Managing Complications in Glaucoma Surgery

Managing
Complications in
Glaucoma Surgery
Francis Carbonaro
K. Sheng Lim
Editors
123
Managing Complications in Glaucoma
Surgery
Francis Carbonaro • K. Sheng Lim
Editors
Managing Complications
in Glaucoma Surgery
Editors
Francis Carbonaro, MD, PhD, FRCOphth. K. Sheng Lim, MBChB, FRCOphth, MD
Mater Dei Hospital St Thomas’ Hospital
Msida London
Malta UK
ISBN 978-3-319-49414-2 ISBN 978-3-319-49416-6 (eBook)

DOI 10.1007/978-3-319-49416-6
Library of Congress Control Number: 2017933708
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Contents
1 Glaucoma Laser �� 1

Jason Cheng, Mariana Cabrera, Jacky W.Y. Lee,
and Yvonne M. Buys
2 Minimally Invasive Glaucoma Surgery�� 21
Kuang Hu, Keith Barton, and Julian Garcia Feijoo
3 Nonpenetrating Glaucoma Surgery (Deep Sclerectomy,
Viscocanaloplasty, and Canaloplasty)�� 51
Jason Cheng, Kuang Hu, and Nitin Anand
4 Trabeculectomy�� 73
Rashmi G. Mathew and Ian E. Murdoch
5 Glaucoma Tube Surgery�� 97
K. Sheng Lim, David Steven, and Francis Carbonaro
v
Glaucoma Laser
1
Jason Cheng, Mariana Cabrera, Jacky W.Y. Lee,
and Yvonne M. Buys
1.1 asers That Increase Aqueous Outflow: Argon Laser

L
Trabeculoplasty
1.1.1 Introduction
Argon laser trabeculoplasty (ALT) was first introduced in 1979 by Wise and Witter
(Coakes 1992). Despite its clinical efficacy in intraocular pressure (IOP) lowering,
its use is limited by scarring of the trabecular meshwork, which may potentially
restrict retreatment.
1.1.2 Procedure
ALT is usually performed with topical anesthesia under direct visualization using a
gonioscopic lens. Initially, only 180° of the meshwork is treated. Around 40–50 laser
spots are aimed at the anterior half of the trabecular meshwork to reduce the chance
of peripheral anterior synechiae (PAS) formation. The laser spot size is 50 μm and
the initial laser energy of 800 mW is titrated until minimal bubble formation in the
pigmented trabecular meshwork is seen. After 4–6 weeks, IOP is reassessed and the
remaining half of the trabecular meshwork may be treated if needed. Topical steroids
are usually given for the first week after ALT (Weinreb and Wilensky 1984).
J. Cheng (*)
Khoo Teck Puat Hospital, Yishun, Singapore
e-mail: [email protected]
M. Cabrera • Y.M. Buys
Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
J.W.Y. Lee
Dennis Lam & Partners Eye Center, Hong Kong, China
F. Carbonaro, K. Sheng Lim (eds.), Managing Complications in Glaucoma Surgery, 1

DOI 10.1007/978-3-319-49416-6_1, © Springer International Publishing AG 2017
2 J. Cheng et al.
1.1.3 Efficacy and Outcomes
In one of the largest randomized controlled trials involving 3608 subjects, comparing
ALT versus Timolol 0.5 % as primary treatment for open-angle glaucoma (OAG), ALT
lowered the IOP by 9 mmHg compared to a 7 mmHg drop in those using medication
alone. At 2 years, 44 % of ALT-treated eyes did not require additional interventions
compared to 30 % in the medication group. By 7 years, the ALT group continued to
have lower IOPs and less visual field progression compared to the medication group.
The authors concluded that ALT had a similar efficacy to Timolol 0.5 % (Glaucoma
laser trial 1991). In the literature, the range of IOP reduction is from 13 % to 32 % in
OAG eyes (Stein and Challa 2007). In comparison with selective laser trabeculoplasty
(SLT), a meta-analysis has concluded that the IOP-lowering effects between the two
lasers were similar or at least one was not inferior to the other (Wong et al. 2015).
1.1.4 Complications
1.1.4.1 Intraoperative Complications

Hyphema can occur from inadvertent laser shots to the iris root or as a result of
blood reflux from the Schlemm’s canal. Pain may be experienced during the laser
treatment despite the application of topical anesthetic agents, and vasovagal syn-
cope has been a reported complication of ALT (Weinreb and Wilensky 1984).
1.1.4.2 Early Postoperative Complications

Immediately following ALT treatment, the protein and inflammatory mediator con-
tents in the anterior chamber are increased. As a result of trabecular meshwork
blockage by extracellular debris and swelling, the IOP may rise by 5 mmHg in 34 %
of patients and up to 10 mmHg in 12 % of patients following treatment (Coakes
1992). The IOP spike usually occurs anywhere from 2 to 4 hours after ALT and is
associated with the use of higher laser energies, 360° as opposed to 180° treatments,
and more posterior laser applications (Coakes 1992). IOP spikes may be prevented
with a topical alpha-adrenergic agent, whereas the control of the inflammation with
topical steroids does not seem to alter the course of IOP elevations (Coakes 1992).
A degree of anterior uveitis is present in all patients after ALT, although it is
often self-limiting and transient in nature. The prescription of a topical steroid is a
common practice after ALT (Coakes 1992).
1.1.4.3 Late Postoperative Complications

Anterior chamber inflammation and too posteriorly placed laser shots may lead to
PAS formation, which can occur at an incidence of 12 %–47 % after ALT (Coakes
1992; Weinreb and Wilensky 1984; Wong et al. 2015). In histological analysis of
eyes treated with ALT, it was found that the trabecular beams were severely dis-
torted together with the loss of the trabecular endothelial cells and the formation of
a cellular sheet that extends from the Schwalbe’s line to the anterior aspect of the
trabecular meshwork (Coakes 1992).
1 Glaucoma Laser 3
Other less common late postoperative complications reported in the literature

include corneal endothelial damage, unexplained visual field loss in two elderly
patients, and even a rare case of presumed sympathetic ophthalmia in an aphakic
eye with uveitis at 1 year after ALT (Juhas 1993; Coakes 1992; Weinreb and
Wilensky 1984).
1.2 asers That Increase Aqueous Outflow: Selective Laser

L
Trabeculoplasty
1.2.1 Introduction
Selective laser trabeculoplasty (SLT) was first described by Latina and Park in 1995.
It is performed using a frequency-doubled (Q-switched) Nd:YAG laser (Wong et al.
2015). It selectively targets melanoctyes in the trabecular meshwork and only deliv-
ers 1 % of the energy used in the former ALT technology. As SLT does not induce
any trabecular meshwork scarring, repeated treatments are possible. In 2001, the
United States Food and Drug Administration approved the use of SLT for the treat-
ment of OAG.
1.2.2 Procedure
As with ALT, SLT is performed under topical anesthesia using a gonioscopic lens.
An initial energy of 0.8 mJ is used with titration in energy level until bubble forma-
tion is just visible in the trabecular meshwork. The laser spot size is 400 μm and the
duration is 3 ns. Nonoverlapping laser shots are applied to 180°–360° of the tra-
becular meshwork. A higher total laser energy has been associated with a greater
chance of IOP reduction (Lee et al. 2015). Postoperative eye drops may vary from a
weak topical steroid, topical nonsteroidal anti-inflammatory, to no postoperative
eye drops.
In a recent meta-analysis of randomized controlled trials on the use of SLT in the

treatment of OAG, it was reported that the range of IOP reduction varies from 6.9 to
35.9 % at ≥12 months post-SLT among patients newly diagnosed with glaucoma to
those who were already on maximally tolerated topical antiglaucoma medications.
Wong et al. concluded that SLT is noninferior to ALT and topical antiglaucoma
medication in terms of IOP reduction and achieving treatment success. The amount
of medication reduction is also similar between SLT and ALT (Wong et al. 2015).
Koucheki et al. reported a similar rate of IOP reduction among primary open-angle
glaucoma (POAG), pseudoexfoliation, and pigmentary glaucoma patients; however,
those with diabetes had a lower amount of IOP reduction following SLT. Pigmentary
4 J. Cheng et al.
glaucoma has been reported to be associated with more complications including

significant pressure spikes following SLT; occasionally requiring surgical interven-
tion (Koucheki and Hashemi 2012).
1.2.4 Complications

Throughout the literature, SLT seems to be a relatively safe procedure without many
severe intraoperative complications (Wong et al. 2015). Some potential complica-
tions during the procedure may include corneal abrasion, subconjunctival hemor-
rhage, hyphema, and ocular pain. Some patients may experience an ipsilateral
headache or photophobia after the laser (Klamann et al. 2014; Wong et al. 2015).

The majority of side effects of SLT are mild and transient including: anterior uveitis,
IOP spikes, conjunctivitis, corneal edema (Fig. 1.1), visual blurring, and only one
case report of choroidal effusion and three case reports of cystoid macular edema
(Klamann et al. 2014; Wong et al. 2015).
Given the lower energy used in SLT as compared to ALT, the majority of anterior
uveitis after SLT settles within 3 to 5 days (Lee et al. 2014a). Koucheki et al. reported
an inflammatory rate of 42.6 % in OAG eyes (Koucheki and Hashemi 2012). Jinapriya
et al. compared the use of artificial tears, prednisolone acetate 1 %, or ketorolac tro-
methamine 0.5 % eye drops four times per day for 5 days following SLT and found
that the use of an anti-inflammatory medication for a short period of time after SLT
did not affect the IOP-lowering efficacy of the laser (Jinapriya et al. 2014).
Fig. 1.1 Corneal edema

after SLT (Taken from a
case report by Moubayed
et al. (2009))
1 Glaucoma Laser 5
Similar to ALT, IOP spikes can occur within 1 to 2 hours of the procedure with
spikes >5 mmHg in about 10 % of patients and spikes >10 mmHg in 3 % following
SLT (Barkana and Belkin 2007). Similar to ALT, a topical alpha-adrenergic agent may
be used as prophylaxis before or immediately after the procedure. However, it should
be noted that increased trabecular meshwork pigment has been associated with sig-
nificant IOP spikes necessitating urgent filtration surgery, thus, lower energies or per-
haps less invasive laser trabeculoplasties like MicroPulse Laser Trabeculoplasty
(MLT) may be considered in these cases (Koucheki and Hashemi 2012).

Given the close proximity of the cornea to the trabecular meshwork, potential dam-
age to the cornea following SLT needs to be considered. Moubayed et al. were the
first to report a case of permanent corneal edema progressing into bullous keratopa-
thy following SLT (Moubayed et al. 2009).
Knickelbein et al. reported four cases that developed corneal edema and subse-
quent corneal thinning and hyperopic shift, with two cases requiring contact lens
wear. Although the cause of this rare complication remains unknown, it may be
associated with myopia (Knickelbein et al. 2014).
Figure 1.2 from Ong and Ong illustrates a marked increase in dark spots/patches
on specular microscopy following SLT reported in two patients with pre-SLT
corneal pigment. Thus, the corneal endothelium should be examined for pigment
deposition, corneal guttatae, or evidence of compromise prior to SLT (Ong and Ong
2013). Lee et al. (2014a) from Hong Kong investigated 111 eyes of 66 Chinese
OAG subjects treated with SLT. They measured the endothelial cell count using a
Fig. 1.2 The corneal endothelium of a patient before and after SLT showing a marked increase in
dark spots/patches on specular microscopy (Taken from a case report by Ong and Ong (2013))
6 J. Cheng et al.
specular microscopy, central corneal thickness (CCT) videokeratography, and the

spherical equivalent using a kerato-refractometer. Readings were taken before and
at 1 month after SLT. The intraclass correlation coefficient (0.997) among these
investigations was high, signifying excellent reproducibility of these measurements.
The mean endothelial cell count was reduced by 4.5 % from baseline (2465.0 ±
334.0 cells/mm2) at 1 week (2355.0±387.0 cells/mm2) after SLT (p = 0.0004). At
1 month (2424.0 ± 379.4 cells/mm2, p = 0.3), the endothelial cell count returned to
baseline levels. The authors attributed inflammatory cell attachment and micro-
scopic endothelial cell edema as the causes of the apparent reduction in endothelial
cell count as both of these conditions can affect the accuracy of cell counts with
specular microscopy. On slit-lamp examination, none of the subjects had any clini-
cally visible corneal edema. In a recent randomized controlled trial that compared
SLT versus prostaglandin analogs in the treatment of primary angle closure glau-
coma in subjects that had at least 180° of angle opening, the 6-month endothelial
cell loss was 4.8 % from baseline (p = 0.001) (Narayanaswamy et al. 2014). This
was in contrast to the 4.5 % transient reduction in the study by Lee et al. (2014a).
The differences in angle opening among the two study populations could have
accounted for the permanent damages documented by Narayanaswamy et al. (2014)
since a narrower angle can predispose the corneal endothelium to absorb a greater
amount of dissipated laser heat.
In Lee et al.’s study (Lee et al. 2014a), CCT decreased 1.1 % from 549.4 ±
37.6 μm at baseline to 543.9 ± 40.2 μm at 1 week (p = 0.02). By 1 month, CCT was
back to baseline level (p = 0.2). Laser heat dissipation could have led to a thermal-
induced corneal stromal contraction in the collagen fibers. When the keratocytes get
replenished, the CCT returns to its original thickness. There was no evidence of
clinically visible scarring on the cornea in the 111 OAG eyes that received SLT
treatment. There were also no statistically significant changes in the spherical equiv-
alent following SLT. Thus, in cases with angle closure elements, the potential risks
of corneal damage should be discussed with patients prior to treatment.
The rate of peripheral anterior synechia formation following SLT is around
2.86 % or less which is significantly less than that reported after ALT (Wong et al.
2015). Damji et al. published the only randomized controlled trial comparing the
safety of ALT versus SLT (Damji et al. 2006). A comparison in the side effects of
these two lasers is summarized in Table 1.1. Table 1.2 summarizes complications of
SLT reported in a recent meta-analysis (Wong et al. 2015).
Key Points
• Intraocular pressure spikes can occur 1 to 2 hour after the procedure.
Topical alpha-adrenergic agent may be used as prophylaxis before or after
the procedure.
• Increased trabecular meshwork pigment has been associated with extreme
intraocular pressure spikes. Therefore, lower energy with close monitoring
is recommended in these patients.
1 Glaucoma Laser 7
Table 1.1 Comparison of complications between ALT and SLT from a randomized controlled by
study by Damji et al. (2006)
Complications ALT (n = 87) (%) SLT (n = 89) (%)
IOP spike > 6 mmHg 3.4 4.5
PAS formation 1.2 1.1
ALT retreatment within 1 year 5.7 3.4
SLT retreatment within 1 year 4.6 6.7
Trabeculectomy within 1 year 8.0 9.0
Glaucoma drainage device within 1 year 0.0 1.1
Cyclophotocoagulation within 1 year 0.0 1.1
PAS peripheral anterior synechiae, ALT argon laser trabeculoplasty, SLT selective laser trabeculo-
plasty, IOP intraocular pressure
Table 1.2 Frequencies of SLT complications

Complications Percentage or number of cases
Side effects reported by case series:
Transient IOP rise 0–62 %
With prophylactic/empirical treatment 0–28.8 %
Anterior chamber inflammation 0–89.3 %
Eye pain/discomfort 0–58 % (up to 65.7 % if redness
included)
Peripheral anterior synechiae 0–2.86 %
Headache 4 %
Photophobia 3–96.7 %
Hyphema 0 %
Pigment dispersion 0 %
Conjunctival hyperemia 9–64 %
Corneal haze 0–0.2 %
Corneal abrasion 0.65 %
Corneal endothelial dark/white spots 50 %
Cystoid macular edema 0 %
Side effects from case reports:
High IOP spikes (IOP 26–65 mmHg) 4 cases
Bilateral anterior uveitis following single eye SLT 1 case
Hyphema 2 cases
Corneal edema/haze/thinning 4 cases
Diffuse lamellar keratitis 1 case
Cystoid macular edema 3 cases
Severe iritis with choroidal effusion 1 case
Taken from a meta-analysis by Wong et al. (2015)
8 J. Cheng et al.
1.3 asers That Increase Aqueous Outflow: Micropulse

L
Laser Trabeculoplasty and Titanium-Sapphire Laser
Trabeculoplasty
1.3.1 Introduction
MicroPulse Laser Trabeculoplasty (MLT) can be delivered using a diode (810 nm)

or a 532 nm/577 nm laser. The MLT technology makes use of a 15 % on and 85 %
off duty cycle to minimize the thermal damage to the surrounding tissues. Although
ALT causes damage and scarring to the trabecular meshwork and SLT destroys
melanocytes through heat, MLT neither destroys nor scars the trabecular meshwork
(Fudemberg et al. 2008).
Titanium-sapphire laser trabeculoplasty (TLT) is an emerging subtype of laser
trabeculoplasty that uses a 790 nm laser (SOLX, Inc., Waltham, Massachusetts,
USA) to emit near-infrared energy in pulses ranging from 5 to 10 ms.
1.3.2 Procedure
Similar to ALT and SLT, MLT is performed under topical anesthesia. However, the
gonioscopic lens of MLT has a built-in, visible, inner reference guide that allows the
surgeon to deliver exactly 10 confluent laser shots per clock hour for a total of 120
shots over 360°. The spot size is 300 μm, treatment duration 300 ms, and an initial
power of 1000 mW. There are no visible endpoints in MLT, hence, the energy is
only titrated down if the patient experiences pain during the procedure. No anti-
inflammatory medications are required after MLT.
For TLT, the wavelength is 690 nm with energies of 30–80 mJ at pulse dura-
tion of 7 ms. The spot size is smaller than SLT or ALT at 200 μm. The laser is
aimed at the pigmented trabecular meshwork and 50 nonoverlapping shots may
be applied to 180° of the pigmented trabecular meshwork. The endpoint is the
formation of bubbles or the visible bursting of pigments from the trabecular
meshwork.
Gossage reported the 2-year data after treatment of 532 nm MLT in 18 POAG eyes.
Three laser energies of 300 mW, 700 mW, and 1000 mW were used and at 4 months,
those receiving 1000 mW had the greatest amount of IOP reduction of 30 %. At
24 months, the amount of IOP reduction in the group receiving 1000 mW treatment
was 24 % (Gossage 2015).
There are very few studies reporting the efficacy of TLT. A 15-month pilot study
with 37 subjects, reported that TLT-treated eyes had a mean IOP reduction of 32 %
as compared to 25 % in the ALT group (Goldenfeld et al. 2009).
1 Glaucoma Laser 9
1.3.4 Complications

There are no reported intraoperative complications from MLT in the literature. In
theory, the risk of intraoperative bleeding and pain should be less than in ALT and
SLT due to the shorter duration of laser action from the duty cycle technology.

Fea et al. (2008) reported on the safety of the 810 nm MLT in 32 eyes of 20
patients with OAG. The inferior 180° of the trabecular meshwork was treated and
a Kowa FM 500 flare-meter was used to measure anterior chamber reaction at
baseline and at 3 h, 1 day, 1 week, and 12 months after MLT. Only one patient
(5 %) was found to have an increase in flare after MLT. The same patient, who
had a history of pigmentary glaucoma, developed an IOP spike of 34 mmHg
requiring oral acetazolamide treatment for 2 days. Otherwise, MLT was well
tolerated apart from burning or heat sensation that was reported in four (20 %) of
the patients.
In a prospective series in Hong Kong by Lee et al. using a 577 nm MLT in the
treatment of OAG, only 7.5 % of treated OAG eyes had a mild and self-limiting
anterior uveitis that resolved without medication. There was no corneal edema
detected on slit-lamp examination and no recorded IOP spikes at day 1, 1 week, or
1 month after MLT (data pending publication). As MLT is still a relatively new
technology; only gaining popularity in the early 2010s, larger-scale, randomized
studies are warranted before its long-term safety in comparison with its predeces-
sors can be determined.
For TLT, the IOP spike rate has been reported to be around 11 %.

At present, the longest study involving the use of MLT in OAG is 2 years. There are
no reported late postoperative complications in the literature (Fudemberg et al.
2008).
In a study of 18 patients with OAG treated with TLT, none of the patients devel-
oped PAS nor were there any reported long-term complications over a 2-year period.
1.4 asers That Increase Angle Width: Laser Peripheral

L
Iridotomy
1.4.1 Introduction
Angle closure glaucoma is an optic neuropathy secondary to raised intraocular

pressure (IOP) due to closure of the drainage angle. A number of different factors
contribute to primary angle closure, including pupillary block, thickened iris root,
cataract, and plateau iris configuration. Peripheral iridotomy removes the
10 J. Cheng et al.
pupillary block mechanism by allowing aqueous to flow from the posterior cham-
ber to the anterior chamber, by-passing the pupil. Laser peripheral iridotomy
(LPI) has now essentially replaced the surgical iridectomy.
LPI is indicated for acute primary angle closure, the fellow eye in acute primary
angle closure glaucoma if the angle is felt to be occludable, primary angle closure
(angle closure with evidence of peripheral anterior synechia or raised IOP, but no
glaucomatous optic neuropathy), primary angle closure glaucoma (primary angle
closure with glaucomatous optic neuropathy) and primary angle closure suspects
(angle closure in at least two quadrants of trabecular meshwork without any of the
above findings). There is some evidence that LPI can be helpful in phacomorphic
glaucoma and pigment dispersion syndrome.
1.4.2 Procedure
Table 1.3 summarizes the technique of LPI. The iridotomy needs to be of sufficient

size to allow aqueous flow and pressure equalization between the anterior and pos-
terior chambers. Mathematical modeling using Navier–Stokes equations suggests
that a peripherial iridotomy length of 50 μm would reduce the pressure differential
to under 1 mmHg (Silver and Quigley 2004). It has been proposed that a minimum
diameter of at least 150 μm is necessary to add in a safety margin to account for
posttreatment iris edema, fibrosis, pigment epithelial proliferation, or pupil dilata-
tion (Fleck 1990).
Table 1.3 Recommendations on technique of performing laser peripheral iridotomy (LPI) at dif-
ferent stages
Stage of procedure Recommendations on technique of performing LPI
Pretreatment Constrict pupil with 1–4 % pilocarpine 3 drops over
10–30 min
Topical anesthesia such as tetracaine or alcaine
Treatment Use iridotomy contact lens such as Abraham (+66D button)
or Wise (+103D button)
Placement of iridotomy at either side of 12 o’Clock or just
above or below 3 or 9 o’clock
Optional pretreatment – argon Stage 1: spot size 50um, duration 0.1 s, power 100–200 mW
laser for dark iris around 15–25 shots
Stage 2: spot size 50um, duration 0.1 s, power 500–700 mW
around 15–25 shots
Nd:YAG settings Power: 1–5 mJ
Spot size and duration is fixed
Posttreatment A single dose of topical Brimonidine 0.2 % and steroid may
be administered to reduce postlaser pressure spike and
inflammation
Topical steroids can be prescribed 4 times a day for 1 week
IOP should be checked 1 h after LPI
Iridotomy should be checked for size and patency
Gonioscopy should be repeated to document change in angle
post iridotomy
1 Glaucoma Laser 11
1.4.3 Complications
1.4.3.1 During Laser Iridotomy Procedure

Bubbles may form during the laser and may obstruct the visualization of the iri-
dotomy site. The size and likelihood of bubbles is related to the argon laser power.
Therefore, starting with a lower power, then increasing the power in stage 2 is rec-
ommended (see Table 1.3) (de Silva et al. 2007). The 12 o’clock position for LPI
placement should be avoided as this is where bubbles congregate. If bubbles form
they are absorbed rapidly and are of no consequence.
Argon laser corneal epithelium burns manifest as milky white spots, whereas cor-
neal endothelial burns appear as opacities. Nd:YAG laser injury to the cornea appears
as star-shaped bursts. These corneal injuries occur due to poor focusing. A mobile eye,
shallow anterior chamber, or cloudy cornea can increase the risk of corneal injury. In
the event of an injury, the procedure may need to be abandoned or a new LPI location
chosen where the anterior chamber is deeper and there is less corneal clouding.
Corneal epithelial burns recover after 1–2 days. Direct endothelial cell damage is not
reversible but usually remains localized. Routine LPI for primary angle closure sus-
pects does not appear to increase the risk of endothelial cell loss. A Singaporean study
comparing the endothelial cell count after LPI to the fellow untreated eye found that
both groups had a reduced endothelial cell count (3.6 % and 3.2 %, respectively) at 3
years, but the difference between both groups was not statistically significant (Kumar
et al. 2013). There have been reports of focal and generalized corneal edema,
Descemet’s membrane detachment, and even delayed corneal decompensation.
Anterior chamber bleeding is a common complication of LPI. Up to 36 % of
patients develop this complication. Fortunately, it is often self-limiting and stops with
gentle pressure on the eye applied with the contact lens (Jiang et al. 2012; Golan et al.
2013). If bleeding continues the iris vessel can be cauterized with the argon laser. The
view may be compromised by the blood clot. The surgeon may wish to choose an
alternative LPI site or wait for the blood to resolve, usually after 20–30 min. Anterior
chamber bleeding can cause blurred vision for several days, elevation of IOP, and
corneal endothelial blood staining. The risk of bleeding can be reduced by avoiding
iris vessels and using pretreatment with argon laser (de Silva et al. 2012). Stopping
antiplatelet therapy does not reduce the incidence of bleeding (Golan et al. 2013).
1.4.3.2 Postlaser Iridotomy Complications

The most common complication after LPI is postlaser IOP elevation, the incidence
of which varies from 5.7 %–40 % depending on the definition of an IOP spike. A
pressure spike usually occurs within the first 1 hour after LPI. The largest prospective
study of primary angle closure suspects receiving LPI was from China. Of the 734
eyes, 9.8 % had an IOP spike of >8 mmHg, and only 0.54 % had an IOP >30 mmHg
after 1 h. 0.82 % continued to have raised IOP at 2 weeks (Jiang et al. 2012). In
another study that included both primary angle closure and angle closure suspects
(therefore patients with angle pathology), the incidence of a postlaser IOP spike of
more than 30 mmHg was higher at 7.2 % (Lee et al. 2014b). Some studies suggest
that the energy used correlates to IOP spikes (Jiang et al. 2012), although other
12 J. Cheng et al.
studies did not confirm this correlation (Lee et al. 2014b; Golan et al. 2013). A higher
starting IOP is a risk factor for IOP spikes. Pre- and/or posttreatment with brimoni-
dine 0.2 % or apraclonidine 0.5 % is helpful in preventing IOP spikes (Yuen et al.
2005). If the IOP is over 30 mmHg at 30–60 min after LPI medical management
should be initiated. Topical beta blocker or oral acetazolamide can be considered. In
rare cases, the IOP may not be controlled medically and filtration surgery may be
required.
Mild iritis is a very common complication but usually resolves with topical ste-
roids within a day. Cycloplegics are rarely required but posterior synechia may
develop. In patients with active or known uveitis the inflammatory response from
LPI can be severe. Intensive topical steroids and even systemic steroids may be
necessary. Iridotomy closure may occur and repeated LPI attempts under steroid
cover may be required.
Unusual visual symptoms have been reported following LPI such as diplopia,
lines, shadows, or ghost images. Linear dysphotopsia is thought to be most specific
to LPI. A Canadian study found that it occurs in around 6.8 % of eyes after LPI. A
superior LPI is 3.6 times more likely to cause linear dysphotopsia than a temporally
placed LPI (Vera et al. 2014). Partially or completely covered LPI by the eyelid was
four times more likely to have these symptoms than an uncovered LPI. This is
thought to be due to the prismatic effect of the tear film at the lid margin. However,
a large, prospective Chinese study found visual acuity and retinal staylight measure-
ments to be the same in both the LPI and the untreated control eye. They also found
that subjective glare and visual symptoms did not differ significantly among those
with LPI that were uncovered, partially covered, or completely covered. There was
no association between size of LPI and glare symptoms (Congdon et al. 2012).
The difference in findings between the Chinese and Canadian studies may be
cultural. Nevertheless, it is important to inform patients about this potential compli-
cation and to give patients time as many will adapt to this symptom. In the event that
the patient is unable to tolerate the symptoms, an opaque contact lens or corneal
tattooing can be considered. Other rare complications include retinal burns, macular
hole, retinal detachment, choroidal effusion, malignant glaucoma, cataract forma-
tion, and zonular weakening.
Key Points
• Pretreatment with argon laser is helpful in dark iris patients to reduce risk
of bleeding and pigment release.
• Iris bleeding can be stopped by applying pressure on the eye with the
contact lens. Persistent bleeding can be cauterized using argon laser.
• Stopping antiplatelet therapy does not reduce the incidence of iris bleeding.
• Intraocular pressure spikes are common and alpha-agonist prophylaxis is
helpful. Intraocular pressure should be checked 30–60 min after the
procedure and managed accordingly.
• Iritis is common and topical steroids should be given to all patients.
• The iridotomy location should be uncovered by the eyelid to reduce the
risk of dysphotopsia.
1 Glaucoma Laser 13
1.5 asers That Increase Angle Width: Argon Laser

L
Iridoplasty
1.5.1 Introduction
Argon laser iridoplasty (ALP) is a procedure to open an appositionally closed angle.

Laser peripheral iridotomy (LPI) is the definitive treatment for pupil block, but ALP
can be helpful in other causes of angle closure such as plateau iris.
ALP can be useful in the acute setting when the cornea is cloudy, the anterior
chamber is very shallow and the eye is inflamed. LPI may be difficult to perform in
this setting and ALP can temporarily relieve the high IOP. Once the IOP is reduced,
the cornea can clear, the eye is less inflamed, and the patient is more comfortable.
All published data have reported a good success rate at breaking the acute attack
(Ritch et al. 2007). At this point, the surgeon can decide to proceed with either LPI
or lens extraction. Studies have shown that primary ALP is as effective as medical
treatment in the management of acute angle closure glaucoma and acute phacomor-
phic glaucoma (Lam et al. 2002; Lee et al. 2013).
ALP may also be helpful for the management of chronic angle closure, plateau
iris syndrome, nanophthalmos, peripheral anterior synechiae, lens related angle clo-
sure, and choroidal effusion-related angle closure. Recently, ALP has been reported
to help reshape and realign the pupil centrally in decentered multifocal intraocular
lenses. There are reports where this has improved distance and near vision (Solomon
et al. 2012).
1.5.2 Procedure
ALP is performed under topical anesthesia in the outpatient setting. Pilocarpine

1–4 % is given three times over 10–30 min. Topical glycerin can be used in extreme
cases to clear corneal edema in acute glaucoma if iris detail is not visible. Argon
laser settings are 500 μm spot size, 0.5 s duration, and 200–400 MW power. An
Abraham or Weiss iridotomy contact lens should be used. The aiming beam is
focused on the peripheral iris close to the limbus. The aim is to create large contract-
ing burns. The power should be reduced if there is any bubble formation or popping
noises. The laser applications should be one to two spot sizes apart and never adjoin-
ing. Postoperative brimonidine 0.2 % or apraclonidine 0.5 % should be given imme-
diately. The IOP should be checked 30–60 min after the procedure and posttreatment
steroids given four to six times a day for 5–7 days.
1.5.3 Complications
Mild iritis is a common finding. The inflammation is usually transient and responds
well to topical steroids. In severe cases, peripheral anterior synechiae, anterior
chamber fibrin, or hypopyon can occur. In the inflamed eye or in known uveitic
14 J. Cheng et al.
patients, the topical steroid strength and frequency should be increased to hourly for
the first 2 days, with regular follow-up. Peri-orbital or systemic steroids can also be
considered in extreme cases.
Post-ALP IOP spikes are not as common as after LPI. Postoperative brimonidine
0.2 % or apraclonidine 0.5 % is helpful. A study reported that only 1 out of 23 eyes
had an IOP spike following ALP for plateau iris syndrome (Ritch et al. 2007).
Raised IOP should be monitored closely and usually responds well to medical
treatment.
Endothelial burns can occur in very shallow anterior chambers and in cases of poor
visualization due to corneal edema. Care must be taken to focus on the iris. The sur-
geon can consider applying the laser in two concentric rings. The first ring is placed
more centrally where the anterior chamber is deeper, to deepen the anterior chamber,
followed by a second more peripheral ring of laser. In a flat anterior chamber or cases
of extensive corneal edema or opacification, ALP is contraindicated. Burns from ALP
are usually larger and more opaque compared to burns seen in iridotomy. The endo-
thelial burns usually disappear in a few days (Ritch et al. 2007) but there have been
reports of localized or general corneal edema and decompensation.
Iris atrophy and a nonreactive pupil can occur after ALP. A case series of 12 eyes
in eight patients reported Urrets–Zavalia syndrome after ALP for persistent occlud-
able angles after ALP. IOP increased in one eye. Seven patients had blurred vision,
two had photophobia, four had glare, and one had discomfort. The mydriasis did not
respond to pilocarpine, but resolved within 1 year (Espana et al. 2007). In patients
receiving ALP for acute glaucoma, the incidence of iris atrophy and nonreactive
pupil are much higher. Lai reported this complication in 8/33 eyes (24 %) at 3 years
postlaser (Lai et al. 2002).
Pigmented burn marks may develop at the locations of laser applications and
corectopia may occur, but are generally of no serious consequence (Lai et al. 2002).
Patients may notice a change in the color of the peripheral iris or a distorted pupil
and should be counseled accordingly.
Not all complications found after LPI occur following ALP. Iris hemorrhage
does not occur in ALP due to the lower power density and the coagulative nature of
argon laser. Lenticular opacification has not been reported.
1.6 asers That Reduce Aqueous Production: Transscleral

L
Photocoagulation
1.6.1 Introduction
Transscleral laser photocoagulation was described by Beckman and Sugar in the

early 1970s. Several types of lasers have been used including ruby laser and Nd:YAG
laser and the technique has evolved from noncontact to contract with a fiber optic
delivery probe. Transscleral diode cyclophotocoagulation (TCP) has become
increasingly popular as it has good penetration and absorption by the pigmented
tissue of the ciliary body.
1 Glaucoma Laser 15
1.6.2 Procedure
The procedure can be performed under a retrobulbar block or with general anesthe-
sia. It can be performed using either an Nd:YAG or a diode laser. The Nd:YAG laser
has a rounded sapphire probe tip that is placed 1–2 mm posterior to the limbus.
Energy settings range from 4 to 9 W for 0.5–0.7 s.
For the 810-nm diode laser, energy levels start at 1500 mW with 2 s duration and
are titrated to just below an audible “pop” sound, which indicates overtreatment.
The number of applications is 17–20. The diode laser has a tip shaped as a footplate,
where the heel is positioned at the limbus, so that treatment is delivered 1.2 mm
posteriorly. The tip needs to be applied firmly to the eye to avoid conjunctival burns.
The positioning of the laser probe may need to be altered in cases of a posterior cili-
ary body such as buphthalmos. Retroillumination of the globe can facilitate locating
the ciliary body. Postoperative medications include atropine and steroid drops, in
addition to continuing prelaser glaucoma medications.
Numerous studies have evaluated the efficacy of TCP. The response rate is 12.3–
66 % with 54–92.7 % (average 73.7 %) obtaining an IOP of 21 mmHg or less after
follow-up periods of 1–2 years (Ishida 2013). Some studies have found a correlation
between a higher amount of energy delivered leading to a better pressure lowering
effect (Hauber and Scherer 2002). However, this has not been observed in several
other studies (Mistlberger et al. 2001). Factors that decrease the success rate include
younger age, posttraumatic cases, and secondary glaucoma with previous vitreoreti-
nal surgery. The outcome is typically less predictable than in other glaucoma surger-
ies, with rates of retreatment ranging from 20 to 40 % after 1 year.
1.6.4 Complications

Conjunctival burns can be produced if the probe is not placed firmly against the eye.
Pupil ovalization or an atonic pupil can result. This risk may be decreased by avoid-
ing the 3 and 9-o’clock positions. Hyphema or vitreous hemorrhage can occur, par-
ticularly in neovascular glaucoma.

