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Editors Selection IGR 16-4

Surgical Treatment: Flap Characteristics and Aqueous Flow

Comment by Don Budenz on:

66274 A Longitudinal Study of Association between Adiposity Markers and Intraocular Pressure: The Kangbuk Samsung Health Study, Zhao D; Kim MH; Pastor-Barriuso R et al., PLoS ONE, 2016; 11: e0146057

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This study by Samsudin and associates examines the influence of trabeculectomy flap thickness, size, and shape, and suture number and position on fluid flow using a silicone model. This clever experiment showed that thinner and larger flaps result in more flow. Triangular flaps created more resistance to flow than rectangular or square flaps, possibly due to the smaller area of triangular flaps.

Although many factors contribute to the amount of flow and IOP postoperatively, scleral flap construction and placement and tension on sutures are important things to consider

Not surprisingly, fewer sutures also produced more flow through the flap. The direction of the fluid flow was away from where sutures were placed due to the fluid taking the path of least resistance. Their findings have important implications for trabeculectomy flap creation during surgery.

Although many factors contribute to the amount of flow and IOP postoperatively, scleral flap construction and placement and tension on sutures are important things to consider. The model created herein suggests that larger, thinner, rectangular flaps result in more flow than smaller, thicker, non-rectangular flaps. Of course one wants to avoid excess flow in the early postoperative period while having the option of enhancing flow once some healing of the conjunctiva has occurred. The results also suggest that one should avoid sutures on the posterior edge of the flap if one wishes to direct flow posteriorly, generally considered an advantage early or late after trabeculectomy surgery because posterior flow results in posteriorly located and more diffuse blebs.

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