
A randomized clinical trial of surgical iridectomy versus
laser iridotomy identified no difference in IOP control
and visual acuity at 3 years post-treatment.10 Surgical
iridectomy should be performed in African and AfroCaribbean patients in whom a laser iridotomy has been
difficult.

Preparation and Premedication


This is performed in exactly the same manner as for
iridotomy. Ensure that patients do not have high or
extensive low PAS. The inflammation induced by
iridoplasty will, in some cases, cause an extension of PAS.
People with low, early (sawtooth) PAS can be treated,
provided they are given pilocarpine qid post-laser, to
splint the angle open for 1 week.

Procedure
Anesthetize the eye with amethocaine, apply a Wise or
Abrahams iridotomy contact lens. Any continuous wave
laser used in pan-retinal photocoagulation may be used
to perform iridoplasty. Different classes of lasers vary
somewhat in their efficacy relative to power, and there is
substantial variation in power uptake between eyes. As
a general rule, you should start with a low power and
increase until the desired effect is achieved. Starting from
100 mW, the desired response is usually achieved at
between 180 mW and 300 mW: Pulse duration 0.5 to
0.7s, and spot size 500 microns. Burns should be applied
as peripherally as possible, throughout 360. A full
treatment requires about 25 to 35 shots, each burn being
placed about 2 aiming beam widths from the area of
discoloration marking the previous shot. The ideal endpoint is a brisk contraction of the iris stroma, without

Management of Angle-closure
charring or a pop (if these occur, turn the power down).
The aiming beam should be crisply focused in a regular
circle. Varying the direction of gaze of the subject often
helps clear visualization of the area to be treated. Most
often, directing gaze away from the quadrant being
treated improves the view.
The procedure is the identical for treatment of acute
cases. The view may be improved a little using topical
glycerine to clear a steamy cornea. The AC should be
examined carefully to determine where the cornea and
iris are in contact. These areas should not be treated
unless no alternative exists. If there is 360 peripheral
iridocorneal apposition, start the treatment more
centrally, and as the burns pull open the angle, rapidly
spiral the treatment into the extreme periphery.

Aftercare
This is exactly the same as for cases having laser PI. In
addition, any cases with PAS should be given pilocarpine
(blue eyes: 2%, brown eyes: 4%) to use qid for 1 week.
All patients are seen 1 week later in clinic and regonioscoped. Stop steroid unless there is evidence of
continued inflammation. If the IOP is raised and there is
anterior segment inflammation, swap to a topical NSAID.
Pilocarpine should be discontinued at 1 week, and the
gonioscopy repeated 3 to 4 weeks later to assess the
effect of iridoplasty on angle configuration.
In selected cases of pure plateau iris syndrome, laser
iridoplasty appears to be highly effective, changing angle
width from 0 to 20 in all cases in a reported series (often
to 30). The changing in angle width is relatively longlasting, with 20/23 eyes retaining open angles throughout
the follow-up period of at least 6 years. The other three
in whom the effect wore off were retreated with a further
change in angle width, suggesting that retreatment is
appropriate in certain selected cases.12

Cataract Surgery and Lens Extraction


Providing trabecular function is reasonably intact (less than
180 of high PAS), any patient with angle-closure and a
visually significant cataract can be very effectively managed
by cataract extraction and IOL implantation.13- 15 In people

185

with more than 180 PAS and uncontrolled IOP who


underwent phacoemulsification cataract surgery
combined with goniosynechialysis within 6 months of an
episode of symptomatic angle-closure (i.e. an acute
attack), IOP was controlled postoperatively without
medication for at least 3 months (and in some cases up to
6 years). All patients retained the same or better visual
acuity than preoperatively.16
Lens extraction remains the definitive method of
managing cases of lens induced angle-closure. These
cases either have very advanced (typically hypermature)
lens opacities or dislocated/subluxated lenses.

Medical Management of Angle-closure


Topical pilocarpine remains an effective medical method
of reversing appositional angle-closure, but has attendant
complications of brow-ache, induced myopia, dimming
of vision and probably accelerated formation of lens
opacities. Long-acting pilocarpine gel is better tolerated,
and has the advantage of a single, night-time dosage
regime. Previous pilocarpine treatment is believed to
prejudice the outcome of trabeculectomy.17 Pilocarpine
use should be carefully considered in patients with
pseudoexfoliation and angle-closure because of the
potential for rupture of zonules.18
Topical atropine is extremely effective in some cases
of secondary angle-closure caused by retrolenticular
forces. Aqueous misdirection (ciliolenticular block/
malignant glaucoma) is one example of the role for
atropine. The key diagnostic features in these cases are
an atypical history or a marked asymmetry in the
appearance of the anterior chamber. For example, angleclosure in a myopic subject who has undergone retinal
detachment surgery, either recently with a gas or oil
posterior tamponade, or in the past and has a very high
indent from an explant are likely to improve with atropine
(and dramatically deteriorate with pilocarpine). If the
central anterior chamber depth is asymmetrical (> 0.6
mm) a secondary cause should be sought, and atropine
considered as a possible treatment. Atropine, however,
is a temporizing measure, and the definitive management
is aimed at the cause of the retrolenticular force.

186

Atlas of Glaucoma Surgery

DETECTION AND CONTROL OF


CONTINUING OPTIC DISK AND VISUAL
FIELD DAMAGE
The natural history of glaucomatous optic neuropathy
accompanying angle-closure is not fully understood. It is
more pressure dependent disease than open-angle
glaucoma. 19 Data from studies of white-on-white
automated perimetry suggest the pattern of field loss in
cases in the more common, asymptomatic from of angleclosure glaucoma is similar to that seen primary open angle
glaucoma, with the exception that field loss in PACG does
not exhibit the same predilection for the superior hemifield
as is characteristic in early to moderate cases of POAG.
Consequently, after any symptomatic episodes have
been dealt with, and all appropriate steps have been
taken to open the drainage angle, the management of
cases of PAC and PACG is broadly analogous to that of
OHT and POAG. Regular examination should assess the
intraocular pressure, the optic disk and visual field, as
well as regular assessment of the angle, ideally by
gonioscopy and either ultrasound biomicroscopy or
optical coherence tomography.
In patients with raised IOP in chronic angle-closure
following a laser iridotomy, prostaglandin analogues have
been shown to outperform beta-blockers in IOP control.20

PREVENTION IS BETTER THAN CURE


The majority of cases of angle-closure glaucoma occur
in the densely populated, relatively poor countries of
Asia. In China alone, it is estimated that some 1.7 million
people are blind in both eyes from PACG. As PACG
exists in an early/latent form (anatomically narrowangles) prior to the onset of severe, visually destructive
disease, and there exist tests which show reasonable
performance in detecting early cases,21,22 it is justifiable
to examine whether population screening and
prophylactic treatment is ethically, scientifically and
economically justifiable.23 Trials to address this issue are
underway.24

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intraocular pressure-lowering effect of latanoprost and timolol in
patients with chronic angle closure glaucoma. A preliminary study.
Ophthalmology 2000;107:1178-83.

ophthalmologyebooks.com

Management of Angle-closure
21. Foster PJ, Devereux JG, Alsbirk PH, et al. Detection of gonioscopically
occludable angles and primary angle closure glaucoma by estimation
of limbal chamber depth in Asians: modified grading scheme. Br J
Ophthalmol 2000;84:186-92.
22. Devereux JG, Foster PJ, Baasanhu J, Uranchimeg D, et al. Anterior
chamber depth measurement as a screening tool for primary angleclosure glaucoma in an east Asian population. Arch Ophthalmol
2000;118:257-63.

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23. Wilson JMG, Jungner G. Criteria for assessing the viability,


effectiveness & appropriateness of a screening programme. 1968;34.
Geneva: World Health Organization. Public Health paper.
24. Nolan WP, Baasanhu J, Undraa A, et al. Screening for primary
angle closure in Mongolia: a randomised controlled trial to determine
whether screening and prophylactic treatment will reduce the
incidence of primary angle closure glaucoma in an east Asian
population. Br J Ophthalmol 2003;87:271-4.

