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EDUCATION ACADEMY
Drugs & Diseases > Ophthalmology

Complications and Management of

Glaucoma Filtering Treatment &
Management
Updated: Oct 13, 2014
 Author: Jacqueline Freudenthal, MD; Chief Editor: Hampton Roy, Sr, MD more...


Complications
Complications of glaucoma and its treatment include the following: (1) intraoperative
and postoperative suprachoroidal hemorrhage; [4] (2) hyphema; (3) hypotony; (4) a flat
anterior chamber and elevated or normal intraocular pressure (IOP), which includes
suprachoroidal hemorrhage, aqueous misdirection, and pupillary block; (5) visual
loss; (6) intraoperative complications of filtration procedures, eg, conjunctival
buttonholes and tears, scleral flap disinsertion, and vitreous loss; (7) postoperative
complications of filtration procedures, eg, bleb leaks, early and late failure of filtering
blebs, encapsulated blebs, symptomatic blebs, cataract formation, and bleb-related
ocular infection; (8) complications of cyclodestructive procedures; and (9)
complications of trabeculotomy and goniotomy.
Each of these complications is discussed below.
Intraoperative and postoperative suprachoroidal hemorrhage
Suprachoroidal hemorrhage is a serious complication that can be seen during or after
any intraocular surgery. If it occurs intraoperatively and cannot be controlled (ie, it is
expulsive hemorrhage), and it can lead to loss of vision. The incidence of this
complication in the general population after cataract extraction is approximately 0.2%.
The incidence of a suprachoroidal hemorrhage in patients with glaucoma who
undergo various types of intraocular surgery is reportedly 0.73%.
Ocular risk factors for a suprachoroidal hemorrhage are glaucoma, aphakia,
pseudophakia, previous vitrectomy, vitrectomy at the time of glaucoma surgery,
myopia, and postoperative hypotony. Systemic risk factors are arteriosclerosis, high
blood pressure, tachycardia, and bleeding disorders. The source of the hemorrhage is
usually 1 of the posterior ciliary arteries, particularly the point of entrance of the short
posterior ciliary vessels into the suprachoroidal space. Vascular necrosis seems to be
present with subsequent rupture of the vascular wall.
Intraoperative suprachoroidal hemorrhage can be associated with a sudden collapse of
the anterior chamber. The patient may complain of sudden pain that breaks through
local anesthesia. If the process is gradual, a dark mass that evolves slowly can be
observed through the pupil; however, if the process is abrupt, the hemorrhage is more
expulsive.
Postoperative suprachoroidal hemorrhage usually occurs within the first week after
glaucoma surgery and is generally associated with postoperative hypotony. Typically,
the development of a suprachoroidal hemorrhage is acute and associated with the
sudden onset of severe pain.
Examination of the anterior segment frequently reveals a shallow anterior chamber
and normal or high IOP. On the fundus examination, a detached and dark choroid is
noted. The choroidal elevations have a dark, reddish brown color. Some patients
present with bleeding into the vitreous cavity and, uncommonly, retinal detachment.
Ultrasonography can be used to aid in the diagnosis of a suprachoroidal hemorrhage
when a fundus examination is not possible.
Hyphema
Hyphema is a common postoperative occurrence in glaucomatous eyes after filtration
surgery, surgical peripheral iridectomy, and trabeculotomy. An example of hyphema
is shown in the image below.

Hyphema. Deposition of RBCs

in the anterior chamber.
View Media Gallery
Bleeding commonly arises from the ciliary body or cut ends of the Schlemm canal,
although it might arise from the corneoscleral incision or the iris.
Hyphema generally occurs during surgery or within the first 2-3 days after surgery.
Intraoperatively, if a bleeding spot does not stop spontaneously, it must be identified
and coagulated. During filtration surgery, performing the internal sclerostomy as far
anteriorly as possible decreases bleeding.
In most cases, no treatment is necessary, and the blood is absorbed within a brief
period of time. Cycloplegics, corticosteroids, restriction of activity, and elevation of
the head of the bed 30-45° (to prevent blood from obstructing a superior sclerostomy)
are recommended. Increased IOP can occur, particularly if the filtering site is
obstructed by a blood clot; if necessary, it should be treated with aqueous
suppressants. Injection of a tissue-plasminogen activator may be considered.
Surgical evacuation can be considered depending on the level of IOP, the size of
hyphema, the severity of optic nerve damage, the likelihood of corneal blood staining,
and the presence of sickle cell trait or sickle cell anemia (infarction of the optic nerve
can occur at a relatively low IOP, and carbonic anhydrase inhibitors are
contraindicated). Liquid blood can be easily removed with irrigation. If a clot has
formed, it can be removed by expression with viscoelastic or with a vitrectomy
instrument set at low vacuum.
