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Editors Selection IGR 16-4
Surgical Treatment: Complications
Comment by Henry Jampel on:
60609 Long-Term Bleb-Related Infections After Trabeculectomy: Incidence, Risk Factors, and Influence of Bleb Revision, Kim EA; Law SK; Coleman AL et al., American Journal of Ophthalmology, 2015; 159: 1082-1091
Kim et al. report a retrospective analysis of a large case series of late trabeculectomy-related infections at a single academic center in the United States. The rationale for the undertaking of such labor-intensive research (almost 2000 eyes operated on over a 20-year period!) is the realization of the importance of this often devastating complication and the hope that by understanding its risk factors we can reduce its occurrence.
An increased incidence in juvenile and pigmentary glaucoma is puzzling
Their work nicely complements older publications on the risk factors for bleb-related infection, 1,2 recent publications from our group,3,4 as well as the ongoing work from the Japanese Collaborative Bleb-Related Infection Incidence and Treatment Study Group.5
The authors' analysis is appropriate and thorough, but is limited by the inherent shortcomings of a retrospective chart review. Particularly frustrating, but totally predictable, is that incomplete and imprecise information on bleb morphology precludes this likely important parameter from being analyzed. They confirm many previously known risk factors, and add a few more. An increased risk with punctal plugs is plausible, due to stagnation of tears on the ocular surface, but an increased incidence in juvenile and pigmentary glaucoma is puzzling. An important finding of this work is that eyes that underwent surgical revision when risk factors were present had a lower likelihood of infection than eyes that did not.
Elimination of the risk of infection is one of the principal reasons we so greatly desire an effective micro-invasive glaucoma operation
Only a few risk factors are modifiable, so education of the patient to recognize early signs and symptoms and report them immediately may be the best way to reduce the devastating sequelae of infection. However, because susceptibility to infection is an inherent property of trabeculectomy, we will continue to see infections as long as we perform it. Elimination of the risk of infection is one of the principal reasons we so greatly desire an effective micro-invasive glaucoma operation.
References
- Soltau JB, Rothman RF, Budenz DL, et al. Risk factors for glaucoma filtering bleb infections. Arch Ophthalmol. 2000 118(3):338-342.
- Jampel HD, Quigley HA, Kerrigan-Baumrind LA, et al. Risk factors for late-onset infection following glaucoma filtration surgery. Arch Ophthalmol. 2001;119(7):1001-1008.
- Jampel HD, Solus JF, Tracey PA, et al. Outcomes and Bleb-Related Complications of Trabeculectomy. Ophthalmology. 2012;119:712-722.
- Solus JF, Jampel HD, Tracey PA, et al. Comparison of Limbus-Based and Fornix- Based Trabeculectomy: Success, Bleb-Related Complications, and Bleb Morphology. Ophthalmology. 2012;119:703-711.
- Yamamoto T, Sawada A, Mayama C, et al. The 5-year incidence of bleb-related infection and its risk factors after filtering surgeries with adjunctive mitomycin C: Collaborative Bleb-Related Infection Incidence And Treatment Study 2. Ophthalmology. 2014; 121(5):1001-1006.
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