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Atlas of Glaucoma Surgery


Dilani Siriwardena, M Francesca Cordeiro

16 Modulation of Wound Healing

Table 16.1: Strategies for modulating wound healing

INTRODUCTION
The wound healing response is the single most important
determinant of the final intraocular pressure after
trabeculectomy, with excessive postoperative scarring
significantly reducing success.1,2 Over the last 20 years
there has been increasing use of agents to modulate this
response and produce an improved outcome from
filtration surgery. Recent advances in molecular and cell
biology have made a major impact on our understanding of the wound healing process and its
modification. This is leading to the advent of new agents
as modulators of the scarring response following
glaucoma surgery.
The glaucoma surgeon has the opportunity to assess
and modulate the wound healing response before,
during and after surgery. In this chapter we look at these
three stages in turn and review the spectrum of antiscarring therapies that are either currently available or
in development for use in each situation. Finally, since
the wound healing response is involved in the
pathogenesis of glaucoma by several different mechanisms, we briefly comment on the potential of modulating other important sites implicated in this disease, such
as modifying the growth factor, TGF- in the trabecular
meshwork and optic nerve head (Table 16.1).

PREOPERATIVE STRATEGIES
Careful preoperative assessment of the patient allows
the glaucoma surgeon to estimate the risk of failure of
drainage surgery. A number of factors are known to
increase the chance of scarring, as summarized in Table
16.2. This knowledge can then be applied to the
individual patient, taking into account their particular

Preoperative strategies

Topical steroid
Oral steroid

Intraoperative strategies

5-Fluorouracil
Mitomycin-C
Beta irradiation
Photodynamic therapy BCECF-AM
TGF antibody
Suramin

Postoperative strategies

Topical steroid
5-Fluorouracil
Tranilast
Interferon alpha 2

Future strategies

Modulate TGF in trabecular meshwork


Modulate TGF in optic nerve head

Table 16.2: Risk factors for scarring and failure after glaucoma
filtration surgery
Risk factor

Comment

Age

Higher risk if younger, especially under 40

Race

Higher risk if African Caribbean, less if


Caucasian

Previous topical
medication

Higher risk with epinephrine or allergy

Uveitis

Higher risk if chronic or active at time of


surgery

Chronic conjunctival
inflammation
Previous failed
glaucoma surgery
Previous conjunctival
surgery
Recent cataract surgery

May be risk factor for up to 6 months

Neovascular glaucoma
Aphakia

characteristics and resulting in a personalized risk


assessment for that patient. Many of the risk factors, such

Modulation of Wound Healing


as previous surgery, inflammation and use of topical
medications are associated with the prior activation of
fibroblasts. This may prime the postsurgical fibroblastic
response causing increased fibrosis and a greater risk of
bleb failure.

Preoperative Topical Steroid


The effect of preoperative topical steroid treatment on
conjunctival histology and trabeculectomy outcome was
prospectively studied by Broadway et al. 3 They
investigated a group of 30 patients who were on topical
glaucoma medications and who were due to undergo
trabeculectomy. They performed conjunctival biopsy one
month prior to surgery and then commenced
pretreatment with topical fluoromethalone 1 percent four
times daily. Two further biopsies were taken at the time
of surgery and all specimens were examined histologically.
They found that pretreatment with topical steroid reduced
the number of inflammatory cells and fibroblasts. They
also looked at the clinical outcome from trabeculectomy
in 16 of these patients, comparing them to 16 matched
control patients who had not received steroid
pretreatment. Success was defined as an intraocular
pressure (IOP) of less than 21 mm Hg without
medication. The pretreated group had an 81 percent
success rate at 12 months compared to a 50 percent
success rate in the control group. This suggested that
pretreatment with topical steroid modulated the early
wound healing response and improved the outcome
from trabeculectomy in this group of patients.
All the patients in this study were at relatively high
risk of failure because although they had not had
previous filtration surgery, they were all on multiple topical
glaucoma medications including topical adrenergic
agonists. Previous work from the same group had shown
that patients in this situation have an increased number
of conjunctival inflammatory cells and fibroblasts and a
reduced trabeculectomy success rate of 45 percent.4-6
Pretreatment with topical steroid has not, however,
become standard practice, but it is used in selected cases
by some clinicians, for example in the uveitic eye in
combination with oral steroid.
Preoperative Oral Steroid
The use of oral prednisolone as an adjunct to
trabeculectomy was investigated in a prospective

189

randomized double-masked placebo controlled trial by


Azuara-Blanco et al.7 They gave patients either 50 mg of
oral prednisone or placebo twice daily for 3 days in the
perioperative period. Success of surgery was defined as
an IOP < 15 mm Hg with no more than one topical
antiglaucoma medication. At 9 months, 63.0 percent of
the steroid group and 65.6 percent of the control group
had achieved this successful outcome, suggesting that
the use of oral prednisone in had no beneficial effect.
However, the patients in this study were not selected for
preoperative risk factors for surgery failure. Many
clinicians will use oral prednisolone pretreatment in
situations where there is a high risk of inflammation and
scarring, such as a uveitic patient or before complex tube
surgery.

INTRAOPERATIVE STRATEGIES
The most common stage to begin modulating the wound
healing response is during surgery. Any preplanned
strategies based on known risk factors may be altered at
this stage by the flexible glaucoma surgeon, who will be
aware of intraoperative findings such as unexpectedly
thin conjunctiva. The introduction of the antiproliferative
agents mitomycin-C and 5-fluorouracil has greatly
improved the outcome from glaucoma filtration surgery,
particularly in patients known to be at high risk of
scarring.8-10 These adjuncts are now in widespread use,
but their toxic cellular effects have been associated with
severe complications, such as hypotony, bleb leaks and
infections.11-14 This has led to the continued search for
alternative intraoperative antiscarring treatments, which
are also discussed below.

5-Fluorouracil
5-Fluorouracil (5-FU) is a cytotoxic agent that
antagonizes pyrimidine metabolism, causing inhibition
of DNA synthesis. In the context of glaucoma surgery,
5-FU has the role of inhibiting proliferation of conjunctival
and Tenons capsule fibroblasts. Surgery is seen by the
body as an injury and immediately stimulates the start
of a cascade of events that are the wound healing
response. A key step in this chain of events is the
proliferation of fibroblasts as these cells synthesize collagen
to form a scar, are responsible for wound contraction

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Atlas of Glaucoma Surgery

and produce matrix metalloproteases (MMPs) to allow


wound remodelling. As 5-FU influences this important
series of events it is an effective agent in the modulation
of wound healing.
The use of 5-FU in glaucoma surgery started in the
early 1980s, but its intraoperative use did not become
more widespread until there was a greater understanding
of its effects on cell biology and the wound healing
response.15,16 Early animal studies had showed that
adjunctive injection of 5-FU following trabeculectomy
decreased fibroblast proliferation and scarring with
prolonged bleb survival compared to no 5-FU.17 Khaw
and co-workers showed in vitro and in vivo that a 5minute exposure of 5-FU clearly caused growth arrest
and a long lasting effect on cultured human Tenons
fibroblasts.18 His group also demonstrated that a single
exposure of 5-FU interferes with ocular fibroblastmediated collagen.19 This added to the developing
concept of using a single intraoperative application of 5FU as a targeted, focal antiscarring treatment to improve
trabeculectomy survival.20-24
The early clinical studies in America and England of
intraoperative 5-FU, both as a sole treatment and as a
supplement to postoperative injections, suggested a
beneficial effect on filtration surgery survival and
enhanced intraocular pressure lowering, with minimal
side effects.25-27 Randomised trials have shown that
intraoperative 5-FU is effective in trabeculectomy surgery
in East and West Africa, a population group who have a
higher risk of scarring and trabeculectomy failure.28, 29
Interestingly, in this population MMC and 5-FU may
have similar efficacy in primary surgery.30 There are a
number of clinical trials about to report their results on
the effect of a single intraoperative application of 5-FU
in low risk patients undergoing first-time surgery. These
include a large randomised, controlled study based at
Moorfields Eye Hospital (MRC 5FU trial) comparing 5FU to placebo and a similar study in Singapore. Results
from these studies will also provide the clinician with
detailed Long-term follow up of the outcome from
trabeculectomy with intraoperative 5-FU, including visual
field and optic disc changes.