Patients may experience pain, photophobia and pigment dispersion. Rare complica-
tions described include lens subluxation, necrotizing scleritis and malignant glau-
coma. Most patients experience a variable degree of anterior uveitis post-operatively
that resolves with steroid treatment. A small subset of patients will develop persis-
tent anterior chamber inflammation, due to disruption of the blood aqueous barrier.
As this is not a true inflammatory reaction, these patients do not require long-term
16 J. Cheng et al.
steroid treatment. IOP fluctuations are common, and 10 % of patients will develop
a significant IOP spike, particularly in those with neovascular glaucoma.

The two main complications following TCP are hypotony (possibly leading to
phthisis) and vision loss. Other late complications include cataract progression,
chronic uveitis, cystoid macular edema and sympathetic ophthalmia (incidence of
0.07–0.7 %). The rate of corneal graft failure is 21 % (Tandon et al. 2014).
Hypotony occurs in 0–25 % of cases and phthisis in 0–9.9 % (Iliev and Gerber
2007). The risk of hypotony and phthisis is related to the amount of laser energy
delivered. The lowest incidence of hypotony was seen in treatment protocols
employing less than 80 J per treatment session. Independent risk factors for hypot-
ony and phthisis are neovascular glaucoma, high pretreatment IOP, and uveitic glau-
coma. For patients with primary open-angle glaucoma (POAG) these complication
rates are lower (hypotony: 0–1.1 % and phthisis: 0–1.6 %). This is likely due to a
lower pretreatment IOP, less energy delivered, and less advanced disease.
Loss of more than two Snellen lines occurs on average in 22.5 % of patients
(range 0–55.2 %) (Ishida 2013). In a series by Schuman et al. (1992) of 116 eyes
with advanced glaucoma treated with contact Nd:YAG TCP, 16 % progressed to no
light perception and 47 % of eyes with a prelaser vision of 20/200 or better lost two
or more Snellen lines. Hypotony was seen in 8 % (5 % had an IOP of 0). Another
large series of 59 eyes followed up for a mean of 19 months (Spencer and Vernon
1999), reported that 32 % of patients with pretreatment vision better than 20/60
dropped two lines or more, and two patients with poor initial visual acuity dropped
to no light perception. No factors have been predictive of vision loss after TCP,
although patients with worse pretreatment vision tend to be at a higher risk of losing
further vision. It is also unclear the extent that vision loss is due to the procedure
versus the natural progression of the disease.
Key Points
• Patients should be counseled for pain and photophobia after the procedure
and adequate anti-inflammatories and analgesia should be prescribed.
• The risk of hypotony, vision loss, and phthisis is low if less than 80 J of
energy is delivered per treatment session
1.7 asers That Reduce Aqueous Production:

L
Endocyclophotocoagulation
1.7.1 Introduction
First described in 1992, a newer method to directly photocoagulate the ciliary pro-
cesses under endoscopic guidance, known as endoscopic diode cyclophotocoagula-
tion (ECP), is performed in conjunction with cataract or vitreoretinal surgery. It can
1 Glaucoma Laser 17
be done in eyes with a good visual potential, but the pressure lowering effect is less
compared to TCP.
1.7.2 Procedure
The laser probe (18-gauge or 20-gauge) can be inserted via a limbal or pars plana
approach. It can be performed with a retrobulbar block or general anesthesia. When
combined with cataract surgery, topical anesthesia with intracameral supplementa-
tion can be used, although a retrobulbar block is frequently employed. Energy is
applied to each process until shrinkage and whitening occur (0.3–0.9 W), treating
270°–360°. If using a pars plana approach, a limited anterior vitrectomy is per-
formed to allow adequate and safe access to the ciliary processes.
ECP is usually performed in two types of glaucoma, mild POAG or advanced sec-
ondary glaucoma. In a large series of patients with POAG, mean IOP decreased
7 mmHg (31 % decrease, range 3.9–10.9 mmHg decrease) after 2 years. In second-
ary glaucoma, the mean decrease was 50 % (range 26–68 %) (Kaplowitz et al. 2014)
after a follow-up of 2–5 years. No factors that decrease the efficacy of treatment
have been identified. However, poor results have been seen when used for congeni-
tal glaucoma, with a failure rate of 78 % at 5 years. The main problem with ECP is
the frequent need for laser reapplications (probably due to regeneration of the cili-
ary epithelium). There is no long-term data on ECP, but it is suggested that success
rates drop rapidly below 50 % after 36 months. A large retrospective study, however,
found IOP under 21 mmHg in 79 % of patients after 5 years, on an average of 1.9
medications (Lima et al. 2010).
1.7.4 Complications

Complications including choroidal hemorrhages and retinal tears/detachment (1 %)
can occur, particularly with the pars plana approach. Iris burns occur in 5 % of
cases.

The three most common early post-ECP complications are fibrin in the anterior
chamber (7–22 %), hyphema (11 %), and CME (1–10 %) (Chen et al. 1997).
Fibrinous uveitis usually responds to topical steroids and resolves in 4–10 weeks.
Hyphema clears with conservative measures but may require surgical intervention.
An IOP spike is seen in 10–14.4 % of patients. Endophthalmitis is a complication
of any intraocular surgery, but the incidence following ECP is unknown. Corneal
edema occurs in 4 % of cases and corneal graft failure in 8 %.
18 J. Cheng et al.

Hypotony can occur in up to 18 % of cases. Larger retrospective studies have
reported hypotony rates ranging from 1.2 to 9 % (Lima et al. 2010; Murthy et al.
2009) after 2–5 years. The endoscope can be used to look for changes in the ciliary
processes and to perform a fibrous membrane dissection, which has been shown to
increase IOP. Phthisis can occur in up to 2.5 % of patients (Lima et al. 2004).
Incidence of vision loss of more than two lines has been described in 1–6 % (Chen
et al. 1997) in studies that have 2–5 years of follow-up. Loss of vision seems to be
related to the severity of the glaucoma, with up to 24 % of patients with advanced
glaucoma losing vision. Cataract progression occurs in 24.5 % of patients. CME has
been reported to occur in 0.7–10 %. To date no cases of sympathetic ophthalmia
have been reported following ECP.
References
Barkana Y, Belkin M. Selective laser trabeculoplasty. Surv Ophthalmol. 2007;52(6):634–54.
doi:10.1016/j.survophthal.2007.08.014.
Chen J, Cohn RA, Lin SC, Cortes AE, Alvarado JA. Endoscopic photocoagulation of the ciliary
body for treatment of refractory glaucomas. Am J Ophthalmol. 1997;124(6):787–96.
Coakes R. Laser trabeculoplasty. Br J Ophthalmol. 1992;76(10):624–6.
Congdon N, Yan X, Friedman DS, Foster PJ, van den Berg TJ, Peng M, Gangwani R, He M. Visual
symptoms and retinal straylight after laser peripheral iridotomy: the Zhongshan Angle-Closure
Prevention Trial. Ophthalmology. 2012;119(7):1375–82. doi:10.1016/j.ophtha.2012.01.015.
Damji KF, Bovell AM, Hodge WG, Rock W, Shah K, Buhrmann R, Pan YI. Selective laser tra-
beculoplasty versus argon laser trabeculoplasty: results from a 1-year randomised clinical trial.
Br J Ophthalmol. 2006;90(12):1490–4. doi:10.1136/bjo.2006.098855.
de Silva DJ, Day AC, Bunce C, Gazzard G, Foster PJ. Randomised trial of sequential pretreatment
for Nd:YAG laser iridotomy in dark irides. Br J Ophthalmol. 2012;96(2):263–6. doi:10.1136/
bjo.2010.200030.
de Silva DJ, Gazzard G, Foster P. Laser iridotomy in dark irides. Br J Ophthalmol. 2007;91(2):222–
5. doi:10.1136/bjo.2006.104315.
Espana EM, Ioannidis A, Tello C, Liebmann JM, Foster P, Ritch R. Urrets-Zavalia syndrome
as a complication of argon laser peripheral iridoplasty. Br J Ophthalmol. 2007;91(4):427–9.
doi:10.1136/bjo.2006.105098.
Fea AM, Bosone A, Rolle T, Brogliatti B, Grignolo FM. Micropulse diode laser trabeculo-
plasty (MDLT): a phase II clinical study with 12 months follow-up. Clin Ophthalmol.
2008;2(2):247–52.
Fleck BW. How large must an iridotomy be? Br J Ophthalmol. 1990;74(10):583–8.
Fudemberg SJ, Myers JS, Katz LJ. Trabecular meshwork tissue examination with scanning
electron microscopy: a comparison of micropulse diode laser (MLT), selective laser (SLT),
and argon laser (ALT) trabeculoplasty in human cadaver tissue. Invest Ophthalmol Vis Sci.
2008;49(5):1236.
Glaucoma laser trial. Ophthalmology. 1991;98(6):841–3.
Golan S, Levkovitch-Verbin H, Shemesh G, Kurtz S. Anterior chamber bleeding after laser peripheral
iridotomy. JAMA Ophthalmol. 2013;131(5):626–9. doi:10.1001/jamaophthalmol.2013.1642.
Goldenfeld M, Melamed S, Simon G, Ben Simon GJ. Titanium:sapphire laser trabeculoplasty ver-
sus argon laser trabeculoplasty in patients with open-angle glaucoma. Ophthalmic Surg Lasers
Imaging. 2009;40(3):264–9.
1 Glaucoma Laser 19
Gossage D. Two-year data on MicroPulse laser trabeculoplasty. 2015. Eye world. Retried from
URL: http://www.eyeworld.org/article-two-year-data-on-micropulse-laser-trabeculoplasty.
Accessed on 1 June 2015.
Hauber FA, Scherer WJ. Influence of total energy delivery on success rate after contact diode laser
transscleral cyclophotocoagulation: a retrospective case review and meta-analysis. J Glaucoma.
2002;11(4):329–33.
Iliev ME, Gerber S. Long-term outcome of trans-scleral diode laser cyclophotocoagulation in
refractory glaucoma. Br J Ophthalmol. 2007;91(12):1631–5. doi:10.1136/bjo.2007.116533.
Ishida K. Update on results and complications of cyclophotocoagulation. Curr Opin Ophthalmol.
2013;24(2):102–10. doi:10.1097/ICU.0b013e32835d9335.
Jiang Y, Chang DS, Foster PJ, He M, Huang S, Aung T, Friedman DS. Immediate changes in
intraocular pressure after laser peripheral iridotomy in primary angle-closure suspects.
Ophthalmology. 2012;119(2):283–8. doi:10.1016/j.ophtha.2011.08.014.
Jinapriya D, D’Souza M, Hollands H, El-Defrawy SR, Irrcher I, Smallman D, Farmer JP, Cheung
J, Urton T, Day A, Sun X, Campbell RJ. Anti-inflammatory therapy after selective laser tra-
beculoplasty: a randomized, double-masked, placebo-controlled clinical trial. Ophthalmology.
2014;121(12):2356–61. doi:10.1016/j.ophtha.2014.07.017.
Juhas T. Sympathetic ophthalmia as a complication of argon laser trabeculoplasty. Ocul Immunol
Inflamm. 1993;1(1–2):67–70. doi:10.3109/09273949309086540.
Kaplowitz K, Kuei A, Klenofsky B, Abazari A, Honkanen R. The use of endoscopic cyclophotoco-
agulation for moderate to advanced glaucoma. Acta Ophthalmol. 2014; doi:10.1111/aos.12529.
Klamann MK, Maier AK, Gonnermann J, Ruokonen PC. Adverse effects and short-term
results after selective laser trabeculoplasty. J Glaucoma. 2014;23(2):105–8. doi:10.1097/
IJG.0b013e3182684fd1.
Knickelbein JE, Singh A, Flowers BE, Nair UK, Eisenberg M, Davis R, Raju LV, Schuman JS,
Conner IP. Acute corneal edema with subsequent thinning and hyperopic shift following
selective laser trabeculoplasty. J Cataract Refract Surg. 2014;40(10):1731–5. doi:10.1016/j.
jcrs.2014.08.002.
Koucheki B, Hashemi H. Selective laser trabeculoplasty in the treatment of open-angle glaucoma.
J Glaucoma. 2012;21(1):65–70. doi:10.1097/IJG.0b013e3182027596.
Kumar RS, Baskaran M, Friedman DS, Xu Y, Wong HT, Lavanya R, Chew PT, Foster PJ, Aung
T. Effect of prophylactic laser iridotomy on corneal endothelial cell density over 3 years
in primary angle closure suspects. Br J Ophthalmol. 2013;97(3):258–61. doi:10.1136/
bjophthalmol-2012-302013.
Lai JS, Tham CC, Chua JK, Poon AS, Lam DS. Laser peripheral iridoplasty as initial treat-
ment of acute attack of primary angle-closure: a long-term follow-up study. J Glaucoma.
2002;11(6):484–7.
Lam DS, Lai JS, Tham CC, Chua JK, Poon AS. Argon laser peripheral iridoplasty versus con-
ventional systemic medical therapy in treatment of acute primary angle-closure glaucoma: a
prospective, randomized, controlled trial. Ophthalmology. 2002;109(9):1591–6.
Lee JW, Chan JC, Chang RT, Singh K, Liu CC, Gangwani R, Wong MO, Lai JS. Corneal changes
after a single session of selective laser trabeculoplasty for open-angle glaucoma. Eye (Lond).
2014a;28(1):47–52. doi:10.1038/eye.2013.231.
Lee JW, Lai JS, Yick DW, Yuen CY. Argon laser peripheral iridoplasty versus systemic intraocular
pressure-lowering medications as immediate management for acute phacomorphic angle clo-
sure. Clin Ophthalmol. 2013;7:63–9. doi:10.2147/OPTH.S39503.
Lee JW, Wong MO, Liu CC, Lai JS. Optimal selective laser trabeculoplasty energy for maxi-
mal intraocular pressure reduction in open-angle glaucoma. J Glaucoma. 2015; doi:10.1097/
IJG.0000000000000215.
Lee TL, Yuxin Ng J, Nongpiur ME, Tan WJ, Aung T, Perera SA. Intraocular pressure spikes after
a sequential laser peripheral iridotomy for angle closure. J Glaucoma. 2014b;23(9):644–8.
doi:10.1097/IJG.0b013e318285fdaa.
20 J. Cheng et al.
Lima FE, Carvalho DM, Avila MP. Phacoemulsification and endoscopic cyclophotocoagula-

tion as primary surgical procedure in coexisting cataract and glaucoma. Arq Bras Oftalmol.
2010;73(5):419–22.
Lima FE, Magacho L, Carvalho DM, Susanna Jr R, Avila MP. A prospective, comparative study
between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory
glaucoma. J Glaucoma. 2004;13(3):233–7.
Mistlberger A, Liebmann JM, Tschiderer H, Ritch R, Ruckhofer J, Grabner G. Diode laser trans-
scleral cyclophotocoagulation for refractory glaucoma. J Glaucoma. 2001;10(4):288–93.
Moubayed SP, Hamid M, Choremis J, Li G. An unusual finding of corneal edema complicating
selective laser trabeculoplasty. Can J Ophthalmol. 2009;44(3):337–8. doi:10.3129/i09-025.
Murthy GJ, Murthy PR, Murthy KR, Kulkarni VV, Murthy KR. A study of the efficacy of endo-
scopic cyclophotocoagulation for the treatment of refractory glaucomas. Indian J Ophthalmol.
2009;57(2):127–32.
Narayanaswamy A, Leung CK, Istiantoro DV, Perera SA, Ho CL, Nongpiur ME, Baskaran M,
Htoon HM, Wong TT, Goh D, Su DH, Belkin M, Aung T. Efficacy of selective laser trabecu-
loplasty in primary angle-closure glaucoma: a randomized clinical trial. JAMA Ophthalmol.
2014; doi:10.1001/jamaophthalmol.2014.4893.
Ong K, Ong L. Selective laser trabeculoplasty may compromise corneas with pigment on endo-
thelium. Clin Experiment Ophthalmol. 2013;41(1):109–110; question and answer 111–2.
doi:10.1111/j.1442-9071.2012.02841.x
Ritch R, Tham CC, Lam DS. Argon laser peripheral iridoplasty (ALPI): an update. Surv
Ophthalmol. 2007;52(3):279–88. doi:10.1016/j.survophthal.2007.02.006.
Schuman JS, Bellows AR, Shingleton BJ, Latina MA, Allingham RR, Belcher CD, Puliafito
CA. Contact transscleral Nd:YAG laser cyclophotocoagulation. Midterm results.
Ophthalmology. 1992;99(7):1089–1094; discussion 1095.
Silver DM, Quigley HA. Aqueous flow through the iris-lens channel: estimates of differential pres-
sure between the anterior and posterior chambers. J Glaucoma. 2004;13(2):100–7.
Solomon R, Barsam A, Voldman A, Holladay J, Bhogal M, Perry HD, Donnenfeld ED. Argon
laser iridoplasty to improve visual function following multifocal intraocular lens implantation.
J Refract Surg. 2012;28(4):281–3. doi:10.3928/1081597X-20120209-01.
Spencer AF, Vernon SA. “Cyclodiode”: results of a standard protocol. Br J Ophthalmol.
1999;83(3):311–6.
Stein JD, Challa P. Mechanisms of action and efficacy of argon laser trabeculoplasty and
selective laser trabeculoplasty. Curr Opin Ophthalmol. 2007;18(2):140–5. doi:10.1097/
ICU.0b013e328086aebf.
Tandon A, Espandar L, Cupp D, Ho S, Johnson V, Ayyala RS. Surgical management for post-
keratoplasty glaucoma: a meta-analysis. J Glaucoma. 2014;23(7):424–9. doi:10.1097/
IJG.0b013e31827a0712.
Vera V, Naqi A, Belovay GW, Varma DK, Ahmed II. Dysphotopsia after temporal versus supe-
rior laser peripheral iridotomy: a prospective randomized paired eye trial. Am J Ophthalmol.
2014;157(5):929–35. doi:10.1016/j.ajo.2014.02.010.
Weinreb RN, Wilensky JT. Clinical aspects of argon laser trabeculoplasty. Int Ophthalmol Clin.
1984;24(3):79–95.
Wong MO, Lee JW, Choy BN, Chan JC, Lai JS. Systematic review and meta-analysis on the
efficacy of selective laser trabeculoplasty in open-angle glaucoma. Surv Ophthalmol.
2015;60(1):36–50. doi:10.1016/j.survophthal.2014.06.006.
Yuen NS, Cheung P, Hui SP. Comparing brimonidine 0.2 % to apraclonidine 1.0 % in the pre-
vention of intraocular pressure elevation and their pupillary effects following laser peripheral
iridotomy. Jpn J Ophthalmol. 2005;49(2):89–92. doi:10.1007/s10384-004-0149-9.
Minimally Invasive Glaucoma Surgery
2
Kuang Hu, Keith Barton, and Julian Garcia Feijoo
2.1 Introduction
Minimally invasive glaucoma surgery (MIGS) interventions are intended to deliver

reduction of intraocular pressure (IOP) with a better safety profile than conventional
glaucoma surgery. There has been active development of novel MIGS devices and
implants, and these continue to evolve.
The role of MIGS is the subject of some uncertainty. Although it is generally
accepted that MIGS interventions are not as effective as conventional glaucoma
drainage surgery, their better safety profiles may make them suitable for patients
who do not require very low intraocular pressures to control their glaucoma. To
resolve such debates, high-quality randomized controlled trial data are required.
When MIGS is being combined with cataract surgery, trials need to disentangle the
effect of phacoemulsification from that of MIGS because phacoemulsification itself
is known to lower intraocular pressure (Chen et al. 2015; Mansberger et al. 2012).
Moreover, the role of MIGS may not be fully established by studies that focus solely
on efficacy and safety. Rather, patients’ quality of life and cost-effectiveness in com-
parison to conventional medical and surgical treatments need to be taken into
account.
Presently, MIGS techniques are designed to increase the outflow of aqueous in
one of several ways. External drainage devices such as the XEN Gel Implant permit
drainage of aqueous into the subconjunctival space. Trabecular bypass techniques
K. Hu (*)
Moorfields Eye Hospital NHS Foundation Trust, London, UK
K. Barton
Glaucoma Service, Moorfields Eye Hospital, 162 City Road, London EC1V 2PD, UK
J.G. Feijoo
Department of Ophthalmology, Hospital Clinico San Carlos, Universidad Complutense,
Instituto de Investigacion Sanitaria HCSC, OFTARED, Madrid, Spain

22 K. Hu et al.
such as iStent, Trabectome, and Hydrus aim to improve access of aqueous from the
anterior chamber to Schlemm’s canal and thence to functional collector channels.
Choroidal shunts such as CyPass are designed to increase drainage of aqueous into
the suprachoroidal space. This chapter will focus on the devices mentioned above.
The principles that emerge are likely to be applicable to other MIGS techniques,
both current and future.
2.2 Trans-trabecular Meshwork Surgeries
2.2.1 iStent
2.2.1.1 Safety and Efficacy

Randomized controlled trials on the first-generation version of the iStent (Glaukos,
Laguna Hills, USA) focused on its use with concomitant phacoemulsification
(Craven et al. 2012; Fea 2010; Samuelson et al. 2011).
In an industry-funded open-label trial involving 240 patients with open-angle
glaucoma controlled with topical medications, implantation of iStent in conjunction
with cataract surgery was compared to cataract surgery alone (Samuelson et al.
2011). Seventy-two percent of eyes treated with iStent versus 50 % of control eyes
achieved IOP of 21 mmHg or lower without use of medication at 12 months. Stent
obstruction was observed in 4 % of subjects and 4 % required stent-related second-
ary surgery in the form of repositioning or replacement. At 15 months postopera-
tively in a separate double-masked randomized controlled trial (Fea 2010), 67 % of
eyes with primary open-angle glaucoma having iStent implantation at the time of
cataract surgery did not require topical medication versus 24 % of eyes who had
cataract surgery alone. At 24 months, patients with stents appear to be more likely
than those without to achieve IOP of 21 mmHg or lower without medication, though
there was no overall difference in ocular hypotensive medication between the two
groups (Craven et al. 2012).
A second generation of device, called the iStent inject, has been developed. This
has a conical shape and is provided on an injector preloaded with two devices.
In a prospective unmasked study (Voskanyan et al. 2014), two iStent inject
devices were implanted in each of 99 patients who had open-angle glaucoma that
was uncontrolled on two or more topical medications. Two-thirds of subjects
achieved an IOP of 18 mmHg or lower without medication at 12 months. The com-
monest postoperative complications were elevated IOP (10 %) and stent obstruction
(3 %). Secondary surgery was performed in 3 % of patients for elevated IOP. The
stent was not visible gonioscopically in 13 % of patients.
An industry-sponsored prospective unmasked randomized trial enrolling 192
subjects (Fea et al. 2014) found that implantation of two iStent inject devices was at
least as effective in terms of IOP control as medical therapy with the fixed combina-
tion of latanoprost and timolol (Xalacom, Pfizer) in patients who had open-angle
glaucoma that was not controlled with a single topical medication. At 12 months,
95 % of eyes treated with stents and 92 % of eyes treated with Xalacom achieved
2 Minimally Invasive Glaucoma Surgery 23
IOP reduction of at least 20 %. 93% of eyes achieved IOP of less than or equal to
18 mmHg in the stent group versus 90 % of eyes in the Xalacom group. One of the
94 patients in the stent group experienced “decompensation” of IOP to 48 mmHg.
2.2.1.2 Procedure
IStent surgery can be performed under topical anesthesia and intracameral anesthe-
sia is recommended. The trabecular stent can be implanted through the clear corneal
incision used for phacoemulsification in cases of combined surgery or through a
1.5 mm incision when the stent is implanted as an isolated operation. A wider inci-
sion facilitates surgical maneuvers and is recommended during the learning curve,
as this facilitates a better implantation angle especially when more than one implan-
tation attempt is required. The injection of acetylcholine into the anterior chamber
is advisable in phakic patients as this minimizes risk of lens damage. In the majority
of cases, the corneal incision should be temporal so allowing the stent to be
implanted in the nasal region of the trabecular meshwork, where the number of col-
lecting channels is greatest.
The G1 Glaukos® trabecular micro-bypass (GT100) is made of titanium and cov-
ered with a layer of heparin (Duraflo® powder). It is L-shaped, measures 1 × 0.4 mm
with an external diameter of 180 μm and is designed to fit within the lumen of the
canal. The end of the canal portion is pointed to allow penetration through the mesh-
work during insertion. Three retention ridges spaced along the half-pipe portion
allow for secure placement of the micro-bypass. The stent is preloaded in a 26-gauge
insertion device with a release button. The stent is usually implanted through a tem-
poral approach in a nasal position. If two implants are used, one is placed inferona-
sally and the other superonasally.
Before starting the iStent procedure, the head of the patient must be repositioned at
45° to the opposite side of the eye undergoing surgery, while tilting the microscope
30° for a good view of the trabecular meshwork on the nasal side of the angle using a
Swan–Jacob gonioscope. After filling the anterior chamber with viscoelastic and
checking the visualization of the angle, the inserter is introduced into the anterior
chamber. The tip of the iStent should approach the trabecular meshwork at an angle of
15° to facilitate penetration. The point of the trabecular micro-bypass must go through
the trabecular meshwork and softly advance through the Schlemm’s canal. Once the
trabecular meshwork covers all of the implant, it is released by pressing the applicator
button. Only the proximal end of the stent should remain visible in the anterior cham-
ber. The stent can be seated in its final position by gently tapping the side of the snor-
kel with the inserter tip. The stent should be placed parallel to the plane of the iris with
the inner part covered by the meshwork and the lumen away from the iris. A small
reflux of blood from the Schlemm’s canal is common and reflects adequate position-
ing of the stent. Excessive resistance indicates a path that is too perpendicular to the
trabeculum. If difficulty is encountered with insertion at the primary location, it is
recommended finding another location inferiorly or superiorly or try inserting 0.5
clock hours inferiorly, and continue to move inferiorly as needed for subsequent
attempts. At the end of the procedure, the anterior chamber is flushed to eliminate any
refluxed blood. This ensures good visualization to confirm that the implant is well
24 K. Hu et al.
located at sufficient depth. The viscoelastic agent can then be removed and the ante-
rior chamber filled with saline solution.
In combined surgery the same corneal incision can be used. When phacoemulsi-
fication has been completed acetylcholine can be injected, then the anterior chamber
should be refilled with a cohesive viscoelastic and then proceed as previously
described.
For iStent inject (GTS400) the procedure is similar. This implant is conic and
smaller than the G1 and also made of titanium. The Stents are preloaded in the cus-
tomized injector system designed to deliver the stents automatically into the
Schlemm’s canal. To do so the inserter should be positioned in the desired position
in contact with the angle but not pushing the tissue. The injector features a release
button on the housing so by pressing this button the stent is released into the
Schlemm’s canal.
2.2.1.3 Patient Selection and Indications

The best indications for the trabecular stent are cases with primary open-angle,
pigmentary, or pseudoexfoliative glaucoma. In secondary open-angle glaucoma,
this type of surgery may be indicated as long as the Schlemm’s canal and collecting
channels are found to be undamaged. A good indication is corticosteroid-induced
glaucoma (Morales-Fernandez et al. 2012). The ideal candidate for this type of sur-
gery is a patient with early or moderate stage glaucoma, also patients with compli-
ance issues, low tolerance to medical treatment or simply patients reluctant to
undergo a chronic daily treatment. Another indication could be high-risk OHT or
early/mid-disease patients with high IOP or suboptimal IOP control but in which a
conventional filtering surgery may be too aggressive.
Patients with advanced glaucoma or those who require very low target pressures
to obtain stabilization of their disease are not suitable candidates. Nevertheless,
iStent could be considered in some cases when a filtering procedure is not recom-
mended or refused by the patient.
Candidates for combined surgery using the iStent are patients with cataract and
open-angle glaucoma with early/mild disease, even if they are well controlled on
two or three medications.
2.2.1.4 Complications
The published evidence shows that, when performed with care iStent implantation
is safe and the complication rate is very low. Visualization and correct selection of
the area of implantation are key for a successful and effective implantation.
Selecting the Area of Implantation Preoperative evaluation of the areas with

more collector channels is difficult. However, with the decompression of the ante-
rior chamber the blood reflux can help identify the areas with more blood reflux.
This is an indirect sign to determine the areas with more favorable anatomy and is
especially helpful when the blood column is fragmented. If these areas are not
accessible through the initial incision, the surgeon should consider making a new
incision.
Intraoperative Complications
Prevention of Complications. Angle Visualization The most common mistake
when performing the surgery the first few times is failure to position the microscope
and/or the patient adequately in order to obtain an adequate view of the trabeculum.
This step is crucial for all the angular surgeries described in this chapter, and the
surgeon should take some time to assure the correct visualization and identification
of the angular structures. This is more difficult when trabecular meshwork pigmen-
tation is poor. So before introducing the inserter in the anterior chamber the surgeon
should check the positions of the patient’s head and the microscope together with
the angle visualization. If visualization is not good enough, position should be
adjusted. By following these steps, most of the complications related to the insertion
procedure can be minimized.
Incorrect Implantation. iStent Position The implant should be completely

inserted in the Schlemms’s canal as described above, so the iStent final position
should be parallel to the iris root with the ridges located on the back wall of
Schlemm’s canal. If it is too superficial or not completely introduced, it may fall out.
Implantation angle is important and iStent position must be checked before it is
released from the applicator. If the implant is not completely introduced the inserter
tip can be used to tap the iStent into place. If snagged in the tissue or the iStent is
outside the canal, or even if it was released before firmly anchored in place and is
loose in the anterior chamber, it can be recovered with the inserter or retinal forceps.
Then it is possible to reload the iStent onto the inserter and try again. In the series
by Arriola-Villalobos et al. (2012), in 33.3 % of cases two attempts were required to
implant the iStent correctly, and in 6 % of the cases a third attempt was needed.
Trabecular Meshwork Tear Once the implant is correctly positioned inside the
Schlemm’s canal, the surgeon must cease all movement and release the implant. If
the movement continues once the iStent is inside the Schlemm’s canal, the iStent tip
will tear the trabecular meshwork. While this might be considered a minor compli-
cation, it will increase the trauma to the outer wall of the canal and even damage the
collector channels. Moreover, with the loosening of the trabecular meshwork inner
wall the tissue required to support the implant is lost. This consideration is also
important if more than one attempt is needed. If during successive implantation
attempts, an adequate implantation angle is not obtainable using the initial incision
a new corneal incision could be performed if necessary.
Cyclodialysis Cleft. Suprachoroidal Implantation If the implantation technique

is inadequate or, more frequently, visualization of the angle structures poor, then
there is a risk of tearing the iris root with the iStent tip and inserting the iStent in the
ciliary band or even introducing the implant in the supraciliary/suprachoroidal
space. This risk is higher when several attempts are required and blood prevents
adequate angle visualization. This increases the risk of bleeding that could also be
26 K. Hu et al.
more severe than usual. If the tear is limited and bleeding is not important the sur-
gery can usually be completed. If the tear is longer and associated with a visible
cleft or the bleeding becomes severe, the procedure should be cancelled.
If the angle structures are incorrectly identified and the ciliary band misidentified
as the pigmented meshwork or if for any reason visualization is not good enough,
there is a risk of implanting the device in the ciliary band or even deeper into the
supraciliary/suprachoidal space. Even if intracameral anesthesia is used if the iStent
touches the ciliary tissue or the iris root, the patient will feel some pain, so this is an
important sign to recognize. In this case, the recommendation is to check the angle
structures and positioning to be sure that the area of implantation has been correctly
identified.
Iridectomy/Iridodialysis/Lens Damage Incorrect manipulation of the inserter in

the anterior chamber may cause iris damage and even iridodialysis. This may also
happen if the angle structures are not correctly identified or if the iris is caught on
the tip of the iStent and the surgeon keeps moving the inserter. Moreover, these
cases usually involve severe bleeding and this can make surgery more difficult. In
phakic patients the surgeon may damage the lens with the inserter and even tear the
anterior capsule of lens. To avoid this complication the use of acetylcholine is rec-
ommended in phakic eyes. Also introduce the inserter slightly up until the pupil is
crossed instead of aiming directly at the angle.
Bleeding Some bleeding is common and usually indicates the blood reflux through
the iStent. But it could be important in case of the complications described above.
Ensuring a correct visualization of the angle is crucial. Also surgery should be car-
ried out with gentle movements. In case of bleeding that prevents visualization the
surgeon should wait until the bleeding decreases or stops completely. Then proceed
to clean the anterior chamber and start the surgical procedure again. If bleeding is
severe or visualization is not good enough the surgeon may have to consider cancel-
ling or postponing the procedure.
Early Postoperative Complications

