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Editors Selection IGR 9-3
Surgery: Combined blebrevision and phacoemulsification
Comment by Sunita Radhakrishnan & Andrew Iwach on:
19564 Surgical revision of failed filtration surgery with mitomycin C augmentation, Anand N; Arora S, Journal of Glaucoma, 2007; 16: 456-461
Needle revision of a failing trabeculectomy bleb is performed more often than a surgical revision due to the inherent challenges in operating on a previously scarred eye as well as problems with tissue integrity following the use of antifibrotic agents. Anand and Arora (1124) report their outcomes in a retrospective series of 54 patients, 41.5% of whom underwent combined bleb revision and phacoemulsification. The surgical technique consisted of dissecting open the pre-existing scleral flap to re-establish filtration and mitomycin-C was applied prior to scleral dissection in all cases. Success was defined by dual criteria of IOP < 18 mm Hg and 20% drop from pre-operative IOP. Patients were classified as partial success if medication or needling was required to achieve this goal. The authors found 64% partial success and 38% complete success at three years after surgery. A large proportion (42.5%) of patients underwent subsequent needle revision and 42.5% required medications to control IOP. A relatively high incidence of early post-operative complications such as shallow AC (28%) and choroidal detachments (17%) occurred, however, only one patient required a second surgical procedure. None of the patients suffered severe visual loss. Like most studies that have reported on outcomes of revision of failing trabeculectomy blebs (surgical or needle revision), this study also has the limitations of being retrospective and including a heterogeneous study population. In addition, about 40% of patients underwent a combined procedure, which may affect ultimate outcomes when compared to surgical revision alone. The success rate reported is similar to that achieved by needle revision (38% to 69% in published literature, depending on the definition of success), however, the early post-operative complications were slightly higher due to the difficulty in achieving secure closure of the scleral flap. Given that a needle revision is less invasive it may have a better risk-benefit profile especially in eyes that have been exposed previously to mitomycin-C. The authors should consider comparing surgical versus needle revisions in their patient population
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