Pakistan Journal of Ophthalmology Vol. 31, No. 4, Oct – Dec, 2015 207 Original Article Role of Laser Suture Lysis in Immediate Trabeculectomy Failure Syed Imtiaz Ali Shah, Shujaat Ali Shah, Partab Rai, Shahid Jamal Siddiqui, Safdar Ali Abbasi, Dure Yakta Shaikh Pak J Ophthalmol 2015, Vol. 31 No. 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Syed Imtiaz Ali Shah Professor, Department of Ophthalmology, Chandka Medical College Larkana syedimtiazalinaqvi@yahoo.com …..……………………….. Purpose: To study the role of laser suture lysis in immediate trabeculectomy failure. Material and Methods: This was a prospective case series study conducted at Department of Ophthalmology, Chandka Medical College Hospital Larkana, Pakistan from May 2007 to May 2015. 21 eyes of 20 patients who underwent trabeculectomy for primary open angle glaucoma and encountered immediate trabeculectomy failure were included in the study. Immediate trabeculectomy failure was considered when IOP during first 48 hours after trabeculectomy remained above 25 mm Hg. Laser suture lysis was carried out with Nd: YAG Laser (1064 nm) or with frequency doubled Nd: YAG Laser (532 nm). The pre- procedure and post-procedure IOP was noted and IOP below 18 mm Hg was considered as successful laser suture lysis. Data entry and analysis was done on SPSS version 20. Results: 12 (60 %) patients out of the total 20 patients were males and 8 (40 %) were females. The mean age ± standard deviation of patients was 61.45 ± 7.37 years and the age range was 47 to 71 years. IOP came down to normal in all the cases after the laser suture lysis, without encountering any major complications. Mean IOP before laser suture lysis was 30.95 ± 2.20 mm Hg and mean IOP one hour after successful laser suture lysis was 13.38 ± 1.53 mm Hg. Conclusion: Laser suture lysis is a safe, effective and day care procedure in the management of immediate trabeculectomy failure. Keywords: Glaucoma, Trabeculectomy, failure, laser, suture. rabeculectomy, described firstly by Cairns in 1968,1 is currently the most popular and widely performed surgery for the treatment of glaucoma.2 Despite the advancements in techniques and instruments, trabeculectomy failure remains a significant problem. The rate of trabeculectomy or bleb failure has been reported to be around 10 – 20%.4-6 Trabeculectomy failure may be early (within one month of surgery) or late (after one month of surgery), the latter being more common8. The importance of early trabeculectomy failure lies in immediate detection and management. These cases can only be detected when either a sign of raised IOP is picked up within first 48 hours or a habit of assessment of IOP during immediate postoperative period is developed. Once this complication occurs and remains undetected, it eventually ends up in resorting to more invasive procedures to control IOP, like another surgical procedure with enhancements, including use of cytotoxic medications (MMC14,15 and 5-FU16,17) and implants.18,19 Topical steroids, 5-florouracil (5-FU), ocular massage.3 releasable sutures9, 10 and laser suture lysis11-13 all have been used for the management of early trabeculectomy failure. We took up this study to see the role of laser suture lysis in immediate trabeculectomy failure. T SYED IMTIAZ ALI SHAH, et al 208 Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology MATERIAL AND METHODS This prospective case series study was conducted at Department of Ophthalmology, Chandka Medical College Hospital Larkana Pakistan from May 2007 to May 2015. Patients of immediate trabeculectomy failure who underwent trabeculectomy for primary open angle glaucoma were included in the study; immediate trabeculectomy failure was considered when IOP during first 48 hours after trabeculectomy remained above 25 mm Hg. We picked up 21 eyes of 20 patients with immediate trabeculectomy failure, out of 367 eyes of 321 patients undergoing trabeculectomy for primary open angle glaucoma; with the mean immediate failure rate of 5.72%. Patients with primary angle closure glaucoma and secondary glaucoma were excluded from the study. All patients underwent trabeculectomy by the first author. Limbal based conjunctival flaps were created and blunt dissection was done followed by wet field cautery to the sclera for acquiring a clear field and securing hemostasis. A 5 × 5 mm triangular scleral flap was formed, an internal window of 1 × 3 mm was created and a peripheral iridectomy was performed. The scleral flap was sutured with three 8/0 silk or 10/0 nylon sutures and the conjunctiva was stitched with buried 8/0 silk sutures. A subconjunctival injection of antibiotic and steroid combination was given at the end of the procedure. Laser suture lysis was carried out with Nd: YAG Laser (1064 nm) or with frequency doubled Nd: YAG Laser (532 nm). 2 to 2.5 milijoules energy was used when Nd: YAG Laser was utilized and 300 to 400 milivolt energy was used when frequency doubled Nd: YAG Laser was utilized. Laser suture lysis of one edge suture of the triangular scleral flap was done and IOP was recorded after 5 minutes. If IOP did not fall, ocular massage was carried out and if IOP still remained high, another edge suture lysis was carried out followed by ocular massage till the IOP came down to below 18 mm Hg, which was considered as normal IOP and the procedure was considered successful. The pre-procedure and post-procedure IOP was noted and data entry and analysis was done on SPSS version 20. RESULTS 21 eyes of 20 patients undergoing trabeculectomy for primary open angle glaucoma with immediate trabeculectomy failure were included in the study. 