Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors

Abstract

Aim To investigate surgical outcomes and success predictors of transconjunctival scleral flap resuturing for the management of hypotony due to overfiltration following trabeculectomy with mitomycin C.Materials and methods Noncomparative, retrospective, interventional case series in which all glaucoma patients from two glaucoma services undergoing transconjunctival scleral flap resuturing between May 2012 and July 2016 were enrolled. Included eyes had to have hypotony [intraocular pressure (IOP) < 6 mm Hg] and/or hypotony maculopathy caused by excessive filtration following trabeculectomy. Key exclusion criteria were wound/bleb leaking and postoperative ocular trauma or infection. Preoperative and postoperative IOP, best-corrected visual acuity (BCVA), fundus imaging, surgical complications, and any subsequent related events or procedures were recorded. Rates of postsurgical hypotony and/or maculopathy resolution and possible success predictors were investigated.Results A total of 22 patients (22 eyes) with a mean age of 56.4 ± 15.2 years were included. Median follow-up was 245 days [interquartilerange (IR); 120-817 days] and mean IOP was increased from 2.9 ± 1.5 mm Hg (1-6 mm Hg) to 8.5 ± 3.1 mm Hg (2-16 mm Hg) at the last follow-up visit (p < 0.01). Approximately 75% of the cases (16 out of 22) had an IOP between 7 and 18 mm Hg at the end of the follow-up period. Median BCVA (log MAR) at last follow-up visit [0.1 (IR; 0.0- 0.3)] was significantly better than preoperative BCVA [0.4 (IR; 0.11.0); p < 0.01]. Hypotony resolved in 81% of the cases, while maculopathy resolution was found in 85% of the cases. Time interval between trabeculectomy and flap resuturing was the only factor significantly associated with patient’s IOP at last follow-up visit (R2 = 0.23; p = 0.036). Success rates (IOP > 6 mm Hg at last follow-up visit) were halved in those left untreated for more than 6 months. No serious adverse event was recorded.Conclusion Our findings support the use of transconjunctival scleral flap resuturing as an effective and safe alternative for hypotony management due to overflitration following trabeculectomy. As time interval seems to influence the odds of hypotony resolution, early intervention is recommended.How to cite this article Scoralick ALB, Almeida I, Ushida M, Dias DT, Dorairaj S, Prata TS, Kanadani FN, Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017;11(2):58-62.

Bleb Compressive Sutures in the Management of Hypotony Maculopathy after Glaucoma Surgery

“…Although the success in IOP increase was not observed in every patient, during the early postoperative period we observed an improvement of the visual acuity in the whole group, similarly to the results observed by Scoralick [ 36 ]. It shows the efficacy of transconjunctival sutures regarding BCVA improvement, and probably additionally confirms that numerous definitions of hypotony are not accurate, as in some patients an increase in IOP even below 6 mmHg allowed for BCVA improvement.…”

“…Clinical assessment had led us to the assumption that a shorter time since the primary procedure may enable obtaining a more prominent increase in the IOP level, which was not confirmed by our results: in this study, at no time-point was IOP correlated with the time since the primary surgery, which was also observed by other authors [36]. However, in our results a longer time since the primary surgery tended to have a negative impact on the final BCVA.…”

“…On the other hand, prolonged hypotony causes irreversible fibrosis within the retina, choroid, or sclera, maintaining the choroid in a folded position [ 31 ]. Scoralick et al found resolution of hypotony maculopathy in 85% of the cases following surgical reintervention, but none of the variables investigated (including the time interval between trabeculectomy and flap resuturing) was significantly associated with postoperative maculopathy resolution [ 36 ].…”

Bleb reconstruction using donor scleral patch graft for late bleb leak and hypotony

“…1 Hypotony is associated with serious visual disability due to choroidal effusion, maculopathy, flat anterior chamber, optic neuropathy and cataract development. 11,12 Bleb leak allows a potential entry site for bacteria and late onset endophthalmitis has been reported at 0.2%. 3 The use of scleral patch graft has been reported by others with good success.…”

“…Most report on the management of early post-operative hypotony using techniques such as passing transconjunctival sutures through the scleral flap. 12,15 There have been some successful reports of reconstructing leaking blebs with amniotic grafts. 16 However, we believe that reconstructing the bleb alone after excision of the diseased conjunctiva will not address the underlying issue of over-filtration and is unlikely to provide a long-term solution with progressive conjunctival thinning leading to leaks.…”