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    Aios Glaucoma SX

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    This document discusses current ideas about glaucoma treatment. It notes that lowering intraocular pressure is the primary way to halt progression of glaucoma based on evidence from clinical trials. While medications are often used as primary treatment, surgery may be better able to lower pressure more consistently and effectively. The document argues that in developing countries like India, where poverty is widespread and access to care is limited, primary surgery may be more practical compared to long-term medication management, given challenges with adherence and follow-up. It also notes that angle-closure glaucoma, which is more aggressive and accounts for nearly half of glaucoma cases in India, further supports considering primary surgery in the local context.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Aios Glaucoma SX

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    subah
    41 views79 pages
    This document discusses current ideas about glaucoma treatment. It notes that lowering intraocular pressure is the primary way to halt progression of glaucoma based on evidence from clinical trials. While medications are often used as primary treatment, surgery may be better able to lower pressure more consistently and effectively. The document argues that in developing countries like India, where poverty is widespread and access to care is limited, primary surgery may be more practical compared to long-term medication management, given challenges with adherence and follow-up. It also notes that angle-closure glaucoma, which is more aggressive and accounts for nearly half of glaucoma cases in India, further supports considering primary surgery in the local context.

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    step by step description of glaucoma surgery for all the new glaucoma specialist

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    AIOS GLAUCOMA SX

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    This document discusses current ideas about glaucoma treatment. It notes that lowering intraocular pressure is the primary way to halt progression of glaucoma based on evidence from clinical trials. While medications are often used as primary treatment, surgery may be better able to lower pressure more consistently and effectively. The document argues that in developing countries like India, where poverty is widespread and access to care is limited, primary surgery may be more practical compared to long-term medication management, given challenges with adherence and follow-up. It also notes that angle-closure glaucoma, which is more aggressive and accounts for nearly half of glaucoma cases in India, further supports considering primary surgery in the local context.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    41 views79 pages

    Aios Glaucoma SX

    Uploaded by

    subah
    This document discusses current ideas about glaucoma treatment. It notes that lowering intraocular pressure is the primary way to halt progression of glaucoma based on evidence from clinical trials. While medications are often used as primary treatment, surgery may be better able to lower pressure more consistently and effectively. The document argues that in developing countries like India, where poverty is widespread and access to care is limited, primary surgery may be more practical compared to long-term medication management, given challenges with adherence and follow-up. It also notes that angle-closure glaucoma, which is more aggressive and accounts for nearly half of glaucoma cases in India, further supports considering primary surgery in the local context.

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    of 79

    CME SERIES (No.

    14)

    Step by Step
    Glaucoma Surgery

    Kirti Singh MD, DNB, FRCS(E)


    Professor, Guru Nanak Eye Centre,
    Maulana Azad Medical College, New Delhi
    email: [email protected]

    Rajinder Khanna MS
    Khanna Eye Clinic, Model Town, New Delhi

    ALL INDIA OPHTHALMOLOGICAL SOCIETY

    (i)
    This CME Material has been supported by the
    funds of the AIOS, but the views expressed therein
    do not reflect the official opinion of the AIOS.

    (As part of the CME Programme)

    For any suggestion, please write to:


    Prof. Rajvardhan Azad
    Hony. General Secretary

    Published by:
    ALL INDIA OPHTHALMOLOGICAL SOCIETY
    Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
    All India Institute of Medical Sciences,
    Ansari Nagar, New Delhi-110029
    Ph.: 011-26593187 Fax: 011-26588919
    email:[email protected]

    Society’s Secretariat Phone: 011-26588327, Email: [email protected]

    (ii)
    Contents

    n Current ideas about glaucoma treatment ....................1

    n Trabeculectomy – How to perform? ........................... 9

    n Combined Surgery. .................................................... 45

    n Non-penetrating Glaucoma Surgery ....................... 61

    (iii)
    Office Bearers
    of the
    All India Ophthalmological Society
    President Dr. Taraprasad Das
    President Elect Dr. K.P.S. Malik
    Vice President Dr. Babu Rajendran
    Hony. Gen Secretary Dr. Rajvardhan Azad
    Joint Secretary Dr. Harbansh Lal
    Hony. Treasurer Dr. Lalit Verma
    Joint. Treasurer Debnath Chattopadhyay
    Editor-Journal Dr. Barun Kumar Nayak
    Editor-Proceedings Dr. Debasish Bhattacharyya
    Chairman Scientific Committee Dr. S. Natarajan
    Chairman ARC Dr Rajinder Khanna
    Immediate Past-President Dr. R. B. Jain

    (iv)
    Foreword

    Dear Colleagues,
    The fast changing scenario of ocular therapy is keeping our fraternity on
    their toes in order to keep abreast. In addition today's patient is more informed
    and demanding. This coupled with the grueling routine grind of clinical
    load, leaves the surgeons with more need yet less time to update their skills.
    The CME booklets initiated by the All India Ophthalmic Society are a step
    taken to fulfill this need by providing well researched material detailing one
    clinical aspect of Ophthalmology. The reading material is concise and
    comprehensive. This issue is also following the tradition of previous CME
    series in dealing with germane issues, which in this issue is that of glaucoma
    surgery.
    Swamped as we are with a multitude of glaucoma medications we tend
    to forget that we are surgeons. In order to impart the best to our patients, we
    need to upgrade our surgical skills in glaucoma. This booklet by dealing
    with three commonly performed glaucoma filtering surgeries seeks to answer
    basic queries, provide in depth knowledge of various steps of surgery and
    analyses the different ways of performing the same. We sincerely hope that
    this booklet befriends your bookshelf, and serves as a ready reckoner.
    We take this opportunity to thank Dr. R. B. Jain, Dr. K. P. S. Malik, Prof. N.
    N. Sood, Prof. H.K. Tewari, Prof. Rajvardhan Azad , Dr. J. C. Das, Prof B.
    Ghosh, Prof Usha Yadav and Dr. B. N. Khanna for their support. We also
    thank the staff of Computype media for their painstaking help in printing.
    Above all thanks to our patients who have contributed to make this book a
    reality.
    Rajender Khanna
    Kirti Singh

    (v)
    Dedication

    We dedicate this book to our mothers

    Parkash Kaur

    and

    Padma Khanna

    You shaped our bodies, moulded our minds and nour-


    ished our souls. The Spirit of Service which we serve will-
    ingly is but a pale reflection of the supreme spirit of Love
    and Service, which is personified in you dear Mother.

    (vi)
    Section I

    Current ideas about glaucoma treatment

    Glaucoma is a progressive disease entity which comprises of specific


    visual field changes corresponding to a characteristic pattern of optic nerve
    head atrophy, which are intraocular pressure sensitive. This progressive
    disorder may be halted, if not reversed with appropriate medical and surgi-
    cal therapy.
    Globally it is the second most common cause of blindness after cataract.
    It accounts for 7-8 million bilaterally blind people.1,2,3 It has been estimated
    that 60.5 million people world wide will be affected by glaucoma by 2010
    and 79.6 million by 2020.4 Asians are likely to represent 47% of their pro-
    jected glaucoma morbidity. About 4.5 million people with open angle glau-
    coma (OAG) and 3.9 million people with angle closure glaucoma (ACG) may
    succumb to glaucoma induced bilateral blindness by 2010, this figure is
    likely to cross 5.9 and 5.3 million mark, respectively, by 2020.4 Glaucoma is
    responsible for 8-12 % of blindness ,5 and 11.4% of low vision morbidity in
    India . 6
    Evidence from several randomized controlled clinical trials has conclu-
    sively established the beneficial effect of lowering of intraocular pressure in
    halting the progression of the disease. 7-9 A frenzy of research over the last
    two decades has identified intraocular pressure as the only factor which we
    can currently modulate to halt the progression of this relentless disease.
    What are the modalities available for IOP control?
    The modalities to regulate IOP are – medical, laser assisted therapy and/
    or filtering surgeries. Currently a vast choice of effective anti glaucoma drugs
    are available. The role of laser trabeculoplasty and glaucoma surgery as a
    primary option has declined by 50-60%, since these glaucoma drugs, par-
    ticularly prostaglandins analogues came into the market. 10, 11 Yet,
    trabeculectomy or other glaucoma filtration surgeries hold an edge over the
    medical options in lowering the intraocular pressure more effectively and
    consistently.12-14

    1
    The current evidence from large multicentric trials like Collaborative
    Initial Glaucoma Treatment study (CIGTS) and Advanced Glaucoma Inter-
    vention study (AGIS) suggest that whereas mild disease could be stabilized
    with mid to high teens of intraocular pressure, a lower IOP in the low teens
    is required to stabilize moderate to advanced glaucoma.12 The benefit of
    maintaining a more optimal control of IOP (around 6- 8 mm Hg lower), and
    a better diurnal control provided by surgery, more than compensates for the
    patient discomfort and risk of cataract progression, which it entails. 14, 15
    Glaucoma filtering surgeries therefore, appear to be the primary option for
    advanced glaucoma where the aim is to achieve a consistently low intraocu-
    lar pressure while medical management is used for the other subgroups.
    This current standard of care has been derived from global trials predomi-
    nantly from developed countries.
    These recommendations of global trials could be interpreted to justify
    primary surgery for any severity of glaucoma in the resource constrained
    developing world context. 16, 17
    Let us clarify and justify this viewpoint by highlighting some facts :
    n Nearly 260 million Indian population (35%) falls below the interna-
    tional poverty line (lower than US 1$ per day). This limits their ability to
    bear the cost of prolonged, regular antiglaucoma medications. 18, 19
    n About 82% of blindness in our country stems from the 74.3% population
    – living in the rural areas – for whom medical facilities are neither easily
    available, nor affordable due to high prevalence of poverty. 20
    n Most ophthalmologists in India (70%) are located in the urban areas and
    cater to only 23% of it’s population. 21, 22 This obviously leads to a mis-
    match in the patient – provider ratio in the rural areas; forcing these
    poorer sections of society to travel long distances for ophthalmic care. 18
    This can be a major hurdle in adherence to therapy and monitoring
    glaucoma drug therapy. 23
    In such a setting, where as Rotchford so succinctly puts it, only “one
    shot” at the patient is allowed, surgical intervention as the primary treat-
    ment modality may be a more realistic option . 1, 18
    Another factor, in favor of primary surgical option in our country, is the
    high prevalence of angle closure glaucoma. (Table 1).24-30 PACG comprising
    almost half,30-33 of all Indian glaucoma is a more relentlessly progressive and
    unforgiving type of glaucoma compared to its gentler POAG cousin. 1, 34 To
    compound this further, angle closure glaucoma more commonly afflicts fe-
    males and people from lower socioeconomic strata, the subgroups with ex-
    tremely limited access to medical care. In addition the more silent, and ag-
    gressive chronic angle closure is the commonest subtype (87%) found amongst
    PACG cases.27, 29, 31 This subtype is so silent and relentless that almost 42-

    2
    Table1. Prevalence of Glaucoma in India
    Mean Age POAG PACG
    Vijaya L, Chennai (Rural population)25,26 >40 yrs 1.62% 1.58%
    Ramakrishnan R (Rural population – Aravind >40 yrs 1.7% 0.5%
    Comprehensive Eye Survey)27
    Jacob A, (Urban population – Vellore Eye Study)28 30-60 yrs 0.41% 4.3%
    Dandona L (Urban population –Andhra Pradesh
    Eye Disease Survey)29, 30 >30 yrs 1.6% 0.7%
    Dandona L (Urban population –Andhra Pradesh
    Eye Disease Survey)29, 30 >40 yrs 2.6% 1.1%

    53% patients present with advanced glaucoma and blindness in one or both
    eyes at the point of first contact.30, 32 In most of these patients, the trabecular
    meshwork synechial closure has crept past the stage where a simple iridec-
    tomy would suffice to halt the disease. This crippling glaucoma warrants a
    trabeculectomy. This is supported by a study, from North India, which
    showed that laser iridotomy with or without medi-
    cations could only control IOP in 30 % of chronic
    ACG eyes.31 A similar study from Singapore, a coun- Glaucoma acounts for
    try where ACG is rampant, has conclusively estab- 12% of blindnes, and
    11.4% of low vision in
    lished the inadequacy of a laser iridotomy alone to
    Indian subcontinent.
    control IOP. 35 Nearly 62% of their patients who were
    on medical therapy after laser iridotomy, subse-
    quently needed a filtering surgery after a mean time period of 7-18 months. In
    the Indian scenario expecting the patients to come for regular monitoring,
    after 6-12 months of having had a laser procedure performed, would be too
    optimistic.
    So why prefer Surgery?
    The aim in glaucoma management is to achieve the lowest possible IOP
    without affecting quality of life. The following points suggest that medical
    therapy may improve the IOP, but not necessarily provide a good quality of
    life for glaucoma patients:
    A. Drug problems
    n Glaucoma medications are often cumbersome to put in the eye by the
    elderly cohort of glaucoma patients.
    n Ocular discomfort ranging from stinging, redness, irritation and dry
    eyes are ubiquitous side effects of medications.
    n Drug preservatives increase expression of HLA DR on conjunctival epi-
    thelial cells, thereby leading to subclinical inflammation.36

    3
    n The systemic side effects of the commonly used glaucoma drugs are very
    significant e.g. two drops of 0.5% Timolol are equivalent to a 10 mg oral
    dose. This can precipitate bronchial asthma in about 4-7 % of the at risk,
    elderly population. 37
    n Currently the most commonly used medication in our country are still
    Beta blockers. However over half of patients on β blockers would have
    changed their medication, would be using an additional drug or would
    undergo trabeculectomy after a 5 year period - this reflects the long term
    loss of effect of these drugs 38
    B. Compliance
    Successful treatment needs good adherence to the drugs by the patient.
    n Studies from developed world, have reported that if more than two anti
    glaucoma drugs are prescribed, almost 25-51% patients forget to instill
    their drugs for more than twice a week. 39, 40, 41 and may miss doses for
    periods ranging between 85-165 days in an year. 39
    n Apart from forgetfulness, need for a continued treatment for life in spite
    of lack of improvement in their vision does not motivate most patients. 1
    n In India compliance would be further dented by poverty, illiteracy and
    ignorance.
    C. Impact of intraocular pressure fluctuation
    Diurnal swings in intraocular pressure has been documented as the
    singular most significant risk factor for glaucoma progression by various
    authors, irrespective of the degree of increase in intraocular pressure, glau-
    coma severity, race or sex.42 Trabeculectomy causes a less turbulent IOP
    wave form than the peaks and troughs seen with medical control. 15, 43
    Is Surgery the panacea?
    The surgical option is however not without drawbacks, namely::
    A. Complications of surgery: The inherent risk of complications, surgeon
    related factors; variation in patients’ healing and inflammatory response;
    risk of sepsis take the sheen off surgery as the best option.
    Endophthalmitis, the most dreaded complication, has been reported in
    0.2-1.5% cases.44, 45,46 The use of antifibrotics like MMC or 5 FU further
    increases this risk to 1.3-3%.45-48
    Hypotonic maculopathy, bleb leaks, choroidal detachments, and cata-
    ract progression are the other dangers of surgical options. 49-51 AGIS and
    CIGTS collaborative studies have conclusively shown a threefold in-
    crease in rate of cataract progression post trabeculectomy. 52-54

    4
    B. Trabeculectomy is not uniformly effective: In a survey conducted by the
    National Health Service (NHS) in United Kingdom (UK), only 84% pa-
    tients achieved target IOP post surgery and of these too, almost all (92%)
    required additional medications to achieve this target.55
    C. The limited life span of functioning trabeculectomy bars it as being
    offered as an alternative for all. The waning effect with time, has been
    reiterated by numerous authors.51, 56, 57, 58 Chen et al reported that the
    benefit of a functioning trabeculectomy declined from 100% at 1 year, to
    82% at 5 years and 67% after 10 - 15 years. 56 Other long term follow up
    studies over 4-10 years reported similar waning of control and almost
    71-80% of these initially successful trabeculectomies required additional
    pharmacological treatment.51, 57, 58
    What does one conclude?
    Although trabeculectomy appears as the better option for the masses in
    Indian scenario, it is not the final solution. No matter what treatment option
    one offers to the glaucoma patient, constant follow up and monitoring has to
    be emphasized. Remember, a lasting cure for glaucoma is yet to be discov-
    ered.
    Key Messages
    Ø In mild to moderate glaucoma, where compliance, affordability of drugs
    and follow up can be ensured, medical management is preferred as the
    primary treatment. In offering treatment to the have nots of the society ,
    trabeculectomy even with its complications, risk of causing cataract ,
    and waning effect will still offer a better chance of preventing irreversible
    blindness.
    Ø For advanced glaucoma the choice again has to be individualized.
    Trabeculectomy would lead to a more consistent and better IOP control.
    This may need to be combined with cataract extraction in some. A trial of
    medical treatment with more potent – though expensive – prostaglandin
    analogues may be done in appropriate situations (an adherent, affording
    patient).

