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Clinical and Experimental Ophthalmology 2012; 40: 388399 doi: 10.1111/j.1442-9071.2012.02769.x
Review
Surgical management of glaucoma: a review
William H Morgan FRANZCO PhD and Dao-Yi Yu MD PhD
Lions Eye Institute, Centre for Ophthalmology and Visual Science, University of Western Australia, Nedlands, Western Australia,
Australia
ABSTRACT
This review will briefly describe the history of surgical
glaucoma treatment and concentrate on the current
surgical strategies for managing glaucoma. A discus-
sion of treatments for angle closure, open-angle glau-
coma and paediatric glaucoma with an emphasis on
drainage surgery are included. The role of cataract
surgery is also briefly described. Drainage surgery
evolved from peripheral iridectomy and sclerotomy
with an increasing understanding of aqueous flow
within the eye and the production of a functioning
bleb. The current mainstays include trabeculectomy,
glaucoma drainage devices as well as goniotomy and
trabeculotomy, which have all been in existence for
more than 40 years. Their various advantages as well
as methods used to minimize their disadvantages,
including the antimitotics and case selection are
discussed. We finish by discussing the preliminary
results of some newer forms of drainage surgery illus-
trating the energetic search for methods to minimize
the problems of hypotony and bleb failure.
Key words: glaucoma, iridectomy, surgery.
INTRODUCTION
Glaucoma is a disease of the optic nerve, which leads
to typical optic disc excavation with loss of ganglion
cell axons and visual field loss. Its major risk factor is
raised intraocular pressure (IOP), which is the only
factor currently treatable. Hence, all treatment is
directed towards lowering IOP towards a safer level
in individual patients. Surgical treatment is required
when medical or laser procedures have been used,
Correspondence: Dr William H Morgan, Lions Eye Institute, Centre for Ophthalmology and Visual Science, University of Western Australia, 2 Verdun
St, Nedlands, WA 6009 Australia. Email: whmorgan@cyllene.uwa.edu.au
Received 9 December 2011; accepted 11 December 2011.
Competing/conflicts of interest: No stated conflict of interest.
Funding sources: No stated funding sources.
2012 The Authors
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
considered or failed. The basic principles of surgical
treatment are to either: (i) improve aqueous flow
within the eye, enabling aqueous access to the angle
drainage structure; (ii) increase aqueous egress from
the eye; and (iii) reduce aqueous production by the
ciliary body. Procedures to improve the resilience of
the optic nerve have been attempted but without
clear documentation of success.1
This review will briefly describe the history of
surgical glaucoma treatment and concentrate on the
current surgical strategies for managing glaucoma
including a somewhat detailed discussion of the
more commonly performed procedures. It includes a
discussion of treatments for angle closure, open-
angle glaucoma and paediatric glaucoma and hence
is necessarily brief in order to accomplish an overall
summary.
History
The earliest surgical treatment described in modern
times is ascribed to William McKenzie in 1830
from Glasgow, referenced by De Wecker in 1879.2
McKenzie performed a sclerotomy, passing a nar-
row knife through the sclera 1 mm posterior to clear
cornea. The aim was to create a junction between the
anterior chamber and external space. It is not known
what the overall success rate was; however, compli-
cations to the ciliary body were described.
Peripheral iridectomy was first described by
Albrecht Von Graefe in 1857.3 He stated that it was
often curative for glaucoma and that the develop-
ment of a cystoid scar postoperatively was advan-
tageous. This cystoid scar was probably a bleb, and
since those times, the generation and maintenance
of a bleb has been a hallmark sign of successful
drainage surgery. In the 1870s sclerotomy, was
Surgical management of glaucoma
described by De Wecker and Holth, cutting a channel
through sclera underneath the conjunctiva to the
anterior chamber producing a filtering cicatrix.2
In 1904, Soren Holth from Oslow described iri-
dencleisis, whereby the sclerotomy was performed
and iris was incarcerated into this wound beneath
the conjunctiva in order to maintain patency
through the sclerotomy.4 Full thickness procedures
of sclerotomy and iridencleisis remained the proce-
dures of choice until trabeculecomy was described
by Cairns in 1968.5 Congenital glaucoma was revo-
lutionized by the description of goniotomy and the
development of surgical gonio lens by Barkan in
the 1930s.6
In 1969, Anthony Molteno described the first
glaucoma drainage tube device, consisting of a
plastic tube to plate, which became the forerunner of
all such devices.7 Currently, derivatives of trab-
eculectomy, glaucoma drainage devices (GDDs) and
goniotomy have become the mainstays of all glau-
coma drainage procedures.
