Revision Trabeculectomy: Pearls and Pitfalls

Abstract

Revision trabeculectomy is used to describe any surgical intervention subsequent to an existing trabeculectomy. Mostly, it is used to describe resurgery for failure of trabeculectomy, as defined by inadequate pressure control. Revision may also be performed for unsafe, uncomfortable or leaking blebs. Mostly bleb failure occurs within the subconjunctival space, although the flap and ostium may be involved or causative. Clear surgical principles, meticulous surgical technique and scrupulous postoperative care are key to successful revision surgery. This review is an attempt to elucidate the technique of bleb revision for bleb failure. How to cite this article: Coote M, Crowston J. Revision Trabeculectomy: Pearls and Pitfalls. J Current Glau Prac 2012;6(3):131-138.

Keywords: Bleb failure; Bleb revision; Glaucoma surgery; Revision trabeculectomy.; Trabeculectomy.

Figs 1A and B

(A) Tenon’s encystment, (B) conjunctival encystment

Fig. 2

Corneal stay suture for proper exposure

Fig. 3

Flow of aqueous following bleb revision

Fig. 4

Advancing forward in the subconjunctival space against the sclera until the fibrosed encapsulation is encountered

Fig. 5

Posterior dissection through the intermuscular septum into the intermuscular space

Fig. 6

Advancing until there is free flow of aqueous

Fig. 7

Vigorous diathermy of the base of the bleb which is often very vascular

Fig. 8

Lifting the flap or remnant to gain unimpeded access to the anterior chamber

Fig. 9

Sharp dissection of the more organized fibrous bleb anteriorly using a #67 ‘Beaver’ blade or similar

Fig. 10

Filling the anterior chamber with a viscoelastic device (in this case ‘Healon’)

Fig. 11A

Placing a triangular sponge with 0.4 mg/ml mitomycin C over the area of the flap and far back to the intermuscular space (with sufficient viscoelastic device in AC to prevent mitomycin C entrance)

Fig. 11B

Antimetabolite application using sponges