Eyeworld

February 2011 "One of the dangers of the use of filtering procedures is the formation of a scar-rimmed avascular and poorly vascularized polycystic bleb, which easily becomes necrotic in conjunctival infection and so causes late infections." H. Goldmann, Br J Ophthalmol 1972; 56:306-308 B leb-related complications have been associated with the variety of glaucoma filtering opera- tions. The evolution of glaucoma operations, beginning with full-thickness procedures to trabeculectomy and then to trabeculectomy combined with the surgical adjuncts 5-FU and mitomycin, is marked by operation-specific early and late complica- tions. However, the one complication dominating all oth- ers is the occurrence of bleb leaks and the potential for late infection. In an editorial in Ophthalmology, Parrish and Minckler opined that late endophthalmitis is filtering surgery's time bomb (Ophthalmology 1996; 103:1167-1168). In fact, the use of intraoperative mitomycin C to enhance filtration is a risk factor for late-onset, bleb-related infection (Jampel et.al, Arch Ophthalmol 2001; 119:1001-1008) with an increased incidence of bleb-related leaks (Greenfield et.al, Arch Ophthalmol 1998; 116:443-447). Primary open-angle glaucoma (POAG) is a chronic, asymptomatic, and, at our present state of knowledge, non-curable disease. The therapeutic goal is to slow the rate of progression of the disease process for each patient. Since the prevalence of this condition is increasing as the aging population grows, we will be dealing with a large number of patients embodying varied stages of disease severity and responses to the range of therapies. In addition, many of these patients will have co-morbid conditions that may influence the approach to managing the condition. Although trabeculectomy combined with the use of an antimetabolite has been the mainstay for the surgical management of POAG for 20 years, several surgical alternatives have emerged within the past few years. For the most part, these procedures are not bleb- dependent and are applied to facilitate IOP control depending on the severity of the disease and the desired level of IOP reduction. We now have the opportunity to perform procedures other than trabeculectomy and to obviate the complications of bleb-centered filtration. This issue of EyeWorld will explore these newer procedures, many of which can be combined with clear- corneal phacoemulsification, and will present the opinions of our experts regarding the most favorable use of these operations. We have learned that trabeculectomy is no longer the only operation and that surgical alternatives have the potential for long-term IOP control without the accompanying litany of complications. Stephen A. Obstbaum, M.D. EyeWorld Chief Medical Editor Publisher Donald R. 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POSTMASTER: Send change of address to EYEWORLD, 4000 Legato Road, Suite 700, Fairfax, VA 22033 Periodical postage paid at Fairfax, VA 22033 and at additional mailing offices. The ideas and opinions expressed in EYEWORLDdo not necessarily reflect those of the editors, publisher or its advertisers. P U B L I S H I N G   S T A F F February 2011 Volume 16 • No. 2 EW NEWS & OPINION 10 A S C R S The official publication of the American Society of Cataract & Refractive Surgery World View Getting past trabeculectomy

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