Malposition. Free Implant As mentioned above, it is important to verify the final
implant position before the end of the surgery. If visualization was not good enough,
it is important to check for the implant position postoperatively. If only the proximal
part of the snorkel is outside the canal, no further intervention is usually needed and
this will not interfere with the efficacy of the procedure. However, if it is just punc-
turing the tissue, outside the canal or positioned unattached in the angle or on the
iris, the surgeon has to consider repositioning the implant to avoid possible future
complications (and for the implant to be functional). However, even if the stents are
detached from the trabecular meshwork they usually will settle on the angle and will
not move (Arriola-Villalobos et al. 2012), since they are highly biocompatible and
well tolerated they may also be left in the anterior chamber. In this case, adequate
follow-up is needed and if inflammation or other problems are detected they should
be removed (Fig. 2.1).
Fig. 2.1 Two malpositioned

iStent implants
Superficial Implantation If the iStent is too superficial or incompletely inserted,

there is a risk of detachment. In the case of superficial implantation, the iStent does
not penetrate the trabecular meshwork completely and can be just engaged in the
superficial layers of the trabecular meshwork. In this case there would be no com-
munication between the anterior chamber and the Schlemm’s canal so the implant
would not be efficacious. Moreover, it could come loose over time. Repositioning
should be considered, but as mentioned before, most of the time the implant will
settle on the iris root and cause no problems.
Cyclodialysis Cleft/Suprachoroidal Implantation If IOP is very low during the

first week a cyclodialysis cleft has to be ruled out. Also if the iStent is not seen in
the angle and the iris root/ciliary tissue appear to have been damaged the area should
be imaged with OCT or UBM to find the stent. Most of the cases can be managed
conservatively as the cleft will close over time. If pressure remains too low or macu-
lopathy develops, it may be necessary to suture the cleft. If the iStent is in the supra-
choidal space but there is no inflammation removal is not necessary but close
follow-up is required.
L ate Postoperative Complications

A 5-year case series study by Arriola et al. showed no major complications regard-
ing stent placement in the meshwork in a 19 patient study after 5 years (Arriola-
Villalobos et al. 2012).
IStent obstruction If the Stent is rotated toward the iris, the anterior chamber is
narrow and not very deep or the iris is floppy, the aqueous humor flow to the iStent
could facilitate the blockage of the device with the iris. This situation can be resolved
by lasering the iris in order to unblock the stent snorkel. This has been described for
both implant types (Fernandez-Barrientos et al. 2010; Arriola-Villalobos et al. 2012;
Arriola-Villalobos et al. 2013; Fea 2010; Samuelson et al. 2011).
28 K. Hu et al.
Endothelial damage Arriola-Villalobos et al. (2013) analyzed prospectively the

endothelial changes after combined surgery (Phaco + GTS400/Glaukos inject). At
2 years of follow-up the endothelial cell count decrease was 13.22 %, a reduction
similar to that reported after phacoemulsification alone. However, if the implant was
malpositioned and in contact with the corneal endothelium, it should be removed to
avoid progressive endothelial damage.
2.2.2 Hydrus

The Hydrus Microstent (Ivantis, Irvine, USA) has been evaluated in an industry-
funded randomized controlled trial in which 100 patients with open-angle glaucoma
and cataract were randomized to receive either Hydrus implantation with concomi-
tant phacoemulsification or phacoemulsification alone (Pfeiffer et al. 2015).
Washed-out diurnal IOP was evaluated at baseline, 12 months and 24 months. IOP-
lowering medications were allowed at other times if follow-up IOP exceeded
19 mmHg or there was evidence of progressive optic nerve damage or visual field
loss. Mean diurnal IOP was calculated from measurements made using a two-person
system (observer and reader), with at least two readings being made at each of three
time points, spaced 4 h apart between 8 am and 4 pm.
At 24 months, the proportion of patients with 20 % reduction in washed-out
diurnal IOP was 80 % in the treatment group compared to 46 % in the control group
(p = 0.0008) assessed on an intention-to-treat basis. In a separate analysis that
excluded patients who did not wash out medications for safety reasons, a 20 %
reduction in washed-out diurnal IOP was achieved in 89 % of the treatment group
versus 64 % of the control group (p = 0.0140). Washed-out mean diurnal IOP at
12 months was 16.6 mmHg in the treatment group versus 17.4 mmHg in the control
group. At 24 months, washed-out mean diurnal IOP was 16.9 mmHg in the treat-
ment group compared to 19.2 mmHg in the control group (p = 0.0093). The propor-
tion of patients using no hypotensive medication at 24 months was 73 % in the
treatment group compared to 38 % in the control group (p = 0.0008).
In terms of adverse events, peripheral anterior synechiae formation was noted in
19 % of treated patients versus 2 % of controls at 24 months (p = 0.0077). However,
the presence of PAS was not thought to affect IOP or medication outcomes. Best-
corrected visual acuity decreased by 2 lines in 2 patients in the treatment group, but
resolved by 1 month. By month 3, best-corrected visual acuity was 20/40 or better
in 96 % of subjects in the treatment group versus 90 % in the control group.
Hypotony and stent migration were not found in the treatment group. Secondary
glaucoma surgery was required in 2 % of the treatment group versus 4 % of the
control group, and the difference was not statistically significant.
2.2.2.2 Patient Selection and Procedure

The Hydrus implant is an 8 mm crescent-shaped implantable device. The implant is
very flexible, made from nitinol (a nickel/titanium alloy), and is preloaded onto a
handheld delivery system. The device not only bypasses the trabecular meshwork
but scaffolds and dilates the Schlemm’s canal. Due to its flexibility it easily sits in
the Schlemm’s canal and dilates it. As it scaffolds around one quarter of the canal it
can provide access to multiple aqueous channels.
The surgery set-up is similar to the IStent surgical procedure described above,
and a goniolens is needed to visualize the angle. Surgery can be performed under
topical anesthesia or the technique of choice of the surgeon. Acetylcholine can be
used in combined procedures; it can be implanted through the same corneal incision
used for the phacoemulsification. For Hydrus alone procedures the implant can be
inserted through a 1–1.5 mm corneal incision. If the target implantation site is not
easily accessible/visible through the phaco incision, a secondary incision can be
performed opposite to the desired implantation site.
After filling the anterior chamber with viscoelastic the delivery system is intro-
duced in the anterior chamber and advanced until the inserter tip comes into con-
tact with the trabecular meshwork. The trabecular meshwork is perforated using
the beveled tip of the cannula. Once opened the device is implanted into the
Schlemm’s canal by rotating the advancement mechanism with one finger. The
inserter terminal segment should be positioned parallel to the canal (flat angle)
and with the bevel pointing slightly up. Otherwise, during the delivery the device
could move down and out of the canal. Also if the angle between the angular sur-
face and the inserter is excessive or the position is forced there could be problems
with the delivery. The implant should advance with little or no resistance, if resis-
tance is found the implant can be retracted and the position can be cautiously
modified.
Once the implant is in place, the central core wire of the delivery system is
retracted, allowing the complete detachment of the implant. The inlet segment
(1–2 mm) should remain in the anterior chamber and the rest of the implant in the
canal. On confirmation of the implant position, surgery is completed once the vis-
coelastic has been removed.
Conceptually the indications of the Hydrus implant are similar to the iStent. But,
due to the dual action of the Hydrus implant, which bypasses the trabecular mesh-
work and expands the Schlemm’s canal thus giving access to multiple collector
channels, it is possible that the IOP reduction could be higher than after iStent
implantation. However, this higher efficacy has still to be established.
Reported complication rate is very low, and when performed in combination with
phacoemulsification the rate is similar to a cataract alone procedure (Pfeiffer et al.
2015).
To avoid intraoperative complications it is very important to visualize the tip of the
inserter, be careful when crossing the pupil with the inserter in phakic eyes and
avoid any movement during the “injection” of the Hydrus into the Schlemm’s canal.
The inserter has to be held steady and kept in contact with the angular tissue with
30 K. Hu et al.
the bevel slightly up. Also, note that the rotation knob of the inserter can be adjusted
so the position of the bevel is comfortable for the surgeon.
Bleeding When the procedure is performed correctly some bleeding is very com-
mon and also indicates the reflux of blood from the venous system. This bleeding
will not affect the patient’s recovery or the final outcome. The presence of blood in
the Schlemm’s canal can also help to detect the best areas for implantation. If when
touching the trabecular meshwork the blood prevents the correct visualization of the
tip or the progression of the device it may be necessary to retrieve the implant, wash
out the blood and viscoelastic, wait for the bleeding to stop, and then proceed again
with the implantation. If the device touches/ruptures the iris or is implanted in the
ciliary body, the bleeding could be more severe and may take some time to stop. If
visualization is not good and the surgeon is unsure of a possible damage to the iris
or ciliary body, cancelling the procedure should be considered and then wait for the
eye to recover.
Incomplete/incorrect insertion The implant should be inserted so that only the

inlet is outside the canal. The insertion angle is extremely important and after open-
ing the meshwork the bevel should be angled up so that the device finds its way into
the Schlemm’s canal. If the bevel is positioned to facilitate a “direct” insertion into
the Schlemm’s canal (parallel to iris root) this may result in the implant going down-
wards damaging the angular structures or even the ciliary body and the iris.
Occasionally if resistance is found and the implant does not progress smoothly
during implantation, the device should not be released. Sometimes if the device is
stuck, movement is transferred to the inserter, moving it in the opposite direction to
the injection movement thus exposing the implant that should remain in the same
position, as it is not being introduced further in the Schlemm’s canal. It is very impor-
tant to recognize this situation and retract the device into the inserter again. The first
step is to check the insertion angle and if after a second attempt, the device is stuck
in the same place a good option is to move to another area even if a new incision is
needed. In any case, the implant should not be released until the surgeon is sure that
it is correctly and completely implanted in the canal. Although the device can be
pushed into the Schlemm’s or pulled out with a manipulator or a blunt instrument,
these maneuvers are only effective when correcting a minor positioning problem. If
any of the windows of the implant are even partially seen in the anterior chamber,
removal of the device should be considered. If trabecular damage is not significant,
the surgeon can consider implanting a second one. Depending on the damaged area
it may be necessary to target or find another implantation site (Fig. 2.2).
Adequate position of the implant should be checked after implantation. As some
bleeding is very common sometimes it might be necessary to remove the viscoelas-
tic and the blood. Although not always possible, it is recommended to check the
whole implant from the distal end to inlet.
Tearing of the trabecular meshwork If the grip is not firm enough or there are
movements during the insertion, the device may rupture the trabecular meshwork
Fig. 2.2 Incomplete/
incorrect placement of
Hydrus implant, with most
of the implant in the
anterior chamber
exposing the external wall of the Schlemm’s canal. If there is not much bleeding a
second implantation attempt can be performed.
Supraciliary/suprachoroidal implantation As in the case of the iStent, if the

angle structures are not correctly identified there is an increased risk of damaging
the ocular structures. The implantation of a device like this in the ciliary body is
painful and involves a high risk of severe bleeding. It is important to recognize this
situation as soon as the implant starts to dissect the ciliary body tissue and retract
the device into the inserter. If the implant was completely released it should be
removed using retina forceps. Depending on the ocular situation and the possible
damage to the ciliary body and iris a new device could be implanted.
Iris or lens damage Rupture of the iris During the surgical procedure the surgeon
should visualize the tip of the inserter and be careful to avoid touching the lens
(in phakic eyes), cornea or the iris. Extra movements or surgical maneuvers increase
the risk of damaging the ocular structures. If these maneuvers are needed for any
reason, correct visualization is key to prevent further damage. If the device has to be
removed, it is important to proceed slowly and control both ends of the device, also
forceps should be used with care to avoid capturing the iris. If visualization of the
device and/or angular structures is not good enough (blood or mixture of viscoelas-
tic and blood), it can be improved by waiting for the bleeding to stop and then wash-
ing out the blood and viscoelastic.
arly Postoperative Complications

E
Hyphema Some bleeding is common and is not usually a problem. Pfeiffer et al.
did not report any severe complications related to bleeding.
Malposition If for any reason, the position of the device could not be checked
intraoperatively it should be as soon as possible. If the device is dislocated, or par-
32 K. Hu et al.
tially out of the Schlemm’s canal it is probably better to remove it. Depending on
the ocular conditions and IOP a new device can be implanted in the same surgery.
L ate Postoperative Complications

There is little published evidence on the long-term complications; however, this
device seems to be very safe.
Corneal Endothelial Cell damage If the surgery is uneventful and the device
position correct, the possibility of significant endothelial damage is very low.
Peripheral Anterior Synechiae (PAS) and Inlet Obstruction Pfeiffer et al.

reported that 18.8 % of patients may develop anterior synechiae after 2 years. These
PAS were located at or near the inlet segment of the implant and consisted in focal
iris tissue adhesion to the device or chamber angle usually of less than 1 clock hour.
However, PAS did not have a negative impact on the success rate. In this series, no
cases of complete blockage of the inlet by the iris were found.
2.2.3 Trabectome
The Trabectome (NeoMedix, Tustin, USA) is designed to electrosurgically ablate

the trabecular meshwork and inner wall of Schlemm’s canal. This enables aqueous
to bypass the juxtacanalicular trabecular meshwork and inner wall of Schlemm’s
canal, which is thought to be the main site of resistance in open-angle glaucoma
(Overby et al. 2009).

Results from the use of the Trabectome were first reported by Minckler et al. (2005).
Company data for 4659 treatments show that it safely reduces the need for drops for
several years and reduces IOP by 26 % (Mosaed 2014). A retrospective study sug-
gested that Trabectome is less effective than trabeculectomy (Jea et al. 2012a). To
date, there are no published randomized controlled trial data.
Rates of successful IOP control decline with time, particularly in the first year
postoperatively (Ahuja et al. 2013; Minckler et al. 2008; Mosaed 2014). Success
rates reported in case series vary from 64 % to over 80 % at 12 months postopera-
tively, and from 62 % to more than 75 % at 24 months. Interpretation of results is
hampered by the absence of clear criteria for the use of IOP-lowering medications
in the postoperative period and by loss to follow-up of a significant proportion of
patients.
Trabectome treatment may be more effective when combined with cataract sur-
gery (Ahuja et al. 2013; Francis 2010; Jordan et al. 2013). Phacoemulsification
itself has been shown to lower IOP (Chen et al. 2015; Mansberger et al. 2012), and
the relative contributions of Trabectome and phacoemulsification are not yet defined
by randomized trials.
Recently, it has been reported that Trabectome treatment may be effective in rela-
tively narrow angles (Bussel et al. 2015a) and also in patients after failed trabecu-
lectomy (Bussel et al. 2015b). Trabectome does not violate the integrity of the
conjunctiva, and one cohort study suggests that the success of subsequent trabecu-
lectomy is not compromised (Jea et al. 2012b).
In a single-center case series (Ahuja et al. 2013), the commonest complications
were hyphema (46 %), microhyphema (27 %), and IOP spike (22 %). Other complica-
tions that have been reported include reduction in visual acuity >2 lines (0–5 %)
(Ahuja et al. 2013; Minckler et al. 2008), delayed onset hyphema (5 %) (Ahuja et al.
2012), and aqueous misdirection (0.4 %) (Ahuja et al. 2013). In the manufacturer’s
case series (Mosaed 2014), hypotony (IOP < 5 mmHg) at day 1 occurred in 1 % but
sustained hypotony at 1 month was rare (0.2 %). Secondary surgery was required in
7 % of cases.

Trabectome surgery may be performed under local anesthesia. The Trabectome
probe consists of an irrigating-aspirating handpiece which is introduced into the
anterior chamber through a 1.6 mm temporal incision in clear cornea. Under gonio-
scopic guidance, the end of the probe is advanced across the anterior chamber
towards the nasal trabecular meshwork. The footplate of the probe is inserted
through the trabecular meshwork into the lumen of the nasal part of Schlemm’s
canal. The footplate is then advanced along the lumen of Schlemm’s canal while
electrosurgical power is applied to ablate the inner wall of Schlemm’s canal and the
overlying trabecular meshwork.
Phacoemulsification can be performed after the Trabectome surgery through the
same corneal incision, following enlargement, or via a separately placed incision.
Some surgeons argue that phacoemulsification should be performed prior to
Trabectome surgery, not afterwards. This way, the surgical view is less likely to be
compromised by blood reflux following Trabectome surgery and the drainage angle
may be more open and accessible. On the other hand, any reduction in corneal clar-
ity at the end of phacoemulsification is likely to produce a poor gonioscopic view
for Trabectome surgery.
Patients need to have surgically visible and accessible nasal drainage angles. To
permit a gonioscopic view of the drainage angle, the patient must be able to rotate his
or her head away from the surgeon. Inability to do this is a contraindication for sur-
gery. Similarly, corneal opacities are a relative contraindication to surgery. Angles
that appear to be relatively narrow on gonioscopy in the clinic may nonetheless be
accessible surgically because the pressure of irrigation from the handpiece causes the
lens-iris diaphragm to move posteriorly. However, angles that have peripheral ante-
rior synechiae are unlikely to be amenable to treatment, because the iris tissue may
not ablate easily and is liable to bleed heavily. The pupil is usually dilated if com-
bined Trabectome-phacoemulsification is planned. Otherwise, preoperative applica-
tion of pilocarpine eye drops may assist with opening the drainage angle. Through
miosis, folds of iris are moved away from the ablation site and the crystalline lens is
34 K. Hu et al.
relatively protected from trauma. If, despite these precautions, iris is being aspirated
into the handpiece, the surgeon should reduce the aspiration flow rate.
It is advisable to deflate the anterior chamber prior to introduction of the
Trabectome probe. This allows blood to reflux into Schlemm’s canal from the col-
lector channels, thereby permitting easier identification of the canal, particularly
in unpigmented angles. Although the blood may drain back into the collector
channels following pressurization of the eye by the irrigating Trabectome probe,
the operator will have had an opportunity to identify the location of the Schlemm’s
canal.
In order to minimize the risk of trauma to the crystalline lens, cornea or iris, the
surgeon should hold the handpiece in such a way that the tip can be comfortably
manipulated in the fingers of one hand. Electrosurgical power should never be acti-
vated when the tip of the probe is dry as this may cause damage to the handpiece.
Rotating the goniolens with one hand and the eye using the handpiece will enable
a greater length of the nasal trabecular meshwork to be visualized. Thus, the poten-
tially treatable area can be maximized.
Reflux of blood from the collector channels into the anterior chamber following
removal of the irrigating handpiece from the eye is to be expected. Indeed, such
reflux is regarded as a sign of correct ablation, and helps to identify the extent of
ablation. The surgeon should quickly repressurize the eye to tamponade the reflux.
Viscoelastic may be used as the tamponading agent if the next step is phacoemulsi-
fication. The viscoelastic is injected so as to displace blood, maintaining the red
reflex for the capsulorhexis to be performed.
Following surgery, IOP-lowering drops should be continued. They may be cau-
tiously withdrawn some weeks or months postoperatively if surgery has been per-
formed as a drop-sparing procedure for patients who are allergic to or intolerant of
one or more eye drops. Patients should be prescribed a course of topical steroids,
antibiotics, and pilocarpine. The pilocarpine drops are intended to prevent the for-
mation of peripheral anterior synechiae, which may occlude the opening in
Schlemm’s canal.
Blood is commonly noted in the angle or on the iris at day 1 postoperatively.
However, it has usually cleared by week 1 (Minckler et al. 2005). Patients should be
counseled preoperatively that their vision may be blurred in the first week owing to
the reflux of blood into the anterior chamber.
Poor Visibility
Excellent visibility of the area to be treated is key to the success of the procedure.
The surgeon must use adequately high microscope magnification when introducing
the footplate into Schlemm’s canal and when ablating tissue. Bubbles of air between the
goniolens and the cornea are to be avoided through the use of sufficient coupling
medium. However, care should be taken to avoid contaminating the top surface of
the goniolens with the coupling medium, as this will reduce visibility. Equally, the
manufacturer’s instructions for setting up the equipment need to be followed metic-
ulously to avoid introducing air into the anterior chamber via the handpiece during
the procedure. Air bubbles in the anterior chamber will block the surgeon’s view.
As the handpiece’s own aspiration function is insufficient to remove intracameral
air, the handpiece needs to be removed in order for the air to be exchanged first with
viscoelastic and then with balanced salt solution. Surgeons are advised to avoid
using the Trabectome probe with viscoelastic in the anterior chamber as this may
adversely affect heat dissipation.
Insertion of Footplate
To minimize any difficulty introducing the footplate into the lumen of Schlemm’s
canal, the surgeon should insert the footplate through the trabecular meshwork at a
point that is not directly opposite the corneal incision. In this way, the tip of the
footplate is directed obliquely (and not parallel to) the plane of the trabecular mesh-
work. It is also important to ensure that the tip of the footplate is not inadvertently
bent or blunted by contact with hard surfaces. Particular care should be taken to
avoid damaging the footplate during the removal of the plastic cap from the end of
the handpiece.
Incomplete Ablation
Incomplete ablation occurs if the footplate of the probe is not introduced properly
into the lumen of Schlemm’s canal. Clean ablation of tissue is thought to be impor-
tant to prevent resealing and closure of Schlemm’s canal. Before starting ablation,
the surgeon should verify correct placement of the footplate by gently tenting up the
tissue with the probe. During ablation, the surgeon must ensure that sufficient elec-
trosurgical power is applied. Application of insufficient power may result in tearing
of the tissues and clogging of the tip with tissue. On the other hand, application of
excessive power risks thermal damage to Schlemm’s canal and the orifices of the
collector channels. Visible charring of tissues is an indication for treatment power
to be reduced. Following ablation, the deroofed Schlemm’s canal should be visible
as a shiny white gutter. It can be helpful to use the blunt heel of the footplate as a
manipulator to verify that the canal has been successfully deroofed. Parts of the
canal that have not been deroofed successfully may be retreated, with care to avoid
thermal damage.
False Passage
False passage with damage to Schlemm’s canal can be avoided by verifying correct
placement of the footplate before starting ablation. Because the tissue to be ablated
is quite thin, it should be easily tented up with the probe. Also, there should be mini-
mal resistance to the advancement of the probe. Resistance may signify that the tip
of the probe is misdirected and has engaged the outer wall of Schlemm’s canal. The
surgeon should reorientate the probe.
36 K. Hu et al.
Bleeding
During ablation, the pressure of irrigation prevents blood reflux from the collector
channels. Therefore, overt bleeding suggests that a vessel containing blood at
arterial pressure has been damaged. This may be due to an unintentionally poste-
rior ablation at the iris root, or due to unrecognized vascular tissue overlying the
trabecular meshwork. Regardless of the cause of the bleeding, the surgeon needs
to assess quickly whether blood is going to prevent proper visualization of the
drainage angle. If so, the Trabectome procedure cannot be completed. The
Trabectome probe should be withdrawn and the bleeding tamponaded immedi-
ately with viscoelastic injected into the anterior chamber. Once done, the surgeon
may cautiously evaluate whether clotting has occurred by exchanging the visco-
elastic for balanced salt solution. If so, there is the option to proceed with phaco-
emulsification (if this was planned). Otherwise, the eye should be closed and
managed for hyphema.
Cyclodialysis Cleft
A cyclodialysis cleft may be created if ablation is performed too posteriorly, at the
root of the iris. This may be heralded by bleeding, or by the appearance of the iris
falling posteriorly. Unless there is bleeding, this complication may be managed con-
servatively, at least initially. A low intraocular pressure is to be expected at day 1
and in the first few weeks postoperatively. Indeed, an unexpectedly low intraocular
pressure found postoperatively is reason to suspect that a cyclodialysis cleft has
been created. Some surgeons withhold pilocarpine postoperatively to encourage the
cleft to heal. Small clefts heal spontaneously. Large ones may require formal repair.
Anterior segment imaging techniques such as optical coherence tomography may
allow the size of clefts to be quantified.
Descemet’s Membrane Detachment

Detachment of Descemet’s membrane may occur if the ablation is performed too
anteriorly or if the trabecular meshwork tissues are being torn rather than ablated.
The measures to ensure correct placement of the ablation and to avoid tearing tis-
sue have been outlined previously. If the detachment is small and confined to the
peripheral cornea, it is unlikely that visually significant corneal edema will
develop.
Trauma to Lens, Iris or Cornea

In order to minimize the risk of trauma to the crystalline lens, iris or cornea, the
surgeon should hold the handpiece in such a way that the tip can be comfortably
manipulated in the fingers of one hand. The probe needs to be passed across the
anterior chamber with due care, ensuring that the handpiece irrigation is switched
on continuously. The surgeon needs to be prepared to perform lens extraction should
the capsule of the crystalline lens be inadvertently punctured during Trabectome
surgery.
Bleeding
The presence of a microhyphema or clotted blood in the angle or on the iris is to be
expected immediately after surgery. Early postoperative hyphema is reported in
46 % of cases (Ahuja et al. 2013), but unless it is large should probably not be con-
sidered a complication of surgery.
IOP Spike
A spike in intraocular pressure of greater than 10 mmHg has been reported in
6–22 % of cases with a median onset of 34 days (Ahuja et al. 2013; Minckler et al.
2008). To avoid this, patients’ usual IOP-lowering eye drops should not be with-
drawn in the early postoperative period.
Hypotony
Early postoperative hypotony should cause the surgeon to suspect that a cyclodialy-
sis cleft has been created. This may be verified gonioscopically or by use of anterior
segment imaging such as optical coherence tomography. Some surgeons withhold
pilocarpine postoperatively to encourage the cleft to heal. Small clefts heal sponta-
neously, whereas large ones may require formal repair.
Late Postoperative Complications
Bleeding
Spontaneous late bleeding, occurring more than 2 months postoperatively and
sometimes recurrent, has been reported by different authors (Ahuja et al. 2012;
Kassam et al. 2014). In one case series (Ahuja et al. 2012), bleeding occurred in 5 %
(12 of 262 cases). All patients had noted a transient decrease in vision, mostly on
waking. Only one case required secondary surgical intervention in the form of trab-
eculectomy for refractory high IOP. The remainder were managed conservatively
with steroid eye drops, with resolution of the hyphema within 2 weeks. Laser coag-
ulation of collector channel orifices has also been employed (Kassam et al. 2014).
Some authors have advocated discontinuation of anticoagulants prior to surgery
(Minckler et al. 2005). Bleeding during and after subsequent trabeculectomy has
also been reported (Kassam et al. 2014; Knape and Smith 2010).
Failure of IOP Control

Secondary surgery is reported to be required in 7 % of cases (Mosaed 2014), with
the commonest secondary procedures being trabeculectomy (4 %) and aqueous
shunt insertion (2 %). Trabectome treatment does not violate the integrity of the
conjunctiva, and one cohort study suggested that failed Trabectome surgery does
not compromise the likelihood of success of subsequent trabeculectomy (Jea
et al. 2012b).
38 K. Hu et al.
Practical Tip: Trans-trabecular Meshwork Surgeries
• Anterior vitrectomy should be performed if there is any chance of vitreous

loss into the AC from previous surgery. Positioning of head of patient and
tilting the microscope are essential for good visualization.
• Blood reflux into the anterior chamber is NOT a complication, it simply
signals a direct communication between the anterior chamber and collec-
tors had been established.
• Membrane formation covering the inlets of iStent & Hydrus as well as
exposed collector channels after Trabectome surgery may benefit from
YAG laser disruption.
2.3 Suprachoroidal Implants
2.3.1 CyPass

The CyPass Micro-Stent (Alcon Inc., Fort Worth, Texas, USA) is implanted into the
supraciliary space to provide a permanent drainage conduit for aqueous along the
suprachoroidal pathway (Saheb et al. 2014) (Fig. 2.3).
In a multicenter single-arm interventional study, patients with open-angle glau-
coma and uncontrolled medicated intraocular pressure >21 mmHg at baseline
were enrolled to receive CyPass Micro-Stent implantation alone (Garcia-Feijoo
et al. 2015). Of 65 eyes treated, results for 55 were available at 12 months owing
to loss to follow-up and early termination. Mean IOP decreased by 35 % from
24.5 mmHg at baseline to 16.4 mmHg at 12 months. Mean number of medications
also reduced from 2.2 at baseline to 1.4 at 12 months. Of 64 eyes that were origi-
nally indicated for conventional glaucoma surgery, 83 % did not require second-
ary surgery at 1 year. The commonest adverse events were cataract progression
(12 %), IOP increases > 30 mmHg beyond 1 month (11 %), and transient hyphema
(6 %).
In a separate study examining the implantation of CyPass combined with phaco-
emulsification (Hoeh et al. 2016), patients who had open-angle glaucoma with IOP
of 21 mmHg or higher despite topical medication or prior surgical glaucoma treat-
ment (cohort 1) were analyzed separately from those who had IOP <21 mmHg with
medical treatment (cohort 2). For cohort 1, there was a reduction in mean IOP from
25.9 mmHg at baseline to 16.2 mmHg at 3 months. The IOP-lowering effect was
sustained at 12 months. The mean number of glaucoma medications was also
reduced from 2.1 at baseline to 1.1 at 12 months. Although no IOP-lowering effect
was found for cohort 2, there was a 75 % reduction in mean number of medications
prescribed at 12 months, with 65 % of the patients still in the study at 12 months
being medication-free. Interpretation of these results is hampered by the lack of
Fig. 2.3 A CyPass in its

correct position in the
anterior chamber
prespecified criteria for the management of IOP-lowering medications, the absence

of a control group receiving phacoemulsification alone and by loss to follow-up. 25
of 65 patients in cohort 1 and 31 of 102 patients in cohort 2 were not followed up at
12 months. In terms of adverse events, 14 % of treated eyes had transient hypotony
(IOP < 6 mmHg) which resolved by 1 month without visual sequelae. Elevated IOP
> 30 mmHg and more than 9 mmHg above baseline occurred in 3 % of patients
overall. Other complications included partial or complete obstruction of the implant
(5 %) and endothelial touch (1 %). Secondary surgery, including stent repositioning,
explantation or penetrating glaucoma surgery was required in 6 %.

The CyPass is a 6.35 mm long fenestrated stent made of polyimide. The device has
three retention rings in its proximal end. These in combination with the fenestra-
tions ensure the stability of the implant in the supraciliary space. It is threaded on a
curved guide wire to facilitate its implantation into the suprachoroidal space follow-
ing the scleral curvature. The guide wire tip is blunt to minimize the risk of tissue
damage. The first step in the surgical procedure is to thread the CyPass on the
retractable guide wire of the inserter.
The procedure can be performed under topical anesthesia and the setup (posi-
tioning of the patient’s head and microscope and use of goniolens) is the same as
in the angular surgeries described above. The implantation is usually performed
using a 1.5 mm clear corneal incision opposite to the place where implantation is
planned. Smaller incisions can be considered, as no lateral movements are required.
When performed in combination with phacoemulsification the same incision can
be used. The injection of acetylcholine is recommended then filling the anterior
chamber with a viscoelastic agent to open the angle and improve access to the iris
insertion. The CyPass inserter is then introduced in the anterior chamber and
directed to the iris root aiming at the iris insertion just below the ciliary band. The
suprachoidal space is virtual and the small rupture of the iris root and the creation
of the dissection plane between the ciliary body and the sclera is easily done with
the blunt tip of the guide wire. If resistance is found it is most likely that the angle
of insertion is too flat (too parallel to the iris plane) so the tip hits the sclera. If this
occurs the insertion angle should be increased to facilitate the access to the
40 K. Hu et al.
suprachoroidal space. If the insertion angle is correct, very little resistance to the
inserter advance is to be expected. The CyPass should be introduced until only two
retention rings are seen, then the guide wire is retracted leaving the device in place
and the inserter can be withdrawn. Some bleeding is common and usually does not
interfere with the surgical procedure. Surgery is completed with the removal of the
viscoelastic agent and the blood. At the end of surgery it is recommended to check
the position of the CyPass: Ideally just two of the retention rings should be visual-
ized in the anterior chamber.
The advantage of a procedure that uses the suprachoroidal drainage is that the
efficacy is not limited by the condition of the posttrabecular outflow system. But an
accessible and sufficiently open-angle is required to prevent the CyPass touching
the cornea or come too close to the corneal endothelium. The indications of this
procedure are potentially wider than trabecular/Schlemm’s Canal surgeries and
include secondary open-angle glaucoma. Garcia-Feijoo et al. reported that after 1
year 25 % of the patients achieved an IOP < 13 mm Hg. If this data is confirmed,
and given the safety profile of the procedure, CyPass implantation could be consid-
ered in more advanced glaucoma cases or after filtration surgery failures. However,
the success rate of these possible indications is still to be established.
In the majority of cases, intraoperative complications arise owing to an inappropri-
ate surgical procedure. So it is most important that an adequate visualization of the
angle is obtained and the implant is inserted at the correct angle.
Inadequate position of the CyPass If the CyPass is too deep or too superficial, it
may cause problems. The recommendation is to check the position of the implant
once surgery is complete. If it is too deep the anterior opening could be blocked by
the iris/ciliary body tissue, the created opening may close leading to a surgical fail-
ure. On the other hand if the implant is too anterior it may come into contact with
the cornea damaging the corneal endothelium. If malposition is evidenced during
surgery the device can be repositioned using retinal forceps.
Bleeding This is one of the most frequent complications arising during surgery.
Some slight bleeding can be expected given that a small perforation has to be made
in the iris. In order to prevent excessive bleeding the implant should be inserted
while avoiding lateral movements. Also if patent iris vessels are seen close to the
angle or running parallel to the iris root, this area should be avoided.
Cyclodialysis. Disinsertion of the Iris For the CyPass insertion no lateral move-
ments are required and should be avoided. Lateral movements during insertion not
only increase the chances of significant bleeding but also could cause sectorial dis-
insertion of the iris. In this case a wide area of direct communication between the
anterior chamber and the suprachoroid space will be created thus increasing the
chances of hypotony or choroidal detachment.
Ciliary Body Damage Although this is theoretically possible, the inserter curva-
ture has been designed to follow the scleral curvature and also the point of the guide
wire is blunt making it very difficult to penetrate the ciliary body tissue. In the pub-
lished papers no relevant damage to the ciliary body has been reported.