Mitomycin-C
The first antiproliferative agent to be used successfully to
enhance the outcome from trabeculectomy was
mitomycin-C.9 Mitomycin-C is an antibiotic agent that is
activated by reduction into an alkylating agent. It has
potent effects on cellular function, inhibiting DNA
replication, mitosis and protein synthesis. In the context
of glaucoma surgery it acts to modulate the wound
healing response at a similar stage to 5-FU, inhibiting
fibroblast proliferation. It is, however, both stronger in
its effect and potentially more toxic than 5-FU.
Khaw and co-workers showed that at clinical
concentrations mitomycin caused cell death and
permanent inhibition, whereas there is only temporary
inhibition of proliferation with late recovery occurred
with 5-FU.20-22 The use of a single five-minute exposure
to mitomycin-C provides a superior surgical success rate
compared to 5-FU injections in many high risk patients
but unfortunately can also result in a greater chance of
bleb leaks and possible infection.14, 31-33 The use of
intraoperative MMC has, however, dramatically
improved the outcome from surgery in patients who
previously had a low chance of successful filtration
surgery, such as people with cicatricial conjunctiva and
young patients with congenital glaucoma.34-36
Adjunctive MMC usage in tube (glaucoma drainage
device) surgery is also now increasingly common.
Although there is relatively little evidence for this practice,
MMC use in this clinical situation could be expected to
be beneficial as tube surgery is most commonly
performed in eyes with complex glaucoma and multiple
risk factors for trabeculectomy failure. Perkins et al studied
the effect of MMC in patients undergoing Molteno tube
surgery and found that it increased the chance of good
IOP control without medications compared to placebo.37
There is no standardised method for the
intraoperative application of MMC and there is great
variation between clinicians in the dose used. Many will
also alter the dose depending on the case and risk factors
for scarring, tailoring the antiproliferative effect to fit an
individual patients requirements. Use of a concentration
between 0.2 mg/ml and 0.5 mg/ml, applied for 2 to 5
minutes is most usual.38 The size of the MMC treatment

Modulation of Wound Healing


area is an important parameter that has been
demonstrated to influence bleb morphology: small
treatment areas give rise to thin-walled, cystic blebs
whereas large treatment areas are associated with more
diffuse-looking, thicker walled blebs.39 Altering clinical
practice in this way with the use of larger treatment areas
to improve the bleb appearance should reduce the
incidence of bleb-related complications after glaucoma
surgery.

Beta Irradiation
Beta radiation was proposed for use as an adjunct to
glaucoma surgery in the late 1960s to early 1970s, long
before modern chemical antiproliferatives.40, 41 It is simple
to use in practice and became established in certain
centres for intraoperative use in the treatment of complex
cases, such as congenital glaucoma. 42 More recent
scientific study has shown in vitro and in vivo that a single
application of beta radiation inhibits proliferation of
human Tenons fibroblasts, causing growth arrest but not
cell death.43 This has led to a renewed interest in the use
of intraoperative beta irradiation in trabeculectomy,
although it has not yet convincingly been proven to be
effective in a randomised controlled trial of routine
glaucoma patients.44-46 The simplicity of its application
and the suggestion that it may avoid some of the side
effects of other chemical antimetabolites, has caused
some clinicians to believe that beta radiation may be
particularly appropriate for use in developing countries.
A study in South Africa has recently been completed
and is due to report on the effect of a single intraoperative
application of -irradiation.

Photodynamic Therapy with BCECF-AM


This technique to modulate wound healing involves the
intraoperative application of BCECF-AM (2,7,-bis-(2carboxyethyl)-5-(and-6)-carboxyfluorescein acetoxymethyl-ester and subsequent photodynamic therapy
during the surgical procedure. BCECF-AM is an
intracellularly acting photosensitiser, which is applied
directly by subconjunctival injection to the site where it
is needed at the start of surgery. When it diffuses into
cells it is altered and becomes fluorescent. After the
formation of the conjunctival flap a focused area of the

191

sclera is illuminated with blue light of the wavelength


450 to 490 nm for 8 minutes. Under these conditions
BCECF-AM produces a photo-oxidative effect that
results in cell destruction of targeted cells. This effect is
strictly limited to the illuminated area.47 A scleral flap is
then dissected in the illumination zone and
trabeculectomy surgery is completed as normal.
Carboxyfluorescein has been demonstrated in vitro
to exer t a phototoxic effect on human Tenons
fibroblasts.47 Grisanti et al showed that, in a rabbit model
of filtration surgery, this form of photodynamic therapy
has the ability to modify postoperative fibrosis.48 Early
clinical studies in Germany from the group of Diestelhorst
and Krieglstein have assessed the effect of photodynamic
therapy in consecutive patient series.49,50 They have
indicated that this technique has potential to improve
bleb survival and provide reasonable IOP reduction.
These studies have also tried to assess the clinical safety
and tolerability of this new treatment and so far there
do not appear to be any significant problems with local
toxicity, intraocular inflammation or patient discomfort.
A multicentre randomised placebo controlled clinical
trial to investigate the efficacy of BCECF-AM based
photodynamic therapy compared to standard
trabeculectomy is now planned.

TGF 2 Antibody (CAT-152)


Transforming growth factor beta (TGF) is a
multifunctional cytokine, which is implicated as the key
growth factor in the process of wound healing and tissue
repair, with its sustained overproduction resulting in tissue
fibrosis. 51 TGF regulates the coordinated sequence of
events involved it the wound healing process, acting as
a macrophage chemoattractant, stimulating fibroblast
migration, proliferation and collagen synthesis, and also
enhancing angiogenesis.51, 52 There are three isoforms of
TGF in mammals: TGF1, TGF2 and TGF3, with
TGF2 being the predominant isoform in the eye.53-55
Glaucoma patients have been found to higher levels of
TGF2 in their aqueous humor than normal subjects.56
CAT-152 is a fully human monoclonal antibody,
which specifically and potently neutralizes the active form
of human TGF-2. Laboratory studies have shown its
ability to modulate the wound healing process in vitro

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Atlas of Glaucoma Surgery

and in vivo. In an animal model of glaucoma filtration


surgery it significantly improved outcome compared to
control (p<0.03).57 Interestingly, when compared to the
effects of MMC treatment histologically, it appeared much
less destructive to local tissue.
In the first randomized controlled clinical trial of CAT152 in trabeculectomy surgery, patients were given 4
subconjunctival injections of either antibody or placebo:
immediately pre- and postsurgery, on day 1 and at week
1. In this initial phase 1 study, no particular complications
were found to be associated with the antibody treatment,
which seemed to be well-tolerated by patients.58 The bleb
morphology seen in the antibody treated group was
encouraging, as these patients had diffuse, blebs covered
by healthy overlying conjunctiva, unlike the focal, cystic,
avascular, antimetabolite treated blebs that can be
associated with complications such as late wound leaks,
hypotony or endophthalmitis. These early results have
led to larger multicentre randomised controlled trials of
this antibody in patients undergoing phacotrabeculectomy and trabeculectomy.

Suramin
Suramin is a growth factor suppressing agent which has
been shown to inhibit wound healing in an animal model
of filtration surgery.59 The first clinical study of this agent
compared 10 patients undergoing trabeculectomy with
intraoperative applications of Suramin with a matched
group in whom mitomycin was used.60 They found the
success rates and IOP lowering to be similar to mitomycin,
but had no cases of hypotony associated with Suramin;
in this study hypotony lasting more than 3 months
occurred in 50 percent of the mitomycin group.

POSTOPERATIVE STRATEGIES
Postoperative Topical Steroid
The use of topical steroid use following trabeculectomy
is well established, although there is wide variation in
clinical practice regarding dosage and treatment period.
The amount steroid used will also obviously be altered
depending on the case and the postoperative progress.
The hallmark trial by Starita et al showing the benefit
of topical steroids after trabeculectomy was published in
1985.61 This randomized prospective trial divided 68 eyes

of 54 patients into three treatment groups: group 1


received no steroids; group 2 received topical
prednisolone acetate 1 percent; group 3 received topical
prednisolone acetate 1 percent and oral prednisone. This
study showed that topical steroids significantly improved
trabeculectomy outcome as compared to the regimen
without topical steroids. It also confirmed that systemic
prednisone did not provide any additional benefit over
topical steroids in this group of unselected patients.
A study of these same patients after 5 years followup confirmed the beneficial effect of topical steroids on
IOP control and also looked at progression of glaucoma
as judged by visual field and optic disc criteria.62 In the
steroid-treated group 94 percent were defined as stable,
compared to 43 percent of the no steroid group. The
final 10-year follow-up study of these patients (46 eyes)
still clearly showed that postoperative topical steroid
treatment conferred an advantage in IOP control and
also visual field and disc progression.63

Postoperative 5-fluorouracil Injection


Postoperative injection of 5-FU was the first technique
of wound healing modulation following trabeculectomy
to become widespread in its use. It has gained support
not only because of its effectiveness, but also because it
is relatively easy to administer the treatment to a localised
area and it can be repeated as needed depending on
the clinical response. The action of 5-FU delivered by
subconjunctival injection post-operatively on the wound
healing process is as an antimetabolite as discussed above
(see intraoperative 5-FU).
The Fluorouracil Filtering Surgery Study (FFSS) was
a prospective multicentre randomised clinical trial of 213
patients who were at high-risk of trabeculectomy failure
due to previous ocular surgery.64 They were randomised
to undergo either trabeculectomy alone or trabeculectomy with a series of postoperative subconjunctival 5FU injections. The treatment regimen was intensive, with
5 mg injections being given 180o from the filtering site
twice daily for the first 7 days after surgery and then
daily on days 8 to 14 (total dose 105 mg). Failure was
defined as an IOP greater than 21 mm Hg or the need
for further surgery to reduce IOP. The largest effect of 5FU was seen at 6 months postoperatively, when 90