Hypotony
Hypotony, or IOP less than 6 mm Hg, after glaucoma surgery can result from
excessive aqueous humor outflow related to excessive filtration, wound leak, or
cyclodialysis cleft or from reduced aqueous humor production related to
ciliochoroidal detachment, inflammation, inadvertent use of aqueous suppressants, or
extensive cyclodestruction. These conditions can coexist; for example, low IOP due to
overfiltration can induce ciliochoroidal detachment and secondary decreased
production of aqueous humor.
Possible complications include the following:
 Flat anterior chamber
 Gradual failure of the bleb
 Visual loss
 Cataract
 Corneal edema
 Descemet membrane folds
 Choroidal hemorrhage
 Macular and optic disc edema
 Chorioretinal folds (predominantly in young patients with myopia)
According to Spaeth, the severity of a flat anterior chamber can be classified as
follows: grade I, when peripheral-iris apposition is present; grade II, when pupillary
border-corneal apposition is present; and grade III, when lens-corneal touch is present.
The depth of the central anterior chamber can be described relative to corneal
thickness. Choroidal effusion occurs when fluid collects in the suprachoroidal space,
resulting in forward movement of the lens-iris diaphragm with the anterior chamber
becoming shallow. On fundus examination, moundlike elevations of the choroid,
commonly in the periphery, are visible.
Flat anterior chamber and elevated or normal IOP
The following 3 conditions should be considered in patients with a postoperative flat
anterior chamber and elevated or normal IOP: (1) suprachoroidal hemorrhage (see
Intraoperative and postoperative suprachoroidal hemorrhage above), (2) aqueous
misdirection, and (3) pupillary block.
 Aqueous misdirection
o Aqueous misdirection is also called malignant glaucoma or ciliary block
glaucoma. It is characterized by a shallowing (flattening) of the anterior
chamber without pupillary block (ie, in the presence of a patent iridectomy) or
choroidal disease (eg, suprachoroidal hemorrhage) and commonly with an
accompanying rise in IOP. Aqueous misdirection occurs in 2-4% of patients
who have undergone surgery for angle-closure glaucoma, but it can occur after
any type of incisional surgery. The chance of developing malignant glaucoma
is greatest in phakic hyperopic (small) eyes with angle-closure glaucoma. In
this condition, the aqueous humor is diverted posteriorly toward the vitreous
cavity, increasing the vitreous volume and shallowing the anterior chamber.
o Decompression and shallowing of the anterior chamber appear to be
predisposing factors by inducing forward movement of the peripheral anterior
hyaloid. Small choroidal effusions and a shallow anterior chamber sometimes
occur before the episode of aqueous misdirection. The anterior hyaloid could
be placed into direct apposition with portions of the secreting ciliary processes.
Thus, the aqueous humor might move directly into the vitreous cavity. In
hyperopic eyes (with a crowded middle segment), the peripheral anterior
hyaloid in its normal position probably is close to the posterior ciliary body. In
such eyes, cataract and filtration surgeries should be considered as high risk for
aqueous misdirection. In aqueous misdirection, a relative resistance to the
anterior movement of the aqueous humor in the anterior vitreous face or the
anterior hyaloid membrane probably occurs.
o The increased resistance can be related to either abnormal permeability or
available hyaloid surface area for fluid transfer. In normal circumstances, the
anterior hyaloid and the vitreous offer insignificant resistance to forward fluid
flow. In some cases, pupillary block occurs first and is followed by aqueous
 misdirection. Perhaps, a sudden onset of pupillary block forces the aqueous
humor into the vitreous and expands the vitreous volume, with forward
displacement of the peripheral hyaloid into direct apposition with the ciliary
body.
o Aqueous misdirection usually occurs in the early postoperative period after
either filtration surgery or cataract surgery. The anterior chamber is shallow,
and the IOP is high. However, with a functioning filtration bleb, the IOP may
not be high. The peripheral iridectomy is patent, and a dilated examination and
a B-scan ultrasonography confirm the absence of choroidal effusion or
hemorrhage. If the adequacy of the surgical iridectomy is in doubt and
pupillary block is possible, a laser iridotomy should be performed.
 Pupillary block
o Pupillary block can be caused by adhesions between the iris and the lens, the
pseudophakos, or the vitreous. The inability of the aqueous humor to pass from
the posterior chamber to the anterior chamber results in the forward movement
of the peripheral iris and closure of the drainage angle. Pupillary block
typically occurs as a flat (shallow) anterior chamber with normal or elevated
pressure. Distinguishing pupillary block from malignant glaucoma may be
difficult. Although a peripheral iridectomy is intended at the time of filtration
surgery, only the stroma of the iris is removed and the posterior pigment
epithelium is left intact in a few patients. In these patients, blockage may
develop. In other patients, the iris may become incarcerated in the wound or the
iridectomy may be obstructed by intraocular tissue, such as the Descemet
membrane, the anterior hyaloid surface, the vitreous (in aphakic eyes), or
ciliary processes.
o Therapy with cycloplegic-mydriatics may resolve pupillary block, but an
Nd:YAG peripheral iridotomy should be performed. The anterior chamber
readily deepens after an iridotomy is performed, although in the presence of
localized compartments of blockage, multiple iridotomies are necessary.