Early complications are mostly related to the surgical procedure. After uneventful
surgery complications are infrequent but can include hyphema, iris damage or dis-
insertion, and endothelial damage. Choroid effusion or detachment is a potential
risk in any anti-glaucoma surgical technique and more so in surgery that involves
the suprachoroid space as an evacuation route for the aqueous humor.
Hyphema As mentioned above in a multicenter single-arm interventional study,

around 7 % of the patients had a transient hyphema that resolved in the first month.
Excessive manipulation of the iris root/supraciliary space and specifically lateral
movements could increase the risk of severe bleeding.
Suprachoidal Hemorrahage This is a risk in any anti-glaucoma surgery and it

could be speculated that might be more likely in suprachoridal surgeries. However,
in the published series this complication has not reported. So it seems that the risk
of having this complication is very low.
IOP spikes In the mentioned follow-up study by Garcia-Feijoo et al., the authors
defined as transient IOP elevation after surgery an IOP >30 mm Hg during a study
visit but that resolved either on its own or with reintroduction of glaucoma medica-
tions on a subsequent visit. These transient spikes were observed in 10.8 % of the
cases. It can be hypothesized that the spikes could be related to the scar tissue cover-
ing the device. Most of the cases resolved with glaucoma medication.
Hypotony This is a possible complication of any suprachoidal surgery, although

no cases of hypotony have been reported.

We lack published evidence on long-term complications, as the follow-up of the
published series is short.
CyPass Displacement The combination of the fenestrations, the retention rings

and the scarring response around the device result in the stabilization of the device
in position. However, migration of the device is theoretically possible. An anterior
migration could result in a device touching the cornea or coming too close to the
endothelium. On the other hand, posterior migration could introduce the CyPass
deep in the suprachoroidal space facilitating the obstruction of the CyPass by the
42 K. Hu et al.
iris. Anterior migration could be more likely and intrasurgical incorrect positioning
and/or excessive scarring/scarring response around the device might play a role in
the displacement of the CyPass.
Corneal Endothelial Damage An anterior position of the anterior tip of the

CyPass can result in endothelial damage. There are no data on the long-term reper-
cussion on the corneal endothelium of well positioned devices.
IOP Spikes As mentioned before the failure of the surgery can be associated with
an IOP spike. Garcia-Feijoo et al. reported that 16.9 % of the patients needed addi-
tional surgery to control the IOP (second CyPass or trabeculectomy).
Obstruction of the CyPass/Synechia The iris can partially or totally obstruct the
anterior opening of the device. In these cases Nd-YAG laser can be used to clear the
synechia. This complication is more likely if the device was inserted too deep. If
this is the case surgical repositioning of the CyPass could be necessary.
Practical Tip: Suprachoroidal Implants

Positioning of head of patient and tilting the microscope are essential for good
visualization.
Membrane formation covering the inlets of Suprachoroidal implant may
occur.
2.4 Subconjunctival Implants
2.4.1 XEN Gel Implant

The Xen Gel Implant (Allergan, Dublin, Ireland) is a 6 mm long porcine collagen
implant cross-linked to prevent degradation. It is designed to be injected ab interno
from the anterior chamber to drain into the subconjunctival or subtenon’s space. No
safety or efficacy data have yet been published in peer-reviewed journals. Two
industry-sponsored studies are ongoing (Clinicaltrials.gov NCT02036541 and
NCT02006693), but neither is a randomized controlled trial.
A recent conference poster (Rekas et al. 2014) reported outcomes from 107 sub-
jects. The mean preoperative, best medicated IOP was 21.8 mmHg. Mean postop-
erative IOPs were 15.9 at 12 months, 15.1 at 18 months, and 14.2 at 24 months.
Anti-glaucomatous medications were reduced from the preoperative median of 2.8
(patients not washed out presurgery) by 64 % at 12 and 18 months, and by 57 % at
24 months. 6 % had secondary glaucoma surgery by 24 months, but no major
adverse events were reported.
In another conference report (Reitsamer 2014), 74 patients had preoperative

Mitomycin C (MMC) injection followed by XEN implantation, with or without
concomitant cataract surgery. The mean preoperative, best medicated IOP was
22.3 mmHg (patients not washed out presurgery). Mean postoperative IOPs were
15.5 mmHg at 3 months, 14.9 mmHg at 6 months, and 14.7 mmHg at 9 months,
though not all patients had reached 9 months of follow-up. Mean number of preop-
erative anti-glaucoma medications was 3.2, and was reduced to 0.5 at 3 months, 1.0
at 6 months, and 0.8 at 9 months. No secondary glaucoma surgery or major adverse
events were reported by 9 months.

The Xen Gel Implant, because of its apparently greater pressure-lowering effi-
cacy, is an alternative to trabeculectomy as a standalone procedure in a propor-
tion of patients. As it is seems less likely to achieve low long-term IOP levels
than trabeculectomy, but does have greater IOP-lowering efficacy than TM pro-
cedures, the Xen seems most appropriate for those with significant IOP eleva-
tion who do not have very advanced glaucoma and hence do not need very low
target IOPs.
On the other hand, when used in combination with phaco, the converse argument
might be that the Xen, because of its greater potential pressure-lowering efficacy,
might be more appropriate than TM procedures.
Xen implantation differs from the trabecular meshwork procedures in that, by
consensus view, Mitomycin C (MMC) injection is required just before implantation
to reduce the subconjunctival healing response. A common contemporary technique
is to inject 0.1 ml of 0.2 mg/ml MMC to the superior subconjunctival space away
from the limbus, just before implantation. The MMC bleb can then be massaged
gently to the superonasal subconjunctival space. Injecting away from the limbus and
superiorly, rather than superonasally is intended to avoid creating a very avascular
bleb close to the limbus in the inter-palpebral conjunctiva.
The superonasal conjunctiva is then dried with a sponge and ink marks made
3 mm from the limbus to indicate the target zone for the implantation.
A corneal paracentesis is made inferotemporally 1 mm into clear cornea from the
limbus. A second paracentesis is made superotemporally for a second instrument
such as a Vera Hook or iris repositor. If an iris repositor is to be used as the second
instrument, a helpful technique is to make a further paracentesis diagonally opposite
to allow the iris repositor to transfix the globe. There are a few advantages to this as
follows:
• While the Vera hook can be used to plug the side port tightly, this is not the case
with the iris repositor or other types of second instrument that are loose and can
move around. In general, while the surgeon is concentrating on the superior con-
junctival area when injecting the Xen, a second instrument such as an iris reposi-
tor that is mobile will not provide stable fixation, and worse still maybe touch
and traumatize intraocular structures such as lens and iris.
44 K. Hu et al.
• Use of the iris repositor to transfix the globe facilitates rotation of the globe and
implantation closer to the superior limbus and less nasal, reducing the likelihood
of dysesthesia from a bleb below the upper lid.
• Use of the iris repositor in the above manner, protects the lens in phakic eyes
from trauma from the injector if the patient moves suddenly during
implantation.
After making the initial incisions, the anterior chamber is inflated using a visco-
elastic such as Healon GV.
The injector is then briefly checked by advancing the Xen slightly to ensure the
device is correctly loaded and then wet with a small amount of balanced salt solu-
tion. The Xen is then gently repositioned back to its original position and the injec-
tor introduced into the anterior chamber. A 20 gauge MVR blade incision just fits
the Xen injector snugly so it may be necessary to wiggle from side to side to get the
shoulder of the injector past the internal opening into the anterior chamber.
The injector is directed into the angle in a line aiming to traverse the angle and
sclera in a line that would result in it exiting sclera just at the 3 mm mark from the
limbus.
If a goniolens is to be used, it should be placed on the cornea at this juncture. It
is impossible to perform gonioscopy and inject at the same time because of the need
for counter-traction with a second instrument. The goniolens can be used to position
the injector at the correct position in the angle if the position can be maintained
while the lens is removed and the second instrument inserted. An indirect goniolens
such as the Ahmed 1.5× Surgical Goniolens (Ocular Instruments, Bellevue,
Washington, USA) is most suitable for this.
After checking the position of the injector tip in the angle on gonioscopy, the
goniolens is removed and the second instrument positioned via the side port. Gentle
pressure is then applied to advance the injector through sclera, taking care not to
advance the slider or inject. As the injector advances, it is important to attempt to
direct it so that it emerges from sclera at the level of the 3 mm marks. If it emerges
anterior to the marks, the result will be a more corneal injection. Behind the marks
will result in an implantation closer to iris, potentially traversing suprachoroidal
space before traversing sclera. If the implant is too close to iris, there is a greater
chance of iris occlusion. If the injector appears to be exiting sclera too far forward
or back, then it is a simple matter to withdraw into the anterior chamber, reposition
and re-advance.
Once the injector tip has exited sclera in the correct plane and is visible subcon-
junctivally, it is worth advancing slightly further to ensure that the injected implant
does not get stuck in episclera. The injector is then rotated through 90 degrees
either clockwise or anticlockwise. At this point the slider on the injector is slowly
advanced to inject the implant. It is important to maintain forward pressure with
the injector at this point to prevent the injector sliding back into the anterior cham-
ber prematurely. Once the slider has moved the full length of its travel, the needle
tip will have retracted and the implant should be visible in the subconjunctival or
subtenon’s space.
Fig. 2.4 A diffuse subconjunctival bleb surrounding a Xen implant
At this point the viscoelastic should be removed from the anterior chamber using
either a manual or automatic irrigation system. One should then be able to see a bleb
developing over the device in the subconjunctival space.
If no bleb is visible, one should firstly look at the device. If the device is curled
up in a pigtail appearance, it may be embedded in Tenon’s capsule and the external
aperture obstructed by Tenon’s. This can be remedied by taking a pair of tying for-
ceps and gently stroking the implant to straighten it. Often a bleb will start to appear
at that point. If the tube is deemed to be too long, it can be fed back towards the
anterior chamber using the forceps and vice versa if it is too short (Fig. 2.4).
If no bleb is still visible it is worth performing gonioscopy again to ensure that the
anterior chamber positioning is correct and the tube is patent at its internal ostium.
Intraoperative complications with Xen relate either to difficulty with implant posi-
tioning or hyphema. In phakic eyes, the potential for lens touch exists, e.g., if the
patient moves during surgery. Management of hyphema and avoidance of lens touch
are as for the procedures previously described.

Apart from hyphema and rarely infection, the risks in the early postoperative period are
low pressure and high pressure. Low IOP is not uncommon, especially in younger patients.
Significant anterior chamber shallowing is relatively uncommon but occasionally requires
topical atropine or serial injections of viscoelastic in out-patients. In the author’s experi-
ence (KB), hypotony does not last more than 2 weeks in the most extreme case.
46 K. Hu et al.
High IOP during the first few days might be indicative of retained viscoelastic,
but more likely occurs from obstruction of the Xen, either externally by Tenon’s, or
occasionally internally, by iris.

As the Xen has only been available for just over 2 years, long-term experience is
almost non-existent. Dysesthesia, blebitis, and endophthalmitis are a possibility
though they seem to be rare. One of the authors (KB) has experienced two cases of
implant exposure in around 120 cases, both necessitating implant removal. Other
than that, the longer term risk is failure of IOP control, but much greater experience
will be required to quantify this accurately.
2.4.2 MicroShunt
The MicroShunt (Innfocus, Miami, Florida, USA) is an 8.5 mm flexible tube of 70

μm lumen diameter made from a polyolefin triblock polymer (poly(Styrene-block-
IsoButylene-block-Styrene)) that is designed to drain from the anterior chamber to
the subtenons space behind the limbus. In that respect, the mode of action is similar
to the Xen. However, the MicroShunt differs from the Xen and any other MIGS-
type procedure in that it is implanted via an ab externo approach. Although some
would regard this as a disadvantage, the mode of implantation does benefit from
minimal anterior chamber intervention, making it an attractive proposition in stand-
alone cases that are not undergoing concomitant cataract surgery.

At the time of writing, there are no published high-quality trials of MicroShunt
safety and efficacy in peer-reviewed journals but a US and European randomized
surgical trial is underway with the stated objective to obtain FDA approval as an
alternative to trabeculectomy.

Implantation of the MicroShunt is believed to be indicated in patients who would
otherwise be suitable for trabeculectomy. The absence of published high-quality
evidence at present makes this difficult to verify.
The implantation procedure involves making a superior limbal conjunctival inci-
sion at the 12 o’clock position, similar to that for trabeculectomy. A subtenon’s
dissection is made in order to open up the subtenon’s space for MMC application.
Light cautery is applied to the episclera to achieve hemostasis in order to ensure that
contact with blood does not blunt the effect of the MMC. MMC is applied in a simi-
lar fashion to a trabeculectomy procedure on a number of sponges over a wide area.
The MMC is then irrigated away using 20 ml of BSS.
A point 3 mm behind the limbus is then marked with ink. A scleral tunnel is then
created with a 1 mm diameter slit knife that is advanced 2 mm to a predefined mark.
The slit knife is then withdrawn and a 25 gauge (orange) hypodermic needle gently
Fig. 2.5 Demonstration of aqueous flow through a Microshunt implant before conjunctival
closure
inserted into the tunnel and advanced to its apex. The needle is then angled in order
to advance it into the anterior chamber parallel to the plane of the iris and subse-
quently withdrawn.
The implant is washed with BSS in order to eliminate static electricity, gently
grasped with tying forceps just in front of the fin and advanced into the anterior
chamber via the tunnel. The Tunnel is designed in a manner to allow the fin to sit
snugly intrasclerally. At this point, the tube portion should be visible in the anterior
chamber, away from iris and cornea and the implant should be immobile in the tun-
nel without sutures.
It is important to ensure that the tube is draining aqueous before closure. This can
be achieved by observing aqueous egress at the external aperture of the tube using a
small sponge or fluorescein. If no flow is observed initially, it can usually be initi-
ated by pressing on the eye gently at the limbus. If repeated firm pressure is insuf-
ficient to initiate flow, a wide bore, thin-walled 23 gauge cannula has been sourced
by the manufacturer of the implant that can be placed over the length of the tube and
used to flush it (Fig. 2.5).
After confirming that the implant is draining, the Tenon’s and conjunctiva are
closed. It is important before reapposing the conjunctiva at the limbus to ensure that
Tenon’s is lifted up over the implant and also brought towards the limbus. This is to
ensure that the implant does not become caught in Tenon’s or bent forward when
conjunctiva and Tenon’s are reapposed.
It is often helpful, where feasible, to suture conjunctiva and Tenon’s separately.
Firstly, one can ensure that Tenon’s does not slip back around the implant. Secondly,
this avoids drawing Tenon’s right up to the limbus, which occasionally, if tight, can
predispose to ptosis.
48 K. Hu et al.
There are relatively few challenges with MicroShunt insertion. These include bleed-
ing on needle insertion that might result in a postoperative hyphema, malpositioning
of the shunt either in iris or cornea, which is simply remedied by removal and cre-
ation of a separate tunnel, and failure to observe flow the through the tube.

Possibly early postoperative complications include hyphema, hypotony, or obstruc-
tion of the tube. To date these are all relatively uncommon. Hypotony is likely to be an
issue in some patients as the internal diameter of the device at 70 μm does not provide
sufficient resistance in a device 8.5 mm long to maintain intraocular pressure without
some additional resistance from conjunctiva and Tenon’s. The reported hypotony rate
from company information is <10 % and all have been stated to resolve spontaneously
within 1 week. The choroidal effusion rate has been reported to be 5 %.

At the time of writing, there are no long-term reports upon which to assess safety or
efficacy.
Practical Tip
• Start 2 mm from the limbus with a smooth single entry initially in the plane
of the sclera then angling forward parallel with the iris plane once half of
the bevel is in the sclera.
• Ensure a single movement without retraction and advancement (as this can
create a false pocket).
• Enlarge the track slightly on exit to aid with initiating the tube entry.
• Check for watertight fit with 2 % fluorescein, suture adjacent to the tube if
leaking.
• Persistent leaks may be stopped by plugging with Tenon’s tissue.
• Ensure flow through the tube at the end of the surgeries. In the case of Xen,
bleb formation is critical at the end of surgery.
• Bleb encapsulation can occur, and needling with 5-fluorouracil should be
considered postoperatively.
References
Ahuja Y, Malihi M, Sit AJ. Delayed-onset symptomatic hyphema after ab interno trabeculotomy
surgery. Am J Ophthalmol. 2012;154:476–80.e2.
Ahuja Y, Ma Khin Pyi S, Malihi M, et al. Clinical results of ab interno trabeculotomy using the
trabectome for open-angle glaucoma: the Mayo Clinic series in Rochester, Minnesota. Am
J Ophthalmol. 2013;156:927–935.e2.
Arriola-Villalobos P, Martínez-de-la-Casa JM, Díaz-Valle D, et al. Combined iStent trabecular

micro-bypass stent implantation and phacoemulsification for coexistent open-angle glaucoma
and cataract: a long-term study. Br J Ophthalmol. 2012;96(5):645–9.
Arriola-Villalobos P, Martínez-de-la-Casa JM, Díaz-Valle D, et al. Mid-term evaluation of the new
Glaukos iStent with phacoemulsification in coexistent open-angle glaucoma or ocular hyper-
tension and cataract. Br J Ophthalmol. 2013;97(10):1250–5.
Bussel II, Kaplowitz K, Schuman JS, et al. Outcomes of ab interno trabeculectomy with the trabec-
tome by degree of angle opening. Br J Ophthalmol. 2015a;99:914–9.
Bussel II, Kaplowitz K, Schuman JS, et al. Outcomes of ab interno trabeculectomy with the trabec-
tome after failed trabeculectomy. Br J Ophthalmol. 2015b;99:258–62.
Chen PP, Lin SC, Junk AK, et al. The effect of phacoemulsification on intraocular pressure in
glaucoma patients: a report by the American Academy of Ophthalmology. Ophthalmology.
2015;22:1294–307.
Craven ER, Katz LJ, Wells JM, et al. Cataract surgery with trabecular micro-bypass stent implanta-
tion in patients with mild-to-moderate open-angle glaucoma and cataract: two-year follow-up.
J Cataract Refract Surg. 2012;38:1339–45.
Fea AM. Phacoemulsification versus phacoemulsification with micro-bypass stent implantation in
primary open-angle glaucoma: randomized double-masked clinical trial. J Cataract Refract
Surg. 2010;36:407–12.
Fea AM, Belda JI, Rekas M, et al. Prospective unmasked randomized evaluation of the iStent inject
((R)) versus two ocular hypotensive agents in patients with primary open-angle glaucoma. Clin
Ophthalmol. 2014;8:875–82.
Fernández-Barrientos Y, García-Feijoó J, Martínez-de-la-Casa JM, et al. Fluorophotometric study
of the effect of the glaukos trabecular microbypass stent on aqueous humor dynamics. Invest
Ophthalmol Vis Sci. 2010;51:3327–32.
Francis BA. Trabectome combined with phacoemulsification versus phacoemulsification alone:
a prospective, non-randomized controlled surgical trial. Clin Surg Ophthalmol. 2010;
28:1–7.
Garcia-Feijoo J, Rau M, Grisanti S, et al. Supraciliary micro-stent implantation for open-angle
glaucoma failing topical therapy: 1-year results of a multicenter study. Am J Ophthalmol.
2015;159:1075–1081.e1.
Hoeh H, Vold SD, Ahmed IK, et al. Initial clinical experience with the CyPass micro-stent: safety
and surgical outcomes of a novel supraciliary microstent. J Glaucoma. 2016;25:106-12.
Jea SY, Francis BA, Vakili G, et al. Ab interno trabeculectomy versus trabeculectomy for open-
angle glaucoma. Ophthalmology. 2012a;119:36–42.
Jea SY, Mosaed S, Vold SD, et al. Effect of a failed trabectome on subsequent trabeculectomy.
J Glaucoma. 2012b;21:71–5.
Jordan JF, Wecker T, Van Oterendorp C, et al. Trabectome surgery for primary and secondary open
angle glaucomas. Graefes Arch Clin Exp Ophthalmol. 2013;251:2753–60.
Kassam F, Stechschulte AC, Stiles MC, et al. Delayed spontaneous hyphemas after Ab interno
trabeculectomy surgery for glaucoma. J Glaucoma. 2014;23:660–1.
Knape RM, Smith MF. Anterior chamber blood reflux during trabeculectomy in an eye with previ-
ous trabectome surgery. J Glaucoma. 2010;19:499–500.
Mansberger SL, Gordon MO, Jampel H, et al. Reduction in intraocular pressure after cataract
extraction: the Ocular Hypertension Treatment Study. Ophthalmology. 2012;119:1826–31.
Minckler DS, Baerveldt G, Alfaro MR, et al. Clinical results with the Trabectome for treatment of
open-angle glaucoma. Ophthalmology. 2005;112:962–7.
Minckler D, Mosaed S, Dustin L, et al. Trabectome (trabeculectomy-internal approach): additional
experience and extended follow-up. Trans Am Ophthalmol Soc. 2008;106:149–59; discussion
159–60.
Morales-Fernandez L, Martinez-De-La-Casa JM, Garcia-Feijoo J, et al. Glaukos trabecular stent
used to treat steroid-induced glaucoma. Eur J Ophthalmol. 2012;22(4):670–3.
Mosaed S. The first decade of global trabectome outcomes. Clin Surg Ophthalmol.
2014;32:21–9.
50 K. Hu et al.
Overby DR, Stamer WD, Johnson M. The changing paradigm of outflow resistance generation:
towards synergistic models of the JCT and inner wall endothelium. Exp Eye Res.
2009;88:656–70.
Pfeiffer N, Garcia-Feijoo J, Martinez-De-La-Casa JM, et al. A randomized trial of a Schlemm’s
canal microstent with phacoemulsification for reducing intraocular pressure in open-angle
glaucoma. Ophthalmology. 2015;122:1283–93.
Reitsamer H. Early results of a minimally-invasive, ab-interno gelatin stent in combination with a
preoperative Mitomycin C injection for the treatment of glaucoma. London: XXXII Congress
of the ESCRS; 2014.
Rekas M, Lewczuk K, Jablonska J, et al. Two year follow-up data with a soft and permanent,
minimally-invasive ab-interno subconjunctival implant in open-angle glaucoma subjects.
London: XXXII Congress of the ESCRS; 2014.
Saheb H, Ianchulev T, Ahmed I. Optical coherence tomography of the suprachoroid after CyPass
Micro-Stent implantation for the treatment of open-angle glaucoma. Br J Ophthalmol.
2014;98:19–23.
Samuelson TW, Katz LJ, Wells JM, et al. Randomized evaluation of the trabecular micro-bypass
stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology.
2011;118:459–67.
Voskanyan L, Garcia-Feijoo J, Belda JI, et al. Prospective, unmasked evaluation of the iStent(R)
inject system for open-angle glaucoma: synergy trial. Adv Ther. 2014;31:189–201.
Nonpenetrating Glaucoma Surgery
(Deep Sclerectomy, Viscocanaloplasty, 3
and Canaloplasty)
Jason Cheng, Kuang Hu, and Nitin Anand
3.1 Introduction
The aim of all nonpenetrating glaucoma surgery (NPGS) procedures is the creation
of a filtration membrane, the trabeculo-Descemet’s membrane (TDM). Aqueous fil-
ters into a subscleral space created by excising a deep scleral flap. The final route for
aqueous outflow differs between the two NPGS procedures. It is thought to be the
subconjunctival space and possibly the suprachoroidal space with deep sclerectomy
(DS) and enhanced flow through the Schlemm’s canal in viscocanaloplasty (VCT)
and its variant, canaloplasty.
The earliest descriptions of DS are in the Russian literature. A form of NPGS,
sinusotomy, was described by Krasnov (1968), who excised a scleral lamella
directly over Schlemm’s canal to expose its lumen. Krasnov noted that care was
required to avoid damage to the inner wall of Schlemm’s canal, which would con-
vert the operation to a fistulizing procedure. He also stated that the anterior chamber
should not empty during the course of surgery, thereby preventing serious
complications. Zimmerman and Kooner and published a comparative trial c omparing
ab-externo trabeculectomy with trabeculectomy about 30 years ago (Zimmerman
et al. 1984). Andre Mermoud popularized the current DS procedure in the 1990s.
VCT (Stegmann et al. 1999) and canaloplasty were both originally described by
Robert Stegmann (Stegmann 1995).
J. Cheng
KhooTeck Puat Hospital, Yishun, Singapore
K. Hu
N. Anand (*)
Cheltenham General and Gloucester Royal Hospitals, Gloucester, UK

52 J. Cheng et al.
3.2 Procedure for NPGS
Deep sclerectomy (DS) is the prototype NPGS procedure. It is important to empha-

size that success of both VCT and canaloplasty is also dependent on the creation of
adequate filtration through the TDM. The surgeon has to be familiar with the anat-
omy of the limbus (Fig. 3.1). The most important landmark is the transition zone.
The SC canal is at the posterior edge of this gray zone. A fornix-based conjunctival
flap is dissected with posterior dissection of MMC is used. The superficial scleral
flap may be rectangular or trapezoid in shape, approximately one-third scleral thick-
ness and 5 mm at the limbus. The flap dissection should start at least 3 mm behind
the posterior edge of the anatomical limbus and is continued 1–2 mm into clear
cornea (Fig. 3.2a). MMC is applied posteriorly and may be applied either before or
after outer sclera flap dissection. Concentrations of 0.2 mg/ml for 1–3 min are ade-
quate for most situations (Fig. 3.2b). Subconjunctival bevacuzimab 0.5 mg at the
end of the procedure may be used in low-risk cases (Anand and Bong 2015). Cautery
should be used sparingly. Blood in the surgical field can be absorbed by PVA sponge
fragments.
The inner or deep scleral flap dissection is critical and must be done under high
magnification (×14). The edges are1 mm inside and can be gradually deepened until
the choroid is visible at the posterior edge and the Schlemm’s canal was incised at
the lateral edges (Fig. 3.2c). The dissection is done at 95 % thickness of the remain-
ing sclera and the choroid should be visible though the sclera. The scleral fibers
become circumferentially oriented when the scleral spur is reached (Fig. 3.2d). The
lateral edges are then extended into the cornea (Fig. 3.2e, f). Dissection centrally
should be done with a PVA or cellulose spears. Sharp instruments should be avoided
at this stage. The deep flap is then dissected in the plane of the scleral spur, de-
roofing the Schlemm’s canal and continued about 1 mm into clear cornea and
excised (Fig. 3.2h). JXT is then peeled with a blunt-tipped capsulorrhexis forceps to
ensure percolation of aqueous through the TDM (Fig. 3.2i). A spacer device may be
placed in the scleral bed and the superficial scleral flap is loosely sutured back with
1-2 10/0 nylon sutures. The conjunctiva was sutured onto the limbus with two 10/0
nylon radial interrupted sutures.
In VCT, high molecular weight hyaluronic acid (Healon GV®) is injected via a
small-caliber cannula into the SC (Fig. 3.3). The aim is to dilate the SC and per-
haps create microperforations in the inner wall (Tamm et al. 2004). Canaloplasty
involves passing a microcatheter into the ostium of Schlemm’s canal. The micro-
catheter incorporates an illuminated tip that can be observed transsclerally during
catheterization of the canal and a lumen through which viscoelastic was delivered
to dilate the canal. Once exposed at the opposite ostium, 10-0 prolene suture
(Ethicon Inc.) is tied to the distal tip of the microcatheter. The microcatheter was
then retracted, injecting Healon GV™. The catheter is removed and the suture is
tied tight exerting tension on the SC. The superficial flap is closure is watertight,
with 5-6 interrupted 10-0 prolene sutures in both VCT and canaloplasty. The aim
of the tight closure is to avoid subconjunctival flow of aqueous and direct flow into
the SC (Fig. 3.4).
3 Nonpenetrating Glaucoma Surgery 53
Fig. 3.1 Anatomy of the

limbus. Top: arrow with
dashed line shows the
anterior edge of the
surgical limbus, the
attachment of the
conjunctiva to cornea. The
solid arrow shows the
posterior edge of the
transition (gray) zone, the
usual location of
Schlemm’s canal. Middle:
conjunctival dissection
reveals a wide transition
zone. Arrows indicate the
same landmarks as in the
figure above. Bottom: the
Schlemm’s canal (arrow)
location just prior to
de-roofing. Note the
distance between the canal
and the anterior edge of the
surgical limbus
54 J. Cheng et al.
a b c
d e f
g h i
Fig. 3.2 Nonpenetrating glaucoma surgery, creation of the trabeculo-Descemet’s filtration membrane.
(a) Arrows indicate dissection of outer sclera flap 1 mm into clear cornea. (b) Posterior diffuse MMC
application for 1–3 min. (c) Deep sclera flap delineation. Edges deepened till Schlemm’s canal is cut
(arrow) and choroid visible at posterior edge. (d) The deep sclera fibers (arrow) become circumferen-
tially orientated just before the Schlemm’s canal is reached. (e, f) The lateral edges are cut with a No.
11 blade on a Bard-Parker handle. This blade has a blunt tip and posterior edge. The blade is angled at
45° to avoid perforation. (g) The dissection is continued at least 1 mm into cornea. The juxtacanalicular
trabecular meshwork is delineated clearly (arrow). Dissection is done by gently rubbing the membrane
with a PVA sponge. Sharp instruments are to be avoided. (h) The deep flap is excised (i) The juxtacana-
licular trabecular meshwork is removed with a blunt-tipped forceps to enhance filtration
Fig. 3.3 Viscocanalostomy. The Schlemm’s canal is dilated by forcefully injecting Healon GV™
through the cut ends
Fig. 3.4 Gonioscopic
view of the superior angle
after canaloplasty. Iris is
partially covering the
TDM. The 10/0 prolene
suture is clearly seen in
the Schlemm’s canal
3.3 Efficacy and Outcomes for NPGS
3.3.1 Deep Sclerectomy
In a series of 194 eyes of 160 consecutive patients who had primary phakic DS, the
probability of achieving an IOP of less than 19 mmHg without medications or nee-
dle revisions was 85 % at 1 year and 78 % at 3 years (Anand et al. 2011). IOP of less
than 13 mmHg was achieved without medications or needle revision in 68 % at
1 year and 60 % at 3 years.
In a randomized controlled trial, DS with mitomycin C yielded complete suc-
cess (defined as IOP ≤21 mmHg without antiglaucoma medications) in 79 %
(15/19) of eyes at 1 year and 53 % (10/19) of eyes at 4 years (Cillino et al. 2005,
2008). Qualified success (defined as IOP ≤21 mmHg with or without antiglau-
coma medications) was seen in 100 % of eyes at 1 year and 79 % (15/19) of eyes
at 4 years.
In another randomized controlled trial, 43 patients were allocated to DS with
reticulated hyaluronic acid (SK-GEL) scleral implant and mitomycin C (Russo
et al. 2008). No goniopuncture or bleb needling was performed. At 4 years, 51 % of
eyes had complete success (defined as achievement of target IOP without antiglau-
coma medications) for a target IOP of <21 mmHg, while 33 % of eyes had complete
success for a target IOP of <18 mmHg.
Reviews of the literature differ in their conclusions about whether DS offers
an equivalent degree of IOP control to trabeculectomy (Eldaly et al. 2014; Rulli
et al. 2013).
There is consensus that, compared to DS, trabeculectomy has a higher risk of
complications such as hypotony (relative risk (RR) 2.1), choroidal effusion (RR
3.8), cataract (RR 3.3), and shallow anterior chamber (RR 4.1) (Rulli et al. 2013).
Blebitis (1 %) and endophthalmitis (0.5 %) have been observed during long-term
follow-up of patients who have had DS (Anand et al. 2011).
56 J. Cheng et al.
3.3.2 Viscocanalostomy
In a randomized controlled trial, 35 % of the 25 patients allocated to VC had total

success (IOP 6–21 mmHg without medication) at 3 years (Yalvac et al. 2004).
Qualified success (IOP 6–21 mmHg with medication) was achieved in 74 % of the
patients at 3 years.
Kobayashi et al. (2003) conducted a randomized controlled trial using a paired
design in which one eye of each participant received VC whereas the other had tra-
beculectomy. At 12 months, 64 % of the eyes treated with VC, achieved IOP ≤
20 mmHg without medication versus 88 % of the eyes treated with
trabeculectomy.
Recent systematic reviews and meta-analyses of the available evidence suggest
that VC is less effective at controlling IOP than trabeculectomy (Eldaly et al. 2014;
Rulli et al. 2013). However, some authors have commented that VC requires a
learning curve that may be relevant to outcomes (Eldaly et al. 2014; Mendrinos
et al. 2008).
Compared to VC, trabeculectomy has a higher risk of complications such as
hypotony (relative risk (RR) 2.6), choroidal effusion (RR 6.0), cataract (RR 3.8),
and shallow anterior chamber (RR 5.5) (Rulli et al. 2013).
3.3.3 Canaloplasty
In a prospective series of 94 patients (Lewis et al. 2011), a suture was successfully

placed in 74 (79 %) of them. Mean IOP was reduced from 24.7 mmHg at baseline
to 15.3 mmHg at 1 year. This result needs to be interpreted with caution because
1-year outcomes were reported for fewer than two-thirds of the patients.
No randomized controlled trials have been conducted to compare canaloplasty
with trabeculectomy. In a retrospective, nonrandomized comparative case series,
canaloplasty achieved a 32 % reduction in IOP at 12 months compared to 43 % for
the trabeculectomy group (Ayyala et al. 2011).
In the series of Lewis et al. (2011), adverse events were reported in 16 %, with
hyphema (3 %) and elevated IOP (3 %) being the commonest.
3.4 Complications for NPGS
Nonpenetrating surgery offers a lower rate of complications when compared to con-

ventional trabeculectomy (17 % vs. 65 %, respectively), with or without anti-
metabolites according to a Cochrane meta-analysis (Eldaly et al. 2014). The
presence of the TDM and absence of an iridectomy result in a stable and quiet
anterior chamber. The TDM acts as a flow-resistor, preventing shallow anterior
chambers and choroidal detachments. However, it is also recognized that with
NPGS procedures, surgical learning curve is steeper and that complication rates
depend on skill and experience of the surgeon.
Many of the complications found in NPGS overlap with trabeculectomy, which