Modulation of Wound Healing


percent of the 5-FU treated group had not required
reoperation compared to 65 to 70 percent in the control
group. The 5-year follow-up of these patients still showed
a benefit from treatment, with a 51 percent failure rate
in the 5-FU group, compared to 74 percent in the control
group.65 This study also documented the longer-term
outcome from trabeculectomy over a period of years,
showing that even though 5-FU improved success,
failure continues to occur at a steady rate in both groups
of patients. Despite improving bleb survival, the intensive
series of 5-FU injections in the FFSS was associated in
particular with the early complication of corneal epithelial
defects and also significantly with the development of
late bleb leaks (9% compared to 2% of controls) and
potential late bleb infection. The use of postoperative 5FU is now common, but far fewer injections are usually
administered. The number of treatments required is
usually titrated according to the individual patients needs
and their wound healing response.

Tranilast
Tranilast (N- (3, 4-dimethoxycinnamoyl) anthranilic acid)
produces an antiscarring effect by suppressing TGF-
activity. In experimental models of eye disease, it has
been found to inhibit progression of proliferative
vitreoretinopathy, reduce choridal neovascularization and
limit subepithelial haze after photorefractive keratectomy.66-68 In vitro assessment of Tranilasts effect on
Tenons capsule fibroblasts has shown that it inhibits cell
proliferation and collagen synthesis.69 This led to the first
prospective randomized controlled trial of postoperative
Tranilast in trabeculectomy patients.70 The 52 patients in
the study were randomized to receive either 0.5 percent
Tranilast drops or saline placebo four times daily for 3
months after surgery. No sight threatening side effects
were found to be associated with Tranilast and the treated
group had greater IOP reduction and larger blebs than
the placebo group over 2 years follow-up.

Interferon Alpha 2

Interferon- is a cytokine with antifibrotic effects and it


has been shown to reduce postoperative scarring
occurring after trabeculectomy. The effect of IFN-alpha
2 was compared to 5-FU in a randomized phase II trial

193

and was found to be useful in controlling postoperative


scarring.71 However, it was not found to be significantly
better than 5-FU and so has not progressed to more
extensive trials.

FUTURE STRATEGIES
Modulation of TGF-
in the Trabecular
Meshwork
Transforming growth factor beta (TGF), as discussed
earlier in this chapter, is a key growth factor in the process
of wound healing and tissue repair, with its sustained
overproduction resulting in tissue fibrosis.51 Tripathis
group have demonstrated that trabecular cells express
the TGF 2 gene and secrete this cytokine into the
aqueous. 72 This group and others have found that
glaucoma patients have higher levels of TGF2 in their
aqueous humour than normal subjects.56 They have
suggested that this overproduction of TGF 2 in
glaucomatous eyes has a role in the pathogenesis of
primary open-angle glaucoma: it may cause an increase
in the extracellular matrix (ECM) deposition in the
trabecular meshwork and so increase outflow resistance.71
More recently, Tripathis group have also shown that
TGF2 modulates the pre-mRNA splicing of the ECM
molecule fibronectin in trabecular cells, stimulating the
synthesis and secretion of fibronectin in a dose-dependent
fashion.73 It may be possible in the future to modulate
this process and so alter the disease process in glaucoma.

Modulation of TGF-
in the Optic Nerve Head
The primary site of glaucomatous damage is at the optic
nerve head. The process of extracellular matrix
remodeling at this structure is increasingly implicated in
the development of disease, although the exact
mechanisms responsible have not been elucidated. It is
believed that the physical force of elevated IOP plays a
role in causing the posterior deformation and bowing of
the lamina cribosaa hypothesis supported by
biophysical modeling data and histological evidence.74-77
The expression of TGF has been shown to be increased
at the optic nerve head in glaucomatous human and
animal model eyes, and it is suggested that this growth
factor is responsible for the remodeling of the lamina
cribosa by activating local cells.78-80, Furthermore, Yuan

194

Atlas of Glaucoma Surgery

and Neufeld have demonstrated elevated levels of


TGF2 in activated microglia in glaucomatous optic
nerve head compared to normals.81 It is hoped that
further understanding of the remodeling at the optic
nerve head in glaucoma and role of the involved growth
factors may allow us to modulate this process in the
future and so modify the disease process in glaucoma.

CONCLUSIONS
Modulation of wound healing is required to enable us
to achieve the ideal of a successful outcome from
glaucoma surgery in all our patients. Currently the most
reliable approach is to use the antiproliferative agents
mitomycin and 5-fluorouracil. However, these agents
are far from perfect and so there is now a search for
new agents to control the wound healing process more
safely.
Increased scientific knowledge of the events involved
in tissue repair is allowing the targeting of biological
molecules to find effective treatments that are potentially
safer, with minimal complications. As in other areas of
medicine, a combination of therapies may be required
to achieve good control of postoperative scarring.
Improved understanding of the wound healing process
and the postoperative period should allow clinician and
scientist to come together to find these more specific,
focal and titratable treatments. It may also be possible in
the future to manipulate the glaucomatous disease
process itself by controlling wound-healing factors, such
as TGF , in the trabecular meshwork and optic nerve
head.

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Modulation of Wound Healing


26. Dietze PJ, Feldman RM, Gross RL. Intraoperative application of 5FU during trabeculectomy. Ophthal Surg 1992; 23: 662-71.
27. Lanigan LP, Stuermer J, Baez KA, Hitchings RA, Khaw PT. Single
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28. Egbert PR, Williams AS, Singh K, et al. A prospective trial of
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29. Yorston D, Khaw PT. A randomised trial of the effect of intraoperative
5-FU on the outcome of trabeculectomy in east Africa. B J Ophthalmol
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30. Singh K, Egbert PR, Byrd S, et al. Trabeculectomy with intraoperative
5-fluorouracil vs mitomycin C. Am J Ophthalmol 1997;123(1):4853.
31. Kitazawa Y, Kawase K, Matsushita H, Minobe M. Trabeculectomy
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32. Skuta GL, Beeson CC, Higginbotham EJ, et al. Intraoperative
mitomycin versus postoperative 5-fluorouracil in high-risk glaucoma
filtering surgery. Ophthalmology. 1992; 99: 438-44.
33. Chen C, Huang H, Bair JS, Lee C. Trabeculectomy with simultaneous
topical application of mitomycin-c in refractory glaucoma. J Ocul
Pharmacol 1990; 6: 175-82.
34. Honjo M, Tanihara H, Inatani M, et al. Mitomycin C trabeculectomy
in eyes with cicatricial conjunctiva. Am J Ophthalmol 1998, 126:82324.
35. Ali-Hazmi A, Zwaan J, Awad A, et al. Effectiveness and complications
of mitomycin-C use during pediatric glaucoma surgery. Ophthalmol
1998;105:1915-20.
36. Beck AD, Wilson WR, Lynch MG, et al. Trabeculectomy with
adjunctive mitomycin-C in pediatric glaucoma. Am J Ophthalmol
1998; 126:648-57.
37. Perkins TW, Gangnon R, Ladd W, et al. Molteno implant with
mitomycin-C: intermediate-term results. J Glaucoma 1998; 7: pp8692.
38. Siriwardena D, Edmunds B, Wormald RPL, Khaw PT. National
survey of antimetabolite use in glaucoma surgery in the UK. B J
Ophthalmol 2004 in press.
39. Cordeiro MF, Constable PH, Alexander RA, et al. The effect of
varying mitomycin-C treatment area in glaucoma filtration surgery
in the rabbit. Invest Ophthalmol Vis Sci 1997;38:1639-46.
40. Cameron ME. Beta irradiation as an adjunct to surgery in refractory
glaucoma. Trans Aust Coll Ophthalmol 1970;2:53-60.
41. Ogino N, Masuda H, Abe Y. Beta-irradiation in the filtering
operation. Nippon Ganka Gakkai Zasshi 1966;70:11.
42. Miller MH, Rice NS. Trabeculectomy combined with beta irradiation
for congenital glaucoma. B J Ophthalmol 1991;75:10.
43. Constable PH, Crowston JG, Occleston NL, et al. Long-term growth
arrest of human Tenons fibroblasts following single applications of
beta radiation. Br J Ophthalmol 1998, 82:448-52.
44. Rehman Shafiq U, Amoaku Winfried MK, Doran Robert ML,
Menage Mitchel J, Morrell Andrew J. Randomized controlled clinical
trial of beta irradiation as an adjunct to trabeculectomy in openangle glaucoma. Ophthalmology 2002;109:302-6.
45. Kirwan JF, Constable PH, Murdoch IE, Khaw PT. Beta irradiation:
new uses for an old treatment: A review. Eye 2003;17:207-15.
46. Lai JS, Poon AS, Tham CC, Lam DS. Trabeculectomy with beta
radiation: long-term follow-up. Ophthalmology 2003;110(9):18226.
47. Grisanti S, Gralla A, Maurer P, et al. Cellular photoablation to
control postoperative fibrosis in filtration surgery: in vitro studies.
Exp Eye Res 2000;70:145-52.
48. Grisanti S, Diestelhorst M, Heimann K, et al. Cellular photoablation
to control postoperative fibrosis in a rabbit model of filtration surgery.
Br J Ophthalmol 1999;83:1353-9.

