Chapter - 6

Therapeutic Options
 139 Medical Therapy of Glaucoma
Dr. Gursatinder Singh, Dr. Prateep Vyas, Dr. Harsh Kumar
Glaucoma is a multifactorial optic neuropathy
in which there is a characteristic acquired loss of
retinal ganglion cells, at levels beyond normal age
related baseline loss and corresponding atrophy
of optic nerve head 1 .Glaucomatous optic
neuropathy is associated with progressive visual
field loss which can lead to total irreversible
blindness, if the disease is not diagnosed early and
treated properly2.The objective of glaucoma
management is to control IOP, limit ON and RGC
damage and preserve vision, ensuring good
quality of life.
We are passing through an exciting phase in
glaucoma therapy. Pilocarpine, beta blockers and
oral CAI's have remained mainstay of glaucoma
therapy for a long time. In the last decade newer
drugs like prostaglandins, alpha adrenergic
agonists and topically instilled CAI's have
provided potent weapons in the armamentarium
of ophthalmologists for medical management of
glaucoma. These can be used as monotherapy or
adjunctive therapy and can be combined with
laser procedures to achieve optimum target IOP.
FACTORS TO BE CONSIDERED BEFORE
STARTING THERAPY
Is the diagnosis of glaucoma established and
what type of glaucoma are we dealing with?
Angle closure glaucomas may require
iridotomy/iridectomy and concurrent medical
management. Different subtypes of glaucoma
need different modalities of treatment.
Baseline IOP and diurnal IOP should be
recorded before starting treatment. Correction for
corneal thickness should be done for Goldmann
applanation tonometer recording.( except when
cornea is on the thicker side, it may be more
prudent to neglect the correction factor and be on
the safe side by taking the pressure without
applying the correction factor)
Are there any risk factors like family history,
large vertical CD ratio, myopia, exfoliation
syndrome, thin cornea, disc hemorrhage, diabetes
mellitus, migraine and older age?
Systemic Hypertension and hypotension are
potential risk factors. High IOP decreases
perfusion pressure and low IOP increases
perfusion pressure. Systemic Hypotension
decreases perfusion pressure. Patients taking
antihypertensives at night may have decrease in
ocular perfusion during sleep at night and
consequent ischaemia related progression.
Older patients have higher risk of progression, but
have less chance of having functional disability,
as the life expectancy is lower.
Severity of disease at presentation. Patients with
advanced field defect at presentation have high
risk of progression.
Decision to treat glaucoma suspects or ocular
hypertensive depends on presence of risk factors
like IOP, CCT, family history, pseudoexfoliation,
large vertical CD ratio.
Treatment goals should be defined not
only in terms of reduction of IOP to target IOP
at reasonable and affordable cost, at the same
time maintaining quality of life and preserving
vision
Four major long term randomized controlled
studies on glaucoma have been completed and
they have concluded that lowering IOP delays the
progression of glaucomatous damage. [(Ocular
Hypertension Treatment Study (OHTS)[3,4,5,6], the
Advanced Glaucoma Intervention Study
(AGIS)[7], the Collaborative Normal Tension

[8]
Glaucoma Study (CNTGS) and Early Manifest
[9]
Glaucoma Trial (EMGT) ]
TARGET IOPAND QUALITY OF LIFE
We know that IOP is the only important
etiological factor we can target to slow or delay
the progression of glaucomatous damage. The aim
of glaucoma management is to achieve a stable
range of measured IOPs likely to retard further
optic nerve damage [10]. AGIS has shown that risk
of progression is greatly reduced, if at all time
points IOP is under 18mmHg in an advanced case
of glaucoma. The concept of target IOP is very
useful in management of glaucoma patients. It is
the highest IOP level expected to prevent further
glaucomatous damage or that can slow disease
progression to a minimum. Target IOP has to be
individualized and it is dynamic, means we have
to redefine target IOP if POAG progresses in spite
achieving apparently low IOP. It varies among
patients and both eyes in the same patient and may
need adjustment during the course of disease.
However it is important to set a correct target IOP
on the first visit itself, as the patient may not come
for follow up as scheduled and we may not be able
to detect progression before it is too late.
Target IOP depends on pre-treatment IOP, optic
disc damage, visual field changes and other
factors.
Age and life expectancy - younger age group
requires lower target IOP, whereas older patients
may be treated with higher target IOP.
IOP at which damage has occurred (pre-
treatment or damaging IOP). For example if the
pre-treatment IOP was 20mmHg then target has to
be near early teens like 12mmHg or so and if the
pre-treatment IOP was in 30's then target can be
around 18mmHg though this will also depend on
the age of the patient and type of disc and field
damage as given below.
MEDICAL THERAPY OF GLA
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Optic disc and visual field changes-
a) An eye with mild glaucoma i.e. early disc
damage, isolated visual field defect outside
central 10 degrees of visual field, MD on visual
field -6dB, the target IOP should be around
18mmHg
b) An eye with moderate glaucoma i.e. moderate
disc damage, arcuate visual field defect not
encroaching on central visual field, MD on
visual field -6 dB to-12dB, the target IOP should
be around 15mmHg
c) An eye with advanced glaucoma i.e. advanced
disc damage CD ratio 0.8-0.9, advanced visual
field defect encroaching on central visual field
threatening fixation , MD on visual field -12, the
target IOP should be around 12mmHg or less.
IOP should be lowered by 30% in cases of NTG
Rate of progression during follow up revise the
target IOP if progression is observed despite
having achieved target IOP.
Cost evaluation, benefit and risk/adverse effects
of treatment need to be considered
Quality of life and progression should not be
compromised
The target IOP should be individualized for each
eye and may be revised depending on progression
of structural damage.
STARTING GLAUCOMATHERAPY
The goal of glaucoma treatment is to maintain
the patient's visual function and related quality of
life, at a sustainable cost. The cost of treatment in
terms of inconvenience and side effects as well as
financial implications for the individual and
society requires careful evaluation[11].
The treatment options available are medical;
lasers or surgical, but medical therapy is the first
option for treatment and should thus be
administered with the goal to achieve the desired
 141 MEDICAL THERAPY OF GLA
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target IOP using least number of medicines with Currently PG's available are latanoprost,
minimum side effects. (0.005%) bimatoprost (0.03% and 0.01%) and
The most appropriate medication should be travoprost (0.004%). A patient not responding to
chosen. It should have the greatest chance of one PG analogue may respond to another drug
reaching target IOP with least side effects and from this group, so switching to another PG can
inconvenience, at an affordable cost. Treatment also be considered.
should be started low and slow i.e. minimal Within the prostaglandin group one should
concentration and frequency[12]. take note of certain situations which are of
Adherence should be ensured by establishing practical importance. The latanoprost group of
a therapeutic alliance with patient and their drugs gives minimal hyperemia and local side
family and using least complex regimen with effects, yet a cold chain needs to be maintained
least disruption of lifestyle [13] . The correct for their efficacy, which may not be possible in
technique of instillation should be taught to some parts of our country. The prostamide group
patient. Demonstrate the preferred method, of drugs (Bimatoprost) gives most hyperemia but
including punctal occlusion and eyelid closure for have greater IOP lowering potential. Travoprost
at least 3 minutes. If 2 drops are to be instilled, forms a middle path where hyperemia is less than
patient should be instructed to wait for at least 5 in prostamides but more than latanoprost group,
minutes between drops[14]. has adequate pressure lowering and does not need
ANTIGLAUCOMA DRUGS AND a temperature control. It is also shown to be
STARTING MONOTHERAPY effective despite one or two daily dosages being
Medical therapy as a rule should start as a missed[15].
single drug. Efficacy, safety, tolerability, quality
of life, adherence and cost of drug must be taken
into consideration while choosing the
management strategy. Monotherapy is first
treatment option and can be started with
prostaglandins (Travoprost, Latanoprost or
Bimatoprost). Start with a drug most likely to
meet treatment goals. The advantages of
prostaglandins (PG's) over other drugs are; better
IOP lowering efficacy (30-35%), convenient
once daily dosage and good safety profile. The
disadvantage of PG's is their high cost, which is
coming down now.
Let us say we start therapy with
prostaglandin, but we have to discontinue the
drug because IOP lowering is not as expected (
20% from baseline) or intolerance due to side
effects occurs. Then instead of adding another
drug we should switch to a different drug.
 MEDICAL THERAPY OF GLA
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Table 1 - Pharmaco-therapy of Glaucoma[16-23]

Iris pigmentation, conjunctival hyperemia,

local irritation, hypertrichosis,trichomegaly,
skin pigmentation, change in colour of iris
cystoid macular oedma put all side effects of
prostaglandins together
 143 MEDICAL THERAPY OF GLA
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ADJUNCTIVE DRUG THERAPY
If the first line monotherapy option
administered alone is efficacious (i.e. IOP
lowering is as expected), but are not sufficient to
achieve target IOP, it is preferable to add another
drug as adjunctive therapy. A single drug should
achieve 20% or more lowering of IOP to be
labeled as useful.Also one should wait at least 2 to
4 weeks for observing the full efficacy of the drug.
We can combine antiglaucoma medications with
each other, as well as laser and surgical
treatments. Adjunctive therapy can be
combination of PG's, betablockers, brimonidine,
topical CAI's or pilocarpine. Newer drugs just
launched in India include brinzolamide which
have neutral pH and thus are more comfortable
for the patient such that that some patients who
would complain of stinging with dorzolamide
would be more compliant with brinzolamide .
Adjunctive drug should belong to a different
pharmacological group (e.g. two beta blockers or
two prostaglandin derivatives should not be
combined). A drug that decreases aqueous
production should be combined with outflow
enhancing drug. Fixed dose combination drugs
may be preferable to separate instillation of same
two agents due to convenience and less exposure
to preservative in the former.
F I X E D C O M B I N AT I O N D R U G
PREPARATIONS
Adrenergic and cholinergic combinations
were reported as early as the 1960s. Fixed
combination eye drops contain two therapeutic
agents in a single bottle. They are preferred over
using two separate drugs due to improved patient
convenience, compliance, fewer side effects and
reduced toxicity of preservatives besides being
cheaper. These fixed dose combinations need to
be cautiously prescribed and contraindications to
beta blockers should be kept in mind as all fixed
dose combinations contain beta blockers.
Prostaglandins/prostamides are
administered once daily at night, but in
combination with timolol they are administered
in the morning.
While using combinations it's preferable to try
each drug component separately so that one can
understand its efficacy and side effects in a
standalone situation before we jump to using a
combination.
Management of glaucoma in pregnancy
Studies have shown IOP to fall by 1.5 mm hg
during pregnancy 24. Anti-glaucoma drugs causing
least harm to the fetus are preferred. Adrenergic
drugs and PG analogues should be cautiously
used as the former cause uterine hypotony while
the latter increase uterine contractility 25, 26 .
Lactating mothers should be cautiously
prescribed anti-glaucoma medicines, as timolol
and betaxolol were found to be secreted in breast
milk in a study27.
CATEGORIES FOR DRUGS IN
PREGNANCY (US FDA) (adapted from
the AAO Medical therapy monogram 2008)
CATEGORY A Adequate studies in pregnant
women have failed to show risk to the fetus in
the 1st trimester (There is no antiglaucoma drug
included in thiscategory)

CATEGORY B Animal studies have failed to
show a risk to the fetus but there are no adequate
studies in pregnant women
OR
Animal studies have shown an adverse effect but
human studies have not shown a risk to the fetus in
the 1st trimester and there is no evidence of risk in
the later trimesters
(Adrenergic agonists i.e. brimonidine is included
in this category)
CATEGORY C Animal studies have shown an
adverse effect on the fetus but there are no
adequate studies in humans but the benefit may
outweigh the risks
OR
There are no adequate human studies( blockers,
carbonic anhydrase inhibitors, prostaglandins,
cholinergic agents and osmotic agents like
mannitol are included in this category)
CATEGORY D Positive evidence of human
fetal risk but the benefits may outweigh the risks
(There are no antiglaucoma drugs included in this
category)
CATEGORY X- Animal or human studies have
shown fetal abnormalities or toxicity and the risk
outweigh the benefits (There are no antiglaucoma
drugs included in this category)
The sequence of management of glaucoma in
pregnancy should thus include careful
observation, laser , medical therapy and finally if
all else fails consider trabeculectomy.
The drug choice during first two trimesters in
pregnency is Brimonidine. Category C drugs can
be used with caution.
Topical carbonic anhydrase inhibitors and
prostaglandin analogues are reasonable choice
during lactational period, If beta blockers are to be
used the infant should be monitored closely and
the paediatrician should be consulted. Avoid alpha
MEDICAL THERAPY OF GLA
UCOMA 144
agonists in the lactational period.
MANAGEMENT OF GLAUCOMA IN
PAEDATRIC AGE GROUP
Management of glaucoma in pediatric age
group is different from adults. Most of the cases
need to be treated surgically and medical therapy
may be used before or as an adjunct to surgery.
Lower concentrations of topical anti-glaucoma
drugs are prescribed as higher plasma levels are
attained due to less body mass and blood volume.
Timolol is recommended to be used in strength of
0.25% to reduce potential side effects. However
0.25% betaxolol is preferred being a cardio
selective beta blocker and Prostaglandins can
bring about significant lowering of IOP in some
patients and can be used. Topical CA-inhibitors
(Brinzolamide and Dorzolamide) can be used
provided there is no corneal endothelial
decompensation. Oral CAI's can cause growth
retardation and metabolic acidosis in children and
thus should be used cautiously for long term.
Brimonidine is a lipophilic drug and crosses
blood brain barrier leading to significant CNS
side effects and is contraindicated in children < 10
years old. Cholinergics and adrenergics have
systemic side effects and are rarely used in
pediatrics glaucomas. Simple measures should be
followed to lower systemic absorption in
pediatric population such as punctual occlusion,
eye lid closure or blotting the excess drops away
during administration28.
COMPLIANCE IN GLAUCOMA
Successful management of glaucoma
requires patient's co-operation, as glaucoma is a
chronic progressive disease requiring life-long
treatment and regular follow up. Compliance in
glaucoma patients can be improved by educating
patients regarding the gravity of the disease and
consequences of non compliance with the
 145 MEDICAL THERAPY OF GLA
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treatment. Prescribing medicines with
convenient dosage schedule and use of fixed
combinations can enhance compliance. Complex
dosage schedules should be avoided as they have
negative impact on adherence. If more than two
drugs are being instilled, fixed dose combinations
increase compliance. Role of communication
and counseling the patient regarding treatment
goals, gravity of the disease and expected side
effects can't be overemphasized, as it can
significantly impact compliance.
Time should be spent on teaching the
correct method of instillation of eye drops in the
eye. Patient should be observed in the clinic
instilling the eye drop and should be given
feedback and corrected. Instructions and method
of instillation along with punctual occlusion
should be clearly understood by patient. Patient
should be asked to recall the instructions (teach
back technique).
In order to check if patient is compliant one can
have a chat in which one starts off by telling that it
is really difficult to take the drugs on time and can
give an example of the self that even I as a doctor
forget to take medicines on the required timings
and may miss a dose or two. This builds up a
rapport with the patient who then is forthcoming
with their own shortcoming on medications
schedule. Asking a relative or the spouse will also
tell us how diligent the patient is in keeping the
schedule of medication. The number of bottles of
a drug used can also give an indication of the same
as does the amount of money spent in a month on
medications.
In short patient should be aware of
-seriousness of the disease,
-side effects of glaucoma medication,
-dosage schedule,
-proper method of instillation of drops
(including punctual occlusion)
- follow up schedule.( most patients need 2
monthly IOP check and 6-9 monthly field test
unless the condition is more advanced and one
decides to do earlier tests or the condition is very
early where you decide to do a yearly check for
fields. IOP however should preferably be
monitored once in two months even in early
cases.)
A multidimentional approach and individualizing
the therapy to each patient is a solution to tackle
the issue of noncompliance.
Points to remember for some commonly used
drugs
Pilocarpine
-always make sure that there is no central opacity
to decrease vision (posterior subcapsular cataract
or central corneal opacity), young persons may
get intolerable headaches and transient myopia
due to accommodative spasm. Best avoided in
those with retinal surgery , peripheral retinal
degenaration and for those who are non compliant
since its thrice daily dosage is minimal.
- if used, must give a drug holiday by dilating the
pupil once in 2 weeks. First do it under direct
observation to see that when we withdraw
pilocarpine for a day (adding an extra
antiglaucoma medication possibly acetazolamide
to cover the rise of IOP) and dilate the pupil to
keep it mobile, if there is no significant elevation
of pressure.
Betablockers
- To be avoided in patients with a history of
asthma/COPD and cardiac diseases (like
bradycardia and greater than 1st degree heart
block), as it causes depression of both related
systems. Betaxolol can be given in pulmonary
patients.

- It should be avoided in patients with history of
depression , Loss of libido in young may prohibit
its use.
- Lipid profile should be done as B blockers can
alter lipid profile decreasing the protective HDL
and increasing the VLDL.
Dorzolamide/Brinzolamide
- Must try and avoid in patients who have a
decompensated cornea or who are prone to
corneal decompensation as in corneal grafts or
endothelial dystrophy.
- Distaste of mouth and local burning stinging is
more common as compared to other anti
glaucoma drugs (more common with
Dorzolamide because of its low pH than with
Brinzolamide )
- must teach punctual occlusion.
Brimonidine
- Should not be prescribed in children less than 10
years of age as studies have shown that it causes
CNS depression.
- Watch for follicular conjunctivitis which is more
common with higher concentration. Lid allergy
with blepheritis kind of picture may be seen quite
often and responds to withdrawal of the drug.
- Some patients may develop severe drowsiness
and sleep off at work. Must question the kind of
work they do and warn the critical ones like
drivers or electricians of the possible problems.
Prostaglandin analogues
- Must be avoided in patients who are soon to
undergo intraocular surgery or who have just had
a surgery, as this can lead to inflammation and/or
CME. Ideally should be discontinued 4-6 weeks
post intra ocular surgery.
- Also to be avoided in patients with pre-existing
inflammation like cases of uveitis or herpes
MEDICAL THERAPY OF GLA
UCOMA 146
simplex keratitis (to avoid recurrence or
exacerbation of disease)
- Look out for periocular hyper- pigmentation and
hypertrichosis in fair people and in patients being
treated in one eye, where it may produce
cosmetically unacceptable side effects.
- In some patients excessive conjuctival
hyperemia may occur and become cause of poor
adherence.
Acetazolamide
Must only be given for short term control of IOP,
if long term therapy cannot be avoided then blood
electrolytes should be monitored and patient
warned of renal stones. Kidney function tests
must be done at regular intervals as the drug is
nephrotoxic. Patients having long standing
diabetes mellitus carry risk of ketoacidosis due to
compromised renal function.
P re s e r v a t i v e s a n d p re s e r v a t i v e f re e
medication
Majority of medication used to treat glaucoma
contain preservative benzalkonium chloride
compounds (BAK).Is BAK bad for the eye? In
fact, they do serve a function they provide an
antimicrobial environment to allow the prolonged
use of medications. This enables to have multiuse
medications. Also for years, it was thought that
BAK helped penetration so there was better drug
effect. In the old days, when pilocarpine was
commonly used for glaucoma, it had such poor
penetration that BAK was added to get more drug
effect. While this is positive, the downside is that
patients can have allergic reactions to the
preservative, can cause dryness of the eye and
also increases risk of failure of surgery due to low
grade conjunctival inflammation.
The action mechanism of preservatives may be
divided into two main categories: surfactants and
 147 MEDICAL THERAPY OF GLA
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oxidants.
Surfactants act upon microorganisms altering the
cellular membrane and resulting in the lysis of the
cytoplasm content. The classical example for this
type of agents is benzalkonium chloride.
Oxidizing preservatives are usually smaller
molecules interfering with cell functions.
Stabilized chlorine and oxygen compounds and
sodium perborate are some examples of oxidizing
preservatives.34
Aclassic case of glaucoma
A 54 year old executive walks into our OPD with
complaints of redness and watering. Though the
complaints were related to allergy, full eye
examination reveals a visual acuity of 6/6 both
eyes, IOP of 22 and 28 in the right and left eyes
respectively. The anterior segment is essentially
normal and the angles are open on gonioscopy.
The lens is clear but the optic disc in the right eye
has a cup of 0.5 vertical diameter and the left eye
has a cup of 0.8 with a notch in the inferior
neuroretinal rim. The patient is immediately
explained the diagnosis of open angle glaucoma
and consent obtained to perform some tests. The
corneal thickness reveals a normal value of 535
and 540 microns. The visual field exam shows
essentially normal field in the right eye and an
arcuate scotoma in the superior quadrant. Though
not essential but an OCT is carried out and reveals
that though the right field exam is normal yet the
OCT shows preperimetric changes in the RNFL
while the left eye obviously has the thinning of
RNFL in the inferior quadrant.
Further inquiry is made about history of diabetes,
hypertension, thyroid disease and any family
member being a glaucoma patient all of which is
negative in this case.
Patient is explained as to what is glaucoma and
how we are going to tackle this disease. He is
advised to start a prostaglandin analogue one drop
at night in each eye at a fixed time say 10 o clock.
He is taught about punctual occlusion and the
importance of this procedure. He is also told to
look out for side effects like mild redness,
irritation, periorbital pigmentation and lash
growth which he needs to report back to us.
He is informed that he must get all his blood
relatives screened for glaucoma.
He is advised to come after three weeks to get the
IOP checked and do repeat fields as to take care of
the learning curve in the field test and hence get a
reliable field which can be used as a baseline for
detecting progression.
Since the fields are essentially normal in the right
eye we expect to set a target pressure of less than
20mmHg in the right eye but since the damage is
moderate in the left eye we need to get the IOP
down to around 14-15 mmHg. We would record
the IOP after three weeks and if the pressure
lowering by the drug given is less than 15 to 20%
then we need to switch the patient on another
medication.
Ideally a diurnal variation should be carried out if
feasible and permitted by the doctors and patients
circumstances, even before starting any
medication since it will give the idea of the peaks
of the IOP and its timings. One can then adjust the
dosing accordingly. Again if permitted one can
repeat the diurnal variation after the patient has
been controlled on medication to see if this
control is extending round the clock.
Salient features
-Confirm patient has glaucoma, get good baseline
fields (2 similar), disc photo or draw it yourself,
applanation IOP/diurnal variation,gonioscopy
and corneal thickness.
-Explain to patient what glaucoma is, what his

therapy is likely to be and what would be his
schedule for follow up. Emphasize that all blood
relatives must be screened.
-Based on investigations decide a target pressure.
One needs to treat patients more aggressively/
have lower target pressure where already the field
and disc show advanced damage, strong family
history of glaucoma, pseudoexfoliation, thinner
cornea, younger patient, initial presenting IOP is
high.
Start monotherapy - Type of this monotherapy
will depend on financial capability, the ability of
that person to withstand the side effects of that
drug (can't think of using timolol in a patient with
asthma or heart block), the work profile (may be
difficult to use a drug requiring strict temperature
control if patient is a frequent traveller), the
number of times he can put the drug comfortably
(compliance greater with PG analogues to be used
once a day and poor with pilocarpine to be used
four times a day)
- If monotherapy does not lower IOP by greater
than 20%, switch to another monotherapy failing
which add another drug. Additional drug should
be from a group with different mechanism of
action (dorzolamide/brinzolamide decreases
inflow while PG analogue increases outflow)
- Allow medications to take effect (2-3 weeks)
before shifting or adding a drug.
- Try each drug in the combination separately
before starting the combination as it will tell about
the side effect and efficacy of each part
-Clearly write the timing of medication, teach
punctual occlusion and decide follow up
-We should not forget to provide the healing touch
in form of giving hope and encouragement to fight
this blinding disease.
MEDICAL THERAPY OF GLA
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inhibitors. Curr Opin Ophthalmol. 2001; 12: 88-93.
22. Mauger TF, Craig EL. Havener's ocular pharmacology.6th ed.
St Louis: Mosby; 1994.
23. Sunness JS. The pregnant woman's eye. Surv Ophthalmol.
1988;32:219238.
24. Kooner KS, Zimmerman TJ.Antiglaucoma therapy during
pregnancypart II.Ann Ophthalmol. 1988; 20: 208211.
25. Salamalekis E, Kassanos D, Hassiakos D, Chrelias C,
Ghristodoulakos G. Intra/extraamniotic administration of
prostaglandin F2a in fetal death, missed and therapeutic
abortions. Clin Exp Obstet Gynecol. 1990; 17: 1721.
26. Lustgarten JS, Podos SM. Topical timolol and the nursing
mother.Arch Ophthalmol.1983; 101: 13811382.
27. Kanner EM, Netland PA. Pregnancy and pediatric patients.
Glaucoma Medical Therapy.2nd ed. Oxford university press.
2008.235-242.
28. Kobelt G. Glaucoma Care Updates. Health economics,
economic evaluation, and glaucoma. J Glaucoma. 2002;
11:531-539.
 Laser Procedures In Glaucoma
Dr. Harsh Kumar, Dr. Gowri J Murthy, Dr. Reena M. Choudhry
Introduction
All practitioners must have a working knowledge
of some basic laser procedures for glaucoma,
especially angle closure since 50% of our
glaucoma patients are angle closure whose first
step is a YAG iridotomy. Besides, cyclo-
destructive procedures for advanced glaucoma
must also be learnt since such patients need to be
dealt with commonly in practice.
The other laser procedures which we will describe
in detail are easily performed by any ophthal-
mologist and should form part of a practitioner's
armamentarium.
Lasers inAngle-Closure Glaucoma
The primary treatment modality of angle closure
glaucoma is laser therapy unlike in open angle
glaucoma especially in Indian population. The
first time a patient of angle closure comes to a
doctor is when he is having an attack or there is a
premonition based on seeing colored haloes
around lights with slight headaches. More often
today in the preventive checkups or in the patients
who have come for a routine or a specific check up
of the eye, the alert doctor detects a shallow
chamber and refers to a specialist. The wide use of
Van Hericks test on a slit lamp has also helped to
diagnose a lot of angle closure suspects.
Once the diagnosis is confirmed on gonioscopy,
one decides if the medications are to be started
first as they have to be done in case of primary
angle closure glaucoma where the elevated IOP
have already caused a disc damage. If the iris
configuration suggests a plateau iris or after
dilation the pressure still rises despite a patent
iridotomy, it is an indication to do an Iridoplasty
(gonioplasty). Also in some cases of acute ACG
where a boggy iris prevents an iridotomy from
being done, an iridoplasty may help in lowering
of IOP when medications are not able to control
150
the IOP.
ND-YAG LASER IRIDOTOMY
The Nd YAG laser delivers intense amount of
energy into a well focused spot over a period of
pico seconds to nano seconds with the extremely
high irradiance produced by YAG laser resulting
in a high energy electron clouds or plasma, which
disrupt the tissue and produce a hole.
It is now conclusively proved that the recurrence
of an acute attack can be prevented by a laser
iridotomy. [ 1 ] The iridotomy also prevents
occurrence of an acute attack in the fellow or
[1,2]
primary angle closure suspect eyes. Iridotomy
is also carried out in cases of iris bombe in
secondary glaucoma causing pupillary block.
Technique:
Pre Laser evaluation: Besides routine total
ophthalmic check up one must carefully look at
the following - the IOP, the clarity of cornea, the
depth of the anterior chamber, the presence of the
crypts and the size of the pupil.
Preoperatively note the following:
1. IOP must be well controlled so that: cornea is
clear and procedure is easier.
2. The procedure itself elevates the IOP and as
most eyes are already compromised due to
glaucoma, a sudden high rise may have disastrous
consequences. This is especially important if the
patient is having an advanced glaucomatous
damage or is a one eyed patient.
3. The pupil must be constricted preoperatively so
that the iris is stretched fully and at its thinnest and
easily penetrable. Pilocarpine must be instilled
pre-laser for this. One drop of pilocarpine may be
put two to three times in the eye to be lasered at ten
minutes interval depending on the requirement.
4.An informed consent is obtained from all
patients.
5. If the IOP pressure is high despite topical
 151 LASER PROCEDURES IN GLA
UCOMA
medications and oral acetazolamide then one may
use even intravenous mannitol to lower the
pressure before the procedure.
6.Must check that the patient is not on anti
coagulants especially in one eyed, in those with a
corneal graft or a very advanced glaucoma we
would like to stop blood thinners for 5 days prior
to procedure in consult with the physician who
has started it.
Operative Technique:
Topical anaesthesia is applied in the form of 4%
Xylocaine. Patient is seated on the Q-Switched
Nd-YAG laser and an Abraham's type of contact
lens is applied. This lens has a +55 D, peripheral
button over a routine contact lens. This lens helps
in the following way: -
a. It stabilizes the eye and prevents undue
movements.
b. It helps to open the eye and keep the lids
retracted during the procedure.
c. It smoothens out the corneal surface.
d.It provides peripheral view, which is highly
magnified.
e. It helps to reduce the axial expansion of plasma,
which reduces the unnecessary spread of the
damage.
f. It increases the power density of the spot.
g.Gives pressure to prevent the bleed from
increasing.
Setting:
Although energy levels vary widely from machine
to machine, and sometimes even within the same
machine, the overwhelming majority of clinical
iridotomies are made with settings between three
and ten millijoules per shot, one to three shots per
burst. Energy levels higher are necessary when
performing iridotomy on thick, velvety smooth,
brown iris in comparison to blue iris. Using either
more power per shot or more shots per burst can
increase energy delivery. Higher energy level and
more shots per burst are associated with a
greater degree of success in fewer treatment
sessions, but also with a greater degree of
intraocular damage. Human and experimental
animal studies have shown that anterior lens
capsule damage is a frequent complication when
relatively central iridotomies are performed in
comparison to peripheral location, using energy
setting of greater than seven millijoules per shot
and three or more shots per burst. In case we use
too low a power setting then we would only be
chipping away at the superficial iris and the
pigment so released decreases the chances of
further laser being effective. Thus one should
use a setting such that iridotomy is complete in
three to four shots and one is using neither too
high or too low energy.
Site: A more peripheral treatment site takes the
advantage of the fact that the iris diameter is
greater than lens diameter and lens begins to
curve posteriorly towards its periphery. Thus the
anterior lens capsule is not directly adjacent to
posterior surface of iris and any excess laser
energy that penetrates the iris is less likely to
damage the lens. One can decrease the
likelihood of intraocular damage by choosing a
peripheral treatment site and by choosing fewer
shots per burst and by not using YAG laser to
enlarge an iridotomy. The only problem of going
too peripheral is decreasing visibility due to
commonly present pannus in Indian eyes. If an
iridotomy opening is too small, one should
create an additional YAG iridotomy at a separate
site or enlarge the previous one should always
aim to hit the spot in a crypt where the thickness
is much less. (Fig.2)
If initial attempt at iridotomy fails to produce a
through and through hole, one can choose to
retreat again at the same site or more for a
separate site. The decision to treat at the same