Usually, this deepening is associated with the sudden escape of aqueous humor
through the iridectomy, confirming the diagnosis of pupillary block. If the laser
iridotomy cannot be completed, a surgical iridectomy should be performed.
o The development of a flat anterior chamber after glaucoma surgery is a
relatively common complication. It is encountered less frequently following a
trabeculectomy procedure than after conventional filtering procedures.
However, a flat anterior chamber with or without ocular hypotonia may
develop after a trabeculectomy procedure. Therefore, the ophthalmic surgeon
who performs intraocular glaucoma surgery should anticipate and be prepared
to manage a postoperative flat anterior chamber.
o A prolonged flat anterior chamber with hypotonia may result in serious
consequences. According to a recent study, most eyes in which a flat anterior
 chamber with hypotonia developed after glaucoma surgery eventually acquired
late cataract. This finding confirms a previous clinical impression that
hypotonia is a cause of late cataract. When the anterior chamber is flat, contact
can occur between the cornea and the lens. Contact between the corneal
endothelium and the anterior lens capsule usually results in damage to the
cornea. Corneal damage can be further aggravated by the elevated IOP caused
by the development of peripheral anterior synechiae.
o Without proper medical and surgical interventions, the eye with a persistent flat
anterior chamber with hypotonia can acquire superimposed secondary
glaucoma that is difficult to control and can eventually develop absolute
glaucoma with possible vascular occlusion. Fortunately, most flat anterior
chambers with hypotonia and choroidal detachment after a filtering procedure
may spontaneously reform. However, this reformation usually occurs at the
expense of varying degrees of peripheral anterior synechiae, closure of the
filtering fistula, and late cataract.
o The flat anterior chamber with hypotonia can be with or without a detectable
external wound leak. When the Seidel test result is positive, a wound leak can
be easily ascertained. However, in many instances, the Seidel test result is
negative with an undetectable wound leak, implying that a flat anterior
chamber with hypotonia can occur in the absence of a detectable external
wound leak.
 Medical management of a postoperative flat anterior chamber
o The first step in managing a postoperative flat anterior chamber with hypotonia
is a trial of medical treatment.
o Cycloplegic agents are known to decrease the vascular transudation by
decreasing the vascular permeability. Cycloplegic agents also relax the ciliary
muscle and, thus, the posterior movement of the lens-iris diaphragm. The
mydriatic effect of cycloplegic agents is also beneficial in preventing posterior
synechiae. The theoretic implication of an increase in the uveoscleral outflow
of the aqueous humor by cycloplegic agents should be considered.
o Hyperosmotic agents may increase the depth of the anterior chamber by
decreasing vitreous volume and suprachoroidal fluid.
o Carbonic anhydrase inhibitors decrease the aqueous humor production.
Reduced aqueous humor formation diminishes flow through the filtering
fistula, increasing the chance of closure of the fistula and reformation of the
anterior chamber. However, the use of a carbonic anhydrase inhibitor may
work against reformation of the anterior chamber by further decreasing the
aqueous humor secretion that is already curtailed in an eye with a flat anterior
chamber with hypotonia.
o Topical and systemic steroids may be tried for their action of decreasing the
transudation and of counteracting the portion of the aqueous humor
 hyposecretion that may be caused by inflammation. Steroids also reduce the
incidence of posterior synechiae and peripheral anterior synechiae.
o A firm application of an eye pad or a tamponade with contact lens or scleral
shell may be beneficial. Conjunctival tamponade against the filtering
corneoscleral fistula implements a decrease in filtration and a better chance of
reformation of the anterior chamber.
o Medical therapy is of little value in the presence of an external wound leak,
necessitating surgical repair.
o Many eyes reform on this regimen. However, with the exception of a wound
leak closure, the practical value of each measure is not clear, aside from
theoretic considerations. Medical therapy is considered a failure if the anterior
chamber fails to form after 5-6 days. At this point, the ophthalmic surgeon is
obligated to surgically reform the anterior chamber. Surgical reformation of a
flat anterior chamber with hypotonia usually requires fluid drainage from the
suprachoroidal space by posterior sclerotomy.
 Surgical management of a postoperative flat anterior chamber
o Posterior sclerotomy for drainage of ciliochoroidal detachment and reformation
of the anterior chamber may be performed at a readily exposable scleral site
over the ciliary body rather than over the choroid, 6-10 mm from the limbus.
o Posterior sclerotomy and reformation of the anterior chamber may be
performed either off site or on site. In the off-site technique, a partial-thickness
incision is created through the peripheral cornea at a site off the previous
trabeculectomy or other filtering surgery. An attempt is made to reform the
anterior chamber with air, which usually fails unless the fluid from the
supraciliary space and the suprachoroidal space is drained. A posterior
sclerotomy is performed to drain fluid from the supraciliary space, which is
continuous with the suprachoroidal space.
o The area of the sclera, 3-5 mm from the limbus and a meridian away from a
rectus muscle, is cauterized using a wet-field cautery. Then, a full-thickness
radial incision of the sclera, about 2 mm in length, is created, entering into the
supraciliary space to drain the accumulated fluid. Enough fluid is drained so
that the anterior chamber can be fully reformed with air. Even when a choroidal
detachment cannot be detected on ophthalmoscopy, enough transudate is
usually present in the supraciliary space.
o A balanced salt solution instead of air was previously used to reform the
anterior chamber. The use of air is preferred because there is a better chance of
maintaining a fully formed chamber and less chance of having to repeatedly
reform the anterior chamber. The peripheral corneal incision may or may not
be closed with a suture. The conjunctival wound overlying the scleral incision
is closed by running 8-0 polyglactin or polyglycolic acid suturing.