12 (60%) patients were males and 8 (40%) were females (Fig. 1). The mean age ± standard deviation of patients was 61.45 ± 7.37 years and the age range was 47 to 71 years. Laser suture lysis was performed within the first week after the trabeculectomy surgery. IOP came down to normal in all the cases, after laser lysis of one suture in 15 (71.43%) eyes and after laser lysis of two sutures in 6 (28.57%) eyes. Mean IOP before laser suture lysis was 30.95 ± 2.20 mm Hg and mean IOP one hour after successful laser suture lysis was 13.38 ± 1.53 mm Hg (Fig: 2). Only two complications were Fig. 1: Age distribution of patients. Fig. 2: Mean IOP before and after laser application. (± 1.53 mm Hg) 990 (± Standard deviation) ROLE OF LASER SUTURE LYSIS IN IMMEDIATE TRABECULECTOMY FAILURE Pakistan Journal of Ophthalmology Vol. 31, No. 4, Oct – Dec, 2015 209 noted after the procedure, which were patient dissatisfaction in 2 cases and bleeding at the sight of laser application in 4 eyes (Table 1), which settled with conservative measures. DISCUSSION The technique of laser suture lysis was initially reported in 1983 by Lieberman13 with a goniolens and then in 1984 by Hoskins and Migliazzo7 with a special lens developed by them for the management of failing filtering blebs. A previous study by Downes SM et al20 has observed that patients at risk of developing trabeculectomy failure can be identified in the early postoperative period on the basis of IOP. This study noted that patients with initial postoperative IOP of greater than 17 mm Hg had increased chances of going into trabeculectomy failure and those patients having initial postoperative IOP lesser than 17 mm Hg had increased chances of a successful trabeculectomy and long term IOP control. This fact shows the importance of adequate drainage immediately after trabeculec- tomy and the probable role of laser suture lysis in preventing not only the immediate trabeculectomy failure but late trabeculectomy failure as well. Laser suture lysis is most successful in IOP reduction when it is performed within two weeks of trabeculectomy. Macken P et al21 have reported many complications in their study on laser suture lysis such as flat anterior chamber, external aqueous leak, iris incarceration, hyphaema, malignant glaucoma and excessive bleb elevation. Similarly other studies have reported ocular hypotony with laser suture lysis after the use of antimetabolites in trabeculectomy,24,25 but in our study we came across minor complications. It seems that laser suture lysis results in more complications in eyes which have undergone trabeculectomy with antimetabolites. Overall our study shows that laser suture lysis is an efficient method for the management of immediate trabeculectomy failure as is reported by other studies.7,13,22,23 CONCLUSION Laser suture lysis is a safe and effective procedure in the management of immediate trabeculectomy failure. It avoids the need of invasive methods and their resultant risks and complications. It is an outpatient procedure, does not require any special expertise and does not need anesthesia. Author’s Affiliation Dr. Syed Imtiaz Ali Shah Professor of Ophthalmology Chandka Medical College, Larkana Dr. Shujaat Ali Shah Trainee Registrar Department of Ophthalmology Chandka Medical College Larkana Dr. Partab Rai Professor of Ophthalmology Chandka Medical College Larkana Dr. Shahid Jamal Siddiqui Professor & Chairman Department of Ophthalmology Chandka Medical College Larkana Dr. Safdar Ali Abbasi Registrar Department of Ophthalmology Chandka Medical College Larkana Dr. Dure Yakta Shaikh Assistant Professor Department of Ophthalmology Chandka Medical College Larkana Role of Authors Dr. Syed Imtiaz Ali Shah Substantial contribution to conception and design, acquisition of data, analysis and interpretation of data for intellectual content. Dr. Shujaat Ali Shah Drafted and revised the manuscript, reviewed the figures, contributed to conception and design, acquisition of data, analysis and interpretation of data. Dr. Partab Rai Contributed to acquisition of data, analysis and interpretation of data and final approval of the study for publication. Dr. Shahid Jamal Siddiqui Revised the study critically and contributed to acquisition of data. Dr. Safdar Ali Abbasi Reviewed the manuscript and contributed to acquisition of data. Dr. Dure Yakta Shaikh Contributed to acquisition of data. SYED IMTIAZ ALI SHAH, et al 210 Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology REFERENCES 1. Cairns JE. Trabeculectomy, preliminary report of a new method. Am J Ophthalmol. 1968; 66: 673-9. 2. Al Habash A, Aljasim LA, Owaidhah O, Edward DP. A review of the efficacy of mitomycin C in glaucoma filtration surgery. Clin Ophthalmol. 2015; 9: 1945-51. 3. Ali M, Akhtar F. 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