Trabeculectomy with Mitomycin-C Application

Patients were prepped and draped in a usual sterile fashion. A fornix based conjunctival peritomy was performed in the superonasal quadrant in the majority of the cases with wide blunt dissection extending posteriorly. Wet-field cautery was utilized to achieve hemostasis. An orthogonal 3 × 4 mm (TF) or 4 × 4 mm (FT) partial thickness scleral flap was dissected extending through limbus into cornea. A sponge soaked in MMC was applied under the conjunctiva for 0.5–3 min. The duration and concentration of MMC application was at the discretion of the surgeon with 0.2 mg/mL for 2 min (TF) or 0.3 mg/mL for 3 min (FT), representing the most prevalent choices. The surgical area was then copiously irrigated with balanced salt solution (BSS). A paracentesis was created to establish access to the anterior chamber, the anterior chamber was entered under the scleral flap and trabeculectomy was performed utilizing a Kelly-Descemet’s punch or a surgical blade. An iridectomy was then performed with Vannas scissors. Two interrupted 10.0 Nylon adjustable sutures (TF) or three interrupted 10.0 Nylon sutures (FT) were used to secure the scleral flap. The anterior chamber was re-inflated with BSS and the suture tension was adjusted to allow slow egress of aqueous without collapse of the anterior chamber. The sutures were locked with two additional throws and subsequently rotated to bury the knots. Finally, the conjunctiva was closed with two interrupted 8.0 Vicryl sutures (Ethicon Inc., Johnson & Johnson, Somerville, NJ, USA). A 9.0 Vicryl running suture on a BV needle (TF) (Ethicon Inc., Johnson & Johnson, Somerville, NJ, USA) or an 8.0 Vicryl running suture (FT) was used to close the wings of the conjunctival incision in a watertight fashion. An additional 9.0 or 8.0 Vicryl mattress suture was passed parallel to the limbus to decrease the incidence of early aqueous leaks. The anterior chamber was formed with BSS and the incisions were examined for leaks. Patients received a subconjunctival injection of 0.4 mL dexamethasone disodium phosphate (4 mg/mL) and of 0.4 mL gentamicin sulfate (40 mg/mL) at the end of the case. Post-operative management with regards to medication selection and additional interventions was at the discretion of the surgeon and did not follow a specific protocol. In combined cases phacoemulsification was initially performed through a separate temporal clear cornea incision that was sutured with a single 10.0 Nylon suture followed by a trabeculectomy as described above. Intraocular lens selection was at the discretion of the surgeon.