After surgery, a strong topical cycloplegic agent and steroid-antibiotic combination
eye drops are applied to the eye. Topical phenylephrine hydrochloride is also used to
prevent posterior synechiae and the rare possibility of pupillary block of the air.
The success of surgical management supports the following 6 important observations:
1. Draining at the area of greatest choroidal detachment is not necessary.
2. Draining at the most dependent location, such as the inferior temporal quadrant,
is not necessary. Any microscopic surgery at the inferior temporal quadrant is
awkward, especially when posterior sclerotomy is performed 6-10 mm from the
limbus.
3. Draining all the fluid from the suprachoroidal space is not necessary; drain only
enough to fill the anterior chamber with air. Once the ciliary body is pushed up
against the sclera, IOP is restored, any demonstrable wound leak or excessive
filtering fistula is repaired, and the remaining fluid in the suprachoroidal space is
readily absorbed spontaneously.
4. The ciliary body is more loosely in apposition against the sclera than the
choroid, and ciliochoroidal detachment begins over the ciliary body. The ciliary
detachment is present even when the choroidal detachment is not detectable on
indirect ophthalmoscopy and B-scan ultrasonography.
5. Whether the detachment of the ciliary body rather than the detachment of the
choroid is the cause of aqueous humor hyposecretion or of increased uveoscleral
outflow of the aqueous humor, restoring the proper anatomical position of the
ciliary body against the sclera seems to be an important consideration in the
surgical management of a flat anterior chamber with hypotonia.
6. An inadvertent penetration into the vitreous during a posterior sclerotomy,
although unlikely, is less consequential through the ciliary body than through the
choroid and the retina. However, intentional vitreous aspiration can be readily
performed (if necessary) through the posterior sclerotomy and the ciliary body.
Postsurgical preventive measures for a reformed flat anterior chamber are described as
follows:
 Even with the successful reformation of a flat anterior chamber after glaucoma
surgery, the development of late cataract is often a problem. Precautionary
measures (at least those of theoretic significance) appear important in the
prevention of a flat anterior chamber after an intraocular procedure. One
precautionary measure is to avoid both sudden and large magnitudes of globe
decompression during intraocular surgery. Preoperatively, IOP is decreased to a
low level by using carbonic anhydrase inhibitors and hyperosmotic agents, in
addition to other glaucoma medications. Patients may not be able to tolerate
carbonic anhydrase inhibitors on a long-term basis, but most patients can tolerate
them for short preoperative periods. The globe is gradually decompressed by
slowly letting out the aqueous humor. The ophthalmic surgeon should avoid
 external pressure and excessive trauma to the globe, especially after the eye is
opened.
 Preoperative recognition of eyes in which intraoperative ciliochoroidal detachment
might develop, despite the usual preventive measures, is important. Eyes with
elevated episcleral venous pressure are particularly predisposed to severe
ciliochoroidal detachment. Elevated episcleral venous pressure may be idiopathic
or familial, or it may be associated with Sturge-Weber syndrome, other causes of
orbital and episcleral arteriovenous malformation or fistula, or superior vena cava
syndrome. In these eyes, performing preventive posterior sclerotomy at the time of
an intraocular procedure may be prudent.
 Adequate closure of the wound in filtering surgery is important. Closure of the
scleral wound must be just right; that is, it must be tight enough to retain the air in
the anterior chamber according to the air test. The air test involves introduction of
air into the anterior chamber with a 30-gauge cannula connected to a glass syringe
filled with air, positioned under the lamellar scleral flap or through a paracentesis
tract. If the air stays in the anterior chamber without tendency to extrude, the
closure of the lamellar scleral flap in trabeculectomy or the size of the
corneoscleral wound in other filtering procedures is considered optimal. If any air
tends to extrude, then the closure is inadequate. In this case, 1 or more interrupted
sutures are placed for tighter closure of the lamellar scleral flap or partial closure
of the filtration wound. Then, the conjunctival wound is closed watertight.
Visual loss
Unexplained loss of the central visual field (ie, wipeout) after glaucoma surgery is
rare. Older patients with advanced visual field defects affecting the central field with
split fixation are at an increased risk. Early, undiagnosed postoperative spikes in IOP
and severe postoperative hypotony are possible causes for wipeout.
