**10. Failed trabeculectomy**

The following is a description of a forty years old male who had a failed trabeculectomy sur‐ gery.IOP was 41 mm. under multiple medications. The

scleral flap was clearly visible and there was no trace of a bleb.The surgery was done as un‐ der:

The conjunctiva was raised with MMC 0.01%. A 100 micron microtrack was made close to the failed area followed by air injection in the anterior chamber.A 300 micron Fugo blade was then used to make a conjunctival opening 7-8 mm proximal to the upper edge of the closed scleral flap.The tip was pushed to the edge of the scleral flap.The tip was activated and insinuated under the edge of closed scleral flap at many places.The subscleral space communication with the anterior chamber was assured. 4 months postoperative, the IOP was 12 mm and the bleb was good.

**Figure 23.** Failed trabeculectomy case, 4 months after MTF and opening the scleral flap with Fugo blade. OCT shows

Minimally Invasive Glaucoma Surgery – Strategies for Success

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467

TCTCF is the least traumatic way of filtration surgery in neovascular glaucoma.The track avoids the new vessel formation in the iris and angle.Decompression may start bleeding in

the angle, but it does not affect the filtration through TCF track.

that the bleb is well made and safe.

**10.1. Neovascular glaucoma**

The movie of this patient is here:

http://youtu.be/T72kVgNeKzY

There are more movies on this topic:

http://www.youtube.com/watch?v=HxZravthPGI

http://www.youtube.com/watch?v=jn7ojuYbmaE

Management of Tenon cyst formation after TCFTCF:

http://www.youtube.com/watch?v=Bo3crwrpUDg

**Figure 23.** Failed trabeculectomy case, 4 months after MTF and opening the scleral flap with Fugo blade. OCT shows that the bleb is well made and safe.

#### **10.1. Neovascular glaucoma**

**9. Comments**

466 Glaucoma - Basic and Clinical Aspects

cation.

der:

**10. Failed trabeculectomy**

was 12 mm and the bleb was good.

There are more movies on this topic:

http://www.youtube.com/watch?v=HxZravthPGI

http://www.youtube.com/watch?v=jn7ojuYbmaE

Management of Tenon cyst formation after TCFTCF:

http://www.youtube.com/watch?v=Bo3crwrpUDg

The movie of this patient is here:

http://youtu.be/T72kVgNeKzY

gery.IOP was 41 mm. under multiple medications. The

From the foregoing description many points are clear. MTF is the least traumatic of all filtra‐ tion operations. Currently we are making 150 to 250 micron filtration tracks. We are trying to cope with the frequent problem of internal block by iris, which has to be cleared with YAG laser. YAG laser management of iris block is a minor intervention.But think of the worldwide lack of YAG lasers in clinics and far off places. All the various strategies descri‐ bed above are attempts to keep the iris away. At the same time filtration should continue. I do all my filtration surgery with a 6X head-worn loupe/microscope. Thus it is possible to perform MTF in any remote area, where the light source shall be a hand held bright LED flash light.No dissection filtration surgery protects conjunctival lymphatics.There is an ever increasing load of tens of millions of glaucoma patients, who can not afford life long medi‐

Now let us consider, minimally traumatic filtration surgery in some specific situations.

The following is a description of a forty years old male who had a failed trabeculectomy sur‐

scleral flap was clearly visible and there was no trace of a bleb.The surgery was done as un‐

The conjunctiva was raised with MMC 0.01%. A 100 micron microtrack was made close to the failed area followed by air injection in the anterior chamber.A 300 micron Fugo blade was then used to make a conjunctival opening 7-8 mm proximal to the upper edge of the closed scleral flap.The tip was pushed to the edge of the scleral flap.The tip was activated and insinuated under the edge of closed scleral flap at many places.The subscleral space communication with the anterior chamber was assured. 4 months postoperative, the IOP

> TCTCF is the least traumatic way of filtration surgery in neovascular glaucoma.The track avoids the new vessel formation in the iris and angle.Decompression may start bleeding in the angle, but it does not affect the filtration through TCF track.

A film on TCTCF in an already failed glaucoma surgery is seen here:

http://www.youtube.com/watch?v=uO57F9gdTU4

#### **10.2. Buphthalmos**

Buphthalmos is one of the most difficult conditions to treat. Failures are common. Therefore it is important that any glaucoma surgery should not leave behind a large foot print on the sclera and the overlying tissues. With the standard approaches, we run short of surgical space and options very soon. Then comes the turn of destructive procedures. Our technique of choice is MTF with or without additional measures to improve chances of success.TCTCF is less commonly employed. The surgery might succeed on the very first attempt or after many attempts. There always remains a chance of successfully doing another atraumatic fil‐ tration operation.

**10.3. Pseudophakic pupil block glaucoma**

A few films on the topic are seen here:

**11. Concluding remarks**

medications and devices.