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    56. Chen TC, Wilensky JT, Viana MA. Long term follow up of initially successful
    trabeculectomy. Ophthalmology 1997, 104: 1120-5.
    57. Pojda SM, Herba E, Zatorska B, Pojda-Wilczek D, Rycerska A, Plech A,Jedrzejewski
    W. [The long-term follow up after trabeculectomy] Klin Oczna. 2001; 103 (4-6):
    161-4.
    58. Ehrnrooth P, Lehto I, Puska P, Laatikainen L Long-term outcome of trabeculectomy
    in terms of intraocular pressure. Acta Ophthalmol Scand. 2002 Jun; 80(3): 267-71.

    8
    Section II
    Trabeculectomy – How to perform?

    Any glaucoma filtering surgery aims at creating a bypass channel at the


    limbus, cirumventing the dysfunctional trabecular meshwork, and redirect-
    ing the aqueous into the subconjunctival space. Trabeculectomy is the com-
    monest glaucoma surgery performed and the current chapter will discuss
    the steps of this surgery.
    HOW TO PREPARE THE PATIENT ?
    Ø It is advisable to withdraw Pilocarpine, at least 2-3 weeks prior to
    surgery.1 Pilocarpine increases permeability of the blood aqueous
    barrier, thereby increasing post operative inflammation which in
    turn may hasten bleb failure. It also causes irreversible miois, so if a
    combined cataract glaucoma surgery is planned, the pupil will not
    dilate on the table.
    Ø Ideally, Prostaglandin group of drugs must also be stopped, as they
    can aggravate surgically induced inflammation. Pre-operatively,
    nonsteroidal drugs like Flurbiprofen or Diclofenac drops have been
    advocated by some to reduce the inflammation induced by iris ma-
    nipulation, but we do not subscribe to this belief. One school of
    thought advocates discontinuing β blockers several days prior to
    surgery so that post operative aqueous flow is sufficient to form and
    maintain a functional bleb.2 However, this may not be always feasi-
    ble.
    Ø The eye is prepared as for any intra-ocular surgery with Povidone
    Iodine lid scrubs, and topical broad spectrum antibiotics started 3
    days prior to the trabeculectomy.
    Ø We routinely prescribe Acetazolamide tablets three times a day/ or
    long acting Acetazolamide once a day, even in those patients whose
    pressures are controlled on topical drugs a day before the surgery is
    scheduled except in those for whom this drug is contraindicated e.g.
    sulpha allergy. This is done to ensure a soft eye on the day of sur-
    gery.

    9
    Ø Sedatives like Diazepam are given on the night before surgery, but
    avoid it’s use on the day of the surgery unless the patient is very
    anxious.
    Ø Intravenous Mannitol 20%, in the dose of 1-1.5gm/kg body weight,
    is given at least 30 minutes before the block. For an adult patient,
    this invariably translates into a full bottle of 350ml. The use of
    hyperosmotics controls the IOP and an eye with controlled IOP is
    less vulnerable to sudden decompression, snuff out, or expulsive
    haemorrhage. In angle closure patients, it allows the lens to fall
    back, and permits a deeper chamber for instrument manipulation.
    In patients with compromised renal function or with cardiac dis-
    ease, Mannitol is avoided. Avoid giving the patient water after Man-
    nitol and always ensure he/she passes urine before shifting to the
    theatre.
    What consent to take?
    This is very important for a sight threatening condition like glaucoma.
    Patients must be clearly explained the risk and benefits of the surgery, in the
    language they understand. They must be told that a “glaucoma surgery will
    only at best preserve their vision and at no time improve it“. The use of
    colloquial term “Motia” for both cataract and glaucoma is very confusing for
    the patient. This is also often responsible for the delay in seeking treatment
    for glaucoma-induced drop in vision, in the mistaken belief that it is cataract
    (Safed Motia).
    The patient must be warned about the possibility of a drop of about 1
    line of corrected visual acuity after trabeculectomy.1, 3 They should also be
    explained that glaucoma surgery will hasten the progression of cataract and
    rarely they may have loss of vision (snuff out phenomenon), in case of ad-
    vanced visual field defects.
    What type of anaesthesia to employ ?
    Patients with advanced visual field compromise are given a lesser vol-
    ume of the peribulbar injection. The intra-ocular pressure spike induced by
    the sheer volume of the local anaesthetic injection can wreak havoc on the
    compromised optic nerve head circulation. Avoid using epinephrine in the
    injection, since it can cause vasoconstriction of the small vessels supplying
    the already compromised optic nerve head.4 Retrobulbar injections are un-
    necessary. Peribulbar or sometimes subtenon injections are sufficient to per-
    form a trabeculectomy. General anaesthesia is only required for children or
    in cases with extensive scarring which would necessitate a prolonged dis-
    section. The use of retrobulbar or peribulbar injection has been documented
    to increase the IOP by 20 mm Hg in 10% eyes, and by 10 mm Hg in 35% of
    glaucomatous eyes.5 So it is best to lower the IOP before giving the block by
    hyperosmotics, as elaborated before.

    10
    The following technique is being used for peribulbar anaesthesia by the
    authors for over a decade.
    Ø A vial of Hyaluronidase powder (1500 IU) is freshly reconstituted in
    2 ml of 2% Lignocaine.
    Ø One third of this solution is added into one full bottle of 2% ligno-
    caine (containing 30 ml). This makes the hyaluronidase concentra-
    tion as 15 IU/ml of fluid.
    Ø 6 ml of Xylocaine is withdrawn from this bottle to which is added 4
    ml of 0.5% Bupivacaine, to achieve a volume of 10 ml.
    Ø 3-5 ml of this mixture is injected at the junction of the lateral one
    third and medial two third of the lower lid, parallel to the orbital
    floor using a 2.5 cm long 22/23 needle. Another 2-3 ml is injected at
    the junction of the medial one third and lateral two third of the
    superior lid. During the injections, the needle is directed parallel to
    the floor or roof of the orbit, taking care that only half the needle
    enters the orbital space. No resistance should be encountered and
    before injecting, a gentle side-
    ways swaying movement is
    made to ensure that the needle Avoid mechanical compresion
    is not in the ocular coats. If the by Super Pinky ball and use of
    eyeball moves along with the epinephrine in the peribulbar
    swaying needle it indicates that injection, in cases of advanced
    the needle has entered the ocu- glaucoma.
    lar coats.
    Recent papers have successfully positioned the use of subtenon, sub-
    conjunctival and topical anaesthesia in trabeculectomy and combined sur-
    gery. 6, 7, 8, 9 Subconjunctival anaesthesia consisting of a 1- to 2 ml injection of
    the Xylocaine -Bupivacaine mixture without hyaluronidase in the
    superotemporal quadrant has been advocated be Azuaro Blanco et al. 7 Other
    authors avoid injectable anaesthesia in advanced glaucoma patients with
    constricted visual fields. They recommend subtenon or topical anaesthesia
    in the form of 2% lignocaine jelly, 0.5% Paracaine eye drops, or 2% Ligno-
    caine drops as an equally effective and safer alternative.8, 9
    In advanced glaucoma cases, where only a small window of visual field is
    left, most surgeons avoid using the compressive ball like Super-Pinky or Honan
    so that sustained mechanical pressure does not jeopardize the vulnerable
    optic nerve head circulation. 2 Instead a controlled gentle digital massage
    with the hand is advocated.
    HOW TO PERFORM THE SURGERY ?
    (a) Selecting the filtration site
    Our personal preference is superior, slightly staggered to the nasal side,
    11
    since it leaves more than adequate space on the temporal side for a repeat
    surgery. Superior limbus site is preferred as the bleb is snugly covered by the
    lid, which protects and hides it’s unsightly appearance. The superior pe-
    ripheral iridectomy (PI) is also covered by the upper lid and thus diplopia
    induced by an inadvertently large PI is also avoided. Inferior trabeculectomy
    should be avoided as the incidence of endophthalmitis increases with an
    inferiorly located bleb 7.8% per patient /year , which is 6 times the risk after
    superior trabeculectomy, especially if concomitant antimitotics are used. 10,11
    Buphthalmos or advanced glaucoma are conditions where the disease may
    not permit enough leeway to repeat the trabeculectomy, and the first
    trabeculectomy is the best take. A truly superior site, centered at 12’O clock
    position is preferred in these conditions, as it gives the best exposure.
    If after conjunctival dissection an collector channel vein is spotted in the
    proposed area of scleral flap it is best to avoid the vessel. This may not
    however be feasible as these veins are often present in the proposed scleral
    flap site (Fig.1). The ooze from these veins, when cut; is very troublesome and
    may need a spot of bipolar cautery
    for control.
    (b) Bridle suture
    The conventional superior rectus
    suture placed 10-15 mm behind the
    limbus can give rise to a haematoma,
    which by releasing growth factors
    facilitates healing at the filtration
    site (Fig.2). Blood contains many
    growth factors, which promote heal-
    Fig.1: Collector channel ing and thereby contribute to bleb
    failure. 2 Furthermore, in a limbal
    based conjunctival flap, the superior rectus traction suture makes conjuncti-
    val suturing difficult. To avoid these complications, some surgeons are now
    switching over to a clear corneal traction suture. (Fig.3) However, we still
    prefer the superior rectus bridle suture as we find it technically easier.
    The pulling force of a corneal traction suture in rotating the eyeball
    downward is superior to that of a superior rectus suture. The surgeon needs
    to minimize on the depth of penetration to avoid corneal perforation and
    avoid taking too superficial a bite, to prevent cheese wiring the corneal tis-
    sue. The ideal suture depth is till 3/4th of the corneal thickness. It is placed 1
    mm from limbus and the pass is at least 4-5 mm wide. The suture material is
    either 7-0 or 8-0 silk or nylon . On the other hand, the suture for superior
    rectus bridle can be a 4-0 silk or even simple autoclaved cotton thread.

    12
    Fig.2: Superior rectus bridle suture Fig.3: Clear corneal traction suture

    (c) Conjunctival incision


    Handle the conjunctiva very gently for it is this care, which will decide
    the fate of your trabeculectomy. Rough handling of conjunctiva not only
    entails the risk of buttonholing but also
    subsequent release of inflammatory me-
    diators, which often herald early death Conjunctiva should be
    of the filtering bleb. The conjunctival handled gently at all times,
    flap can either be limbal based or fornix hold with a non traumatic
    based. (Fig.4&5). toothed forceps whenever
    possible.
    Two large recent studies using for-
    nix or limbal based conjunctival flaps
    reported similar survival rates with either type. Interestingly the incidence of
    wound leak was more in fornix based flap in one study and with limbal
    based flap in the other. It appears that the operator is a more important factor
    than the position of flap, in this context.12, 13 Mandic et al in 2004, conducted
    a prospective study wherein the first eye undergoing phacotrabeculectomy
    with mitomycin C received a fornix-based conjunctival flap, and the fellow
    eye when operated, received the limbal based flap. They found no difference

    Fig.4: Limbal based flap Fig. 5: Fornix based flap

    13
    in the safety or efficacy of the procedure between the two eyes, except that
    mild early bleb leak, was more common in the fornix flap group. 14 This
    study is in concurrence with most of earlier studies which compared ext-
    racapsular cataract surgery combined with trabeculectomy with
    phacotrabeculectomy and found that the use of limbal or fornix based flap
    resulted in equivalent lowering of IOP. 15, 16, 17, 18
    The minimal manipulation of conjunctiva with the fornix based ap-
    proach minimizes the risk of a posteriorly placed restricting scar and should
    allow better posterior flow. 19 Dr Peng Khaw, the author of Moorfield safe
    technique of trabeculectomy has studied this in detail. He coined the term
    “ring of steel “, where a ring of fibrosis forms at the forniceal end of the bleb
    during healing process, which restricts posterior flow (Fig. 6&7). Since it
    coincides with the conjunctival incision in the limbus based flap, he has
    abandoned using the limbal based flap. He advocates a fornix based flap.
    The following table encapsulates the different aspects of the two con-
    junctival flaps. (Table 1)
    An adequate scleral exposure is important, and this should govern the
    length of conjunctival incision. A minimum of 8-9 mm incision length is
    required for a limbus based flap, however a 6-7 mm incision may be ad-
    equate if a fornix based flap is performed. Some surgeons advocate a relax-
    ing incision at the edge of the first incision. This is called a L shaped inci-

    Table 1. Comparison between limbal versus fornix based conjunctival flap


    Limbal based Fornix based
    Location At the limbus 8 mm behind the limbus
    Conjunctival incision length Longer Shorter
    Scleral and conjunctival More extensive, button- Less
    handling holing more common
    Haemorrhage More Less
    Exposure of operating field Not so well Better
    Scleral flap dissection Difficult Easier
    Mitomycin application More cumbersome Easier
    Releasable suture placement Technically more difficult Technically easier
    Surgical time Longer Shorter
    For combined surgery Cumbersome Easier
    Wound leak Risk minimal Potential risk
    Bleb morphology Overhanging bleb Posteriorly directed bleb
    Bleb massage postoperatively Do with confidence Do with trepidation
    Astigmatism induced Less More, especially with bleb
    forming corneal sutures,
    reverts after suture
    removal
    In re-surgery More difficult Easier

    14
    Fig.6: Limbal based flap giving rise to a Fig. 7: “Ring of steel”
    scar at the incision site which restricts the
    bleb.
    sion and it reduces the length of main conjunctival incision while providing
    similar exposure. Thus lesser clock hours of conjunctiva need to be dissected
    20 (Fig.8).