Non-penetrating surgery was first popularized by
Krasnov in 1964 with sinusotomy (deep sclerec-
tomy)8 in an effort to reduce postoperative hypotony
and other more common complications of full thick-
ness drainage procedures. This has been modified
more recently with the addition of a collagen wick-
type implant.9
IOP elevation in glaucoma
Most of the aqueous outflow from the eye occurs
through the trabecular meshwork, and hence, access
to the meshwork is vital for IOP regulation. Trabe-
cular meshwork function may become diseased,
tending to block aqueous passage through to the
canal of Schlemm and aqueous veins. Normal
aqueous humour resistance occurs mainly around
the juxta-canalicular meshwork;10 however, it is not
known where the bulk of resistance change occurs
in primary open-angle glaucoma, although it is
assumed to occur in the juxta-canalicular and adja-
cent trabecular meshwork tissue.
Internal forces within the eye can lead to a
force pushing the iris-ciliary body diaphragm or
iris-lens diaphragm forward against the trabecular
meshwork causing occlusion.11 A combination of
these forces due to increasing fluid resistance
between the lens and iris, lens and ciliary body,
increased lens size and mal position of the ciliary
body are the major underlying causes of primary
angle closure.12,13 Inflammatory, fibrovascular or
metaplastic tissue changes within the angle can
lead to contraction of iris across the meshwork.
In primary congenital glaucoma, the trabecular
meshwork has not cleaved and differentiated
normally.
2012 The Authors
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
389
Indications for surgery
Surgical treatment is indicated when the form of
glaucoma is clearly defined and medical treatment
has failed. This usually includes clear evidence of
glaucomatous progression, that is visual field and/or
optic disc changes from baseline, or that the IOP is in
excess of a logical target considering the patients life
expectancy and other needs. The type of glaucoma
surgery must be carefully chosen to fit the particu-
lar patient in order to minimize complications and
maximize the chances of success.14
Angle-closure glaucoma
Surgical peripheral iridectomy was the mainstay of
acute and chronic angle-closure glaucoma treatment
until the advent of modern laser peripheral
iridotomy.3 It is important to recognize that persis-
tent angle closure is common following laser or sur-
gical iridectomy, and the patient must be kept under
regular review, including regular gonioscopy.15 It is
important to clarify the cause of the angle closure and
initially note whether a pushing force is being
applied to the iris and ciliary body, forcing them
towards the trabecular meshwork and leading to
closure. This is generally due to aberrant anatomical
structures and flow relationships within the eye and
underlies primary angle closure. Particular attention
needs to be made towards diagnosing pupil block in
order to justify iridectomy in the first place and sec-
ondly noting the presence of plateau iris, lens dis-
proportion or ciliary block.13,16 For example, plateau
iris tends to respond better to peripheral iridoplasty
than to lens extraction, whereas lens disproportion
and ciliary block generally respond well to standard
lens extraction. A more complete description of these
factors is described by Ng and Morgan.13 Non-
primary angle-closure mechanisms include rubeosis
iritis17 and uveitis18 both with peripheral anterior
synechial closure as well as less common conditions
such as irido-corneal endothelial syndrome with
metaplastic tissue causing contraction and rarely
tumours leading to seeding of the angle or mass
effect inducing compression. These types will not be
successfully treated by iridectomy or other internal
flow enhancing procedures and will usually require
drainage surgery.
Cataract surgery
Lens extraction tends to open the angle, eliminating
lens disproportion, reducing ciliary block, and to
some extent, plateau iris.19,20 In these situations, it is
important to assess the angle and determine whether
the closure is appositional, or whether there are
some peripheral anterior synechiae present. During
390
the cataract surgery, one can expect an increased rate
of complications. These range from a shallow ante-
rior chamber with decreased instrumentation and
capsular access. The use of high viscosity viscoelas-
tics frequently makes these steps safer and easier.
There is less room for lens fragment manipulation,
and it is easier for corneal endothelial damage to
occur. Additionally, the posterior capsule frequently
appears to be under positive pressure, making the
likelihood of capsule rupture greater. Rarely, these
patients can go into ciliary block on the table, and so
the surgeon should be prepared to perform a vitrec-
tomy, zonulectomy and anterior hyaloidectomy if
required.21,22 Patients can develop ciliary block, post
cataract extraction, and the same corrective surgery
may be required. If patients are noted to have
peripheral anterior synechiae of recent onset, then
goniosynechiolysis should be considered during the
lens extraction procedure.20 Various techniques have
been described, but we find the easiest technique
is to use the irrigating cannula at the end of the
procedure whilst removing viscoelastic and gently
push the iris away from the corneoscleral junction
in the region of the peripheral anterior synechiae.