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49. Diestelhorst M, Grisanti S. Photodynamic therapy to control fibrosis


in human glaucomatous eyes after trabeculectomy: a clinical pilot
study. Arch Ophthalmol 2002;120:130-4.
50. Jordan JF, Diestelhorst M, Grisanti S, Krieglstein GK. Photodynamic
modulation of wound healing glaucoma filtration surgery Br J
Ophthalmology 2003;87:870-5.
51. Border WA, Noble NA. Transforming growth factor in tissue fibrosis
N Eng J Med 1994;331:1286-92.
52. Cordeiro MF, Bhattacharya SS, Schultz GS, et al. TGF-1, -2 & 3 in vitro: biphasic effects on tenons fibroblast contraction,
proliferation & migration. Invest Ophthalmol Vis Sci 1999.
53. Connor TB, Roberts AB, Sporn MB, et al. Correlation of fibrosis
and transforming growth factor-beta type 2 levels in the eye. J Clin
Invest 1989; 83:1661-6.
54. Jampel HD, et al. Transforming growth factor- in human aqueous
humor. Curr Eye Res 1990; 9: 963-69.
55. Pasquale LR, et al. Immunolocalisation of TGF1, TGF2, and
TGF3 in the anterior segment of the human eye. Invest Ophthalmol
Vis Sci 1993;34:23-30.
56. Tripathi RC, et al. Aqueous humor in glaucomatous eyes contains
an increased level of TGF-2. Exp Eye Res 1994;59:723-8.
57. Cordeiro MF, Gay JA, Khaw PT: Human Anti-TGF-2 monoclonal
antibody: a new anti-scarring agent for glaucoma filtration surgery.
Invest Ophthalmol Vis Sci 1999; 40:2225-34.
58. Siriwardena D, Khaw PT, King AJ, et al. Human antitransforming
growth factor 2 monoclonal antibodyA new modulator of wound
healing in trabeculectomy: a randomized placebo controlled clinical
study. Ophthalmology 2002;109(3):427-31.
59. Mietz H, Chevez-Barrios P, Feldman RM, Lieberman MW. Suramin
inhibits wound healing following filtering procedures for glaucoma.
Br J Ophthalmol 1998;82:816-20.
60. Mietz H, Kriegelstein GK. Suramin to enhance glaucoma filtering
procedures: a clinical comparison with mitomycin. Ophthalmic Surg
Lasers 2001; 32:358-69.
61. Starita RJ, Fellman RL, Spaeth GL, et al. Short- and Long-term
effects of postoperative corticosteroids on trabeculectomy.
Ophthalmology 1985;92:938-46.
62. Roth SM, Spaeth GL, Starita RJ, et al. The effects of postoperative
corticosteroids on trabeculectomy and the clinical course of glaucoma:
five-year follow-up study. Ophthalmic Surg 1991;22:724-29.
63. Araujo SV, Spaeth GL, Roth SM, Starita RJ. A ten-year follow-up on
a prospective, randomized trial of postoperative corticosteroids after
trabeculectomy. Ophthalmology 1995;102:1753-59.
64. The Fluorouracil Filtering Surgery Study Group. Fluorouracil filtering
surgery study one-year follow-up. Am J Ophthalmol 1989;108:62535.
65. The Fluorouracil Filtering Surgery Study Group. Five-year followup of the fluorouracil filtering surgery study. Am J Ophthalmol
1996;121:349-66.
66. Ito S, Sakamoto T, Tahara Y, et al. The effect of tranilast on
experimental proliferative vitreoretinopathy. Graefes Arch Clin Exp
Ophthalmol 1999;237:691-6.
67. Takehana Y, Kurokawa T, Kitamura T, et al. Suppression of laserinduced choroidal neovascularization by oral tranilast in the rat.
Invest Ophthalmol Vis Sci 1999;40:459-66.
68. Furukawa H, Nakayasu K, Gotoh T, et al. Effect of topical tranilast
and corticosteroids on subepithelial haze after photorefractive
keratectomy in rabbits. J Refract Surg 1997;13(suppl):S457-8.
69. Oshima T, Kurosaka D, Kato K, Kurosaka H, Mashima Y, Tanaka Y,
Tajima S. Tranilast inhibits cell proliferation and collagen synthesis
by rabbit corneal and Tenons capsule fibroblasts. Curr Eye Res
2000;20:283-6.
70. Chihara E, Dong J, Ochiai H, Hamada S. Effects of Tranilast on
filtering blebs: a pilot study. J Glaucoma 2002;11(2):127-33.

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71. Gillies MC, Brooks AMV, Young S, et al. A randomized phase II trial
of interferon-alpha 2b versus 5-fluorouracil after trabeculectomy.
Aust New Zealand J Ophthalmol 1999;27:37-44.
72. Tripathi RC, Chan WF, Li J, Tripathi BJ. Trabecular cells express
the TGF-beta 2 gene and secrete the cytokine. Exp Eye Res
1994;58:523-8.
73. Li J, Tripathi BJ, Tripathi RC. Modulation of pre-mRNA splicing
and protein production of fibronectin by TGF-beta2 in porcine
trabecular cells. Invest Ophthalmol Vis Sci 2000;41:3437-43.
74. Bellaza AJ, Hart RT, Burgoyne CF. The optic nerve head as a
biomechanical structure: infinite finite element modeling. Invest
Ophthalmol Vis Sci 2000;41:2991-3000.
75. Hernandez MR, Andrzejewska WM, Neufeld AH. Changes in the
extracellular matrix of the human optic nerve in primary open-angle
glaucoma. Am J Ophthalmol 1990;109:180-8.

76. Morrison JC, Dorman-Pease ME, Dunkelberger GR, Quigley HA.


Optic nerve head extracellular matrix in primary optic atrophy and
experimental glaucoma. Arch Ophthalmol 1990;108:1020-24.
77. Hernandez MR, Pena JDO. The optic nerve head in glaucomatous
optic neuropathy. Arch Ophthalmol 1997;109:180-8.
78. Pena JDO, Taylor AW, Ricard CS, Vidal I, Hernandez MR.
Transforming growth factor isoforms in human optic nerve heads.
Br J Ophthalmol 1999;83:9-218.
79. Cordeiro MF, Khaw PT. The healing optic nerve in glaucoma:
Transforming growth factor- and optic nerve head remodeling. Br
J Ophthalmol 1999;83:132-3.
80. Cordeiro MF, Halfyard AS, Khaw PT, Fitzke FW, Keagan DJ.
Objective assessment of changes at the optic nerve head in a rat
model of glaucoma. Invest Ophthalmol Vis Sci 2001;42 S2750.
81. Yuan L, Neufeld AH. Activated microglia in the human optic nerve
head. J Neurosci Res 2001;64:523-32.

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Gonzalo Muoz, Jos I. Belda-Sanchs, Jos Prez-Santonja, Daniel Eles

17 Glaucomatous Complications of Refractive Surgery

GLAUCOMA ASSOCIATED WITH PHAKIC


INTRAOCULAR LENS IMPLANTATION
Elevated intraocular pressure (IOP) after phakic
intraocular lens (IOL) implantation can be caused by
several mechanisms. It is important to recognize the cause
of the increased IOP to be able to treat the patient in the
proper manner. The following situations may present
after phakic IOL implantation.