have been covered in the previous chapter. This section will focus on complications
specific to DS, VCT, and canaloplasty.
3.4.1 Intraoperative Complications for NPGS
Precise scleral flap dissection is crucial. The outer or superficial scleral flap should
be half to third thickness. If too thin, aqueous will transude through the flap. Also a
thin scleral flap is prone to necrosis due to a poor vascular supply. This is particu-
larly relevant if MMC or bevacizumab are used (Fig. 3.5).
The inner or deep sclera flap dissection is crucial. If too shallow, the dissection
will pass over the SC with little or no filtration. If the dissection is quite shallow
with a “white” scleral bed, a third deep flap may be dissected at the correct depth to
deroof the SC. If the dissection is slightly shallow and uneven, tissues forming the
SC roof can be grasped and avulsed as shown in Fig. 3.6.
Perforation of the TDM is the most common intraoperative complication. The
incidence of perforation is around 30 % for the novice and decreases to 2–3 % in the
more experienced surgeon (Karlen et al. 1999; Sanchez et al. 1997). Perforation of
the TDM can be classified by size into microperforations or large transverse perfo-
ration and by location into anterior or posterior.
TDM microperforations often occur while extending the lateral edges of the flap
into the cornea. To avoid perforations, the eye should be made soft by releasing
aqueous via a paracentesis. This should be done just before the SC is deroofed. If
these microperforations are anterior with minimal shallowing of the anterior cham-
ber, the procedure should be continued as normal. Sometimes the microperforation
can be left covered by the corneal–scleral stump. The dissection of the TDM should
be meticulous and the surgeon should avoid the temptation to complete the opera-
tion quickly after an anterior perforation. The outer sclera flap may be suture tightly
a b
Fig. 3.5 Necrosis of the superficial (outer sclera flap). (a) Necrosis and blebitis occurred within
the first month after DS with subconjunctival bevacizumab in an 80-year-old Caucasian female
with severe Sjogren’s syndrome and dry eyes. (b) Scleral necrosis observed 2 years after DS with
MMC. Patient was asymptomatic and IOP in low teens
58 J. Cheng et al.
a b c
d e f
Fig. 3.6 Superficial dissection of the inner scleral flap (a and b). The scleral flap is placed under ten-
sion to tent the scleral fibers overlying the SC and these are grasped with a blunt-tipped forceps and
avulsed (c, d). The SC is now deroofed with free flow of aqueous and the procedure is continued ( e, f)
The juxtacanalicular tissues are also meticulously removed (arrow)
a b
Fig. 3.7 Perforations of the TDM. (a) Large transverse perforation (arrows) and (b) a small pos-
terior perforation while removing JXT tissue with gush of aqueous (arrow)
and the anterior chamber reformed at the end of the procedure. The use of viscoelas-
tic to maintain the anterior chamber is to be discouraged as residual viscoelastic
may cause a postoperative IOP rise. A large transverse tear at the junction between
the trabeculum and Descemet’s membrane (corresponds to Schwalbe’s line) may
occur spontaneously or on minimal applied pressure with a PVA spear (Fig. 3.7).
The incidence has not been reported but may occur in 1–2 % of cases. In both a
posterior tear and a transverse tear, the iris will relapse and an iridectomy should be
performed (Fig. 3.8). The surgeon can excise the deep flap and perform a punch
sclerectomy under the superficial flap, converting the procedure to a trabeculec-
tomy. If the deep flap has already been is higher and tight sutures and good closure
is imperative. It is advisable to dissect a half-thickness outer sclera flap during the
a b c
Fig. 3.8 Transverse spontaneous linear perforation with iris prolapse (a). The iris was reposited
with intradermal intracameral Miochol® and a small peripheral iridectomy was performed (b). The
inner scleral flap was excised and the outer flap sutured with interrupted 10/0 nylon sutures (c). The
IOP was 12 mmHg at 3 years after surgery
surgeon’s learning curve to ensure watertight closure in case of perforation. Often

the transverse linear perforation is not visible on postoperative gonioscopy (Fig.
3.8).
Intraocular bleeding is rare in NPGS because the IOP is reduced slowly and a
peripheral iridotomy is not performed. Blood reflux from Schlemm’s canal may
occur when the episcleral venous pressure rises above the IOP. This may be a favor-
able sign, indicating an intact outflow pathway. It may fill the subscleral lake and
may perhaps stimulate subscleral fibrosis postoperatively. Some experts believe that
early laser goniopuncture may be indicated in this situation.
Descemet’s membrane detachment (DMD) can occur in all three types of
NPGS. The detachment tends to extend from the surgical site in DS and VCT, but
tends to occur 180° from the polypropylene suture knot in canaloplasty.
In VCT, the detachment is usually noted at the time of forceful injection of vis-
coelastic. The management involves removal of the viscoelastic and injection of
anterior chamber air bubble tamponade. Rarely, blood can be trapped within the
detachment. This blood and can be left if it is peripheral, although it may take
months to clear. There is one reported case of blood remnants still visible 2 years
after surgery (O’Brart et al. 2004). Hemorrhagic Descemet’s detachment involving
the visual axis can lead to long-term decrease in visual acuity (Yalvac et al. 2004).
Air tamponade is helpful in this situation but occasionally inert gas (such as perflu-
ropropane (C3F8) or sulfur hexafluoride (SF6) gas), or fixation sutures (descemeto-
pexy) may be needed.
DMD after canaloplasty is not uncommon. In a large case series, DMD was
observed 12 out of 124 eyes (7.2 %). Eighty-three percent (10/12) of the DMDs
involved the inferior quadrants and measured <3 mm. Hemorrhage within the DMD
was seen in 58 %. Two patients had large detachments measuring 5–6 mm extend-
ing into the visual axis. DMD resolved completely with or without drainage except
for 1 patient who developed corneal decompensation, needing penetrating kerato-
plasty (Jaramillo et al. 2014).
DMD occurs less frequently after DS. A database search of 1250 DS and com-
bined phacoemulsification and DS procedures done in our institution over 14 years,
we identified four cases (0.003 %). Three were observed 2–4 months after DS and
60 J. Cheng et al.
a b
Fig. 3.9 Bleb (a) and gonioscopy (b) 3 years after DS with subconjunctival bevazizumab and a
large transverse perforation. The iris at the lateral edge of the iridectomy is attached to the
TDM. However the linear perforation has closed spontaneously
one more than 2 years after surgery (Fig. 3.9). All four eyes had IOP over 20 mmHg.
Interestingly, the DMD resolved after laser goniopuncture in one case and after
needle revision in three cases (Anand N, unpublished data). The implication is that
the etiology of DMD after DS differs from that of VCT. DMD after DS may become
manifest if the outflow resistance is high and the aqueous passing through the TDM
then accumulates between the corneal stroma and Descemet’s membrane. In a case
series of nine patients with DMD, four after VCT and five after DS, the authors have
emphasized this difference. DMD after VCT is observed immediately after surgery
and weeks to month after DS. They performed descemetopexy in four eyes (Ravinet
et al. 2002).
Intraoperative adverse events specific to canaloplasty include the inability to
cannulate the Schlemm’s canal, trauma to the canal and microcatheter passage
into the suprachoroidal space (Grieshaber et al. 2011). Difficulties in cannulating
Schlemm’s canal is usually related to the dissection, identification and de-roofing
of the canal. Resistance or blockage of the microcatheter may occur due to a tight
opening, hitting an open collector channel, an incomplete canal or scarring in the
canal. Injection of viscoelastic into the canal can aid penetration, by dilation and
lubrication. The surgeon can also try passing the microcatheter in the opposite
direction. Excess force may cause a tear in the trabecular meshwork and cause
microcatheter penetration into the anterior chamber. The polypropylene suture is
passed through the canal and tightened to maintain its patency. If the suture breaks
during knot-tying, then it will need to be replaced. In case of unsuccessful circum-
ferential SC catheterization, the procedure may be converted into 180° metal tra-
beculotomy. If the tension suture cheese wires through the trabecular meshwork
after successful complete catheterization, it is converted into 360° trabeculotomy
(Alnahrawy et al. 2015).
Precise suturing of the conjunctival flap is not so critical after NPGS procedures.
There is very little flow into the subconjunctival space after VCT and a slow flow
after DS. Conjunctival buttonholing and retraction likewise do not have the serious
implications as after trabeculectomy.
a b
c d
e f
Fig. 3.10 (a) A 76-year-old Caucasian male was seen in clinic with IOP of 21 mmHg and a
detachment of the Descemet’s membrane (arrows). (b) Needle revision was done with subconjunc-
tival MMC 0.02 mg. Blood filled the space between the DM and corneal stroma (arrows). (c) Three
months later, there was still some blood but with no contiguity with the trabeculo-Descemet’s
window (arrows) and subscleral lake. The bleb was cystic. (d) A year later (e, f), the IOP had
increased to 25 mmHg and the bleb had failed. The faint outline of the DM detachment could still
be seen (arrows)
3.4.2 Early Postoperative Complications for NPGS
A meta-analysis on prospective comparative studies of NPGS and trabeculec-

tomy concluded that the absolute risk of hypotony, choroidal effusion, cataract,
and flat or shallow anterior chamber was higher after trabeculectomy (Rulli et al.).
62 J. Cheng et al.
This is explained by the presence of an additional level of resistance, the

TDM. Early complications differ slightly between DS and VCT and canaloplasty.
Early hypotony is desirable after DS as the outer scleral flap is sutured loosely to
allow subconjunctival aqueous outflow and has been considered to be a favorable
prognostic indicator (Shaarawy et al. 2004). In VCT and canaloplasty, the outer
scleral flap is tightly sutured, the IOP is between 10 and 20 mmHg and some
authors have gone to the extent of reporting a subconjunctival bleb as a compli-
cation after VCT.
Early bleb-related complications, such as conjunctival edge leaks and over-
exuberant blebs with dysesthesia, though uncommon, may be seen after DS. Early
conjunctival edge leaks invariably resolve in 1–2 weeks even if MMC has been used
with DS and may need resuturing only if the procedure was complicated by intraop-
erative perforation (Anand et al. 2011).
Hyphema is uncommon after DS (2–15 %) and is due to low early postoperative
IOP and blood reflux into the SC (Anand et al. 2011; Kozobolis et al. 2002).
Hyphema occurs more frequently after VCT and canaloplasty as there is more
trauma with microperforations to the inner wall of the SC. According to one study,
hyphema (average height 1.8 mm) may be quite common after canaloplasty, can be
seen in 85 % and usually resolves after a week. IOP < 16 mmHg without medica-
tions depended significantly on the presence of hyphema. The authors felt that it
possibly represented a restored and patent physiologic aqueous outflow system
(Grieshaber et al. 2013). Blood in subscleral space above the TDM is occasionally
observed in the early postoperative period. It may stimulate fibrosis and lead to
early failure. If it persists for than 2–3 weeks and the IOP is high, laser goniopunc-
ture may be considered (Barnebey 2013).
The IOP may be high the early postoperative period after VCT and may some-
times be due to retained viscoelastic. This can be managed by topical antihypoten-
sive agents. Gonioscopy is essential if the IOP is elevated immediately after surgery.
The TDM maybe occluded by the iris. This may rarely happen even after an uncom-
plicated procedure. The mechanism may be a low IOP and a higher posterior cham-
ber pressure pushing the iris towards the TDM. Eyes with a high plateau iris are
susceptible. Management is Argon and/or Nd:YAG laser iridoplasty or surgical revi-
sion as described in the section for laser goniopuncture.
3.4.3 Late Postoperative Complications for NPGS
There are few delayed complications after nonaugmented NPGS. Most delayed

complications are due to intraoperative perforation, laser goniopuncture and adjunc-
tive MMC. Direct trauma to the eye can cause rupture of the TDM with iris pro-
lapsed (Fig. 3.11). This is extremely rare and related to the severity of the force
applied to the eye. The TDM can withstand high IOPs.
Bleb-related complications include fibrosis and encapsulation. The conjunctival
filtering bleb is generally very shallow and diffuse. Needle revision of the fibrosed
bleb can be performed, like after trabeculectomy. It is usually performed after laser
a b
c d
e f
Fig. 3.11 (a) Caucasian female with direct trauma to eye presented with peaked pupil and iris
prolapse through the membrane and was visible under the conjunctiva. The surgical site was
explored and the prolapsed iris was excised (b, c). Tenon’s capsule was sutured over scleral flap to
decrease leak through the thin superficial scleral flap (d). The patient had no postoperative compli-
cations with a deep anterior chamber and good bleb a week after the revision (e, f)
goniopuncture and MMC is the preferred antifibrotic agent. The probability of

maintaining IOP less than 19 mmHg without glaucoma medications is about 50 %
5 years after needle revision of DS. Needle revision has significant risks and com-
plications including iris incarceration, bleb leaks, infections and hypotony
(Koukkoulli et al. 2015). Needle revision of encapsulated blebs after DS has been
64 J. Cheng et al.
reported but no long-term outcomes are available. Like trabeculectomy, there is a

probably a high rate of recurrence of encapsulation or failure.
The incidence of surgically induced cataract is low. Decrease in visual acuity due
to cataract formation is more common in trabeculectomy compared to NPGS
(Eldaly et al. 2014). In head-to-head studies, Russo et al. reported 9/50 developed
cataracts in the trabeculectomy group compared to 2/43 in the NPGS group (Russo
et al. 2008). Yalvac reported 7/25 and 2/25 respectively, while Kobayashi reported
2/25 and 0/25 respectively (Kobayashi et al. 2003; Yalvac et al. 2004). The Advanced
Glaucoma Intervention Study (AIGS) estimated that the rate of cataract formation
after the first trabeculectomy was 78 % at 5 years. The risk of cataract is doubled if
there is a significant postoperative inflammation or a flat anterior chamber which is
rare after NPGS (AGIS Investigators 2001).
The probability of cataract surgery after DS is 2.5 % at 1 year, 16.4 % at 3 years,
26 % at 5 years, and 38 % at 7 years. The median survival time (50 % probability)
for cataract surgery after DS was 155 months. Age was the most significant risk fac-
tor. MMC application at time of DS was not significantly associated with cataract
surgery. However, 26 % of eyes needed an increase in number of glaucoma medica-
tions, bleb needling, or further glaucoma surgery to maintain IOP control after
phacoemulsification. This is probably due to bleb failure in some eyes, not unlike
that seen in trabeculectomy (Anand et al., Poster, American Academy of
Ophthalmology, Annual Meeting 2014).
3.5 Complications Specific to Mitomycin C (MMC) Use

in NPGS
Subconjunctival MMC application with NPGS will result in a higher frequency of

large, avascular and cystic blebs. The reported incidence however varies significantly
(Anand and Atherly 2005). Kozobolis et al. reported no avascular cystic blebs in their
prospective comparative trial on MMC with DS. They did not do laser goniopuncture
and 70 % of blebs had failed by 3 years in both groups. Anand et al. in a retrospective
case series observed cystic blebs in 36.5 % of cases. The frequency of cystic blebs
was 58 % when MMC was applied on the anterior sclera, and was significantly lower
at 30 % when MMC was applied posteriorly with conjunctival edge-protection. Most
(60 %) of the eyes had laser goniopuncture and about 15 % had needle revision in the
4-year follow-up. This difference in approach may explain the marked difference in
the incidence of avascular blebs reported in the two studies.
There have been two reports of blebitis after DS (Wallin and Montan 2007;
Anand et al. 2011) and one report of endophthalmitis (Fig. 3.12) following DS with
MMC where intraoperative perforation had occurred (Anand et al. 2011).
MMC is not commonly used with VCT or canaloplasty as these procedures do
not rely on subconjunctival drainage. Most authors recommend four to seven sutures
to tightly close the scleral flap until no aqueous leakage is seen. With this technique,
a postoperative bleb is only found in 0–16 % of cases (Carassa et al. 2003; Sunaric-
Megevand and Leuenberger 2001; Stegmann et al. 1999). If two to three sutures are
a b
c d
Fig. 3.12 Caucasian female patient with endophthalmitis 2 years after DS with MMC and intra-
operative perforation. Three days after intravitreal injection broad-spectrum antibiotics, the hypo-
pyon (a) and abscess in the avascular bleb (b) can still be seen. The eye improved rapidly (c) and
gonioscopy at 3 weeks showed iris synechiae (d)
used to close the scleral flap, then a bleb is seen more often (57–100 %) (O’Brart
et al. 2004; Luke et al. 2002). In a retrospective comparative study of VCT, avascu-
lar blebs were observed more frequently, when MMC was applied under the super-
ficial scleral flap (Yarangümeli et al. 2005). In a case series of canaloplasty, MMC
was applied under the outer scleral flap before deep flap dissection. Seven eyes
(35.0 %) had biomicroscopic evidence of mild conjunctival elevation over the area
of incision at 12 months with no complications (Barnebey 2013).
3.6 Laser Procedure After NPGS Goniopuncture
3.6.1 Introduction
NPGS procedures like DS have two levels of resistance to aqueous outflow – the
TDM and subconjunctival tissues. Aqueous flow across the TDM may decrease in
time due to fibrosis on its external interface. Resistance to outflow may also increase
due to progressive fibrosis of the subscleral and subconjunctival tissues.
Microperforations in the TDM may be created by Nd:YAG laser, thereby increasing
66 J. Cheng et al.
aqueous flow and further increasing efficacy. If goniopuncture is required early, dis-
section of the TDM may have been inadequate resulting in a thick membrane that
yields insufficient rate of filtration (Mendrinos et al. 2008). It may be performed
weeks to years after NPGS (Mermoud et al. 1999). Anecdotally laser goniopuncture
(LGP) is more effective in lowering IOP in the presence of a subconjunctival filtra-
tion bleb. The presence of a bleb with raised IOP implies increasing resistance at the
TDM level. More than half the eyes undergoing DS will have laser goniopuncture
by 3 years after surgery (Anand and Pilling 2010). DS may be regarded as a two-
staged procedure where the TDM is punctured to achieve the target IOP, a few
months after the initial surgery.
3.6.2 Procedure
LGP is performed with the Q-switch Nd:YAG laser. A Magnaview™ gonioscopy

lens is preferred because of the magnification (×1.3–1.5) and superior view of the
angle. The TDM is seen as a semi-transparent diaphanous membrane. The aim is to
create a small perforation at the anterior edge of the TDM. Iris may occasionally
occlude single central goniopuncture and cover the rest of the TDM. Therefore it is
preferable to puncture the TDM at either end. Laser energy levels vary between 2
and 4 mJ, depending on TDM thickness. The TDM may have a concave configura-
tion and the bleb may be quite low before LGP. LGP will allow aqueous to pass
through, changing the TDM configuration to convex and increase the height of bleb
(Fig. 3.13). Figure 3.14 shows the different varieties of ostia seen after
LGP. Prophylactic argon iridoplasty may be performed prior to LGP in eyes with
convex peripheral iris or a plateau iris configuration. It may also be indicated in eyes
where the TDM is antero-posteriorly narrow.
LGP can be done after all three types of NPGS. It is perhaps most effective after DS
as the procedure results in the lowest distal resistance to outflow due to the forma-
tion of a subconjunctival bleb.
In a large case series of patients who had DS, at 2 years after goniopuncture the
probability of maintaining IOP < 15 mmHg with a 20 % decrease from pre-laser
IOP and no further glaucoma procedure or medication was 50 % (Anand and Pilling
2010). A similar long-term success rate was reported recently by another study (Al
Obeidan 2015).
In a small case series of VCT, 36 % of eyes underwent LGP. Success after LGP,
defined as IOP < 19 mm Hg without medication was noted in 33 % by last follow-up
(Alp et al. 2010). Grieshaber et al., in a small case series of canaloplasty, performed
LGP in 18 % of eyes within 3 months after surgery. They reported a mean IOP drop
of 6 mmHg after LGP. Long-term results are not available.
a c
b d
Fig. 3.13 Note the concave configuration of the TDM (a) and the low bleb (b) prior to goniopunc-
ture. One month after LGP, the bleb is more diffuse (c) and the conjunctival vessels are of a smaller
caliber due to tissue turgor. The TDM is not convex (d) and a small puncture can be seen (arrow)
3.6.4 Complications of Laser Goniopuncture
Laser goniopuncture can cause a rapid drop in IOP to leading to iris incarceration.
The pressure in the posterior chamber can be higher than in the anterior chamber
immediately after LGP, driving the iris into the puncture. This is why most authors
advise delaying goniopuncture until at least 3–4 weeks after surgery when sufficient
healing has occurred. Hypotony occurs in 0–4 %, and can be associated with cho-
roidal detachment and maculopathy (Mermoud et al. 1999; Anand and Pilling 2010;
Vuori 2003). If the IOP is very high, it should be pre-treated with medication to
lower the IOP before GP to reduce the pressure differential.
Iris incarceration occurs in around 0–13 % after GP (Vuori 2003; Anand and
Pilling 2010; Mermoud et al. 1999). In a case series of 258 patients, the commonest
complication of goniopuncture following DS is iris synechiae or incarceration.
Overall it was observed in 13 % of cases after LGP. Acute symptomatic rise in IOP
occurs in 1.7 % of cases after LGP, due to iris blocking outflow through the
TDM. Hypotony has been reported in up to 4 % after goniopuncture, mostly in eyes
with adjunctive MMC. Less common complications reported were delayed bleb
leak and blebitis. About one in four eyes treated with goniopuncture required argon
68 J. Cheng et al.
a b
c d
Fig. 3.14 Openings in the TDM (arrows) after laser goniopuncture. Blood often refluxes into the
Schlemm’s canal as the IOP drops below 12 mmHg. (a). The gonipunctures should be tiny and
barely visible (b). A large puncture (c) or an inadvertent linear rip of the TDM (d) increase the risk
of iris incarceration
laser iridoplasty, and a similar proportion required needle revision. The argon laser
was done either prophylactically or to remove iris from the TDM or goniopunctures
(Anand and Pilling 2010).
In a study with sequential gonioscopy after DS, Sponsel et al. concluded that risk
of failure was associated with narrow gonioscopic angle insertion and synechia, but
not with shallow approach or trabecular pigmentation (Sponsel et al. 2013). The
first intervention for raised IOP and iris synechia or prolapse though perforation or
puncture should be Argon and/or Nd:YAG Laser iridoplasty. After instilling a drop
of pilocarpine 2 %, Argon laser burns should be used to shrink the iris and pull it
away the Descemet’s window. The parameters are 100 μm spot size, 0.4–0.5 ms and
energy levels between 200 and 500 mW to create microcavitation (bubbles).
Nd:YAG laser 1–2 mJ may then be used to disrupt the iris plug or break the syn-
echiae. Sometimes only the latter is needed (Anand and Pilling 2010). If this fails,
then surgical release may be necessary via a paracentesis combined with peripheral
iridectomy. Focal iridectomy can be performed bimanually via paracenteses using
retinal forceps and microscissors in instances of irreducible iris incarceration into
the drainage zone (Sponsel et al. 2013).
In order to minimize the risk for iris incarceration, Anand and Pilling recom-
mended the following measures:
Fig. 3.15 Acute symptomatic IOP rise with iris synechiae at TDM. Patient present with severe
pain in eye and an IOP over 50 mmHg 3 months after laser goniopuncture. The bleb was flat and
injected (a) and the TDM was completely covered by TDM (arrows b). The iris was removed from
the TDM by Argon laser burns (arrows, c)
70 J. Cheng et al.
• DS is not routinely performed in phakic eyes with shallow anterior chambers and
a convex peripheral iris configuration or a high plateau iris configuration.
• During surgery try to make a wide trabeculo-Descemet’s membrane window,
more than 2 mm.
• Laser goniopuncture is avoided in the first month when the outflow resistance at
the subconjunctival level is low.
• Laser puncture is performed at the anterior edge of the TDM, starting with lower
energy levels (2–3 mJ) to avoid a large puncture.
• Laser puncture is performed at each lateral edge rather than at the center of the
trabeculo-Descemet’s membrane window.
• Prophylactic argon iridoplasty is performed where it is felt that the iris may
incarcerate in the puncture site and if immediate post-LGP gonioscopy shows
contact between the iris and the trabeculo-Descemet’s membrane window.
• All patients undergo routine gonioscopy at each follow-up visit to identify any
iris incarceration. If not possible, do gonioscopy in all eyes with raised IOP.
References
Al Obeidan SA. Incidence, efficacy and safety of YAG laser goniopuncture following nonpenetrat-
ing deep sclerectomy at a university hospital in Riyadh, Saudi Arabia. Saudi J Ophthalmol.
2015;29:95–102.
Alnahrawy O, Blumenstock G, Ziemssen F, Szurman P, Leitritz MA, Dimopoulos S, Voykov
B. Exit strategies in canaloplasty: intraoperative conversion into 180-degree trabeculotomy
or 360-degree trabeculotomy in cases of unsuccessful catheterisation of Schlemm’s canal:
influence of degree of canal cleavage. Graefes Arch Clin Exp Ophthalmol. 2015;253(5):779–
84. doi: 10.1007/s00417-015-2955-9. Epub 2015 Feb 18.
Alp MN, Yarangumeli A, Koz OG, Kural G. Nd:YAG laser goniopuncture in viscocanalos-
tomy: penetration in non-penetrating glaucoma surgery. Int Ophthalmol. 2010;30(3):245–52.
doi:10.1007/s10792-009-9312-0.
Anand N, Atherley C. Deep sclerectomy augmented with mitomycin C. Eye (Lond).
2005;19(4):442–50. doi:10.1038/sj.eye.6701403.
Anand N, Bong C. Deep sclerectomy with bevacizumab and mitomycin C: a comparative study.
J Glaucoma. 2015;24(1):25–31. doi:10.1097/IJG.0b013e3182883c0c.
Anand N, Pilling R. Nd:YAG laser goniopuncture after deep sclerectomy: outcomes. Acta
Ophthalmol. 2010;88(1):110–5. doi:10.1111/j.1755-3768.2008.01494.x.
Anand N, Kumar A, Gupta A. Primary phakic deep sclerectomy augmented with mitomycin C:
long-term outcomes. J Glaucoma. 2011;20(1):21–7. doi:10.1097/IJG.0b013e3181ccb926.
Ayyala RS, Chaudhry AL, Okogbaa CB, et al. Comparison of surgical outcomes between canalo-
plasty and trabeculectomy at 12 months’ follow-up. Ophthalmology. 2011;118:2427–33.
Barnebey HS. Canaloplasty with intraoperative low dosage mitomycin C: a retrospective case
series. J Glaucoma. 2013;22(3):201–4. doi:10.1097/IJG.0b013e31824083fb.
Carassa RG, Bettin P, Fiori M, Brancato R. Viscocanalostomy versus trabeculectomy in white
adults affected by open-angle glaucoma: a 2-year randomized, controlled trial. Ophthalmology.
2003;110(5):882–7. doi:10.1016/S0161-6420(03)00081-2.
Cillino S, Di Pace F, Casuccio A, et al. Deep sclerectomy versus punch trabeculectomy: effect of
low-dosage mitomycin C. Ophthalmologica. 2005;219:281–6.
Cillino S, Di Pace F, Casuccio A, et al. Deep sclerectomy versus trabeculectomy with low-dosage
mitomycin C: four-year follow-up. Ophthalmologica. 2008;222:81–7.
Eldaly MA, Bunce C, Elsheikha OZ, Wormald R. Non-penetrating filtration surgery versus tra-
beculectomy for open-angle glaucoma. Cochrane Database Syst Rev. 2014;2:CD007059.
doi:10.1002/14651858.CD007059.pub2.
Grieshaber MC, Fraenkl S, Schoetzau A, Flammer J, Orgül S. Circumferential viscocanalostomy
and suture canal distension (canaloplasty) for whites with open-angle glaucoma. J Glaucoma.
2011;20(5):298–302. doi:10.1097/IJG.0b013e3181e3d46e.
Grieshaber MC, Schoetzau A, Flammer J. Orgül SPostoperative microhyphema as a positive
prognostic indicator in canaloplasty. Acta Ophthalmol. 2013;91(2):151–6. doi:10.1111/j.1755-
3768.2011.02293.x. Epub 2011 Dec 9
The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of
intraocular pressure and visual field deterioration.The AGIS Investigators. Am J Ophthalmol.
2000;130(4):429–40.
Jaramillo A, Foreman J, Ayyala RS. Descemet membrane detachment after canaloplasty: inci-
dence and management. J Glaucoma. 2014;23(6):351–4. doi:10.1097/IJG.0b013e318279ca7f.
Karlen ME, Sanchez E, Schnyder CC, Sickenberg M, Mermoud A. Deep sclerectomy with col-
lagen implant: medium term results. Br J Ophthalmol. 1999;83(1):6–11.
Kobayashi H, Kobayashi K, Okinami S. A comparison of the intraocular pressure-lowering effect
and safety of viscocanalostomy and trabeculectomy with mitomycin C in bilateral open-
angle glaucoma. Graefes Arch Clin Exp Ophthalmol. 2003;241(5):359–66. doi:10.1007/
s00417-003-0652-6.
Koukkoulli A, Musa F, Anand N. Long-term outcomes of needle revision of failing deep scle-
rectomy blebs. Graefes Arch Clin Exp Ophthalmol. 2015;253(1):99–106. doi:10.1007/
s00417-014-2810-4.
Kozobolis VP, Christodoulakis EV, Tzanakis N, Zacharopoulos I, Pallikaris IG. Primary deep scle-
rectomy versus primary deep sclerectomy with the use of mitomycin C in primary open-angle
glaucoma. J Glaucoma. 2002;11(4):287–93.
Krasnov MM. Externalization of Schlemm’s canal (sinusotomy) in glaucoma. Br J Ophthalmol.
1968;52(2):157–61.
Lewis RA, von Wolff K, Tetz M, Koerber N, Kearney JR, Shingleton BJ, Samuelson
TW. Canaloplasty: three-year results of circumferential viscodilation and tensioning of
Schlemm canal using a microcatheter to treat open-angle glaucoma. J Cataract Refract Surg.
2011;37(4):682–90. doi:10.1016/j.jcrs.2010.10.055.
Luke C, Dietlein TS, Jacobi PC, Konen W, Krieglstein GK. A prospective randomized trial of
viscocanalostomy versus trabeculectomy in open-angle glaucoma: a 1-year follow-up study.
J Glaucoma. 2002;11(4):294–9.
Mendrinos E, Mermoud A, Shaarawy T. Nonpenetrating glaucoma surgery. Surv Ophthalmol.
2008;53:592–630.
Mermoud A, Karlen ME, Schnyder CC, Sickenberg M, Chiou AG, Hediguer SE, Sanchez
E. Nd:Yag goniopuncture after deep sclerectomy with collagen implant. Ophthalmic Surg
Lasers. 1999;30(2):120–5.
O’Brart DP, Shiew M, Edmunds B. A randomised, prospective study comparing trabeculectomy
with viscocanalostomy with adjunctive antimetabolite usage for the management of open angle
glaucoma uncontrolled by medical therapy. Br J Ophthalmol. 2004;88(8):1012–7. doi:10.1136/
bjo.2003.037432.
Ravinet E, Tritten JJ, Roy S, Gianoli F, Wolfensberger T, Schnyder C, Mermoud A. Descemet
membrane detachment after nonpenetrating filtering surgery. J Glaucoma. 2002;11(3):244–52.
Rulli E, Biagioli E, Riva I, et al. Efficacy and safety of trabeculectomy vs nonpenetrating surgical
procedures: a systematic review and meta-analysis. JAMA Ophthalmol. 2013;131:1573–82.
Russo V, Scott IU, Stella A, Balducci F, Cosma A, Barone A, Delle Noci N. Nonpenetrating deep
sclerectomy with reticulated hyaluronic acid implant versus punch trabeculectomy: a prospec-
tive clinical trial. Eur J Ophthalmol. 2008;18(5):751–7.
72 J. Cheng et al.
Sanchez E, Schnyder CC, Mermoud A. Comparative results of deep sclerectomy transformed to

trabeculectomy and classical trabeculectomy. Klin Monatsbl Augenheilkd. 1997;210(5):261–
4. doi:10.1055/s-2008-1035050.
Shaarawy T, Flammer J, Smits G, Mermoud A. Low first postoperative day intraocular pressure
as a positive prognostic indicator in deep sclerectomy. Br J Ophthalmol. 2004;88(5):658–61.
Stegmann RC. Visco-canalostomy: a new surgical technique for open angle glaucoma. An Inst
Barraquer. 1995;25:229–32.
Stegmann R, Pienaar A, Miller D. Viscocanalostomy for open-angle glaucoma in black African
patients. J Cataract Refract Surg. 1999;25(3):316–22.
Sponsel WE1, Groth SL. Mitomycin-augmented non-penetrating deep sclerectomy: preoperative
gonioscopy and postoperative perimetric, tonometric and medication trends. Br J Ophthalmol.
2013;97(3):357–61. doi: 10.1136/bjophthalmol-2012-301886. Epub 2012 Nov 2.
Sunaric-Megevand G, Leuenberger PM. Results of viscocanalostomy for primary open-angle
glaucoma. Am J Ophthalmol. 2001;132(2):221–8.
Tamm ER, Carassa RG, Albert DM, Gabelt BT, Patel S, Rasmussen CA, Kaufman
PL. Viscocanalostomy in rhesus monkeys. Arch Ophthalmol. 2004 Dec;122(12):1826–38.
Vuori ML. Complications of Neodymium:YAG laser goniopuncture after deep sclerectomy. Acta
Ophthalmol Scand. 2003;81(6):573–6.
Wallin OJ, Montan PG. Blebitis after deep sclerectomy. Eye (Lond). 2007;21(2):258–60.
doi:10.1038/sj.eye.6702494.
Yalvac IS, Sahin M, Eksioglu U, Midillioglu IK, Aslan BS, Duman S. Primary viscocanalostomy
versus trabeculectomy for primary open-angle glaucoma: three-year prospective randomized
clinical trial. J Cataract Refract Surg. 2004;30(10):2050–7. doi:10.1016/j.jcrs.2004.02.073.
Yarangümeli A, Köz OG, Alp MN, Elhan AH, Kural G. Viscocanalostomy with mitomycin-C: a
preliminary study. Eur J Ophthalmol. 2005;15(2):202–8.
Zimmerman TJ, Kooner KS, Ford VJ, Olander KW, Mandlekorn RM, Rawlings EF, Leader BJ,
Koskan AJ. Trabeculectomy vs. nonpenetrating trabeculectomy: a retrospective study of two
procedures in phakic patients with glaucoma. Ophthalmic Surg. 1984;15(9):734–40.
Trabeculectomy
4
Rashmi G. Mathew and Ian E. Murdoch
If you have not seen all the complications mentioned in this chapter, the likelihood
is, you have not operated enough. Every surgeon has complications. What makes an
excellent surgeon is the ability to deal with the complication safely and appropri-
ately. Most of the complications outlined below are fortunately rare and little or no
evidence exists for their management. Much of what is written below is from our
own personal experience.
A key factor to the success of any operation is careful preoperative assessment
and planning. Prevention is better than cure. Anticipation of potential problems
prior to surgery enables a surgeon to take precautions to minimize the likelihood of
complications and be prepared, should they arise. Careful preoperative assessment
of the patient and risk factors also allows the patient to be counseled appropriately
in the face of increased risks and have an appropriate level of expectation regarding
the surgery. As with all surgeries, each step needs to be meticulously performed in
order to garner the best possible outcome.
In this chapter we look at important preoperative, perioperative, early and late
postoperative factors in turn. For each, we present a largely personal view for con-
sideration, looking at tips to prevent as well as manage complications of trabeculec-
tomy surgery. The trabeculectomy technique we use is a version of the “Moorfields
Safe Surgery” technique (Dhingra and Khaw 2009). A fornix-based, conjunctival
flap, followed by the application of cytotoxic on sponges to a broad sub-Tenon’s
space extending behind the posterior edge of the anticipated sclera flap in an
R.G. Mathew (*)

Department of Glaucoma, Moorfields Eye Hospital NHSFT, London, UK
Honorary Clinical Senior Lecturer, Centre for Medical Education, Institute of Health
Sciences Education, Barts and the London School of Medicine at Queen Mary,
University of London, London, UK
I.E. Murdoch
Institute of Ophthalmology, University College, London, London, UK

74 R.G. Mathew and I.E. Murdoch
outward fan. Copious washout of the cytotoxic is followed by creation of a rectan-

gular scleral flap, paracentesis, sclerostomy, and peripheral iridectomy. Releasable
10/0 nylon sutures are used to close the sclera flap and interrupted 10/0 nylon sutures
to secure the Tenon and conjunctiva to the limbus.
4.1 Preoperative Risk Factors
4.1.1 Ocular Factors
Risk Factor Refractive Error: High myopia.

