Outcomes and Bleb-Related Complications of Trabeculectomy

Glaucoma Service and Dana Center for Preventive Ophthalmology, Wilmer Ophthalmological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Ophthalmology (Impact Factor: 5.56). 01/2012; 119(4):712-22. DOI: 10.1016/j.ophtha.2011.09.049
Source: PubMed

ABSTRACT To determine rates of success and complications of trabeculectomy surgery.
Case series.
Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008.
By using the Wilmer Institute's billing database, we identified all patients at least 12 years of age coded as having undergone trabeculectomy between May 2000 and October 2008 by 1 of 2 glaucoma surgeons and whose surgery was not combined with another operation. From the chart, we abstracted demographic information on the patients and clinical characteristics of the eyes. The Kaplan-Meier product-limit method and Cox proportional hazard models were used to look at success rates and characteristics associated with inadequate intraocular pressure (IOP) reduction. Complications were tabulated.
(1) Success rate of trabeculectomy, as determined by the achievement of each of 4 different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications.
During the study period, 797 eyes of 634 persons underwent trabeculectomy without concurrent surgery. The success rates 4 years after surgery, with or without the use of IOP-lowering eye drops, were 70%, 72%, 60%, and 44%, for achievement of target IOP, ≤18 mmHg and ≥20% IOP reduction, ≤15 mmHg and ≥25% reduction, and ≤12 mmHg and ≥30% reduction, respectively. Increased chance of success was associated with European-derived race; use of mitomycin C (MMC); higher concentrations of MMC, when used; and higher preoperative IOP. Age and previous intraocular surgery were not associated with surgical success. Complications included worsening lens opacity in 242 of 443 phakic eyes (55%), loss of ≥3 lines of acuity (Snellen) in 161 eyes (21%), surgery for bleb-related problems in 70 eyes (8.8%), and infection occurring >6 weeks after surgery in 27 eyes (3.4%). A total of 101 eyes of 94 patients had at least 1 subsequent operation for inadequate IOP control.
Trabeculectomy surgery performed by 2 experienced glaucoma specialists achieved target IOP at 4 years in 70% of those operated and was associated with progressive cataract and small risks of bleb-related complications. These results are comparable to those reported in smaller series.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: The aim of the study was to evaluate the long-term outcomes of a large series of 'modern' trabeculectomies with specific respect to traditional risk factors for failure. Methods: 636 consecutive 'modern', augmented 'safe-technique' trabeculectomies performed over an 11-year period (1998-2008) were assessed in a single centre, observational, cohort study. Traditional risk factors for failure (previous surgery, long-term exposure to topical medication, young age, secondary glaucoma and trainee surgeon) were assessed using various success outcome criteria. Success survival was defined with respect to various intraocular pressure (IOP) targets, using criteria for both complete and two categories of qualified success. A multivariate logistic regression analysis was performed to account for the significant number of patients with more than one risk factor. Results: The mean follow-up period was 65.5 (± 35.7) months. At final follow-up the mean IOP for all eyes was reduced from 23.4 (± 6.2) mmHg pre-operatively to 11.9 (± 4.2) mmHg (p<0.001) and the mean number of topical anti-glaucoma medications was reduced from 2.3 to 0.4 (p<0.001). Complete success rates were 65% (IOP ≤ 15 mmHg, no medications) and 71% (IOP ≤ 21 mmHg, no medications) at final follow-up. Qualified success rates varied from 78% to 97%, depending on IOP threshold. Outcomes for the various risk factor groups were compared with a 'risk-free' control group. Overall, traditional risk factors for failure did not significantly influence outcome for the various success criteria, but surgery performed by trainee surgeons had less satisfactory outcomes compared to surgery performed by a more senior surgeon. Clinic-based post-operative interventions were more frequently required in eyes with 'traditional' risk factors for failure. Conclusions: In a large cohort of mainly Caucasian patients, appropriately augmented, 'modern', 'safe-technique' trabeculectomy was highly successful and, together with 'modern' post-operative management, appeared to annul the effect of most 'traditional' risk factors for failure such as previous surgery, long-term exposure to topical medication, relative youth and secondary glaucoma.
    Clinical and Experimental Ophthalmology 11/2014; 5(6):1000371. DOI:10.4172/2155-9570.1000371 · 1.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To summarize the role of cataract surgery in the glaucoma patient, in terms of the effect on intraocular pressure (IOP) as well as diagnostic and therapeutic considerations for those with both conditions. Recent evidence suggests that cataract extraction may produce a significant and sustained IOP reduction in individuals with open-angle glaucoma, ocular hypertension, and angle-closure glaucoma. Cataract removal may improve the practitioner's ability to interpret perimetric testing, and re-establishing perimetric and optic nerve imaging baselines is recommended after cataract surgery. The sequence of cataract surgery relative to glaucoma surgery impacts the likelihood of complications and surgical success. There are multiple benefits to perform cataract surgery prior to glaucoma surgery while cataract surgery after trabeculectomy increases the risk of subsequent filtration failure. As "minimally invasive glaucoma surgeries" continue to improve in terms of efficacy, there is an evolving role for combined cataract and glaucoma surgery in patients with early to moderate stages of glaucoma.
    Middle East African journal of ophthalmology 01/2015; 22(1):10-7. DOI:10.4103/0974-9233.148343
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The objective of the study reported here was to evaluate the outcome of a modified filtering trabeculotomy (FTO) without iridectomy in open-angle glaucoma compared with that of conventional trabeculectomy (trab). Thirty eyes of 30 patients who underwent modified FTO were prospectively followed for 1 year and were compared with 87 conventional trab patients (87 eyes), matched for age and preoperative intraocular pressure (IOP). The FTO procedure consisted of a deep sclerectomy and trabeculotomy preserving the trabeculo-Descemet membrane, without iridectomy. Main outcome measures were complete success (IOP <18 mmHg and >/=30% IOP reduction, without medication), IOP, visual acuity, medication, complications, and subsequent surgeries. In the conventional trab group, the median preoperative IOP was 23.0 mmHg (interquartile range 20.0-27.0) with 3.0 (2.0-3.0) medications, compared with 23.0 mmHg (20.0-27.0) and 3.0 (2.8-4.0) in the modified FTO group. Median postoperative IOP at 12 months was 12.0 mmHg (10.0-13.0) in the conventional trab and 11.0 mmHg (8.0-14.0) in the modified FTO group (P=0.3). The complete success rate at 1 year was 83.1% and 79.3% in the conventional trab group and modified FTO group, respectively (P=0.8). The complications hypotony (20.7%, 24.1%), choroidal detachment (2.3%, 10.3%), and bleb scarring (17.2%, 13.8%), were present in the conventional trab group and modified FTO group, respectively. The outcomes of reduced IOP and medications in the FTO group were not different to those in the conventional trab group over 1 year, but some complications were more often seen with the modified FTO technique. The new filtration trabeculotomy, however, has the advantage of avoiding iridectomy, thus reducing the risk of cataract formation, and may result in the development of more favorable blebs by controlling the flow over two resistance levels.
    Clinical ophthalmology (Auckland, N.Z.) 01/2015; 9:483-92. DOI:10.2147/OPTH.S74853