    The conjunctival flap is created using a non-traumatic forceps like Pierce


    Hoskin’s forceps and Westcott’s scissors, taking care not to buttonhole the
    conjunctiva. 21 The chance of buttonholing in-
    creases manifold in repeat surgeries, or post cata- Both limbal and fornix
    ract surgery. Some surgeons use saline or based conjunctival flap
    Xylocaine subconjunctival injection in the con- give equivalent IOP
    junctival area to be dissected to create a cleavage control,the latter is pre-
    plane, between the conjunctiva and episcleral ferred in repeat surgeries.
    tissue. In repeat surgeries, where the conjunc-
    tiva is scarred, a fornix based flap is preferred.
    The dissection is done beneath the flap with the Westcott scissors, just short
    of the superior rectus suture (Fig.9). This also allows placement of Mitomy-
    cin sponges till the posterior edge of the cleared subconjunctival space,
    away from the cut ends of the conjunctiva and finishing just short of the
    superior rectus insertion.

    Fig.8: Relaxing cut at the edge of a fornix Fig. 9: Posteriorly directed subconjunctival
    based conjunctival flap, L shaped incision. dissection ensures adequate space for the
    MMC sponges to be placed more posteriorly

    15
    (d) Tenonectomy
    Some surgeons advocate tenonectomy as an aid in achieving lower IOP,22,
    23, 24 whereas others have concluded that it has no beneficial effect. 25, 26, 27 In

    fact, Scott et al went so far as to say that tenonectomy had an etiological role
    in the development of encysted blebs. A comprehensive study from Turkey
    sought to prove that leaving behind a thick Tenon capsule in young patients,
    in Mitomycin-C augmented trabeculectomy would prevent bleb leaks. How-
    ever, they found that over a 2 year follow up avascular thin-walled bleb still
    formed in 84% eyes., shallow anterior chamber occurred in 31%, hypotony
    in 16 %, and endophthalmitis in 2%. Thus even a thick Tenon’s capsule was
    no safeguard against MMC complications. 28 Miller et al, have advocated
    partial tenonectomy as being equivalent to total tenonectomy. 29
    The authors recommend, partial tenonectomy only in young patients
    and children where a thick Tenon capsule is present (Fig.10).
    (e) Haemostasis
    Blood releases many healing factors, which would unfortunately also
    cause conjunctival and scleral scarring thereby precipitating and aggravat-
    ing bleb failure. Thus, meticulous subconjunctival and episcleral haemosta-
    sis is not only essential for adequate exposure and dissection, but also to
    ensure longevity of the bleb. A wet field cautery is ideal, but in settings where
    Tadworth ball cautery needs to be used, overenthusiastic applications of the
    latter is to be avoided since it causes scleral shrinkage, thus making it diffi-
    cult to close the scleral flap without tension. Scleral collector channel veins are
    difficult to coagulate, the trick is to cauterise them lightly, and further check
    the ooze with gentle pressure by a swab stick or sponge (Fig.11). If Mitomycin
    use is planned, this may be the opportune time to do it as the oozing will
    disappear or decrease after Mitomycin application. A mild ooze will be
    quenched by the aqueous outflow after performing sclerostomy. So there is
    no reason to be too aggressive in controlling minimal bleeding.

    Fig.10: Partial tenonectomy being per- Fig. 11: Gentle wet field cautery being ap-
    formed. plied.

    16
    Fig.12: Rectangular scleral flap dissected. Fig.13: The dissection is carried on beyond
    Note the flap is held with a McPherson or the scleral spur, the blue grey tranlucent
    other atraumatic, non-toothed forceps. zone, till 1 mm into clear cornea.

    (f) Scleral flap dissection


    There are multiple ways to do it. A rectangular or a triangular flap is
    outlined in dimensions of 4-4.5 x 4.5 - 5 mm (rectangular) or 4.5-5 x 3.5 mm
    (triangular) (Fig.12).21, 30 The base of the trian-
    gle rests at the limbus.
    Lift the scleral flap
    The instrument used could be either a with a non-toothed –
    Bard Parker handle, a 11 number blade, a dis- Kelman McPherson or
    posable cutting knife or a diamond knife. The suture tying – forceps.
    tip of the triangle or one corner of the rectan-
    gle is lifted with a non toothed forceps ( the
    author’s preference is a Kelman McPherson forceps). A lamellar cleavage
    plane is then dissected with a Crescent blade. The trick to get a clean cut, is to
    slide the blade tip by gentle tiny thrusts, at the leading edge corner of the
    scleral flap, before lifting it up with the forceps. It is best to aim at keeping the
    plane of dissection at 1/2 to 2/3rd depth of the sclera.
    The dissection is carried on 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 fibres, 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 1 mm of clear cornea (Fig. 13). The Schlemm’s canal is
    usually situated just anterior to the circumferential fibres of the scleral spur,
    sometimes it is found behind it. 21
    Another way is to make a straight scleral incision about 4-5 mm from the
    limbus and dissect a scleral pocket, similar to a manual small incision cata-
    ract surgery (Fig. 14). 20, 31 The two side incisions are then cut with a dispos-
    able blade, keeping the flat of the Crescent blade as a support on the base

    17
    Fig.14: Dissect a scleral pocket 4-5 mm pos- Fig.15: First side cut made, keeping the cres-
    terior to the limbus. cent blade as a guard.

    (Fig. 15 &16). The side incisions in


    this case are not cut until the limbus
    (but only till 1-2 mm away) to en-
    courage posterior flow of the aque-
    ous. ( Moorfield’s safe trabeculec-
    tomy technique). In this technique,
    it is essential to use a punch to per-
    form the sclerostomy.2 Fig. 14, 15, 16
    depict the steps with a limbal based
    flap, whereas Fig.17,18, 19 depict the
    Fig.16: Second cut made – thereby creating same steps with a fornix based flap.
    a scleral flap. Note the ends stop short of
    the limbus by 1-2 mm (arrow). The scleral flap should neither be
    too thick as it will offer high resist-
    ance to aqueous flow, nor too thin
    because then the chance of flap de-
    hiscence would increase, or the
    aqueous seepage through the flap
    may be excessive. A thin scleral flap
    can cause over filtration, hypotony,
    or the flap can become
    staphylomatous. Ideally, the scleral
    flap should be half the scleral thick-
    ness.21 In case the first nick is too
    deep and one realises it during the
    lamellar dissection, direction can be
    Fig.17: Scleral pocket dissected in a fornix
    changed to make it less deep, for the
    based flap.
    rest of the dissection. It is better to
    have a flap of irregular thickness
    rather than have too thick or thin a flap.

    18
    Fig.18: First side cut of the scleral pocket. Fig.19: The second cut is made, the ends of
    The incision is made over the crescent guard. the incision stop short of the limubs by 1
    mm (arrow).

    (g) Mitomycin application


    Mitomycin is a bioreductive alkylating agent that undergoes metabolic
    reductive activation, and has various oxygen tension-dependent cytotoxic
    effects and arrests the cells in the S-phase
    by inhibiting cross-linking of DNA.32, 33 MMC 0.2 mg/ml subcon-
    Mitomycin is the preferred antifibrotic junctivally for 3 minutes,
    in India, America and Japan whereas 5 followed by 30 second
    Fluorouracil is a more popular antimetabo- subsclerally is recom-
    lite in the United Kingdom. 34, 35 mended.
    Indications for use of MMC / 5 Fluorouracil
    n Young patients, less than 40 years.36
    n Secondary glaucoma- uveitic, neovascular, aphakic, post kerato-
    plasty.36
    n Prior failed trabeculectomy.
    n High preoperative intraocular pressure, more than 35-40 mm Hg at
    presentation. However, PACG (primary angle closure glaucoma )
    patients, prior to peripheral iridotomy are an exception to this rule.
    The pressures in these cases get partially controlled with iridotomy.
    If such high pressures persist after a patent iridotomy then only
    should MMC be considered for primary use.
    n Buphthalmic eyes - initially MMC was reserved for repeat surgery 37
    but recent trends show that more surgeons are now using it as a
    primary modality. 38
    Dose::
    The concentration of MMC has long been as issue of debate.

    19
    Maquet JA et al has recently sought to solve the debate by comparing
    three different dosages of MMC namely: 0.1 mg/ml, 0.2 mg/ml, 0.4 mg/ml
    for 2 minutes in 60 trabeculectomies and 83 combined surgeries, and re-
    ported no significant differences in IOP control and postoperative complica-
    tions with the three dosages. 39 Ozkiris et al also concur with the view that
    IOP control is similar whether 0.4 or 0.2 mg/ ml of MMC is used. 37 However,
    Meitz et al reported that using a higher concentration of 0.5mg/ml led to
    larger IOP drop and a better success rate.40 Some studies have, however,
    cautioned against using the higher concentration (0.4 mg/ml), as it can in-
    crease the complications without providing any additional benefit in IOP
    control. 36 Thus the higher doses of MMC > 0.2 mg / ml maybe reserved for
    cases with more than two risk factors for bleb failure. 36, 41 This viewpoint is
    endorsed by the authors.
    Duration of application:
    The duration for which Mitomycin is applied varies from 2-5 minutes,
    however, a duration beyond 3 minutes, increases the risk of hypotony and
    visual acuity loss.42, 43, 44
    The authors recommend 0.2 mg / ml, applied for 3 minutes as standard
    MMC protocol. In high risk cases like – repeat surgeries, uveitic and
    neovascular glaucoma 0.4mg/ml. is preferred and applied for no longer
    than 4 minutes. During their tissue repair experiments, Khaw et al have
    documented that the maximum uptake of the drug is within 3 minutes after
    which it plateaus out.2
    In addition to the 3 minute subconjunctival application, we also apply
    it intrasclerally for 30 seconds
    When to apply it?
    Mitomycin could be applied before 45 or after complete scleral lamellar
    flap dissection.42, 46
    The previous fear of Mitomycin C (MMC ) percolating through the scle-
    ral bed, and causing toxicity to the ciliary body were ill founded, so
    intrascleral use has now become more common.47, 48 However, few studies
    state that intrascleral Mitomycin did cause more ocular hypotony, choroidal
    detachment and a shallow anterior chamber.46 Thus intrascleral applica-
    tion although is no longer taboo, it’s use must be judicious. As stated before
    the authors recommend subconjunctival use for 3 minutes and intra-scleral
    (beneath the scleral flap) for a mere 30 seconds.
    How to prepare it?
    Mitomycin C comes in a vial as purple colour powder in 2 mg or 10 mg
    potency (Biochem laboratories). It is freshly reconstituted with distilled wa-
    ter or normal saline in concentration of 0.2 - 0.5 mg/ml. Add 10 ml of dis-
    tilled water to the 2 mg bottle, shake it, after reconstitution the fluid assumes
    20
    a light purple colour. A colour, which is not purple, indicates ineffective
    drug and such bottles must be discarded The concentration of MMC in this
    fluid is 0.2 mg /ml. It can be used for multiple surgeries done during the
    same day but should be discarded at the end of the day.
    Technique of application:
    Merocel sponges are cut into multiple pieces. MMC is squirted onto cut
    pieces of the Merocel sponges (Fig.20). Excess Mitomycin is squeezed out
    with forceps, these soaked sponges are then pushed under the conjunctiva
    in all directions with the aim that contact with the cut edges of conjunctiva is
    avoided (to prevent retardation of healing), while a large subconjunctival
    area is covered (Fig.21). The larger area covered leads to a more diffuse bleb.
    Fig. 22 shows a 6 month post operative MMC bleb when MMC was used
    with a single sponge application and Fig. 23 shows the more diffuse bleb
    obtained when the multiple cut sponge technique of MMC application was
    used. After the requisite time limit, the sponges are removed, and freshly
    soaked sponges are then re-inserted for 30 seconds beneath the scleral flap.
    Subsequently these sponges are also removed and the area washed with
    running Ringer lactate. The cotton used
    to soak this fluid and the sponges are
    discarded, the instruments used in MMC Using multiple small cut
    application are not used again in the MMC soaked sponges
    surgery, to avoid any MMC contamina- increases the contact area
    tion of the surgical field. Even the sur- of MMC and leads to a more
    geon must change gloves, since this an- diffuse, healthier bleb.
    timitotic drug can be hazardous. The
    soaked sponges must be disposed of in
    an incinerator or safely in concordance with bio-waste rules and the instru-
    ments washed and autoclaved as maybe the routine.

    Fig.20: Cut Merocel sponges are soaked in Fig.21: The soaked sponges are pushed un-
    Mitomycin C solution. der the conjunctiva. Prior space is created
    there with the help of a scissors.

    21
    Fig.22: Localised avascular bleb attained Fig.23: Diffuse bleb attained after authors
    after the older technique of MMC applica- started using cut sponges method of MMC
    tion. application.

    Success Rate:
    Mitomycin trabeculectomy is uniformly successful, with most patients
    achieving a IOP in the low teens47, 49 The success rate drops proportionately
    with increasing number of risk factors. 36 A very low success rate has been
    reported in glaucoma secondary to paediatric cataract surgery, namely 36.8%
    at the end of 3 years.50 The success rate also declines over time from - 83.3%
    at 1 year, to 60% in the 6th year.47A recent Cochrane database review of
    eleven trials involving 698 participants, wherein MMC augmented
    trabeculectomy combined with cataract surgery and primary trabeculectomy
    were reviewed, concludes that Mitomycin C reduces the relative risk of fail-
    ure of trabeculectomy, both in eyes at high risk of failure and in those under-
    going primary surgery.51
    What are the complications associated with Mitomycin use?
    (i) Cataract
    Almost 20- 66% patients develop some lens opacity over a 3 year period post
    trabeculectomy The addition of antimitotic drugs increases this risk.52, 53
    (ii) Avascular blebs, bleb leak
    A 2 year prospective study on Mi-
    tomycin bleb characteristics of 125
    eyes, reviewed avascularity,
    transconjunctival oozing and leaks.
    The surgeries studied were
    trabeculectomy, deep sclerectomy,
    combined procedures and the MMC
    concentration used was 0.2 mg/ml
    for 2 minutes. This study revealed
    that bleb leaks occurred in 13.6 %
    Fig.24: Avascular bleb of MMC
    trabeculectomy.
    cases, and that most eyes developed