Intraoperative complications of filtration procedures
See the list below:
 Conjunctival buttonholes and tears
o Conjunctival buttonholes and tears can lead to failure of bleb formation and a
flat anterior chamber. The usual cause of conjunctival buttonholes is
penetration of the tissue by the tip of a sharp instrument (eg, needle, scissors,
blade) or the teeth of a forceps. Buttonholes and tears are more likely to occur
in patients with extensive conjunctival scarring.
o To diagnose a buttonhole intraoperatively, the conjunctiva should be carefully
examined at the end of the procedure by filling the anterior chamber and
raising the filtering bleb. If recognized, the buttonhole should be closed during
surgery. If it is located in the center of the conjunctival flap, a purse string
closure is attempted, either internally on the undersurface of the conjunctiva or
 externally if the flap has been reapproximated. Use of 10-0 or 11-0 nylon on a
tapered (vascular) needle is recommended.
o When the conjunctival buttonhole or tear occurs at the limbus, it can be sutured
directly to the cornea, which should be deepithelialized. A mattress suture or, if
large, a running suture with 10-0 nylon can be used. When the buttonhole or
tear occurs near the incised edge of a limbal-based conjunctival flap, the
sutures used to close the conjunctival incision can be placed anterior to the tear.
 Scleral flap disinsertion: A thin scleral flap can be torn or amputated from its base
during the surgical procedure. If sclerostomy has not been performed, a new
scleral flap should be dissected in a different area. If sclerostomy has been
performed, reapproximation of the scleral flap can be attempted with 10-0 or 11-0
nylon sutures. If unsuccessful, additional tissue is needed to cover the sclerostomy.
This tissue can be obtained by transferring a piece of the Tenon capsule or a flap
of partial-thickness sclera from the area adjacent to the defect. Alternatively, donor
sclera, fascia lata, or pericardium can be used.
 Vitreous loss
o Vitreous loss during glaucoma surgery is an uncommon complication,
especially in phakic eyes. Predisposing conditions to vitreous loss include high
myopia, previous intraocular surgery, trauma, aphakia, and lens subluxation.
Loss of vitreous can be associated with such complications as corneal edema,
epithelial downgrowth, uveitis, retinal detachment, cystoid macular edema, and
endophthalmitis.
o The vitreous can mechanically plug the sclerostomy, leading to filtration
failure. The vitreous should be removed from the surgical site and the anterior
chamber with a vitrectomy instrument, avoiding damage to the lens in phakic
eyes. In the aphakic eye where the vitreous fills the anterior chamber, an
anterior vitrectomy can be planned as part of the primary procedure. In phakic
or pseudophakic eyes where the vitreous is in the anterior chamber, pars plana
vitrectomy may be considered to adequately remove the vitreous from the
posterior segment and to avoid lens or intraocular lens subluxation and lens
injury.
Postoperative complications of filtration procedures
See the list below:
 Bleb leaks
o Bleb leaks can occur early in the postoperative period or months to years after
filtration surgery. An inadvertent buttonhole in the conjunctiva during a
filtering procedure or a wound leak through the conjunctival incision can be
responsible for an early bleb leak. Spontaneous late bleb leaks are more
frequent in thin avascular blebs, which occur more frequently when
 antimetabolites are used in the filtering procedure and after full-thickness
procedures.
o The incidence of early and late bleb leaks is probably higher in
trabeculectomies supplemented with antimetabolites than in nonsupplemented
surgeries. Leakage of the filtering bleb can be associated with hypotony, a flat
(shallow) anterior chamber, and choroidal detachment, and it may increase the
chance of bleb infection and subsequent endophthalmitis. Early leaking can
flatten the bleb, leading to subconjunctival-episcleral fibrosis, which
jeopardizes a satisfactory long-term filtration.
o Bleb leaks are detected with the Seidel test. The tear film is stained with
fluorescein. A fluorescein strip is applied to the inferior tarsal conjunctiva or
directly, albeit gently, to the bleb. Without applying pressure, the eye is
examined under cobalt blue illumination. If a leak is present, unstained aqueous
humor flows into the tear film. If no spontaneous leakage is present, pressure
may be gently applied to either the globe or the bleb while the suspicious area
is examined.
o Various nonsurgical and surgical modalities can be used in the treatment. In
early and late bleb leaks, autologous fibrin tissue glue (AFTG) offers an
alternative nonsurgical treatment and is at least as effective as and, in some
ways, may be superior to other nonsurgical modalities of treatment. [5]
 Early and late failure of filtering bleb
o Failed blebs are associated with inadequate IOP control and impending or
established obstruction of aqueous humor outflow. The causes of failed
filtering operations are divided into intraocular, scleral, and extraocular factors.
Extraocular changes account for most failures of external filtering operations.