site depends partially on the degree of pigment
dispersion and hemorrhage caused by the
previous partial treatment. Especially on thick
brown irides an incomplete treatment may result
in a thick cloud of dispersed iris pigment. This
cloud makes it difficult to visualize or focus
adequately on the base of the previously partial
thickness treatment. Repeated applications of
laser energy into this pigment cloud may result in
increased pigment dispersion and hemorrhage
rather than a patent iridotomy. So one should wait
till one can see clearly the previous treated area or
move to a new area with slight increase in energy
setting.
End point: Once the iridotomy is complete one
can notice a sudden out flowing of the pigment
from the posterior to the anterior chamber along
with sudden deepening of the anterior chamber.
The presence of retro illumination may be looked
for after a few weeks of laser iridotomy ( Fig1),
however it is not a sure sign of total penetration.
Postoperative management: The patient should
be continued on anti-glaucoma medications,
which he was previously taking along with an
additional anti-glaucoma agent for at least one
week. Also steroid antibiotic combination should
be started in QID dosage for at least 3 to 4 days.
Pilocarpine must be continued post operatively
for around 5 days in order to keep the iris
stretched and keep the iridotomy patent.
LASER PROCEDURES IN GLA
UCOMA 152
Complications and their management:
a) Micro hemorrhages: These are perhaps the
commonest association of YAG iridotomy. At
times the hemorrhage may just fill up the anterior
chamber partially resulting in a hyphema. Mostly
however once the hemorrhage is occurring one
should stop the procedure & apply pressure on the
globe with the lens (Contact lens) which will
invariably abort the bleeding. One might have to
postpone the procedure for another sitting on next
day if the media becomes too cloudy. One can
also make the patient wait in a sitting position for
about an hour when the media usually clears and
then one can try the iridotomy at another site.
b) Elevation of Intraocular Pressure: This is
indeed the single most important complication
since the iridotomy is being carried out in eyes
already having elevated IOP tension. (Details
regarding Pressure dynamics given under IOP
rise after iridotomy).
c) Uveitis: The uveitis is essentially more of
pigment dispersal and a result of irritation to the
iris rather than a specific iritis. This is seen in all
the cases undergoing iridotomy & usually
subsides by itself requiring no specific therapy.
d) Corneal burns: may occur occasionally due to
malfocusing but disappear within minutes. If one
has attempted an iridotomy in a very shallow
chamber, then also the endothelium may get
damaged but the opacity so caused does not
spread and since it is in the periphery it does not
interfere with vision.
e) Lens damage: though has been documented as
a capsular damage, is unlikely to occur if one
stops putting laser shots through the already
patent iridotomy. It is possible to damage the
zonules though in some situations and this could
lead to difficulty during phaco procedures.
 153 LASER PROCEDURES IN GLA
UCOMA
Special situations:
Difficult iridotomy (Fluffy dark iris without
crypts) Under this kind of situation the usual
technique of PI would fail. One can use an Argon
pre-treatment in 2 forms. We can prepare the
iridotomy site by stretching it out by placing the
low power (0.3 0.4 mw) longer time (0.2 sec.)
300 500 Micron burns around the proposed site
in a drumhead pattern. (fig 2.)
Depicts argon stretch marks applied with central YAG
shot to create an iridotomy in a thick iridis
Also one could place a couple of Argon burns on
the proposed site of YAG PI so that it could be
flattened and would not fluff up 4 . If laser
iridotomy cannot be completed in the first sitting
and there is too much pigment, patient can be
recalled at a later date and the iridotomy can be
completed.
IOP rise after iridotomy
Understanding of pressure dynamics after Nd:
YAG laser iridotomy is important to avoid visual
or field damage by acute pressure elevations in a
compromised optic nerve head. This becomes
critical since most patients are treated on an
outpatient basis and understanding of the factors
leading to significant acute elevations may help to
cut down the costs of monitoring.
The peak acute IOP elevation post iridotomy was
seen at one hour in more than 75% of cases in all
the types of angle closure eyes. All cases that
developed a significant IOP elevation always
manifested it within the first four hours post laser
even if the peak elevations were at a later time.[5]
[6]
This fact is substantiated by other authors and is
significant because only those patients with
elevated IOP within the first four hours need
closer surveillance.
A significant IOP elevation was recorded in 40%
of the chronic group, while in the other groups; it
was approx 11.1% to 17.8%.5
An eye with a higher pre-laser IOP is more likely
to develop significant post laser IOP elevation.
This, coupled with the fact that chronic cases with
occluded angles have a greater chance of
developing acute post-laser IOP elevation, leads
us to postulate that only a trabecular meshwork
already incapable of maintaining normal IOP is
likely to be compromised by further collection of
obstructive debris
The long-term result of Nd: YAG laser iridotomy
show excellent control in cases of fellow eyes,
subacute eyes, and without topical medication.
Up to 75% of chronic eyes also maintain fairly
reliable control with additional angle closure
glaucoma topical antiglaucoma medication.
Those with a comparatively greater gonioscopic
angle closure and those where there was no
significant widening (even by single grade) post
iridotomy do not achieve long-lasting IOP control
with iridotomy and drug alone. Such patients
should be operated if they are unlikely to follow-
up regularly while the rest should be closely
monitored to detect early field deterioration or
constant IOP elevations.
To blunt the post-laser IOP spike, especially in
vulnerable cases with field loss, it is suggested
that an additional antiglaucoma drug be added to
the regimen already being used to control IOP.
Therefore those maintained on pilocarpine are
started on topical timolol maleate a few days
before the laser application. Dorzolamide and
Brimonidine can be added along with oral

acetazolamide, while those, receiving all three
medications start additional oral glycerol (of the
commonly available, inexpensive medicines).
All cases should be preferably called in the next
day to check for any IOP rise and look for
complications and antiglaucoma medications can
be adjusted accordingly.
PERIPHERAL IRIDOPLASTY
Krasnov was the first to use laser energy placed
near the iris root to separate iris. and trabecular
meshwork. Today the procedure is done by
placing laser beams of long duration, low power
and large spot size in the extreme iris periphery to
contract iris stroma between the site of the burn
and the angle, thereby opening it.[6]
Indications :
1. Plateau iris syndrome
2. An unbreakable attack of Angle closure
glaucoma where laser iridotomy is not possible
3. Angle closure glaucoma due to lens
intumesence.
4.Adjunct to laser trabeculoplasty.
5. Topiramate induced bilateral high myopia with
acute angle closure where iridotomy does not
work.
Technique:
The procedure is done under topical 4%
Xylocaine using a single/double mirror gonio-
scopic lens with laser antireflective coating. If
possible pupil should be constricted 1 hour before
treatment with 2% pilocarpine to facilitate the
application of laser beams to the extreme
periphery. In situations where the gonioscope
cannot be applied like in corneal edema one can
directly place the spots in the peripheral iris.
Contraction burns with Argon laser setting at 500
microns spot size, 0.2 to - 0.5 second duration and
Power between 200 400 mJ are applied with the
contact lens in place aiming at the about 1 mm
LASER PROCEDURES IN GLA
UCOMA 154
away from the root of Iris. Approximately 20-40
o
spots are given over the 360 leaving a gap of 2
spot diameters between each spot to spare visible
radial vessels.(Fig.3)
Depicts a case of acute angle closure where iridopasty
had to be done as a primary procedure to control the
attack and bring down the IOP after which the
PI is carried out.
The contraction effect is generally seen
immediately associated with deepening of the
anterior chamber at the burn site. If this is not
visible then one should change the settings by
decreasing the spot size or increasing the power.
If on doing so the iris retracts but the angle does
not open then it means that the synechiae are so
strong that the iridoplasty is unlikely to help.
It is important to realise that acute angle closure
may sometimes not be controlled by medications
and even repeated mannitol injections may not
bring down the pressure adequately. In such
situations the iris is too boggy and it may be
impossible to create an iridotomy opening. Here
performing an iridoplasty with or without a
contact lens can control the IOP thus controlling
the attack. One may then carry out an iridotomy
later.
Diode laser may have better penetration. In
situations where the iris is too bowed then one can
apply a row of spots further away from the iris
root so the visible area of iris will then contract
and allow the spots to be placed more
peripherally.
 155 LASER PROCEDURES IN GLA
UCOMA

Postoperative treatment - Patients are given

topical steroids four times a day for 3 5 days
along with topical beta blocker complications
include a mild Post operative iritis which
responds to topical steroids, corneal endothelial
burns and transient IOP rise.

References:

1. Nolan WP, Foster PJ, Devereux JG et al. YAG laser iridotomy

treatment for primary angle closure in East Asian eyes. Br J
Ophthalmol. 2000; 84: 1255-9.
2. McGalliard JN, Wishart PK. Theeffect of ND YAG iridotomy
on intraocular pressure in hypertensive eyes with shallow
anterior chambers. Eye. 1990; 4: 823-9.
3. Gedde SJ. Management of glaucoma after retinal detachment
surgery. Curr opinion Ophthalmol. 2002; 13: 103-109.
4. Kumar Harsh: Sood NN, Kalra VK. Evaluation ofArgon pre
treatment for mode locked Nd-YAG Laser peripheral
iridotomy in angle closure glaucoma. Glaucoma. 1990: 12:
126.
5. Kumar Harsh: Sood NN, Kalra VK: Pressure dynamics
following mode locked Nd-YAG laser iridotomy in angle
closure glaucoma. Glaucoma. 1990: 12: 39-46.
6. Kumar Harsh, Sood NN: Gonioplasty in angle closure
glaucoma uncontrolled with a patent Nd-YAG Laser
iridotomy. Glaucoma July/Aug. 1991; 13 : 149-151.
7. Ritch R, Tham CC, Lam DS: Argon laser peripheral iridoplasty
(ALPI): An update. Surv Ophthalmol. 2007 May Jun; 52(3):
279-88.
8. Sbeity Z, Gvozdyuk N, Leibmann JM, Ritch R: Argon laser
peripheral iridoplasty for Topiramate induced bilateral acute
angle closure. Einhorn Clinical research Centre, New York Eye
and Ear Infirmary NY USA

ARGON LASER TRABECULOPLASTY
Laser Trabeculoplasty (ALT) is commonly used
laser treatment in Primary Open Angle Glaucoma
(POAG). It is based on the concept of applying
low energy laser burns to trabecular meshwork
(TM) to increase the aqueous outflow resulting in
lowering of intraocular pressure (IOP).
Equipment required:
Laser- Any photocoagulative laser can be used
like apart from Argon, like Diode, or Frequency
doubled Nd:YAG.
Contact lens- Ritch trabeculoplasty laser lens,
Goldmann single or three mirror lens, or Thorpe
four mirror goniolens.
Indications:
POAG:
-ALT is effective as initial, replacement, or
adjunctive therapy in the management of OAG.
- Primary treatment withALT can be considered
in noncompliant patients or those who are unable
to use topical medications.
-ALT can be used as an effective replacement
therapy in patients where use of topical
antiglaucoma medications are contraindicated
(pregnancy, ocular surface disease, etc)
-ALT can be considered as an adjunct to maximal
medical therapy in patients where a window
period is required to defer filtration surgery due to
patient's physical status.
Ocular hypertension
Pseudoexfoliation glaucoma
Pigmentary glaucoma
Patients with pseudophakia and aphakia with
open angle glaucoma can also be subjected to
ALT, but the IOP lowering effect in the aphakic
eyes is not as good as the pseudophakic.
ALT should be avoided in advanced cases of
open angle glaucomas and in patients with
extreme IOP elevation despite medical treatment
(above 35mmHg).
LASER PROCEDURES IN GLA
UCOMA 156
We must remember that the maximum lowering
of IOP can be around 5-6mmHg with this
procedure and only 60-80% of Indian eyes will
respond to this.Also the effect may wane off with
time
Contraindications:
Secondary open angle glaucoma like
neovascular, uveitic and traumatic.
Developmental glaucoma.
Angle closure glaucoma.
Media haze due to corneal cloudiness.
Procedure:
Informed signed consent is taken It is
important to inform the patients that there is only
50 % possibility of achieving the desired
reduction in IOP and the effect might wean off
over a period of time.
Topical anaesthesia is achieved with
Proparacaine 0.5%, or 4% Xylocaine eye drops
Brimonidine 0.15- 0.2% can be used if not
contraindicated 1 hour before the procedure to
minimize the postoperative IOP rise.
The laser procedure requires gonioscope for
visualization of anterior chamber angles like the
Goldman single or three mirror lens, or Ritch
trabeculoplasty laser lens with antireflective
coating on the front surface for laser application.
The preferred goniolens is inserted with
coupling fluid and entire angle is examined
carefully.All angle structures should be identified
before starting the laser procedure.
The parameters recommended are 50m spot
size, 0.1- 0.2 second duration and 700 1200 mW
of power (average of 800-900 mW in Indian eyes
with pigmentation).
The power should be adjusted to produce a
depigmentation spot or a small bubble at the
treatment site. Power settings may be reduced in
 157 LASER PROCEDURES IN GLA
UCOMA
highly pigmented angles and increased for lightly
pigmented trabecular meshwork (TM.)
The beam should be focused at the junction of
pigmented and non pigmented TM remaining a
little anterior rather than posterior. The spot must
be well focussed This placement minimizes early
post-laser pressure rise and peripheral anterior
synechiae formation.
50 laser spots are applied in 180 degrees or 100
spots in 360 degree of the circumference. The
burns are regularly spaced from one end of the
mirror to the other.
Post procedure protocol:
Anti glaucoma medications are continued and
gradually decreased depending upon the IOP
lowering effect of the procedure.
Topical Brimonidine or Oral Acetazolamide (if
not contraindicated) is given after the laser
procedure to blunt the post laser IOP spike.
Topical steroids or anti inflammatory drops are
recommended for 5-7 days, to minimize
inflammation.
Complications:
Post laser IOP spike in the early period is not
uncommon and is mostly transient but in few
cases the increase in IOP may persist.
Mild iritis is common after ALT which clears
rapidly but occasionally may persist for months.
Peripheral Anterior Synechiae (PAS) Posterior
placement of burns can result in PAS formation.
Post laser follow up:
IOP is measured after 1 and 4 hours of the laser
procedure and if the IOP rise is not significant
patients are reviewed at 1 week, 4 weeks and 3
months. In case IOP reduction is satisfactory, a
gradual reduction of medication is attempted. It
usually takes 3-6 weeks for the desired effect of
laser treatment.
Mechanism of action:
The most widespread accepted mechanism by
which the outflow facility is increased is the
mechanical theory proposed by Wise & Witter.
They postulated that the thermal energy produced
by absorption of laser by pigmented TM causes
shrinkage of collagen leading to opening up of the
intertrabecular spaces in untreated areas and
expanding the Schlemm's canal by pulling the
meshwork centrally. Other theories propose
increased phagocytic & migratory activity of
surviving endothelial cells near the laser lesions
increasing the transcellular flow of aqueous into
Schlemm's canal. Other cellular and biological
changes involve elimination of some trabecular
cells, which stimulates the remaining cells to
produce a different composition of extracellular
matrix with lesser outflow obstructing properties.
Results and limitations:
Detailed knowledge of anterior chamber anatomy
and its many variations is imperative for a
successful ALT procedure. The variation in
degree of pigmentation and width of the anterior
chamber may interfere with accurate laser
application to the trabecular meshwork. In a
narrow angle the peripheral iris might sometimes
obscure good visualization of the meshwork and
in this situation, manipulation by asking the
patient to look in the direction of the mirror being
used often provides deeper view into the angle. In
cases where this does not suffice, peripheral laser
iridoplasty can be done to open the angles and
trabeculoplasty can be attempted at a later stage.
IOP lowering effect is assessed after 4-6 weeks,
when all cellular and biologic changes have taken
effect. Most studies report 20-30% of IOP
reduction in about 60-70% of patients treated.
The IOP lowering effect of ALT tends to wean off
over time. The failure of trabeculoplasty over

time could be due to thermal damage to collateral
tissues leading to scarring of TM and migration
of endothelial cells, occluding intertrabecular
spaces leading to reduced aqueous outflow.
Repeat ALT is not very effective. The glaucoma
laser treatment trial showed that 7 years after
ALT, laser-treated eyes had a lower IOP, better
fields, and better optic nerve head parameters,
than eyes treated with medication, but In Indian
eyes the efficacy ofALT is still to be established.
SELECTIVE LASER TRABECULOPLASTY
Selective laser trabeculoplasty (SLT) is an
alternative trabeculoplasty procedure introduced
by Latina et al in 1995. In SLT, frequency
doubled, Q- switched Nd:YAG laser selectively
targets pigmented TM cells without causing any
structural damage to the non pigmented cells.
There is therefore no or little photocoagulation-
induced thermal damage. This results in milder
tissue response and the potential for repeated
treatment.
Equipment required:
Laser- Q-switched Frequency doubled Nd:YAG
(532 nm) ( not the same as used for retinal spots in
a standard 532 frequency doubled Pea green
laser)
Contact lens- Latina lens, Goldmann single or
three mirror lens.
Indications:
The indications for treatment with SLT are similar
to the indications for ALT. In addition, SLT can be
a useful treatment alternative in patients who have
history of failed ALT in the past. Because of the
non-destructive and potentially repeatable
properties of SLT, it may be used as the first line
treatment for POAG.
Procedure:
Informed signed consent is taken.
To p i c a l a n e s t h e s i a i s a c h i e v e d w i t h
Proparacaine 0.5%, or 4% Xylocaine eye drops.
LASER PROCEDURES IN GLA
UCOMA 158
Brimonidine 0.15- 0.2% can be used if not
contraindicated 1 hour before the procedure to
minimize the postoperative pressure rise.
Latina lens or Goldmann 3 mirror lens is used for
visualization of angle and laser delivery.
The preferred gonio lens is inserted with
coupling fluid and entire angle is examined
carefully.
The parameters fixed are spot size of 400 m
and pulse duration of 3 nsec. The power setting is
the only variable mode from 0.6-1.3 mJ
depending on the pigmentation of TM.
The large 400 m spot is centered on the TM and
effectively covers the entire TM with some
overlap onto scleral spur and Schwalbe's line.
The power can be titrated till it causes the
cavitation bubbles (champagne bubbles) to form
in the aqueous humor just in front of the TM.
50-100 contiguous, but not overlapping, spots
are applied along 180-360 degrees of TM. In eyes
with heavily pigmented TM, only 180 degrees is
treated first.
Highly pigmented TM will normally require
lower energy (approximately 0.6 - 0.8 mJ)
whereas lightly pigmented will require higher
energy (0.8 -1.3 mJ) in order to reach treatment
endpoint (champagne bubbles).
Post Procedure protocol and follow up:
The post laser protocol and follow up is similar to
ALT. Non steroidal anti inflammatory drugs can
be used topically instead of topical steroids for 3-
4 days.
Complications
The complications in SLT are similar to those
reported in ALT. SLT causes less tissue damage
and hence fewer PAS formation as compared to
ALT. However the SLT is carried out with a
specific machine which has to be bought
separately for this specific purpose and is an
expensive proposition.
 159 LASER PROCEDURES IN GLA
UCOMA
CYCLODESTRUCTIVE PROCEDURES
Cyclodestruction, or destruction of the ciliary
body, is a surgical method used to reduce
intraocular pressure in the management of
glaucoma. Cyclodestruction, conventionally, has
been reserved for eyes which are unresponsive to
outflow enhancing surgeries, like trabe-
culectomy, and valve implants.
Historically, Vogt (penetrating cyclodiathermy)
in the 1930s, and Bietti (cyclocryotherapy) in
1950 , were early proponents of this procedure.
Since then, various refinements in technique have
been developed, with the advent of Lasers, and
newer imaging, and viewing technologies.
Methods of Cylophotocoagulation:
Cyclodestruction by transpupillary visualization
Cyclodestruction by transvitreal route
(endophotocoagulation)
Trans scleral Cyclophotocoagulation.
Cyclodiathermy
Cyclocryo therapy
Diode TSCPC
NdYAG TSCPC
Ultrasound CPC
Endoscopic Cyclophotocoagulation.
Irrespective of the method used, what is
common to all the methods, is that -
Destruction of the ciliary body is irreversible
There is always associated inflammation,
which is incited by the destructive procedure.
Loss of visual acuity may result due to
inflammatory, and other changes like cystoid
macular edema
Due to these facts, cyclodestruction therefore, is
reserved for Intractable, or refractory Glaucoma.
Outflow enhancing surgeries, like
Trabeculectomy, and Valve implants, should have
already been tried, or deemed not possible, before
considering cyclodestruction. One advantage of
certain types of cyclodestruction is that, it can be
performed in a non invasive manner (e.g.
Transscleral CPC).
Transpupillary Cyclophotocoagulation:
In few situations where, the ciliary processes can
be directly visualised, in aphakic eyes, or those
with aniridia ( congenital/traumatic) where part
or whole of the iris is absent, transpupillary
cyclophotocoagulation can be tried.
Equipment required:
- Diode orArgon Laser.
- Contact lens- Goldmann three mirror lens
Indications:
Aphakic, aniridic eyes with raised IOP intractable
to maximal medical management. Scarred
conjunctiva/ thin sclera, therefore, conventional
outflow enhancing surgeries not possible.
Procedure:
Topical anesthesia with Paracaine, or 4%
xylocaine
Goldmann three mirror contact lens applied with
the help of coupling agent.
Settings:
Argon laser, 1,000 mW, with a 50-micron spot
size for 0.1 second. For hemostasis, 200- micron
spot size, with 0.2 sec duration and lower power
can be used.
Extent: Depending on IOP reduction required,
and visibility, one to three quadrants may be
treated.
Post Procedure protocol:
Anti glaucoma medications are gradually
decreased, after noting drop in IOP.
Topical steroids, and cycloplegics, are prescribed
to minimize inflammation, typically tapered over
two to four weeks.
Disadvantages
Possible in only a few eyes with ability to
visualize Ciliary processes and applicable to
aphakic, rarely, pseudophakic eyes.