    22
    bleb avascularity within the first year after surgery. Transconjunctival ooz-
    ing eventually occurred in all eyes with avascular blebs and the incidence of
    leaks gradually increased with time. 45 Thus avascular blebs seen with MMC
    use, should be regarded with suspicion and monitored more vigilantly for
    signs of infection (Fig.24). Another study has however reported that these
    leaks are rarely significant enough to require surgical reconstruction.47
    (iii) Bleb dysesthesia
    It is a term applied to the group of conditions caused by the cystic, over-
    hanging or elevated blebs. These blebs lead to tear film irregularities, blink-
    ing problems, dellen formation, dry eyes and foreign body sensation. 54
    (iv) Hypotony
    Ocular hypotony, hypotonous maculopathy, choroidal detachment and
    a shallow anterior chamber are quite common after the use of Mitomycin,
    more so with the intrascleral application. 46 The 2-3 year post surgery inci-
    dence of hypotony, varies from 16- 42%, but fortunately hypotonous
    maculopathy is relatively infrequent.55, 56
    (v) Risk of endophthalmitis
    The risk of endophthalmitis is indisput- 5 Fluorouracil protocol:
    ably higher with the use of antifibrotics. The Subconjunctival 5 mg
    incidence of blebitis varies from 0.8- 7.5%, and is injected OD, starting
    increases with time, the mean onset usually from day 1 till day 10
    being 3 years post trabeculectomy 55, 57, 58 Ag- post trabeculectomy.
    gressive medications controlled the infection
    in almost 68% cases, according to one study,
    but the visual prognosis was usually grim. 57 A review by Solomon et al
    found that incidence of endophthalmitis increased from 0.3% for plain
    trabeculectomy to 0.8 -1.3% for 5-FU and MMC trabeculectomy which im-
    plies a 3 - 4 times increase. 59, 60 The mean interval between the initial filtering
    surgery and endophthalmitis has been reported to range from 2-5 years. 59, 61
    DeBry PW et al retrospectively reviewed 239 eyes and calculated the 5 year
    probability of developing a bleb leak, blebitis, or endophthalmitis to be 17.9%,
    6.3%, and 7.5%, respectively.58
    An analysis of risk factors, leading to the development of
    endophthalmitis, has pointed bleb leaks/defects, bleb manipulations/nee-
    dling/compression sutures, laser suture lysis, autologous blood injection,
    inferior bleb location, nasolacrimal duct obstruction and diabetes as the
    major risks. The organisms isolated have usually belonged to the Streptococ-
    cus and Staphylococcus species 60, 62
    An interesting observation by Wells et al from Moorfield Hospital, Lon-
    don was that limbus based conjunctival flaps in paediatric glaucoma treated

    23
    by MMC augmented trabeculectomy had to a 3 times higher risk of develop-
    ing cystic blebs (which are highly prone to infection). They postulated that
    bleb morphology, related to conjunctival flap technique contributes to the
    increased risk of endophthalmitis.63 Thus this group routinely uses fornix
    based conjunctival flaps.
    (h) What are the alternatives to Mitomycin?
    1. 5-Fluorouracil - It is used as multiple post operative subconjunctival
    injections or as a single intra-operative application. 64 It is available in an
    ampoule - 500mg in 5 ml and 250 mg in 2.5 ml (Biochem Labs).
    n 5 FU injections are given every day for 10 days, in the dose of 5 mg.
    To make this injection, withdraw 1 ml of 5 FU from the 500 mg / 5ml
    ampoule. This 1ml has 100 mg of the drug. To this 1ml add 9ml of
    distilled water and make it into a 10 ml solution. Of this 10ml, with-
    draw 0.5ml, which will contain 5 mg of the active drug. The dose
    recommended by the Fluorouracil study group is 2 to 5 mg per injec-
    tion 65, 66
    For the treatment to be effective the injections should be started from
    the first day after trabeculectomy65
    n Intra-operative dose of 50 mg/ml can be applied over the site with
    soaked Merocel sponges for a period of 5 min, with equally effica-
    cious results. (Fig. 20). A lower dose of 25mg/ml has also been found
    to be effective. 67 Intraoperative use of 5-FU, necessitates lesser post-
    operative 5-FU injections and has fewer side-effects like corneal
    epitheliopathy without compromising the success rates. 68, 69, 70, 71
    Like any trabeculectomy, 5-fluorouracil augmented surgery also, shows
    a decline in effect over time, the probability of successful control of a func-
    tioning filter at 1 year has been estimated to drop to 61% by 5 years, 44% by
    10 years, and 41% by 14 years. 70, 72
    Comparisons between Mitomycin and 5 FU augmented trabeculectomy
    have reported equivalent results 73, 74, 75 whereas some studies have shown
    that MMC is more effective. 40, 56
    2. Amniotic membrane
    Use of human amniotic membrane implanted under the scleral flap /
    conjunctival flap has been reported to be equally efficacious and much safer
    than the use of MMC.76, 77, 78 While comparing amniotic membrane with
    MMC, blebs attained with MMC were found to be more thin walled, more
    leaky, and more frequently led to persistent hypotony and hypotonous
    maculopathy.78 An experimental study proved the greater destruction of
    fibroblasts and macrophages by MMC, versus amniotic membrane.79 In the
    author’s experience, amniotic membrane is a much safer alternative to MMC.

    24
    3. Other modalities
    Beta irradiation, TGF Beta, photo-
    dynamic therapy, are the other
    modalities which have been effec-
    tively used to prevent bleb fibrosis.80,
    81, 82

    (i) Side port creation / paracentesis


    After application of MMC, the
    anterior chamber is entered via a
    side-port incision. This is made with
    V lance similar to the one made dur-
    Fig.25: Creating a side port after dissecting ing phacoemulsification except that
    the scleral flap. Note the tangential entry of the direction is never towards the
    the V lance. centre of the chamber, instead it is
    tangentially directed towards 6’O’
    clock, parallel to iris (Fig 25). If the pupil is dilated, as is the case sometimes
    with retrobulbar block, intracameral pilocarpine is injected from the sideport
    to miose the pupil. One must ensure
    that the angle of the V lance is directed
    tangential and not perpendicular to the Create the anterior cut of the 2
    by 3 mm sclerostomy with 3.2
    limbus. Entry with the tip being perpen-
    mm keratome, entered at
    dicular may inadvertently damage the
    junction of blue grey zone where
    lens by a precipitous entry, whereas in it merges into clear cornea.
    a tangential entry the knife faces away
    from the centre of the lens, over the blan-
    ket of the iris, thereby safeguarding the lens.
    This sideport serves many important functions:
    n Is used to titrate aqueous flow through the scleral flap before tying
    the scleral sutures.
    n In advanced glaucomatous damage cases, paracentesis is used to
    perform a controlled decompression as the smaller side port entry
    is self sealing compared to the larger sclerostomy incision. This con-
    trolled decompression is desirable to prevent “snuff out” phenom-
    enon.
    n It allows for the anterior chamber to be reformed with viscoelastic
    or Ringer lactate solution as the need may be, in case the anterior
    chamber (AC) becomes shallow during the surgery.
    n Titration of the bleb at the end of surgery can be done and a patent
    sclerostomy, with adequate aqueous flow can be ensured.
    n In case of persistent shallow chamber during the post -operative
    period, AC reformation is facilitated if the side port is already present.
    25
    Fig.26: AC is entered with a 3.2 mm Fig.27: Entry bevelled at the base of the
    keratome in a controlled manner. scleral flap, where the blue grey zone merges
    into clear cornea.

    (j) Sclerostomy
    After paracentesis, the inner sclerostomy block is marked out with the
    blade in the dimension 1.5 - 2 mm by 3.0 mm, at the base of the hinge of the
    superficial scleral flap. 83 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 zone merges into the clear cor-
    nea (Fig.26, 27). It is preferable to err on the side of an anterior incision (nearer
    the cornea) than a too posterior one, since this would entail risk of ciliary
    body being damaged or exposed. This happens, especially in the tightly
    stretched globe of the buphthalmic eyes where the limbal stretching is bi-
    zarre and landmarks are obscured. It is not unheard of to cut the block too
    posteriorly, mistake the stretched, thinned out ciliary body for iris and get
    vitreous after mistakenly sniping at the ciliary body to perform a peripheral
    iridectomy.
    One should not insert the
    keratome fully if one wants the in-
    ner sclerostomy dimensions to be
    only 2 mm long, however a full en-
    try is needed when aiming for a 3
    mm wide inner sclerostomy. After
    entering with the keratome, the
    keratome is slowly withdrawn
    thereby ensuring a controlled de-
    compression (Fig.28). At least 0.5 mm
    of the scleral bed is left, on either
    side of the sclerostomy, so that
    Fig.28: The keratome is withdrawn slowly. when the superficial scleral flap is
    in this case of advanced visual field loss,
    sutured, the sclerostomy margins
    viscoelastic has been injected in the AC be-
    fore withdrawing the keratome. This is an are not exposed.
    additional safeguard to prevent “snuff out”.

    26
    The sclerostomy block is cut with a Vannas scissors or size 11 number
    blade. We have found it easier to enlarge the entry with the keratome and
    then cut back on the sides with the Vannas scissors.83 The posterior edge
    (length of the rectangular block), nearer the apex of the flap is then cut with
    a horizontally angled Vannas scissors.
    While using the Kelly Descemet’s punch, a smaller sclerostomy of 1 -1.5
    by 1.5-2 mm dimensions is made, which is more than adequate. 84, 85 The
    authors prefer the punch since it creates a compact neat hole without any
    jagged margins, and gives controlled cutting at all times thus avoiding
    shallowing of AC (Fig.29). The initial entry is made with the keratome, the
    punch is then introduced through this incision, with the cutting side turned
    posteriorly towards the fornix, and 5-6 bites are taken (Fig.30). The position-
    ing is such that the tissue is excised from the posterior tip of the incision.86
    Each bite creates a 0.2 - 0.3 mm opening, our practice is to take at least 5-6
    bites so as to create an adequately big sclerostomy, the size should be mini-
    mum 1.5-2 mm by 2 mm.83
    The other punches which can be used are Luntz Dodick, Crozafon, De-
    Laage, Katena, Holth, Crestani.84, 85, 87,
    88

    (k) Peripheral iridectomy An adequate peripheral


    irridectomy, the base being
    Peripheral iridectomy is performed as large as the inner
    through the inner sclerostomy with a sclrostomy opening is
    Vannas scissors and a single toothed mandatory.
    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. In order to avoid
    making too large an iridectomy with resultant glare and /or diplopia, the
    forceps is angled almost vertically down inside the sclerostomy. Keeping the

    Fig.29: Kelly’s Descemet punch being used Fig.30: The cut scleral peice along with tra-
    to create the sclerostomy. The punch faces becular meshwork in the jaws of the punch.
    down onto the globe and is directed poste-
    riorly, towards the fornix.

    27
    forceps tangential to the sclerosto-
    my’s forniceal end can result in mak-
    ing too large an iridectomy. Avoid
    forcefully pulling out the iris as this
    may cause an iridodialysis and/ or
    lens damage. The rationale for per-
    forming an iridectomy is preventing
    iris incarceration into the scleros-
    tomy and relieving the element of
    pupil block glaucoma. The iridec-
    tomy base should be wider than the
    Fig.31: Peripheral iridectomy being per- inner sclerostomy opening (Fig. 31).
    formed.
    A few studies have suggested that
    trabeculectomy may work without
    a peripheral iridectomy 89 However in the Indian scenario with angle clo-
    sure glaucoma being so prevalent, it would be rather unjustified to per-
    form a trabeculectomy or a phacotrabeculectomy without performing a
    peripheral iridectomy.
    (l) Scleral flap sutures
    Scleral flap sutures regulate aqueous outflow. 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 too great, and may result in hypot-
    ony. If the scleral flap is too tight, the IOP will remain too high, placing the
    patient at risk of sudden loss of remaining visual field (“snuff out”) or addi-
    tional ganglion cell loss with resultant worsening of glaucomatous optic
    neuropathy. Manipulation of the suture tension and flap’s fit could modu-
    late aqueous flow beneath the flap, thereby the IOP.90
    The first modality used to modulate aqueous flow post-operatively was
    the development of Simmon’s plastic tamponade shell in 1970. This pre-
    vented hypotony by ensuring a tight flap fit in the early postoperative pe-
    riod.91
    A subsequent development was laser suture lysis. In laser suturolysis
    the sutures holding the scleral flap, are cut during the first few days or weeks
    after surgery, thus allowing a better aqueous run off.92 The technique was
    first described by Lieberman using a Goldmann goniolens. Subsequently
    many modifications have been made in the lenses, designed to facilitate
    comfort and proper focusing of the beam.93-96 These lenses compress the
    conjunctiva to expose the underlying sutures.95, 96 The disadvantages of this
    technique are- it requires access to argon laser, the cost and availability of
    which can be a major limiting factor in India. It also requires a Hoskin’s or

    28
    equivalent lens, which enables compression of the filtration area during the
    procedure. Manipulating the operated area so soon after surgery carries the
    inherent risk of infection, flap dehiscence and wound leak, not to mention
    extreme patient discomfort and trepidation. Additionally, sutures maybe
    obscured by haemorrhage, overlying edema or a thick Tenon capsule all of
    which, preclude suture release (Fig.32). In addition laser suture lysis has its
    attendant share of complications such as conjunctival burns, conjunctival
    flap leak, hypotonous maculopathy, malignant glaucoma, iris incarceration
    and hyphema.97-100
    These problems led to the innovation of releasable sutures, which were
    introduced by Schaffer et al 101 but popularized by Cohen and Osher.102 The
    use of releasable sutures minimized the incidence of shallow anterior cham-
    ber and hypotony in the early postoperative period 97, 103, 104 Once the wound
    and anterior chamber stabilize, the sutures are released to enhance the out-
    flow of aqueous humor. The resultant situation, resembling a full thickness
    surgery, ensures a good bleb function and provides lower long term IOP 104-
    106 In a nutshell it combines the benefits of partial thickness filtration surgery

    by allowing a formed anterior chamber in the immediate post operative pe-


    riod along with those of full thickness
    filtration surgery by allowing a freer flow
    of aqueous and consequently lower Tightness of releasable
    intraocular pressures (IOP) once the su- sutures is modified on table
    tures are removed in the later post op- by titrating the aqueous
    erative period. egress by injecting fluid from
    the paracentesis port.
    In our country, where the preva-
    lence of angle closure glaucoma is al-
    most equal to that of open angle glaucoma, preexisting shallow AC is very
    common. This demands that the scleral sutures offer adequate resistance to
    aqueous outflow at least in the immediate postoperative period so as to
    prevent further shallowing. It is also a well-established fact that aqueous
    flow is essential to keep the bleb
    patent and functioning. So the glau-
    coma surgeon is constantly walking
    on a tightrope as to how tightly to
    tie the sutures. The sutures should
    be tight enough to prevent shallow
    AC and loose enough to keep the
    aqueous flowing. Releasable su-
    tures comfortably overcome these
    problems.
    How to tie these releasable sutures?
    In a triangular flap, when the Fig.32: Subconjunctival haemorrhage ob-
    base of the triangle/ rectangle stops scures the scleral flap sutures.