High myopes tend to have more elastic sclera and may also have thinner sclera.
Potential Complication Hypotony.
How to Avoid We recommend using a minimum of three releasable sutures for the
closure of the trabeculectomy flap on table. Check for any leaks on the table with
2 % fluorescein after tying of the releasables. If leaks are present on the table,
tighten the existing releasables and reassess with 2 % fluorescein. Should the leak
persist, use further releasables or fixed sutures depending on the location of the leak.
The other key to avoiding hypotony in these patients is the creation of a relatively
thick flap and avoidance of a thin flap. Water tight closure in thin flaps is difficult
and sutures may cheese-wire the flap.
It is also important that these patients wear their eye shield while sleeping and
avoid heavy lifting, bending, and eye rubbing in the early postoperative period.
Risk Factor Refractive Error: High hypermetropia.
Potential Complication Aqueous misdirection.
How to Avoid Avoidance of hypotony and anterior chamber shallowing is the key.
We recommend a minimum of three releasables to close the trabeculectomy flap.
Always check for any leaks on the table with 2 % fluorescein. At the end of the
operation instill a drop of 1 % atropine and continue this once daily for at least 4
weeks. It is also important that these patients wear their eye shield while sleeping
and avoid heavy lifting, bending, and eye rubbing in the early postoperative period.
Risk Factor Ocular surgery: coexistence of cataract.
Potential Complication Aggressive postoperative wound healing.
How to Avoid The question about whether to perform cataract surgery before or
after trabeculectomy surgery is an old chestnut and is widely debated in glaucoma
circles. The literature reports between 10 and 61 % of trabeculectomies failing after
cataract surgery (Mathew and Murdoch 2011; Chen et al. 1998; Swamynathan et al.
4 Trabeculectomy 75
2004; Crichton and Kirker 2001; Rebolleda and Munoz-Negrete 2002; Park et al.
1997; Casson et al. 2002; Wong et al. 2009; Ehnrooth et al. 2005). Interpretation of
the results is, however, hampered by very few having a control group, different study
methods, definitions of failure, and patient groups. To our knowledge there are only
two case–control studies in the literature comparing the eyes that had trabeculectomy
alone with those that had trabeculectomy with subsequent cataract surgery. One
study showed no difference in failure rates at 1 year (Chen et al. 1998) and the other
showed a significantly higher failure rate in the group that had cataract extraction
subsequent to trabeculectomy surgery (Swamynathan et al. 2004). It has been shown
that flare exists in the anterior chamber for up to 6 months after cataract surgery
(Siriwardena et al. 2000). In comparison, anterior chamber flare levels return to base-
line levels 4 weeks after trabeculectomy surgery. This can have implications for the
success of trabeculectomy surgery and whether to perform cataract surgery before or
after trabeculectomy, if cataract is present. The debate is still unresolved and we
recommend full discussion with your patient of the pros and cons of the three options
of cataract surgery first, trabeculectomy first, or combined surgery. Factors such as
severity of glaucoma, severity of cataract, time constraints, social circumstance, state
of fellow eye, and expectations all need to be considered.
Risk Factor Previous ocular surgery: vitrectomized eye, corneal graft surgery,
aphakia, conjunctival scarring, squint surgery.
Potential Complication Difficult conjunctival dissection and aggressive wound

healing.
How to Avoid It is important to carefully plan surgery in these cases and a number
of factors need to be considered. It is thought that the Tenon’s fibroblasts are acti-
vated from previous surgery and these patients often have a tendency to mount an
aggressive wound healing response for this reason. An important consideration is
careful assessment of the mobility of the conjunctiva, as this may be tethered down
in places from previous surgery, making clean dissection difficult. One surgical tip
is to use a 30-gauge needle with saline to hydrodissect under the conjunctiva, sepa-
rating it from the sclera to facilitate trauma free dissection. If there has been previ-
ous vitreo-retinal surgery, it is important to assess for the presence of retinal buckles.
Aqueous shunt surgery is often first line for these patients. The plate can often be
placed behind the buckle and the tube can run over the buckle or a small area of
buckle can be removed to allow the tube to lie flat. One must bear in mind that the
sclera under the buckle can often be very thin and in extreme cases may warrant a
scleral patch graft to restore scleral integrity.
Risk Factor Adverse ocular surface Stevens–Johnson syndrome, ocular cicatricial

pemphigoid, atopic keratoconjunctivitis, drop intolerances (chronic red eye),
blepharitis.
Potential Complication Excessive scarring, infection.

How to Avoid The commonest of these conditions is drop intolerance and chronic
red eye as a result. These eyes are prone to scarring and it is important to optimize
the ocular environment prior to embarking upon surgery.
Patients with drop allergies or intolerance to preservatives might benefit from a
switch to preservative-free preparations. Consider giving them a “drop holiday” by
stopping all topical medication and lowering the intraocular pressure with oral acet-
azolamide on a short-term basis if not medically contraindicated. It is important to
check that they do not have renal impairment and ensure that their serum potassium
is regularly monitored, as it can cause hypokalemia. On commencement of acet-
azolamide, advise patients to take the tablets on a full stomach and increase their
intake of potassium-rich foods, such as bananas and tomatoes.
One may also consider the use of short-term preoperative steroid drops prior to
surgery. This has been shown to reduce the number of fibroblasts and inflammatory
cells present within the conjunctiva (Broadway et al. 1996).
For those with blepharitis (especially posterior blepharitis (Poornima Rai,
Personal communication)) it is very important to detect and treat the blepharitis
with appropriate therapy including good lid hygiene, topical fusidic acid, or oral
tetracyclines.
In all cases with chronic disturbance of the ocular surface consider aqueous
shunt surgery.
Risk Factor Compromised lacrimal system (chronic dacrocystitis, mucoceles).
Potential Complication Infection.
How to Avoid In patients with chronic dacrocystitis and mucoceles, the patient is
predisposed to bleb-related infection and endophthalmitis. It is important to only
perform glaucoma surgery once the patient has had this definitively treated, most
commonly with a dacryocystorhinostomy.
Risk Factor Abnormal vasculature, Sturge–Weber syndrome, caroticocavernous

fistula, arterio-venous malformations.
Potential Complication Excessive scarring and failure, excessive intraoperative

bleeding.
How to Avoid In those patients with caroticocavernous fistula, Sturge–Weber syn-

drome, and arterio-venous malformations of the conjunctiva and episclera, it is
important to bear in mind that these patients have a propensity to bleed. These
patients may also have choroidal hemangiomas and other retinal vascular abnor-
malities, thus making them more prone to suprachoroidal hemorrhages. In such
cases, it may be that aqueous shunt surgery is an alternative to consider.
Risk Factor Lash trichiasis, lid absence.

4 Trabeculectomy 77
Potential Complication Exogenous endophthalmitis.
How to Avoid It is important that aberrant lash growth is remedied before under-
taking trabeculectomy surgery. The patient may require simple lash electrolysis or
plicating procedure to optimize lid position. In cases of partial lid absence, consider
aqueous shunt surgery and place in a position, where some lid is present.
Risk Factor Uveitis.
Potential Complication Hypotony posttrabeculectomy surgery.
How to Avoid These patients often have hypotony in the context of a flat bleb. It is
often a matter of tiding them over until the ciliary body perks up. It is important to
maintain the patient on appropriate therapy for the duration of the inflammatory eye
disease. There are two benefits of high-dose topical steroids; ensuring ciliary body
function to keep flow through the newly established trabeculectomy and second,
reducing the potential for scarring, when little flow or no flow is present through the
sclerostomy.
4.1.2 Systemic Factors
Risk Factor Diabetes.
Potential complication(s) Poor wound healing; failure in those with active dia-
betic retinopathy; postoperative hypotony, due to “brittle” ciliary body function,
secondary to ischemia.
How to Avoid Multiple complications may arise in patients with diabetic eye
disease. Again, the importance of thorough preoperative assessment and counsel-
ing of the patient cannot be stressed enough. Prior to undergoing surgery, blood
sugar control must be optimized. In those with poor control and particularly those
with active diabetic retinopathy or proliferative retinopathy, an aqueous shunt is
usually the first-line surgical approach. This is because VEGF levels in these
patients are usually high and can lead to aggressive scarring and failure of trab-
eculectomy surgery. It is important to work closely with the medical retinal
experts ensuring that full laser and medical therapy are undertaken to control the
diabetic eye disease. In those with neovascular glaucoma, consider giving anti-
VEGF therapy a few days prior to surgery, to initiate regression of neovascular-
ization, limit perioperative bleeding, and reduce pain from ocular ischemia
(Kotecha et al. 2011).
Diabetics are also prone to poor wound healing, so ensure that flap closure is
water-tight and conjunctival closure is especially secure, as these eyes are much less
forgiving.
Diabetic patients can behave like uveitics, due to “brittle” ciliary body function.
They may also have hypotony in the context of a flat bleb.
Risk Factor Hypertension, COPD, anticoagulation.
Potential Complication Suprachoroidal hemorrhage.
How to Avoid Suprachoroidal hemorrhage generally occurs secondary to sudden

drops in ocular pressure or prolonged periods of hypotony. In a surgical context
this is usually on the operating table or the day after surgery. Hypertension and
COPD as well as older age are risk factors for suprachoroidal hemorrhage.
Anticoagulation, for example with warfarin, is not a confirmed independent risk
factor, but can certainly exacerbate a suprachoroidal hemorrhage. For warfarinized
patients, ensure the international normalization ratio (INR), is within the therapeu-
tic range prior to surgery. For most procedures, it has been recommended to stop
the anticoagulant treatment prior to surgery and then restart within 12–24 h after
their surgery, but this should only be done in conjunction with the patient’s physi-
cian (Kiire et al. 2014).
Both hypertension and COPD should be optimized before surgery and sudden
reduction of the intraocular pressure and prolonged periods of hypotony on table
should be minimized. As part of our standard trabeculectomy technique, we always
create an anterior chamber paracentesis, after fashioning the trabeculectomy flap
and prior to creation of the sclerostomy and have balanced salt solution (BSS) ready
to hand to refill the anterior chamber, should it shallow. In high risk cases, one may
also consider the use of an AC maintainer to avoid sudden AC shallowing and pro-
longed hypotony. We also recommend considering preplacement of releasables, in
order to close the eye and regain integrity as quickly as possible, once the scleros-
tomy and peripheral iridectomy have been created.
4.2 Perioperative Complications
Risk Factor High intraocular pressure.
Potential complication Decompression retinopathy; suprachoroidal hemorrhage.
How to avoid In patients with uncontrolled intraocular pressure requiring urgent

surgery, it is important that their intraocular pressure is optimized as much as pos-
sible prior to surgery. The best method of achieving this is use of general anesthesia.
The vasodilatation with general anesthesia combined with use of hyperventilation
to increase pO2 and decrease pCO2 is extremely effective in reducing intraocular
pressure and no other systemic or topical therapy is required. If it is not possible to
safely undertake a general anesthetic, intravenous acetazolamide may be considered
an hour before surgery. Mannitol and oral glycerol are no longer recommended
because of adverse systemic side effects. Remember acetazolamide is a diuretic,
4 Trabeculectomy 79
hence provision should be made for this side effect in theater. If all of the above are
not possible, the final resort is to make an anterior chamber paracentesis and slowly
release small amounts of aqueous from the paracentesis to bring the IOP gently
down. This is absolutely a final resort and NOT the first option.
Surgical Step Traction suture.
Potential complication Full-thickness suture, tearing out, distorting closure.
How to avoid A traction suture is not a prerequisite for trabeculectomy surgery

and it can be perfectly adequately completed in the vast majority of patients without
such a suture. Most, however, prefer to use a suture in which case placement of the
suture is the first consideration. A vast majority of surgeons place the suture in the
cornea at 12’o-clock. Consideration may be given to the use of 3 and 9 o’clock or
even 6’o-clock (see Fig. 4.1) traction suture(s).
Both of these options avoid a gaping effect on the scleral flap, which can cause
aqueous flow from the anterior chamber and distort the anatomy.
If the cornea is perforated full thickness, during placement of the traction suture
this should be easily identified by not only sensation but also the egress of aqueous.
Simply withdraw the needle and hydrate the wound if need be and place the suture
more superficially elsewhere. Should the anterior chamber have gone very shallow,
simply wait and it will refill allowing the operation to proceed as usual.
Fig. 4.1 (a) Traction sutures placed at 3 and 9 o’clock to avoid distortion of scleral flap.
(b) Traction suture placed at 6 o’clock to avoid distortion of scleral flap
We recommend releasing the traction suture prior to entering the anterior cham-
ber to avoid the risk of anterior chamber shallowing and difficulty closing the scleral
flap due to countertraction (if the traction suture is in the 12 o-clock position).
Surgical Step Conjunctival incision and dissection.
Potential complication Incomplete dissection of Tenon’s capsule from sclera.

This can lead to difficulty in dissecting the scleral flap, as the Tenon’s tissue can
make it difficult to judge the depth of the scleral flap. Releasable sutures can also
become embedded in Tenon’s which is adherent to the sclera, making them prone to
snapping when trying to remove them.
How to Avoid Tenon’s attaches approximately 0.5 mm behind the anatomical lim-
bus. While dissecting, take the decision to take both the Tenon’s and conjunctival
tissue at the same time, or dissect each layer in turn. We find that a generous conjunc-
tival opening at the limbus, enables easier and cleaner dissection of the Tenon’s from
the scleral bed. Should there be any adherent Tenon’s capsule on the sclera, it is
important to remove this by gentle scraping with a Tooke’s knife, or similar instru-
ment. Alternatively gentle cautery may shrink the adherent Tenon’s for easy removal.
We find combined closure of the Tenon’s and the conjunctiva at the limbus very
helpful. If the Tenon’s tissue is not brought forward at the limbus, then it can stick
down posteriorly with scarring and cause the trabeculectomy to fail. Meticulous
dissection at the start of the operation facilitates bilayered closure at the end.
Surgical step Conjunctival incision and dissection.
Potential complication Conjunctival buttonholes.
How to avoid Our standard technique is a fornix-based conjunctival flap. After the
conjunctiva and Tenon’s tissue has been dissected from the limbus, try to only grasp
Tenon’s tissue, either by rolling the limbal tissue backward over your forceps and so
the Tenon’s tissue is presented anteriorly, or by sliding a pair of toothed forceps
underneath the Tenon’s and grasping it from the under surface. This enables you to
hold the “meaty” part of the Tenon’s tissue and avoids accidental buttonhole of the
conjunctiva when grasping both tissues together.
Some patients do however have very friable conjunctiva, and no matter how care-
ful the dissection, conjunctival buttonholes may occur. Should a conjunctival button
hole arise, it can be cut out if sufficiently anterior and enough tissue is available to
be brought down to the limbus after the buttonhole has been excised. If the button-
hole is posterior, then we would ordinarily repair with a purse-string suture, of
either 10/0 vicryl or nylon. Both these sutures have their merits. Vicryl is absorbable
and due to the “vicrylitis” or tissue inflammation, encourages tissue healing. The
healing, however, may be overaggressive and encourage scarring of the trabeculec-
tomy. The nylon suture is only slowly absorbable, so may need removal at some
stage. It is, however, less inflammatory for the tissues. Care must be taken to gently
4 Trabeculectomy 81
close the buttonhole, so as not to cheese-wire the tissue and create an extension of
the original buttonhole. Completion of the suture from the undersurface of the con-
junctiva ensures very good burying of the knot and fewer problems.
Surgical Step Cytotoxic application.
Potential Complication Thin-walled cystic bleb.
How to Avoid We advocate, as part of the Moorfields Safe Surgery technique, that
a large area of cytotoxic is applied more posteriorly (Dhingra and Khaw 2009). To
achieve this, Tenon’s tissue is grasped at the limbal end of dissection, to keep it
away from mitomycin C (MMC) and avoid contact of MMC with the conjunctiva.
MMC soaked sponges are placed on the scleral bed, to give a large, posterior treat-
ment area. Any excess MMC that has washed up at the limbus, is dabbed, during the
3-min treatment period. The sponges are then removed and the scleral bed is irri-
gated copiously with 20 ml of balanced salt solution (BSS). A large posterior treat-
ment area is important, as it promotes diffuse posterior flow of aqueous and we
believe may help prevent a “ring of steel” forming.
Surgical Step Cautery.
Potential Complication Focal thinning of sclera with aggressive cautery.
How to Avoid Although cautery is important to stop bleeding from episcleral and
scleral vessels, aggressive cautery can cause focal scleral thinning, and irregular
thickness to the scleral flap. Most bleeds do stop of their own accord, when given
time. Another trick to reduce bleeding is to use topical 0.1 % epinephrine. The vaso-
constriction decreases vascularity in the operative field and aids in the cessation of
bleeding.
Surgical Step Scleral flap dissection.
Potential Complication Thin scleral flap: Full-thickness hole in scleral flap.
How to Avoid Thin scleral flaps are trouble. Sutures cheese-wire through them.
They are difficult to close and can lead to anterior leaks and hypotony.
The key is recognition on the operating table. First, if there is an area of thin
sclera, try and avoid this and move the site of the flap, laterally or medially to an
area of healthier sclera.
If one does inadvertently create a full-thickness hole in the scleral flap, it can be
subtle and we always recommend checking for leaks. Use of 2 % fluorescein after
the flap has been sutured closed and the anterior chamber refilled to a physiological
pressure with BSS via the paracentesis helps considerably in this respect. If a full-
thickness hole is detected, then this should be closed with either a patch of Tenon’s
(autograft), or tutoplast at the time of surgery.
Rotational scleral flap

Thicker new flap
Too thin first flap
Fig. 4.2 (a) Dissection of a larger, thicker scleral flap, which incorporates the original thin scleral
flap. (b) Dissection of a rotational scleral flap, which covers over the original thin scleral flap
If the flap is very thin overall, one can cut a flap around the original flap (see
Fig. 4.2a), at a deeper depth, thus incorporating the original thin flap. This a good
option, as normal anatomy is retained, it facilitates good flap closure and the posi-
tion of the trabeculectomy remains optimal.
An alternative is to move to a new site.
Finally, if the leak is persistent and material scarce, a rotational scleral flap may
be fashioned and folded over the original thin scleral flap (see Fig. 4.2b).
Potential Complication Thick scleral flap: Valving.
How to Avoid Valving is the phenomenon that occurs when drainage only occurs
on applying pressure behind the scleral flap. It is because there is no overlap of the
side arms of the scleral flap and the sclerostomy (see Fig. 4.3a, b).
In order to detect valving, it is important to check drainage at the time of surgery.
Once the sclerostomy and peripheral iridectomy are created, the scleral flap should
be folded down, but not sutured down and the anterior chamber refilled with BSS
via the paracentesis. If BSS is freely flowing out of the flap and the anterior chamber
is spontaneously shallowing, then valving is not present and the flap can be closed.
If on the other hand, no flow is seen from the back end of the flap once the anterior
chamber is filled it indicates that aqueous will not drain from the flap, even if all the
sutures have been removed. If this occurs two measures can be taken. The first is to
cut-down the side arms more anteriorly. This however should not be undertaken, if
the side arms are already very anterior, as it can lead to postoperative limbal leaks.
The alternative is to enlarge the sclerostomy posteriorly. Once, one or both of these
steps have been undertaken, then fold the flap back down and test again for flow.
Once, you are confident that flow is present, then the flap can be sutured down.

4 Trabeculectomy 83
Fig. 4.3 (a) A valving effect is created due to lack of overlap between side arms of scleral flap and
sclerostomy. (b) Overlap of side arms of scleral flap and sclerostomy, thus avoiding valving effect
Leak from full thickness incision Leak sealed with box stitch
Fig. 4.4 (a) Creation of a full-thickness incision in sclera, when creating initial posterior scleral
flap edge. (b) Repair of the full-thickness incision sutures, once scleral flap is completed
Potential Complication Thick scleral flap: Full-thickness initial incision.

Persistent hypotony.
How to Avoid A full-thickness incision is not always spotted at the time of surgery
and equally may not always lead to trouble. None-the-less it can result in persistent
hypotony and the explanation only becomes clear on exploration of the operative
site. A full-thickness incision most commonly occurs during the initial creation of
the posterior flap edge, but full thickness can also be achieved with side arms and
with enthusiastic flap dissection (both free hand and with the crescent knife). The
principal method of avoidance is being aware that this can happen and lead to prob-
lems. If it does occur, suturing the defect is the simplest approach. In order to repair
the defect, finish creating the scleral flap; this enables complete visualization of the
full-thickness defect and avoids distortion while suturing it closed. It is important
that the full-thickness incision is completely clear and then closed with either inter-
rupted or box suture(s) (see Fig. 4.4a, b).
If adequate dissection is not performed then the subsequent dissection may either
cut the suture out or be completely distorted by the suture. The same principal
applies if undertaking a revision. Take the whole operation down and explore using
2 % fluorescein. Suture the defect and then restore normal operative anatomy in
your usual fashion.
Potential Complication Premature anterior chamber entry.
How to Avoid This most usually happens at the anterior limit of sclera flap dissec-
tion. If it occurs, aqueous will be noticed at the scleral flap and the anterior chamber
may shallow. A paracentesis is important for surgical control, so if there is not one
already present and the anterior chamber has shallowed, insert a Rycroft cannula
into the site of anterior chamber entry and fill the anterior chamber from here. Once
the anterior chamber has deepened, create a paracentesis.
The site of premature entry can often be used to create the sclerostomy, it will
otherwise require repair.
Potential Complication Anterior drainage of aqueous, high anterior bleb with cor-
neal epithelial disturbance.
How to Avoid The direction of aqueous flow is related to the scleral flap shape.
Aqueous will preferentially follow the shortest route from sclerostomy to subcon-
junctival space. Figure 4.5 illustrates how this might vary with different flap shapes
and why we prefer an oblong flap.
Surgical Step Sclerostomy.
Potential Complication Too small/too anterior: valving.
How to Avoid See section on valving above.
Potential Complication Too large/too posterior.
How to Avoid When dissecting the scleral flap, correct identification of the blue-
gray transition zone of the surgical limbus is key. This zone is approximately 1.2 mm
and is due to the oblique interface of the sclera and cornea. Posterior to this zone is
the opaque white sclera and anterior to it, is clear cornea.
When advancing from sclera to cornea, a sharply demarcated white line is
encountered that roughly corresponds to the level of scleral spur. Next the tissue
appears grayish over the trabeculum giving way to clear cornea at the level of
Schwalbe’s line. Therefore, to ensure entry into the anterior chamber, the incision
must be in the anterior portion of this transition zone (Van Buskirk 1989).
4 Trabeculectomy 85
Fig. 4.5 Preferential flow of aqueous in direction of shortest path out of scleral flap. Different flap
shapes influence direction of aqueous flow
Should the sclerostomy be made too posteriorly, the danger is catching the cili-
ary body tissue. This can lead to profuse bleeding, or even creation of a cleft. Should
this situation arise the bleeding usually stops by closing the flap, allowing blood to
drain externally, and simply waiting. In the unlikely event of a cleft being created
this may need suturing to close.
Potential Complication A partial thickness/shelved sclerostomy.
How to Avoid By definition, a sclerostomy is a full-thickness hole in the sclera. If

using a scleral punch to create the sclerostomy, it is important to hold the punch
vertically, to ensure a full-thickness bite of the sclera is taken. When the scleros-
tomy is full-thickness, a knuckle of iris tissue will often present itself, through the
patent sclerostomy. If there is any doubt explore and enlarge.
Surgical Step Surgical peripheral iridectomy.
Potential Complication Bleeding.
How to Avoid The iris is supplied by anterior ciliary and long posterior ciliary
arteries, which anastomose at the circulus arteriosus major and then supply the sub-
stance of the iris. The iris is a vascular structure and has the potential to bleed
p rofusely on creation of a peripheral iridectomy. In the event of hemorrhage from

the iris tissue, place the scleral flap down and refill the anterior chamber via the
paracentesis and wait for the bleeding to stop. The elevated anterior chamber pres-
sure acts as a tamponade to stop bleeding. If the bleeding is profuse, another alterna-
tive is to gently press on the back of the scleral flap and allow blood to drain out via
the sclerostomy. This can, however, run the risk of prolonged hypotony. Washing
blood out of the anterior chamber is not for the faint-hearted and we warn against
cavalier removal of blood. If it is deemed necessary, tissue plasminogen activator
(tPA) can be injected into the anterior chamber enabling blood clots to be removed
more freely. There is a risk of rebleeding with anterior chamber washout. This risk
is increased if tPA is used.
There is a shift in paradigm regarding the creation of a surgical peripheral iridec-
tomy. Some surgeons advocate not performing surgical peripheral iridectomy in
eyes that have deep anterior chambers and are not predisposed to the iris blocking
the ostium (De Barros et al. 2009). However, the risk of iris obstruction will remain
should the anterior chamber shallow in the absence of a peripheral iridectomy.
While this can be controlled on the operating table, care must be taken when remov-
ing releasable sutures and massaging the bleb, in an outpatient setting.
Surgical Step Suturing of scleral flap.
Potential Complication Perioperative hypotony.
How to Avoid Sudden reduction in intraocular pressure and prolonged periopera-

tive hypotony is best avoided since it may lead to suprachoroidal hemorrhage. A
helpful step in prevention of prolonged hypotony is the use of preplaced scleral
sutures (either releasable or fixed). These facilitate swift closure of the scleral flap
and restore integrity of the eye. In eyes at higher risk of suprachoroidal hemorrhages
or with advanced field loss it may be worth considering use of an anterior chamber
maintainer to give greater stability of the anterior chamber.
Potential Complication Suture track leak.
How to Avoid This commonly happens with thin scleral flaps. It can also happen
with full-thickness bites through the scleral flap, particularly when taking releas-
ables through the base of the flap (limbal end). Recognition is important, and the use
of 2 % fluorescein facilitates detection of leaks. In these circumstances first consider
repositioning the sutures to stop the suture track leak. If this is not practical because
the scleral flap is very thin and friable or repositioning of sutures is unlikely to help,
it is important to remember that they often resolve and a temporary tamponade of
the anterior chamber with v iscoelastic or gas may be all that is indicated. Should the
flap be torn by the suture then repair may be required as outlined in the section on
scleral flap dissection.
4 Trabeculectomy 87
Potential Complication Leakage from scleral flap edge.
How to Avoid Again detection is key and the use of 2 % fluorescein can be very
helpful. Remedying a leak from the scleral flap edge may simply require additional
fixed or releasable sutures. In cases, where the flap edge continues to leak, it is
important to consider whether the anatomy of the flap has been distorted in some
way. The simplest solution is to take down all scleral sutures, assess the scleral flap
anatomy, and replace all the sutures again. Keep reviewing the situation in search of
a solution, which is almost always possible. The final resort is to tamponade the
anterior chamber with gas or viscoelastic to reduce flow out of the sclerostomy in
the early postoperative period.
Potential Complication Postoperative hypotony.
How to Avoid This may be caused by loosening of one or more of the scleral
sutures. We personally advocate placement of three releasable sutures to the scleral
flap: one each to the nasal and temporal ends and one centrally (Dhingra and Khaw
2009). It is important to ensure that the sutures are tied tightly enough at the time of
surgery and to detect any leaks at the time of surgery.
4.3 Early Postoperative Complications
Potential Complication IOP rise.
How to Manage This is the preferred early complication of trabeculectomy sur-

gery simply because it ensures that you are in control of the eye and it is easily recti-
fied. Too low a pressure is much more challenging. Removal of releasable sutures,
laser suture lysis, bleb massage, and needling of the bleb are all tools to employ. As
a very rough guide there is a window of about 6 weeks to establish a good surgical
fistula in Caucasian eyes. This window is reduced in Asian eyes and still further
reduced in African eyes.
It is also worth noting, that in the first 1–2 weeks, the trabeculectomy flap can be
sealed shut with blood and massage often does not achieve flow of aqueous from the
sclerostomy, or even precipitates bleeding into the anterior chamber. If the IOP is
normal, then monitor and the clot will usually lyse within a couple of weeks,
enabling establishment of aqueous flow.
We believe that the postoperative care is as important as the surgery during this
window. Prior to enlisting patients for surgery, it is important to counsel them about
frequent steroid use, frequent clinic visits, and bleb manipulations in clinic to ensure
they understand what they are undertaking and that it requires full participation
from their part. As is the case for successful repair in retinal detachment surgery, the
first trabeculectomy has your best chance of achieving excellent IOP control for the
patient long term. It is this window of opportunity that both you and your patient must
commit to in order to ensure establishment of a functional surgical fistula. Review as
often as required, manipulate the bleb as often as required, always being mindful of
overdoing it and ending up with hypotony! Involvement of patients in this process is
critical. In some carefully chosen instances they can even be enlisted in self-massage
of the bleb. Subconjunctival injections of steroid and antimetabolite may be helpful, if
the patient is showing signs of scarring and topical steroid use is essential.
The IOP can still be elevated, despite doing all you can to lower the IOP (e.g.,
bleb massage, removal/lysis of scleral flap sutures, subconjunctival injections of
steroid, and antimetabolite). If this is the case, do not panic, as IOP does frequently
goes through a “2 -month” spike (accordingly earlier in Asian and African eyes),
from which complete recovery of bleb function and IOP are the norm, as the bleb
remodels. This seems to be due to a natural healing process and does not necessarily
need intervention (unless the IOP is unacceptably high).
Potential Complication Limbal leakage. Limbal or anterior drainage of aqueous

can lead to hypotony, infection, and possibly early scarring and failure of the
trabeculectomy.
How to Avoid and Manage Prevention is the key, water-tight closure at the limbus
is important. As outlined above, we bring down Tenon’s tissue to the limbus and
secure it together with the conjunctiva to the anatomical limbus. Our standard
method of closure is to use two purse-string sutures at the conjunctival edges and
then horizontal mattresses sutures to close the center (see Fig. 4.6).
At the time of surgery, any leakage directly through the scleral flap or from the
edges of the scleral flap should be identified and remedied on table. Small limbal
leaks usually resolve spontaneously with no adverse effect (Henderson et al. 2004).
If there is persistent hypotony, the patient should be taken back to theater and the
trabeculectomy site explored for potential causes, such as very anteriorly placed side
Fig. 4.6 Bilayered closure of Tenon and conjunctival tissue to the anatomical limbus
4 Trabeculectomy 89
arms, or leakage through a thin scleral flap. It is also important to bear in mind that
the patients may inadvertently be rubbing their eyes for iatrogenic reasons, such as
loose sutures and eye drop allergies or intolerances. If this is the case, removing the
cause if possible and advocating 24-h use of an eye shield may help stop the leak.
If there is dehiscence of the conjunctiva from the limbus, this should be taken
back to theater and resutured straight away.
Potential Complication Hypotony (no conjunctival leakage).
How to Avoid and Manage It is important to ascertain the underlying cause of the
hypotony and whether this is related to the surgery itself or to ocular risk factors for
hypotony. Hypotony in relation to the surgery may be due to loose scleral flap
sutures, full-thickness hole in the scleral flap, full-thickness scleral incision when
creating the scleral flap, or even the patients rubbing their eyes due to ocular irrita-
tion. The commonest ocular-related risk factors for postoperative hypotony are high
myopia and uveitis.
It is important to monitor these patients closely for resolution and to intervene in a
timely manner if revision is needed. Our advice is to have a low threshold for revision
in cases of hypotony, particularly in the presence of choroidals and hypotony macu-
lopathy. If there is hypotony with the presence of a shallow anterior chamber, atropin-
izing the eye may allow the anterior chamber to deepen. Injecting a tamponade into
the anterior chamber is a sound way of temporizing while awaiting resolution (for
example, in the case of suture track leakage or high myopia). The tamponade may be
an ophthalmic viscosurgical device (OVD) or gas (isovolumetric SF6 or C3F8). The
principal risk with such tamponades is a swing of the IOP a few hours after the injec-
tion to an extremely high IOP requiring release of the tamponade. Patients should be
warned of this risk and given clear instructions regarding where to attend for immedi-
ate attention. The choice of tamponade is dependent on how profuse the leak is (the
more profuse, the more viscous the OVD) and the surgeon’s preference.
If there is hypotony in the context of a deep anterior chamber, with no choroidals
or hypotony maculopathy, then it may be better to closely observe the patient for
resolution of hypotony. Patients should be advised to rest and wear a shield over the
eye especially during sleep. In particular rubbing of the eye, Valsalva maneuvers,
and bending with the head dependent should be avoided, since there is a risk, not
only of the leak being perpetuated but also of suprachoroidal hemorrhage.
In cases where hypotony is present, with a flat bleb, for example, in uveitics, it is
important to keep the patient on high-dose topical steroid, as there may be poor flow of
aqueous to maintain the surgical fistula due to temporary shutdown of the ciliary body.
Potential Complication Hyphema.
How to Avoid and Manage The blood may come from the iridectomy site or from
the scleral flap site. It is important to note that these usually spontaneously clear
remarkably quickly and resolve in most eyes. Thus rest is the first and foremost
treatment. Consideration should be given to any contributory systemic factors, aspi-