Dose response curve unpredictable.
Entire ciliary process is not visible, only anterior
part which is visible, is photocoagulated.
Few reports in literature, anecdotal case reports,
large studies not possible.
Advantages - non invasive, equipment easily
available.
Transvitreal endophotocoagulation of ciliary
processes:
Equipment required: 20/23 gauge vitrectomy set
up, 20/ 23 gauge endo laser probe, and 810 nm
diode laser.
Indications:
Neovascular Glaucoma, in conjunction with
peripheral retinal laser
Silicone oil induced Glaucoma
Borderline corneal endothelium, in aphakic/
pseudophakic eyes with refractory glaucoma.
Procedure:
Standard, but thorough 3 port pars plana
vitrectomy is done, with infusion in
inferotemporal quadrant. Through one of the
superior ports, the endolaser probe is introduced;
the other port is closed with a plug. Infusion
pressure is kept low. External depression of the
ciliary body/ pars plana area is done by a muscle
hook/ Johnson bud, while viewing directly
through the operating microscope. The ciliary
processes are visualised.
Laser settings:
Continuous mode, power start at 150 mW and
slowly increase till whitening and shrinkage of
ciliary processes takes place. Laser can be done
from 270- 300 degrees of the ciliary processes
depending on the extent of IOP reduction
required.
Post procedure:
Topical steroids and antibiotics, tapered over a six
week period, rarely, systemic steroids may be
required, in case of excessive inflammatory
LASER PROCEDURES IN GLA
UCOMA 160
reaction. Anti glaucoma medications tapered
based on IOP response.
Advantages
Ciliary destruction is done under direct
visualization and can be combined with
vitrectomy procedure.
No special equipment required and basic
vitrectomy set up used.
Laminations Can be performed only in aphakic,
and pseudophakic eyes.
The entire ciliary process is not visualized.
Trans Scleral Cyclodestruction:
Cyclocryotherapy:
Bietti was the first person to propound cryo
destruction of the ciliary body. However, with the
introduction of the cryoprobe by Amolis, this
technique became more popular. Today,
cyclocryotherapy has limited applications and
has largely been replaced by transscleral laser
cyclodestruction techniques. However in our
country where lasers may not be available to a
vast majority of doctors it is a viable tool in
absence of other alternatives.
Equipment:
Cryoprobe, with refrigerant (e.g. liquid nitrogen)
Indications:
Reduction of IOP in painful blind eyes, or in
absolute glaucoma. It is contraindicated in eyes
with useful vision. In case no alternative is
available and standard surgery can not be
performed because of prior surgery or scarring it
may be done in partially seeing eyes with graded
approach.
General principles :
Application of subzero temperatures, and
freezing the ciliary body tissues, results in
destruction of the ciliary epithelium, and results
in decreased production of aqueous humor. It has
been shown that to achieve, reproducible, and
consistent cyclodestruction, the temperature at
 161 LASER PROCEDURES IN GLA
UCOMA
the sclera should reach -80 degrees, and this
temperature should be maintained for at least 60
seconds. The procedure invariably results in
intense ocular inflammation, due to destruction of
tissue. The results are not predictable, and risk of
phthisis bulbi, or non response of IOP to
cyclocryotherapy, exists.
Procedure:
The procedure is painful, and should be
performed under retro bulbar, or peribulbar
anaesthesia. The cryo probe tip is placed, 1.5 mm
away from limbus, superiorly, and 1mm away
from the limbus inferiorly, nasally and
temporally. The probe should be pressed firmly
on to the sclera, in order to effectively freeze the
ciliary processes. Once the cryo probe has been
activated, it is kept in position for 60 seconds, and
after this cryoactivation is stopped and the probe
is gently lifted from the sclera. Must remember to
allow the probe to release itself from the sclera
which might take a few seconds but this is
important as trying to remove the probe suddenly
has resulted in sclera rupture. Also the thaw time
after the freeze is the time when the ice crystals
formed in the cells expand resulting in there
destruction. Usually 180 degrees of
cyclodestruction is done requiring 5 to 8
applications of the probe. 360 degrees of
cyclodestruction is never done, and will result in
anterior segment ischemia and necrosis, if done.
In seeing eyes one may resort to only 90 degrees
or less to prevent chances of complications.
Post cryo management:
Topical steroids, cycloplegics, and antibiotics, are
given, in addition to systemic NSAIDS for pain.
Topical and systemic anti glaucoma medications
are continued, and tapered after IOP reduction has
been noted.
Advantages and Limitations:
Non invasive procedure
Inexpensive equipment, available in most
hospital settings
Unpredictable response
Success rates vary from 64-75%
Incidence of phthisis bulbi up to 17% in reported
studies
50-65% have reduction in visual acuity post
cyclocryo, therefore, not preferred in today's
context when better procedures are available, in
eyes with useful vision.
Transscleral Laser Cyclodestruction:
Transscleral cyclodestruction is a widely
employed method to destroy the ciliary processes
and reduce aqueous secretion. The laser
procedures used are:
1. Trans scleral Diode Cyclophotocoagulation.
2. Trans scleral Nd:Yag Laser cyclodestruction.
Non contact
Contact
Transscleral Diode Laser
Cyclophotocoagulation or TSCPC.
Equipment required: 810 nm Diode Laser, G
probe- for Trans scleral application of laser.
Indications:
For reduction of IOP in eyes with refractory
glaucoma, unresponsive to conventional outflow
enhancing surgeries, like Trabeculectomy, and
glaucoma valve implants. Can be a primary
procedure in eyes with limited visual potential.
Procedure:
The procedure is performed under retro bulbar or
peribulbar anesthesia. A 810 nm semiconductor
diode laser with a G probe (600 m diameter
quartz fiber with a spherical protruding tip
oriented by the footplate of the hand-piece).
Laser settings:
With a power of 1750 to 2000 mW for 2.0 sec
increase by 250 mW till a audible "pop" sound is
heard, then turn down the energy by 250 mW and

proceed with treatment. Recently there is a trend
to use lower power and longer duration. Re-use of
the G probe multiple times, may decrease
efficiency. Cleaning of the tip with 70% isopropyl
alcohol, or ethylene oxide sterilisation after
clearing charred debris from foot plate has been
recommended.
Extent to be treated:
270 degrees, 18 applications, or 21-24
applications over 360 degrees. Avoid sites of
previous filtering surgery/ tubes, and areas of
thin sclera. Laser extent if seeing eye.
Post laser protocol:
Steroid-antibiotics QID, tapered over 1 month,
cycloplegic eye drops, to reduced inflammation
and pain. Anti-glaucoma medications are
gradually tapered depending on IOP response.
Pressure lowering will be evident by 1 week.
Retreatment if necessary can be considered after 1
month.
Complications:
Intraocular inflammation due to breakdown of
blood ocular barrier
Vision loss in up to 40% of patients has been
reported.
Hypotony
Rarely, retinal detachment, phthisis bulbi,
scleral thinning/ necrosis, and sympathetic
ophthalmia in the other eye, have been reported.
Endoscopic Cyclophotocoagulation:
Endoscopic delivery, offers precision in terms of
location, and energy delivery. The development
of the 20 and 23 gauge ECP probe, with combined
functions of an 810 nm red diode laser, video
endoscope, and illumination in a single probe,
enabled endoscopic Cyclophotocoagulation. The
machine is a standalone unit, with a laser console,
Television monitor, and semi disposable probes.
Endoscopic Cyclophotocoagulation is not part of
LASER PROCEDURES IN GLA
UCOMA 162
standard vitrectomy machines. Endoscopic
Cyclophotocoagulation offers a better safety
profile, better preservation of BCVA, and has
similar success rates, as compared to Trans scleral
Cyclophotocoagulation.
Indication:
Reduction of IOP in Glaucoma's refractory to
traditional outflow enhancing procedures.
Eyes with scarred conjunctiva, s/p repeat
trabeculectomies.
Post penetrating keratoplasty glaucoma
Post retina surgery glaucoma
Neovascular glaucoma
Other glaucomas e.g. congenital glaucoma,
post traumatic glaucoma, where conventional
outflow enhancing surgery is not feasible, or
carries a low rate of success.
Equipment:
Endoscopic Cyclophotocoagulation console with
810 nm diode laser, 20/ 23 gauge ECP probe, and
standard operative setup including vitrectomy
machine.
Procedure:
ECP can be performed by either Limbal, or Pars
plana route. The procedure is as follows:
Limbal ECP:
Limbal ECP can be performed, in phakic,
aphakic and pseudophakic eyes.
Two clear corneal incisions are made with the side
opening knife, about 1.2 mm size. A highly
retentive viscoelastic is placed under the iris, to
push the lens/IOL posteriorly, thus widening the
ciliary sulcus, and enabling visualisation of the
ciliary body. The ECP probe is advanced through
the paracentesis, and the ciliary processes are
visualised on the TV monitor.
Laser settings used for CPC are:
30- 50 mW
Continuous mode.
 163 LASER PROCEDURES IN GLA
UCOMA
The aiming beam is focussed on the ciliary
processes, and laser is activated. Each ciliary
process is photocoagulated with the end point of
whitening and shrinkage of the ciliary processes.
Extent of CPC: 180- 360 degreed of CPC can be
done, depending on the IOP reduction required.
IN One should avoid 360 degree
photocoagulation, to avoid risk of hypotony and
phthisis.
After the ECP, using a bimanual irrigation,
aspiration probe, the visco is aspirated out, and
the clear corneal wounds are hydrated, or sutured.
Pars plana ECP:
This procedure can be performed only in
pseudophakic, or aphakic eyes.
A standard three port pars plana vitrectomy is
performed. One of the superior ports is plugged
by a scleral plug, and the ECP probe, is advanced
through the other superior port, with the infusion
on in the infero temporal port. The ciliary
processes are visualised, and cyclo-
photocoagulation is done, with similar settings
as mentioned in the Limbal ECP.
The advantage of the pars plana route is that it can
be combined with vitreoretinal procedures that
the patient may require, as in retinal co
morbidities which may require vitrectomy, and
retinal procedures. These situations are
commonly encountered in Diabetic NVGs,
Silicone oil induced glaucomas, and in post
traumatic glaucomas. Also, in situations where
the corneal endothelium is borderline, or in post
PK eyes, the procedure may be of advantage, as
the endothelium is not affected by any
procedures, during the surgery.
Post Surgery protocol:
Antiglaucoma medications must be continued
and tapered as per IOP response, which usually
occurs after the 1st to second week, after ECP.
Steroid and antibiotic drops, and cycloplegics are
prescribed, on a tapered dosage schedule over 6
weeks.
In Limbal ECP, one should be watchful of
immediate post operative IOP spikes, due to the
usage of highly retentive viscoelastics. Post op
IOP spikes are less common in the pars plana
ECP.
Advantages:
ECP has a safer profile, when compared to
TSCPC, as reported in literature. However, as in
any Cyclodestructive procedure.
The complications encountered are:
Post op Uveitis
Post op IOP spikes.
Hypotony or risk of phthisis bulbi
Retinal detachment.
Cystoid macular edema.
Loss of BCVA.
ECP is an invasive procedure, and risk of
endophthalmitis, hypothetically, is present,
though not yet reported in literature.
The major limiting factors, in this procedure
being accepted in a wide spread manner, is the
prohibitive cost of the equipment, and its stand
alone use for the procedure only, with semi
disposable probes.
Ultrasound EPC:
Newer methods of ultrasound cyclodestruction
have become available. Not much is known about
the safety and efficacy of these new techniques, as
yet.
In conclusion, though in most situations a last
resort, destruction of the ciliary body, by various
techniques, remains an important method of
managing raised IOP in Glaucoma.
Modifying the bleb by Lasers
Scarring down the bleb: In certain situations the
trabeculectomy bleb is very high and dome
shaped. Also it can protrude on to the cornea.
These result in patient discomfort along with

formation of dry spots on the cornea along the
elevated bleb as the lid is unable to lubricate the
cornea adequately.
In such situations one can paint the bleb with a dye
such as gentian violet using cotton buds after
putting topical anesthesia.(Fig.3)
One can then use any coagulative laser like
Argon, frequency doubled YAG and diode with
the same settings as in gonioplasty, large spot size
of 500 microns, time of 0.15 seconds and power
of 0.2 to 4 watts. The laser is are absorbed by the
dye and results in flattening of the bleb 8.
Delimitation of bleb: many a times the bleb
extends on the nasal or temporal aspect and the
same procedure can be carried out on the nasal
and temporal aspect which will delimit the bleb.
LASER PROCEDURES IN GLA
UCOMA 164
References:
1. Vogt A. Versuche zur intraokularen druckherabsetzun
mittelst diathermieschadigung des corpus ciliare
Zyklodiathermiestichelung). Klin Monatsbl Augenheilkd.
1936; 97: 6723.
2. Bietti G. Surgical intervention on the ciliary body; new
trends for the relief of glaucoma. JAMA 1950; 142:
88997.
3. Scott A. Pastor, Kuldev Singh, David A. Lee, Mark S.
Juzych, ,Shan C. Lin, Peter A. Netland, Ngoc T.A.
Nguyen. Cyclophotaocoagulation- A report by the
American academy of Ophthalmology, Ophthalmology.
2001; 108: 21302138.
4. L i m J I , L y n n M , C a p o n e A J r . C i l i a r y b o d y
endophotocoagulation during pars plana vitrectomy in
eyes with vitreoretinal disorders and concomitant
uncontrolled glaucoma. Ophthalmology. 1996; 103:
10416.
5. Kosoko O, Gaasterland DE, Pollack IP, Enger CL. Long
term outcome of initial ciliary ablation with contact diode
laser transscleral cyclophotocoagulation for severe
glaucoma. The Diode Laser Ciliary Ablation Study
G r o u p . O p h t h a l m o l o g y. 1 9 9 6 ; 1 0 3 : 1 2 9 4 3 0 2 .
6. C h e n J , C o h n R A , L i n S C , e t a l . E n d o s c o p i c
photocoagulation of the ciliary body for treatment of
refractory glaucomas. Am J Ophthalmol.1997; 124:
78796.
7. Murthy GJ, Murthy PR, Murthy KR, Kulkarni VV,
Murthy KR. A study of the efficacy of endoscopic
cyclophotocoagulation for the treatment of refractory
glaucomas. Indian J Ophthalmol. 2009; 57: 12732.
8. Sony P, Kumar H, Pushker N. Ophthalmic Surg Lasers
Imaging Treatment of overhanging blebs with frequency
doubled Nd:YAG laser. Ophthalmic Surg Lasers
Imaging. 2004 Sep-Oct;35(5):429-32.
 165 Trabeculectomy- Indications &
Technique Of Surgery
Dr. Kirti Singh, Dr. Mayuri Khammar, Dr. Krishnadas
Trabeculectomy, and its modifications, use a
common concept to lower IOP by creation of a
fistula between the anterior chamber of the eye
and the Sub Tenon or sub conjunctival space. The
aqueous humor is diverted by this fistula from the
anterior chamber into the subconjunctival space ,
collected into the episcleral and conjunctival
veins and finally into the systemic circulation.
Incisional Glaucoma Surgeries- Making the
decision to operate
Glaucoma combines a group of diseases with
varying degrees of optic nerve damage and visual
field loss with several medical, ophthalmic, and
socio economic issues presented by individual
patients. Several of these factors combine to
make the benefit to risk assessment highly
variable and challenging and the decision to
operate difficult in each patient. Incisional
glaucoma surgeries like trabeculectomy lower
IOP by providing an alternate path for aqueous
humor outflow and limits progression of the
disease in most of the uncomplicated, primary
glaucomas. The final decision to perform
trabeculectomy in a patient is based on our
knowledge of the natural history of progression of
glaucoma correlated with patient's history and
status, rate of progression of optic nerve damage
and the patient's response to medical/laser therapy
and relative benefits and risks of surgical
intervention. The risk of blindness in a patient's
lifetime given the extent of damage, response to
more conservative measures, and rate of
progression of optic nerve damage are major
considerations in the decision to operate.
Patients with advanced glaucoma who have not
reached the targeted low IOP are appropriately
managed surgically in order to achieve stability of
visual field loss. Surgical management is
typically recommended when medical and often
laser therapies have failed to prevent progressive
optic nerve damage or visual field loss. Initial
glaucoma surgery without a prolonged trial of
medical or laser treatment are indicated only in
specific situations, where patients present with
very advanced damage and high IOP and urgent
intervention is required to preserve residual
visual fields and preserve quality of life. Most
patients are tried multiple topical glaucoma
medications, often in combination, before their
response to treatment and adherence and
tolerance to treatment is taken into consideration
to decide on surgical management. Adverse drug
reactions, intolerance, escalating cost, complex
drug regimen are factors limiting strict
adherence to medical management of glaucoma,
and surgical intervention may become necessary
in such situations to provide the benefit of long
term IOP control and preserve vision.
Incisonal glaucoma surgeries are successful in
70-80% of patients in reducing IOP and
preserving vision. It frequently eliminates or
reduces the need for prolonged medical therapy,
reducing ocular adverse effects of medical
treatment, cost and compliance issues, However,
glaucoma surgery may fail in 20-30% of patients
to achieve long term IOP control and also carries
risk of significant ocular complications,
including loss of vision or quality of life. Hence,
the recommendation for surgery should be
carefully taken after failure of more conservative
modalities of treatment and only if in the
consideration of the treating ophthalmologist, the
benefits of such surgical treatment far outweigh
any risk involved. Surgery is always preceded by
extensive discussion with the patient and his/her
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
family of the proposed procedure, post operative
management and care essential to maximize the
potential benefits of surgery, and the impending
complications. For most patients with
uncontrolled IOP with progressive optic nerve
damage and visual field loss, the decision to
operate is often safe and the most appropriate.
With discussion of possible adverse effects of
surgery, some patients may prefer to overcome
compliance issues or tolerate minimal adverse
effects of medications to delay or avoid surgery.
Both the treating physician and the patient's
family should carefully weigh the risk of visual
loss in patient's lifetime and the decision is not
always easy and often imprecise.
In summary, glaucoma surgery is usually required
when IOP is uncontrolled or optic nerve damage
is progressive despite a trial of medications and/
or laser. The greater the degree of glaucoma
damage and higher the IOP, greater is the need for
surgical intervention. While frequently
successful in controlling IOP and preventing
progressive visual loss, glaucoma surgery may
also have vision threatening complications both
in the early and later post operative phase. Any
decision to operate requires careful counseling of
the patient of potential risks and benefits of
surgical management and the need for often
frequent and prolonged post operative care and
follow up.
History of Glaucoma Filtering Surgery
Von Graefe in 1857 first described surgical
management of glaucoma when he reported
reduction in IOP following removal of a large
piece of iris. These were in the era preceding
description of anterior chamber angles by
gonioscopy and perhaps were eyes with angle
closure glaucoma which were reported to have
fall in intraocular pressures following iridectomy.
Y 166
Eliot described a full thickness filtering
procedure by using a trephine (1909) to fashion
an anterior sclerectomy under a conjunctival flap,
combined with a peripheral iridectomy. Such full
thickness procedures, though were very popular
in the first half of the twentieth century, were
often accompanied by hypotony and flat
chambers which led to evolution of guarded,
partial thickness filtering procedures.
Trabeculectomy, in which a partial thickness
scleral flap in fashioned over excision of a
corneo- scleral window was first described by
Sugar in 1961 and later widely published by
Cairns with some modifications in 1968. Since
then, Trabeculectomy, with or without an
antimetabolite, continues to be the gold standard
in surgical management of glaucoma. Since then,
several surgical and wound healing modifications
have been added to the procedure. These
modifications principally address the wound
healing process to minimize fibroblast
proliferation, sub conjunctival scar tissue
formation in an attempt to keep the surgical sub
sclera fistula open and functional.
Preoperative Considerations & Diagnostic
Approach
Meticulous history taking is crucial in the
decision making process preceding
trabeculectomy.
Prior Ocular Surgery: Any previous ocular
surgery involving the conjunctiva is commonly
associated with preexisting conjunctival fibrosis
and with an increased risk of excessive post
operative conjunctival scarring and failure of
glaucoma filtering surgery. A judicious use of
antimetabolites, the type, concentration and
duration of exposure of which depends on the
potential risk of failure is imperative in eyes with
prior ocular surgery to minimize sub conjunctival
 167 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Y
fibrosis. Special considerations need to be taken in
cases of previous history of vitreo retinal
surgeries. In cases of scleral bucking surgeries, the
position of buckles and explants need to be
checked to decide on the most appropriate site of
trabeculectomy. The risk of trabeculectomy
failure is considerable when silicon oil has been
used, and in such instances, the use of primary
drainage device implantation is preferable. Eyes
with prior history of vitrectomy, especially in the
absence of lens and the posterior capsule, are at
higher risk of becoming hypotonous during
glaucoma surgery with possibility of
suprachoroidal effusions or hemorrhage.
Uncomplicated clear corneal cataract surgeries
have post operative trabeculectomy outcome
almost similar to that of eyes without prior
conjunctival surgery. However cataract
extractions through scleral tunnel and incisions
have thinned sclera, conjunctival scarring and are
at increased risk of trabeculectomy failure.
Previous surgical sites need to be avoided for
fashioning a scleral flap for trabeculectomy to
prevent conjunctival buttonholes. In such
instances there may also be inadequate
conjunctiva sufficiently intact to cover the scleral
flap.
Uveitis: A history of uveitis is an important risk
factor for trabeculectomy failure. In general
ocular inflammation needs to be adequately
controlled at least 3 months prior to surgery. An
intensified steroid/immunosuppressive therapy
pre- and postoperatively and a subconjunctival
steroid injection at the completion of
trabeculectomy is likely to minimize post
operative inflammation and sub conjunctival
scarring. Oral /systemic steroid therapy may be
considered in cases of severe/active uveitis. In
select eyes, primary drainage device may be
implanted in place of trabeculectomy to enhance
surgical success.
Retinal Diseases: treatment of active retinal
diseases including proliferative diabetic
retinopathy, diabetic macular edema, vascular
occlusive retinopathies and age related macular
degenerations may require treatment before
filtering surgery to prevent aggravation. unless
IOP is uncontrollable.
Ocular Diseases/Refractive Status: Eyes with
high myopia have low scleral rigidity and thin
sclera and have risk of globe perforations during
retrobulbar injections. Highly myopic eyes also
are at risk of ocular hypotony and hypotonic
maculopathy following use of strong anti
metabolites like mitomycin. In such instances,
less potent anti mitotic agents like 5 flurouracil or
biodegradable collagen implants (Ologen ) may
be substituted to optimize filtering success. In
eyes with Nanophthamos, which are at increased
risk of choroidal /uveal effusions and malignant
glaucoma, a prophylactic sclerostomy may be
considered. In eyes with aphakia with vitreous
proplase, an anterior vitrectomy combined with
trabeculectomy may be indicated, but such
procedures may be associated with prolonged
hypotony and risk of choroidal hemorrhages.
Anterior chamber maintainers or alternately, non
penetrating surgeries like deep sclerectomies or
drainage implants may be considered in these
eyes. External ocular infections, inflammations
and allergies, and active lid diseases like
blepharitis need to be adequately treated before
filtering surgeries.
Topical glaucoma medications: prolonged ocular
glaucoma medical therapy, especially adrenergic
drugs, miotics and prostaglandin analogues and
preservative contained in topical ocular drugs
(Benzalkonium Chloride , in particular) increase
susceptibility to trabeculectomy failure from
conjunctival scarring and fibrosis owing to
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
conjunctival inflammation. Oral Carbonic
anhydrase inhibitors may be substituted in place
of beta antagonists, alpha agonists and
prostaglandin analogues. In case of prolonged
ocular medication use, pre operative topical
steroids for a few weeks, such as fluromethalone
have been reported to reduce severity of
conjunctival scarring following glaucoma
filtering surgery.
Systemic Medication: Oral anticoagulants and
anti platelet therapy need to be discontinued one
week prior to glaucoma filtering surgeries to
reduces incidence of retrobulbar hemorrhage
following anesthetic injections, severe
conjunctival bleeding during tissue dissection and
reduce risk of intraoperative and delayed
suprachoroidal hemorrhages, all of which can
threaten vision or post operative success of
filteing procedures. Decision to discontinue
these medications need to be carefully considered
against the risk of thromboembolism and in
consultation with the patient's cardiologist
/internist. Oral anti-coagulants could be replaced
by low molecular weight heparin injections until
the day of glaucoma filtering surgery if it is not
considered safe to discontinue anti coagulant
therapy.
Clinical Evaluation
Best corrected visual acuity and a recent visual
field evaluation is considered mandatory to
establish a baseline prior to surgery and be able to
distinguish pre operative progression from
changes in vision and visual fields occurring after
surgery. Patients with advanced visual field loss
especially those within central five degrees of
fixation, or two contiguous scotomas of < 5dB in
the central four test locations of the visual field,
increase the risk of irreversible decrease in visual
acuity of two Snellen lines or more following
Y 168
surgery.
Careful anterior segment slit lamp biomicroscopy
is essential to identify risk factors for failure or
carefully consider the factors that require
attention during surgery. Extent of lens
opacification and cataract need to be assessed
especially since trabeculectomy significantly
increases risk of cataract progression.
Concomitant cataract surgery may be considered
with filtering surgery in case of significant lens
changes. A shallow anterior chamber is risk factor
for post operative shallow chambers or aqueous
misdirection. Surgical modifications such as
thicker scleral flaps, tighter scleral flap sutures,
anterior chamber maintainers, post operative use
of strong cycloplegics like atropine may be
indicated. Presence of vitreous in eyes with
trauma or prior cataract surgery may also call for
modifications in surgery type/techniques. A
thorough gonioscopic evaluation and
ophthalmoscopy is also indicated to exclude
pathology in the angle and the retina.
A careful clinical assessment of the eye and the
adnexa may also assist in determination of the
type of anesthesia to be employed. An
enophthalmic eye, deep seated globe in the socket
may benefit from retrobulbar anesthesia since the
volume of anesthetic injected makes the eye more
prominent with better exposure of the superior
limbus. Presence of blepharospasm may mandate
facial or lid block since squeezing of the eyes
inadvertently during surgery increases the
intraocular pressure with repeated prolapse of iris
intra operatively. A high myopia increases risk of
globe perforation during retrobulbar anesthesia.
If axial length exceeds 26 mm, it is preferable to
administer sub tenon anesthesia. Since such eyes
are also at risk of hypotonic maculopathy if
mitomycin is used, one should prefer 5
flurouracil.
 169 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Determination of target intraocular pressure is
crucial and determines the type of filtering
surgery and plan of any surgical modifications
indicated. A requirement of a higher target IOP,
for instance, one can consider thicker scleral
flaps, tighter scleral flap closure and delay laser
suture lysis or plan non penetrating glaucoma
surgeries. A low target IOP may mandate use of
antimetabolites, thinner scleral flaps, fewer
scleral flap sutures or their earlier release or lysis
and more frequent post operative follow up visits
and evaluation to plan better bleb modulation to
prevent filtration failure.
Ocular Anesthesia for Glaucoma Filtering
Surgery
Local Anesthesia
Local Anesthesia offers several advantages over
general anesthesia, especially in elderly patients
with glaucoma who often have significant
systemic co morbidity including cardiac and
pulmonary disease. Local anesthesia has low risk
of systemic complications associated with
general, including post operative nausea,
vomiting and malignant hyperthermia. For local
anesthesia either 2% lignocaine or a mixture of
50:50 Bupivocaine 0.5% and lignocaine is
preferred. The following methods of
administration are commonly used to achieve
ocular anesthesia :
Retrobulbar
Peribulbar
Subconjunctival
Sub Tenon's
Topical
A retro bulbar block provides excellent anterior
segment anesthesia and akinesia, wherein 3-5 ml
of the anesthetic is injected across the inferior
orbital rim into the muscle cone. However, this
technique has several potential ocular and
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systemic complications including globe
perforation, optic nerve injury, retro bulbar
hemorrhage, central retinal artery/vein occlusion,
systemic absorption with cardiopulmonary
adverse events, and subarachnoid infiltration
with brain stem paralysis and respiratory
depression and death . Peri bulbar block
potentially decreases some of the risks associated
with retro bulbar injections. Since the anesthetic
is injected outside the muscle cone, potential
injury to the optic nerve and the globe is
avoided. However the larger volume of
anesthetic required (7 ml) can increase the orbital
volume and intraocular pressure and cause
chemosis. Anesthesia obtained is often
suboptimal with inadequate akinesia. Both of
these techniques are not ideal in patients with
bleeding diathesis. Subconjucntival and Sub
Tenon anesthesia are administered to obviate the
complications associated with peri bulbar and
retrobulbar anesthesia. Although prospective
randomized studies have reported anesthesia
comparable to that of retrobulbar anesthesia ,
akinesia could be insufficient. Subconjunctival
hemorrhage is an additional disadvantage.
Although there is complete lack of akinesia,
several surgeons have reported uneventful
glaucoma filtering surgery with topical
anesthesia (Proparacaine or tetracaine).
Intracameral lignocaine can be used to
supplement topical drugs while performing
intraocular manipulation and iridecotmy. Most
local administration of anesthetics, since they
involve conjunctival injections, manipulation,
injury and hemorrhage, carry a slightly increased
risk of subconjunctival fibrosis and failure of
filtering surgery.
General Anesthesia is used in young children, and
in adults who are anxious or unable to co operate
for local anesthesia. General anesthetic agents
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
can influence the IOP significantly. Most
anesthetic agents are associated with significant
lowering of IOP. Significant fluctuations in IOP
associated with general anesthesia and
endotracheal intubation with increased incidence
of postoperative nausea and vomiting, can
potentially increase the risk of intra operative and
post operative suprachoroidal hemorrhage. The
risk of choroidal hemorrhage is especially high in
children with advanced glaucomatous optic nerve
damage, long standing glaucoma and in eyes with
buphthalmos due to reduced scleral rigidity.
Trabeculectomy: Results & Outcome
Trabeculectomy achieves reasonable IOP
lowering in 65-85% of adults, depending on the
type of glaucoma, disease severity, use of anti-
metabolites, post operative healing response and
bleb modulation techniques, duration of follow
up, and the skill and meticulousness with which
surgery is performed and followed up. The
success rate (qualified) may be increased to 90%
with addition of IOP lowering therapy in the post
operative period. It is difficult to compare
surgical results across various populations, eye
providers and surgeons owing to variations of
techniques employed and definitions of success.
Few long term studies of outcome of
trabeculectomy are available. Parc et al had
reported 15 year follow up of 73 eyes of 49
patients (Olmsted County study) who had had
trabeculectomy with a mean pre operative IOP of
27.6 + 8.5 mmHg. Post operatively mean IOP had
remained at 14.7 + 3 mmHg with or without
medications. The probability of progression to
blindness was 46% at 10 years, although mean
IOP had remained at 15 mmHg throughout the
follow up period. Eyes going blind had more
advanced field loss at the time of surgery.
The Otago Glaucoma Surgery Outcome Study
Y 170
described long term outcome of trabeculectomies
performed on 841 eyes of 607 patients who had
first time trabeculectomies for primary open angle
or closed angle glaucoma and followed for a mean
period of 7.5 years. The probability of
trabeculectomy controlling IOP at first, ten and
twenty years was 96%, 86% and 79%
respectively. Visual acuity was either preserved or
improved in 68% eyes between pre operative
assessment and last follow up. The probability of
not being blind following trabeculectomy at first,
ten and twenty years was 98%, 83% and 70%
respectively. However, the proportion of those
with glaucomatous field loss increased during
follow up from 16% at 0-5 years to 50% for those
with 21 years or more of follow up. A repeat
drainage procedure was required in 65 ( 8%) of
eyes. Although IOP was well controlled by
trabeculectomy, a steady decline in IOP control,
visual acuity and visual field occurred during
follow up. 79% had IOP<21 mmhg at 20 years
with or without medications.
Landers et al recently reported a twenty year
follow up study of trabeculectomy in a Caucasian
population. A total of 234 patients (330
procedures) who had undergone trabeculectomy
were retrospectively reviewed. The study
indicated that trabeculectomy survival at 20 years
was approximately 60% without topical
medications, 90% with topical medications, with
15% becoming blind. Patient age (youth), pre
operative medications, glaucoma type and
severity independently influenced the outcome of
trabeculectomy. The study concluded that
trabeculectomy is a long term solution to IOP
control. Eyes, however, were reported to become
blind with an incidence of 0.8% per year
throughout the 20 year follow up period.
Significant association were found between rate
of blindness and severity of visual field loss at the
 171 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
time of trabeculectomy, type of glaucoma,
previous surgery and number of pre operative
medications used.
Trabeculectomy ,in general, has a low rate of
postoperative complications and gives good
long-term control of IOP in most eyes with the
rate of failure increasing with length of follow
up. Many risk factors may influence this estimate,
including patient age, preoperative topical
medication use, glaucoma type, and glaucoma
severity.
Technique of Trabeculectomy
Site of filtration area
Superior limbus has always been the preferred
site since the lid would snugly cover the bleb and
superior peripheral iridectomy (PI). This would
prevent exposure of bleb, reduce risk of bleb
infection and prevent diplopia induced by an
inadvertently large iridectomy. An inferior
trabeculectomy is to be avoided as it increases the
risk of bleb related endophthalmitis by 6-7 times
than a superiorly placed trabeculectomy.
The ideal site would be centered at 12 o clock
which in addition to being well covered by the lid
, gives maximum room for the posterior extension
of the filtering bleb. However there are some
factors which need to be taken into consideration
before deciding this site.
A non-virgin conjunctiva due to prior surgeries
would have some areas of scarring at limbus
especially in case where cataract surgery has
been done by extra-capsular cataract surgery,
technique manual small incision cataract surgery
or prior trabeculectomy. The conjunctival
mobility is assessed preoperatively on slit lamp
by employing a moistened swab to check for
conjunctival freedom at limbus. This can also be
done on operating table after placing the bridle
suture. The sites where conjunctiva is adherent to
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the limbus are best avoided but this may not be
possible in cases of poorly performed ECCE
which involves superior 4-6 clock hours.
- The age of patient: For young patients where the
anticipated life of the filter is low a site staggered
to the nasal side of 12 o clock is preferred as it
leaves more than adequate space on the temporal
side for a repeat surgery. This may not hold for
buphthalmos where the first surgery ideally
provides the best rehabilitation; a true superior
trabeculectomy is preferred since it provides the
best exposure to perform a trabeculectomy with
trabeculotomy.
- Cause of glaucoma: Cases of secondary
glaucoma like aphakic, neovascular or uveitis
where survival of trabeculectomy is poor and a
second tube surgery may be required; the
temporal site is again left free for the second
surgery.
Stage of glaucoma: Advanced or end stage
glaucoma which would gives one a fighting
chance only would require a pure superiorly
placed bleb as that is technically easier to do and
involves less manipulation. The surgeon may
never require performing a second surgery if
disease is very advanced.
- Location of emissary veins: If an emissary vein
is spotted in the proposed area after conjunctival
dissection it is better to stagger the flap so that the
incision does not overlie the vein. If cut these
vessels ooze excessively, requiring excessive
cautery which can cause scleral shrinkage.
Figure 1 : Identification of an emissary vein is
of significance to prevent excessive bleeding.
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
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Traction /Bridle Sutures forceful entry has to be guarded against as it