Results of goniosynechiolysis are mixed but can be
favourable, particularly and only when the underly-
ing cause of the angle closure is being treated as
well.23,24
Cataract extraction surgery significantly lowers
the pressures in all forms of glaucoma, including
primary open-angle glaucoma, through mechani-
sms which are not entirely understood. The average
IOP reduction in primary open-angle glaucoma is
reported to be from 24 mmHg.25 This pressure low-
ering can be long lasting, although some studies
indicate that it may only last a year or so. So, effective
cataract surgery can complicate the interpretation
of results of drainage surgery where the drainage
surgery is combined with cataract surgery. It is likely
that some of the effect of combined cataract surgery/
drainage surgery is simply due to the removal of the
cataract itself.
Drainage procedures
These form the bulk of glaucoma surgery. They are
only safe if there is no intraocular force tending
to push the lens-iris, lens-ciliary body diaphragm
anteriorly. If one performs a drainage procedure in
this situation (classically this occurs in ciliary block),
then the reduced pressure in front of this force will
lead to exacerbation of its effect with the lens-
iris diaphragm being pushed further forward,
often leading to corneo-lenticular touch and other
complications.26
Trabeculectomy is the classic and current mainstay
for glaucoma drainage surgery and was originally
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
Morgan and Yu
conceived as a way of shunting aqueous humour
through to the canal of Schlemm by excising part of
the trabecular meshwork exposing the canal of
Schlemm.27 It was quickly observed that a bleb was
formed, implying that the fluid drainage was occur-
ring through to the sub-conjunctival space. More
recent emphasis has been on performing a simple
clear corneal ostomy avoiding dissection of the tra-
becular meshwork to minimize the risk of ciliary
body damage. The aim is to form a safe, functioning
bleb.
Safety
It is essential that the bleb is safe in the long run and
has minimal chance of breaking down or leaking and
becoming infected. For this reason, trabeculectomy
surgery is generally performed beneath the upper
eyelid so the bleb is protected by the lid. Allowing a
bleb to form inferiorly increases the risk of bleb
exposure with a greater risk of infection.28 It is pref-
erable to attempt the formation of a more posterior
bleb to minimize the chance of bleb exposure at the
limbus and also to minimize the chance of bleb
extension upon the cornea.29
Functioning
The bleb must be able to collect and disperse
aqueous humour. The dispersal of aqueous humour
is poorly understood; however, recent evidence sug-
gests that sub-conjunctival lymphatics and formation
of aqueous vein connections, as observed in animal
models (Fig. 1), are likely to be important in the
maturation of human trabeculectomy blebs.30 Bleb
morphology is a poor predictor of IOP reduction,
although a higher bleb is more likely to result in a
lower pressure.31 Most surgeons prefer a modestly
elevated, diffuse, relatively large and posterior bleb
for reasons of safety. Most observers try to avoid a
significantly vascularized bleb. Trabeculectomy bleb
failure is commonly ascribed to the process of fibro-
sis, gradually contracting the bleb down to and flat-
tening it against the scleral flap. This process of
fibrosis may occur around the bleb and limit the
egress of aqueous humour from the bleb to the sur-
rounding lymphatics and vessels.
Surgical technique for trabeculectomy
The technique has remained very similar to the
original description by Cairns 43 years ago.5 There
have been some stylistic variations with many sur-
geons initially performing a fornix-based flap and
then shifting to a limbal-based flap with the intro-
duction of antimitotics and concerns over wound
2012 The Authors
Surgical management of glaucoma 391

Figure 1. Sequence of video frames (Panels AI) after injection of uorescein into the anterior chamber of a rabbit 2.4 years after
microstula drainage surgery. Panel A is a frame recorded immediately after uorescein injection and shows lling in the anterior chamber
(AC). The rst appearance of extraocular uorescein (Panel B, yellow arrow) is a small patch near the distal end of the scleral channel. The
extent of uorescein increases (Panel C), and draining lymphatics become apparent (Panels DF, wavy arrows). An aqueous vein can be
seen located at the distal edge of the bleb (Panels GI). However, it was difcult to determine whether this vein was a normal aqueous vein
superimposed on the bleb, or whether it played a role in draining the bleb. Panel J shows a magnied image of the late phase (Panel I).