rin or anticoagulant use which may be amenable to intervention.
If the intraocular pressure is elevated in the context of hyphema, medical man-
agement may be the best option. The scleral flap may be sealed with clot and manip-
ulation may restart active bleeding. Once the hyphema has resolved, it is, of course,
extremely important to establish good flow through the trabeculectomy flap.
If medical therapy fails to control the intraocular pressure sufficiently, an ante-
rior chamber washout may be required. It is worth considering an injection of tPA
into the anterior chamber (see perioperative complications: hyphema). Oral
tranexamic acid can also be used, to prevent rebleeding, when evacuating the clot.
Potential Complication Suture irritation.
How to Avoid and Manage Meticulous closure of the conjunctiva, ensuring all
sutures are buried with trimmed ends, helps to avoid this problem. Nevertheless,
despite the utmost care, suture irritation can still occur. All proud ends and redun-
dant sutures can be trimmed or removed; for others reassurance and the promise of
removing the conjunctival sutures 3–4 weeks from the date of surgery is usually
sufficient. We endeavor to remove all conjunctival sutures 3–6 weeks after surgery
in order to avoid subsequent irritation and the risk of bleb-related infection.
Potential Complication Snuff out.
How to Avoid and Manage Snuff out or wipe out of vision is a rare devastating
complication (Costa et al. 1993). It is irreversible and typically occurs in patients
with end-stage glaucoma. It is important to counsel patients thoroughly before
embarking upon surgery and this is one of the rare complications to include in the
discussion. As with all consultations it is important to present the relative risks of
procedures and the rationale for intervention.
Although there is no evidence base as to why this occurs it has been hypothe-
sized that sudden changes in intraocular pressure may contribute to this phenome-
non. General anesthetic has been suggested as beneficial for those with end-stage
glaucoma as there is no direct pressure on the optic nerve from the volume of the
sub-Tenon’s or peribulbar anesthesia and the intraocular pressure is lowered prior to
ocular decompression. The use of an anterior chamber maintainer may also be con-
sidered to minimize sudden changes in intraocular pressure.
It should be noted that we have seen rare cases where the vision has been mark-
edly decreased (even to NPL) postdecompression and yet has subsequently recov-
ered over a few days. Thus visual loss on the first postoperative day, although
serious, is not necessarily final.
Potential Complication Visual acuity decrease.
How to Avoid and Manage A majority of patients will experience loss of up to

one line of acuity immediately posttrabeculectomy surgery. This can be due to a
4 Trabeculectomy 91
number of reasons including the new IOP, anterior chamber cells (red or white!),
and corneal epitheliopathy. The most common reason, however, is irregular astig-
matism from the flap. This has been well documented and takes up to 1 year to
resolve completely (Hayashi et al. 2000). Simply waiting is almost always
sufficient.
4.4 Late Postoperative Complications
Potential Complication Scarring, IOP rise.
How to Manage This is the most common complication of trabeculectomy sur-

gery. If simply a clinical observation in the presence of adequate IOP and no
glaucoma progression, then conservative management is indicated. If accompa-
nied by a mild pressure rise and the patient previously responded, was compliant
with, and tolerated previous topical ocular hypotensive therapy, then the resump-
tion of drop treatment is usually adequate to retain glaucoma control. The next
option frequently considered is needling revision of the bleb, usually with adjunc-
tive cytotoxic and steroid therapy. In essence this is simply puncturing and slicing
a hole(s) through the scar tissue to reestablish the surgical fistula. There is little
evidence in the literature concerning needling, largely because of the very varied
clinical population in whom it is performed with variation in age, time after sur-
gery, diagnosis, type of bleb morphology, precipitation of failure (cataract sur-
gery, uveitis, other ocular surgery, etc.), technique, and many other factors
(Rotchford and King 2008). Success is variable and case selection is crucial. For
the patient, the postoperative care can be as involved as the trabeculectomy and,
with variable success rates, it is important to consider whether the patient defi-
nitely needs the needling revision or not. If you decide to proceed, ensure you
perform gonioscopy to check that the internal ostium of the sclerostomy is not
completely plugged with iris tissue. It is also important to consider the external
ocular environment, the conjunctival morphology, and scleral flap prior to pro-
ceeding with needling revision.
Once you are happy that you have restored aqueous flow sufficiently, you may
consider giving a subconjunctival injection of 5-fluorouracil (5-FU) and steroid.
The next possible approach to a scarred bleb is to consider trabeculectomy revi-
sion. This can either be the same site revision or a second trabeculectomy at a dif-
ferent site.
A final option is to consider other surgeries such as a drainage tube or cyclodiode
ciliary body ablation.
Potential Complication Bleb dysesthesia.
How to Manage Bleb dysesthesia occurs due to disruption of the natural lid con-
tour over the globe. Patients may complain of varying degrees of discomfort.
Symptoms of bleb dysesthesia can vary from an awareness of the bleb, to constant
discomfort, symptoms of exposure keratopathy, and even bubble formation and

audible clicking, particularly in those with 360° exuberant blebs.
Counseling in these patients is important, as many patients are able to tolerate the
symptoms, particularly in mild cases if they understand the cause. It is always worth
trying a course of preservative-free ocular lubricants in the first instance, but these
are not always effective.
A variety of approaches can be tried:
1 . Injection of autologous blood (Smith et al. 1994)

2. The use of Palmberg sutures to limit the bleb (Palmberg and Zacchei 1996)
3. Revision of the bleb, with a patch graft (Clune et al. 1993)
4. Limiting incisions (Rossiter et al. 1999)
In the instance of persistent dysesthesia in the presence of a diffuse functional

trabeculectomy our own approach is to undertake limiting incisions laterally and
medially to the scleral flap. The cut edges can be “tacked” down to the scleral bed
with sutures to limit the bleb.
For those patients with “high” domed blebs that cause intractable ocular discom-
fort, revision and bleb excision can give temporary relief, but the blebs commonly
recur over time. Our own approach is to excise, completely seal with a patch graft,
and insert an aqueous shunt to control the intraocular pressure.
Do note that none of these measures are suitable for an overdraining bleb causing
hypotony. Please see the section on hypotony.
Potential Complication Cystic leaking bleb, endophthalmitis.
How to Manage It is important to remember that many blebs leak intermittently

without the cognizance of the ophthalmologist. The majority do not come to harm.
When considering whether to revise or observe, full consideration should be given
to the patient’s ocular, personal, and social environment. For example, one may be
more likely to revise if the patient suffers from chronic infections, lives in an unsuit-
able home environment, self-neglects, or has restricted access to health care. If these
concerns are present, it is better to revise than observe.
It is important to have a full discussion with the patient of the risks and ensure
the understanding of seriousness of condition. If one gauges that the patient has a
poor understanding of the situation, then a revision should be done.
It is a good idea to reinforce patient education, either in the form of patient infor-
mation leaflets on bleb-related infection or with the help of a nurse counselor.
We also endeavor to give patients a supply of prophylactic topical antibiotics,
which they are asked to commence immediately if they develop symptoms of bleb-
related infection and are unable to reach expert review within an hour. The patient
is asked to start these immediately and seek ophthalmic care as soon as possible, if
they develop signs of an infection.
Potential Complication Hypotony in the presence of a deep anterior chamber.

4 Trabeculectomy 93
How to Manage Hypotony is not just a figure, but a figure combined with signs. Signs
of pathological hypotony include permanently or intermittently blurred vision. For
example, vision may be blurred in the morning or when standing for prolonged periods.
Permanent blurring or fluctuating vision, folds at the macula, or choroidals are signs
that the eye needs attention. It is important to seek out an underlying cause that may
require urgent attention, such as leaking bleb, retinal detachment, or uveitis.
If the eye is symptomatic, you have to either consider reducing outflow, by either
using a tamponade in the anterior chamber or surgical revision. Use of a tamponade
is really to buy time, before taking them to the operating theater.
If the patient is phakic, cataract surgery may produce enough inflammation to
result in sufficient scarring to reverse the hypotony. In borderline cases, this can be
a good measure, otherwise revision is the best and most definitive option. It should
be noted that reversal of hypotony is often not immediate after cataract surgery.
Potential Complication Bleb-related infection.
How to Manage This can occur at any time point after surgery. In a meta-analysis
we have done of ten publications in which the occurrence of infection in 4346 trab-
eculectomies has been reported over time, the incidence of bleb-related infection is
approximately 0.5 % per year (Katz et al. 1985; Wolner et al. 1991; Greenfield et al.
1996; Higginbotham et al. 1996; Mochizuki et al. 1997; Uchida et al. 2001; DeBry
et al. 2002; Muckley and Lehrer 2004; Shigeeda et al. 2006; Sharan et al. 2009). It
is important to counsel all patients using verbal and written information with special
attention to those with cystic or leaking blebs. Patients should be advised to obtain
emergency eye care as soon as possible if a bleb-related infection is suspected, as
time to treatment is critical (see Fig. 4.7).
All departments have a protocol to treat bleb-related infection and so we are not
going to talk about antibiotic regimes. The point we would like to highlight is that
Fig. 4.7 Photograph of

bleb-related infection,
displaying classic “white
on red” sign (Photograph
taken by Ms. Poornima
Rai, Consultant
Ophthalmologist,
Moorfields Eye Hospital,
London)
steroids are critical to the visual outcome (Kangas et al. 1997). The inflammatory
reaction precipitated by the infection can have devastating effects on the retina. We
inject intravitreal dexamethasone at the same time as intravitreal antibiotics and
commence patients on topical steroids and antibiotics immediately and oral steroids
12–24 h after intravitreal injections. The exception to the rule is suspicion of a fun-
gal infection, in which case steroids should be withheld.
Potential Complication Progression of cataract.
How to Manage The incidence of cataract formation is 10–61 % after trabeculec-

tomy surgery (Mathew and Murdoch 2011). It is not known why there is such a dra-
matic increase in cataract formation. The etiology is thought to be multifactorial. It is
an age-old debate as to whether cataract surgery should be performed before or after
trabeculectomy surgery and which way round is better for trabeculectomy survival. If
trabeculectomy surgery is performed before, it is important to counsel patients regard-
ing the risk of cataract progression. Please see section on coexistence of cataract.
Potential Complication Glaucoma progression despite controlled intraocular

pressure.
How to Manage One can expect a continued rate of attrition of the ganglion cells
even after surgery. In addition to normal attrition with age there may be ongoing
loss during the immediate postoperative period. This may cause progressive visual
field changes, which eventually plateau out. There is, however, a small subgroup of
patients who continue to progress despite what appears to be optimum pressure
control. This is a heart-sink moment for most clinicians. Two immediate questions
to consider are
1. Is the IOP sufficiently low compared to the preoperative pressure at which they
were advancing?
2. Is there sufficient control of IOP throughout the day?
If the answer to both the above questions is “Yes”, then vascular and other factors
need to be considered. If the patient is taking systemic antihypertensive therapy it is
important to consider 24-h blood pressure monitoring (Graham and Drance 1999).
If there are nocturnal dips in blood pressure a change in therapy may eliminate these
and halt glaucoma progression. Gingko biloba may improve blood flow to the optic
nerve head; it does not affect the IOP (Rhee et al. 2001). There is very little evidence
regarding its efficacy.
Conclusion
This chapter is a practical guide for anticipation, prevention, and management of
common and sight threatening complications of trabeculectomy surgery.
Reported results of this well-established operation are happily improving over
time and success proportions in excess of 90 % at 1 year and 80 % at 2 years are
not uncommon (Kirwan et al. 2013). While there is still plenty of room for
4 Trabeculectomy 95
improvement, the operation is becoming much more predictable. Our aim has
been to provide a framework for considering complications of trabeculectomy
surgery. We hope it is helpful for anticipation, prevention, and management of
complications in your own practice.
References
Broadway DC, Grierson I, Stürmer J, Hitchings RA. Reversal of topical antiglaucoma medication
effects on the conjunctiva. Arch Ophthalmol. 1996;114(3):262–7.
Casson RJ, Riddell CE, Rahman R, et al. Long-term effect of cataract surgery on intraocular pres-
sure after trabeculectomy. Extracapsular extraction versus phacoemulsification. J Cataract
Refract Surg. 2002;28:2159e64.
Chen PP, Weaver YK, Budenz DL, et al. Trabeculectomy function after cataract extraction.
Ophthalmology. 1998;105:1928e35.
Clune MJ, Shin DH, Oliver MMG, et al. Partial thickness scleral patch graft revision of trabecu-
lectomy. Am J Ophthalmol. 1993;115:818–20.
Costa VP, Smith M, Spaeth GL, et al. Loss of visual acuity after trabeculectomy. Ophthalmology.
1993;100:599–612.
Crichton AC, Kirker AW. Intraocular pressure and medication control after clear corneal phaco-
emulsification and AcrySof posterior chamber intraocular lens implantation in patients with
filtering blebs. J Glaucoma. 2001;10:38e46.
De Barros DS, Da Silva RS, Siam GA, et al. Should iridectomy be routinely performed as a part of
trabeculectomy? Two surgeons’ clinical experience. Eye. 2009;23:362–7.
DeBry PW, Perkins TW, Heatley G, et al. Incidence of late-onset bleb-related complications fol-
lowing trabeculectomy with mitomycin. Arch Ophthalmol. 2002;120:297–300.
Dhingra S, Khaw PT. The moorfields safer surgery system. Middle East Afr J Ophthalmol.
2009;16:112–5.
Ehnrooth P, Lehto I, Puska P, et al. Phacoemulsification in trabeculised eyes. Acta Ophthalmol
Scand. 2005;83:561e6.
Graham SL, Drance SM. Nocturnal hypotension: role in glaucoma progression. Surv Ophthalmol.
1999;43(Suppl 1):S10–6.
Greenfield DS, Suner IJ, Miller MP, et al. Endophthalmitis after filtering surgery with mitomycin.
Arch Ophthalmol. 1996;114:943–9.
Hayashi K, Hayashi H, Oshika T, Hayashi F. Fourier analysis of irregular astigmatism after trab-
eculectomy. Ophthalmic Surg Lasers. 2000;3:94–9.
Henderson HW, Ezra E, Murdoch IE. Early postoperative trabeculectomy leakage: incidence, time
course, severity, and impact on surgical outcome. Br J Ophthalmol. 2004;88:626–9.
Higginbotham HJ, Stevens RK, Musch DC, et al. Bleb-related endophthalmitis after trabeculec-
tomy with mitomycin C. Ophthalmology. 1996;103:650–6.
Kangas TA, Greenfield DS, Flynn Jr HW, et al. Delayed –onset endophthalmitis associate with
conjunctival filtering blebs. Ophthalmology. 1997;104:746–52.
Katz LJ, Cantor LB, Spaeth GL. Complications of surgery in glaucoma. Early and late bacterial
endophthalmitis following glaucoma filtering surgery. Ophthalmology. 1985;92:959–63.
Kiire CA, Mukherjee R, Ruparelia N, et al. Managing antiplatelet and anticoagulant drugs in
patients undergoing elective ophthalmic surgery. Br J Ophthalmol. 2014;98:1320–4.
Kirwan JF, Lockwood AJ, Shah P, et al. Trabeculectomy in the 21st century: a multicentre analysis.
Ophthalmology. 2013;120:2532–9.
Kotecha A, Spratt A, Ogunbowale L, et al. Intravitreal bevacizumab in refractory neovascular glau-
coma. Arch Ophthalmol. 2011;129:145–50.
Mathew RG, Murdoch IE. The silent enemy: a review of cataract in relation to glaucoma and tra-
beculectomy surgery. Br J Ophthalmol. 2011;95:1350–4.
Mochizuki K, Jikihara S, Ando Y, et al. Incidence of delayed onset infection after trabeculec-
tomy with adjunctive mitomycin C or 5-fluorouracil treatment. Br J Ophthalmol. 1997;81:
877–83.
Muckley ED, Lehrer RA. Late-onset blebitis/endophthalmitis: incidence and outcomes with mito-
mycin C. Optom Vis Sci. 2004;81:499–504.
Palmberg P, Zacchei AC. Compression sutures: a new treatment for leaking or painful filtration
blebs. Invest Ophthalmol Vis Sci. 1996;37:s444.
Park HJ, Kwon YH, Weitzman M, et al. Temporal corneal phacoemulsification in patients with
filtered glaucoma. Arch Ophthalmol. 1997;115:1375e80.
Rebolleda G, Munoz-Negrete FJ. Phacoemulsification in eyes with functioning filtering blebs: a
prospective study. Ophthalmology. 2002;109:2248e55.
Rhee DJ, Katz LJ, Spaeth GL, et al. Complementary and alternative medicine for glaucoma. Surv
Ophthalmol. 2001;46:43–55.
Rossiter JD, Godfrey SJ, Claridge KG. A case of a 360 degree exuberant trabeculectomy bleb. Eye.
1999;13:369–79.
Rotchford AP, King AJ. Needling revision of trabeculectomies bleb morphology and long-term
survival. Ophthalmology. 2008;115:1148–53.
Sharan S, Trope GE, Chipman M, et al. Late-onset bleb infections: prevalence and risk factors. Can
J Ophthalmol. 2009;44:279–83.
Shigeeda T, Tomidokoro A, Chen YN, et al. Long-term follow-up of initial trabeculectomy
with mitomycin C for primary open-angle glaucoma in Japanese patients. J Glaucoma.
2006;15:195–9.
Siriwardena D, Kotecha A, Minassian D, et al. Anterior chamber flare after trabeculectomy and
after phacoemeulsification. Br J Ophthalmol. 2000;84:1056–7.
Smith MF, Magauran R, Doyle JW. Treatment of postfiltration bleb leak by bleb injection of autol-
ogous blood. Ophthalmic Surg. 1994;25:636–7.
Swamynathan K, Capistrano AP, Cantor LB, et al. Effect of temporal corneal phacoemulsi-
fication on intraocular pressure in eyes with prior trabeculectomy with an antimetabolite.
Ophthalmology. 2004;111:674e8.
Uchida S, Suzuki Y, Araie M, et al. Long-term follow-up of initial 5-fluorouracil trabeculectomy in
primary open-angle glaucoma in Japanese patients. J Glaucoma. 2001;10:458–65.
Van Buskirk EM. The anatomy of the limbus. Eye. 1989;3:101–8.
Wolner B, Liebmann JM, Sassani JW, et al. Late bleb-related endophthalmitis after trabeculectomy
with adjunctive 5-fluorouracil. Ophthalmology. 1991;98:1053–60.
Wong TT, Khaw PT, Aung T, et al. The Singapore 5-fluorouracil trabeculectomy study:
effect on intraocular pressure control and disease progression at 3 years. Ophthalmology.
2009;116:175e84.
Glaucoma Tube Surgery
5
K. Sheng Lim, David Steven, and Francis Carbonaro
5.1 Background
Tube and plate glaucoma drainage devices have been in general use since AC
Molteno introduced his first glaucoma drainage device (GDD) in 1969 (Molteno
1969). For much of their history, these devices have been implanted in eyes that had
failed trabeculectomy. However, more recent studies, notably the Tube versus
Trabeculectomy Study’s (TVT 5-year result) (Gedde et al. 2012) have suggested
that tube surgery may be appropriate at much earlier stages of glaucoma. Certainly,
in the instance of aphakia, secondary glaucoma resulting from surgery, or any other
cases where there is excessive conjunctival scarring, primary tube surgery may well
be the best long-term option.
The use of tube surgery declined during the 1980s, when surgeons encountered
many visually devastating complications, which brought about the regulation of
tube surgery in many large ophthalmic centers. However, as the complication mech-
anisms became better understood, and means to avoid them were developed, tube
surgery’s popularity made a resurgence in the late 1990s, and in some centers it has
become more widely performed than trabeculectomy (Lim et al. 1998).
In this chapter we will review the current rate of complications associated with
glaucoma tube surgery, describe the mechanisms that cause these complications,
and detail precautions against, and management of, complications should they
occur. Table 5.1 lists the contemporary glaucoma drainage devices that are most
commonly used.
K. Sheng Lim • D. Steven

St Thomas Hospital, London, UK
F. Carbonaro (*)
Mater Dei Hospital, Msida, Malta

98 K. Sheng Lim et al.
Table 5.1 Contemporary glaucoma drainage devices

Year of Tube diameter/ Resistance
introduction material Plate size/material mechanism
Molteno 1969 0.63 mm OD 135 mm2 None
0.30 mm ID Polypropylene
Silicone
Baerveldt 1990 0.63 mm OD 200, 250, 350, 425, None
0.30 mm ID 500 mm2
Silicone Silicone
Ahmed 1993 0.63 mm OD 185 mm2 Venturi valve
0.30 mm ID FP7 model silicon plate
Silicone with silicone valve in
polypropylene box
OD outside diameter, ID inside diameter
5.2 Evaluating Glaucoma Drainage Device Results
Most GDDs have been developed in a virtual publication vacuum, with little avail-
able data to substantiate manufacturers’ claims for flow performance or biocompat-
ibility (Prata et al. 1995). Clinical data are largely restricted to uncontrolled
retrospective case series (Krawczyk 1995) with variable follow-up and differing
definitions of surgical success. Evaluation is further complicated by the heterogene-
ity of inclusion criteria. Series include a variable proportion of complex cases, such
as neovascular glaucoma, in which there is a higher risk of filtration failure.
Overall success rates, in terms of IOP control, appear similar between devices
(Table 5.2), with a reasonably high proportion of cases achieving a final IOP in the
target range at 1 year after surgery. Half to two-thirds of these cases still require
glaucoma medications, however, target IOPs in the low teens (≤16 mmHg) may be
more realistic in terms of preventing disease progression than commonly adopted
target levels (≤21 or 22 mmHg).
Another important caveat concerns attrition rates, or continued increments in the
proportion of filtration failures with lengthening postoperative follow-up. Again,
evaluation is difficult, with few series including either long-term data or survival
analysis (Mills et al. 1996) (Table 5.2). Mills et al. reported a 10 % failure rate per
postoperative year in a series including longer-term follow-up for single and double
plate Molteno tubes. Extrapolating from this would suggest that many GDDs have
a functional lifespan of less than 5 years before failure though fibrous encapsula-
tion. However, the 5-year data from the Tube vs. Trabeculectomy (TVT) study
found a 10 % failure rate per year for the first 3 years, and an average of 5 % per year
for the subsequent 2 years, which may indicate better long-term results with less
complex cases (Gedde et al. 2012).
5.2.1 Tube Use, Tube Type, and Complication Risk
Clinical series reporting GDD procedures are characterized by frequent problems

in addition to filtration failure (Table 5.3), with overall complication rates
Table 5.2 Success rates of current GDDs
Follw-up Success rate Success rate
No. of (months) w/o with
Type Investigator Year Diagnosis eyes mean ± SD Success criteria medication medications
Molteno
SP and DP Mills et al. (1996) 1996 Mixed (25 % 77 44a IOP ≤22 mmHg and 23 % 34 %
neovascular) NFCb
SP Mermoud et al. (1993) 1993 Neovascular 60 24.7±13.4 IOP ≤21 mmHg 17 % 20 %
and NFCb
5 Glaucoma Tube Surgery
SP Heuer et al. (1991) 1992 Mixed (no 50 14.9±8.9 5 ≤IOP ≤21 mmHg 10 % 40 %
DP neovascular) 52 16.4 ± 6.8 and NFCb 12 % 63 %
SP Minckler et al. (1988) 1988 Mixed (50 % 90 17.6 IOP ≤21 mmHg 7 % 40 %
neovascular) and NFCb
Ahmed valve Coleman et al. (1995) 1995 Mixed 60 9.3a IOP <22 mmHgc,d NA NA (78 %)e
and NFCb
Coleman et al. (1997) 1997 Penetrating 31 16a IOP <22 mmHgc,d 26 % 39 %
keratoplastyf and NFCb,g
Coleman et al. (1997) 1997 Pediatric-mixed 24 16.3±11.2 IOP <22 mmHgc,d 33 % 38 %
and NFCb
Barton et al. (2014) 2014 Mixed 106 36 IOP <22 mmHgc 20 % 84%h
(ABC group) and NFCb,g
Christakis et al. (2013) 2013 Mixed 124 36 IOP <18 mmHg 13 % 57 %h
(AvB study) IOP >5 mmHgc
and NFCb,g
Krupin disk The Krupin Study 1994 Mixed 50 25.4±2.4 IOP ≤19 47 % 33 %
Group (1994) and NFCb
Fellenbaum et al. 1994 Mixed 25 13.2 6 ≤ IOP ≤21 28 % 36 %
(1994) and NFCb
(continued)
99
Table 5.2 (continued)
100
Follw-up Success rate Success rate

No. of (months) w/o with
Type Investigator Year Diagnosis eyes mean ± SD Success criteria medication medications
Baerveldt Seigner et al. (1995) 1995 Mixed 103 13.6±0.9 5 ≤ IOP ≤22 and 45 % 27 %
200, 250, 350, NFCb
500 mm2
200, 350, Sidoti et al. (1995) 1995 Neovascular 36 15.7±7.2 6 ≤ IOP ≤21 and 33 % 17 %
500 mm2 NFCb
350 mm2 Lloyd et al. (1994) 1994 Mixed 37 15.5±4.8 6 ≤ IOP ≤21 and 14 % 70 %
500 mm2 36 14.1±5.4 NFCb 36 % 47 %
Diameters Barton et al. (2014) 2014 Mixed 100 36a IOP <22 mmHgc 33 % 72%h
mixed/not (ABC group 3 years) and NFCb,g
specified.
350 mm2 Christakis et al. (2013) 2013 Mixed 114 36 IOP <18 mmHg 33 % 86%h
(AvB study) IOP >5mmHgc
and NFCb,g
350 mm2 Gedde et al. (2009) 2009 Mixed 107 36 IOP <21 mmHg 56 % 85 %
(TvT 3 year study) IOP >5 mmHgc
and NFCb,g
a
Median follow-ups in months
b
With no further glaucoma surgery or devastating complication
c
Or reduction of >20 % if preoperative IOP >22 mmHg
d
Data from same patients may appear in more than one of these three series
e
Total success rate only
f
Concurrent or prior
g
Including graft failure
h
Defined as 100 % – %(reported failure rate). The figure therefore includes qualified successes
NFC no further complications, Molteno SP Molteno single plate, Molteno DP Molteno double plates, ABC study Ahmed Baerveldt Comparison study (Barton
et al. 2014), AvB study Ahmed versus Baerveldt study (Christakis et al. 2013), TvT study tube versus trabeculectomy study (Gedde et al. 2009)
K. Sheng Lim et al.
5 Glaucoma Tube Surgery 101
Table 5.3 Cumulative complication rates among currently used GDDs

Implants Ahmed Ahmed Baerveldt Baerveldt
valve valve implant implant
(1990s) (recent) (1990s) (recent)
Studies Coleman ABC 2014a Lloyd 1994 ABC 2014a
1995
Coleman AvB 2013b Sidoti 1995 AvB 2013b
1997
Coleman Smith 1993 TvT 2009c
1997
Siegner 1995
n= 115 267 249 354
Complication category Rate (%) Rate (%) Rate (%) Rate (%)
Choroidal effusion 14.00 % 6.00 % 23.00 % 9.90 %
Tube erosion, occlusion, 17.30 % 7.90 % 15.60 % 9.30 %
malposition
Shallow anterior chamber 3.50 % 7.10 % 16.50 % 9.60 %
Persistent corneal edema/ 3.50 % 8.60 % 11.60 % 11.60 %
decompensation
Persistent diplopia/motility 3.50 % 8.60 % 21.00 % 6.20 %
disorder
Iritis/uveitis 1.70 % 4.90 % 3.60 % 5.10 %
Hyphema 0.00 % 2.20 % 11.00 % 2.80 %
Vitreous hemorrhage 3.50 % 1.10 % 7.00 % 1.10 %
Encapsulated/encysted bleb 3.50 % 5.60 % 1.60 % 1.40 %
Retinal/choroidal detachment 0.00 % 1.50 % 5.00 % 2.50 %
Phthisis bulbi 0.00 % 0.00 % 2.40 % 1.40 %
Aqueous misdirection/malignant 0.90 % 0.70 % 2.00 % 1.40 %
glaucoma
Suprachoroidal hemorrhage 3.50 % 0.00 % 0.80 % 1.40 %
Other complicationsd 4.30 % 6.40 % 6.00 % 9.30 %
n = Postoperative 0.6 0.6 1.3 0.7
complications per patient
testede
% of tested patients 60–70 %f 45 %a,b 60–70 %f 51%a,b,c
experiencing complications.
a
Ahmed Baerveldt comparison study (Barton et al. 2014)
b
Ahmed versus Baerveldt study (Christakis et al. 2013)
c
Tube versus Trabeculectomy study (Gedde et al. 2009)
d
Complications whose rate was <2 % in all categories
e
Note that some patients had more than one complication
f
Estimate: (Heuer et al. 1991; Siegner et al. 1995)
typically around 60–70 % (Heuer et al. 1991; Siegner et al. 1995). While partly
attributable to the complex nature of cases typically selected for implantation, the
range of complications observed also reflects design and material inadequacies
inherent in contemporary GDDs. The origin of most complications can be traced
to just two fundamental mechanisms: poor flow control and suboptimal material
biocompatibility.
In the past, tube surgery was performed on patients with advanced forms of glau-
coma, such as neovascular glaucoma, which carried a higher risk of complications.
In recent times, surgeons have increasingly used tubes to treat less advanced
patients, resulting in a lower rate of complications recorded in recent studies.
5.3 ajor Postoperative Complications

M
and Their Mechanisms
The risk profile of major postoperative complications following the implantation of

a glaucoma drainage device (GDD) is similar to those that follow a trabeculectomy.
Drainage issues give rise to “early hypotony” and the subsequent “hypertensive”
phases, whereas a range of mechanical and inflammatory problems can beset the
tube’s interactions with the anterior chamber. Further complication categories,
including eye motility and infections, are associated either with the tube or the plate.
5.3.1 Poor Flow Control
Insufficient internal flow regulation and uncontrolled extrinsic leakage have all been
implicated in the problems associated both with excessive aqueous outflow in the
early postoperative stages and with the impediments to drainage that can follow.
The different complication risk profiles of Ahmed and Baerveldt implants reflect
important differences in their design and the way they manage hypotony.
5.3.1.1 GDD and Flow Control Mechanisms

Since Molteno’s original device, minimizing rates of hypotony has been the main
drive behind modifications to GDDs and implantation techniques. This is typi-
cally experienced over the first two postoperative months, until formation of a
fibrous capsule around the plate offers sufficient resistance to aqueous outflow.
Hypotony is associated with a catalog of early and late complications (Table 5.3).
Anterior chamber flattening is especially hazardous in the context of GDD
implantation because contact with the tube element can cause significant damage
to the lens and cornea. In addition, all GDD devices are susceptible to a later
elevation of IOP brought about by bleb encapsulation. GDDs can be categorized
into those with no internal resistance mechanism, such as the Baerveldt implant,
and those which aim to provide set internal flow resistance, such as the Ahmed
valve.
Early independent examinations of the flow characteristics for Ahmed,
Baerveldt, and other GDDs revealed a significant discrepancy between observed
function, and the manufacturers’ claims for flow resistance (Prata et al. 1995). The
Krupin valve appeared not to close after initial opening in perfusion tests con-
ducted at physiological flow rates. Resistance values also varied considerably
between devices from the same manufacturer, indicating deficiencies in quality
control (Porter et al. 1997). However, subsequent flow examinations (Eisenberg
et al. 1999; Francis 1998) showed that the Ahmed valve might indeed have a more
consistent opening and closing pressure. Clinically, hypotony was still reported in
5–20 % of cases after Ahmed GDD implantation (Coleman et al. 1997; Coleman
1997). Inconsistencies in flow control continue to be observed in some Ahmed
valves, prompting some surgeons to perform flow-testing with saline
pre-implantation to ensure the valve opening and closing pressures remain with
appropriate boundaries (Jones et al. 2013).
5.3.1.2 Early Hypotony and Its Consequences

The primary outcome of hypotony is a shallow or flat anterior chamber. The shal-
lowing of the anterior chamber greatly increases the risk of even a correctly posi-
tioned tube touching the corneal endothelium or the iris, which ultimately increases
the risk of corneal decompensation, or uveitis, respectively. Hypotony also increases
the chances of tube occlusion (Bailey and Sarkisian 2014). Severe flattening of the
anterior chamber can bring the iris and cornea into contact. Although it has been
shown not to cause devastating complications itself (Fiore 1989), iridocorneal touch
can result in adhesion, cataracts, and endothelial cell loss, which put the cornea at
greater risk of decompensation (Hosoda et al. 2013).
Choroidal effusions, which involve the filling of the suprachoroidal space with
serum, are commonly associated with postoperative hypotony and flat anterior
chambers. For the most part, they are asymptomatic and resolve once IOP is nor-
malized. However, if choroidal effusions should expand and touch one another,
“kissing choroidals” may cause irreversible damage. Inflammation of capillaries
with serous choroidal effusions may trigger suprachoroidal hemorrhage. The use of
GDDs, as opposed to trabeculectomy, generally appears to reduce the risk of cho-
roidal effusion (Gedde et al. 2009; Schrieber and Liu 2015). Chronic hypotony can
also lead to macular edema with resulting decrease in vision and if this occurs man-
agement to reverse the hypotony should be instilled.
5.3.1.3 Bleb Encapsulation