These sutures ensure adequate exposure of the would cause corneal perforation. Too superficial a
superior limbs till the fornix and keep the eye in bite also is to be avoided as it could cause cheese
inferior position throughout the surgical wiring of the corneal tissue. The corneal bite has
procedure. Thus the relevant structures are is in to be 4-5 mm wide. The suture material is either 6/
clear view of the surgeon. The traction suture 0 or 7/0 silk or nylon on a spatulated needle.
maybe of two types: superior rectus or corneal.
1.Superior rectus bridle suture : Conventionally
superior rectus traction suture or bridle suture is
used to expose the superior limbus area. The
muscle tendon is grasped with a Lester superior
rectus forceps. A curved spatulated cutting needle
pre threaded with autoclaved cotton or 4 /0 silk
suture is passed underneath the tendon. The eye is
rotated inferiorly and suture is affixed to the
drapes beneath the inferior eye lid.
The suture is placed 10-12 mm behind the limbus
to provide ample exposure. If tendon is damaged
during traumatic entry a hematoma ensues which
by releasing growth factors facilitates healing of
wound (Figure 2). Blood contains many growth
factors, which promote healing and thereby
contribute to bleb failure. In a limbal based
conjunctival flap; the superior rectus traction
suture makes conjunctival suturing difficult. To
Figures 2 & 3: Superior rectus suture and clear corneal suture used
avoid these complications, some surgeons are
as bridle suture during trabeculectomy
now switching over to a clear corneal traction
suture (Figure 3).
Corneal traction suture: The pulling force of a Some surgeons advocate use of topical
clear corneal traction suture in rotating the vasoconstrictor agent and/or injection of saline
eyeball downward is superior to that of a superior beneath the conjunctiva prior to making the first
rectus suture. In addition it provides better cut to minimize bleeding and aid in conjunctival
exposure and avoids risk of subconjunctival dissection respectively.
haemorrhage or postoperative ptosis subsequent
to traumatic superior rectus traction. The risk of Conjunctival flap creation
conjunctival fibrosis and filtration failure is Conjunctiva should be handled very gently and
expected to be lesser with a claear corneal tration with an atraumatic forceps whenever possible.
sutute. This suture is placed 2 mm anterior to The conjunctiva is held gently at the limbus, a
limbus at half thickness of the corneal stroma. A
 173 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
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fold is created and elevated. Using a toothed

forceps (Pierce Hoskin or Lim's) to hold and
Westcott scissors to cut , a three to four clock
hours of conjunctiva is separated from the limbus.
Rough handling of conjunctiva should be avoided
as it not only carries the risk of buttonholing but
also causes subsequent release of inflammatory
mediators, which may facilitate bleb failure.
(Figure 4)
Figure 4- Fashioning a conjunctival flap

For conjunctival flap creation either a limbal or

fornix based flap can be made. In eyes with prior
surgeries like cataract, retinal detachment which
has led to residual scarring in limbal area and
immediately posterior to it, a fornix based flap is
the better option. Creating a limbal based flap in
such situations could jeopardize integrity of the
conjunctiva during dissection. Thus for repeat
surgeries fornix based flap is preferred, unless
during conjunctival testing no significant
adhesions are noted.
Table 1. Benefits and disadvantages of limbal and fornix based conjunctival flap in trabeculectomny
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Y 174

Literature is replete with studies claiming or amniotic membrane to be placed later on.
equivalent IOP control with both limbal (Figure
5) and fornix based (Figure 6)conjunctival flaps.
The authors routinely prefer a fornix based flap ,
as the minimal manipulation of the conjunctiva
with this approach permits a better posterior flow.
In limbal based flap a ring of fibrosis is often seen
at the site of the initial conjunctival incision or
forniceal end of the bleb. Aptly coined as ring of
steel, the fibrotic response of the conjunctiva
occurs during healing and restricts posterior flow
of aqueous (Figure:7) and increases the possibility Figure 5- Limbus Based Flap
of thin walled, focal, cystic blebs predisposing to
bleb leaks, hypotony and bleb related
endophthalmitis. A fornix based flapis hence
preferred to prevent such bleb related
complications.
Technique:
To create a fornix based flap the conjunctiva is
grasped at the limbus with a non-traumatic
forceps, tented up and incision made with a
Vannas or Westcott scissors. The incision is then
carried on parallel to limbus till the extent Figure 6: A fornix based conjunctival flap
required. If a conjunctival relaxing incision is
planned then 2-3 clock hours is sufficient, if not
then 4-5 clock hours of incision is required.
Around 6-7 mm sclera area needs to be exposed.
For superonasal or superotemporal placed
trabeculectomy a relaxing incision is very useful
to give adequate exposure.
Posterior dissection is then performed with
Westcott scissors whose curve is held parallel to
scleral curvature. Subconjunctival dissection is
Figure 7: Ring of steel denoting the fibrosis
carried till 8-9 mm away from limbus. Use of
taking place at the site of conjunctival suturing
blunt tip instruments and tight moist cotton swab
in a limbal based flap during the process of
stick allows gentle dissection which minimizes
healing.
inflammatory mediator release and subsequent
subconjunctival fibrosis. This gives ample space
for the pledgets of subconjunctival Mitomycin C
 175 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
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Tenonectomy Scleral flap creation

The role of tenonectomy in optimizing
trabeculectomy outcomes is debatable. One
study claims that tenonectomy was one of the
causes of encysted blebs. An intact Tenon capsule
may prevent thin blebs, leaks and other bleb
related complications following mitomycin
augmented trabeculectomy. A detailed discussion
follows in the section on special techniques in
trabeculectomy.
The shape is as per the surgeon's choice from
triangular, rectangular to trapezoidal. The
dimensions are 4-4.5 x 4.5-5 mm (rectangular)
or 4.5-5 x 3.5 mm (triangular). The instrument
used could be either a Bard Parker handle, with a
11/ 15 number blade, a disposable cutting knife
or a diamond knife. The tip of the triangle or one
corner of the rectangle should always be lifted
with a non toothed forceps (Figure 9).

Haemostasis
Blood releases many healing factors, which
would unfortunately also cause conjunctival and
scleral scarring thereby precipitating and
aggravating bleb failure. Thus, meticulous
subconjunctival and episcleral haemostasis is not
only essential for adequate exposure and
dissection, but also to ensure longevity of the
bleb. (Figure 8). The huge Tadworth ball cautery
is not recommended. Instead judicious use of
Wetfield cautery is advocated. Emissary veins
may be difficult to coagulate. In case of persistent
ooze we have found that after gentle cautery,
scleral dissection can be carried on. Once
sclerostomy is done the egress of aqueous is
usually enough to stop the minimal ooze. Thus
one must not be aggressive in cauterizing these
bleeders as it would increase inflammatory
mediators. Gentle cautery with re-assessment Figure 9- Fashioning a Scleral Flap
with swab stick or sponge is recommended
The lamellar cleavage plane is then dissected with
a disposable crescent blade. During dissection the
plane of dissection is kept at 1/2 to 2/3rd depth of
the sclera. During dissection the field is kept dry
to enable creation of a smooth plane. An irregular
depth flap would scar down to the bed more easily
and predispose to bleb failure. A thin flap allows
more flow of aqueous, creation of such a flap
Figure 8 : Gentle cauterization with
the Wetfield cautery is recommended.
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
flap is technically difficult and one is liable to
cause buttonholing. Too thin a flap may give rise
to a overfiltering bleb and predispose to bleb
leaks especially if anti-mitotics are used.
The other technique is to make a partial thickness
scleral groove 4-5 mm posterior to limbus to
create the posterior border of the sclera flap.
Through this initial cut a lamellar dissection is
carried forward till the limbus with a crescent
blade, like the manoeuvre done while performing
a manual SICS surgery. Keeping the crescent in,
vertical cuts with disposable blade or Vannas
scissors are made on the two sides, so as to create
a 5 X 4 mm or 4 x 4mm half thickness scleral flap.
The flap stops short of the limbus by 1 mm to
minimize aqueous outflow from the anterior
edges and cause a overhanging bleb.
The dissection is carried till one crosses the blue
grey barrier where the white scleral fibres merge
into the grey zone. The white, opaque sclera with
crisscrossing fibres merges into a grey band of
parallel fibers, which overlies the scleral spur.
Anterior to this lies the transparent corneal tissue.
The junction of the posterior border of the blue
grey zone (trabecular band) and the sclera is the
external landmark for the scleral spur. The
dissection is further carried on into 1mm of clear
cornea(Figure 10). The Schlemm's canal is
usually situated just anterior to the scleral spur,
sometimes it is found behind it.
Blue gray zone overlies
Schlemms canal and
trabecular meshwork
Figure 10: Scleral flap dissection till
the Scleral spur and then beyond into clear cornea.
Y 176
MMC application
Mitomycin could be applied before, or after
complete scleral lamellar flap dissection.
However, few studies state that intrascleral
Mitomycin can cause more ocular hypotony,
choroidal detachment and a shallow anterior
chamber. Thus intrascleral application must be
done judiciously and we use it for 30 seconds only.
The advantage of using mitomycin after lamellar
sclera dissection is that one can avoid using the
anti-metabolite in case there has been an
inadvertent damage to the sclera flap during
dissection and prevent flap related complications,
over-filtration, flat chambers and hypotony.
Mitomycin application is done by soaking cut
pieces of surgical sponges and applied
subconjunctivaly till as far posterior as the
insertion of superior rectus muscle. An attempt is
made to cover a broad area around the proposed
scleral flap. Care must be taken not to allow MMC
sponges to come into contact with the cut end of
conjunctiva as that may impair healing. The
concentration of MMC used is 0.2 mg /ml or 0.4
mg/ml for one to three minutes depending on the
potential risk factors for filtration failure.
Anterior chamber paracentesis
After application of MMC and its washout , the
anterior chamber is entered via a side-port
incision (Figure 11). This is made with V lance
just as during phacoemulsification except that the
direction is not towards the centre of the pupil,
but instead is oblique/ tangential and directed
downwards, parallel to iris. If the pupil is dilated,
as is the case sometimes with retrobulbar block,
intracameral pilocarpine is injected just after
creating the side port, to miose the pupil.
 177 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
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The purpose of anterior chamber paracentesis is
three fold;
a. It serves as entry point to insert a second
instrument to maintain the anterior chamber and
prevent its collapse.
b. It is used to titrate the bleb during and at the end
of surgery to ensure patency of sclerostomy and
water tightness of conjunctival closure. If an
anterior chamber maintainer is to be used as in
cases of aphakic glaucoma, to prevent scleral
collapse then another paracentesis at 6 o clock has
to be made .
c.It lowers IOP and prevents sudden
decompression during the sclerostomy
procedure.
Figure 11: Creating Paracentesis: Note the tangential entry
Sclerostomy
Anterior to the sclerolimbal junction (where the
white sclera merges into the blue translucent
zone) is the clear cornea. A bevelled entry at an
acute angle to the scleral bed, with the tip of the
3.2 mm keratome, is made just where the
translucent blue zone merges into the clear cornea
(Figure 12). Failure to identify this landmark
would cause creation of a posterior sclerostomy
over the cilary body which would not only give
rise to excessive bleeding while attempting an
iridectomy, but also cause blockage of the ostium
by the ciliary tissue. It is preferable to err on the
side of an anterior incision (nearer the cornea)
than too posterior, rather than risk the ciliary body
being damaged or exposed. This happens,
especially, in the tightly stretched globe of the
buphthalmic eyes where limbal stretching
obscures landmarks.
Figure 12 : A beveled entry is made at an acute angle to the scleral
bed with a 3.2 mm keratome blade.
After entering with the keratome, a controlled
withdrawal is made, by slowly withdrawing the
keratome. The sclerostomy block is cut with a
Vannas scissors, 11 number check blade or the
Kelly Descemet's punch. One punch bite removes
0.25 mm2 tissue so that making 5-6 punches
creates a sclerostomy of 1.0 -1.5 by 1.5-2.0 mm
dimensions. The punch need to be rotated
vertically so as to create a cut perpendicular to the
sclera bed which is unlikely to close down with
valvular action (Figure 13). The other punches
which can be used are Luntz Dodick, Crozafon,
De-Laage, Katena, Holth, Crestani. The
sclerostomy can also be outlined by a disposable
blade and then anterior chamber is entered with a
keratome and the partial thickness cuts are
converted into full thickness by introducing a
Vannas scissors into the sclerostomy sides.
(Figures 14,15)
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Y 178

Figure 15: The inner sclerostomy has been created.

Peripheral iridectomy
This extremely important step is performed
through the inner sclerostomy with a Vannas
scissors and a single toothed fine forceps like
Lim's or Pierce Hoskin's. The cut is performed
keeping the scissors parallel to the limbus, so as to
get a broad base (Figure 16). Forceful pull on the
iris is to be avoided as this may cause an
iridodialyis and/ or lens damage. The rationale for
performing an iridectomy is preventing iris
Figure 13: A Kelly Descemet's punch is used to
incarceration into the sclerostomy and relieving
create the sclerostomy Around 4- 5 punches are
the element of pupil block glaucoma. The
required to create a 1.5 by 1.5 m area sclerostomy.
iridectomy base should be wider than the inner
Note the perpendicular position of the punch.
sclerostomy opening. Pigment release always
occurs after a full thickness PI and on stroking the
iris back into the chamber a red retro glow is
visible through the PI. A small hyphema may
occur during a PI but is usually self limited unless
the uveal tissue cut is from the ciliary body in
which case a steady stream of blood would be
seen. Closing the preplaced scleral sutures and
placing a large air bubble in the anterior chamber
would help in controlling the bleeding.

Figure 14: After outlining the inner sclerostomy

block with a disposable blade, the sclerostomy is
being cut using a Vanna's scissors.

Figure 16: Peripheral iridectomy

 179 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Scleral flap sutures
Scleral flap sutures regulate aqueous outflow and
prevent excessive filtration and hyptony. The
resistance to bulk flow of aqueous is largely
determined by the apposition of the flap to the
underlying sclera adjacent to the sclerostomy,
which in turn is determined by the suture position
and tension. If the scleral flap is poorly
constructed or too loose, trans sclerostomy flow
will be excessive, and may result in hypotony. If
the scleral flap is too tight, the IOP will be too
high, which places the patient at risk from sudden
loss of remaining field if the glaucoma is
advanced (snuff out) or further ganglion cell
loss and resultant worsening of glaucomatous
optic neuropathy.
In a triangular flap, the apex of the flap should be
tied with a non releasable suture, and the two
sides are secured with two releasable sutures. If
the base of the triangle/ rectangle, stops short of
the limbus by 1mm (safe surgery technique) then
three sutures ( in triangular flap) and 5 sutures (for
rectangular flap) are adequate. If however the
sides of the triangle/ rectangle reach upto the
limbus, then 2 additional sutures, one on each of
the limbal edges of the side arms of the triangular/
rectangular flap, are required. These additional
two sutures are safeguards which prevent
hypotony, once the releasable sutures are
removed. These limbal sutures are not made
releasable; instead the more distal ones are made
releasable. The reasoning is, that once the
proximal sutures are released, aqueous flow
would be directed parallel to the limbus thereby
creating an overhanging bleb, whereas if the
distal sutures are released the aqueous flow would
be directed posterior toward the fornix and lead to
a diffuse, posteriorly located bleb.
The suture tightness can be adjusted on the table
Y
by watching the egress of fluid from the scleral
flap edges, by titrating from the side port. (Figure
17)
Figure 17: Titration from the paracentesis site is performed after
scleral flap suturing to ensure adequate egress of fluid
Releasable sutures are probably as effective as
laser suture lysis. The disadvantages of releasable
sutures include the need for additional
intraoperative manipulation and postoperative
discomfort from the externalized suture, corneal
epithelial defects, increased risk of intraocular
infection, and, if antimetabolites are used, the risk
of an aqueous leak around the suture site.
Conjunctival flap closure
In a limbus based flap, the incision is closed with
continuous 8-0 nylon, or 8-0 vicryl. Alternatively
a key running suture maybe used. The superior
rectus bridle suture is released at this stage, to
allow for proper coaptation of the wound
edges.The absorbable Vicryl sutures induce more
inflammation but are the sutures of choice in
children, where conjunctival suture removal
would necessitate another general anaesthesia.
Small closely spaced passes are taken in a running
fashion. Interlocking of the suture is not
necessary. The ends however are interlocked, tied
and cut.
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
For a fornix based flap initially two wing sutures
are placed at the edges with 8-0 /10-0 nylon. The
bite must be taken through the sclera tissue to
prevent flap retraction at a later stage . After
securing the ends and suturing a relaxing incision
if present with 8-0/10-0 nylon the anchoring
sutures are placed.( Figures 18,19.20)
Figure 18 : The relaxing incision is sutured with 8-0 monofilament
nylon. .
Figure 19 : Conjunctival anchoring sutures in place, in fornix
based flap .
The following line diagram explains the step by
step technique of putting these anchoring sutures.
The shaded red brown represents cut end of
conjunctiva.
Y 180
Step 1 : The first pass is made through the stromal
side of the conjunctiva (1) , exiting from
epithelial side of conjunctiva (2). The suture
length is from 2 to 3 . At point 3 the needle
traverses entire thickness of conjunctiva to
emerge from beneath the conjunctiva.
Step 2 : After emerging on the deep surface of
conjunctiva the needle traverses through partial
thickness of corneal stroma at 2 mm from limbus,
to exit at point 4 .
Step 3: After emerging from point 4 on corneal
side, after leaving a small stretch of suture
exposed on corneal surface (4 to 5), the needle
enters corneal stroma again, traverses a short
segment (5 to 6) in superficial stroma.
Step 4: At point 6 which is opposite to point 1, the
needle exits the cornea. After emerging from
point 1 on corneal side, again a small stretch of
suture is left exposed on corneal surface (6 to 7).
The needle then enters corneal stroma and
traverses a short segment (7 to 8 ) in superficial
stroma. .
 181 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Y

Titration is done from the side port with a 24 /26

gauge hydrodissection canula mounted on a 2 cc
syringe filled with balanced salt solution or
Ringer lactate. The anterior chamber is reformed
through the side port and egress of fluid is
watched from the edges of the sclera flap.
Step 5: The end of 0 and 8 are tied with three The first time it is done to check for egress of fluid
throws, two throws, one throw and cut flush so flow which simulates aqueous flow in the
that the knot is buried beneath conjunctival flap postoperative period. Excess outflow requires
placement of a second tight releasable suture, no
flow requires undoing the first releasable and
redoing it to make it less taut.
The second time again titration ensures slow
egress of fluid, poor flow should cause us to
loosen the releasable and vice versa. Just like
Goldilocks the flow has to be just enough, not
too fast, not too slow.
At the end of the surgery, titration is done to form
the bleb thereby ensuring patency of the
sclerostomy and adequate tightness of the scleral
The blue arrows depict sutures (Figure 21). Any leak from the anchored
the segment 5- 6 which
conjunctiva would imply inadequate closure and
is in superficial stroma
of corneal side. require placement of additional sutures. Thus
water tightness of the conjunctival closure is
checked on table. In addition any small blood
clot/ pigment in sclerostomy area is washed out.

Figure 20 : Conjunctival anchoring mattress sutures magnified.

Bleb titration
This step is to be performed once to as much as
three times during trabeculectomy.
i) After placement of first releasable suture
ii) Before tightening the second tie of second
releasable suture
iii) At end of surgery after placing all the
conjunctival anchoring sutures.