The conjunctival bleb was small in size and surrounded by a narrow diffusion zone along with a number of drainage vessels. At least two
large lymphatic vessels were seen with uneven calibre located each side of the conjunctival bleb and running parallel to limbus (brownish
bent arrow). A conjunctival vein was also visible. From gure 15 in Yu et al.30

healing. More recently, there has been a tendency thinner flap may tend to encourage greater flow.
towards shifting back to a fornix-based flap in an None of these factors or style variations have been
effort to encourage more posterior drainage. Other shown to make any significant difference to longer
stylistic variations include, whether a triangular or term outcomes.32 The use of releasable sutures does
rectangular scleral flap is cut, the length of the flap allow for some titration of pressure in the postop-
and the thickness of the flap. A longer flap may erative period. It is generally safer to aim for a
tend to encourage more posterior drainage, and a tighter flap during surgery and hence attempt to
2012 The Authors
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
392
have a modest pressure reduction down towards
5 mmHg, rather than 0 mmHg, and release a suture
if that is not reached. Other attempts at pressure
modification in the early postoperative period
include laser suture lysis, which unfortunately can
be difficult or impossible if there is overlying
conjunctival haemorrhage. The other modifiable
process is that of the fibrosis itself. Postopera-
tive 5-fluorouracil injections have been shown to
improve bleb outcome and reduce IOPs in selected
patients.33 These can be given either as a bolus
adjacent to the bleb or involving some needling of
peri-bleb fibrotic tissue in the later postoperative
period.34
Bleb modifying agents include mainly antimi-
totic drugs such as 5-fluorouracil and mitomycin C.
The use of these agents does represent a major
advance in achieving more desirable outcomes for
patients, particularly those who are at higher risk of
trabeculectomy failure. This risk increases with
certain racial genetic ancestry such as those with
African, East Asian or South Asian decent. Other
risks for failure include those with any prior
intraocular surgery, uveitis or rubeosis iridis.
Eyes which have had significant trauma and par-
ticularly eyes that are aphakic are very prone to
failure. Younger patients are also more prone to
increased fibrosis. So when assessing a patient for
trabeculectomy surgery, it is important to assess
their risks of bleb failure and your own surgical
experience. Younger patients and particularly those
from the earlier mentioned racial backgrounds
should, in general, receive mitomycin C at the time
of surgery. Caucasian or older patients could receive
5-fluorouracil at the time of surgery. Certain
patients should not receive any antimitotic agents.
These may be elderly Caucasian patients and par-
ticularly patients who are on immunosuppressant
agents already, for example, those who may have
coexistent rheumatoid arthritis treated with sys-
temic steroids and other immunosuppressants.
Injections of 5-fluorouracil adjacent to the bleb can
be given postoperatively in order to reduce fibrosis
and lower IOP. The risks of 5-fluorouracil include
corneal epithelial stem cell toxicity with punctuate
epithelial erosions leading to epithelial break-
down and stromal thinning.34 Patients being
given 5-fluorouracil should have their corneal epi-
thelium carefully monitored, and further injections
of 5-fluorouracil should not be given if signs of tox-
icity are seen. Mitomycin C has very profound
effects upon mitosis and can lead to very thin avas-
cular blebs which pose a significant risk of infec-
tion.34 It can also inhibit the healing of the scleral
flap upon the scleral bed, leading effectively to a
full thickness procedure with marked hypotony
and attendance complications.
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
Morgan and Yu
The effectiveness of trabeculectomy
The success rates of trabeculectomy vary between
4098%.35 Two major reasons exist for this variation.
One is that the definition of success is so varied, with
there being at least 100 separate definitions of drain-
age surgery success, so comparing one study with
another is often very difficult.35 The other factor is the
patient group variation used in different studies due
to factors mentioned earlier. Generally accepted
effectiveness in appropriately chosen trabeculecto-
mies for low-risk patients is about 9095% signifi-
cant pressure reduction for at least several years and
83% 10-year survival.36 The average 5 year survivals
for mixed low and higher risk cases are from 6037 to
80% (Fig. 2).38 Please note that definitions of success
vary between studies. Early complications of trab-
eculectomy include hypotony with the development
of hypotonous maculopathy, choroidal effusions,
shallow anterior chamber and corneal lenticular
touch with corneal trauma. The commonest cause of
severe hypotonous complications is a leaking trab-
eculectomy bleb, often through inadvertent cutting
of a conjunctival button hole or conjunctival wound
dehiscence. It is essential to check the wound and
conjunctiva for leaks in the early postoperative
period using the Seidel test. Hypotony also occurs in
patients who are simply over-draining with a large
bleb. In this situation, hypotony will usually resolve
spontaneously. However, if there is a conjunctival
leak, these complications can persist and cause
1.0
1st = first intervention
0.9 2nd = second intervention
3rd = third intervention
0.8
PROBABILITY OF FAILURE
ALT: 2nd
0.7
0.6
0.5 ALT: 1st
Trabeculectomy: 3rd
0.4
0.3 Trabeculectomy: 2nd
Trabeculectomy: 1st
0.2
0.1
0.0
0 2 4 6 8 10 12 14
YEARS SINCE INTERVENTION
Figure 2. KaplanMeier probabilities of failure of interventions.