Early failure of filtering blebs is characterized by high IOP, a deep anterior
chamber, and a low and hyperemic bleb. Failing blebs should be promptly
recognized because if the obstruction is not relieved, permanent adhesions
between the conjunctiva and the episclera can lead to closure of the fistula. A
tight scleral flap and episcleral fibrosis are the most common causes of early
bleb failure. Internal obstruction of the fistula by a blood clot, the vitreous, the
iris, or an incompletely excised Descemet membrane is also possible.
o To reduce postoperative subconjunctival fibrosis and to preserve bleb function,
postoperative topical steroids are routinely used. The use of antifibrotic agents
in filtering procedures is associated with a higher success rate but also with a
higher complication rate (eg, wound leak and hypotony from overfiltration,
hypotony maculopathy, ocular infection). Individualized consideration of the
risk-benefit ratio is recommended.
o During the first 2 weeks after surgery, 5-fluorouracil (5-FU) is usually
administered in 5-mg aliquots. The dose is adjusted according to the tolerance
of the corneal epithelium of each eye. Intraoperative application of 5-FU has
 been described. Complications associated with using postoperative 5-FU
include corneal and conjunctival epithelial toxicity, corneal ulcers, conjunctival
wound leaks, subconjunctival hemorrhage, and inadvertent intraocular spread
of 5-FU. The frequency of complications is reduced with lower titrated doses
of 15-50 mg administered in 3-10 injections according to individual response.
o MMC is approximately 100 times more potent than 5-FU. Postoperative
complications associated with overfiltration, hypotony maculopathy, bleb leak,
and bleb-related ocular infections are more likely to occur when MMC is used.
o Digital ocular compression and focal compression can be used to temporarily
improve the function of a nonfunctioning filtering bleb. Digital ocular
compression can be applied to the inferior sclera or the cornea through the
inferior eyelid or to the sclera posterior to the scleral flap through the superior
eyelid. Focal compression is applied with a moistened cotton tip at the edge of
the scleral flap. Because of potential complications, digital ocular compression
is suitable for patients who are physically capable of performing it and who
have had a beneficial response to the initial massage by the ophthalmic
surgeon.
o In the early postoperative period, laser suture lysis can enhance the filtration.
Gonioscopy performed before the laser can confirm an open sclerostomy with
no tissue or clot occluding its entrance. Specially designed lenses or equipment
can be used. Examples are the Hoskins, Ritch, or Mandelkorn lenses; the
central button edge of the Zeis and Sussman lenses; the Goldmann lens; glass
rods; or glass pipettes.
o After the suture is cut, if the bleb and IOP are unchanged, ocular massage or
focal pressure can be applied. Usually, only 1 suture is cut at a time to avoid
the possible complications of overfiltration. A hole in the conjunctiva may
occur because of trauma from the contact lens or the thermal burn of the laser.
If a subconjunctival hemorrhage occurs, suture lysis can be difficult. In these
cases, a krypton red laser or a diode laser should be used because its
wavelengths are least absorbed by blood. Some sutures have more influence in
restricting the aqueous humor runoff than other sutures. These key sutures
should be identified during surgery, and caution should be exercised when
cutting them.
o The timing of suture release is critical. Suture lysis is effective within the first 2
weeks after surgery without antimetabolites; later, fibrosis of the scleral flap
may negate any beneficial effect of this procedure. If antimetabolites have been
used at the time of surgery, suture lysis can be effective months after surgery.
o Releasable sutures are as effective as laser suture lysis. The use of releasable
sutures allows the ophthalmic surgeon to tightly close the scleral flap, knowing
that the flow can be increased postoperatively. The externalized sutures are
easily removed and are effective in cases of hemorrhagic conjunctiva or
 thickened Tenon capsule tissue (which makes suture lysis difficult).
Disadvantages of releasable sutures include additional intraoperative
manipulation and postoperative discomfort from the externalized suture;
corneal epithelial defects; and, possibly, increased risk of ocular infection.
o In patients with an incarceration of iris or vitreous occluding the sclerostomy,
an Nd:YAG laser internal revision can be tried. When the cause of filtration
failure is a blood clot or a fibrinous clot occluding the sclerostomy, tissue
plasminogen activator can be helpful. Recombinant tissue plasminogen
activator is a serine protease with clot-specific fibrinolytic activity. It can be
injected into the anterior chamber or subconjunctivally at a dose of 7-10 mg in
0.1 mL. It works rapidly; within 3 hours, the effect is usually apparent.
Hyphema is the most frequent complication.
 Encapsulated blebs
o Encapsulated blebs are localized, elevated, and tense filtering blebs with
vascular engorgement of the overlying conjunctiva and a thick connective
tissue. This type of bleb commonly appears within 2-4 weeks after surgery.
Encapsulation of the filtering bleb is associated with a rise in IOP after an
initial period of pressure control after glaucoma surgery. They can interfere
with upper lid movement and tear film distribution, leading to corneal
complications, such as dellen and astigmatism. Often, it is seen through the
eyelid, simulating a lid mass.
o The frequency of bleb encapsulation after trabeculectomies without
antimetabolites is 8.3-28%. In trabeculectomies with postoperative 5-FU, the
reported incidence is frequently higher. The frequency of encapsulated blebs
after guarded filtering procedures is lower with mitomycin-C (MMC) that with
5-FU.
o Predisposing factors may include male sex and the use of gloves with powder,
as well as previous treatment with sympathomimetics, argon laser
trabeculoplasty, and surgery involving the conjunctiva. The causes of
encapsulation are not clearly identified, but inflammatory mediators are
probably involved in their development. The long-term prognosis for IOP
control in eyes that develop encapsulated bleb is relatively good.