Figure 21 : Bleb titration

 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
POSTOPERATIVE REGIMEN
Topical steroid antibiotic combinations are
prescribed at 2-4 hourly intervals to suppress
wound healing for first 2 weeks. They are then
tapered gradually and are prescribed for a total of
6-8 weeks. Prednisolone or betamethasone
combination with antibiotic is used. Topical
cycloplegics namely homatropine drops or
tropicamide are routinely used by some surgeons
to reduce ciliary spasm, prevent synechiae, or
deepen the anterior chamber.
Surgical Modifications in Trabe- culectomy
Tenonectomy:
The healing and scarring of conjunctival and
scleral flap determine the outcome of
trabeculectomy surgery. Treatments affecting
wound healing increase the likelihood of
achieving long term filtration, especially in eyes
with a poor surgical prognosis. Different
techniques have been advocated for modulation
of wound healing in glaucoma in glaucoma
surgery. Pharmacological modulation of wound
healing in filtering surgery to lower the
intraocular pressure is an established practice
today. Tenonectomy is another method to
modulate wound healing. Several authors have
commented on the improved results from
excision of tenon's capsule because this is the
origin of much of the fibrous tissue issue reaction
that causes drainage failure.
Technique:
After conjunctival flap completion tenon's
should be separated from conjunctiva.
Tenonectomy can be performed in either fornix
based or limbal based conjunctival flaps. The
conjunctiva is grasped with a non-traumatic fine
forceps. Toothed forceps that can cut the
conjunctiva should not be used for the risk of
damage or button holing of conjunctiva. The
tenon's capsule in bluntly separated / dissected
Y 182
from the episcleral using Westcott's scissors
(preferably blunt tip instrument). Dissection is
carefully proceeded to separate the Tenon's
capsule from conjunctiva and tenons excised.
Care should be taken to avoid button holing of
conjunctiva. A blunt and as much as possible non-
traumatic undermining of the Tenon's capsule is
carried out, in order to minimize inflammatory
mediator release and to reduce the post scar
formation. The sub tenon's space should be
dissected at least 8 mm posterior from the limbus.
Care should be taken to leave 2 mm of conjunctiva
at the limbus.
Advantages:
Many studies have proved that tenonectomy
results in better IOP reduction than in
t r a b e c u l e c t o m y w i t h o u t t e n o n e c t o m y.
Tenonectomy results in thinner and more
transparent blebs. This may facilitate in
suturolysis when required.
Limitations and complications:
It may be difficult to identify the Tenon's capsule
and perform blunt dissection, more so for the
beginners. This may lead to conjunctival button
holing which will need repair. This in itself will
result in conjunctival scarring and bleb failure in
long term.
There is a fear of delayed complications from
blebs covered only with a thin conjunctival layer.
These blebs are produced with pharmacological
modulation; therefore, one should avoid
tenonectomy in filtering surgery along with
pharmacologic modulation. As a delayed
complication, thin blebs can leak and eventually
may get infected. Leaks from thin blebs will be
seen as sweating drops on fluorescin stain.
Releasable Sutures:
The aim of glaucoma surgery is to maintain a
steady flow of aqueous out of the anterior
 183 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
chamber through the scleral window, under the
sclera flap into the sub-conjunctival space. But
maintaining the right amount of flow is a
challenge to the surgeon. The bleb can be a failure
due to overfiltration (hypotony) or
underfiltration (hypertony). Very tight sutures
can result in tight scleral flap closure and thus
reducing flow of aqeous into the bleb causing a
low bleb and raised or normal IOP. If the sutures
are very loose, it will result in overfiltration and
thus hypotony and flat chamber in early post-
operative period which may lead to choroidal
detachment, suprachoroidal hemorrhage, cataract
and bleb failure. This is where titration of
filtration in early postoperative period becomes
important. Many methods are proposed for that;
releasable sutures, digital massage, laser
suturolysis, adjustable sutures.
Digital massage is done by pressing the globe
gently by finger in the lower half or by cotton bud
near the sclera flap margin. It temporarily opens
the passage. Limitation of the procedure is that it
lowers the IOP only transiently and it is also
painful to the patient.
Laser suturolysis is another option in case where
sclera flap needs to be loosened or filtration
increased. It proves to be useful many times but
has its own limitations. Visualization of sutures
may not be possible due to thick tenon's or sub-
conjunctival hemorrhage. There is a potential for
conjunctival buttonholing. Above all there may
not be ready access to laser and also patient may
not be cooperative for the procedure.
Releasable sutures offer the benefit of
modification of the filtration rate postoperatively
at the slit lamp with relative ease without the need
of laser. They have an advantage over suturolysis,
as visualization of free end of suture is not
difficult as it on the surface of cornea, easy to
remove and required cooperation from patient is
Y
also minimal.
Releasable sutures can be placed in combination
with permanent sutures to offer a controlled
titration. In triangular flaps one releasable suture
at apex and two permanent sutures at the sides can
be taken or one permanent suture at the apex and
two releasable sutures can be taken on the sides of
the flap or all three releasable sutures can be
taken. In rectangular flaps two permanent
sutures at the corners and two releasable sutures
at the side vertical walls can be taken. It is
recommended to take releasable suture at the
apex as it encourages posterior drainage thus
resulting in a more posterior diffuse bleb. This
prevents complication of blebitis and
overhanging bleb associated with anterior blebs.
Technique of releasable sutures :
There are many techniques of performing
releasable sutures.We describe in detail one such
technique. In fornix based conjunctiva flap
Releasable suture can be taken from corneal side
or the scleral side. When taking suture from the
corneal side first bite (Figure.22), 2-3 mm long,
is taken in the clear cornea at the base of the flap,
parallel to the limbus. Second bite (Figure.23)
starts just adjacent to the previous exit, passes
under the limbus, perpendicular to the limbus and
comes out through the sclera flap. Third bite
(Figure.24) is taken through the sclera flap and
then through the adjacent sclera. Then the suture
is tied on a loop with three or four throws to form a
slipknot (Figure.25). Care should be taken not to
keep the loop too long or else it gets entangled in
the tenons and is difficult to remove. The loose
end of the thread at the corneal side is pulled out
and trimmed flushed to the cornea (Figure.26).
The thread retracts a little and gets embedded in
the cornea, not giving any foreign body sensation.
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Figure 22 : First bite for releasable suture
Figure. 23 : Second bite for releasable suture
Figure. 24: Third bite for releasable suture
Figure.25: Slip knot with 3 4 throws
Y 184
Fig. 26 : Final picture of releasable suture
This method of placing releasable suture can be
reversed by holding the needle backhand, taking
the first bite through the sclera adjacent to the
sclera flap and coming out through the sclera flap,
second bite through this flap, going under the
limbus and coming out through the clear cornea.
Then a horizontal bite is taken in the clear cornea.
The suture is tied at the sclera flap on a loop with
three of four throws. The loose end at clear cornea
is pulled out and trimmed at the corneal side. In
limbal based conjuctival flap the procedure is
same as in fornix based flap. The second bite
under the limbus passes under the conjunctival-
tenon's flap and comes out through the sclera flap.
When to remove the sutures:
Indications for removal of releasable sutures are a
flat bleb in the immediate post operative period
with a normal to deep anterior chamber depth with
a normal or rising trend of IOP or even at lower
pressure if the target pressure for the individual
patient was not achieved. Best results are obtained
when removed in the early post-operative period.
Early removal is easy and also provides greater
reduction in IOP. If the target pressure was
achieved, the suture removal can be delayed to 3-4
weeks. Removal after 4 weeks may be difficult
due to onset of fibrosis and entangling of the loop
in the tenons.Late removal of sutures may also not
be very effective.
 185 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
Y
How to remove the sutures :
It is relatively very simple to remove these
sutures. Antibiotic drops are instilled 3-4 times
before suture removal. Topical anesthetic drops
are instilled. With a 26 gauge needle, the suture is
lifted out of the sub epithelial tract on the cornea.
This free end of the suture is held as close to the
base near the cornea and gently pulled out. It
generally comes out very smoothly in early post
operative period.
Limitations and complications :
Although very effective, releasable sutures do
have their own set of limitations and
complications. Most dreaded complication is
potential to decrease resistance too much and thus
resulting in over-filtration. This can result in
sudden hypotony with a flat anterior chamber and
can cause choroidal detachment.
As the suture lies on the corneal surface and is
connected internally to the bleb and sclera flap, it
provides a tract for infection. In case patient
acquires some surface infection, it may lead to
blebitis or in very unfortunate cases to
endophthalmitis. Sometimes the buried end of
suture in cornea may become exposed and rub on
corneal surface causing 'Windshield Wiper
Syndrome' causing corneal abrasion or erosion.
Last but not the least inability to release the suture
fails the purpose of taking these sutures. Suture
may break while attempting to release it. In this
situation, laser suturolysis of these sutures can be
attempted.
To summarize, releasable sutures are an easy and
effective way to prevent early post operative
hypotony and shallow chamber. Guarded suture
removal within first four weeks gives best results.
Specific situations in filtering Surgery:
REFRACTORY GLAUCOMA
The term 'refractory glaucoma' refers to a group
of glaucomas which are known not to respond
favorably to surgical ocular hypotensive
treatment. Like other glaucoma filtering
surgeries, trabeculectomy fails as a result of
excessive scarring of the filtering bleb. The bleb
scarring tends to occur in especially aphakia,
younger subjects, glaucoma secondary to uveitis,
and neovascular glaucoma.
The adjunctive use of antiproliferative agents
including 5-fluorouracil (5-FU) and Mitomycin
C (MMC) improves the prognosis of glaucoma
filtering surgery by inhibiting fibroblast
proliferation, leading to filtering bleb formation.
Trabeculectomy with adjunctive MMC has been
reported to improve surgical success in
refractory glaucoma.
ANGLE CLOSURE GLAUCOMA:
In eyes with angle closure glaucoma
Trabeculectomy increases the chance of further
shallowing of the anterior chamber, the risk of
developing malignant glaucoma, and the risk of
cataract formation.
The same techniques of filtration surgery are
used as in POAG, although some surgeons
advocate tighter suturing of the trabeculectomy
flap to avoid low IOP in the immediate
postoperative period. A low IOP may contribute
to further anterior chamber shallowing, which
may lead to a higher rate of malignant glaucoma
postoperatively. Here, releasable sutures play a
role in maintaining anterior chamber depth in
early post-operative period and preventing
complications of shallow anterior chamber.
 TRABECULECTOMY- INDICATIONS & TECHNIQUE OF SURGER
NEOVASCULAR GLAUCOMA
Neovascular glaucoma responds poorly to
standard glaucoma procedures, but the success
rate can be improved by choosing the most
appropriate surgical treatment for each
individual case. The choice of a surgical
approach may be influenced by several factors,
including the stage of the disease. Many surgeons
favour drainage implants when the disease is
more advanced or when severe inflammation is
present, which would be associated with a poorer
prognosis if trabeculectomy were chosen.
Trabeculectomy without antimetabolites has not
proven to be an effective choice for treating the
disease, with failure rates up to 80 percent being
reported. However, on average, a trabeculectomy
with mitomycin C for neovascular glaucoma has
a success rate of about 50% and for a glaucoma
implant in a similar setting has a success rate of
about 60%.
NVG eyes have a great propensity for intraocular
bleeding during and after surgery, which will
negatively affect the outcome. It is important to
note that, do not perform intraocular surgery
before injection of anti- VEGF agents. The iris
associated with neovascular glaucoma is very
vascular and thickened, stop anticoagulant
therapy before surgery. The sudden drop in
intraocular pressure will cause the fragile
neovascular vessels to bleed severely.
TRABECULECTOMY IN PAEDIATRIC GLAUCOMA
Although guarded filtration procedures
(trabeculectomy) have become the mainstay of
glaucoma surgery in adults, their use in infantile
and pediatric glaucoma is limited. A guarded
filtration procedure can be considered if two or
m o r e a t t e m p t s a t a n g l e s u rg e r y ( e . g . ,
trabeculotomy or goniotomy) have been
Y 186
unsuccessful. The exuberant healing response of
infants and children greatly reduces the success
rate of filtration surgery in this patient population.
The use of antimetabolites (Mitomycin-C) will
help in controlling exuberant healing response
and gives improved success rate. The filtration
bleb that develops after a guarded filtration
procedure in which antimetabolites have been
used is usually thin and cystic and prone to
infection. Because bleb thinning increases with
time after surgery, additional problems could be
anticipated with longer follow-up.
If significant buphthalmos is present, the surgeon
must be particularly cautious when making the
partial-thickness scleral flap because the sclera in
these eyes is extremely thin and elastic. Therefore
after making the scleral flap it shrinks. So always
take large size scleral flap. The surgical limbus is
also stretched so landmark may not be clear.
Conjunctival suturing may be done with 8/0 or 9/0
vicryl.
The surgeon should take into consideration of
social situation of the child. It is unlikely that the
parent or responsible guardian will take action at
the earliest sign of a bleb infection or
endophthalmitis, in which case filtering surgery
with anti mitotics is risky.
Guarded filtration procedures should be
considered with caution in cases of childhood
glaucoma associated with surgical aphakia. The
need for extended-wear contact lenses for aphakic
correction and the prevention of amblyopia raise
the risk of devastating endophthalmitis to an
unacceptably high level if a filtration bleb is
present, particularly given the poor hygiene of
toddlers and young children.
 187
Antimetabolites and Methods
to Prevent Bleb Scarring.
Dr. Sirisha Senthil, Dr. Binita Thakore
Introduction
Trabeculectomy, introduced by Cairns in 1968,
remains the standard surgical procedure for the
reduction of intraocular pressure (IOP) in patients
with medically uncontrolled glaucoma
worldwide.[1,2] The reported failure rates range
from 60% at 4 years to 21% at 20 years. However,
brosis of the sub-conjunctival tissue may lead to
bleb failure, decreasing the long term success of
trabeculectomy.[5-7] With the introduction of
adjunctive anti-metabolites, such as 5-
uorouracil (5-FU) and mitomycin-C (MMC),
which significantly decrease the post-operative
sub-conjunctival scarring, has improved the long
term success of trabeculectomy.[8-11] However, the
use of adjunctive anti-metabolites during surgery
have increased the incidence of bleb-related
complications like thin avascular blebs, hypotony
maculopathy, blebitis, and endophthalmitis.[12-14]
Hence one has to weigh the benefits and risks of
using the antimetabolites and use them
judiciously in patients with high risk for failure of
trabeculectomy. Ologen, a biodegradable,
porous, porcine, collagen implant is an alternative
adjunct during trabeculectomy aimed to improve
the long term success of trabeculectomy by
decreasing the sub-conjunctival scarring but with
apparently less bleb-related complications.
The success of trabeculectomy can be improved
by identifying risk factors for failure and taking
appropriate preoperative and intraoperative
precautions. Also appropriate postoperative
management is essential for the diagnosis and
management of failing filtering blebs.
Pre operatively,
One should recognize eyes at high risk for
failure of trabeculectomy and use adjunctive anti-
metabolites to decrease scarring and increase the
success rate.
Stopping topical miotics and prostaglandin
analogues 1-2 weeks preoperatively can help in
decreasing the ocular congestion and
inflammation.
Use topical steroids preoperatively for inflamed
eyes like uveitic glauocomas.
Stop systemic anticoagulants to minimize
bleeding intra operatively.
Intra-operatively,
Care should be taken to minimize the trauma to
the tissue while dissecting or cauterizing.
One should prevent excessive bleeding and
achieve good homeostasis during the procedure.
Use of intraoperative mitomycin C (0.2 mg/ml)
subconjunctivally or subsclerally for 1-2 minutes,
subconjunctival (5-Fluorouracil 50mg/mlor)
placing a collagen implant subconjunctivally in
high-risk cases or in resurgeries can improve the
success rates of trabeculectomy.
Postoperatively,
One should be aware that failure of filtration
surgery is primarily due to subconjunctival
fibrosis rather than closure or obstruction of the
internal ostium.
A diffuse elevated bleb generally has greater
chances of success (Fig.1).
 ANTIMETABOLITES AND METHODS TO PREVENT BLEB SCARRING. 188

Preventing scarring and decreasing the If there is iris or vitreous or blood clot blocking
inflammation by using adequate postoperative the ostium, it needs to be cleared and the ostium
steroids, deepening the anterior chamber by using needs to be reopened with YAG laser.
cycloplegics can prevent shallow anterior 1. Once you recognize the IOP is high and
chamber and closure of the PI or ostium or ostium is patent in the early post operative
malignant glaucoma. period, digital ocular massage can be
The most important step in the management of a performed. This can be done as early as day 1,
failing bleb is early recognition of failure and and up to 4 weeks. Digital ocular massage can be
appropriate treatment. performed by applying gentle pressure over the
The Signs of Bleb Failure are: inferior sclera though the lower lid for 10-15
Local conjunctival hyperemia seconds or pressure applied superiorly behind
(Fig. 2) the scleral flap, through the eyelid with the
patient looking downwards under direct
visualization on the slitlamp biomicroscope.
While applying digital massage, the amount of
pressure needed to form the bleb, the elevation
of the bleb, the presence or absence of leak has
to be noticed. Digital ocular pressure will push
Exercise vascularization aqueous through the sclerostomy into the
Increased IOP subconjunctival space, thus lowering the IOP.
Flat bleb 2. Early inflammation and hyperemia should be
Highly elevated cystic bleb treated aggressively with hourly topical steroids
(Fig. 3) with or without administration of sub-tenon 5
fluorouracil, 5mg i.e (0.1 ml of 5-Fu; 50mg/ml,
away from the bleb under topical anesthesia).
The 5-FU injections can be repeated monthly up
to 3 months to weekly thereafter until
improvement is seen.
3. If bleb forms reluctantly with digital massage
during first 2 weeks post operatively, laser
Small avascular cystic blebs suturolysis can be considered. If MMC was used
The important step in deciding if the bleb has during trabeculectomy, suturolysis can even be
failed or not is to confirm the patency of the performed several weeks after surgery.
sclerostomy. (Fig. 4 a & b) a. Argon green laser and a Hoskins/Blumenthal
lens is used
b.100 400 mW power, 0.01ms and 50 spot
size

FIG 4b Internal ostium

Fig 4a Scarred internal ostium plugged with iris tissue
 189 ANTIMETABOLITES AND METHODS TO PREVENT BLEB SCARRING.
c.At a time only one suture is removed
d. This is followed by digital massage to form the
bleb
e. Anti-inflammatory agents and steroids have to
be continued
(Fig.5)
Laser suturelysis with Hoskins lens
4. If releasable sutures are used, then they need to
be removed and digital massage to be given to
form the bleb.
5. Despite all these if the IOP is high, bleb
needling can be performed. Needling is an
intraocular procedure and should de performed
under sterile settings in outpatient clinic or in the
operating room. The needling can be
supplemented with injection of an antimetabolite
A 0.1 ml of 0.04 mg/ ml MMC or 5mg of 5FU in a
tubular syringe (this concentration is 10 times
lower than that used during trabeculectomy) is
taken.
Needling:
Procedure:
Topical betadine and antibiotic eye drops are
instilled in the eye. A bent (ideally 30G or 26G)
needle bevel up is used. The needle is introduced
subconjunctivally, 7-8 mm behind the limbus.
Ask the patient to look down, enter bevel up, and
slowly advance it in the sub-conjunctival space
till the scleral flap is reached. If there is a tight
suture, it is cut with the bevel of the needle. The
needle is then moved back and forth in an attempt
to disrupt all scar tissue in the sub-tenons space,
taking care not to traumatize the blood vessels or
puncture the conjunctiva. If bleb forms well, the
needle is slowly withdrawn outside and the
conjunctival entry is closed with cotton bud for a
minute, to prevent leakage at the injection site. If
bleb does not form well, there the needle is
introduced between the cut edges of the scleral
flap and lifted up or the needle is introduced into
the anterior chamber to create a channel of
communication.
Mitomycin C is commercially available in sealed
vial (2 mg.) in powder form. This has to be diluted
by 5 ml of distilled water so that the concentration
becomes 0.4 mg/ml. 0.1 ml of this solution is
diluted with 0.9 ml of distilled water and, injected
subconjunctivally posterior to the bleb through a
separate entry posterior to the needling site,
antibiotic drops/ betadine drops are applied after
the injection. Use a separate syringe and needle
for the anti metabolite injection
At the end of needling procedure, the increase in
size of the bleb or changing appearance of the
bleb from flat to elevated or cystic to diffuse
indicate restoration of aqueous flow from the
anterior chamber to the subconjunctival space.
Complications may include Hyphema, flat AC,
choroidal detachment, conjunctival buttonholes
and rarely endophthalmitis.
If all these fail, then bleb revision or repeat
trabeculectomy or a tube shunt procedure will be
required.
Complications related to antimetabolites use:
Late leaking blebs have become increasingly
common with the widespread use of anti-
metabolites in glaucoma filtering surgery, and are
mostly associated with thin-walled and avascular
blebs. Vision threatening complications of
leaking bleb include hypotony, shallow or flat
anterior chamber, hypotonic maculopathy,[16]
[17]
choroidal detachment, cataract formation,
epithelial downgrowth, chronic inflammation
 ANTIMETABOLITES AND METHODS TO PREVENT BLEB SCARRING. 190
and bleb failure. A leaking bleb may predispose
the patient to infection and endophthalmitis,[12-19]
leading to loss of the eye. These complications
can be prevented by proper and timely
intervention.
Prolonged hypotony is associated with disc
edema, vascular tortuosity and chorioretinal folds
in the macular area. Persistent folds in the
macular area can lead to a marked reduction in
visual acuity. High myopes are more prone to
hypotonic maculopathy especially when
mitomycin C is used. Prevention of this
complication is by minimizing the use of
antimetabolites and using tight wound closure
with releasable sutures. Injection of autologous
blood into the bleb has been reported with
variable success. Surgical procedures include
conjunctival compression sutures, resuturing the
scleral flap, patch grafting with donor sclera or
revision of the bleb are indicated when hypotony
is associated with visual loss. Large thin-walled
avascular blebs ( Fig.6)
are at increased risk of leaks or rupture. Severe
coughing, vigorous rubbing of the eye may also
precipitate late bleb leaks. If the leak is small,
aqueous suppressants and topical antibiotics to
prevent infections may be sufficient. Bandage
contact lens and tissue glue have a limited role in
the management of late leaking blebs. Bleb repair
with conjunctival autograft, with or without
scleral patch graft may be necessary.
Blebitis and endophthalmitis are hazardous
complications whose incidence has increased
after the use of anti metabolites. Blebitis usually
responds to intensive topical antibiotic treatment.
Bleb-related endophthalmitis requires aggressive
immediate treatment with topical, systemic,
intravitreal antibiotics combined with core
vitrectomy.
Postoperative 5-FU injections can cause corneal
epitheliopathy and wound leaks and hence care
should be taken to avoid contact of 5FU with the
corneal epithelium.
Dealing with the complications of antimetabolite
surgery is an arduous job for the patient as well as
the surgeon. However, these complications can be
significantly decreased with the judicious use of
these adjunctive antimetabolites.
Conclusion
You can prevent a bleb from failing starting with
preoperative preparation, precautions taken
during surgery, modifications during surgical
procedure. Post operatively, early identification
and appropriate interventions can salvage most of
the blebs and increase the survival and success
rates of trabeculectomy. Surgical filtering
procedure with adjunctive antimetabolites
enhances the long term success of trabeculectomy
when used appropriately in indicated cases.
 191 ANTIMETABOLITES AND METHODS TO PREVENT BLEB SCARRING.

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glaucoma filtration surgery. Arch Ophthalmol. 1988; 106:
89-94.
8. Bindlish R, Condon GP, Schlosser JD, D'Antonio J, Lauer KB,
Lehrer R. Efficacy and safety of mitomycin-C in primary
trabeculectomy: Five-year follow-up. Ophthalmology. 2002;
109: 1336-41; discussion 41-2.
9. Lama PJ, Fechtner RD. Antifibrotics and wound healing
in glaucoma surgery. Surv Ophthalmol. 2003; 48: 314-46.
10. Beckers HJ, Kinders KC, Webers CA. Five-year results
of trabeculectomy with mitomycin C. Graefes Arch Clin
Exp Ophthalmol. 2003;241:106-10.
11. Katz GJ, Higginbotham E, Lichter PR, Skuta GL, Musch
DC, Bergstrom TJ, et al. Mitomycin C versus 5-fluorouracil
in high-risk glaucoma filtering surgery. Extended follow
up. Ophthalmology. 1995;102:1263-9.
12. Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF,
Flynn HW Jr. Endophthalmitis after filtering surgery with
mitomycin. Arch Ophthalmol. 1996; 114: 943-9.
13. Higginbotham EJ, Stevens RK, Musch DC, Karp KO, Lichter
PR, Bergstrom TJ, et al. Bleb-related endophthalmitis after
trabeculectomy with mitomycin C. Ophthalmology.
1996;103:650-6.
14. Jampel HD, Pasquale LR, Dibernardo C. Hypotony
maculopathy following trabeculectomy with mitomycin C.
Arch Ophthalmol. 1992; 110: 1049-50.
15. Chen HS, Ritch R, Krupin T, Hsu WC. Control of filtering bleb
structure through tissue bioengineering: An animal model.
Invest Ophthalmol Vis Sci. 2006; 47: 5310-4.
16. Newhouse RP, Beyrer C. Hypoton as a late complication of
trabeculectomy. Ann Ophthalmol. 1982; 14: 685-86.
17. O'Connor DJ, Tressler CS, Caprioli J. A surgical method to
repair leaking filtering blebs. Ophthalmic Surg. 1992; 23: 336
38.
18. Khaw PT, Doyle JW, Sherwood MB, Smith F, McGorray S.
Effects of intraoperative 5-fluorouracil or mitomycin-C on
glaucoma filtration surgery in the rabbit. Ophthalmology
1993; 100: 367-72.
19. Ticho U, Ophir A. Late complications after glaucoma filtering
surgery with adjunctive 5-fluorouracil. Am J Ophthalmol.
1993; 115: 506-10.
 Complications of Trabeculectomy
Dr. Manju Pillai, Dr. Sathyan Parthasarthi, Dr. Alan Robin
Trabeculectomy is currently the preferred
surgical procedure for most forms of glaucoma.
Despite its relative success, there are still various
complications occurring both in the immediate
postoperative period as well as later, even months
or years following the procedure. The purpose of
this chapter is to better define the problems
associated with filtering surgery.
Functioning blebs
Filtration surgery lowers the IOP by creating a
fistula between the inner compartments of the eye
and the subconjunctival space (i.e., filtering bleb).
In a successful trabeculectomy, there are loose
junctions in the outer layers of the conjunctiva
creating visible microcystic changes allowing the
egress of aqueous into the tear film. Early (e.g.,
conjunctival button holes, bleb leak, excessive
filtration, hyphema, flat anterior chamber,
choroidal detachment, dysasthesia, hypotony,
filtration failure) and late (e.g., bleb leak,
excessive filtration and hypotony, bleb
dysesthesia,
192
bleb encapsulation, filtration failure, blebitis,
endophthalmitis, cataract) complications
associated with filtering procedures should be
managed adequately to prevent further problems.
Intra-operative Complications
1. Conjunctival Buttonhole
2. Flap Disinsertion or Tear
3. Flap hole
4. Intraoperative flat anterior chamber
5. Iris root or ciliary body bleeding
6. Iridodyalysis
7. Cyclodialysis
1. Conjunctival Buttonhole
a. Try and prevent this complication during the
early stage
Careful dissection
Non-toothed forceps
Broad based grip
Fornix based approach
b. Early in surgery
If the buttonhole is noted in friable conjunctival
tissue before the creation of the scleral flap, a new
site may be selected for the procedure. One must
however gently close the existing dissection.
c. Late in surgery
Horizontal mattress suture (10.0 nylon or 9.0
vicryl on a vascular needle)
Small perforations (e.g., from a suture needle)
usually heal spontaneously, even in the presence
of anti metabolites, within 2472 hours by simply
withholding / reducing the frequency of steroid
drops
Healon-5 can be used to retard the flow of such
leaks and facilitate healing
Focal perforations 12 mm in size should be
closed with a 10-0 nylon suture on a micro
vascular tapered needle, using a mattress or
purse-string closure
 193 COMPLICATIONS OF TRABECULECTOMY

In case of button hole close to limbus, posterior

dissection allows anterior sliding of fresh
conjunctiva towards the limbus.
2. Flap Disinsertion or Tear
Suture with 10-0 nylon
To try a different site depending upon when this
occurs
3. Flap hole

Signs of supra choroidal hemorrhage

Suture if possible
Patch with tenon's capsule
Sclera patch grafting covering the hole
4. Intraoperative flat anterior chamber
Maintain anterior chamber depth throughout the
surgery using air or viscoelastic agents. Reasons
that need to be identified for causing a flat
anterior chamber:
- Aqueous misdirection
- Retrobulbar haemorrhage
- Speculum pushing on the globe
suprachoroidal hemorrhage
Sudden increase in firmness of eye
Flattening of theAC
Forward movement of intraocular contents
Loss of red reflex
Prevention:
Consider pre-placing flap sutures
Treatment
Close eye
Consider scleral drainage 3-4 mm posterior to
limbus
Prevention - suprachoroidal haemorrhage
Pre-operative considerations:
Anti-coagulants to be discontinued
Mannitol or oral carbonic anhydrase inhibitors
Consider prophylactic posterior sclerotomy
Avoid
Excessive tissue distortion
Prolonged hypotony especially in eyes
with narrow angle
5. Iris root or ciliary body bleeding
May cause blockage of internal ostium
Management
Wet field 23G cautery
Tamponade with viscoelastic
Tight closure with extra sutures
Apply sponge with topical epinephrine