    29
    short of the limbus by 1mm ( safe sur-
    gery technique) then three sutures
    ( in triangular flap) and five sutures
    E (for rectangular flap) are adequate
    (Fig. 33).
    D
    If however the sides of the trian-
    gle/ rectangle reach upto the limbus,
    C
    then 2 additional sutures, one on each
    B
    A of the limbal edges of the side arms of
    the triangular flap, maybe required.
    These additional two sutures are safe-
    guards which prevent hypotony, once
    Fig.33: Rectangular flap which is not dis- the releasable sutures are removed.
    sected till limbus would require 5 sutures,
    of which 2 are releasables. Sutures placed These limbal sutures are not made re-
    at A & E are fixed, B & C or D are made leasable instead the more distal ones
    releasable. are made releasable.
    The reasoning for making the
    distal sutures releasable is as follows. If the limbal sutures are made releas-
    able, aqueous flow would be directed parallel to the limbus thereby creating
    an overhanging bleb once they are released, whereas if the distal sutures are
    made releasable the aqueous flow would be directed posteriorly toward the
    fornix and lead to a diffuse, posteriorly located bleb.
    The suture tightness can be adjusted on the operation table by watching
    the egress of fluid from the scleral flap edges, by titrating from the sideport. If
    the flow is excessive the sutures are tightened and if poor the sutures are
    loosened.
    How effective is the release?
    The documented amount of immediate reduction in IOP is in the range
    of 7 -9 mm Hg; if the sutures were released during the first three postopera-
    tive weeks.97, 106 The efficiency was decreased if they were released later.
    Within the first week a 5 mm Hg drop, was noted in 70% cases, compared to
    only 20% if the release was done after the third week.97
    Many authors have speculated about the possibility of dangerous eleva-
    tion in IOP with the tight closure of scleral flap with releasable sutures 103.
    However, this fear has never been substantiated. The assurance that the
    suture can be released in the postoperative period allows the surgeon to
    secure the scleral flap tighter than usual thus minimizing hypotony and if
    high IOP is found in the postoperative period one or more suture may be
    released to allow improved filtration, which is not possible with permanent
    sutures.
    Another consideration is the increased astigmatism induced by the re-

    30
    leasable sutures, since they impinge Fig 34: Wilson’s technique of tying
    releasable suture (5 Steps)
    on the cornea. Hornova et al
    showed that though postoperative
    astigmatism increased by +2.8 D on
    the 1st day, it declined to +2 D by 1st
    month and after removal, a minimal
    residual astigmatism of +0.25D was
    created. 108
    Popular techniques of releasable sutures:
    Various releasable sutures tech-
    niques have been described. 102, 109,
    110, 111
    Step 1
    Wilson described a mattress
    type scleral suture, which was ex-
    ternalized with the knot on the cor-
    nea. Postoperatively, the suture
    could be cut or removed.107
    1. Richard Wilson’s technique (Fig.
    34)
    Ø A preplaced corneal grove
    is created at the base of the
    scleral flap – 1-1.5 mm from
    the limbus (optional). (Step
    1) Step 2

    Ø The first pass is taken from


    this groove/ clear cornea,
    traverses diagonally be-
    neath the sclera flap, and
    out through the flap (Step
    2).
    Ø Suture then loops over the
    scleral flap
    Ø Re-enters into the scleral
    bed 0.5 mm away from
    limbal edge of the scleral
    flap (Step 3).
    Ø Traverses beneath the scle-
    ral flap crossing over the
    suture in Step 2. Step 3

    31
    Step 4 Step 5

    Ø Emerges 1-1.5 mm in the clear cornea adjacent to the step 1 suture


    (Step 4).
    Ø The two ends are tied (Step 5). The tightness of the sutures is ad-
    justed to approximate the edges of the scleral flap and aqueous flow
    is titrated by injecting fluid from the side port and watching its
    egress from the sides of the sutured scleral flap.
    Ø The corneal end of the suture is then cut flush, to avoid leaving a
    protruding suture end.
    Ø Two such sutures are placed on the two sides of triangular or apices
    of the rectangular scleral flap (Fig. 33).
    The knot can be cut later on the
    slit lamp, under topical anaesthesia
    and the suture pulled out.
    2. Kolker’s modification of Cohen and
    Osher technique of releasable sutures 102:
    Fig 35-37.
    Ø The needle of a 10-0 ny-
    lon suture is passed first into the in-
    tact sclera posterior to the scleral flap
    and then brought out anteriorly
    Fig 35: The needle is passed into sclera through the scleral flap, at A.
    and through flap. After passing the needle
    through base of scleral flap, beneath the Ø This suture is then passed
    conjunctival insertion, it is taken through through the base of the scleral flap at
    the peripheral cornea. B, beneath the conjunctival flap in-

    32
    Fig 36: Superficial intracorneal pass C to Fig 37: The suture is tied with a qua-
    D. The knot is cut flush at sutures exit druple throw slipknot.
    from E.

    sertion, through partial thickness cornea 1 to 2 mm from the limbus,


    and then out on to the epithelial surface of the cornea, at C (Fig.35)
    Ø A small superficial pass through the adjacent cornea is then made -
    Kolker’s modification C to D. (Fig.36)
    Ø Four throws of the distal end of the
    suture are then passed around the Shallow anterior
    tying forceps before the suture end chamber is at least 3
    lying on the surface of the scleral flap times less frequent
    is grasped to make a hemibow slip- when releasable
    knot. (Fig.37) sutures are used.104
    Ø The tightness of the sutures is ad-
    justed to approximate the edges of the scleral flap and restrict aque-
    ous flow.
    The corneal end of the suture is then cut flush to avoid leaving a protrud-
    ing suture end.
    These sutures are released as and when required, under topical anaes-
    thesia using the slit lamp. The exteriorized corneal loop is pulled out with a
    suture holding forceps. The sutures are released one at a time, within 10-14
    days of conventional trabeculectomy. Suture removal usually produces an
    immediate increase in filtration with enlargement of the filtering bleb and a
    fall in IOP. Suture removal after 2-3 weeks has little effect on bleb appearance
    or IOP. 97, 103 However, in cases of trabeculectomy with antifibrotics, suture
    removal maybe delayed until 2-3 weeks after surgery, as post suture removal
    hypotony is more likely prior to 3 weeks.105, 112, 113 In case the IOP remains
    controlled, the sutures need not be removed, until 5-6 weeks have elapsed,
    by this time healing has occurred, and removal of suture would not affect
    the IOP.

    33
    What are the Complications of releasable sutures?
    Windshield wiper keratopathy occurs due to rubbing of the suture ends
    on the cornea with lid movements. This is seen as a distinctive wedge shaped
    keratopathy that resembles the pattern left on a car windshield by the wiper
    blade. 97,106 Although this keratopathy resolves with release or trimming of
    the suture, there is a potential for infection and techniques have been de-
    scribed to avoid this complication. The persistent track left after trimming of
    the suture, also poses a risk of bleb infection. Other complications reported
    are epithelial abrasion and subconjunctival bleed following the release of
    the sutures.97 However, the only complications noted by the authors after a
    decade of routinely using releasable sutures are mild conjunctival irritation,
    mucous deposit near the knot, and occasional bleed during removal. Some-
    times when the suture release is delayed for more than a month, then the
    knot gets so deeply buried beneath the corneal epithelium that it needs to be
    dissected. Such deeply buried knots may be left in place if they entail too
    much corneal dissection.
    (m) Anterior chamber reformation
    Viscoelastics may be used to reform the AC and check the blood ooze if
    any, after the scleral flap sutures have been tied (Fig. 38). The authors have
    been using Methylcellulose for the last 5 years to keep the AC formed and
    have witnessed no untoward incidence with it. Injection of methylcellulose
    is very beneficial in case of a post iridectomy bleed, as it limits the bleed and
    pushes the blood away from the sclerostomy cleft. Use of a viscoelastic has
    also been recommended by Wilson et al, who in a case control series found
    that viscoelastic use decreased the risk of complications.114
    (n) Conjunctival flap closure
    A. In a limbus based flap, incision is closed with continuous 8-0 nylon, or
    8-0 vicryl, the edges of which are interlocked. The absorbable Vicryl does
    induce more inflammation but is the
    suture of choice in children where
    conjunctival suture removal would
    necessitate another general anaes-
    thesia. Some surgeons prefer it for
    adults too since it ensures more pa-
    tient comfort. Our personal choice is
    8-0 nylon. Use of a round bodied nee-
    dle is preferred, to avoid cutting
    through the conjunctiva. The supe-
    rior rectus bridle suture is released
    at this stage, to allow for proper co-
    aptation of the wound edges. Small
    Fig 38: Viscoelastic being injected from the
    closely spaced passes are taken in a
    side port to reform the anterior chamber.
    running fashion. Interlocking of the
    34
    suture is not necessary. The ends however are interlocked, tied on itself and
    not cut too short. A little longer end causes less irritation, a short end may
    stand up and rub against the lid and cause more discomfort. Too long a
    suture also leads to a corneal abrasion and should be avoided.
    If antifibrotics are used or if the conjunctiva is very thin, tenon layer is
    sutured separately using interrupted 6 -0 vicryl sutures.
    B. For fornix based flap- 10 zero nylon is the suture of choice. One or two
    sutures are placed at either end of the incision taking the bite from the an-
    chored conjunctiva to the loose conjunctiva of the flap. These are called as

    Step 1

    Step 1 – The needle of 10 zero monofila- Step 2


    ment nylon enters the sclera facing con-
    junctival end and exits on the conjuncti- Step 2 – The needle re-enters 2-3 mm
    val surface A. away from the surface of the conjunc-
    tiva, point B.

    Step 3 Step 4

    Step 3 – The needle impales and Step 4 – The needle exits and forms a
    traverses through superficial corneal loop of 2-3 mm, parallel to the limbus
    stroma entering 1-2 mm away from lim- and re-enters corneal stroma again per-
    bus and traversing for 1-2 mm from pendicular to limbus at point E.
    point C to D. The direction is perpen-
    dicular to the limbus.

    Fig 39: Diagrammatic representation of corneal anchoring sutures.

    35
    Step 5

    Step 6

    Step 6 – The sutures at point A and F are


    tied together with initial 3 throws, sub-
    sequent 2 and 1 throw, the knot is then
    Step 5 – The needle re-enters the cor- cut flush.
    neal stroma at point E and traverses
    intracorneally till point F.

    the wing sutures. The conjunctiva is anchored to the limbus with 2-3 hori-
    zontal mattress sutures which involve intracorneal bites (Step 1-6 in Fig. 39).
    The knots are placed to lie between conjunctiva and cornea so as to not
    irritate the cornea (Fig.40,41). Another way is to create a shallow preplaced
    groove at the corneal limbus, and bury the knots into them. The incidence of
    wound leak and conjunctival retraction with this corneal anchoring tech-
    nique is minimal. 2, 114 One study reported mild early wound leakage that
    resolved with conservative treatment in only 12% eyes.114 If the conjunctival
    edge drapes snugly over the limbus after tying the two wing sutures and
    there is no wound leak noted on bleb titration then the corneal anchoring
    sutures need not be given.
    (o) Bleb titration
    At the end of the surgery, titration is done from the side port with a 24 or
    26 gauge hydrodissection canula (the blunt tipped fine bored disposable
    needle which comes with Healon or Hyvisc, can also be used for this pur-
    pose). A 2 cc syringe filled with Balanced salt solution or Ringer lactate is
    attached to this needle and AC is reformed through the side port. The bleb
    will be formed on table, thereby ensuring patency of the sclerostomy and
    adequate tightness of the scleral sutures (Fig.42). In addition water tightness
    of the conjunctival closure is checked.
    WHAT IS THE POSTOPERATIVE REGIMEN?
    Topical steroid antibiotic combinations are prescribed at 2-4 hourly in-
    tervals 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 atropine ointment are routinely used by some

    36
    Fig.40: Wing sutures at the end of conjunc- Fig.41: Corneal anchoring sutures in posi-
    tival incision. tion. L shaped conjunctival incision sutured.

    surgeons to reduce ciliary spasm,


    prevent synechiae, or deepen the
    anterior chamber.
    Marquardt D et al, has pro-
    pounded an intensive post opera-
    tive care regime, where wound heal-
    ing control measures were used.
    These measures were, an increase
    Fig 42: Bleb titration with 26 guage canula
    in topical steroid administration if
    from side point. Note the bleb being formed.
    corkscrew vessels are present; re-
    peated injections of 5-Fluorouracil
    (5-FU) at the beginning of bleb scarring; and/or needling plus 5-FU admin-
    istration if an encapsulated bleb developed. In a retrospective study span-
    ning 4-5 years, the patients subjected to these wound healing measures at-
    tained target IOP more frequently. 115 This study only highlights that vigilant
    post operative care is crucial for the continuing function of the filtering sur-
    gery.

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    43
    44
    Section III
    Combined Surgery

    Cataract and glaucoma often coexist in the elderly patient and either one
    affects the treatment and prognosis of the other condition. Cataract can hinder
    the monitoring of glaucoma whereas cataract surgery influences both
    intraocular pressure and the functioning of a prior glaucoma filtering sur-
    gery. Glaucoma surgery, on the other hand, increases the risk of cataract
    progression. Combined surgery (phacoemulsification with penetrating or
    non penetrating filtering surgery) has the advantage of treating two distinct
    morbidities in a single operation. The enhancement in vision and the subse-
    quent reduction in glaucoma medications significantly enhance the patients’
    quality of life.1
    WHAT ARE THE SURGICAL OPTIONS IN SUCH PATIENTS?
    Minimally invasive cataract surgery like phacoemulsification or manual
    small incision cataract surgery ( SICS) reduce surgical trauma and hence
    improve results of combined surgery.
    The following surgical options are available for the patient having coexist-
    ent cataract and glaucoma.
    A. Where the glaucoma - is controlled on one topical antiglaucoma drug,
    cataract extraction alone is performed. This may do away with the
    need for the single antiglaucoma medication in the immediate and
    intermediate follow up period. Over a long term follow up, the glau-
    coma medications may need to be reintroduced. A recent study moni-
    tored IOP changes over a 5 year period, after clear corneal
    phacoemulsification, in glaucoma patients and suspects. They re-
    ported small but significant sustained decrease in IOP in almost
    85%, with the same number of glaucoma medications or less. 2
    B. In advanced glaucoma where, in a previously recorded 10-2 visual
    field testing (the current cataract status, may not allow a fresh 10-2
    testing), the fields were so constricted that macular split is impend-
    ing, then trabeculectomy alone is done first. This strategy is particu-
    larly important in eyes at high risk for filter failure, e.g. as eyes that
    have had prior intraocular surgery, neovascular glaucoma or young
    individuals. Cataractous lens is removed, by clear corneal temporal
    phacoemulsification at a later date, which should be at least 6 months
    after the trabeculectomy has been performed. The rationale for this
    is that the target IOP required for advanced glaucoma cases is in

    45
    the low teens and a combined procedure would rarely achieve
    that level of pressure control even when augmented with
    antimetabolites. 3, 4, 5
    C) Combined surgery is performed in the following case scenarios :
    n Borderline controlled glaucoma despite maximum tolerable anti glau-
    coma therapy.
    n Adequate IOP control but unacceptable drug side effects.
    n Number of topical medications required to control IOP are more
    than two.
    n Poor socioeconomic status - the patient is unable to afford the glau-
    coma medication.
    n Poor access to medical care facilities- where frequent follow up is
    unlikely e.g. elderly people who reside in villages and are brought to
    the hospital by their care givers.
    n Patients not compliant with medical therapy.6
    n A one eyed patient with significant cataract and moderate glau-
    coma defect, wherein the other eye has lost vision due to glaucoma.
    n Patient opting for surgery as an alternative to glaucoma drugs
    The advantages of combined surgery are:
    Ø Two morbidities are handled in one sitting.
    Ø Economical.
    Ø Post cataract surgery the glaucoma patient is subjected to IOP spikes,
    which damages the vulnerable optic nerve head further.7, 8 The IOP spike
    has been documented to reach almost twice the pre-operative IOP lev-
    els.8 Combined surgery blunts this spike.
    Ø The need for frequent and long term topical corticosteroids post cataract
    extraction, may exacerbate the glaucoma in steroid responders. Con-
    comitant glaucoma surgery would downplay this effect.
    Ø May be sight saving in the long run, since many patients delay the sec-
    ond surgery till a irreversible stage is reached.
    Ø AGIS trial has proven that even after adjustment for age and diabetes,
    over a 7-11 years of follow up, trabeculectomy increases the risk of cata-
    ract formation by 78%.9 Thus more than half of the patients on whom a
    trabeculectomy is performed, would become visually handicapped from
    a cataract within the next 5 years or so, and would anyway require a
    cataract surgery.

