Abstract
Trabeculectomy with an antimetabolite is considered the “gold standard” for the surgical management of glaucoma. The concept of the operation is to lower the IOP by creation of a fistula between the anterior chamber of the eye and the sub-Tenon and subconjunctival space, so that the aqueous humor is finally collected into the episcleral and conjunctival veins.
The bleb surgical site is in the upper globe, preferably under the upper eyelid in order to reduce infections or bleb leakage. No scleral flap size or shape has been proven to be superior.
The desired size of the ostium should be more then 40–50 mm in diameter, because below that size, significant resistance to the physiological aqueous outflow can still remain.
A fornix-based conjunctival incision is preferred over the limbal-based fashion due to lower postoperative complications. The outcome of filtration surgery is improved by the use of antimetabolites, mainly 5-fluorouracil and mitomycin-C. Their main action is inhibition of the fibroblast proliferation and activity, thus achieving higher success rates, lower IOP, and fewer glaucoma medications.
Unfortunately, these adjunctive agents increase the risk of vision-threatening complications.
The nylon suture is preferred to suture the sclera flap and conjunctiva because of its low tendency to create anti-inflammatory response.
Thorough postop treatment and follow-up are mandatory to a successful outcome, mainly to keep the fistula open and to prevent the formation of the conjunctival “ring of steel.”
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References
Sugar HS. “Experimental trabeculectomy.” Am. J. Ophthalmol. 1961;51:623.
Cairns JE. Trabeculectomy. Preliminary report of a new method. Am J Ophthalmol. 1968;66(4):673–9.
Pablo LE, Perez-Olivan S, Ferreras A, et al. Contact versus peribulbar anaesthesia in trabeculectomy: a prospective randomized clinical study. Acta Ophthalmol Scand. 2003;81:486–90.
Carrillo MM, Buys YM, Faingold D, Trope GE. Prospective study comparing lidocaine 2% jelly versus sub-Tenon’s anaesthesia for trabeculectomy surgery. Br J Ophthalmol. 2004;88:1004–7.
Edmunds B, Bunce CV, Thompson JR, et al. Factors associated with success in first-time trabeculectomy for patients at low risk of failure with chronic open angle glaucoma. Ophthalmology. 2004;111:97–103.
Edmunds B, Thompson JR, Salmon JF, Wormald RP. The National Survey of Trabeculectomy. III. Early and late complications. Eye. 2002;16:297–303.
Hu CY, Matsuo H, Tomita G, et al. Clinical characteristics and leakage of functioning blebs after trabeculectomy with mitomycin-C in primary glaucoma patients. Ophthalmology. 2003;110:345–52.
Wells AP, Cordeiro MF, Bunce C, Khaw PT. Cystic bleb formation and related complications in limbus-versus fornix-based conjunctival flaps in pediatric and young adult trabeculectomy with mitomycin C. Ophthalmology. 2003;110:2192–7.
Kohl DA, Walton DS. Limbus-based versus fornix-based conjunctival flaps in trabeculectomy: 2005 update. Int Ophthalmol Clin. 2005;45(4):107–13.
Agbeja AM, Dutton GN. Conjunctival incisions for trabeculectomy and their relationship to the type of bleb formation: a preliminary study. Eye. 1987;1:738–43.
Henderson HW, Ezra E, Murdoch IE. Early postoperative trabeculectomy leakage: incidence, time course, severity, and impact on surgical outcome. Br J Ophthalmol. 2004;88:626–9.
Jones E, Clarke J, Khaw PT. Recent advances in trabeculectomy technique. Curr Opin Ophthalmol. 2005;16(2):107–13.
Ng PW, Yeung BY, Yick DW, Tsang CW, Lam DS. Fornix-based trabeculectomy using the ‘anchoring’ corneal suture technique. Clin Experiment Ophthalmol. 2003;31(2):133–7.
Levkovitch-verbin H, Goldenfeld M, Melamed S. Fornix-based trabeculectomy with mitomycin-C. Ophthalmic Surg Lasers. 1997;28(10):818–22.
Negi AK, Kiel AW, Vernon SA. Does the site of filtration influence the medium to long term intraocular pressure control following microtrabeculectomy in low risk eyes? Br J Ophthalmol. 2004;88:1008–11.
Chang L, Crowston JG, Cordeiro MF, et al. The role of the immune system in conjunctival wound healing after glaucoma surgery. Surv Ophthalmol. 2000;45:49–68.
Das J, Sharma P, Chaudhuri Z. A comparative study of small incision trabeculectomy avoiding Tenon’s capsule vis-a-vis trabeculectomy with mitomycin-C. Indian J Ophthalmol. 2004;52:23–7.
AGFID Project Team. Experimental flow studies in glaucoma drainage device development. Br J Ophthalmol. 2001;85:1231–6.
Wells AP, Bunce C, Khaw PT. Flap and suture manipulation after trabeculectomy with adjustable sutures: titration of flow and intraocular pressure in guarded filtration surgery. J Glaucoma. 2004;13:400–6.
Melamed S, Ashkenagi I, Glorinski J, Blumenthal M. Tight scleral flap trabeculectomy with post operative laser suture lysis. Am J Ophthalmol. 1990;109:303–9.