Post operative complications
Bleb leaks:
Early postoperative bleb leak is a common
complication of trabeculectomy. There is a wide
variation in the reported incidence of this
complication from 0% to 30%.
Postoperatively, it is useful to distinguish
between point leaks (seen in 2% of eyes at 3
months following either 5-FU or mitomycin- C
filtration surgery) and transconjunctival aqueous
oozing (seen in 12% of eyes, especially in large
avascular areas, and following digital massage).
Often such defects can be carefully monitored
and/or treated prophylactically with antibiotic
drops, with the vast majority spontaneously
resolving (and often benignly recurring.)
Recurrent leaks have a higher association with
blebitis or endophthalmitis. Patients, need to be
alerted to the symptoms of early infection, so as to
seek immediate medical attention.
Late leaks / persisting leaks: Ideal treatment
aims to eliminate leaks and hypotony while
preserving filtration function and maintaining
target intraocular pressure (IOP).
Successful resolution often requires surgical
revision.
Various surgical approaches have been reported
with varying degrees of success, including
conjunctival advancement with or without
excision of the pre-existing bleb.
COMPLICATIONS OF TRABECULECTOMY 194
Bleb excision with sclera patch grafting and
conjunctival advancement done for a leaking bleb
The flat anterior chamber with hypotony
The depth of the chamber and the extent of the
bleb will depend on several factors, including. the
tightness of the scleral flap, the firmness of the
eye patch, The size of the hole, the amount of
aquous produced, whether there is a viscoelastic
in the anterior chamber and the use of
antimetabolites at the time of the surgery.
Shallow chambers by Spaeth
The anterior chamber depth can be graded post
operatively as Grade 1 shallow: Peipheral irido
corneal touch, Grade 2:Mid peripheral irido
corneal touch and Grade 3 : Lenticulo corneal
touch. With a grade III chamber, the lens-cornea
touch can result in corneal decompensation,
permanent PAS, and cataract. With grade II
changes, one can watch temporarily, and with
grade I changes, these findings are more unlikely.
Grade 1: Shallow chamber. Although the
peripheral iris and cornea are touching, the
central anterior chamber surrounding the
pupillary area remains formed.
 195 COMPLICATIONS OF TRABECULECTOMY
Grade 2 : Shallow chamber. The anterior
chamber is quite compromised, with iris-to-
corneal apposition peripherally and centrally,
although the area anterior to the pupil and lens
(vitreous or IOL) remains formed. To clinically
monitor this small chamber over time, its depth
can be graded with that of a fraction of the
overlying cornea.
Grade 3 : Shallow chamber. The anterior
chamber is completely collapsed, with
pupillarycorneal touch and sometimes even
lenscorneal touch.
The most important after classifying the chamber
depth is to determine whether the IOP is either
higher than expected or excessively low in
conjunction with one of these three
configurations of shallow chamber.
When one clinically evaluates flat or shallow
chamber one needs classify them into two
different categroies: those with low pressures and
those with high pressures. Remember that a high
pressure in an eye with a flat chamber is an IOP in
the high teens or higher!
Flat anterior chamber with hypotony could be
due to
Over filtration
Bleb leaks
Choroidal effusions
Treatment
1. Hypotony caused by excessive filtration
usually resolves with routine postoperative
medical management. Therefore, the initial
management of postoperative hypotony with a
formed anterior chamber and elevated bleb is
conservative. Restrictions in activity (e.g.,
bending, weightlifting) and avoidance of
Valsalva-positive conditions (e.g., constipation,
vigorous coughing, sneezing, or nose blowing)
are recommended, especially in patients at risk
for suprachoroidal hemorrhage (e.g., aphakic,
vitrectomized, or elderly individuals with very
high preoperative IOP).
2. In complicated cases with a shallow anterior
chamber, loss of bleb height, decreased vision,
or persistent hypotony, the mechanism
responsible for this condition should be
addressed.
3. The use of pressure patching, large bandage
contact lenses, the Simmons shell, and
symblepharon rings may be temporarily
beneficial by tamponading the filtration site,
which allows gradual improvement in the
anterior chamber depth.
4. However, a flat chamber with lens-corneal
touch (grade 3) requires urgent intervention
with prompt anterior chamber reformation;
otherwise, rapid cataract development and
irreversible corneal endothelial injury will
occur.
Prolonged flat anterior chamber should be
reformed immediately and the cause
addressed so that it does not recur.
Patch
Reform chamber
Healon GV
Surgical revision
Large diameter contact lens

Choroidal effusions
Are related to inflammation but it is not clear
that the use of oral corticosteroids can reduce the
effusions.
Occurs more with hypotony or can cause
hypotony.
Chamber can be deep or shallow
Choroidals themselves contribute to hypotony
Will resolve with increased IOP
Choroidal effusions must address underlying
cause
Wound leak
Loose flap
Management
In case of loose sutures of flap or bleb
leak because of retracted conjunctiva,
resuturing is advised.
The anterior chamber is re-formed with
a viscoelastic.
Surgical drainage in case of large
choroidal effusions - One sclerostomy
inferiorly is made 4 mm behind the
limbus and over the pars plana to drain a
kissing choroidal effusion.
Flat anterior chamber in normotensive and
hypertensive eyes
Normal or elevated IOPs with a flat
anterior chamber indicate that excessive
filtration is not the cause of the flat
chamber.
COMPLICATIONS OF TRABECULECTOMY 196
Causes could be
Pupillary block
Expansion of the choroid or
enlargementof the suprachoroidal space
by blood or effusion
An increase in vitreous volume caused by
blood or effusion
Misdirection of aqueous
Patent iridectomy exists; there are two common
causes of flat chamber with normal or high IOP
after glaucoma surgery:
Ciliary block (e.g., aqueous misdirection
syndrome, malignant glaucoma) and
Suprachoroidal hemorrhage (SCH)
Ciliary block glaucoma
Historically this condition was commonly
appreciated as a complication of a
filtering procedure in eyes with pre-
existing angle-closure glaucoma or
shallow anterior chambers.
Clinically, ciliary block glaucoma is
suspected in the presence of a grade 2 or 3
shallow chamber, with the prominent
shallowing of the peripheral and central
anterior chambers simultaneously and a
relatively high IOP.
To diagnose ciliary block glaucoma, it is
essential to eliminate the possibility of
pupillary block; hence a patent iridotomy
must be established before this diagnosis
Choroidal expansion, suspected as an
initiating event in acute angle-closure
glaucoma, may also be a contributory.
Management
Eliminate the possibility of pupillary
block
Cycloplegics as well as topical steroids
should be instituted
 197 COMPLICATIONS OF TRABECULECTOMY

Agents to reduce aqueous production Deep Chamber and high IOP

Eliminate pupillary block, retrocapsular 1. Internal Blockage - Identify with Gonioscopy
block, and hyaloid block by respectively
lasering through the iris, posterior
capsule, and hyaloid face with a Nd:YAG
laser
Pars plana vitrectomy will usually be
curative in phakic eyes or vitreous
aspiration. If this occurs in one eye, it is
more likely to occur in the fellow eye.
Suprachoroidal haemorrhage
Presents as Iris
Sudden loss of vision during the first 4 Blood
or 5 postoperative days Vitreous
The pressure may be quite high and the Manage based on etiology
patient may have nausea and vomiting In case of internal block : Disengage iris
Predisposing factors of Suprachoroidal (laser, mechanical)
hemorrhage TightFlap : digital compression 180 degrees
Tr a u m a t i z e d e y e s , a p h a k i a , away or attempt laser Suture lysis / release a
pseudophakia, proliferative diabetic releasable suture and digital massage
retinopathy, vitrectomized eyes,and in External Blockage - Blood/fibrin
large eyes with pathologic myopia or Unresolved cases Revision is advised
congenital glaucoma
6% in eyes with IOPs between 30 and
39 mmHg and 11% in eyes with IOPs of
4049 mmHg
Axial length greater than 25.8 mm
At least four to five days are necessary
for a clot to lyse in the suprachoroidal
space. Early Encapsulation : needling can be done to
In case of small haemorrhage IOP can break open the capsule
be controlled by topical anti glaucoma Endophthalmitis
medications and systemic Thin -walled bleb in general and of
acetazolamide ( if not contraindicated) antimetabolite use in particular are major risk
till the clot gets lysed. Usually drainage factors for intraocular infection.
is not necessary and visual results are Other risk factors include myopia, thin-walled
good. blebs with leaks, concurrent upper respiratory
In case of large haemorrhage, drainage will be infection, and blebs located at the inferior
more easily accomplished through a posterior limbus
sclerostomy if waiting an adequate period of time. Onset of infection can be anywhere from the
 COMPLICATIONS OF TRABECULECTOMY 198

first few days to up to 20 years later. Mean is 14

months. Bacteria are different than cataract
endophthalmitis.

Pars plana vitrectomy in required cases

Use fortified topical antibiotics as well with
Cycloplegics.

Hypotonic Maculopathy
Risk factors
Male
As High as 2.0% incidence Young age
Blebitis and infection that penetrates into the High myopia
vitreous cavity Antimetabolites
Organisms
Streptococci: can penetrate intact conjunctiva, Management
can rapidly progress to endophthalmitis Surgical revision (fresh conjunctiva
Staphylococcus with or without scleral patch graft).
Haemophilus influenzae Autologous blood injection
Compression suture
Management
Blebitis Conclusion
Treat aggressively with topical and Prompt recognition and apt management of the
systemic (moxifloxacin) resultant complication post trabeculectomy yield

Very close follow-up a better outcome in patient care and management.
Endophthalmitis The underlying principle of repeated follow ups
Vitreous tap and intravitreal and continuous care forms the foundation of
antibiotics glaucoma care and management.
A combination of
- Vancomycin 1 mg (10 mg/ml)
-Amikacin 400 micrograms in 0.1 ml
Ceftriaxone 2mg in 0.1 ml, or Ceftazidime
 199 Bleb Evaluation
Dr. Maitreyee Das, Dr. Reena Sharma
Successful glaucoma filtration surgery is
characterized by the passage of aqueous humor
from anterior chamber to subconjunctival space
which results in formation of a filtering bleb.
Aqueous humor from the bleb may exit by
multiple pathways. Clinical evaluation of
trabeculectomy bleb is one of the main concern of
a glaucoma surgeons. Bleb morphology changes
continually since after its inception1. If we learn to
assess them externally with slit-lamp
biomicroscope, we can anticipate the pathology
going under conjunctiva or tenon's layer, which
will help us plan our future management 2 .
BLEBASSESSMENT CRITERIA
What is an Ideal bleb?
An ideal bleb is one which is diffuse in
distribution, low in height, microcystic in
composition and pink in colour ( i.e. with uniform
superficial conjunctival blood vessels), the wall
of the bleb should not be thick 3,4 . An ideal bleb
should ideally be projected posteriorly under the
cover of upper lid.
5
But this is not always the situation . What we
practically see or create in our everyday practice
might be different from ideal.
The following characteristics of the bleb need to
be evaluated in the post operative course
1. Height
Lower the bleb height, better is the outcome.
A low bleb with larger area having no localized
thinning gives an excellent IOP control 6. If the
bleb height is increased abruptly specially near
the limbus, a localized tear film instability is
produced over the cornea anterior to the bleb. This
leads to a dellen. This gives a foreign body
sensation.
An increased bleb height is also seen in Tenon's
cyst. A tenon's cyst is a large thick walled bleb,
mostly localized at the operated site and is
typically increased in height. There is a sharp line
of demarcation surrounding the bleb area. As the
aqueous inside the cyst is not able to diffuse
freely, the wall of the bleb gradually thickens up
and the vicious cycle goes on unless intervened
surgically.
Sometimes, in glaucoma patients treated with
trabeculectomy, there is no correlation between
bleb shape and IOP 6.
2. Area
The area of the bleb can be assessed by passing a
slit beam over the bleb from one side to the other.
Larger the area, better is the diffusion of aqueous,
lower is the IOP A large uniform bleb of low
height with normal vascularity is the ideal
outcome of trabeculectomy.
3. Vascularity
An ideal bleb should not be angry looking, rather
it should have a vascularity similar to the
surrounding conjunctiva. Increased vascularity
(angry vessels) either over the bleb or
surrounding it is a sign of bleb failure 8. This
increase in vasculature is a sign of underlying
fibroblastic proliferation which leads to scarring
of the bleb in near future.
4. Thickness of the wall
An ideal bleb should have a thin wall and either it
would show microcystic compartments or it
should have a uniform translucency throughout.
If the wall is thickened, bleb loses its
translucency 9. In a thin walled bleb, aqueous
diffuses out very easily.

Cystic bleb
A cystic bleb is usually avascular and thin walled.
A multicystic bleb is always the desired outcome
of trabeculectomy. But a large cystic bleb is
usually the result from intra-operative use of
Mitomycin C. These blebs tend to overhang the
cornea. They usually produce the long term
complications of trabeculectomy like bleb leak,
bleb rupture, blebitis and bleb related
endophthalmitis. Too large a bleb can lead to
hypotony and or hypotonic maculopathy. They
sometimes need surgical correction.
Leaking bleb
A bleb leak can be early or late. Early leaking bleb
(within a week after surgery) is usually due to
failure of watertight conjunctival closure or could
be due to unnoticed per operative conjunctival
button hole. In these situations, anterior chamber
is usually shallow and Siedel's test is positive.
Initially they need conservative management
which when fails calls for surgical intervention.
Late bleb leaks are seen a few months or even
years after trabeculectomy. They are common of
with the use of antimetabolites per operatively.
These late leaking of the blebs can be of two types.
One will show positive Siedel's test, the other
might not show an obvious Siedel's positive but
the bleb as a whole sweats. If a wet fluorescein
strip is put on the entire area of the bleb, the bleb
shows a pattern of small multiple oozing sites
which is known as sweating of the bleb 3.
These if left untreated can lead to hypotony and its
consequences. These blebs need surgical
correction.
BLEB EVALUATION 200
BLEB GRADING SYSTEMS
To avoid variability among the observers
and to render the observation a maximum
reproducibility there exist two International
systems for grading a bleb 10 . One is The Indiana
Bleb Appearance Grading Scale (IBAGS, 2003),
11
described by Cantor et al and the other is
Moorfield Bleb Grading System (MBGS).
Classifying the blebs according to this system
gives reproducibility and general agreement.
The Indiana Bleb Appearance Grading Scale
(IBAGS, 2003)
IBAGS is a simple standardized method of
classification. Here high interobserver agreement
was found. This uniform system of classification
facilitates early recognition of failing bleb pattern
and promotes early intervention. Briefly IBAGS
evaluates a bleb based on 4 parameters. A
standardised set of reference photographs for
each parameter on the grading scale is available.
The 4 parameters are Height, Extent, Vascularity
and Siedel's Test.
1. Height(H)- scale of H0 flat bleb; H1, low bleb
elevation; H2,moderate bleb elevation; H3, high
bleb.
2. Extent(E)- scale of E0, no visible bleb or
extending to less than 1 clock hour; E1, extent
equal to or greater than 1 clock hour but less than 2
clock hours; E2, extent equal to or greater than 2
clock hours but less than 4 clock hours; E3, extent
equal to or greater than 4 clock hours
3. Vascularity(V)- V0, avascular/white(no
microcysts visible on slit lamp); V1,
avascular/cystic(microcysts of conjunctiva
visible on slit lamp examination; V2,
mildvascularity; V3, moderate vascularity; V4,
extensive vascularity(vascular engorgement).
 201 BLEB EVALUATION
4.Siedel's test(S)-S0, no bleb leak; S1, pinpoint
transconjunctival leakage visible on bleb
surface(at multiple points), without streaming of
fluid within 5 seconds of application; S2,
streaming aqueous egress visible within 5
seconds of application of fluorescein (diffuse or
localised).
Moorfields Bleb Grading System (MBGS)
In the MBGS (details and reference photographs
available at www.blebs.net.),four parameters are
scored, and in addition, the area and vascularity
are subdivided.
In this grading standard reference photos are
provided. Describing a bleb, three main aspects
have to be considered: area, height and
vascularity. There are six criteria to assess: 2
describing area, 1 describing height and 3
describing vascularity.
1) AREA
The peripheral margins (maximal area) of the
bleb, as well as the central demarcated area of the
bleb are assessed.
1a. Central demarcated area (located over the
scleral trap door) of the bleb is compared to that of
the total conjunctival area visible in the picture.
The area is given a score of 1-5 depending on its
extension; 1 0%, 2 25%, 3 50%, 4 75%, 5 antifibrosis therapy should not rely on waiting for
100%.
2a . Maximal area (peripheral margins) of the bleb
compared to the total area visible in the
photograph of conjunctiva. The area is given a
score of 1-5 depending on its extension; 1 0%, 2
25%, 3 50%, 4 75%, 5 100%.
2) HEIGHT
The height is compared to the height of the
reference photographs provided and given a score
of 1 4
3)VASCULARITY
Vascularity relates to various parts of the bleb
3a. central demarcated area of the bleb (area
described in 1a)
3b. the surrounding peripheral part of the bleb
(area described in 1b)
3c. peripheral non bleb conjunctiva
The various grades of vascularity are 1
avascular, 2 normal vascularisation, 3 mild
vessel inflammation, 4 moderate vessel
inflammation, 5 severe vessel inflammation
4) SUBCONJUNCTIVAL BLOOD
Yes if subconjunctival blood greater than scleral
trapdoor
No if subconjunctival blood is smaller than
scleral trapdoor or not found
SUMMARY
Careful examination of the postoperative bleb
provides important information regarding wound
healing activity. Postoperative application of
the IOP to rise, as scar tissue will already have
formed. Rather, antiscarring activity should be
titrated against the level of active scarring, which
can be determined from the bleb appearance and
anterior chamber activity.
 Clinical Evaluation of Trabeculectomy BLEB 202

MORPHOLOGIC CLASSIFICATION OF TRABECULECTOMY BLEBS BY INDIANA

BLEBAPPEARACE GRADING SYSTEM (IBAGS)

Slit-lamp photographs ( Fig 1- 5) of some of the trabeculectomy blebs are shown. They are all
classified according to IBAGS system .
Fig 1 Fig 4

H3E2V0S0 H1E1V1S0

Fig 2 Fig 5

H3E3V0S0 H1E1V2S0

Fig 3

H1E2V2S0
 203 CLINICAL EVALUATION OF TRABECULECTOMY BLEB

References

1. Relationship between formation of a filtering bleb and an

intrascleral aqueous drainage route after trabeculectomy:
Evaluation using ultrasound biomicroscope :- Jinza K. et al
Ophthalmic Research 2000, vol. 32, no.5, pg. 240-243
2. Correlation between the early morphological appearance of
filtering blebs and outcome of trabeculectomy with
mitomycin-C :- Sacu, Stefan et al, J. of Glaucoma , Oct,
2003, vol.12, Issue 5, pg.430-435
3. A pilot study on slt-lamp adapted optical coherence
tomography imaging of trabeculectomy filtering blebs : -
Thomal Theelen et al , Graefe's Archive for clinical
Ophthalmology , vol. 245, no.6 (2007), 877-882
4. Evaluation of subconjunctival bleb function after
trabeculectomy using slit-lamp optical coherence
tomography and ultrasound biomicroscopy : Zhang Yi et al,
Chinese medical J. 2008, vol. 120, no.14, 1274-1279
5. Conjunctival incision for trabeculectomy and their
relationship to the type of bleb formationA preliminary
study : - A M Agberia et al, Eye (1987)1, 738-743
6. Ultrasound biomicroscopic evaluation of filtering blebs after
laser suturolysis trabeculectomy : - T. Avitable et al,
Ophthalmologica, vol. 212, suppl. 1, 1998
7. Recent advances of trabeculectomy technique : - Jones et al,
Current Opinion in Ophthalmology, April 2005, vol.16,
Issue 2 , 107-113
8. Mitomycin-C augmented glaucoma surgery : Evaluation of
filtering bleb avascularity and trans-conjunctival oozing and
leaks : - N. Anand et al, Br. J. Ophthalmology, 2006, 90 :
175-180
9. Needling revision of trabeculectomy : Bleb morphology and
l o n g - t e r m s u r v i v a l : - A l a n P. R o t c h f o r d w t a l ,
Ophthalmology, vol. 1115, issue 7, 1148-1153, July 2008
10. A pilot study of a system for grading of drainage bleb after
glaucoma surgery : - Wells, A P et al, J. of glaucoma, Dec.
2004, vol. 13, issue 6, 454-460
11. Morphologic classification of filtering blebs after glaucoma
filtration surgery : The Indiana Bleb Appearance Grading
Scale (IBAGS) : - L B Cantor et a;, J. of Glaucoma June
2003, vol. 12, issue 3, 266-271
 Management Of The Failing Bleb
Dr. Suneeta Dubey, Dr. Taru Dewan, Dr. Nitin Anand
Trabeculectomy is the mostly commonly
performed glaucoma surgical procedure. It is a
technically simple procedure to perform. Good
surgical technique will decrease complications
but not increase success rates. Long-term success
will depend on individual wound-healing
response and adequate postoperative
management. This includes early recognition of
failure of filtration into the conjunctival bleb.
Trabeculectomy failure is not uncommon. The
most frequent cause of failure is fibroblast
proliferation and scar tissue formation at
episcleral-Tenon's interface. This represents
normal wound healing.
After trabeculectomy wound-healing in the
conjunctiva occurs in overlapping phases and
continues for years after surgery. A basic
understanding of wound healing processes and
histologic changes of the developing filtering bleb
are mandatory to interpret correctly the
morphologic appearance of the developing
filtering bleb.
Sequence of events in wound-healing
Tissue trauma with release of plasma
proteins and blood cells
Fibrin-fibronectin clot/matrix
Migration and proliferation of
inflammatory cells, fibroblasts in new
capillaries
Collagen synthesis
Fibrovascular granulation tissue
Continued collagen synthesis, capillary
resorption, disappearance of fibroblasts
Dense collagenous sub - conjunctival
episcleral scar
Wound-healing can be pharmacologically
204
modulated by using antimetabolites or more
recently anti-VEGFs like Bevacizumab during
surgery. 5-Fluorouracil (5-FU) inhibits
fibroblast proliferation, thereby decreasing scar
tissue formation. Mitomycin-C (MMC) is a
nucleic acid alkylating agent and Inhibits DNA,
RNA, and protein synthesis. It inhibits fibroblast
and endothelial cell division, cell death, and
decreased collagen synthesis.
The Conjunctival Filtration Bleb
Always examine the bleb under high-power (x16
times) magnification on slit-lamp.
An ideal bleb should be a low lying, diffuse, with
vascularity similar to that of surrounding
conjunctiva. The walls should be relatively thick
walled l but translucent enough to be able to see
the superficial scleral flap (fig 1a ). Subepithelial
microcysts should be visible (fig1b).
Figure 1a. Ideal bleb and
b., subepithelial microcysts (arrows)
Morphologic changes of the developing filtering
bleb after trabeculectomy can predict early failure
even if the intraocular pressure is still normal. In
clinical practice, follow-up of the filtering bleb
according to a standardized morphologic
classification may help to predict outcome and
provide clues for the necessity and timing of
further treatment. Importance of a careful slit
lamp examination of bleb characteristics cannot
be overemphasized.
 205 MANAGEMENT OF THE AILING
F BLEB
The Failing bleb
It is caused by excessive fibroblastic proliferation
within 2 wks leading to scarring at the
conjunctival and episcleral interface.
It is important not to confuse early conjunctival
hyperaemia with a failing bleb (fig1).
Signs of a failing bleb (fig 2b and 3)
Increasing vascularity (corkscrew vessels) of
the conjunctival vessels
Loss of SC Microcysts
Increasing opacity of subconjunctival tissues
Decreased conjunctival mobility
Localising bleb
Increasing IOP
Eyes with corkscrew conjunctival vessels in the
first 2 weeks had significantly higher mean IOP,
than eyes without during the first postoperative
year after trabeculectomy with MMC.4
Figure 2- a. Early bleb appearance with mild
conjunctival vessel dilatation and underlying
scleral flap visible and b. a failing, localised bleb.
Figure 3. Bleb failure within first two
weeks after trabeculectomy. Note the
corkscrew conjunctival vessels.
Encapsulated Blebs(Encysted or Tenons Cyst)
They are probably caused by excessive collagen
synthesis within 2-4 weeks and characterized by a
high IOP, deep AC, a tense, elevated, thick walled
bleb with large vessels present over the bleb but
with intervening avascular areas and there are
very few or no microcysts in the wall.
Compression of subconjunctival tissues reduces
transconjunctival aqueous drainage. Male
gender is the only consistent risk factor for bleb
encapsulation. The reported frequency of
encapsulation is 15-30%.5
Figure 3. Examples of early bleb encapsulation.
The blebs failed in cases a. and b. The bleb is
partially encapsulated (arrows) in figure 3c.
Postoperative Management of the Bleb
Postoperative visits should be dictated by bleb
appearance IOP and risk factors for failure. Some
surgeons see the patients weekly for 6 weeks to
detect early bleb failure.
Medications after trabeculectomy
Topical steroids are mandatory. Prednisolone
acetate 1% every 1-2 hourly while awake for at
least 2 months. Taper when bleb is pale and thin.
Continue when bleb is thick and hyperemic. Be
mindful of steroid-induced IOP elevation. This
may be the case in eyes with diffuse functional
blebs and high IOP. Aqueous suppressants may
then be used till the steroids are withdrawn.
Cycloplegics are rarely needed with modern
trabeculectomy. Atropine or cyclopentolate may
be used to decrease ciliary spasm (pain) and/or
deepen anterior chamber . Broad-spectrum
topical

Antibiotics for 7-10 days is sufficient. Longer if
conjunctival edge leak.
Interventions in first postoperative week
Bleb massage may be done in the first few days if
IOP is high to promote aqueous flow and dislodge
any subscleral fibrin clot. Massage bleb through
lid or with glass rod/cotton swab. To do massage,
ask the patient to look down and apply firm and
steady digital pressure through the upper lid. In
many cases, with a tightly sutured scleral flap and
no sub-conjunctival flow, a bleb will form. The
practice of asking patients to do ocular digital
massage to promote aqueous flow and increase
chances of bleb survival is of doubtful efficacy.
Check carefully for conjunctival edge-leaks. If
persistent, may lead to bleb failure. Also withhold
all manipulations/ injections till leaks resolve or
sutured.
In cases of impeding failure, administer 5-FU
(5mg, 0.1 ml of 50mg/ml) into bleb.
One or two injections per week is probably
adequate.
Give as long as bleb requires (when bleb
vascular).
Hold back if side effects like corneal epithelial
toxicity.
Subconjunctival steroids like beta or
dexamethasone can also be given along with 5-FU
injections.
Subconjunctival Bevacizumab (1.25 2.5mg)
may be administered to decrease bleb vascularity.
Its role in inhibiting fibrosis at this stage is still
uncertain.
Laser suturolysis can be done in eyes where no
antimetabolite is used.
MANAGEMENT OF THE AILING
F BLEB 206
Interventions after the first week
Laser suturolysis or removable of scleral
adjustable/removal suture should be done by the
first 1-2 weeks if no antimetabolite used during
trabeculectomy. It may be delayed if MMC was
used. Use of releasable sutures has made slit lamp
removal easy using forceps under topical
anaesthesia.
Another option when non-releasable sutures are
applied is Argon laser suturolysis (200-300mW,
0.1-0.2s,50micron). A suturolysis lens (Hoskins,
Bluementhal, Mandelkorn ,Ritch etc.)is used to
blanch the conjunctiva and flatten the suture. This
allows focused laser delivery. One suture is
removed in one sitting to avoid precipitous fall in
IOP. The Blumenthal lens is probably the easiest
lens to use.
If MMC has been used avoid early suture
removal as it may lead to long-term hypotony.
Figure 4a. A localised bleb with corkscrew conjunctival
vesels at 2 weeks after phacotrab with MMC.
b. Argon suturolysis with the Blumenthal lens (inset) was
done in two sittings and IOP dropped from 30 to 5 mmHg.
c. The bleb at 2 months was diffuse, translucent, with
vascularity similar to surrounding conjunctiva
and IOP was 12mmHg.
If IOP still high despite massage and suture
removal, needle flap elevation can be
tried.(discussed with needle revision below).
Always administer SC 5-FU with this procedure
to minimize scarring. This procedure should be
used sparingly.
 207 MANAGEMENT OF THE AILING
F BLEB

In cases of early failure, gonioscopy is essential to

rule out internal obstruction. Rarely the iris or
vitreous (in combined phacotrab with
zonular/capsular breaks) may be obstructing the
sclerostomy. Various techniques are described in
the literature to remove the offending tissue.
These were described when trabeculectomy was
done in high-risk eyes (aphakic, disorganised
anterior segment etc.). Nowadays tube surgery is
more likely to be done in these eyes. It is probably Figure 6. Management of encapsulated blebs
better to surgically revise the trabeculectomy with
Needle Revision of Failing Blebs
iris excision, vitrectomy and MMC application
Needle Revision (NR) is a 'closed' surgical
and/or Bevacizumab application early if these
technique for rejuvenating failed or failing blebs.
manoeuvres fail.
Its main appeal is that it can be performed quickly,
and in an outpatient setting. However there are
many factors which need to be considered (figure)
before performing NR. If done indiscriminately
on every failing bleb the failure rate will be quite
high.