    46
    D) Occasionally, filtering surgery alone can postpone the need for cataract
    extraction, when vision is compromised because of the use of miotic therapy
    which is discontinued after trabeculectomy.
    HOW EFFECTIVE IS COMBINED SURGERY?
    A whole gamut of studies both prospective and retrospective, vouch for
    its effectiveness.11, 12, 13 However, in terms of IOP control it is less effective
    than trabeculectomy performed alone.3, 4, 5. 14
    WHAT ARE THE DIFFERENT TECHNIQUES OF COMBINED SURGERY?
    A. ECCE trabeculectomy versus Phacotrabeculectomy
    ECCE trabeculectomy is associated with excessive conjunctival and scle-
    ral manipulations, thereby leading to scarring of the incision area and hence
    reducing the efficiency as well as the longevity of the filtering bleb. 15, 16 The
    larger incision also causes more derangement of the blood aqueous barrier
    leading to increased inflammation, an increased incidence of wound leaks
    and subsequent shallow anterior chamber.13, 15, 16, 1718, 21, 22
    Phacotrabeculectomy on the other hand
    minimizes the derangement in the balance
    of forces between the intravascular and in- Combined surgery is less
    terstitial compartment by maintaining con- effective in reducing IOP
    trolled chamber dynamics. This decreases as compared to a
    chances of anterior chamber reaction, trabeculectomy per-
    hyphema and hypotonous maculopathy. 17 formed alone.
    The smaller scleral and conjunctival inci-
    sions reduce stimuli to wound healing, in-
    flammation and postoperative bleb scarring.18, 19 This results in better IOP
    control, reduced complications and improved bleb longevity.13, 15-18, 21, 22
    B. Manual Small Incision Cataract Surgery and Trabeculectomy
    Thomas et al, on comparing phaco-triple versus Blumenthal manual
    small-incision cataract surgery triple, found the two techniques to be equally
    efficacious.24 In the authors’ experience manual SICS triple gives equivalent
    IOP control, equivalent visual acuity gain and induced astigmatism when
    compared with Phaco triple using a non foldable IOL.
    HOW DOES ONE PREPARE FOR SPECIAL ODDS IN COMBINED
    SURGERY?
    Other than the routine preoperative evaluation for any intraocular sur-
    gery, certain special entities need to be assessed and planned for, since these
    may cause intra-operative difficulties and ultimately mar the success of the
    outcome.

    47
    A. Small non dilating pupil
    This is a common confounder and is due to atrophy of iris stroma, chronic
    miotic use , posterior synechiae or prior angle closure attacks. The solution is
    to withdraw miotics at least 2-3 weeks before surgery, and confirm extent of
    pupil dilatation 2-3 days prior to surgery.
    The following manoeuvres can then be employed:
    Ø Mechanical stretching of the pupil with two Sinsky hooks intro-
    duced from two sideports, under viscoelastic blanket. The hooks
    can be made to pull their sided pupil margins towards their respec-
    tive side ports. The stretching is repeated at 90O to the first plane.
    Ø Disposable Grieshaber iris hooks, introduced from 4 side ports, can
    be used.
    Ø Pupil expanders.
    Ø Multiple small sphincterotomies.
    Ø A large superior PI is made, which is extended by a straight nick to
    the pupil margin. After completing the phacoemulsification, this
    nick is closed with 10 zero Prolene suture.
    Since the introduction of the iris hooks, the pupil mutilating surgeries
    involving cutting of the pupil margin area are very rarely employed.
    B. Increased post surgical inflammation
    Anticipate increased inflammation after surgery. To minimize this the fol-
    lowing regimen is implemented:
    Ø Topical antibiotic steroid combination is started 2 days prior to
    surgery
    Ø Prostaglandin analogues are withdrawn 2 -3 weeks before surgery,
    if feasible, as they increase the intensity of the post operative inflam-
    mation.
    Ø Post operatively topical corticosteroids are used more frequently
    and for a longer duration than for routine trabeculectomy. Some-
    times systemic corticosteroids are also required.
    C. Pseudoexfoliation and uveitic glaucomas
    Ø Anticipate weak zonules and keep capsule tension rings handy.
    Ø Hydrodissection should be gentle.
    Ø Phaco-chop and other techniques using minimal phaco energy
    should be employed.
    Ø Specular microscopy is done to assess corneal endothelial status,

    48
    and in case of low counts, dispersive viscoelastics like Chondroitin sul-
    phate, or viscoadaptive like Healon GV may be employed to ensure minimal
    endothelial disruption.25
    D. Repeat gonioscopy a week or so before surgery, to confirm angle status
    Ø Check for peripheral anterior synechiae
    Ø Patency of laser PI, if present
    Ø If synechiae are extensive or pseudoexfoliative material is seen—
    goniosynechiolysis and/or trabecular aspiration is attempted during sur-
    gery. 26 The authors use the irrigation and aspiration probes of the
    phacoemulsification machine and gently vacuum the angle area in the infe-
    rior 180 degrees in superior site phacoemulsification or nasal 180 degrees in
    temporal phacoemulsification.
    E. IOP spikes can be very high post surgery and are devastating to the
    compromised optic nerve head circulation. 8 To reduce spiking, meticulous
    removal of the viscoelastic is mandatory. Intracameral pilocarpine must
    always be injected at the end of phacoemulsification. This not only blunts
    the IOP spike but ensures a cleaner, smaller,
    more peripheral iridectomy. 27
    2 site approach gives
    F. In case of vitreous loss – a scleral fix- rise to better looking
    ated lens is the preferred option com- blebs, but the IOP
    pared to an anterior chamber IOL. The control is almost similar
    best would be an IOL placed on the an- to single site surgery.
    terior capsulorrhexis, wherever feasible.
    G. Conjunctiva of the glaucoma patients has usually been exposed for a
    long time to anti glaucoma drugs and is prone for a dry eye situation due
    to steroid use in the post operative period. 28 Thus steroids must be used
    sparingly and judiciously along with tear supplements.
    SHOULD A SINGLE SCLERAL SITE OR A 2 SITE APPROACH
    BE PREFERRED ?
    A recent study by Shingleton et al compared the results of 1-site versus 2-
    site phacotrabeculectomy for over 1 year and found them to be similar with
    respect to IOP control and visual gain.29 Comparable results have also been
    reported by others.30, 31 Over a longer follow up with MMC augmented
    phacotrabeculectomy, no difference was noted in the mean IOP irrespective
    of number of sites used, although clinically apparent filtering blebs were
    more common in the 2 site group.32, 33, 34 Our experience concurs with
    Shingleton’s findings.
    Despite this, some researchers have however, advocated a 2-site ap-
    proach in which the phacoemulsification component is performed through
    a temporal corneal approach followed by a trabeculectomy performed supe-

    49
    riorly. They contend that 2 site phacotrabeculectomy entails less conjuncti-
    val manipulation and leads to a slightly better control of IOP ( around 1-3
    mm Hg better ).12, 13, 21
    SHOULD ONE PREFER FORNIX OR LIMBAL BASED CONJUNCTIVAL
    FLAP ?
    The studies analysing fornix-or limbus-based flap in
    phacotrabeculectomy have noted a shorter surgical time and relatively faster
    postoperative improvement in vision with the fornix-based flap.35 However,
    early bleb leakage was more frequent with fornix flap technique.36, 37 An-
    other case control study compared phacotrabeculectomy augmented with
    mitomycin C, wherein the first eye received a fornix-based conjunctival flap,
    and the fellow eye of the same patient was assigned to the limbus-based
    group. No significant intergroup difference was found in either the IOP con-
    trol or complications.38
    WHAT ARE THE STEPS IN PATIENT PREPARATION?
    In addition to routine preoperative preparation, the following treatment
    protocol should be implemented:
    Ø Intravenous mannitol is given at last 30 minute before wheeling the
    patient in for surgery.
    Ø Pupil dilatation is aided with flurbiprofen or diclofenac drops, ap-
    plied every 15 minutes interval for at least 1 hour. They could also be
    initiated a day before surgery at 6 hourly intervals.
    Ø Peribulbar anaesthesia is used without adrenaline.
    Ø Unless dealing with advanced glaucoma, a good massage with the
    Super Pinky ball is performed.
    WHAT IS THE TECHNIQUE ?
    A. Same site phacotrabeculectomy through the scleral tunnel
    Same as in trabeculectomy with the following exceptions:
    l Fornix based conjunctival flap - technically easier, ensures better
    exposure and shortens surgical time in the authors’ experience.
    l Scleral tunnel phacoemulsification is performed.39
    l The length of the scleral incision is predicted by the type of IOL
    (foldable or non foldable). The scleral pocket starts 2-3 mm behind
    the limbus.
    l After IOL insertion, intracameral pilocarpine is injected to make the
    iris taut, and pupil miosed.
    l The integrity of the watertight wound is deliberately breached by

    50
    removing a block of tissue from the posterior lip of the scleral tunnel,
    with a Kelly Descemet’s punch. The punch is inserted and rotated to
    face the posterior lip of the incision.40 Around 5-6 nibbles are taken
    so as to create a sufficiently large sclerostomy, approximately 1.5 by
    1.5 mm. Under a 3 mm flap, sclerostomy as large as 2 mm can be
    made. The tissue is excised from the posterior lip of the incision.
    l Peripheral iridectomy is performed through the sclerostomy, using
    a Lim’s forceps. The forceps should be pushed down vertically rather
    than tangentially.
    l A 3-3.5 mm incision can be left unsutured but larger incisions
    should be sutured. A single loose cross suture is sufficient. Although
    few studies have reported no untoward complications with
    sutureless 4- 7 mm scleral tunnel incisions ,41, 42, 43 we recommend
    suturing of the larger scleral incisions and many studies support
    our viewpoint.19,20, 31, 32, 44 If inadvertently the inner sclerostomy be-
    comes larger, than also the scleral flap should be sutured, to prevent
    over filtration.45
    l Releasable sutures are the pre-
    ferred modality. 24, 45, 46
    The use of a punch to per-
    l The aqueous flow is then titrated form a sclerostomy through
    through the side port and the su- the scleral tunnel is techni-
    ture tightness and number is ad- cally easier than performing
    justed according to the aqueous a Vannas sclerostomy.
    egress.
    l Conjunctival closure needs to be very meticulous. In fornix based
    conjunctival flap the sides are anchored to the cornea with two wing
    sutures, and the centre is anchored to clear cornea, anterior to the
    limbus with a horizontal
    mattress suture (Fig. 1).
    These sutures are released
    after 2 weeks once a bleb is
    formed and limbal reattach-
    ment of the conjunctiva has
    occurred.
    l The advantages of the scle-
    ral tunnel approach is that
    the edges of the tunnel are
    not grasped during dissec-
    tion, thus the incidence of
    flap perforation or tear is Fig. 1: Conjunctiva anchored to the limbus with (black
    arrows) two wing sutures at the ends and centrally to
    less, compared with stand- the cornea with (blue arrows) two horzontal mattress
    ard flap making.39 The fur- sutures.

    51
    ther dissection of scleral pocket into clear cornea allows production
    of anterior scleral ostium, which promotes successful filtration.
    B. Same site phacotrabeculectomy through the scleral flap
    l A triangular / trapezoidal scleral flap is dissected at the superior
    pole.
    l Dimensions of the flap are : 3 x 3 or 4x 3 mm - if foldable IOL is to be
    used; 3 x 6 mm – if 5.5 mm PMMA IOL is to be used; 3 x 7 mm – if a
    6-6.5 mm PMMA IOL is to be used.
    l The scleral flap is dissected till 1-1.5 mm into the clear cornea.
    l Phacoemulsification is performed through the base of the flap.
    l After IOL insertion, a sclerostomy is performed preferably with a
    punch / 11 No Bard Parker blade/Vannas scissors.
    l Peripheral iridectomy is done.
    l Closure of the scleral flap, by two regular sutures at the upper cor-
    ners and two releasable sutures at the edges of the flap is performed.
    In case of a triangular flap the apical suture is fixed and the side arm
    sutures are releasables.
    l Conjunctival closure is done as mentioned above.
    C. Phacotrabeculectomy through two different sites
    l The trabeculectomy flap is prepared at the superior site. The flap is
    dissected and left.
    l If mitomycin is planned, it is applied at this stage. Thorough rinsing
    of the area of MMC application is done.
    l The surgeon then shifts to the temporal side of the patient and per-
    forms a clear corneal phacoemulsification, inserts the IOL, injects
    intracameral pilocarpine and hydrates the wound. A little amount
    of viscoelastic is injected into the AV to make the eye turgid, so as to
    enable an easier and cleaner sclerostomy.
    l The surgeon again shifts to the superior trabeculectomy site and
    inserts the keratome at the base of the scleral flap, performs an inner
    sclerostomy, peripheral iridectomy and secures the scleral and con-
    junctival flap with sutures.47
    l Bleb titration is done on table as detailed earlier.
    D. Phacofracture or Blumenthal triple through single site (Fig.2)
    l A 5.5 mm scleral tunnel is made superiorly.
    l Manual small incision cataract surgery is performed and a 5.5 mm

    52
    Step 1: Nucleus bissection performed in the Step 2: Nucleus half being removed by Irri-
    anterior chamber, under viscoelastic cover. gating vectis.

    Step 3: Second half of the nucleus being re- Step 4: Trabectomy by using a punch
    moved through the scleral tunnel, after IOL inser-
    tion.

    Fig 2: Phacofracture triple – technique.