Estimated cumulative failure rates (and 95% condence intervals)
at 5 years are 35.5% (30.640.4), 42.4% (29.055.9) for argon laser
trabeculoplasty (ALT) as rst and second interventions, respec-
tively; 17.9% (13.921.9), 20.7% (13.328.2), 34.4% (17.651.1)
for trabeculectomy as rst, second and third interventions,
respectively. From gure 1 in The AGIS Investigators.38
2012 The Authors
Surgical management of glaucoma
significant permanent disability. Hence, any conjunc-
tival leak or dehiscence should be closed as soon as
possible. More significant is the risk of infection,
termed blebitis, in the late postoperative period. This
risk approximates 1.2% in Japanese over a mean
3.5 years in patients treated with no antimitotic.39
In a North American population, the risks of
endophthalmitis (7.5%) and blebitis (6.3%) over 5
years following mitomycin C trabeculectomy are
higher.40 Hence, it is important to carefully select the
antimitotic for the particular patient. The most
common complication in the late postoperative
period is failure with fibrosis of the bleb. Initial
signs are usually a rise in pressure, cystic or flattened
appearance of the bleb with surrounding scar tissue,
which may be hypervascular, tending to wall it off.
This can often be treated with 5-fluorouracil
needling. If this fails, then medical therapy may need
to be reinstituted or a subsequent additional drain-
age procedure performed.
Patients need to be carefully informed about the
nature of this surgery and in particular the short- and
longer term risks. It is essential to inform patients
that their vision will not be improved by surgery,
and in fact, it could be somewhat worse. Some
719% of patients experience a sustained reduction
in visual acuity postoperatively.26,41 The rate of
cataract formation is increased following drainage
surgery and so patients need to be warned of this
possibility. They need to be warned that an artificial
channel is being created, and that the body will
attempt to close it down through the process of fibro-
sis and that you may need to give injections or other
agents to mollify this process.
GDDS
In 1969, Anthony Molteno first described a silicone
tube to polyethylene plate apparatus designed to
minimize the problems associated with fibrosis
obliteration of blebs.7 The functional principle was
that the silicone tube inserted into the anterior
chamber and connected to the plate acted as a
conduit and diffusional surface area that could not be
obliterated. The success of this design has seen the
production of similar devices by other groups
(Baerveldt, Ahmed, Krupin).
Indications
The most common indication for GDD implantation
is where trabeculectomy surgery, particularly with
an antimitotic agent has failed or where trabeculec-
tomy surgery is most likely to fail. The latter form
primary tube surgery indications and include iri-
docorneal endothelial syndrome and rubeosis iridis,
2012 The Authors
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
393
both of which do very poorly with trabeculectomy.
Additionally, complicated glaucomas due to chronic
uveitis and aphakia generally do better with GDDs
than with antimitotic-augmented trabeculectomies.
The same essential aims are being achieved by these
devices, namely the formation of a safe, functioning
bleb. The blebs do tend to be safer following glau-
coma drainage device insertion, mainly because they
are posterior to the rectus muscle insertions and
induce overlying fibrous tissue encapsulation. There
is a reduced late risk of infection following drainage
tube implantation. The exceptions here are when the
wound dehisces or the tube erodes through the
conjunctiva.
Glaucoma drainage tube results
Glaucoma drainage tube function tends to last longer
than trabeculectomy. A 10-year study of primary
tube surgery with some additional risk factors
showed qualified success rates of approximately
95%.42 Three-year success rates of 85% when tubes
are inserted following cataract surgery or trabecu-
lectomy are reported in a multicentre randomized
trial.43 It is however, important to acknowledge that
these patients were mainly elderly Caucasians,
whereas success rates of 50% at 5 years (Fig. 3) from
other high-risk clinical and demographic groups are
reported.44
Safety
The long-term safety of GDDs are generally
excellent. The major concern for most surgeons is the
1.0 CS
0.9 QS
Cumulative probabilities
0.8 30% R
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0 2 4 6 8 10 12
Years
Figure 3. KaplanMeier survival curves for all patients, plotting
the cumulative probabilities against time that (i) the intraocular
pressure (IOP) remains below 22 mmHg without additional
medical treatment (complete success: CS) (ii) the IOP remains
below 22 mmHg with or without additional medical treatment
(qualied success: QS); and (iii) the IOP remains below the target
IOP (set as a 30% reduction from the mean preoperative IOP;
-30%R) following tube implantation. From gure 2 in Broadway
et al.44
394
risk to the cornea of having a silicone tube passing
through or adjacent to the endothelium. In patients
with one single tube entry into the anterior chamber,
the reported risk of corneal decompensation is
18%.45 Where initial tube surgery has failed due to
fibrosis and IOP elevation and a second tube inser-
tion has been performed, this carries a higher risk of
corneal decompensation of up to 44%.46 The risk to
pre-existing corneal grafts is high, and hence, the
concern is in patients with penetrating keratoplasty.