Figure5. Gonioscopy in 2 eyes with ECCE and

trabeculectomy. 5a.Vitreous and uveal tissue
are blocking the sclerostomy. 5b. The IOL haptic
is in the fibrosed internal sclerostomy.

Intensive postoperative management for

trabeculectomy (without MMC) as described
above may improve one-year success rates
compared to trabeculectomy with no
postoperative management.6
Figure 6. Some factors to
Management of Encapsulated Blebs consider before performing needle revision.
Management is conservative, frequent topical
steroid and aqueous suppressants. The role of
Timing
frequent digital massage is questionable as most
Early NR is also termed as 'Needle flap elevation'
will resolve spontaneously. Needle revision is best
or 'Needling'. Usually done in a tight scleral flap
avoided in the first 3 months after surgery. A
scenario, after other manipulations have failed.
randomised trial from Brazil showed no benefit of
Performed with a 29- or 25- gauge needle.
needle revision over medical management in
Procedure similar to that described for NR below.
encapsulated blebs.7;8
Under topical anaesthesia, the needle is inserted
 MANAGEMENT OF THE AILING
F BLEB 208

under the flap and the fibrotic adhesions are

broken by gentle lateral movements. If needling
is indicated in the first few weeks after surgery, it
implies that there is aggressive fibrosis and that
anterior subconjunctival filtration is unlikely to
be established. The literature has conflicting
Figure 7. A flat bleb with subscleral fibrosis,
results regarding timing of NR with at least one This is manifested internally by the absence of
report suggesting more failure with NR within 6 the subscleral cleft. In this case vitreous and uvea
are also blocking the internal sclerostomy.
months.9
Location Bleb Morphology
Needle Revision is probably best performed in Bleb morphology plays an important role in
the OT for reasons listed in table1. Apraclonidine deciding which blebs to needle. The most
1%, 5-10 minutes prior to NR decreases appropriate indication for NR is probably
conjunctival vascularity and improves blebs with subconjunctival fibrosis (raised,
visualization of subconjunctival tissues. discrete, non-inflamed). The surrounding
Table 1. conjunctiva is mobile and these can be easily
tested in an anaesthetized eye with a cotton bud.
On Slit Lamp In Operating Room
NR in eyes tight scleral flaps with subscleral
Quick, no waiting More Control
fibrosis has poor outcomes (fig 7).
Must be ambidextrous Better exposure
As mentioned earlier encapsulated blebs have a
Less exposure and control Sterile procedure
significant rate of recurrence and failure in the
Can check IOP to titrate the Less bleeding (apraclonidine 1%)
procedure long-term (fig 8).
Gonioscopy
Gonioscopy is done for two reasons
1. To rule out internal obstruction of sclerostomy
by iris or vitreous (figure 6a). This is rare as in
most cases there is an adequate iridectomy.
2. To look for a subscleral cleft . A patent
Figure 8. Recurrence of encapsulation
subscleral fistula and may be an important after needle revision and eventual failure of bleb.
favourable prognostic factor for needle revision.
A study with UBM has shown that only eyes with Antifibrotics (Wound-healing modifying
a patent sub-scleral tract (fig.7) were likely to agents)
have successful IOP control at 2 years after NR.10 5-Fluorouracil (Subconj 5mg )
Most commonly used antifibrotic agent.
Poor penetration of ocular tissues

Figure 6. Anterior segment OCT and
goniophotography showing the
subscleral route (cleft) for aqueous drainage.
Mitomycin C
Excellent penetration of ocular tissues and will
reach ciliary body with SC injection.
 209 MANAGEMENT OF THE AILING
F BLEB
Very narrow therapeutic index when injected
subconjunctivally. Subconj. MMC 0.001-0.002
11
mg is safest. The incidence of bleb vascularity
increases from 0% to 60% if dose of MMC is
increased from 0.001-2 mg to 0.004mg.
Wide variation in studies (0.004mg to 0.04mg).
Use lower doses (0.01ml of MMC 0.2mg/ml) to
avoid complications.
MMC can also be applied on the conjunctiva for
3-7 minutes before needle revision. Ensure that
it is washed away by 10-20ml saline before
NR.12;13
Anti-VEGFs (Bevacizumab)
No published results, one case report of a single
case. 14
Use in selected cases of low-risk eyes with late
bleb failure.
Bevacizumab 1.25-2.5 mg into bleb at end of
procedure.
Non-toxic, can be injected into anterior
chamber as well at end of any glaucoma
procedure
Timing ofAntimetabolite (AM) injection
Giving the injection before NR allows the
surgeon to administer a mixture of lignocaine and
AM, thereby decreasing pain and allowing for a
'deeper 'needling'. Also allows diffusion and
absorption of AM into subconj. tissues. When
AM is injected in bleb after NR, small amounts
may enter the in the AC. This is because of a lower
pressure in AC compared to subconjunctival
tissues. However, prior injection makes it
difficult to assess success due to conj. chemosis.
If giving AM injection after NR, ensure that it is
injected well away from bleb.
The Needle Revision Procedure- Tips (fig9)
Larger the gauge of needle used, more the
complications
Asses conjunctival mobility
Enter superior conjunctiva at least 10 mm
from limbus and make a tract subconjunctivally
to the region of fibrosis (long needle track)
Initially stabbing, 'to and fro' motion of
needle with multiple passes
Join these by moving needle sideways,
using the bevel to cut
If excessive subconjunctival bleeding,
abandon procedure
Always know where the needle is in
subconj/subscleral space
Entry into AC rarely needed
If blood tracks into anterior chamber
Ask patient to shut eyes tight if on slit lamp
AC washout, partial viscoelastic fill in OT
Cautery to site of needle entry is optional
Take your time!
Figure 9. The technique for needle revision
Management after Needle Revision
Treat as after trabeculectomy with Intensive
topical & SC steroids
Supplementary 5-FU injections may be given
depending on bleb appearance.
Supplementary MMC injections should be
avoided.
One study has suggested that repeated NR with
MMC 0.008 mg will improve success rates.15
However the mean interval between NRs was 5
months. Avoid needle revision at close intervals
and wait for the inflammation to settle.
 MANAGEMENT OF THE AILING
F BLEB 210

Regardless of criteria of success, technique or

Figure 10. 1. Postoperative management of NR. Needle
Revision+5FU , 2 weeks later IOP 7mmHg. 2. Month
later IOP 23 mmHg, topical steroids tapered. 3. Two
months later, IOP 19 mmHg, inflamed bleb. Two-hourly
prednisolone 1% started. 4. 3 Months after NR, IOP 20 mmHg ,
steroids tapered. 4. 6 months later, IOP 17 mmHg.
IOP crept over 22 mmHg at year 2 and topical beta
antimetabolite used, success rates of NR are
around 40-60% at 3-5 years.
In general MMC augmentation gives better
outcomes. There are two published studies on
comparative outcomes on NR with 5-FU and
MMC with conflicting results. The first
16;17

blockers commenced.
demonstrated significantly better early success
Outcomes of needle revision
with MMC.16 However both studies show that
There are many studies on NR outcomes in
after the first 3 months there is a steady and equal
literature but most are sort-term and of limited
rate of failure in both groups. This suggests
value.
wound-healing is never completely inhibited,
regardless ofAM used.
Table2. Some 5-FU needle revision studies with follow - ups of more than a year

Table3. MMC needle revision studies.

 211 MANAGEMENT OF THE AILING
F BLEB

Reference

1. Cantor LB, Mantravadi A, WuDunn D et al.

Morphologic classification of filtering blebs after glaucoma
filtration surgery: the Indiana Bleb Appearance Grading
Scale. J.Glaucoma. 2003;12:266-71.
2. Wells AP, Crowston JG, Marks J et al. A pilot
study of a system for grading of drainage blebs
after glaucoma surgery. J.Glaucoma. 2004;13:454-60.
3. Picht G, Grehn F. Classification of filtering blebs in
trabeculectomy: biomicroscopy and
functionality.Curr.Opin.Ophthalmol.1998;9:2-8.
4. Sacu S, Rainer G, Findl O et al. Correlation between the
early morphological appearance of filtering blebs and
outcome of trabeculectomy with mitomycin C. J.Glaucoma.
2003;12:430-5.
5. Schwartz AL, Van Veldhuisen PC, Gaasterland DE et al.
The Advanced Glaucoma Intervention Study (AGIS): 5.
Encapsulated bleb after initial trabeculectomy.
Am.J.Ophthalmol. 1999;127:8-19.
6. Marquardt D, Lieb WE, Grehn F. Intensified postoperative
Figure 12. Flow-chart for bleb management.
care versus conventional follow-up: a retrospective long
Reference term analysis of 177 trabeculectomies. Graefes
Arch.Clin.Exp.Ophthalmol. 2004;242:106-13.
1. Cantor LB, Mantravadi A, WuDunn D et al. 7. Costa VP, Correa MM, Kara-Jose N. Needling versus
Morphologic classification of filtering blebs after glaucoma medical treatment in encapsulated blebs. A randomized,
filtration surgery: the Indiana Bleb Appearance Grading prospective study. Ophthalmology. 1997;104:1215-20.
Scale. J.Glaucoma. 2003;12:266-71. 8. Costa VP, Arcieri ES, Freitas TG. Long-term intraocular
2. Wells AP, Crowston JG, Marks J et al. A pilot pressure control of eyes that developed encapsulated blebs
study of a system for grading of drainage blebs following trabeculectomy. Eye. 2006;20:304-8.
after glaucoma surgery. J.Glaucoma. 2004;13:454-60. 9. Mardelli PG, Lederer CM, Jr., Murray PL et al. Slit-lamp
3. Picht G, Grehn F. Classification of filtering blebs in needle revision of failed filtering blebs using mitomycin C.
trabeculectomy: biomicroscopy and Ophthalmology 1996;103:1946-55.
functionality.Curr.Opin.Ophthalmol.1998;9:2-8.
4. Sacu S, Rainer G, Findl O et al. Correlation between the
early morphological appearance of filtering blebs and
outcome of trabeculectomy with mitomycin C. J.Glaucoma.
2003;12:430-5.
5. Schwartz AL, Van Veldhuisen PC, Gaasterland DE et al.
The Advanced Glaucoma Intervention Study (AGIS): 5.
Encapsulated bleb after initial trabeculectomy.
Am.J.Ophthalmol. 1999;127:8-19.
6. Marquardt D, Lieb WE, Grehn F. Intensified postoperative
care versus conventional follow-up: a retrospective long
term analysis of 177 trabeculectomies. Graefes
Arch.Clin.Exp.Ophthalmol. 2004;242:106-13.
7. Costa VP, Correa MM, Kara-Jose N. Needling versus
medical treatment in encapsulated blebs. A randomized,
prospective study. Ophthalmology. 1997;104:1215-20.
8. Costa VP, Arcieri ES, Freitas TG. Long-term intraocular
pressure control of eyes that developed encapsulated blebs
following trabeculectomy. Eye. 2006;20:304-8.
9. Mardelli PG, Lederer CM, Jr., Murray PL et al. Slit-lamp
needle revision of failed filtering blebs using mitomycin C.
Ophthalmology 1996;103:1946-55.
 Bleb Associated Infections
Dr. Prashant Garg, Dr. G. Chandrashekhar
Introduction:
The aim of glaucoma surgery is to reduce the
intra-ocular pressure (IOP) in cases that are
refractory to treatment with medical therapy.
Since it was described in 1968 by Cairns
trabeculectomy has undergone multiple
medications, and is now generally considered to
be the gold standard for glaucoma surgery.
Glaucoma drainage devices (GDD) are
comparatively more recent, but are gaining in
popularity particularly in cases where the
conjunctiva is scarred and not in a healthy state.
While glaucoma filtering procedures are effective
in lowering IOP they are associated with
complications such as hypotony, at anterior
chamber and cataract. Another important
complication of glaucoma procedures with
ltering blebs is the risk of developing infection at
the site of the ltering bleb. Infections after
glaucoma filtering surgery are infrequent but
potentially devastating complications. Early
identification and appropriate management is
very crucial in salvaging eyes with these
complications. Therefore, all ophthalmologists
must be aware of risk factors, clinical signs and
primary management of these complications.
Glaucoma surgery and endophthalmitis
While the overall incidence of infection after
intraocular surgery is reported to be 0.05 to 0.19%
it is much higher after glaucoma filtering surgery
and is estimated to be 0.124 to 1.8% i.e. 10 times
higher. While the incidence of immediate
postoperative infection is estimated to be 0.124%,
the incidence of late infections with partial
thickness procedures is estimated to be 0.2 to
1.5%. Bleb-related infections are comprised of a
spectrum of conditions, which range from blebitis
212
to bleb related endophthalmitis.
Blebitis: The term blebitis first used by Brown et
al in 1994 describes a presumed infection in or
around the ltering bleb when there is
mucopurulent infiltrate in the bleb, and this may
be associated with mild to moderate anterior
chamber activity. Vitreous involvement is
characteristically absent in this disease and is the
key differentiating factor from endophthalmitis.
Bleb associated endophthalmitis (BAE): Bleb-
related endophthalmitis occurs when in addition,
there is vitreous involvement, often presenting
with hypopyon and severe visual loss.
It is important to bear in mind that bleb-related
infections including endophthalmitis can occur at
any time following surgery. Classically these are
classified as early onset bleb related infections
and late onset infections. Conventionally, the
infections developing within 1 month after the
surgery are categorized as acute or early-onset
while the one developing 1 month after the
surgery are catagorized as late-onset.
It is important to differentiate between an early
onset disease from late onset disease as these both
differ in terms of pathogenesis, causative agents
and prognosis.
Risk factors for bleb associated infections
The patients who are at increased risk of
developing bleb related infections are those:
having thin and cystic blebs
inferior or nasal blebs
presence of bleb leaks and
where antimetabolites such as mitomycin
have been used.
Other risk factors are: postoperative
complications, history of prior bleb infection, and
chronic use of antibiotics. In addition, young
 213 BLEB ASSOCIATED INFECTIONS
subjects, black race, subjects with axial myopia
and presence of systemic diseases such as
diabetes are also associated with increased risk of
infections.
If we look at the histopathology of blebs these are
comprised of thinned epithelium. The underlying
stroma is relatively avascular and has very little
inflammatory cells. All these changes are more
marked in blebs associated with use of anti-
metabolites.
Peter DeBry and associates estimated that 5 year
probability of developing bleb leaks and bleb
related infection in patients where anti-
metabolites have been used are 18% and 8%
respectively.
Although bleb leaks have been suggested as an
important risk factor in the development of bleb-
related infections, a clear causative relation
between them has not yet been established. It has
been questioned which comes rst, the bleb leak
or the infection.
Common organisms that cause bleb related
infections.
As for the etiology Staphylococcus epidermidis
(more common) or Staphylococcus aureus are the
commonest organisms to cause blebitis.
The most common causative organism associated
with early-onset BAE is Staphylococcus
epidermidis similar to that of acute
endophthalmitis after cataract surgery.
In contrast the most common organisms causing
late onset endophthalmitis belongs to
Streptococcal species and H influenze.
Clinical presentations of patients with bleb
related infections.
Typically the patients of blebitis and BAE report
sudden onset of red eye followed by eye pain,
photophobia, discharge, and decreased
vision. Many of these patients have prodromal
features such as brow ache, headache or external
eye infections. The prodrome is longer in blebitis
while in endophthalmitis it is usually accelerated,
with sometimes only a several hour history of
rapidly worsening ocular pain, visual acuity, and
redness. On clinical examination you will notice
localized conjunctival injection associated with
milky content of bleb, loss of translucency and
mild to moderate anterior chamber reaction. In
bleb associated endophthalmitis in addition to
these features you will notice inflammatory cells
in vitreous cavity.
Managing blebitis
It is very important to examine these patients as
soon as possible probably within an hour.
Perform a thorough clinical examination
including dilated fundus examination to rule out
endophthalmitis. Frequent instillation of
appropriate antimicrobial therapy is the
management of choice. Start treatment with an
antibiotic that has broad spectrum of activity
specially against gram positive organisms. In
addition to the spectrum of microorganism
coverage other considerations in choosing the
most appropriate antibiotics are: better kill
kinetics and higher intraocular penetration on
topical administration.
Fourth generation fluoroquinolones such as
moxifloxacin 0.5%, gatifloxacin 0.5% or
basifloxacin 0.6% offer all these advantages and
can be used in the treatment of blebitis. In severe
blebitis cases it is better to use combination of
fortified drops viz fortified cefazolin 5.0% and
fortified vancomycin.
The drugs must be administered every half to one
hour to quickly attain therapeutic concentration.
To ensure compliance to therapy and close
monitoring it will be useful to admit

these patients and evaluate periodically.
Subconjunctival injection of antibiotics or
systemic therapy is usually not necessary except
probably in cases where either the condition is
severe or/and the compliance to topical therapy is
questionable.
Additional therapy is given in the form of
cycloplegic agents and analgesics.
The intensive therapy should be continued for 48
to 72 hours. Response to therapy will be evident
by improvement in symptoms, reduction of
congestion, and reduction in anterior chamber
reaction. Once there is response to initial therapy
the frequency of antibiotics instillation can be
reduced to 2 hourly administrations.
Do not taper antibiotics and do not use it on a
chronic basis as both results in colonization of
ocular surface by resistant microorganisms.
Microbiology work-up either in the form of
conjunctival swab or anterior chamber tap is not
necessary except for the research purpose.
The therapy should not be delayed in these cases
even if you do not have microbiology facility or
awaiting results of microbiology work-up.
Managing bleb associated endophthalmitis
Once you have identified involvement of vitreous
refer the case to a center with vitreo-retina surgery
facility and expertise to handle these cases. As a
comprehensive ophthalmologist you must explain
the patient the need for emergency management.
In the mean time start treatment described in the
management of blebitis along with systemic
therapy with one of fluoroquinolones.
One must remember that management pearls of
EVS study after cataract surgery cannot be applied
to patients of endophthalmitis after glaucoma
surgery especially late onset disease.
It is important to subject all these patients to pars
plana vitrectomy rather than relying on vitreous
BLEB ASSOCIATED INFECTIONS 214
tap and injection of antibiotics. Subconjunctival
antibiotic injections near the bleb site are also
recommended to dry the source of infection.
Busbee et al clearly showed that percentage of
eyes with no light perception was much higher in
tap group compared to vitrectomy group.
After PPV continue treatment with frequent
instillation of fortified antibiotic solutions
covering both gram positive and negative
organisms till microbiology results are available.
In addition systemic antibiotics must be used.
Once the infection is brought under control
reevaluate these patients to identify avoidable risk
factors. All patients with bleb leak must be
subjected to bleb repair.
Patient education
This is very important in early diagnosis. All
patients of glaucoma filtering surgery must be
clearly explained about the warning signals viz
brow ache, headache, associated light sensitivity
and decrease of vision. These patients must be
asked to report to ophthalmologists immediately
without any delay. Fig - 1
Over hanging cystic bleb with likelihood of infection
Fig - 2
Wound Leak
215 BLEB ASSOCIATED INFECTIONS

Fig - 3 References:

1. Prasad N, Latina MA. Blebitis and endophthalmitis after

glaucoma filtering surgery. Int Ophthalmol Clin 2007
Spring;47:85-97.
2. Mac I, Soltau JB. Glaucoma-filtering bleb infections. Curr
Opin Ophthalmol 2003, 14:9194.
3. Busbee BG. Update on treatment strategies for bleb-associated
Endophthalmitis. Curr Opin Ophthalmol 2005;16:170174.
4. Reynolds AC, Skuta GL, Monlux R, Johnson J. Management
of blebitis by members of the American glaucoma society: A
s u r v e y. J o u r n a l o f G l a u c o m a 2 0 0 1 ; 1 0 : 3 4 0 3 4 7 .
Blebitis 5. Brown RH, Yang LH, Walker SD, et al. Treatment of bleb
infection after glaucoma surgery. Arch Ophthalmol
1994;112:5761.
6. Ciulla TA, Beck AD, Topping TM, et al. Blebitis,
earlyendophthalmitis, and late endophthalmitis after
Fig - 4
g l a u c o m a - f i l t e r i n g s u r g e r y. O p h t h a l m o l o g y
1997;104:986995.
7. DeBry PW, Perkins TW, Heatley G, Kaufman P, Brumback
LC. Incidence of late-onset bleb-related complications
following trabeculectomy with Mitomycin. Arch Ophthalmol.
2002;120:297-300.
8. Lehmann OJ, Bunce C, Matheson MM, et al. Risk factors for
development of post-trabeculectomy endophthalmitis. Br J
Ophthalmol 2000;84;1349-1353.
9. Busbee BG, Recchia FM, Kaiser R, et al. Bleb-associated
endophthalmitis - Clinical characteristics and visual outcomes.
Ophthalmology 2004;111:14951503
10. Ramakrishnan R, Bharathi MJ, Maheshwari D, et al. Etiology
and epidemiological analysis of glaucoma-filtering bleb
infections in a tertiary eye care hospital in South India. Indian J
Bleb Associated Endophthalmitis Ophthalmol 2011;59:445-53.
 Glaucoma Drainage Devices
Dr. Julie Foreman, Dr. Ramesh S Ayyala
Introduction
Glaucoma drainage devices (GDD) create
alternate aqueous pathways by channeling
aqueous from the anterior chamber through a long
tube to an equatorial plate that promotes bleb
formation. Glaucoma drainage devices are being
used more frequently in the treatment of glaucoma
that is unresponsive to medications or
trabeculectomy operations. In certain
conditions, like neovascular glaucoma, ICE
syndrome, penetrating keratoplasty with
glaucoma, glaucoma following retinal
detachment surgery, etc., it is becoming the
primary operation.
Below is a review of the indications, surgical
techniques, complications and management of
complications, and ways to improve the success
of the Ahmed Glaucoma Valve. The techniques
and methods presented are from my personal
experience having worked with the Ahmed
Glaucoma drainage device for several years.
Indications
The most common indications for using the
Ahmed Glaucoma drainage devices include
neovascular glaucoma (NVG), uveitic glaucoma,
penetrating keratoplasty with glaucoma,
iridocorneal endothelial syndrome, traumatic
glaucoma with hyphema and failed
trabeculectomy or canaloplasty, and other
conditions where in glaucoma follows ocular
s u rg e r y ( s u c h a p e r i p h e r a l p e n e t r a t i n g
keratoplasty, retinal detachment repair with
silicone oil, or scleral buckle). Its use is becoming
increasingly common in children for treatment of
congenital glaucoma after previous surgeries have
failed. Because of its valve-like mechanism, it is a
useful alternative to trabeculectomy in
216
patients sustaining trauma with resulting acute
hyphema and elevated intraocular pressure.
The most common indication that we see the
Ahmed Glaucoma Valve used in our practice, as a
referral glaucoma based service, is in patients
with open angle glaucoma status post failed
trabeculectomy.
The Venturi Effect ofAhmed glaucoma valve
To reduce internal friction within the valve
system, the Ahmed Glaucoma Valve (AGV)
utilizes a specially designed, tapered trapezoidal
chamber to create a Venturi effect to help aqueous
flow through the device. As demonstrated by
Bernoulli's equation of hydrodynamic principle,
the inlet velocity of aqueous entering the larger
port of the Venturi chamber increases
significantly as it exits the smaller outlet port of
the tapered chamber. In an AGV this increased
exit velocity greatly helps in evacuating aqueous
from the valve, thereby helping to reduce valve
friction.
Surgical Techniques
The quadrant of the eye chosen for tube
implantation should be selected carefully.
Previous surgeries performed on the eye in the
area of proposed drainage device implantation
may have lead to conjunctival scarring and scleral
thinning making conjunctival dissection and
implantation of the device difficult. The ideal
location for placement of the device is the
superotemporal location approximately 8-10 mm
from the limbus. However, others have placed
the device superonasally, inferonasally, and
inferotemporally. I prefer the superotemporal
location. In my experience the other locations
 217 GLAUCOMA DRAINAGE DEVICES
lead to a higher rate of post-operative diplopia
and tube erosion, especially when placed
inferiorly. The placement and securing of the
AGV to the sclera are important, and certain key
steps in the procedure must be maintained
consistently to impart the highest chance of
success for the procedure. Below are my steps in
implanting theAGV.
Ahmed Glaucoma Valve Implantation
Surgical technique
1. 7-0 Vicryl corneal traction stay suture is placed
through 12 o' clock limbus to help rotate the eye
inferiorly and expose the superior conjunctiva
adequately.
2. Creation of a small limbal peritomy at 12
o'clock with Westcott scissors
3. Sub-Tenons' injection of 50:50 preservative-
free (1%) lidocaine- (1: 10,000) epinephrine
injection into the quadrant of surgery. Injection of
this mixture achieves multiple objectives:
anesthesia, dissection of the sub-Tenons' tissue in
a non-traumatic fashion, and prevention/control
of bleeding to some degree. The mixture can be
injected posteriorly into the muscle cone to
achieve more anesthesia as needed.
4. Further dissection with Westcott scissors
followed by wet-field cautery
5. The Ahmed valve is then primed with balanced
salt solution using a 30 gauge cannula. I like to
prime it once followed by slow injection to make
sure that BSS drops are able to escape out of the
valve even at very low pressure.
6. The end-plate is inserted into the sub-Tenons'
pocket and secured to the sclera 8-10 mm
posterior to the limbus. Care should be taken to
avoid touching the valve mechanism or the plate
itself with instruments as this may lead to more
fibrosis in the capsule following surgery and
failure of the valve mechanism
(red zone in Fig 1).
Placement of the plate too far posteriorly
(especially in a small eye or on the nasal side) will
lead to potential damage to the optic nerve from
the end plate touching/pressing on the nerve
( Fig 2).
7. 23 gauge needle is used to make an entry into
the anterior chamber. The needle should enter the
AC 0.75 mm posterior to the limbus. Care should
be taken to enter into the AC is through the
trabecular meshwork so as to position the tube on
the surface of the iris and away from the cornea.
8. If the patient is pseudophakic, the tube can be
placed in the sulcus to avoid possible tube-
corneal touch. This is achieved by entering the
sclera 1 mm posterior to the limbus in such a way
that the 23 guage needle enters the AC under the
iris in the sulcus. Make sure that the needle is
posterior to the iris and anterior to the IOL.
Following the withdrawal of the needle, inject
Viscoelastic through the needle tract to balloon
the iris anteriorly and displace the IOL/capsular
bag posteriorly. This will facilitate placement of

