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Abstract #19194 Published in IGR 3-1
Management of the failing filter
Melamed SJournal of Glaucoma 2001; 10: 129-132
With regard to these controversial series, the editor presents a 50-year-old Afro-Caribbean patient with moderate disc damage who underwent an uncomplicated right trabeculectomy with mitomycin C because of inadequate control with medical therapy. After two weeks, despite a large bleb, the intraocular pressure had risen to 25 mmHg. The releasable suture was removed and the pressure dropped to 12 mmHg. After another two weeks, the pressure rose again to 28 mmHg, and a large encapsulated bleb was seen. The questions asked are: what are the mechanisms and what is your treatment; what are the indications and contraindications for needling; and what do you do after needling has failed. The experts are Remo Susanna and Carlo Traverso. Susanna suggests as causes tight closure of the flap, suprachoroidal hemorrhage, or a failing bleb. In this case bleb, encapsulation was the most likely cause of pressure rise. He would first use vigorous medical therapy and has good experience with this method. A success rate of 70-92% has been reported after this approach, although more than half the patients may require the continuous use of glaucoma medication. If medical therapy does not work, he would undertake slit-lamp needle revision, which is only repeated once. If needling is insufficient, Susanna describes a circular intervention with mitomycin. However, in many cases he would simply carry out further filtration surgery at a new site. If all that fails, he would consider a tube implant or cyclophotocoagulation. Traverso also describes his needling technique with the slit lamp in detail, and feels that this is a relatively benign procedure. If needling fails, he would proceed to surgical revision or a new filtering procedure. On the other hand, the editor does not have much faith in medical therapy. His preference is for surgical removal of the cyst with the application of anti-fibrosis agents. Neither is he very happy with needling techniques. He would try medical treatment in the case of the encapsulated bleb, and if that does not work, he would perform a second trabeculectomy or drainage implant surgery.
Classification:
12.8.10 Woundhealing antifibrosis (Part of: 12 Surgical treatment > 12.8 Filtering surgery)