Trabecular Block by Viscoelastic


An incomplete wash of viscoelastic can lead to significant
transitory IOP rise (>10 mm Hg) during the first
postoperative days after phakic IOL surgery and is the
most common cause of postoperative IOP increase (Fig.
17.1). Incidence of 7.2 to 20.8 percent for angle-supported
phakic IOLs,1-4 4.5 to 15.6 percent for iris-fixated phakic
IOLs5-11 and 5.8 to 23.2 percent for posterior chamber
phakic IOLs12-16 have been reported. Pain and some degree
of vision loss may be present, but the eye shows normal
reactive pupil, deep anterior chamber, permeable
iridotomies and no corneal edema. Very rarely, viscoelastic
can be the cause of a pupillary block.13 Once the cause is
clear and pupillary block is rulled out, decompressing the
eye using the port incision or through a new paracentesis
can be done. Topical beta-blocker, alpha-2 agonist or oral
acetazolamide up to 1.0g a day can be used to control
IOP. Prevention includes complete intraoperative removal
of viscoelastic and IOP reducing therapy with oral
acetazolamide during the first two days after phakic IOL
implantation on a routine basis. The use of cohesive
viscoelastics is preferable for phakic IOL surgery, since this

kind of viscoelastics can be removed from the anterior


chamber more easily than the dispersive ones.

Pupillary Block
Situation arising from an obstruction of aqueous humor
circulation from the posterior to the anterior chamber
caused by touch between the phakic IOL and the
pupillary border (Fig. 17.2). Typically the patient presents
with intense pain and photophobia, and examination
shows a narrow angle, with forward displacement of the
iris, crystalline lens and phakic IOL in the absence of a
patent iridotomy. This can be caused by any kind of
phakic IOL but is more likely after posterior chamber
phakic IOLs. Reported incidences are 0 to 11.5 percent
for angle-supported phakic IOLs,1-4 0 to 0.8 percent for
iris-fixated phakic IOLs5-11 and 0 to 12.5 percent for
posterior chamber phakic IOLs.12-16 Pupillary block is
avoided by making permeable iridotomies with the
Nd:Yag laser preoperatively or by performing a surgical
intraoperative iridotomy or iridectomy. It is important to
make sure that both layers of the iris are perforated by
observing the anterior capsule of the crystalline lens or
the zonular fibers through the iridotomy. In the presence
of a pupillary block after anterior chamber phakic IOL
implantation, miosis with pilocarpine may help to unblock
the pupil separating it from the IOL before iridotomies
are enlarged surgically or with the Nd:Yag laser. In the
presence of pupillary block after posterior chamber phakic
IOL implantation, the chamber is very flat, the IOL looks
overvaulted, and the treatment implies dilating the pupil
with phenylephrine 10 percent and atropine 1 percent,
and performing a new peripheral iridotomy or enlarging

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Atlas of Glaucoma Surgery

Fig. 17.1: Trabecular block by viscoelastic is the most common


cause of elevated IOP after phakic IOL implantation. Anterior
chamber depth is normal and iris plane is in a physiological
position (Courtesy of Highlights of Ophthalmology)

Fig. 17.2: Pupillary block after posterior chamber phakic IOL


implantation. The anterior chamber is flat and the IOL and iris
are forwarded, but the position of the crystalline lens is normal
(Courtesy of Highlights of Ophthalmology).

the previous ones. If this is not effective a surgical


iridectomy or lens removal may be necessary.

Malignant Glaucoma
This situation implies a peripheral block at the trabeculum
and reversed aqueous flow towards the vitreous. It can
follow pupillary block when aqueous accumulates in the
posterior chamber and pushes the iris forward (Figs
17.3A and B). The incidence of malignant glaucoma
after phakic IOL implantation is very rare, but seems to
be more common after posterior chamber phakic IOL,
ranging from 0.1 to 1.4 percent.12-16 Typically intense
pain, vomiting, photophobia and very high IOP are
present, and the slit-lamp exam shows corneal edema,
a non-reactive pupil with mydriasis, and a narrow

Figs 17.3A and B: Malignant glaucoma after posterior chamber


phakic IOL implantation. Atalamy with forwarded crystallineIOL-iris and misdirection of the aqueous humor to the vitreous
cavity (Courtesy of Highlights of Ophthalmology)

anterior chamber, situation which is not reversed by


enlarging the iridotomy. Initial treatment includes
inducing mydriasis to unblock the pupil and intravenous
mannitol to dehydrate the vitreous. If there is no progress,
explantation of the phakic IOL must be done, but

Glaucomatous Complications of Refractive Surgery

199

sometimes it is necessary to perform phacoemulsification


and posterior vitrectomy via pars plana to solve the
problem.

Angle Closure
In larger than needed posterior chamber phakic IOLs,
the angle can be closed by excessive pushing of the
peripheral iris forward. This is called excessive vault (Figs
17.4 and 17.5). Angle closure is more frequent in
hyperopic patients because the anterior chamber angle is
usually narrower. On average, a properly sized posterior
chamber phakic IOL reduces the iridocorneal angle width
by 15 to 20 percent. Changing the lens for a smaller one
with smaller vault, or extracting the PIOL can solve the
situation. In the presence of an angle-supported phakic
IOL, angle closure can be caused by anterior synechiae,
but this is an extremely infrequent situation (Fig. 17.6).

Fig. 17.4: Adequate vaulting of a posterior


chamber phakic IOL

Pigment Dispersion
Excluding the cases produced by excessive surgical
trauma, this is a very rare complication after phakic IOL
surgery. It has been reported after the use of posterior
chamber phakic IOLs with excessive vault and IOLperipheral iris touch, together with the development of
cataract (Figs 17.7A and B).

Steroid-induced Glaucoma
It has been reported in 13 to 30 percent of patients after
phakic IOL implantation for high myopia.1-3
The IOP raises between the second and the fourth
week after surgery while topical steroids are used.
Recently marketed topical steroids such as rimexolone
can help to decrease the incidence of steroid glaucoma.
In the presence of steroid glaucoma after phakic IOL
implantation, topical steroids should be discontinued and
non-steroidal antiinflammatory drugs together with antiglaucomatous agents should be used until the IOP
normalizes. Phakic IOLs do not seem to produce IOP
elevation in the long-term.1,3,15
In summary, in the presence of IOP increase in the
first few days after phakic IOL implantation:
Check the patency of the iridotomy and if in doubt
enlarge it with the Nd:Yag laser. Sometimes the
haptic of the IOL may be closing the iridotomy

Fig. 17.5: Excessive vaulting of a posterior chamber phakic


IOL, with pushing of the peripheral iris and angle narrowing

Fig. 17.6: The haptic of an angle supported phakic IOL can


produce anterior synechiae and rarely a chronic elevation of
the IOP

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Atlas of Glaucoma Surgery


Steroid-induced Glaucoma after Lasik Associated with Interface Fluid (Diffuse Lamellar
Keratitis-like Reaction)

Figs 17.7A and B: Pigment dispersion after posterior chamber


phakic IOL implantation with excessive vault and IOL-peripheral
iris touch

Treat IOP increase with oral acetazolamide 250 mg


every 6 hours and topical beta-blocker or topical
alpha-2 agonist twice a day, and stop the topical
steroid as soon as possible
In the presence of a posterior chamber phakic IOLs,
check the gap between the lens and anterior capsule
to look for signs of excessive vault which may be
closing the anterior chamber angle.

GLAUCOMA AFTER LASER ASSISTED IN


SITU KERATOMILEUSIS
Patients undergoing laser assisted in situ keratomileusis
(LASIK) may present glaucomatous complications in the
postoperative period, which include the following.