the tube into the sulcus. I prefer to see the tip of the
tube in the pupillary area.
9. The tube is then implanted into the eye by
passing the tube through the needle tract in the
sclera. This could be tricky sometimes. The tube
should be held close to the tip with a fairly heavy
forceps and advanced through the scleral needle
tract with a second forceps (by feeding the tube
between the two forceps).
10. Placement of the scleral patch graft and
closure of the conjunctiva is achieved using 10.0
nylon suture. If conjunctiva is fibrosed one can
perform relaxing incisions ( Fig 3)
to mobilize the conjunctiva and pull it down to the
limbus. I trim the patch graft prior to securing it to
the sclera and remove fibrous tissue on the surface
of the graft to ensure a low profile of the graft and
improved cosmesis.
Postoperative Care
Postoperative care consists of topical application
of antibiotics, cyclopentolate 1% and non-
steroidal anti-inflammatory (Acular/Nevanac)
drops (four times/day) for one week and steroids 8
times a day with gradual tapering over a 4 to 8
week period with regular follow up visits.
Combined Cataract Surgery with AGV
implantation
The question also arises as whether to perform
GDD implantation at the time of cataract
extraction. At the time of surgery, some surgeons
prefer to implant the GDD into the sub-Tenon's
GLAUCOMA DRAINAGE DEVICES 218
pocket and secure it to the sclera, before
performing the cataract surgery. My personal
preference would be to perform the cataract
surgery through a clear cornea temporal incision
followed by the GDD implantation. There are
several pearls that I have learned through my
experience when combining cataract and GDD
placement as listed below:
Cataract surgery- Surgical Pearls
1. Temporal limbal/corneal incision is the
preferred incision.
2. Pupil: Small pupil/ synechial attachments to the
lens capsule are usually seen in patients with
glaucoma either due to drops (pilocarpine) or
because of the underlying conditions (uveitis,
neovascular glaucoma or trauma). Floppy iris
syndrome is very frequently seen in these
situations. I prefer to inject 0.1 cc of preservative-
free lidociane 1% mixed with 1: 10,000
preservative-free epinephrine (mixed 50:50) via
the paracentesis site. This mixture provides the
required anesthesia for pupil manipulation, helps
to dilate the pupil, and stabilize the iris in case of
floppy iris syndrome. This is followed by the
injection of 0.1 cc of viscoelastic (avoid high
molecular weight viscoelastics). Next,
synechiolysis is performed using a viscoelastic
cannula. Pupil stretching in patients with
underlying diseases such uveitis or neovascular
glaucoma should be done in an atraumatic
fashion. I prefer to use 2 pupil-stretching forceps
(color buttons) to dilate the pupil to approximately
7 mm. Re-injection of viscoelastic will stabilize
the iris and maintain the dilated pupil size.
3. 6 mm capsulorhexis is the preferred size to
allow for proper positioning of the IOL inside the
bag and prevent the IOL from forward
displacement and pupillary capture, in the event
the patient develops hypotony and/or choroidal
effusions following glaucoma surgery.
 219 GLAUCOMA DRAINAGE DEVICES
4. Following the implantation of the IOL (after
cataract extraction) leave the viscoelastic in the
AC to maintain the IOP to proceed with the GDD
surgery. Also, the retained viscoelastic will help
prevent immediate postoperative hypotony.
5. Always, close the cataract incision site with a
10-0 Nylon suture at the end of the surgery and
ensure the wound is water tight.
6. Intra-cameral injection of decadron (0.1 cc) at
the end of the case helps in preventing
postoperative inflammation. Intra-vitreal
Kenalog (0.1 cc) is also useful in patients with
both uveitis.
7. In patients with uveitis with glaucoma and
cataracts, a GDD with smaller surface area (such
as the pediatric Ahmed valve) is advisable to
prevent post-operative hypotony.
8. Patients with NVG and cataract, intra-vitreal
injection of Avastin is advised at the time of
surgery or 1-2 days pre-operatively, as these
patients have a tendency to bleed (seek the retinal
surgeons advice).
Complications in the immediate post-operative
period
1. Choridal effusions and shallowing of the
anterior chamber.
Cycloplegics can be used to deepen the anterior
chamber. Topical and oral steroids also help to
reduce the choroidal effusion. I typically use
topical steroid drops 8 times/day and oral
prednisolne 20 mg once a day for 7 days and 10
mg once day for 7 days. Anterior chamber
reformation with high molecular weight visco-
elastic (Healon GV or Healon 5) should be
considered in cases with flat chambers from over
filtration or those with very shallow chambers
with significant choroidal effusions. Choroidal
effusion drainage should be considered in cases
with kissing choroidal effusions or choroidals
persisting despite a previous course of
cycloplegics and steroids.
2. Hyphema
Hyphema can be seen in some patients, especially,
in patients with NVG. Usually, the hyphema will
resolve without any additional measures.
Anterior chamber washout should be considered
in patients with total hyphema with tube blockage
and elevated IOP. Intracameral injection of tissue
plasminogen activator (TPA) (12.5 micrograms)
can also be considered in cases with tube
obstruction with hyphema or fibrin.
3. Suprachoriadal hemorrhage
Hemorrhage should be suspected in patients with
severe ocular pain, shallow anterior chamber,
moderate to elevated IOP and choroidal effusion
with a dark appearance. B-scan will help in
making the diagnosis. Small to moderate size
hemorrhages can be treated conservatively with
oral steroids, pain medications, topical steroids,
and cycloplegic agents. Moderate to severe
suprachoroidal hemorrhages need to be drained
10-14 days after the occurring event.
4. Anterior dislocation of the intraocular lens with
pupillary capture:
This is typically seen in patients with hypotony,
shallow chambers and choriodal effusions. The
IOL can be repositioned into the bag by injecting
viscoelastic into the anterior chamber and gentle
manipulation of the IOL with a viscoleastic
cannula. This can be performed either at the slit
lamp or in the main operating room depending on
the patient's and surgeon's comfort level.
5. Endophthalmitis
Infection should be suspected in patients with
pain, conjunctival injection, cell and flare in the
anterior chamber, and vitritis. This should be
recognized immediately and treated promptly
with the help of a retina surgeon.

Complications in the late post-operative period
1.Tube or plate erosion
Tube erosion may present as a complication in
the postoperative period (Fig 4).
Most commonly it presents insidious in onset
and noted on clinical exam. The patient may
also present with complaints of foreign body
sensation and a red eye. In the setting of tube
erosion, surgical repair should be undertaken as
soon as possible and frequent administration of
antibiotic
drops should be begun.
The location of the erosion is very important in
surgical planning.
Plate erosions are hard to fix and the AGV is best
removed and a new AGV placed in a different
location.
Tube erosion can generally be repaired. The
technique involves mobilization of the
conjunctiva on either side of the erosion using
sub-conjunctival injection of the previously
mentioned lidocaineepinephrine mixture. The
tube itself is washed with antibiotic-BSS solution.
It then is covered by a scleral patch graft which is
secured to the surrounding sclera. The mobilized
conjunctiva is pulled over the scleral patch graft
and secured to the limbus using 10.0 nylon suture.
Conjunctival relaxing incisions are performed as
needed.
GLAUCOMA DRAINAGE DEVICES 220
2. Diplopia
Diplopia is usually related to the height of the
bleb. The risk of diplopia can be minimized by
choosing the correct size implant to match the
orbital size and by choosing the right location. My
preferred location is the superotemporal quadrant.
If the GDD is to be placed superonasally due to
any reason, such as scarring from previous
surgery, I use a pediatric Ahmed valve in this
location due to space requirements. The decision
of which size of Ahmed device (Adult or
pediatric) should be tailored to reduce the
incidence of diplopia. Patients with deep-set eyes
and those with tight orbits are at a higher risk of
developing diplopia if an adult size device is used.
One should also avoid placing the adult device in
the inferior quadrants (esp. inferior temporal)
because of poor cosmesis and increased risk of
diplopia. If diplopia should develop despite the
above precautions, the patient should be managed
on a case-by-case basis with the aid of a
strabismus specialist. Generally, one should try to
reduce the height of the bleb by needling with
MMC injection (0.1 cc at 0.4mg/cc) followed a
week later by digital massage. This procedure can
be repeated to obtain the correct size bleb. Freznel
prisms can be some help. If the patient still
complaints of intractable diplopia, either removal
of the AGV or muscle surgery in cases where IOP
control is critical should be performed.
3. Tube retraction
The key to managing tube retraction is prevention.
Tubes that are cut too short at the time of surgery
have a higher likelihood of retraction leading to
further complications post-operatively. The
method that I use to ensure adequate tube
placement and length intra-operatively is to place
the tube over the cornea and cut with Wescott
scissors to create a large bevel at the end of the
tube. The adequate tube length is when the tip of
 221 GLAUCOMA DRAINAGE DEVICES
the tube reaches the pupillary border in this
position. Another scenerio that can lead to tube
retraction occurs when the tube is cut when the eye
is soft. When the eye returns to physiologic
pressure, the tube will appear to have retracted
from its original position. Typically this can
happen when the tube is in the way of performing
penetrating keratoplasty or cataract surgery.
Special attention should paid to avoid excessive
cutting of the tube in an eye that is soft as the tube
protrudes more into the anterior chamber when
the pressure is low or when the globe is open, as in
penetrating keratoplasty surgery.
If tube retraction occurs despite careful planning,
a tube extender can be placed and the tube
reinserted into theAC in the preferred position.
Using the Tube Extender
The tube extender can be obtained from New
World Medical (the manufacturers of the Ahmed
glaucoma valve). The surgery technique is as
follows. Following limbal peritomy and
conjunctival dissection, the tube is identified and
freed from scar tissue from the limbus to bleb-
plate intersection. The tube is removed from the
anterior chamber and a small amount of
Viscoleastic is injected into the AC. Note Do not
disturb the bleb itself. The tube extender is then
brought to the operation site. I prefer to trim its
wings off completely and use just the tube. The
wings make the device bulky and difficult to fit in
the limited space available. The anterior portion of
the tube extender is then trimmed to extend 1 mm
anterior to the limbus and inserted into the anterior
chamber. The posterior end of the tube is then
threaded into the tube of the AGV. The tube
extender is then secured to the surrounding
episclera with a mattress suture (10-nylon) and
then covered with a scleral patch graft. This is
followed by conjunctival closure to the limbus.
Note: Instead of the tube extender from the
company, one can potentially use a 22 gauge
AngioCath tubing. It is made of the same
material as the tube extender. It attached to the
original tube and cut to the intended length. The
tube/Angiocath junction can be secured to the
sclera with 10.0 prolene in a figure-of-eight
fashion.
Hypertensive phase
The hypertensive phase commonly occurs 1-2
months after GDD implantation as the capsule is
beginning to form around the drainage plate.
The intraocular pressure shows a slow steady
rise as more collagen is laid down around the
plate. It is my experience that this phase is best
treated at its earliest sign with aqueous
suppressants such as timolol/dorzolamide drops
twice a day with frequent digital massage. The
goal is to lower the pressure in order to decrease
the amount of collagen produced. Collagen
begets more collagen on exposure to high IOP.
Some people believe that the aqueous in patients
with glaucoma and high pressure contains
increased cytokines that stimulate more
collagen. What ever the cause may be, starting
aqueous suppressants as soon as the IOP
increase beyond 18 mm Hg decreases the risk of
hypertensive phase. If the hypertensive phase
fails to respond the topical aqueous suppressants
and digital massage, and bleb encapsulation is
apparent on clinical exam, bleb needling with
0.1ml of Mitomycin C (0.4 ml) can be performed
at the slit lamp ( Fig 5).

If needling fails, the IOP continues to rise, and a
thick encapsulated bleb impedes aqueous flow.
The patient may be taken back to the operating
room for blebectomy and partial removal of the
thick, fibrous bleb with MMC application at the
time of surgery.
Needling of the bleb Surgical technique
The eye is anesthetized using topical lidocaine
drops followed by Betadine prep. A lid speculum
is then placed in the eye, and the patient positioned
at the slit lamp. A tuberculin syringe pre-loaded
with 0.01 ml Mitomycin C (MMC, 0.4mg/cc) on a
30 gauge, inch needle is then used to gently
enter the bleb from the nasal side. The bleb is
punctured in multiple locations using to and fro
motions of the needle. In successful cases, this is
followed immediately with enlargement of the
bleb. The needle is then withdrawn, followed by
cautery to the needle entry point.
Bleb Encapsulation with failure
The failure rate of the valves is 10%/year. The
main reason for failure is bleb encapsulation. This
means that the bleb wall becomes too thick and
compact to let aqueous escape into the sub
conjunctival space to access the blood vessels.
Treatment options include topical aqueous
suppressants, digital massage and needling with
MMC. In cases that do not respond the
encapsulated bleb can surgically excised. Some
patients may need multiple drainage devices to
adequately control IOP over their lifetime (Fig 6)
GLAUCOMA DRAINAGE DEVICES 222
Blebectomy with MMC
Blebectomy is performed in the following
fashion: the eye is rotated inferiorly with the help
of a 7-0 Vicryl (Ethicon) suture. Limbal peritomy
is performed followed by sub-Tenon's injection of
preservative free lidocaine 1% mixed 50:50 with
preservative free epinephrine (1:1000) to dissect
the conjunctiva from the underlying
encapsulation and to control bleeding. Further
dissection is completed with the help of Westcott
scissors. The conjunctiva is reflected posteriorly
to expose the roof of the encapsulated bleb( Fig 7).
The bleb roof is then dissected using a 15 degree
sharp blade. Care is taken not to cut the silicone
plate or disturb the valve mechanism. The edges
Fig.7
of the bleb wall are cauterized. Once the roof of
the bleb is excised, the valve mechanism is
examined. In some cases, a tongue of fibrous
tissue from the roof is found to invade the valve,
leading to its failure. Once this tissue is carefully
removed, aqueous is usually seen seeping of the
valve mechanism. Once the valve mechanism is
confirmed to be properly functioning, a Weck-
cell sponge soaked in MMC (0.4/mg/cc) for 40
seconds is placed on the cut edges of the bleb and
then draped with the overlying conjunctiva. Once
the sponge is removed, the conjunctiva is replaced
and secured back to the limbus using 10-0 vicryl
(Alcon). Postoperative medications after
 223 GLAUCOMA DRAINAGE DEVICES
blebectomy include topical corticosteroids and
topical antibiotics. Antiglaucoma medications are
used as needed along with digital massage.
AGV Blebectomy combined with Baerveldt
glaucoma implant:
Due to the 50-60% incidence of bleb re-
encapsulation following blebectomy, I have
started performing the Baerveldt glaucoma valve
placement in the inferior nasal quadrant along
with Ahmed glaucoma implant blebectomies . I
perform these procedures in eyes who cannot
tolerate a pressure spike should the bleb re-
encapsulate after a blebectomy. I first place the
Baerveldt glaucoma implant under a scleral flap
and donor scleral patch graft in the inferonasal
quadrant as described earlier. I ligate my
Baerveldt glaucoma implants with a 7.0 Vicryl
suture and use the same suture to make 3 slits in
the silicone tube under the half thickness scleral
flap. After completing the Baerveldt placement
with conjunctival closure similar to the Ahmed
valve placement described earlier, I then perform
the blebectomy of the Ahmed valve implant. I
have found that this technique helps to avoid the
immediate elevated IOP post-operatively while
waiting for the capsule to form and the 7.0 vicryl
ligature to loosen. It also avoids the immediate
drop in pressure as the 7.0 vicryl opens up around
4-6 weeks post-operatively. I have had much
success with this technique and avoided most of
the complications generally associated with the
Baerveldt glaucoma implant.
Corneal decompensation and glaucoma
drainage devices
Corneal decompensation appears to be one of the
main complications following glaucoma
drainage device surgery. It has been reported in
up to 30% of the patients with long-term follow
up. Graft failure from decompensation or
rejection in patients with penetrating
keratoplasty and glaucoma following glaucoma
drainage device surgery has been reported in the
range of 10%-51%. The etiology of corneal
decompensation and graft failure is probably
multifactorial. Care should be taken to place the
tube as far as possible away from the corneal
endothelium to ensure preserved endothelial
functioning. A sulcus placed tube is helpful in
pseudophakic eyes. In those cases that result in
significant corneal decompensation, a DSAEK
can be performed.
Tips to improve success in selected cases
1) Modification in the presence of scleral
buckle and silicone oil
Frequently, patients will have had prior retinal
surgery and subsequent elevated of intraocular
pressure. Patient with silicone oil posteriorly may
present as a dilemma in valve placement. In the
presence of silicone oil, some physicians place the
valve inferiorly due to the belief that silicone oil
may wander into the anterior chamber and clog the
tube due to it's propensity/buoyancy to drift
superiorly. However, I find that the tube can still
be placed in the superotemporal quadrant if the
tube is positioned horizontally and left long rather
than vertical. This decreases the risk of clogging
of the tube by silicone oil if the oil should happen
to migrate into the anterior chamber.
The presence of a scleral buckle may make
placement of the Ahmed valve more difficult. The
valve can be secured to the buckle using 9.0
Prolene (Ethicon). In cases where there is not
enough space to implant the end plate, the end
plate can be resized by cutting with Wescott
scissors (avoiding the creation of sharp edges) .
The valve mechanism is left intact and positioned
in the quadrant of choice in the usual manner.
 GLAUCOMA DRAINAGE DEVICES 224

2) Uveitic glaucoma
Uveitic glaucoma often presents with elevated
intraocular pressure but there may be hypotony
following surgical intervention due to ciliary body
shutdown. I find that the best approach in these
situations is to choose a pediatric Ahmed valve
(Model FP8) with intravitreal injection of
Kenalog at the time of surgery. This tactic helps to
avoid flat chambers and choroidals following
surgical intervention and the steroid injection
helps combat any post operative inflammation
that may be present.
3) Tube issues when performing PKP and DSAEK
The presence of chronic angle closure glaucoma
with 360 degree PAS and shallow anterior
chamber depth, uveitis, and the presence of
multiple Ahmed Glaucoma Valves are each
associated with a higher risk of graft failure in
patients undergoing DSAEK in the presence of
glaucoma valves. Placing the tube in the
graft over the flap and tube. I find this method
provides better protection against erosion of the
tube in this susceptible area.
Refrence
1. Ayyala RS, Zurakowski D, Smith J, Monshizadeh R, Netland
PA, Richards DW, Layden WE. A clinical study of the Ahmed
glaucoma valve implant. Ophthalmology 1998; 105:1968
1976.
2. Ayyala RS, Harman LE, Stevens SX, Margo CE, Michelini
Norris MB, Ondrovic LE. Comparison of different
biomaterials for the glaucoma drainage devices. Arch
Ophthalmol 1999; 117:233-236.
3. Ayyala RS, Margo CE, Michelini-Norris MB. Comparison of
different biomaterials for the glaucoma drainage devices: Part
4. Arch Ophthalmol 2000; 118:1081-1084.
5. Ayyala RS. Penetrating keratoplasty and glaucoma. Surv
Ophthalmol 2000; 45:91-105.
6. Ayyala RS, Layden WE, Slonim CB, Margo CE. Anatomic and
histopathologic findings following a failed Ahmed glaucoma
valve device. Ophthalmic Surg Lasers 2001; 32:248-249.
7. Hong CH, Arosemena A, Zurakowski D, Ayyala RS. Glaucoma
drainage devices: A systematic literature review and current
controversies. Surv Ophthalmol 2005;48-60.
8. Ayyala RS, Parma SE, Karcioglu ZA. Optic nerve changes
following posterior insertion of glaucoma drainage device in a
rabbit model. J Glaucoma 2004;13:145-148.
9. Hinkle DM , Zurakowski D, Ayyala RS. A comparison of the
polypropylene plate AhmedTM glaucoma valve to the silicone
plate AhmedTM glaucoma flexible valve Eur J Ophthalmol
2007;17(5)696-701.

sulcus, away from the cornea, in my opinion helps

to avoid possible corneal decompensation due to
tube-corneal touch and allow the circulating
nutrients in the aqueous to perfuse the corneal
endothelium without being whisked away by the
tube.

Scleral patch graft vs scleral flap vs pericardial

flap
The choice between which technique to use is
purely surgeon's preference. I choose to use a
scleral patch graft to cover the tube at the limbus.
I secure the graft to the sclera using 10.0 Nylon
sutures and then trim the excess patch graft as
needed. For my inferiorly placed valves, I modify
the technique by using a 15 degree blade to make a
partial thickness scleral flap. I then insert the tube
under the flap and secure the flap to the globe
using 10.0 nylon sutures. I then use a donor
scleral patch graft and secure the scleral patch
 225 GLAUCOMA DRAINAGE DEVICES

Ex-PRESS GLAUCOMA FILTRATION DEVICE IN GLAUCOMA SURGERY
Dr. Manish Shah

All current surgical approaches to control IOP,
aim at creating a passage to divert aqueous from
the anterior chamber into the subconjunctival
space. The success of the procedure is determined
complications including hypotony, erosion of the
conjunctiva over the device and other adverse
effects To avoid these problems Dahan and
(2-7).

by the amount of aqueous drainage this passage Carmichael suggested implantation of the EX-
provides on a long term basis. The surgical PRESS device under a scleral flap.
procedure generally tends to fail due to scar
formation in the passage which tends to close the
passage down either totally or partially, and as
amount of drainage provided is inadequate the
IOP begins to rise. In other situations there can be
excessive drainage of aqueous resulting in very
low IOP and the resultant complications.
The EX-PRESS Glaucoma Filtration Device is
a non-valved MRI compatible device which is
now available with approval of the US FDA to be
used for glaucoma surgery. It is made of medical
grade stainless steel and 3 mm in length. The
currently available model P-50 ( inner diameter 50
micron and outer diameter 400 microns), consists
of a metal tube with one end having a beveled
axial tip and this is designed to remain in the Surgical Technique
anterior chamber. The other end has a flange The studies done till date use the technique
(Faceplate) and this is designed to be implanted described by Dahan and Carmichael. A partial
below a partial thickness scleral flap. The central thickness scleral flap with dimensions 4 X 4 mm
beveled end has side opening ( Relief port) as is used, the minimum dimensions should be 2.5 X
well to act as alternative drainage access in case 2.5 mm to completely cover the faceplate of the
the opening at the tip were to be occluded. There is device. Anti-fibrotic agents such as 5 FU and
a spur on the other side of the relief opening, Mitomycin C may be used in a fashion similar to
which serves to lock the device in place on that used for trabeculectomy. The EX-PRESS
implantation, and prevents extrusion. The distal device is inserted into a pre-incision made by a
faceplate end has a groove in the flange, which 25G needle for the P 50 model in the limbal zone
maintains a subscleral patent passage for aqueous at the Blue Line where the clear cornea transits to
drainage. grey. The direction of entry is parallel to the iris.
The biocompatibility of the device was tested in The device is inserted with the spur directed
rabbits and found to be satisfactory. The initial sideways and turned 90 degrees to direct the spur
clinical trials were done by implanting the device posteriorly. Once in place the device is released
subconjunctivaly to drain the aqueous directly from the inserter by pressing a button and remains
from the anterior chamber to the subconjunctival in place. The faceplate should to flush with the
space. This however had a high rate of

sclera. The scleral flap is sutured with 10/0 Nylon
sutures with optional releasable sutures. The
conjunctival flap may be limbus based or fornix
based as per the surgeons preference. Post-
operative care is similar to that provided for
standard trabeculetomy.
Discussion
The EX-PRESS Glaucoma Filtration Device
has been a promising development in the field of
glaucoma surgery. A large series of 345 patients
were evaluated and reported 2009. This series was
divided into 231 receiving the EX-PRESS alone
and 114 eyes receiving EX-PRESS beneath
scleral flap with phacoemulsification. Surgical
success at 3 years was found to be 94.8% and
95.6% respectively. The reduction of intra-ocular
pressure from baseline and the reduction in
number of medications was significant in both
groups. The reduction in intra-ocular pressure was
more significant in the group receiving the EX-
PRESS alone, in this series(9).
Good and Kahook have recently reported further
benefits of the EX-PRESS with a retrospective
study comparing consecutive results of EX-
PRESS implantation versus trabeculectomy.
This report included 35 patients in each of two
arms of the study, and both showed similar
number of successes. The follow up period was 28
months. The unqualified success was 77.14% in
the EX-PRESS group and 74.29% in the
trabeculectomy group. Long term bleb
morphology was comparable. One interesting
finding was the post-operative vision recovery
between the two groups. Patients in the EX-
PRESS group tended to regain visual acuity in
one week whereas the trabeculectomy group
achieved this at closer to one month. Post-
operative visits were lesser in the EX-PRESS
group versus the trabeculectomy group.
GLAUCOMA DRAINAGE DEVICES 226
Complications
Commonest complications reported in both
prospective and retrospective randomized studies
were hyptony and choroidal effusions in the early
postoperative periods. Martis et al reported
hypotony in 4% of the EX-PRESS group versus
32% in the trabeculectomy group and choroidal
effusions in 8% of EX-PRESS group versus
38% in the trabeculectomy group. Leo et al have
reported similar figures for hypotony in both
groups.
None of the studies have reported erosion of sclera
or conjunctiva overlying the implant in the
subscleral implantation technique as was often
reported with the earlier technique.
Other observations include hyphaema, bleb
encapsulation, endophthalmitis, and iris touch.
These were infrequent.
Conclusion
The EX-PRESS Glaucoma Filteration Device
provides and alternative to standard
trabeculectomy for primary open angle glaucoma
with some advantages such as earlier visual
rehabilitation, lower incidence of hypotony and
choroidal effusions. Whether it is able to provide
better long term success remains to be seen with
studies with longer follow up.
 227 GLAUCOMA DRAINAGE DEVICES

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