    PMMA IOP is inserted (Fig. 2– Step 1, 2, 3). The technique used may
    be Phacofracture, Blumenthal or sandwich technique.
    l Inner lip sclerostomy is performed using the Kelly’s punch (Fig. 2–
    Step 4).
    l The remaining steps are same as for phacotrabeculectomy through
    same site.
    E. Mitomycin use
    The use of mitomycin combined with phacotrabeculectomy achieves the
    best IOP lowering of all types of combined cataract and glaucoma surgery
    currently possible, but can be associated with potentially sight-threatening

    53
    complications. 21, 44, 48 However, many researchers advocate its use since it
    causes better IOP control, larger blebs and requirement for less anti glau-
    coma medications. 21, 24, 25, 45, 49, 50
    F. Combined surgery in deep sclerectomy
    Non penetrating deep sclerectomy can be combined with
    phacoemulsification. The early results of phacotrabeculectomy vesus phaco
    -deep sclerectomy are comparable as both give about 30% drop of IOP, but
    delayed bleb leaks are more often seen in the phacotrabeculectomy group. 51
    Deep sclerectomy combined surgery has been documented to result in qui-
    eter eyes with less incidence of inflammation, and hyphema.52 However,
    long term control of IOP is better in trabeculectomy eyes.
    WHAT ARE THE COMPLICATIONS OF COMBINED SURGERY?
    Anterior chamber inflammatory reaction is usually more after phaco
    trabeculectomy than after plain trabeculectomy.3, 53 Probably the breakdown
    of blood aqueous barrier lasts longer after phacotrabeculectomy. It is hy-
    pothesised that the release of lenticular crystalline material and epithelial
    cells into aqueous humor, the effect of ultrasound and/or the high volume of
    fluid passing through the eye at the time of surgery upregulates the produc-
    tions of fibrogenic cytokines in the aqueous humor. This lesser inflamma-
    tion, accounts for the better IOP control seen after trabeculectomy alone as
    compared to phacotrabeculectomy.54
    Fibrinous exudation is the commonest complication observed followed
    by hyphema, and choroidal detachment (Fig. 3). 13, 32, 55, 56, 57 The incidence of
    fibrinous reaction after ECCE trabeculectomy has been documented to be as
    high as 27-54%. 17, 18, 55, 58 Late complications reported are posterior syn-
    echiae and posterior capsule opcification.54, 59, 60

    Fig. 3: Anterior chamber inflammation – Fig. 4: Shallow bleb prior to suture removal,
    post operative day 1. post operative day 14.

    54
    WHAT IS IMPACT OF COMBINED SURGERY ON BLEB MORPHOLOGY?
    In the authors’ experience, blebs in combined surgeries are usually flat-
    ter and not so pronounced as in trabeculectomy alone (Fig. 4). Other re-
    searchers have concurred with this and concluded that bleb height is lesser
    with the single site phaco-trabeculectomy and almost 2/3rd cases do not
    show a good bleb 15, 18, 24, 61 Limbal based flaps form higher blebs than fornix
    based flaps, 15% vs 9% in. one study.15 So the surgeon should not be worried
    at the absence of a good bleb, the filter still functions nevertheless.
    HOW DOES CATARACT SURGERY AFFECT FUNCTIONING
    TRABECULECTOMY BLEBS?
    A knowledge of this is relevant since this is a very common scenario
    faced by the ophthalmologist. Most studies have shown that cataract sur-
    gery in patients with prior trabeculectomy increases the intraocular pressure,
    increases the need for antiglaucoma drugs, and decreases bleb size espe-
    cially if extracapsular cataract extraction is done 62, 63, 64 The probable rea-
    sons for bleb failure include - inflammation of the conjunctiva adjacent to the
    filtering bleb after a corneoscleral incision and probable transient decrease
    in aqueous humor production in the first few days after cataract extrac-
    tion.64, 65 Post-operative intraocular inflammation and shallowing of ante-
    rior chamber results in peripheral anterior synechiae, and synechiae forma-
    tion around the sclerostomy site. Thus the chances of long term failure of the
    bleb are increased.66, 67
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    43 Bloomberg LB. Modified trabeculectomy / trabeculotomy with no stitch cataract
    surgery. J Cataract Refractive Surg 1996 Jan-Feb; 22(1): 14-22.
    44 Vyas AK, Bacon PJ, Percicval SPB. Phacotrabeculectomy : comparison of results

    57
    from 3. 5 and 5, 2 mm incisions. Ophthalmic Surgery and lasers 1998, 29 (3): 227-233
    45 Cohen JS, Geff LJ, Novack GD, Wind BE. A placebo controlled double masked
    evaluation of Mitomycin C in combined glaucoma and cataract procedures. Oph-
    thalmology 1006, 103(11): 1934-1942
    46 Stark WJ, Goyal RK, Awad O, et al. The safety and efficacy of combined phaco-
    emulsification and trabeculectomy with releasable sutures. Br J Ophthalmolol 2006,
    90: 146-149
    47 Weitzman M, Caprioli J. Temporal corneal phacoemulsification combined with sepa-
    rate-incision superior trabeculectomy. Ophthalmic Surg Lasers 1995; 26: 271-273.
    48 Carlson DW, Alward WLM. Barad JP et al. A randomized study of Mitomycin
    augmentation in combind phacoemulsification and trabeculectomy. Ophthalmol-
    ogy 1997, 104: 719-724.
    49 Asia Pacific Glaucoma Guidelines. South East Asia Glaucoma Interest Group
    2003-4.
    50 Detry-Morel M. Combined interventions: cataract and glaucoma review of the litera-
    ture. Bull Soc Belge Ophtalmol. 1998; 268: 45-60
    51 Funnell CL, Clowes M, Anand N. Combined cataract and glaucoma surgery with
    mitomycin C: phacoemulsification-trabeculectomy compared to phacoemulsification-
    deep sclerectomy. Br J Ophthalmol. 2005 Jun; 89(6): 694-8.
    52 Gianoli F, Schnyder CC, Bovey E, Mermoud A, Combined surgery for catract and
    glaucoma: phacoemulsification and deep sclerctomy compared with
    phacoemulsification and trabeculectomy. J Catarct Refract Surg 1999, 25: 340-346.
    53 Wedrich A, Menapace R, Radax U, Papapanos P. Longterm results of combined
    trabeculectomy and small incision cataract surgery. J Cataract Refract Surg 1995; 21:
    49-54.
    54 Siriwardena D, Kotecha A, Minassian D, et al. Anterior chamber flare after
    trabeculectomy and phacoemulsification. Br J Ophthalmol 2000; 84: 1056-1057.
    55 Hoffmann E, Schwenn O, Karallus M, et al. Long-term results of cataract surgery
    combined with trabeculotomy. Graefes Arch Clin Exp Ophthalmol. 2002 Jan; 240(1):2
    56 Cagini C, Murdolo P, Gallai R. . Long term results of one-site phacotrabeculectomy.
    Acta Ophthalmol Scand. 2003 Jun; 81(3): 233-6
    57 Casson RJ and Salmon JF. Combined surgery in the treatment of patients with
    cataract and primary open angle glaucoma. J Cataract Refractive Surg 2001, 27:
    1854-1863.
    58 Raitta C, Tarkkanen A. Combined procedure for the management of glaucoma and
    cataract. Acta Opthalmol 1988; 66: 667-670.
    59 Shin DH, Vandenbelt SM, Kim PH, et al. Comparison of long-term incidence of
    posterior capsular opacification between phacoemulsification and
    phacotrabeculectomy. Am J Ophthalmol. 2002 Jan; 133(1): 40-7.
    60 Ober MD, Lemon LC, Shin DH, Nootheti P, Cha SC, Kim PH. Posterior capsular
    opacification in phacotrabeculectomy : a long- term comparative study of silicone
    versus acrylic intraocular lens. Ophthalmology. 2000 Oct; 107(10): 1868-73.
    61. Shingleton BJ, Chaudhry IM, O’Donoghue MW, et al. Phacotrabeculectomy: limbus-
    based versus fornix-based conjunctival flaps in fellow eyes. Ophthalmology 1999;
    106: 1152-1155.
    62 Casson RJ, Riddell CE, Rahman R, Byles D, Salmon JF Long-term effect of cataract
    surgery on intraocular pressure after trabeculectomy: extracapsular extraction ver-
    sus phacoemulsification J Cataract Refract Surg. 2002 Dec; 28(12): 2159-64.

    58
    63 Chiselita D, Antohi I, Medvichi R, Danielescu C, et al. The influence of cataract
    surgery on the efficacy of trabeculectomy in patients with open-angle glaucoma.
    Oftalmologia. 2004; 48(2): 71-80
    64 Rebolleda G, Munoz-Negrete FJ Phacoemulsification in eyes with functioning filter-
    ing blebs: A prospective study. Ophthalmology. 2002 Dec; 109(12): 2248-55.
    65 Mandal AK, Chelerkar V, Jain SS, Nutheti R. Outcome of cataract extraction and
    posterior chamber intraocular lens implantation following glaucoma filtration sur-
    gery. Eye. 2005; 19(9): 1000-8
    66 Vass C, Menapace R. Surgical strategies in patients with combined cataract and
    glaucoma. Curr Opin Ophthalmol. 2004 Feb; 15(1): 61-6.
    67 Jampel HD, Friedman DS, Lubomski LH et al. Effect of technique on intraocular
    pressure after combined cataract and glaucoma surgery: An evidence-based review.
    Ophthalmology. 2002 Dec; 109 (12): 2215-24.

    59
    Section IV
    Non-penetrating Glaucoma Surgery

    Nonpenetrating glaucoma surgeries, namely deep sclerectomy (DS) and


    viscocanalostomy work by enhancing the natural aqueous outflow chan-
    nels, while reducing outflow resistance to which trabecular meshwork at-
    tributes 75% and outer wall of Schlemm’s canal (SC) 25%. A deep scleral flap
    and external wall of SC is removed leaving behind corneal stroma, anterior
    trabeculum and Descemet’s membrane, thus creating a scleral lake. The aque-
    ous humor leaves the anterior chamber through the intact
    trabeculodescemet’s membrane and reaches
    the scleral lake, from where it egresses into
    different pathways. To further enhance the DS is a good surgery for
    filtration, even the inner wall of the Sch- mild to moderate
    lemm’s canal and juxtacanalicular glaucoma, wherein the
    meshwork are peeled gradually using a spe- target IOP is in the mid
    cially designed Mermoud forceps, or teens.
    capsulorrhexis forceps. 1, 2

    WHO FATHERED IT?


    Louis de Wecker was the first one to describe it 1869-71 but it was
    Krasnov who performed the procedure almost a century later in 1962. 3 In the
    sinusotomy which he performed, a lamellar band of sclera was removed,
    Schlemm’s canal was opened from 10-2’O clock. At a later date he performed
    a surgical peripheral iridectomy. This is the equivalent to DS followed by
    goniopuncture of today. Thus, Krasnov deserves the title of being the father
    of deep sclerectomy.

    HOW DOES IT WORK?


    Aqueous humour flows through the thin trabeculodescemet’s membrane,
    which offers little resistance to aqueous outflow and allows a gradual fall in
    IOP thereby reducing the incidence of shallow anterior chamber (AC). The
    resistance offered by trabeculo-descemet’s membrane is low enough to en-
    sure a significantly low IOP and simultaneously high enough to maintain
    anterior chamber depth. The main site of aqueous outflow resistance is the
    juxtacanalicular meshwork, therefore removing this tissue after de-roofing

    61
    Schlemm’s canal (SC) along with floor (inner wall) of SC hits the nail on the
    head, by removing the villain of the story.
    How does the aqueous drain ?
    Through four proposed mechanisms: .
    a. Subconjunctival filtering bleb: A low, diffuse subconjunctival bleb forms.
    b. Intrascleral bleb: The empty scleral space left beneath the superficial scle-
    ral flap is transformed into an intra scleral bleb over time. To maintain
    the patency of this intrascleral bleb various implants namely collagen ,
    hyaluronic, HEMA etc. have been used. These prevent this space from
    collapsing upon itself. The aqueous humor from this space is probably
    absorbed by new aqueous drainage vessels.4
    c. Subchoroidal passage: The thinned scleral bed (10% of original thickness)
    allows aqueous to permeate through it into the suprachoroidal space.
    d. Episcleral drainage via Schlemm’s canal: On either side of deep sclerectomy
    the two surgically created ostia of Schlemm’s canal drain the aqueous
    into the episcleral veins.
    WHERE ALL IT WORKS ?
    n Open angle glaucoma and its variants 5, 6
    n For mild to moderate glaucoma
    n Target pressure required is in the mid teens
    It seems to work well in most races7, but there have been some reports
    where it seems to be less effective in blacks.8
    The long term control of IOP in DS, is less efficient than that with con-
    ventional trabeculectomy. 9, 10 The short term efficacy is however, quite simi-
    lar to trabeculectomy.11, 12
    The success of the surgery maybe predicted from the IOP on the first
    postoperative day. Andre’ Mermouds’ group observed that first day IOP of <
    5 mm Hg, is associated with a prolonged success and less requirement for
    subsequent goniopunctures.12
    WHERE ALL IT DOES NOT WORK ?
    l Narrow angle glaucoma : In narrow angle glaucoma, the pathology
    and resistance to outflow lies prior to the juxtacanalicular meshwork,
    thus DS is unable to rectify it.
    l Post-traumatic Angle Recession Glaucoma
    l Post-laser Trabeculoplasty treatment
    l Neovascular glaucoma

    62
    WHAT ALL IMPROVES THE EFFICACY OF THE SURGERY ?
    The main nemesis of any glaucoma filtration surgery, especially in the
    Indian, Oriental and Afro-African races is subconjunctival and subscleral
    fibrosis, which ultimately leads to it’s failure. The two methods used to pre-
    vent fibrosis at the level of subscleral and subconjunctival space are the use
    of implants or the time tested antimitotics. 13
    1. Implants
    That the use of implants is essential for the continuing function of the DS
    filter has been conclusively proven by Shaarawy T et al. They randomized
    one eye of each patient to receive a Collagen implant whereas the other eye
    underwent a DS without implant. At a 5 year follow up the filter was func-
    tioning in 69% of the implant eyes compared to only 38% of the plain DS
    eyes. Implants not only enhance the success rates, provide significantly lower
    IOP levels, but also lower the need for postoperative medications and
    goniopunctures.14 Implants can be both absorbable and nonabsorbable.
    a. Absorbable
    l Collagen implant (AquaflowT, Starr
    Surgical AG), 2.5 by 1 mm, is a puri-
    fied biologically inert, porcine scle- Implants or MMC
    ral collagen.15 The water content of dramatically improve
    the hydrated device is 99%, and it the success and
    swells to two to three times its dry longevity of deep
    size, after placement in the subscle- sclerectomy.
    ral space. Complete resorption of the
    implant occurs by 6-9 months16, 17
    l Healon GV 18, 19
    l Reticulated cross-linked sodium hyaluronate implant SK Gel (Cor-
    neal Laboratories Paris, France) swells up in contact with water.
    This biosynthetically produced implant is triangular in shape and
    comes in two sizes - 3.5 and 4.5 mm. 20, 21
    l Autologous sclera.22
    l Amniotic membrane - It creates an anatomic barrier by keeping the
    potentially adhesive surfaces apart, and also prevents fibrosis of the
    decompression space. It has anti-fibrotic properties owing to down
    regulation of TGF- Beta (responsible for fibroblastic activation in
    wound healing), and the avascular stroma of amniotic membrane
    inhibits ingrowth of new vessels. It has been used as an alternative
    to the prohibitively expensive implants. 23, 24

    63
    b. Non absorbable
    l T-Flux( IOL Tech). This T shaped hydrophilic acrylic device is 0.2
    mm thick. Its two arms are placed in the cut ends of the Schlemm’s
    canal. It is anchored to the sclera using a 10 zero monofilament
    nylon suture through a hole in its limb .18, 25
    l T- bar – Stainless steel.
    l Mermoud X ( CARE group).
    l PMMA – less expensive. 16
    2. Antimitotics
    Mitomycin-C, 5-fluorouracil, daunorubicin also minimize fibrosis,
    thereby prolonging the survival of deep sclerectomy, consistently produce
    lower IOP and reduce the requirement of goniopunctures.20, 24, 26, 27, 28 The
    dose used is 0.2-0.4% placed under the superficial scleral flap and in the
    sub-conjunctival space for 2- 4 minutes. Caution needs to be used with mito-
    mycin, as its application on the area of scleral flap, is associated with a high
    incidence of bleb avascularity, transconjunctival ooze, avascular blebs and
    delayed bleb leaks. 29
    HOW TO PERFORM A DEEP SCLERECTOMY ?
    l A limbal-based / fornix based conjunctival flap is created. (Fig 1)
    l Haemostasis is ensured with minimal wet field bipolar cautery, taking
    care to avoid any of the aqueous draining channels. The key is to use
    cautery to a minimum to avoid damage to the collector channels, aque-
    ous veins which are going to be the main drainage pipes for aqueous in
    this surgery.
    l Excess Tenon tissue is excised .
    l A 5x5 mm rectangular/ parabolic, one-third scleral thickness flap is
    made and dissected 1 –1.5 mm anteriorly into clear cornea with a dis-
    posable crescent knife (Fig. 2 & 3).

