**7. Mitomycin**

**3.** Peripheral iridotomies are done with Fugo blade. The important thing is to wash out completely all the pigment/debris produced during iridotomy, because even a small par‐

**5.** Push away any subconjunctival fluid close to the limbus, by sweeping with a cannula.

**7.** Healaflow may be deposited under the conjunctiva if so desired, at this stage.

**8.** A small air bubble is placed in the anterior chamber. It pushes out some NaHa and aque‐

**Figure 19.** A naked 75 micron Fugo blade tip kept close to the conjunctiva retracting sapphire blunt blade, passes through the conjunctiva and limbus as soon as it is activated.The bleb forms slowly. Air is injected in the anterior

**6.** For MTF, use a 75 micron naked filament Fugo blade tip.Push the conjunctiva towards the cornea, with a blunt sapphire knife. When the limbal area is clearly seen, the activated tip is passed through the conjunctiva and the limbus in to the anterior chamber. The aqueous does not come out, but the track making is complete,since cavitation bubbles are seen to arise in the anterior chamber. One can make two or more tracks if so desired. A second track can not be made if aqueous has started flowing out, because the naked tip does not work in the water. NaHa in the anterior chamber helps make more than one

ticle can block the filtration track from inside.

**4.** Fill the upper part of anterior chamber with NaHa.

ous, proving that the system is working.

track.

462 Glaucoma - Basic and Clinical Aspects

chamber at the end.

MMC reduces scar formation. This helps to improve results. Unlike other surgical techni‐ ques in which MMC is applied under the conjunctiva with sponges, we raise a bleb with 0.1 to 0.2 ml of a desired concentration of MMC. This assures a wider spread that results in a borderless bleb.Our OCT observations of the blebs show that MTF cases maintain a healthy cover of the conjunctiva. There is no danger of bleb leakage, because no conjunctival flap is made. MMC concentration has been used varying from 0.005 % to 0.04 %. The higher risk cases receive higher concentration of MMC. The deposited MMC is left as such,its dilution starts as soon as the track is made and aqueous starts draining. The mainstream glaucoma surgery does not give a thought to lymphatics. We believe that they are the crux of success‐ ful filtration surgery. It is a great satisfaction that they are not damaged by MMC with the concentration used. An MTF opening is small compared to tracks made with other techni‐ ques. Therefore it is all the more important that it should not get scarred on the outside.

**8. A bandage contact lens**

lens riding over track area

how the iris has blocked the track from inside.

A bandage lens provides a soft lid over the external opening of MTF. It helps to maintain the depth of the anterior chamber. At the time of surgery there is already formed a bleb that pre‐ vents it from occupying its intended place. However, after 3-4 hours, when the taped eye is opened, the bandage lens shall be found sitting over the track. The bandage lens may be re‐ moved after a week or two. If no bleb is seen under the bandage lens, it is a sign that some‐

Minimally Invasive Glaucoma Surgery – Strategies for Success

http://dx.doi.org/10.5772/54421

465

**Figure 22.** A bandage lens over two MTF tracks.The anterior chamber has good depth.OCT shows a bandage contact

**Figure 21.** A 35 years old case of MTF, shows the presence of filled lymphatics under the conjunctiva, one month after surgery, both on slit lamp optical section and with OCT. The OCT image is particularly striking. IOP is 9 mm, down from 35 mm.
