Technique to Address an Overfiltering Trabeculectomy Flap During Surgery

For Glaucoma Physician's Surgical Pearls video series, Nur Cardakli, MD, and Jasdeep Sabharwal, MD, present a technique to address an overfiltering trabeculectomy flap at the time of surgery. Transcript of the narration follows below:

Here, we show a technique to address an overfiltering trabeculectomy flap at the time of surgery. After placement of 3 flap sutures, the flap continues to be leaking at an amount more than desired.

To address this, a compression stitch is fashioned. A 10-0 nylon is passed, distal to proximal, partial thickness through the sclera adjacent to and perpendicular to the edge of the trabeculectomy flap, passed over the flap, and then again passed partial thickness proximal to distal on the other side of the flap. In the same fashion, the suture is then passed back to where it started. Note that the trabeculectomy flap itself is not touched and no additional holes or manipulation is performed on the flap. Care is taken not to puncture the conjunctiva.

The suture is then tied utilizing a slipknot to adjust the tension, with an additional throw to lock the tension as desired. The suture is then buried in a typical fashion. The eye is reinflated with BSS and the trabeculectomy flap now has aqueous flow as desired and is holding pressure. This compression stitch can later be lysed via laser suture lysis in the clinic to adjust outflow. This procedure provides an alternative to the placement of additional flap sutures and managing a persistently leaky flap at the time of trabeculectomy surgery without further flap manipulation.

Thank you for watching our video. Please e-mail us if you have any questions.

Nur Cardakli, MD, is an ophthalmology resident at the Wilmer Eye Institute, Johns Hopkins Medicine. She reports no disclosures. She can be reached at nur.cardakli@jhmi.edu.

Jasdeep Sabharwal, MD, is an associate at North Bay Eye Associates in Petaluma, California. He reports no disclosures. He can be reached at jsab.ophtho@gmail.com.

Mary Qiu, MD, the editor of this series, is a glaucoma and cataract surgeon who completed her glaucoma fellowship at the Cole Eye Institute at Cleveland Clinic and her ophthalmology residency training at the Wilmer Eye Institute at Johns Hopkins. Her special interests include neovascular glaucoma; tube revisions and exchanges; optimizing technique and outcomes for nonvalved tubes, goniotomy, and canaloplasty; surgical education for trainees; and creating and sharing her surgical videos.