**Author details**

Daljit Singh

**References**

3

block. This may be followed by MTF or TCTCF.

http://www.youtube.com/watch?v=etyBCd4pWoU http://www.youtube.com/watch?v=CtgNZGwFOJU http://www.youtube.com/watch?v=8R\_n729PWno

MTF tracks. As yet there is no other tool that can do the same.

Guru Nanak Dev University, Amritsar, India

Blade. Ann Ophthalmol. 2008; 40,1; 8-14

Through one or more 0.7 mm pocket incisions in the cornea, Fugo blade 100 micron glauco‐ ma tip is introduced and many iridotomies are done to completely overcome the pupillary

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469

An estimated 80 million (and increasing by millions every year) cases of glaucoma patients worldwide are a challenge to the ingenuity of the surgeons and the producers of glaucoma

We have understood the presence and importance of lymphatics under the conjunctiva and in the adjoining tissues. We have tried to preserve the lymphatics by minimally invasive techniques of TCTCF and especially MTF. Besides new surgical innovations, we have also made use of newer viscoelastic and spongy materials in the hope of preserving the filtration tracks as well as saving the conjunctival lymphatics. Much work/research remains to be done before we and other workers in the field can declare a victory over the worldwide blinding epidemic of glaucoma. Needless to say, Fugo blade is helpful in making TCF and

[1] Bethke WC. A New Clue to Lymphatic Drainage? Review of Ophthalmology. 2002; 9,

[2] Dow T, Devenecia G. Transciliary Filtration (Singh Filtration) with the Fugo Plasma

[3] Eisenstein P. World's Smallest Knives. Popular Mechanics. 2003; 180, 10; 56-8.

**Figure 24.** A ten year old buphthalmos child who had MTF 5 years before. The surgery was successful on the very first attempt. In both eyes IOP is 12 mm without medication.MMC 0.01 was used to balloon the conjunctiva at the begin‐ ning of surgery. There was a wait period of 4 minutes, before MTF was done.

A few films on MTF in buphthalmos are here:

MTF for buphthalmos, Healaflow put under the conjunctiva at the end:

http://www.youtube.com/watch?v=glddXJmSOeg

TCTCF in a case of pediatric glaucoma (patient 10 years old).Mitomycin injected under the conjunctiva at the end:

http://www.youtube.com/watch?v=Xfe6ac659Xc

Another MTF for buphthalmos:

http://www.youtube.com/watch?v=ezIJ\_8HIeMM

Micro-spherophakia and buphthalmos:

http://www.youtube.com/watch?v=yM-raYTKdcg&feature=relmfu

#### **10.3. Pseudophakic pupil block glaucoma**

A film on TCTCF in an already failed glaucoma surgery is seen here:

Buphthalmos is one of the most difficult conditions to treat. Failures are common. Therefore it is important that any glaucoma surgery should not leave behind a large foot print on the sclera and the overlying tissues. With the standard approaches, we run short of surgical space and options very soon. Then comes the turn of destructive procedures. Our technique of choice is MTF with or without additional measures to improve chances of success.TCTCF is less commonly employed. The surgery might succeed on the very first attempt or after many attempts. There always remains a chance of successfully doing another atraumatic fil‐

**Figure 24.** A ten year old buphthalmos child who had MTF 5 years before. The surgery was successful on the very first attempt. In both eyes IOP is 12 mm without medication.MMC 0.01 was used to balloon the conjunctiva at the begin‐

TCTCF in a case of pediatric glaucoma (patient 10 years old).Mitomycin injected under the

ning of surgery. There was a wait period of 4 minutes, before MTF was done.

MTF for buphthalmos, Healaflow put under the conjunctiva at the end:

http://www.youtube.com/watch?v=yM-raYTKdcg&feature=relmfu

A few films on MTF in buphthalmos are here:

conjunctiva at the end:

Another MTF for buphthalmos:

Micro-spherophakia and buphthalmos:

http://www.youtube.com/watch?v=glddXJmSOeg

http://www.youtube.com/watch?v=Xfe6ac659Xc

http://www.youtube.com/watch?v=ezIJ\_8HIeMM

http://www.youtube.com/watch?v=uO57F9gdTU4

**10.2. Buphthalmos**

468 Glaucoma - Basic and Clinical Aspects

tration operation.

Through one or more 0.7 mm pocket incisions in the cornea, Fugo blade 100 micron glauco‐ ma tip is introduced and many iridotomies are done to completely overcome the pupillary block. This may be followed by MTF or TCTCF.

A few films on the topic are seen here: http://www.youtube.com/watch?v=etyBCd4pWoU http://www.youtube.com/watch?v=CtgNZGwFOJU http://www.youtube.com/watch?v=8R\_n729PWno