 Symptomatic blebs
o Filtering blebs are usually asymptomatic. Some patients experience discomfort,
which is most common with large nasal blebs extending onto the cornea. Tear
film abnormalities with dellen formation and superficial punctate keratopathy
may occur. Corneal astigmatism, visual field defects, and monocular diplopia
have been described in patients in whom large filtering blebs migrated onto the
cornea.
o Artificial tears and ocular lubricants can be helpful, especially in patients with
abnormal tear film. Several chemical and thermal methods have been used to
 shrink blebs. A temporary medial tarsorrhaphy can alleviate symptoms of a
nasal bleb by shifting it superiorly. Large blebs that extend onto the cornea can
be freed by blunt dissection. The corneal extension can be excised with a cut
parallel to the limbus, usually with excellent results. Partial surgical excision
and conjunctival flap reinforcement are usually helpful, though bleb failure is
possible.
o Ulrich and coworkers described 3 patients in whom full-thickness glaucoma
filtering procedures were complicated by marked extension of the bleb over the
cornea, with subsequent symptoms that required surgical intervention. [6] The
surgical management in each case involved blunt dissection of the bleb from
the cornea, with revision of the remaining portion of the bleb differing in each
case according to the intraoperative findings. Light microscopic examination of
one surgical specimen revealed a markedly attenuated epithelium covering
hydropic corneal stroma. The authors postulate that the mechanism of
formation involves aqueous humor dissection between corneal epithelium and
stroma, leading to abnormal hydration of the superficial lamellae.
 Cataract formation
o Cataract formation and progression of preexisting cataract can occur after
filtration procedures. The reported incidence is 2-53%. Lens opacification is
the main cause of early visual loss after filtration surgery. Intraoperative
lenticular trauma is possible and can be recognized shortly after surgery.
o A postoperative flat anterior chamber with lens-corneal touch rapidly
precipitates cataract formation. Other probable risk factors include age,
presence of exfoliation, use of air to reform the anterior chamber, profound
hypotony, use of miotics and topical steroids, and inflammation.
o Cataract extraction can be associated with an impairment of the function of the
filtering bleb. Phacoemulsification of the lens with a corneal incision induces
less conjunctival inflammation than large scleral incisions, and, theoretically, it
may be the best method to preserve bleb function. Postoperative
subconjunctival injections of 5-FU can be considered. [7, 8] If IOP control is
borderline, a combined cataract extraction and filtration procedure may be the
best choice.
 Bleb-related ocular infection
o Ocular infections related to filtration procedures can occur months to years
after the initial surgery. The incidence of bleb-related ocular infections after
filtration procedures not supplemented with antifibrotic agents is 0.2-1.5% after
mid- and long-term follow-up. Inferior filtering blebs and the use of antifibrotic
agents during filtration surgery increase the probability of bleb-related ocular
infection. Thin bleb walls, frequently seen after full-thickness procedures and
trabeculectomies with antimetabolites, and bleb leaks are probably associated
with an increased risk of infection.
 o Bleb-related ocular infections can affect 3 compartments: the subconjunctival
space, the anterior segment, and the vitreous cavity. The spread of infection
usually proceeds in that order. Because the fluid within the bleb is continuous
with the anterior chamber, the bleb may be considered an exteriorized portion
of the anterior chamber. Therefore, an infection of the bleb affecting the
subconjunctival space (blebitis) has the potential to rapidly spread posteriorly.
The bacteria that cause bleb-related endophthalmitis certainly arise from the
ocular flora. The most commonly involved organisms include Streptococcus
species, Haemophilus influenzae, and Staphylococcus species.
o Patients with bleb-related ocular infection usually present with ocular pain,
blurred vision, tearing, redness, and discharge. Examination often reveals
conjunctival and ciliary injection (most intense around the bleb edge); purulent
discharge; variable intensity of periorbital chemosis; corneal edema; and
anterior chamber reaction, including keratic precipitates and, in some cases,
hypopyon. The bleb typically has a milky-white appearance with loss of clarity;
a pseudohypopyon within the bleb can be observed. A positive result on the
Seidel test is common. Some patients may have a substantial leak, hypotony,
and even a flat anterior chamber. Alternatively, increased IOP is possible
because of internal closure of the sclerostomy site with purulence and debris.