    Fig.2: Superficial scleral flap being


    Fig.1: Limbus based conjunctival flap dissected.

    64
    Fig.3: End point of superficial scleral flap Fig.4: Deep scleral flap being dissected

    l Mitomycin, if needed, is applied in the dose of 0.2 -0.4 mg/ml for 2-3
    minutes. The same precautions and technique is used as elaborated in
    Section II. 28
    l A second 5x5 mm deep scleral flap approximately 90% of scleral thick-
    ness is then dissected leaving a thin
    layer of deep sclera over the choroid.
    This smaller deeper flap stops short – At 90% depth, blue brown
    of the larger superficial flap by leav- choroid is visible during
    ing a small margin on each side. An dissection.
    important tip is that if one is in the – Microperforations during
    right plane, at 90% depth, one will see surgery are usually
    the bluish brown choroid shining inconsequential.
    through the thin layer of sclera. At this
    point it is advisable to increase the magnification of the microscope to
    16-20 X (Fig. 4).
    l Near the limbus, the random arrangement of the scleral fibres gives way
    to a parallel, circumferential arrangement, namely the scleral spur. Usu-
    ally Schlemm’s canal lies just anterior to this. Thus the circular ligament
    serves as a landmark for the identification of Schlemm’s canal (Fig. 3).
    l The Schlemm’s canal is then deroofed. Some surgeons prefer to do a
    paracentesis before this step to reduce the bulge of the Schlemm’s canal
    (SC). After deroofing , the sclerocorneal dissection is carried forward for
    1-1.5 mm to remove the sclerocorneal tissue in front of the anterior
    trabeculum, and inner wall of the SC. Radial incisions with the help of a
    blunt diamond knife are made from the edges of the deep flap and the
    floor of SC . The juxta canalicular trabecular meshwork is gently peeled
    with the help of a special forceps, or a capsulorrhexis forceps. The area
    must be meticulously dried before peeling the inner wall of SC. Avoid
    perforating the trabeculo-descemet’s membrane at this stage, by keeping
    the magnification at a maximum and dissection slow and gentle.

    65
    Fig.5: Cutting deep scleral flap. Note the Fig.6: Amniotic membrane being placed
    aqueous percolation. from a spatula onto the scleral bed

    l The end point of dissection is when the aqueous starts percolating


    through the remaining thin trabeculo-descemet’s membrane. The deep
    scleral flap is then excised at the base taking the corneoscleral tissue
    overlying anterior trabeculum using a Vannas scissors or diamond knife.
    (Fig 5 )
    l A simple yet novel modification by Abdelrahman AM is to insert the
    trabeculotome through a vertical cut at one end of the deeper scleral flap,
    just anterior to the scleral spur (anterior to the circumferential band of
    scleral fibres and just at the posterior end of the translucent blue grey
    zone). This is made after complete superficial flap dissection and once
    the deep flap has been marked out. The trabeculotome is then intro-
    duced into the SC and traverses it horizontally. At the other edge of the 3
    x 3 mm deeper scleral flap, a direct vertical incision is made over the
    trabeculotome, and the instrument tip is allowed to exit. The handle of
    the trabeculotome is then rested on the surface. With the trabeculotome
    in place, the deeper flap is dissected and the SC is opened along its
    posterior wall thereby exposing the steel arm of the trabeculotome. 30
    With this technique SC is easily identified and completely de-roofed.
    l An implant or 10 x 6 mm amniotic membrane with the epithelial side up,
    is then placed over the deep scleral
    bed. The amniotic membrane does
    not need to be sutured (Fig 6). Al-
    ternatively an implant- collagen, T
    flux etc. can be placed on the scle-
    ral bed and anchored with one or
    two 10 zero nylon sutures,
    l The superficial scleral flap is se-
    cured to the scleral bed with two
    loose interrupted 10-0 nylon su-
    Fig.7: Suturing the superficial scleral flap tures and the knots are buried
    - with 2 loose sutures (10/0 nylon). (Fig 7).

    66
    l Conjunctiva and tenon capsule are closed in two or single layers.
    l The trick is to perform the deep dissection under high magnification, in
    as dry a field as possible.
    l At the start of the deeper flap dissection, Mermoud recommends that the
    posterior limit of the deep flap is cut upto 100% depth, this induced
    microperforation gives a clue as to the depth of the sclera. Hold the edge
    of sclera at one corner a with a non toothed forceps, then with a crescent
    blade the dissection plane is made, a hair breadth above the full thick-
    ness cut.
    THE POSTOPERATIVE COURSE
    Topical antibiotic corticosteroid drops are prescribed for 6-8 weeks,
    cycloplegics are usually not required. Visual acuity returns to baseline within
    7-10 days and there is virtually no anterior chamber inflammation. Usually
    a very shallow diffuse bleb forms within the first week.
    Fibrosis at the level of trabeculo-Descemet’s membrane, inspite of im-
    plant usage is seen in more than half (51-63%) the patients. 19, 31, 32 In this
    scenario a technique known as
    Goniopuncture needs to be performed. This
    is usually required 3-21 months after sur- Effect of DS wanes with
    gery 31, 33 It is performed once insufficient time, and gonipunctures
    aqueous percolation has been documented with Nd:YAG need to be
    by rising IOP. It is done with a Neodymium: performed in 50 - 60%
    YAG laser, using a gonioscopic mirror lens cases.
    - (CGI from LASAG or Rousell &
    Frankhauser from Haag Streit). The aiming beam is focused on the thinned
    out, less pigmented trabeculo-Descemet’s membrane with a power of 2-4 mJ.
    Around 5-15 shots may be required at the level of Schwalbe’s line, and also
    above and below it. Some air bubbles may be generated during the procedure
    and a dramatic fall in IOP is usual, within hours of a successful
    goniopuncture.33 Spontaneous iris prolapse with subsequent IOP rise is a
    common complication which may need treatment with pilocarpine, laser
    goniosynechiolysis, and rarely surgical revision.19, 34,
    This converts the procedure into a minipenetrating one, but since this is
    usually done more than 10-12 months after the primary surgery, the risks of
    hypotony and shallow AC are very minimal.
    With time filtration of DS wanes inspite of goniopunctures. Supplemen-
    tal medications and / or repeat surgery is required in more than 50% after 4-
    5 years.6,19 In a 6 year retrospective follow up, the success rate, defined as an
    IOP lower than 21 mm Hg, was 66.46% at 60 months off all glaucoma medi-
    cations and 80.32% with additional medical or surgical treatment. 32

    67
    WHAT ARE THE MODIFICATIONS OF DEEP SCLERECTOMY ?
    1. Combined with cataract surgery
    Combined phacoemulsification with DS, with or without implant / an-
    timitotics achieves target IOP in almost 85% cases. 3, 35 The most frequently
    observed complications are conjunctival wound leakage, severe inflamma-
    tory reaction and hyphema.35, 36, 37. Phacotrabeculectomy controls the intraocu-
    lar pressure more effectively compared to DS phacoemulsification, 38 but
    carries a greater risk of hypotony and visual deterioration.39
    The technique:
    Ø Perform a temporal clear corneal phacoemulsification .
    Ø Anterior chamber is filled with viscoelastics to create a firm eye, and
    the corneal wound is sutured even if it is self sealing.
    Ø The surgeon then shifts to the superior site for DS.
    Ø To observe for percolation of aqueous after de-roofing of SC, the AC
    is partly emptied of viscoelastic and refilled with BSS/Ringer to
    evaluate the adequacy of trabecular meshwork removal.
    Ø After conjunctival flap suturing, the viscoelastic is completely aspi-
    rated from the eye
    or Alternatively
    Ø First the superficial scleral flap is dissected, deeper flap outlined
    Ø Mitomycin is applied and washed
    Ø Then clear corneal temporal phacoemulsification is performed
    Ø The rest of the steps are as outlined above
    2. Laser assisted Deep sclerectomy
    Carbon dioxide and Erbium: YAG lasers have been used to ablate the roof
    and floor of the Schlemm’s canal. 40, 41
    3. Viscocanalostomy
    First proposed by Robert Stegman in 1991, in South Africa where a glau-
    coma surgery was required for people living in poor hygienic conditions
    with poor drug compliance and limited accessibility to medical care. The
    surgical steps are same as for deep sclerectomy till Schlemm’s canal is
    deroofed. Then by a paracentesis the IOP is lowered, the two cut ends of
    Schlemm’s canal are cannulated with a special 165 µm canula and high
    molecular weight sodium hyaluronate is slowly injected into the canal. Upto
    1-2 clock hours of the canal is atraumatically dilated. The slow injection is
    repeated six to seven times on each side.7 The rest of the procedure is same as
    described for deep sclerectomy except that the outer scleral flap is tightly
    68
    secured with 6-7 10/0 nylon sutures to ensure that a intrascleral chamber is
    created. Healon GV is left beneath the superficial scleral flap.
    WHAT ARE THE COMPLICATIONS NOTED IN DS?
    I. Intra-operative
    (a) Perforation of the trabeculodescemet’s membrane (TDM): It is the com-
    monest complication in the learning phase and has been reported to be as
    high as 30% in the learning period. That this surgery has a steep learning
    curve is evident by the fact that in experienced hands this rate comes down
    to 3%. Perforation with no iris prolapse occurs due to a large Descemet’s tear
    or anterior trabeculum hole. To avoid subsequent iris prolapse or peripheral
    anterior synechia, small amount of low molecular weight viscoelastic should
    be injected into the anterior chamber. A perforation of the TDM transforms a
    non-penetrating surgery into a penetrating one.
    (b) Microperforation of TDM : This is the commonest complication after
    the learning curve is over. Seen in almost 7.0 % cases, it is almost always
    located in the thinnest portion, namely the anterior trabeculum and De-
    scemet’s membrane. 9, 18 Small perforations
    with deep anterior chamber are generally
    ignored and the surgery can be continued. The hallmark of DS is
    (c) Hemorrhages: Intra-operatively minimal complications
    bleeding may occur either at the like less inflammation,
    conjunctivoscleral level or in the uveal tis- less shallow AC and less
    sue and can also be seen secondary to blood cataract.
    reflux from the Schlemm’s canal. During the
    conjunctival and then the scleral dissection, major bleeding should be treated
    with light wet field cautery. Intraocular bleeding from any uveal or retinal
    vessels; secondary to IOP drop is rare, since the IOP fall is more controlled in
    this surgery.
    II. Early Postoperative
    a) Wound leak: It is seen due to insufficient wound closure. 10, 18, 32
    b) Hyphema : Relatively rare complication of non-penetrating surgery.
    The blood in the anterior chamber can be due to rupture of small iris vessels
    or from a leak of red blood cells through the TDM.18, 32
    c) Inflammation : Degree of anterior chamber inflammation is very nomi-
    nal since the anterior chamber is not opened. Penetration of anterior cham-
    ber leads to the breakdown of blood-aqueous humour barrier, which leads to
    release of inflammatory mediators.
    d) Hypotony : Mean IOP can drop upto 5.0 mm of Hg on the first postop-
    erative day. It is short lived, self resolving and does not require any treat-
    ment. In fact, early hypotony without any perforation is an excellent indica-

    69
    tor of good surgical dissection and prognosticates a successful surgery.
    e) Shallow or flat anterior chamber : After an uncomplicated deep sclerec-
    tomy a totally flat chamber is almost never seen. A shallow chamber necessi-
    tates ruling out conjunctival wound leak, pupillary block and malignant
    glaucoma. Shallow chamber with hypotony can be due to perforation of
    TDM or choroidal detachment .
    f) Decreased visual acuity : Visual deterioration after deep sclerectomy
    is very mild since no postoperative cycloplegics, are prescribed and anterior
    chamber inflammation is nominal. Visual acuity may decrease by one or two
    Snellen lines for the first postoperative week only. The drop is probably due
    the readaptation of retinal and choroidal blood flow to a new level of
    intraocular pressure.
    g) Cataract formation: Due to maintenance of anterior chamber depth,
    relatively slower fall of IOP and low degree of inflammation there have been
    no reports of surgically induced cataract so far . However, few studies have
    documented progression of preexisting senile cataract. 31, 32
    III. Late postoperative complications
    Late postoperative complications of deep sclerectomy are not much dif-
    ferent from those seen in trabeculectomy because the late complications are
    mostly related to the excessive scarring of the operated tissues.
    a) Fibrosis of subconjunctival bleb : Fibrosis and flattening of the sub
    conjunctival bleb is common after deep sclerectomy but as such it does not
    have much influence on IOP because the presence of intra scleral bleb re-
    duces the need for a subconjunctival bleb. If the IOP is adequate, then a flat
    bleb does not require any treatment. Needling with 5 FU or revision of sur-
    gery is required only if IOP control fails.
    b) Increased intraocular pressure : Late increased IOP may be caused by
    TDM, subscleral or subconjunctival fibrosis. Ultrasound biomicroscopy of
    the surgical site would help in visualizing the site of obstruction.
    Goniopunture, medical therapy or revision of filtering surgery would be the
    subsequent modalities to control the IOP.
    c) Late rupture of trabeculodescemet’s membrane : Usually does not occur
    spontaneously because the membrane’s outflow resistance builds up slowly
    for several weeks after surgery. Subsequent to ocular trauma rupture of the
    membrane has been reported, however it usually resolves without treatment.
    References
    1 Mermoud A, Ravinet E. Surgical technique. In Eds: Mermoud A, Shaarawy T, Ritch
    R. Nonpenetrating glaucoma surgery. London, Martin Dunitz, UK 2001; 97-108.
    2 Mermoud A. Nonpenetrating surgery. In Eds: Shaarawy T, Mermoud A eds. Atlas
    of glaucoma surgery. Vol II. New Delhi, Jaypee Brothers Medical (Publishers P) Ltd.,
    India 2006 : pg103-130.

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    3 Krasnov MM. Externalization of Schlemm’s canal (sinusotomy) in glaucoma. Br J
    Ophthalmol 1968; 52: 157-161.
    4 Delarive T, Rossier A, Rossier S et al. Aqueous dynamic ad histological findings after
    deep sclerectomy with collagen implant in an animal model. Br J Ophthalmol 2003,
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    5 Mermoud A, Schnyder CC, Sickenberg M, Chiou AG, Hediguer SE, Faggioni R J
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