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Jefferson Berryman, Michele Lim, James D Brandt, Han Kim; Ab interno trabeculectomy revision: efficacy and safety. Invest. Ophthalmol. Vis. Sci. 2019;60(9):3745.
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Limited surgical options exist for regaining intraocular pressure (IOP) control in eyes with failed trabeculectomies. Grover et al. recently described a technique for ab interno bleb revision using a Grover-Fellman sclerostomy spatula. We performed a retrospective case series to determine the efficacy and safety of this technique in an academic medical center.
A total of 23 eyes of 21 patients underwent ab interno trabeculectomy revision. All patients followed the same protocol in the operating room with sub-Tenon’s injection of mitomcyin-C followed by bleb revision using a Grover-Fellman spatula through a paracentesis incision. Main outcome measures were IOP and surgical complications. Success was defined as a >20% reduction in IOP without the need for further procedural intervention.
Mean patient age was 65.2 years and 13 of 23 (56.5%) eyes had a diagnosis of primary open angle glaucoma. Mean follow-up time was 9.1 ± 5 months. Change in mean IOP and medications from baseline to 12 months post-surgery was 19.2 ± 5.6 mmHg to 11.7 ± 5.0 mmHg and 3.1 ± 1.0 to 1.1 ± 1.4 medications respectively. 15 eyes (65.2%) were considered to have procedural success at most recent postoperative follow-up. 11 of these eyes maintained IOP reduction of >20% on no topical medications while 4 required IOP lowering therapy to reach the goal. 8 eyes (34.8%) failed the procedure, 5 of which were maintained on topical medications alone. Of the remaining failures 1 eye required trans-scleral laser cyclophotocoagulation, 1 received a glaucoma drainage device, and 1 underwent ab externo bleb needling. 3 total eyes (13.0%) experienced post-operative complications. 1 eye (4.3%) developed severe vision loss of unknown etiology, 1 eye, with prior pars plana vitrectomy, developed a suprachoroidal hemorrhage at post-operative week 1 which resolved spontaneously with no effect on visual acuity, and 1 eye developed corneal edema at month 12 requiring a corneal transplant.
Ab interno trabeculectomy revision using a Grover-Fellman spatula with mitomycin-C achieved IOP control in the majority of patients in this series and suggests that this is a viable option for reviving a failed bleb without violating the conjunctiva. However, we found slightly higher IOP failure and surgical complication rates than have been previously reported and care must be taken when selecting patients for this procedure.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.
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