Cystic bleb formation and related complications in limbus- versus fornix-based conjunctival flaps in pediatric and young adult trabeculectomy with mitomycin C

Childhood glaucoma surgery in the 21st Century

“…[33][34][35][36] Subsequently, simple modifications to the intraoperative application of MMC and to the surgical technique have reported much reduced long-term complication rates and more favourable bleb morphology. 37,38 In 1994, Tixier et al 39 were the first to publish their results of non penetrating surgery (deep sclerectomy) in children following reports in adults of its advantageous risk profile. Again the origins of this technique, like penetrating surgery (trabeculectomy) derived from the 1960s when Krasnov 40 described it in an attempt to avoid the potential complications associated with ocular entry.…”

“…34,78,83 Furthermore, success in infants has been reported to be lower than older age groups 33,35,82 and when compared with GDD. 72 However, it is our experience that with simple modifications to the surgical technique and with suitable anti-scarring potency and application technique (Moorfields Safer Surgery System), 37,38 trabeculectomy can be associated with satisfactory outcomes in appropriate cases, even infants.…”

Advances in the management of paediatric glaucoma

“…40 A number of modifications to the filtering technique have been described in achieving Management of paediatric glaucoma M Papadopoulos and PT Khaw favourable bleb morphology. 41 An ideal bleb is one which is elevated and diffuse, without any restricting scar, the so-called 'ring of steel'.…”

“…41 An ideal bleb is one which is elevated and diffuse, without any restricting scar, the so-called 'ring of steel'. A combination of the following three techniques is likely to achieve this: (i) fornix-based conjunctival flap, 40 as it minimises the chance of a posterior scar restricting aqueous diffusion, often seen following the posterior incision of limbal-based conjunctival surgery, (ii) large antimetabolite treatment area, 42 which results in a greater area for diffusion, and (iii) posterior flow encouraged through a large, scleral flap with short side incisions, with thoughtful placement of a combination of fixed, adjustable and releasable sutures to avoid anterior limbal aqueous jets ( Figure 5).…”

Trabeculectomy is not the best surgical option for glaucoma

“…The risk of bleb-related endophthalmitis (BRE) ranges from 1.5% per patient year 3 to 10% in one year, 4 with 11 recent studies giving an average incidence of 2.8% per year. [5][6][7][8][9][10][11][12][13] As the mean follow-up of these 11 studies was 19 months, the true incidence may be higher, as institutional reviews of BRE show that the mean time of presentation of BRE is 32 months postoperatively. [14][15][16][17][18] Of equal importance as a cause of central visual loss after MMC trabeculectomy is hypotony maculopathy, with a mean incidence of 3.2% per annum reported in 7 recent studies (mean follow-up of 28 months).…”