Topical steroids are part of the normal postoperative


regimen following LASIK. Myopic patients undergoing
refractive corneal procedures are at higher risk of
developing steroid-induced glaucoma. The rise of
intraocular pressure due to topical steroids can cause
fluid collection in the potential space between the flap
and the stromal bed, leading to erroneous low
applanation tonometry readings. This fluid results from
transudation of aqueous humor across the stromal bed
due to increased IOP.
The clinical picture of steroid-induced glaucoma after
LASIK is similar to that of diffuse lamellar keratitis (DLK)
(Fig. 17.8).17-18 If a patient presenting fluid collection in
the interface after LASIK due to increased IOP is
misdiagnosed as having an inflammatory or an infectious
process, higher doses of topical steroids will be used, thus
producing a worsening of the induced glaucoma. Slitlamp examination of these patients show an optically clear
fluid-filled space confined to the interface. Elevated IOP
is often misdiagnosed, because the standard central
measurement of intraocular pressure by Goldmann
tonometry is erroneously very low. 19 This low IOP is caused
by the airbag effect of the interface fluid, together with
the LASIK reduction of corneal thickness, which also
underestimate Goldmann applanation tonometry.20
Diffuse lamellar keratitis typically appears 1 to 3 days
after LASIK, and lasts no more than 10 days with
appropriate treatment. A patient who has been on topical
steroids for DLK and does not improve should be
carefully evaluated for steroid-induced glaucoma
associated with interface fluid. In addition, a diagnosis of
late DLK made more than 10 days after LASIK should
make us think of this syndrome and look for the fluid in
the interface.18
If interface fluid develops, IOP should be measured
on the peripheral cornea or with other methods such as
the Tono-pen. Topical steroids should be tapered or
discontinued if possible, and medications to lower IOP
should be initiated. With proper diagnosis and
management, profound glaucomatous optic neuropathy
can be avoided.18

Glaucomatous Complications of Refractive Surgery

201

Fig. 17.8: Clinical picture of steroid-induced glaucoma after


LASIK. Diffuse lamellar keratitis-like reaction, with collection of
fluid at the interface level and paradoxically low IOP readings

Acute Optic Neuropathy after LASIK


A positive scotoma and profound loss of vision
immediately after uneventful LASIK is a rare complication
of the technique.21 A relative afferent pupillary defect is
normally present. Anterior segment is unremarkable, and
posterior segment examination may show a normal optic
disk or signs of papiledema. The visual field shows
altitudinal defects or scotoma corresponding to focal
defect in the retinal nerve fiber layer. This scotoma does
not usually progress but rarely disappears (Figs 17.9A
to C). Barotrauma and ischemia have been implicated
in the development of acute optic neuritis after LASIK.
Intraocular pressure reaches 80 to 230 mm Hg during
the application of suction and 140 to 300 mm Hg during
the microkeratome pass. This may compress the ganglion
cells, the retinal nerve fiber layer and the lamina cribosa.
Ischemia of the optic nerve and retina may be due to
temporal closure of the short posterior cilliary arteries
and central retinal artery when IOP exceeds 45 mm Hg.
Risk factors for developing acute optic neuropathy
after LASIK include age over 35 years, cardiovascular
disease, diabetes and systemic hypertension.21 Local
factors include tilted optic nerve, palor of the optic nerve,
drusen of the optic disk, small optic disk with no cup
and previous glaucoma or ischemic neuropathy.21 To
minimize the incidence of LASIK induced optic neuritis,
it is important to reduce the time of IOP rise at maximum,

Figs 17.9A to C: Altitudinal visual field defect as a result of


acute optic neuropathy after LASIK. Visual field one week (A),
one month (B) and six months (C) after uneventful LASIK

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especially in patients with the above mentioned systemic


or local risk factors.

REFERENCES
1. Muoz G, Ali JL, Monts-Mic R, et al. Angle-supported phakic
intraocular lenses followed by lasik for the correction of high myopia.
Am J Ophthalmol 2003;136:490-9.
2. Baikoff G, Arne JL, Bokobza Y, et al. Angle-fixated anterior chamber
phakic intraocular lens for myopia of -7 to -19 diopters. J Refract
Surg 1998;14:282-93.
3. Ali JL, de la Hoz F, Perez-Santonja JJ, et al. Phakic anterior chamber
lenses for the correction of myopia: A 7-year cumulative analysis of
complications in 263 cases. Ophthalmology 1999;106:458-66.
4. de Souza RF, Forseto A, Nose K, et al. Anterior chamber intraocular
lens for high myopia. J Cataract Refract Surg 2001;27:1248-53.
5. Guell JL, Vazquez M, Gris O. Adjustable refractive surgery: 6-mm
Artisan lens plus laser in situ keratomileusis for the correction of high
myopia. Ophthalmology 2001;108:945-52.
6. Ali JL, Mulet ME, Shalaby AMM. Artisan phakic iris claw intraocular
lens for high primary and secondary hyperopia. J Refract Surg
2002;18:697-707.
7. Prez-Santonja JJ, Bueno JL, Zato MA. Surgical correction of high
myopia in phakic eyes with Worst-Fechner myopia intraocular lenses.
J Refract Surg 1997;13:268-81.
8. Menezo JL, Cisneros AL, Rodriguez-Salvador V. Endothelial study
of iris-claw phakic lens: four year follow-up. J Cataract Refract Surg
1998;24:1039-49.
9. Dick HB, Ali J, Bianchetti M, et al. Toric phakic intraocular lens:
European multicenter study. Ophthalmology 2003;110:150-62.

10. Budo C, Hessloehl J, Izak M, et al. Multicenter study of the Artisan


phakic intraocular lens. J Cataract Refract Surg 2000;26:1163-71.
11. Maloney RK, Nguyen LH, John ME. The Artisan Lens Study Group.
Artisan phakic intraocular lens for myopia: short-term results of a
prospective multicenter study. Ophthalmology 2002;109:1631-41.
12. Zaldivar R, Davidorf JM, Oscherow S, et al. Combined posterior
chamber phakic intraocular lens and laser in situ keratomileusis:
Bioptics for extreme myopia. J Refract Surg 1999;15:299-308.
13. Jimnez-Alfaro I, Bentez del Castillo JM, Garca-Feijoo J, et al.
Safety of posterior chamber phakic intraocular lenses for the
correction of myopia. Ophthalmology 2001;108:90-9.
14. Sanders DR, Martin RG, Brown DC, et al. Posterior chamber phakic
intraocular lens for hyperopia. J Refract Surg 1999;15:309-15.
15. Uusitalo RJ, Aine E, Sen NH, et al. Implantable contact lens for high
myopia. J Cataract Refract Surg 2002;28:29-36.
16. Davidorf JM, Zaldivar R, Oscherow S. Posterior chamber phakic
intraocular lens for hyperopia of +4 to +11 diopters. J Refract Surg
1998;14:306-11.
17. Lyle WA, Jin GJC. Interface fluid associated with diffuse lamellar
keratitis and epithelial ingrowth after laser in situ keratomileusis. J
Cataract Refract Surg 1999;25:100912.
18. Hamilton DR, Manche EE, Rich LF, et al. Steroid-induced glaucoma
after laser in situ keratomileusis associated with interface fluid.
Ophthalmology 2002;109:659-65.
19. Najman-Vainer J, Smith RJ, Maloney RK. Interface fluid after LASIK:
Misleading tonometry can lead to end-stage glaucoma. J Cataract
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20. Rehany U, Bersudsky V, Rumelt S. Paradoxical hypotony after laser
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2001;108:6605.

Index

203

Index

type 1 45
type 2 45
type 3 45

A
Abexterno trabeculectomy 103
Ahmed valve 58
Ahmed valve combined with
secondary and sutured intraocular
lens implantation 69
Ahmed valve implantation and vitreoretinal surgical procedures 70
Ahmed valve in combined procedures
68
cataract extraction and Ahmed valve
implantation 68
complications and their management
71
early postoperative complications
73
intraoperative complications 71
late postoperative complications
74
indications 59
models for implantation 58
AGV-B1 58
AGV-FP7 58
AGV-S2 58
AGV-S3 58
penetrating keratoplasty and Ahmed
valve implantation 67
surgical technique 59
technique for double plate Ahmed 66
Anesthesia 11
general 11
local 12
Antimetabolite related complications 16
Antimetabolites 141
Antiscarring agents 17
Argon and Nd:YAG lasers 49
Argon lasers traculoplasty 161

B
Bleb 45, 141
encapsulated 45

C
Cairns technique 36
Capsulorrhexis 177
Closure of the scleral flap 179
Combined cataract glaucoma surgery 170
choice of the procedure 172
special considerations 170
surgical options 171
cataract surgery alone 171
combined cataract and glaucoma
procedure 171
glaucoma surgery first 172
surgical procedure 173
closure of the conjunctiva 179
conjunctival flap 174
hemostasis 174
mitomycin-C 175
phacoemulsification 175
postoperative care 180
scleral flap 175
traction suture 174
Complications of transscleral Nd:YAG
cyclophotocoagulation 38
Control of bleb fibrosis by antiinflammatory agents 80
Control of bleb fibrosis by delayed drainage
of aqueous 81
Control of intraocular pressure 98
Cyclocryocoagulation 38
Cyclodestruction in glaucoma 37
current cyclodestructive procedures 38
infrared 810 nm diode laser
cyclophotocoagulation 38
red 647 nm krypton and 670 nm
diode laser
cyclophotocoagulation 41
early cyclodestructive procedures 37
cyclodiathermy 37