In those patients, it is wise to cover them with sys-
temic steroids in the immediate postoperative
period. Those patients need to be warned of symp-
toms of graft rejection also. Most surgeons will try to
position the tube as far from the cornea as possible.
Pars plana insertion in vitrectomized eyes is thought
to reduce corneal decompensation risk but can
increase posterior segment complications.47 We do
this where possible, particularly in children. We also
position the tube between the iris and intraocular
lens where possible (Fig. 4).
Other complications are similar to those occurring
with trabeculectomy. In particular, hypotonous
complications can occur in the early postoperative
period and again are most likely due to wound
dehiscence or leakage through other sites within
the conjunctiva. Any conjunctival wound dehiscence
or erosion must be treated immediately. A wound
breakdown over the plastic tube or plate is a serious
complication and usually will not heal without the
use of a free or advancement conjunctival graft over a
scleral patch graft. The risks of leaving a conjunctival
wound dehiscence or wound breakdown are dire.
Because the apparatus is plastic, it is not uncommon
for epithelium to grow around the plastic in an effort
to exteriorize this foreign body. The consequence is
Figure 4. Molteno tube inserted between iris and intraocular
lens in a subject with iridocorneal endothelial syndrome.
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
Morgan and Yu
that the epithelium will gradually grow down the
tube towards and into the anterior chamber and can
cause epithelial ingrowth. Additionally, desquamat-
ing epithelial cells can pass down the tube and enter
the anterior chamber.
Surgical technique variations
With any of these devices, the plate should be
sutured behind the level of the rectus insertions. The
tube should be covered either by a thick scleral flap
or preferably incorporated with a free scleral graft
above or below the scleral flap under the conjuncti-
val closure. This extra bulk over the tube minimizes
the risk of early or late tube extrusion. The conjunc-
tiva needs to be closed carefully to prevent wound
dehiscence. This is extremely important in young
children where it is usually impossible to examine
them until the next examination under anaesthesia.
It is most important to warn patients to not rub their
eyes. Rubbing the eye leads to the tube abrading
adjacent tissue; that is iris, lens, ciliary body and
cornea. It also puts significant stress upon the wound
and increases the risks of wound dehiscence. This is
very important in young children where the wound
simply cannot be observed at routine visits. Antimi-
totic agents have been used in conjunction with
GDDs but have not been shown to make any differ-
ence to the long-term pressure control or outcome.
Mitomycin C applied to the overlying Tenons layer
has however, been shown to reduce the IOP rise
during the hypertensive phase.48 The tube should
be occluded for the first 6 weeks postoperatively
in order to avoid severe hypotony. This is easily
achieved using an absorbable vicryl suture and
cutting a small slit in the tube between the vicryl and
anterior chamber to allow some temporary drainage.
The pressure will usually fall in the first few
weeks then gradually rise until the vicryl suture dis-
solves at about 6 weeks postoperatively. Then it is
likely to fall again and rise as fibrovascular tissue
grows around the plate. In younger patients in par-
ticular, this often causes the so-called hypertensive
phase whereby the IOP can rise excessively, neces-
sitating treatment with aqueous suppressants.
The hypertensive phase ends as the fibrovascular
response matures, usually at 512 months post-
surgery, with a longer time in younger patients.48
Comparisons between drainage
tube devices
There appears to be little significant difference in
long-term pressure lowering between the three
major devices currently used (Molteno, Baerveldt,
Ahmed);49 however, true randomized controlled
2012 The Authors
Surgical management of glaucoma
trials comparing them are few and short, with 2 to 3
years follow-up. The Molteno and Baerveldt are non-
valved devices and tend to have a lower IOP in the
late postoperative period compared with the Ahmed
valve.50 The profile of complications is similar and
does not appear to be significantly different between
the devices. Bleb encapsulation and a hypertensive
phase at 3 months post-sugery appear more likely
with Ahmed.51 The 350 mm2 and 500 mm2 Baerveldt
tube plate system are associated with a greater risk of
strabismus and extraocular muscle movement disor-
der postoperatively.50 The size of the plate has been
thought to be a significant factor in determining
postoperative pressure reduction; however, beyond a
plate surface area of approximately 200 mm2, there
appears to be little difference in pressure reduction.49
The paediatric and early single-plate Molteno tubes
appear to produce a higher IOP than the double plate
and more recent third-generation larger single-plate
tubes. However, there appears to be little difference
between the larger Molteno tube plates and
Baerveldt tube plates in terms of IOP reduction.50
Modifying bleb function
There is no evidence that postoperative injections
of 5-fluorouracil or mitomycin C improve or fav-
ourably modify drainage tube device function.