Vitreous reaction is not evident in early cases of blebitis, but, if untreated, the
infection spreads to the posterior segment.
o Bleb-related ocular infections have been classified into 3 different stages. In
grade I, only bleb involvement is present. Erythema around the bleb and the
milky-white appearance of the bleb with loss of clarity is observed. In grade II,
the infection has extended into the anterior chamber, and cells and flare are
noted. Hypopyon may be seen. In grade III, the vitreous is involved. If the
media is not clear (ie, dense cataract), B-scan ultrasonography can be helpful to
detect involvement of the retrolental area.
Complications of cyclodestructive procedures
The use of cyclodestructive procedures in its various forms is typically restricted to
eyes with recalcitrant and end-stage glaucoma because of the limited predictability.
Some eyes require multiple treatments to achieve lower pressure, whereas other eyes
become hypotonus or phthisical after a single session.
The cyclodestructive procedures that are currently used are cyclocryotherapy,
noncontact Nd:YAG laser cytophotocoagulation (CPC), contact Nd:YAG laser CPC,
contact diode CPC, and endophotocoagulation. The latter techniques offer the
potential of a more controlled destruction of the ciliary body processes and a lower
incidence of complications compared with cyclocryoablation. For example, the 810-
nm semiconductor diode laser possesses the theoretic advantages of good penetration
and selective absorption by the pigmented tissues of the ciliary body.
Endophotocoagulation offers the possibility of selectively treating the ciliary body
epithelium with relative sparing of surrounding tissues.
Possible complications of cyclocryotherapy include severe pain, elevated IOP,
hyphema (common in eyes with neovascular glaucoma), visual loss (wipeout fixation
in patients with advanced optic nerve damage), choroidal detachment, retinal
detachment, chronic hypotony, cystoid macular edema, anterior segment necrosis,
vitreous hemorrhage, aqueous misdirection, cataract, lens subluxation, and phthisis.
Pain often occurs during the first 2 days after cyclocryotherapy, and strong analgesics
(narcotics) should be used.
Laser cyclodestructive procedures do not usually require strong analgesia.
A major concern after cyclodestructive procedures is the possibility of phthisis bulbi
(0-7%). Phthisis bulbi is more common in patients with neovascular glaucoma and in
patients who underwent cyclocryotherapy in 4 quadrants; it is least common after
diode laser CPC. The possibility of sympathetic ophthalmia after cyclodestructive
procedures is also a concern. Sympathetic ophthalmia has been reported after
noncontact Nd:YAG laser CPC and contact Nd:YAG laser CPC.
Complications of cyclodialysis
Cyclodialysis is not a popular procedure because of its unpredictability. Some
ophthalmologists still use it, especially in aphakic and pseudophakic glaucoma. After
the procedure, miotics are used to maintain an open cleft; cycloplegics should be
avoided. Cyclodialysis initially lowers the IOP by increasing uveoscleral outflow and
then by decreasing the formation of aqueous humor.
Common complications of cyclodialysis are intraoperative bleeding and hyphema,
which may limit its long-term success. Postoperative hypotony is associated with the
accumulation of fluid between the ciliary body and the sclera. If the accumulation of
fluid extends posteriorly, it may reach the macula, impairing visual acuity. The degree
of hypotony is not related to the length of the cleft in the angle that is observed
gonioscopically.
If visual function is compromised, cryotherapy can be used to partially close the cleft.
Cryotherapy may be ineffective, or it may induce complete closure of the cleft and
elevate IOP. Surgical closure of the cleft may be necessary. Spontaneous closure of
the cleft may occur months after a successful surgery, producing an acute rise in IOP
and pain resembling an attack of acute angle-closure glaucoma. In some cases,
intensive miotic treatment associated with phenylephrine can reopen the cleft.
Other possible complications include corneal opacity, injury to the Descemet
membrane, iridocyclitis, corectopia, lens subluxation, cataract, vitreous loss, vitreous
hemorrhage, retinal detachment, and myopic refractive shift.
Complications of trabeculotomy and goniotomy
Trabeculotomy and goniotomy are the first surgical options in treating infants with
glaucoma. Trabeculotomy is preferred when the cornea is so clouded that the angle
cannot be properly visualized. UBM can be used to evaluate the anterior chamber
angle before and after surgery in infants with glaucoma and corneal opacity.
Trabeculotomy can be a useful option in treating some adults with glaucoma.
Intraoperative complications during trabeculotomy can be attributed to difficulty in
identifying the Schlemm canal, which is more difficult to locate in infants than in
adults. The initial goal is to open the outer wall of the Schlemm canal without
perforating the inner wall into the anterior chamber. If penetration into the anterior
chamber occurs, the iris may prolapse. In this case, iridectomy may be necessary.
If the subciliary space is incorrectly probed, forward rotation into the anterior
chamber is not possible unless considerable force is exerted, causing cyclodialysis and
iridodialysis. If the tip of the trabeculotomy probe is held toward the cornea during
rotation, a tear in the Descemet membrane can occur, but it is usually small and does
not cause corneal edema.
Severe complications after trabeculotomy and goniotomy are rare. Moderate bleeding
into the anterior chamber is common. Blood clots are usually resorbed within a few
days.
Next: Outcome and Prognosis

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