Long-term management of postoperative IOP relies on the formation of a bleb, or
fibrous capsule around the end plate. A successful bleb must not adhere to the plate,
but form a space around it which filters out aqueous humor. Early postoperative
hypotony is expected to correct itself following the proliferation of fibroblasts
around the plate (Schwartz et al. 2006).
However, it is not uncommon for the filtering bleb to overcompensate, leading to
elevated IOP, which typically presents any time between 2 and 12 postoperative
months. The greater the surface area and the thinner the wall of fibroblasts, the
lesser the resistance to aqueous outflow. The bleb’s inflammatory response to the
arrival of aqueous into the end plate may initiate a positive feedback system, since
thickened capsule walls inevitably increase intraocular (and bleb) pressure, intensi-
fying the stress response of the fibroblasts, causing them to thicken. Although the
risk of postoperative hypotony is less with Ahmed implants, they are markedly more
susceptible (Chen and Palmberg 1997) to bleb encapsulation, possibly due of their
smaller size and rougher surface material (Choritz et al. 2010).
5.3.2 Complications of the Tube and Anterior Chamber
The tube’s implantation technique is the foremost factor in the successful drainage
of the anterior chamber. Whether or not it is the result of poor flow control, hypot-
ony increases the risk of tube-related complications being initiated in the shallowed
anterior chamber, since tube tips are far more likely to come into contact with the
iris or cornea.
5.3.2.1 Leakage Around the Tube

All the commonly used devices feature a round silicone anterior chamber tube with
a diameter of between 0.56 and 0.63 mm (Table 5.2). The recommended technique
for insertion is through a paracentesis track created by either a 22 or 23 gauge
(0.65 mm) hypodermic needle. Debate over the optimum needle gauge continues
(Coleman et al. 1995), but insertion often requires considerable manipulation. Even
then, the tube to paracentesis fit can be poor, and uncontrolled leakage external to the
tube is common. More rarely, the implant tube has been shown to erode at its entry
point to the anterior chamber, resulting in fluid leakage (Al-Torbak 2001) (Fig. 5.1).
5.3.2.2 Hyphema
Hyphema generally occurs when vessels are damaged as the tube enters the anterior
chamber, whether because of a posterior insertion hitting the iris root or abnormal
vessels angle vessels, such as in neovascular glaucoma. Bleeding will be exacer-
bated in hypotony. It is important, especially in cases of neovascular glaucoma, to
examine the angle prior to surgery to look for angle new vessels or peripheral
Fig. 5.1 Fluorescein
dilution by aqueous
leakage around the tube
after implantation
Practical Tip: Tube Entry with a 25G Needle
• Start 2 mm from the limbus with a smooth single entry initially in the plane
of the sclera then angle forward parallel with the iris plane once half of the
bevel is in the sclera.
• Ensure a single movement without retraction or advancement (as this can
create a false pocket).
• Enlarge the track slightly on exit to aid with initiating the tube entry.
• Check for watertight fit with 2 % fluorescein, suture adjacent to the tube if
leaking.
• Persistent leaks may be stopped by plugging with sub-Tenon’s tissue.
• Anterior vitrectomy should be performed if there is any chance of vitreous
in the AC, usually from previous complicated cataract surgery.
Fig. 5.2 Perioperative
hyphema in a neovascular
glaucoma after tube
insertion into the anterior
chamber. The bleeding is
from the angle blood
vessels
anterior synechiae in the area of planned insertion and either avoid the affected
areas or avoid vessels by inserting more anteriorly (Fig. 5.2).
5.3.2.3 Tube Blockage by Iris, Vitreous, or Cornea

During the implantation of a GDD, it is very important that the bevel of the tube is cut
upwards toward the corneal endothelium. This will eliminate, or at least reduce, the
risk of iris tissue occluding the tube at its entry site. Should iris occlusion occur at a
later date, it may be necessary to perform a secondary iridectomy or to re-site the tube.
Argon laser can sometimes be used to retract iris tissue from around the tube as well.
The blockage of the tube by vitreous in the anterior chamber or sulcus space is a
commonly encountered problem. Generally, if the eye has (a) had prior partial
vitrectomy, (b) had any loss of vitreous during cataract surgery, or (c) had even a
suggestion of vitreous strands coming into the anterior chamber during tube surgery,
then it is necessary to perform an anterior vitrectomy at the time of tube surgery. This
will reduce the risk of vitreous incarceration into the tube.
The chances of corneal endothelial touch can be greatly mitigated by good surgi-
cal technique. It is advisable to implant a tube entry site well into the pigmented
trabecular meshwork area; and it is important that entry plane of the needle is at
least parallel to the iris plane. Should corneal endothelial touch occur postopera-
tively, it is essential that the tube is revised, either by re-siting or trimming. Prolonged
corneal touch will cause the failure of its endothelial cells in the long run.
5.3.2.4 Corneal Decompensation

Persistent corneal edema has been cited as the most frequent postoperative complica-
tion for GDDs that appears after 12 months (Topouzis et al. 1999). Corneal preserva-
tion relies on the health of its endothelial cells, which lie between it and the anterior
chamber. High IOP causes the loss and morphological change of these cells, whereas
excessive shallowing of the anterior chamber following GDD implantation brings the
corneal endothelium into contact with the tube, causing long-term mechanical trauma
(Alvarenga et al. 2004). The risk of this complication is greatly elevated among
patients with preexisting corneal pathologies or grafts (Gedde et al. 2009).
To minimize the risk of any anterior chamber part of the tube touching corneal
endothelium, it is essential to make sure that the tube lies much closer to the iris than
the cornea (Fig. 5.3).
5.3.3 Subconjunctival and Explant Complications
5.3.3.1 Diplopia
Diplopia is a fairly common problem, although in the TVT trial, a similar rate of
diplopia is encountered in both trabeculectomy and tube surgery. The first generation
Fig. 5.3 Tube in the

anterior chamber too close
to endothelium and
subsequent intermittent
rubbing caused localized
corneal edema around the
tube entry site
of Baerveldt tube implants, whose plates did not feature a perforating anchoring
hole, encountered a very high proportion of patients with postoperative diplopia.
Since the introduction of perforating holes in the later Baerveldt plates, the diplopia
risk has been greatly reduced, but remains significantly higher than that of the Ahmed
implant. This reflects the greater size of the Baerveldt end plate. It is important to
thoroughly assess the patient preoperatively, and warn the patient of this potential
complication. The diplopia is often self-limiting and may be observed in the early
postoperative phase (Rauscher et al. 2009). Persistent cases may often be managed
with prismatic correction but occasionally squint surgery or even explantation of the
device may be required.
5.3.3.2 Tube or Plate Erosion

In general, the tube in the subconjunctival space needs to be covered either by a long
needle track, by a scleral flap created as per trabeculectomy, or else a patch graft
formed either from donor pericardium, sclera, or cornea to reduce the risk of ero-
sion. Once the tube is properly covered, the risk of erosion is less than 2 % in the
reported literature. It is most common adjacent to the limbus as this is where the
greatest angulation of the tube occurs and where overriding eyelid movement is
greatest (Fig. 5.4) (Panarelli et al. 2016). Micromotion of the tube may also play a
role. This can be reduced by the placement of one to two mattress sutures of either
10-0 nylon or 9-0 prolene to anchor tube to the sclera.
5.3.3.3 Poor Biocompatibility

In the context of GDD implantation, biocompatibility describes how safely the syn-
thetic material interfaces with living tissues. Suboptimal biocompatibility is mani-
fest in an array of complications including early fibrinous occlusion of the tube,
corneal endothelial failure, tube migration, extrusion, and fibrous encapsulation
leading to filtration failure. Protein adhesion and micromotion are key elements in
the mechanism of these complications.
Fig. 5.4 Eroded tube

despite previous
pericardium patch graft
Elastomeric silicone (polydimethylsiloxane) remains the most commonly used

material in current GDDs. Silicone, PMMA, and other hydrophobic polymers used
in GDDs have a relatively high binding affinity for plasma and interstitial fluid pro-
teins such as albumin, IgG, and fibrinogen all of which are adsorbed within hours of
implantation (Pitt et al. 1988). Cellular adhesion, cytokine release, and chronic
inflammation are thought to be mediated via elements of this protein film (Tang and
Eaton 1995).
Continuing low grade inflammation is exacerbated by micromotion, or micro-
scopic shearing of the implant, relative to the surrounding tissues. Plate elements of
contemporary GDDs often restrict the movements of the extraocular muscles, either
directly or through adhesions with septal elements of the orbital tissues. Even where
this does not produce a frank motility disturbance, it is likely that shear forces trans-
mitted through the relatively rigid materials used in GDD construction produce sig-
nificant micromotion. In rabbit experiments, fenestration of the Baerveldt GDD
significantly reduced fibrous encapsulation thicknesses compared with unfenes-
trated controls, as was observed at explantation 6 months postoperatively (Jacob-
LaBarre et al. 1995). In addition to causing subconjunctival fibrosis after GDD
implantation, micromotion effects may be transmitted through the tube directly to
the anterior chamber, where it may cause corneal endothelial cell loss. The co-
occurrence of these effects with perioperative endothelial damage is possibly a
major contributor to corneal endothelial failure.
Progressive fibrous encapsulation limits the filtration life of all contemporary
GDDs. Whether due to poor flow control, or suboptimal biocompatibility, the mech-
anism that causes the inexorable progression from low grade inflammation, to sub-
conjunctival fibrosis has not yet been adequately addressed.
5.4 Managing Postoperative Complications
5.4.1 Managing Hypotony
The flow chart (Fig. 5.5) illustrates the management of patients with hypotony
post-tube surgery. The key component of assessing whether intervention is required
is to determine whether the anterior chamber is formed, or if there is any other
associated retinal complication. Should there be a flat anterior chamber, the tube
needs to be tied; otherwise there will be long-term consequences, including corneal
endothelial failure as well as suprachoroidal hemorrhage. If the anterior chamber is
only slightly shallow, then an intervention is only justified in cases of maculopathy
or suprachoroidal effusion. It will then be necessary to administer injections of a
cohesive viscoelastic such as Healon. If there is no indication of these conditions,
despite a shallow anterior chamber, then the patient can be reviewed very closely on
a weekly basis until their condition improves. It may also be good clinical practice
to add atropine 1 % twice a day to the eye, in order to reduce the risk of aqueous
misdirection.
No other complication Review every week
Formed
Review every week, or
Maculopathy or effusion inject Healon into the
anterior chamber.
Anterior chamber
No other complication Review every week
Shallow
Inject healon into the

Maculopathy or effusion
anterior chamber.
Flat Tie tube.
Fig. 5.5 A flowchart for the management of early hypotony
Iris Vitreous Cornea

Precautionary Cut the tube bevel Note whether partial vitrectomy has occurred, Implant the tube deep in the trabecular
measure upwards towards the or whether vitreous strands are observed in meshwork, and, entry plane of the
cornea. the anterior chamber. needle must be parallel to the iris plane.
Secondary iridectomy, or If any of the above occur, an anterior Re-site or trim the tube. If retracted tube
If Blocked vitrectomy is necessary. extender can be utilised.
re-siting of the tube.
Fig. 5.6 Management of tube-related complications
5.4.2 Managing Tube Blockage/Retraction and Hyphema
Figure 5.6 summarizes the main causes of tube blockage, preventative measures,
and recourse if the tube is blocked. Most hyphemas can be observed but if extensive,
then blocking the tube intracameral tissue plasminogen activator (3–5 μg diluted to
a total of 0.1 ml with sterile water) (Panarelli et al. 2016) together with topical myd-
riatics and steroids may dissolve the clot. Persistence of blockage requires anterior
chamber washout in theater.
5.4.2.1 Tube Retraction

If the tube is suspected to have retracted significantly into the sclerostomy tract caus-
ing complete occlusion of the tube, this must be associated with the absence of drain-
age into the bleb over the plate. Should this be confirmed, a tube extender (New World
Medical, California, USA) is a useful tool to overcome this complication (Fig. 5.7).
5.4.2.2 Viscoelastic Injection Technique

When postoperative hypotony results in a shallow anterior chamber, it is necessary
to inject Healon into the anterior chamber. In the office, this can be achieved with
the use of topical anesthetic and a needle piercing the cornea; 150–200 μl is typi-
cally administered, depending on the desired volume of the anterior chamber.
Fig. 5.7 Tube extender

(New World Medical,
California, USA) used to
extend a previously retracted
tube
Practical Tip: Viscoelastic Injection

• Insulin syringe (1 ml with needle), preloaded with 150 μl of Healon and
bend needle for easier access
• Topical anesthesia with tetracaine
• Betadine 5 % installation into the conjunctival sac
• Assistant to hold the eyelid may be required
• A slit lamp Healon injected via the peripheral cornea into the anterior
chamber
• Recheck the IOP in 30 min and review in 5–7 days
5.4.2.3 Tube Tie Technique

Where the hypotony is severe or persistent despite multiple viscoelastic injections
into the anterior chamber, it is best to halt the flow of aqueous from the anterior
chamber by tying off the tube. Once the free end of the tube is accessed through an
incision in the cornea, it is tied off, typically with an 8-0 prolene suture. Multiple
permanent ties of prolene are advised in the AC portion of the tube, ideally with an
intraluminal 3-0 prolene suture. These permanent sutures can be loosened at a later
stage using an argon laser.
Practical Tip: Tube Tie Technique:

• Perform in theater with general anesthesia if possible.
• If the tube is long enough to externalize, then proceed as follows (if the
tube within the AC is too short to be exernalized, then a conjunctival perit-
omy will be required, the tube is removed from the AC, tied off, and then
replaced).
• Place AC maintainer and perform paracentesis with an MVR blade.
• Incise cornea over tube as in figure.
Figure: incision to externalize tube.
• Externalize the tube by hooking out with a Sinskey hook.

• 3.0 supramid or prolene can be placed within the tube lumen if not already
in position.
• Two to three 8.0 prolene sutures can then be tied over the tube and the tube
replaced in the AC and the conjunctival incision sutured, 3.1.1 tie.
• The 8.0 prolene sutures can be lasered under direct visualization with a
gonioscopy lens when increased flow is desired (argon laser settings 0.5 s,
200 μm, 150–200 mW), typically after at least 6 weeks.
5.4.3 Managing Choroidal Effusions and Hemorrhage
If the IOP is within acceptable limits, choroidal effusions can be observed as they
usually resolve without treatment beyond steroid drops and cycloplegics (Schrieber
and Liu 2015). If the intraocular pressure is low, then this should be addressed as
shown in Fig. 5.4. If the choroidal detachments are touching, “kissing choroidals”
or the anterior chamber flat, then surgical intervention is required.
Suprachoroidal hemorrhage can be an intraoperative complication, termed
expulsive hemorrhage, or more commonly can occur postoperatively, when it is
known as delayed suprachoroidal hemorrhage (DSCH). More frequently after tube
Practical Hint: Draining Choroidal Effusions

• Place AC maintainer (in some situations this alone may be enough to allow
some resolution of effusions).
• Place sclerotomies in area of choroidals 4–8 mm back from limbus.
• Open the conjunctiva and then make radial incisions gradually through
sclera with number 15 blade.
• As the suprachoroidal space is entered the serosanguinous effusion should
start draining.
• Gently massage the globe with a cotton bud as this may assist in drainage,
which should be continued until fluid egress ceases.
• The sclerotomies can be left open to drain more fluid, the conjunctiva
securely closed with 7.0 vicryl suture.
surgery than trabeculectomy in most series DSCH presents with a sudden onset of
pain, loss of vision, shallowing of the anterior chamber, and increased IOP. Other
symptoms can also include nausea (Vaziri et al. 2015). They can often be left to
clear, especially if peripheral, but there is no clear guidance from the literature with
some reporting resolution of large hemorrhages with conservative management
(Chu and Green 1999), and good results described with early intervention (Pakravan
et al. 2014). If the hemorrhage is massive with retinal apposition, a flat anterior
chamber or severe persistent pain, then drainage and reformation of the anterior
chamber can be attempted. This can be done early, within the first 24–36 h, or
delayed by 1 week to allow clot dissolution to occur. Vitrectomy may be required
if an associated retinal detachment develops. Visual outcomes are generally poor,
so recognition and, where possible, mitigation of risk factors is important
(Jeganathan et al. 2008).
Table: Risk Factors for DSCH

• High preoperative pressure
• Severe early postoperative hypotony
• Previous intraocular surgery
• Long axial length
• Aphakia
• Anticoagulation
• Systemic hypertension
5.4.3.1 Malignant Glaucoma

Malignant glaucoma, or aqueous misdirection syndrome, is rare, but can present at
any time postoperatively, typically with a shallow anterior chamber and high intra-
ocular pressure. Most cases respond to medical treatment with IOP lowering agents
and topical mydriatics and steroids. Disruption of the anterior hyaloid face with
Nd:YAG laser can be tried in pseudophakic patients, peripheral to the IOL. If these
measures are unsuccessful, then surgical intervention is required in the form of core
vitrectomy, often combined with cataract extraction in phakic patients (Kaplowitz
et al. 2015).
5.4.3.2 Managing Tube Exposure

Exposure of the tube places the patient at risk of endophthalmitis and therefore all
cases should be revised. The tube must be covered with a patch graft of donor peri-
cardium, sclera, or cornea and this then covered with conjunctiva. The risk of fur-
ther conjunctival breakdown is minimized by the use of a rotational flap of
conjunctiva, usually from the conjunctival fornix and this is therefore recommended
(Grover et al. 2013). The other option is to use a tube extender to divert to adjacent
subconjunctival space with relatively healthier conjunctiva (Fig. 5.7 and 5.8).
Fig. 5.8 Rotational

conjunctival graft covering
the tube extender and
pericardial patch
Practical Tip: Covering an Exposed Tube

• Perform surgery under GA if possible as can be uncomfortable under LA.
• Instill preoperative apraclonidine 1 % and adrenaline into the conjunctival sac.
• Place a 7.0 silk traction suture in the cornea.
• Excise a small rim of conjunctiva and scrape exposed sclera to improve
adhesion of graft.
• Place a 10.0 nylon mattress suture over the tube to reduce micromovement
of the tube.
• Cover the tube with a patch graft (such as tutoplast pericardium), anchor-
ing with a 10.0 nylon suture anteriorly and a mattress suture across the
graft.
• Dry conjunctiva and mark out a pedical flap of sufficient size to rotate to
and cover conjunctival defect.
• Incise flap and rotate into position, suturing securely with 10.0 nylon.
• Administer subconjunctival cefuroxime and dexamethasone and give
dexamethasone and antibiotic drops postoperatively.
5.4.3.3 Managing Plate Erosion

Erosion of the plate through the conjunctiva is rare and when it occurs it usually
requires explantation. Preventive measures include care to ensure that the wings
of the Baerveldt plate are behind the rectus muscles, otherwise the plate can come
to lie superficially under the conjunctiva where it is more prone to erode. Firm
sutures are needed to secure the plate to the sclera and to avoid eye rubbing
postoperatively.
5.4.4 Managing Bleb Encapsulation
There is little evidence to suggest that MMC use intraoperatively in the region of the
plate or 5-FU injections postoperatively are beneficial in the long term (Law 2008).
One study to report positive effects with these two combined used an older version
of the Ahmed valve and a surgical technique that may also have contributed to lower
intraocular pressure (Alvarado et al. 2008). Revision of thick-walled blebs with
excision of fibrous tissue has been described in a small case series (Eibschitz-
Tsimhoni et al. 2005). Molteno advocates an “anti-inflammatory fibrosis suppres-
sion” regimen consisting of oral prednisone, colchicine, and NSAIDs in three
divided doses per day in the early postoperative period, started in the first 3 weeks
and continued for 4–8 weeks (Vote et al. 2004; Fuller et al. 2002). This has not been
widely used or studied due to concerns about the possible systemic side effects.
Ultimately, a significant proportion of tube patients require topical IOP lowering
agents. Unlike after trabeculectomy surgery this is not usually a sign of impending
or total bleb failure.
Conclusion
Postoperative complications are frequently associated with tube surgeries, the
most common ones are hypotony, tube touching endothelium, tube occlusion,
tube erosion, and bleb encapsulation. Most of these complications can be mini-
mized with careful surgical techniques or perioperative testing of the flow
characteristics through the tubes, but once encountered, most need urgent rec-
tifications, or long-term sequelae will prevail.
References
Al-Torbak A. Transcorneal tube erosion of an Ahmed valve implant in a child. Arch Ophthalmol.
2001;119(10):1558.
Alvarado JA, et al. Ahmed valve implantation with adjunctive mitomycin C and 5-fluorouracil:
long-term outcomes. Am J Ophthalmol. 2008. 146(2):276–84.
Alvarenga LS, et al. The long-term results of keratoplasty in eyes with a glaucoma drainage device.
Am J Ophthalmol. 2004;138(2):200–5.
Bailey AK, Sarkisian SR. Complications of tube implants and their management. Curr Opin
Ophthalmol. 2014;25(2):148–53.
Barton K, et al. Three-year treatment outcomes in the Ahmed Baerveldt comparison study.
Ophthalmology. 2014;121(8):1547–57.e1.
Chen PP, Palmberg PF. Needling revision of glaucoma drainage device filtering blebs.
Ophthalmology. 1997;104(6):1004–10.
Choritz L, et al. Surface topographies of glaucoma drainage devices and their influence on human
tenon fibroblast adhesion. Invest Opthalmol Vis Sci. 2010;51(8):4047.
Christakis PG, et al. The Ahmed versus Baerveldt study. Ophthalmology. 2013;120(11):2232–40.
Chu TG, Green RL. Suprachoroidal hemorrhage. Surv Ophthalmol. 1999;43(6):471–86.
Coleman AL. Initial clinical experience with the Ahmed glaucoma valve implant in pediatric
patients. Arch Ophthalmol. 1997a;115(2):186.
Coleman AL, et al. Initial clinical experience with the Ahmed glaucoma valve implant. Am
J Ophthalmol. 1995;120(1):23–31.
Coleman AL, et al. Clinical experience with the Ahmed glaucoma valve implant in eyes with prior
or concurrent penetrating keratoplasties. Am J Ophthalmol. 1997b;123(1):54–61.
Eibschitz-Tsimhoni M, et al. Incidence and management of encapsulated cysts following Ahmed
glaucoma valve insertion. J Glaucoma. 2005;14(4):276–9.
Eisenberg DL, et al. In vitro flow properties of glaucoma implant devices. Ophthalmic Surg Lasers
Imaging Retina. 1999;30(8):662–7.
Fellenbaum PS, et al. Krupin disk implantation for complicated glaucomas. Ophthalmology.
1994;101(7):1178–82.
Fiore PM. The effect of anterior chamber depth on endothelial cell count after filtration surgery.
Arch Ophthalmol. 1989;107(11):1609.
Francis B. Characteristics of glaucoma drainage implants during dynamic and steady-state flow
conditions. Ophthalmology. 1998;105(9):1708–14.
Fuller JR, et al. Anti-inflammatory fibrosis suppression in threatened trabeculectomy bleb failure
produces good long term control of intraocular pressure without risk of sight threatening com-
plications. Br J Ophthalmol. 2002;86(12):1352–4.
Gedde SJ, et al. Three-year follow-up of the tube versus trabeculectomy study. Am J Ophthalmol.
2009;148(5):670–84.
Gedde SJ, et al. Treatment outcomes in the Tube Versus Trabeculectomy (TVT) study after five
years of follow-up. Am J Ophthalmol. 2012;153(5):789–803 e2.
Grover DS, et al. Forniceal conjunctival pedicle flap for the treatment of complex glaucoma drain-
age device tube erosion. JAMA Ophthalmol. 2013;131(5):662–6.
Heuer DK, et al. Glaucoma update IV. In: Preliminary report of a randomized clinical trial of single
plate versus double plate molteno implantation for glaucomas in Aphakia and Pseudophakia.
Springer Science + Business Media; 1991. p. 244–9.
Hosoda S, et al. Ophthalmic viscoelastic device injection for the treatment of flat anterior chamber
after trabeculectomy: a case series study. Clin Ophthalmol. 2013;7:1781–5.
Jacob-LaBarre JT, et al. Total integration of an ocular implant/prosthesis. Ophthalmic Plast
Reconstr Surg. 1995;11(3):200–8.
Jeganathan VS et al. Risk factors for delayed suprachoroidal haemorrhage following glaucoma
surgery. Br J Ophthalmol. 2008;92(10):1393.
Jones E, et al. Preimplantation flow testing of Ahmed glaucoma valve and the early postoperative
clinical outcome. J Curr Glaucoma Pract. 2013;7(1):1–5.
Kaplowitz K, et al. Current concepts in the treatment of vitreous block, also known as aqueous
misdirection. Surv Ophthalmol. 2015;60(3):229–41.
Krawczyk CH. Glaucoma drainage devices and the FDA. Ophthalmology. 1995;102(11):1581–2.
Law SK. A modified technique of Ahmed glaucoma valve implantation with adjunctive use of
antifibrotic agents. Am J Ophthalmol. 2008;146(2):156–8.
Lim KS, et al. Glaucoma drainage devices; past, present, and future. Br J Ophthalmol.
1998;82(9):1083–9.
Lloyd MA, et al. Intermediate-term results of a randomized clinical trial of the 350- versus- the
500-mm2 Baerveldt implant. Ophthalmology. 1994;101(8):1456–64.
Mermoud A, et al. Motteno tube implantation for neovascular glaucoma. Ophthalmology.
1993;100(6):897–902.
Mills RP, et al. Long-term survival of molteno glaucoma drainage devices. Ophthalmology.
1996;103(2):299–305.
Minckler DS, et al. Clinical experience with the single-plate Molteno implant in complicated glau-
comas. Ophthalmology. 1988;95(9):1181–8.
Molteno AC. New implant for drainage in glaucoma. Clinical trial. Br J Ophthalmol.
1969;53(9):606–15.
Krupin eye valve with disk for filtration surgery. Ophthalmology. 1994;101(4):651–8.
Pakravan M, et al. An alternative approach for management of delayed suprachoroidal hemorrhage
after glaucoma procedures. J Glaucoma. 2014;23(1):37–40.
Panarelli JF, Nayak NV, Sidoti PA. Postoperative management of trabeculectomy and glaucoma
drainage implant surgery. Curr Opin Ophthalmol. 2016;27(2):170–6.
Pitt WG, Grasel TG, Cooper SL. Albumin adsorption on alksyi chain derivatized polyurettianes.
Biomaterials. 1988;9(1):36–46.
Porter JM, Krawczyk CH, Carey RF. In vitro flow testing of glaucoma drainage devices.
Ophthalmology. 1997;104(10):1701–7.
Prata JA, et al. In vitro and in vivo flow characteristics of glaucoma drainage implants.
Ophthalmology. 1995;102(6):894–904.
Rauscher FM, et al. Motility disturbances in the tube versus trabeculectomy study during the first
year of follow-up. Am J Ophthalmol. 2009;147(3):458–66.
Schrieber C, Liu Y. Choroidal effusions after glaucoma surgery. Curr Opin Ophthalmol.
2015;26(2):134–42.
Schwartz KS, Lee RK, Gedde SJ. Glaucoma drainage implants: a critical comparison of types.
Curr Opin Ophthalmol. 2006;17(2):181–9.
Sidoti PA, et al. Experience with the Baerveldt glaucoma implant in treating neovascular glau-
coma. Ophthalmology. 1995;102(7): p. 1107–18.
Siegner SW, et al. Clinical experience with the Baerveldt glaucoma drainage implant.
Ophthalmology. 1995;102(9):1298–307.
Tang L, Eaton JW. Inflammatory responses to biomaterials. Am J Clin Pathol.
1995;103(4):466–71.
Topouzis F, et al. Follow-up of the original cohort with the Ahmed glaucoma valve implant11. The
views expressed herein are those of the authors and are not the official opinions of the
Department of the Navy, the Department of Defense, or the United States Government. Am
J Ophthalmol. 1999;128(2):198–204.
Vaziri K, et al. Incidence of postoperative suprachoroidal hemorrhage after glaucoma filtration
surgeries in the United States. Clin Ophthalmol. 2015;9:579–84.
Vote B, et al. Systemic anti-inflammatory fibrosis suppression in threatened trabeculectomy fail-
ure. Clin Exp Ophthalmol. 2004;32(1):81–6.

Managing Complications in Glaucoma Surgery

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What are some of the laser procedures discussed for glaucoma treatment?

What are some of the laser procedures discussed for glaucoma treatment?

What are some types of glaucoma drainage devices mentioned?

What are some types of glaucoma drainage devices mentioned?

Managing

ISBN 978-3-319-49414-2 ISBN 978-3-319-49416-6 (eBook)

Library of Congress Control Number: 2017933708

© Springer International Publishing AG 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

1 Glaucoma Laser ������������������������������������������������������������������������������������������ 1

1.1  asers That Increase Aqueous Outflow: Argon Laser

F. Carbonaro, K. Sheng Lim (eds.), Managing Complications in Glaucoma Surgery, 1

1.1.3 Efficacy and Outcomes

1.1.4.1 Intraoperative Complications

1.1.4.2 Early Postoperative Complications

1.1.4.3 Late Postoperative Complications

Other less common late postoperative complications reported in the literature

1.2  asers That Increase Aqueous Outflow: Selective Laser

1.2.3 Efficacy and Outcomes

In a recent meta-analysis of randomized controlled trials on the use of SLT in the

glaucoma has been reported to be associated with more complications including

1.2.4.1 Intraoperative Complications

1.2.4.2 Early Postoperative Complications

Fig. 1.1 Corneal edema

1.2.4.3 Late Postoperative Complications

specular microscopy, central corneal thickness (CCT) videokeratography, and the

Table 1.2 Frequencies of SLT complications

1.3  asers That Increase Aqueous Outflow: Micropulse

MicroPulse Laser Trabeculoplasty (MLT) can be delivered using a diode (810 nm)

1.3.3 Efficacy and Outcomes

1.3.4.1 Intraoperative Complications

1.3.4.2 Early Postoperative Complications

1.3.4.3 Late Postoperative Complications

1.4  asers That Increase Angle Width: Laser Peripheral

Angle closure glaucoma is an optic neuropathy secondary to raised intraocular

Table 1.3 summarizes the technique of LPI. The iridotomy needs to be of sufficient

1.4.3.1 During Laser Iridotomy Procedure

1.4.3.2 Postlaser Iridotomy Complications

1.5  asers That Increase Angle Width: Argon Laser

Argon laser iridoplasty (ALP) is a procedure to open an appositionally closed angle.

ALP is performed under topical anesthesia in the outpatient setting. Pilocarpine

1.6  asers That Reduce Aqueous Production: Transscleral

Transscleral laser photocoagulation was described by Beckman and Sugar in the

1.6.3 Efficacy and Outcomes

1.6.4.1 Intraoperative Complications

1.6.4.2 Early Postoperative Complications

1.6.4.3 Late Postoperative Complications

1.7  asers That Reduce Aqueous Production:

1.7.3 Efficacy and Outcomes

1.7.4.1 Intraoperative Complications

1.7.4.2 Early Postoperative Complications

1.7.4.3 Late Postoperative Complications

Lima FE, Carvalho DM, Avila MP. Phacoemulsification and endoscopic cyclophotocoagula-

Minimally invasive glaucoma surgery (MIGS) interventions are intended to deliver

F. Carbonaro, K. Sheng Lim (eds.), Managing Complications in Glaucoma Surgery, 21

2.2 Trans-trabecular Meshwork Surgeries

2.2.1.1 Safety and Efficacy

2.2.1.3 Patient Selection and Indications

Selecting the Area of Implantation Preoperative evaluation of the areas with

1 Glaucoma Laser �� 1

1.1 asers That Increase Aqueous Outflow: Argon Laser

1.1.3 Efficacy and Outcomes

1.1.4.1 Intraoperative Complications

1.1.4.2 Early Postoperative Complications

1.1.4.3 Late Postoperative Complications

1.2 asers That Increase Aqueous Outflow: Selective Laser

1.2.3 Efficacy and Outcomes

1.2.4.1 Intraoperative Complications

1.2.4.2 Early Postoperative Complications

1.2.4.3 Late Postoperative Complications

1.3 asers That Increase Aqueous Outflow: Micropulse

1.3.3 Efficacy and Outcomes

1.3.4.1 Intraoperative Complications

1.3.4.2 Early Postoperative Complications

1.3.4.3 Late Postoperative Complications

1.4 asers That Increase Angle Width: Laser Peripheral

1.4.3.1 During Laser Iridotomy Procedure

1.4.3.2 Postlaser Iridotomy Complications

1.5 asers That Increase Angle Width: Argon Laser

1.6 asers That Reduce Aqueous Production: Transscleral

1.6.3 Efficacy and Outcomes

1.6.4.1 Intraoperative Complications

1.6.4.2 Early Postoperative Complications

1.6.4.3 Late Postoperative Complications

1.7 asers That Reduce Aqueous Production:

1.7.3 Efficacy and Outcomes

1.7.4.1 Intraoperative Complications

1.7.4.2 Early Postoperative Complications

1.7.4.3 Late Postoperative Complications

2.2 Trans-trabecular Meshwork Surgeries

2.2.1.1 Safety and Efficacy

2.2.1.3 Patient Selection and Indications

L ate Postoperative Complications

2.2.2.1 Safety and Efficacy

2.2.2.2 Patient Selection and Procedure

arly Postoperative Complications

L ate Postoperative Complications

2.2.3.1 Safety and Efficacy

2.2.3.2 Patient Selection and Procedure

Early Postoperative Complications

Late Postoperative Complications

2.3 Suprachoroidal Implants

2.3.1.1 Safety and Efficacy

2.3.1.2 Patient Selection and Procedure

2.4 Subconjunctival Implants

2.4.1 XEN Gel Implant

2.4.1.1 Safety and Efficacy

2.4.1.2 Patient Selection and Procedure

2.4.2.1 Safety and Efficacy

2.4.2.2 Patient Selection and Procedure

3.2 Procedure for NPGS

3.3 Efficacy and Outcomes for NPGS

3.3.1 Deep Sclerectomy

3.4 Complications for NPGS

3.4.1 Intraoperative Complications for NPGS

3.4.2 Early Postoperative Complications for NPGS