Attempts have been made to excise thickened
Tenons layer overlying the plates, but again, this
has not been shown to cause significant or long-
lasting pressure reduction.46 The use of systemic
fibrosis modifying agents (prednisolone, colchicine
and non-steroidal anti-inflammatory drugs) may
modify bleb maturation in the early postoperative
period; unfortunately, there is little evidence, and
there are no randomized controlled studies to
clearly support their use.42
Paediatric glaucoma drainage surgery
Idiopathic primary congenital glaucoma is the single
largest cause of paediatric glaucoma and is identified
when there is no other physical abnormality afflict-
ing the patient. When there is another associated
physical disorder, this is termed secondary paediatric
glaucoma. The commonest cause of the latter is con-
genital cataract which is strongly associated with
subsequent paediatric glaucoma. Many paediatric
syndromes are also associated with glaucoma. The
primary congenital glaucomas generally respond
very well to goniotomy or trabeculotomy52 as well as
trabeculectomy.53 Visual stability of 71% at 10 years
and 58% at 34 years are reported.53 Short-term IOP
success rates of 90% are reported.54 Secondary con-
genital glaucomas usually respond poorly to these
2012 The Authors
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
395
procedures, and so, it is important to make an accu-
rate diagnosis in order to aid prognostication and the
optimum choice of surgery.
In paediatric glaucoma where there is significant
other ocular abnormality such as Peters syndrome,
persistent hyperplastic primary vitreous and follow-
ing a congenital cataract removal, a GDD is usually
required.55 If the secondary glaucoma occurs before
12 months of age and the associated ocular abnor-
malities are not too significant, then trabeculectomy
or goniotomy can be attempted. In primary congeni-
tal glaucoma, successful trabeculectomy or goni-
otomy is more likely if surgery is done prior to the
first 12 months of life.54 After 12 months of age, the
success rate dramatically declines. This effect may be
due to the reduced plasticity of drainage tissues with
ageing.
Technique
Goniotomy was the first described and requires a
good view of the angle so that the goniotomy knife
can be inserted ab interno, across the anterior
chamber to engage the trabecular meshwork in order
to cut down to the canal of Schlemm.6 Generally, a
120 incision of the meshwork is made. Trabeculo-
tomy requires surgical exposure similar to trab-
eculectomy wherein a conjunctival and scleral flap
are created, then a radial incision is made down to
the canal of Schlemm, which needs to be clearly
identified. An angled Harms trabeculotome is
inserted into the canal of Schlemm. The parallel
prong of the probe is kept anterior to the wound, and
the device levered centrally, rupturing the inner wall
of the canal of Schlemm and the overlying trabecular
meshwork, creating a junction between the anterior
chamber and canal. This procedure can be performed
when the anterior chamber view is poor, which is
very useful in some patients with buphthalmos. If
the canal of Schlemm cannot be found or seen, then
a standard trabeculectomy without antimitotic can
be performed.53
Postoperatively, a bleb is frequently observed to
last a few months before flattening out and becoming
obliterated. However, in the majority of patients, sig-
nificant pressure reduction remains. It is possible in
these patients that junctions between the canal of
Schlemm or surgical ostomy and lymphatics or
aqueous veins have been created. Unfortunately,
pressure reduction in the absence of a bleb occurs
only very rarely in adults following surgery.
The outcomes from the three procedures are
comparable, and little significant difference exists
between trabeculotomy, goniotomy or trabeculec-
tomy in the long term.53,56 However, trabeculotomy
success rates of 67%, compared with 54% for trab-
eculectomy, are reported in a higher risk Arabic
396
population.57 The procedure chosen tends to depend
upon surgeon preference as well as patient media
clarity.
Secondary congenital glaucoma
treatment
Trabeculectomy with mitomycin C has been
attempted in many patients with these conditions.
However, there is a more recent trend towards using
GDDs with better pressure lowering reported.55 The
concerns are long term, particularly related to corneal
decompensation. If the child has had a vitrectomy,
then our practice is to insert the tube through the
pars plana to minimize possible corneal contact.