Nd:YAG cyclophotocoagulation
38
indications for partial cyclodestruction
42
mechanism of intraocular pressure
reduction 42
Cyclodiathermy 38

D
Deep sclerectomy 102, 131
management 137
Nd:YAG goniopuncture after NPGS
138
perforation of trabeculo-Descemets
membrane 137
results of NPGS 138
surgical steps 131
Diffuse lamellar keratitis-like reaction 200
Digital ocular massage 141
Diurnal pressure curve 126

E
Extracapsular method for combined
surgery 179

F
5-Fluorouracil 142
Failing filtering bleb 45
Filtering surgery 46
Filtration surgery-preoperative details 12
Fornix-based flap 179
Frequency doubling technology 112

G
Glaucoma 1
Glaucoma filtration surgery 23
intraoperative complications 24
conjunctional, scleral and iris
bleeding 25
conjunctival tear 24

204

Atlas of Glaucoma Surgery

scleral flap damage 24


suprachoroidal hemorrhage 25
vitreous loss 25
wound leak 25
postoperative complications 26
wipe out of remaining field/
vision 26
astigmatism 31
blebitis and endophthalmitis 30
cataract 30
choroidal effusion 26
fistula blockage 28
hypotony: due to aqueous
overdrainage 26
late bleb leak focal or diffuse 29
posterior division of aqueous
(malignant glaucoma) 27
ptosis and strabismus 31
pupil block 28
raised intraocular pressure 27
shallow/flat anterior chamber 26
subconjunctival fibrosis 28
postoperative management of 23
Glaucomatous complications of refractive
surgery 197
glaucoma after laser assisted in situ
keratomileusis 200
acute optic neuropathy after LASIK
201
angle closure 199
glaucoma associated with phakic
intraocular lens implantation
197
malignant glaucoma 198
pigment dispersion 199
pupillary block 197
steroid-induced glaucoma 199
steroid-induced glaucoma after
Lasik associated with interface
fluid 200
trabecular block by viscoelastic
197
Guarded sclerostomy procedure 11

H
Haemophilus 30
Holy Grail of glaucoma treatment 1

I
Intraocular pressure 1
economical burden of IOP lowering
strategies 7
ideal treatment to reduce IOP 1
in surgery better than drugs 1
issue of compliance and persistence 4
long-term IOP reduction 2

minimal IOP diurnal fluctuations 3


ocular side effects and complications
5
sufficient reduction of IOP 1
systemic side effects and complications
6
IOL insertion 177
Iridectomy 179

K
Kelly-Descemets punch 178

L
Laser trabeculoplasty 2, 161
Limbus-based flap 179

M
Management of angle-closure 182
change angle configuration and
prevent further closure 183
cataract surgery and lens extraction
185
laser iridoplasty 184
laser iridotomy 183
medical management of angleclosure 185
surgical iridectomy 184
detection and control of continuing
optic disk and visual field damage
186
immediate control of symptoms and
raised IOP 182
prevention 186
Management of filtration failure 50
bleb needling 52
bleb reconstruction 54
digital compression 50
laser cautery of bleb vessels 54
laser suturelysis 50
complications 51
historical aspects 50
indications 50
technique 50
trephination 52
technique 53
Minskys maneuver 121
Mitomycin-C 32, 142

N
Nd:YAG goniopuncture 141
Nd:YAG laser 27
Nd:YAG laser cyclophotocoagulation 37
Neovascular glaucoma 95
New technique versus classic
trabeculectomy 36

Nonpenetrating deep sclerectomy (NPDS)


112
anatomic landmarks 113
complications of surgery 115
triangular flap dissected too deeply
115
triangular flap dissected too
superficially 115
contraindication 113
early indication of NPDS in open-angle
glaucomas 112
gonioscopy after NPDS 122
learning curve 121
ND:YAG laser goniopuncture 123
follow-up 124
NPDS pearls 121
surgical technique 113
Nonpenetrating glaucoma surgery 102,
104, 140
complications and management 142
early postoperative complications 142
bleb leak 143
bleeding during gonioscopy 145
cataract formation 145
choroidal detachment 143
hyphema 143
hypotony 143
inflammation 143
malignant glaucoma 145
ocular hypertension 143
shallow anterior chamber 143
suprachoroidal hemorrhage 144
TDM rupture 145
late postoperative complications 145
bleb fibrosis 146
cataract progression 146
Descemets membrane detachment
146
encapsulated bleb 146
iris prolapse 145
peripheral anterior synechiae 146
scleral ectasis 147
postoperative medication 140
routine evaluation regimen and
management 140
Nonpenetrating surgery 102
postoperative medications 109
surgical technique 104
trabeculo-Descemets perforation
108
Normal bleb maturation and function 45

O
Ocular hypotensive medications 6
One-stitch technique 61

Index
P
Pars plana tunnel 64
Peripheral iridectomy 35
Phaco and Ahmed valve combined
procedure 68
Phacoemulsification 177
Phacotrabeculectomy 98, 150
Pilocarpine 182
Pre-and intraoperative drops 12
hypotensive agents 13
nonsteroidal anti-inflammatory drugs
13
parasympathetic agonists 12
povidone-iodine 12
steroids 12
sympathetic agonists 12
Primary open-angle glaucoma 4, 97, 182

R
Risk factors for filtration failure 46
Risk factors for scarring and failure after
glaucoma filtration surgery 188

S
Schlemms canal 102, 103, 122
Schwalbes line 137
Scleral-tunnel technique 36
Sclerectomy 178
Secondary glaucomas 98
Selective laser trabeculoplasty 161
complications of SLT 167
delivery of SLT 166
effectivity of SLT 164
place of SLT in relation of ALT 161
SLT laser 162
Severity of glaucoma 84
Signs of filtration failure 47
bleb encapsulation 49
due to blockage external to the ostium
49
due to blockage of the internal ostium
48
Sinusotomy 103
Stegmanns technique 107
Streptococcus 30
Sub-Tenons space 33

T
TDM holes 137
Tenons capsule 45
Trabeculectomy 1,11, 32, 98
surgical modifications 32
surgical technique for 13
antimetabolite treatment duration
and washout 18

block removal (sclerostomy) 19


conjunctival clamp 17
conjunctival closure 21
conjunctival incision 13
infusion 18
intraoperative antimetabolite use
15
paracentesis 18
peripheral iridectomy 20
position of filtration area 13
postoperative antimetabolite
injections 22
postoperative medications 22
scleral flap 14
scleral flap sutures 20
traction suture 13
type of sponge 18
with a scleral tunnel technique
combined with mitomycin-C 32
Trabeculotomy ab externo 150
techniques 150
Transscleral contact cyclophotocoagulation
37
Transverse tear 131

205

double plate Molteno implant 78


historical background 77
process of bleb formation
(immediate drainage of
aqueous) 77
illustrative cases 93
case of buphthalmos
associated with Sturge-Weber
syndrome 93
case of combined cataract and
glaucoma surgery 95
case of neovascular glaucoma 95
case of simple buphthalmos 93
case of traumatic glaucoma 97
case of uveitic glaucoma 96
results 97
single plate Molteno implant 78
to treat complex cases of glaucoma 77

V
Vicryl tie technique 81
Viscocanalostomy 102

W
U
Use of Molteno implants 77
current surgical technique 83
choice of surgical technique 84
cytostatic agents 91
direct control of bleb fibrosis by
systemic anti-inflammatory
agents 91
early complications 92
indications 83
indirect control of bleb fibrosis by
hypotensive agents 91
late complications 92
long-term management (all cases)
91
postoperative management in eyes
drained by delayed drainage
of aqueous (vicryl tie
technique) 90
postoperative management of
cases with immediate drainage
of aqueous 91
preoperative management 84
selection of implant area 83
surgical technique for delayed
drainage of aqueous 84
surgical technique for immediate
drainage of aqueous 88
surgical technique for neovascular
glaucoma 89

Wound healing 188


future strategies 193
modulation of TGF- in the optic
nerve head 193
modulation of TGF- in the
trabecular meshwork 193
intraoperative strategies 189
5-fluorouracil 189
beta irradiation 191
mitomycin-C 190
photodynamic therapy with
BCECF-AM 191
suramin 192
TGF 2 antibody (CAT-152) 191
postoperative strategies 192
interferon alpha 2 193
postoperative 5-fluorouracil
injection 192
postoperative topical steroid 192
tranilast 193
preoperative strategies 188
preoperative oral steroid 189
preoperative topical steroid 189
strategies for nodulating wound healing
188

Y
YAG laser capsulotomy and hyaloidotomy
74

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