Aykan U, Bilge AH, Akin T, Certel I, Bayer A. Laser suture lysis or releasable sutures after trabeculectomy. J Glaucoma. 2007;16(2):240–5.
Schaffer RN, Hetherington J, Hoskins HD. Guarded thermal sclerostomy. Am J Ophthalmol. 1971;72:769–72.
Kolker AE, Kass MA, Rait JL. Trabeculectomy with releasable sutures. Arch Ophthalmol. 1994;112:62–6.
Raina UK, Tuli D. Trabeculectomy With releasable sutures a prospective, randomized pilot study. Arch Ophthalmol. 1998;116:1288–93.
Heuer DK, Parrish II RK, Gressel MG, Hodapp E, et al. 5-Fluorouracil and glaucoma filtering surgery, II: a pilot study. Ophthalmology. 1984;91:384–94.
Chen CW. Enhanced intraocular pressure controlling effectiveness of trabeculectomy by local application of mitomycin C. Trans Asia Pac Acad Ophthalmol. 1983;9:172.
European Glaucoma Society. Terminology and guidelines for glaucoma. 2nd ed. Savona: DOGMA; 2003.
Rothman RF, Liebmann JM, Ritch R. Low-dose 5-fluorouracil trabeculectomy as initial surgery in uncomplicated glaucoma: long-term followup. Ophthalmology. 2000;107:1184–90.
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(3):297–300.
Membrey WL, Poinoosawmy DP, Bunce C, Hitchings RA. Glaucoma surgery with or without adjunctive antiproliferatives in normal tension glaucoma: 1 intraocular pressure control and complications. Br J Ophthalmol. 2000;84:586–90.
Singh K. Trabeculectomy with intraoperative mitomycin C versus 5-fluorouracil prospective randomized clinical trial. Ophthalmology. 2000;107(12):2305–9.
Suzuki R, Dickens CJ, Iwach AG, et al. Long-term follow-up of initially successful trabeculectomy with 5-fluorouracil injections. Ophthalmology. 2002;109:1921–4.
Khaw PT, Jones E, Mireskandari K, et al. Modulating wound healing after glaucoma surgery. Glaucoma Today. 2004, July/Aug: 12–19.
Khaw PT. Advances in glaucoma surgery: evolution of antimetabolite adjunctive therapy. J Glaucoma. 2001;10(5 Suppl 1):S81–4.
El Sayyad F, Belmekki M, Helal M, et al. Simultaneous subconjunctival and subscleral mitomycin C application in trabeculectomy. Ophthalmology. 2000;107:298–301.
Batterbury M, Tebbs CA, Rhodes JM, Grierson I. Agaricus bisporus (edible mushroom lectin) inhibits ocular fibroblast proliferation and collagen lattice contraction. Exp Eye Res. 2002;74:361–70.
Saika S, Yamanaka O, Okada Y, et al. Pentoxifylline and pentifylline inhibit proliferation of human Tenon’s capsule fibroblasts and production of type-I collagen and laminin in vitro. Ophthalmic Res. 1996;28:165–70.
Mead AL, Wong TT, Cordeiro MF, et al. Evaluation of anti-TGF-beta2 antibody as a new postoperative anti-scarring agent in glaucoma surgery. Invest Ophthalmol Vis Sci. 2003;44:3394–401.
Wong TT, Mead AL, Khaw PT. Matrix metalloproteinase inhibition modulates postoperative scarring after experimental glaucoma filtration surgery. Invest Ophthalmol Vis Sci. 2003;44:1097–103.
Shingleton BJ, Chaudhry IM, O’Donoghue MW. Phacotrabeculectomy: peripheral iridectomy or no peripheral iridectomy? J Cataract Refract Surg. 2002;28(6):998–1002.
Baudouin C, Pisella PJ, Fillacier K, et al. Ocular surface inflammatory changes induced by topical antiglaucoma drugs: human and animal studies. Ophthalmology. 1999;106:556–63.
Vote B, Fuller JR, Bevin TH, Molteno AC. Systemic anti-inflammatory fibrosis suppression in threatened trabeculectomy failure. Clin Exp Ophthalmol. 2004;32:81–6.
Traverso CE, Greenidge KC, Spaeth GL, et al. Focal pressure: a new method to encourage filtration after trabeculectomy. Ophthalmic Surg. 1984;15:62.
Khaw PT, Sherwood MB, Doyle JW, et al. Intraoperative and post operative treatment with 5-fluorouracil and mitomycin-c: long term effects in vivo on subconjunctival and scleral fibroblasts. Int Ophthalmol. 1992;16:381–5.
Hoffman RS, Fine IH, Packer M. Stabilization of flat anterior chamber after trabeculectomy with Healon5. J Cataract Refract Surg. 2002;28(4):712–14.
Savage JA, Condon GP, Lytle RA, et al. Laser suture lysis after trabeculectomy. Ophthalmology. 1988;95:1631–8.
Salmon JF, Kanski J. Trabeculectomy. In: Salmon JF, Kanski J, editors. Glaucoma: a colour manual of diagnosis and treatment. 3rd ed. London: Elsevier, Butterworth- Heinemann; 2004. p. 139–50.
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Cotlear, D., Melamed, S. (2014). Incisional Therapies: Trabeculectomy Surgery. In: Samples, J., Schacknow, P. (eds) Clinical Glaucoma Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-4172-4_26
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