With congenital cataract surgery and intraocular lens
placement, we will tend to implant the tube either
between the iris and intraocular lens or as far poste-
riorly within the anterior chamber as possible. There
is scant long-term data regarding treatments for sec-
ondary congenital glaucoma, but the data from the
use of GDDs are promising.55
Cyclodestructive procedures
Cyclodestructive procedures using laser or cryo-
therapy are used to reduce the formation of aqueous
humour by the ciliary processes. Most commonly,
this is performed with a cyclodiode laser using an
810-nm continuous wave laser. This can be per-
formed as an outpatient or in children under general
anaesthetic. More recently, endoscopic cyclodiode
laser has been used in some patients. Cyclodiode
laser is generally reserved for patients who have
failed drainage surgery and has reported pressure
lowering success rates of 38 to 55% at close to 2
years.58,59 There have been comparisons of this with
the GDDs; however, cyclodiode laser tends to cause
more inflammation, and the longer term visual
results show that up to 30% can lose two or more
lines or vision.60 Poorer visual outcomes from cyclo-
diode laser compared with drainage devices are
demonstrated in several studies.58,59 Generally, cyclo-
diode laser is used in patients who have failed GDDs
or who lack useful vision.
Complications
Significant pain can be expected for the first few days
after laser and must be explained to the patient.
Usually, only 180 of the ciliary body circumference
is treated. Usually two or three treatment episodes
are required for long-standing pressure control.
There is an 8% risk of hypotony at 2 years particu-
larly in neovascular eyes.58,59 If this occurs, then
unfortunately, it cannot be successfully treated, and
Clinical and Experimental Ophthalmology 2012 Royal Australian and New Zealand College of Ophthalmologists
Morgan and Yu
the patient will end up with a phthisical eye. This is
the reason for judicious treatment over 180 only at
each treatment session. There is a small risk of sym-
pathetic ophthalmitis following cyclodiode laser.61
Curiously, sympathetic ophthalmitis is not reported
following uncomplicated trabeculectomy or GDD
insertion. Because patients undergoing cyclodiode
laser generally have markedly reduced facility of
outflow, and cyclodiode laser reduces aqueous pro-
duction, the diurnal and other variations in aqueous
production will lead to increased IOP variation.
Hence, following cyclodiode laser, the IOP tends to
be brittle, with large fluctuations which can be an
additional problem for glaucoma control. For all of
these reasons, our own practice is to relegate cyclo-
diode as the last choice in surgical intervention.
Other drainage procedures
Several procedures are being popularized at present,
with suggestions that they may minimize post sur-
gical complications and yet still produce acceptable
or excellent long-term pressure reduction. Unfortu-
nately, most of the published follow-up periods are
short, being of the order of 1 year or less, and the
definitions of success vary greatly, making it difficult
to compare these new procedures with each other
or with standard drainage procedures. None of
them have been shown to be superior to standard
trabeculectomy.62
Deep sclerectomy with collagen implant has been
reported to have a 5690% success rate at 1 year, but
meta-analysis demonstrates less effective IOP reduc-
tion compared with trabeculectomy.63 There are
fewer hypotony-related complications reported.63
Bleb formation is noted to occur with deep sclerec-
tomy and can be modified with antimitotics. Visco-
canalostomy has a reported success rate of 3679%
at 1 year.64 Metal (EX-PRESS, Alcon, Hunenberg,
Switzerland) shunts across the inner corneosclera
beneath a trabeculectomy-style scleral flap, replacing
hand-cut ostomy, are reported to have up to an 88%
success rate at 1 year and 70% success at 5 years
(IOP 18).65 Cyclodialysis cleft formation with the
insertion of a metal implant to maintain patency is
reported to have some success, but the results are not
reported in peer-reviewed literature. Cyclodialysis
cleft without implant is reported to have 14%
success rate at 1 year.66
Ab-interno procedures, which tend to minimize
conjunctival surgical trauma, have been described.
Trabecular meshwork ablation with trabectome has a
reported a 55% success rate at 1 year.64 Unpublished
results of a stent from the anterior chamber to canal
of Schlemm (Glaukos i-stent, Laguna Hills, CA,
USA) inserted ab interno suggest a 66% (IOP 21)
success at 18 months.64,67 Additionally, excimer laser
2012 The Authors
Surgical management of glaucoma
trabeculotomy has been described applying laser ab
interno with success rates of 41 to 91% at 1 year.68
In summary, current glaucoma surgical practice
involves the judicious assessment of patients and
the judgement of whether medical treatment is
adequate. It is paramount to adequately measure
glaucoma progression and clearly justify surgical
intervention as there are significant risks. It is also
paramount to fully assess the patient and determine
the most effective and safest procedure best suited to
their condition. The current mainstays of surgery,
being trabeculectomy, GDDs and paediatric trabecu-
lotomy and goniotomy, have been in existence for
more than 40 years and have been refined somewhat.
Currently, a lot of work is taking place to develop
newer potentially safer forms of glaucoma surgery,
but unfortunately, none have been shown to be supe-
rior to the traditional procedures.
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