Chapter 243 – Complications of Glaucoma Surgery and Their Management
J. WILLIAM DOYLE
M. FRAN SMITH
In the ideal world, surgery proceeds smoothly and outcomes are uncomplicated. Unfortunately, in the real world, despite a surgeon’s best efforts, complications may occur. This is especially true in the field of glaucoma—glaucoma surgery, unlike many other ocular procedures, is not particularly “forgiving” in nature. Nonetheless, good final outcomes may often be achieved in spite of the occurrence of complications. The key to success is for the surgeon to be alert and be able to identify and address any problems promptly.
Before the discussion of complication management in filtration surgery, it is worth repeating an old surgical axiom. Without a doubt, the best surgical complication management is avoidance of the complication in the first place. Preoperatively, ensure that the patient stops the intake of all aspirin-like products, and discontinue topical epinephrine (adrenaline) compounds to decrease the quantity of superficial bleeding. Consider the use of preoperative topical antibiotics. Intraoperatively, meticulous attention to detail is important, especially if antimetabolites are being used. It is imperative to handle the conjunctiva gently. When the partial-thickness trabeculectomy flap is being closed, consider using extra, releasable-style sutures. If intraocular pressure (IOP) is too high postoperatively, a stitch may be pulled easily. But if too much drainage occurs postoperatively, an insidious cycle of overdrainage may be established—and this cannot always be corrected readily.
Nonetheless, complications intermittently occur. Filtration surgery complications are most easily categorized as intraoperative, early postoperative, and late postoperative.
In no other situation is the axiom given before more appropriate—the best complication management of the buttonhole is initial avoidance of the complication. Toothed forceps are the problem here—they should not be on the glaucoma tray. Bishop-Harmon or suture-tying forceps are preferable when conjunctiva is handled. Better yet, the use of a dry cellulose sponge, with its tip cut off, to stretch conjunctiva up and away from the area of interest is safe. If a buttonhole occurs anyway, management requires patient, complete hole closure if successful surgery is to ensue. If a buttonhole cannot be closed in a watertight fashion and detection of the hole has occurred early in the surgery, consideration must be given to rotation of the site of the trabeculectomy flap to a different area, away from the hole. Also, if antimetabolite use was planned but not initiated prior to discovery of the buttonhole, the surgeon must consider no exposure, or limited exposure, to antimetabolite, applied well away from the buttonhole.
Closure technique for a conjunctival buttonhole depends on its location, size, and shape. The most easily closed buttonhole
Figure 243-1 Repair of buttonhole close to limbus.
Figure 243-2 Two-layer closure of intraoperative buttonhole in central bleb zone. Following Tenon’s layer closure, conjunctiva is closed.
is the short limbal tear, which may be closed with a horizontal mattress suture of double-armed 10-0 nylon. Cornea just anterior to the tear is deepithelialized. One arm of the suture is passed to one side of the hole, through conjunctiva and partial-thickness anterior Tenon’s layer, and into the cornea in front of the tear. The other needle of the double-armed suture is passed similarly on the other side of the hole. When the two ends are tied, conjunctiva is pulled safely down, with considerable overlap, onto clear cornea. The deepithelialized cornea quickly heals to the underside of the overlapped conjunctiva ( Fig. 243-1 ).
Linear tears of conjunctiva away from the limbus are probably best closed in two layers with a running suture. An 8-0 polyglactin suture on a vascular needle is used first to close Tenon’s layer, from the Tenon’s layer side. For conjunctival layer closure, the conjunctival flap is flapped over and 10-0 or 11-0 nylon sutures are used, preferably on a vascular needle ( Fig. 243-2 ). Similarly, small, round holes can be closed using a two-layer technique and purse-stringing the suture around the hole.
Figure 243-3 Peripheral intraoperative buttonhole closure. Repair by inclusion in conjunctival incision closure.
Finally, linear tears in conjunctiva near a fornix incision are frequently best addressed by incorporation of the tear into the final incision closure (see Fig. 243-3 ).
After buttonhole repair, it is essential that watertightness be tested before proceeding further. Balanced salt solution may be squirted vigorously at one side of the closure and any seepage through to the other side carefully sought. Also, after final incision closure, it is best to recheck for leakage using fluorescein dye. Inflation of the bleb with balanced salt solution through the corneal paracentesis and application of fluorescein dye is a simple way to mark any leaks. The time to address such leaks is while the patient has good anesthesia and is still in the operating room. Postoperatively, when inflammation occurs and the conjunctiva has become thinned because of aqueous flow, definitive surgical repair may not be possible.
TRABECULECTOMY SCLERAL FLAP TEAR/DISINSERTION.
Occasionally, despite the surgeon’s attempt to dissect up a sufficiently thick (about two thirds of the total scleral thickness) scleral flap, tissues are such that a “ratty” flap is produced. These flaps tend to tear or disinsert. If the tear is found early and is small enough, direct suture closure using 10-0 nylon may be attempted. Similarly, if the flap base is disinserted partially, an attempt may be made to reposit the flap using a double-armed horizontal mattress suture externalized through clear cornea ( Fig. 243-4 ). Some surgeons have reported successful reposition of a totally disinserted flap using two 10-0 nylon sutures through the flap base and out the peripheral cornea. However, total disinsertion and large tears are usually a reflection of exceptionally poor quality (ratty) sclera; such flaps do not tolerate sutures well and tend to “cheesewire,” which results in larger defects. Rather, this complication may be best addressed by placement of an additional cover over the problem flap.
Tenon’s tissue is readily available in all eyes. The surgeon may choose to excise a 4 × 3?mm piece of redundant Tenon’s tissue from up in the superior fornix near the incision or alternatively from the inferior fornix if excess tissue is not present superiorly. This excised rectangular piece of tissue may be sutured at its four corners over the full-thickness sclerotomy.  If excess leakage is noted after anterior chamber reformation, additional sutures may be placed. Other choices of coverage material are donor sclera, dura, pericardium, or even fascia lata. Most operating rooms have at least one of these materials present in a convenient prepackaged form. The material is hydrated in balanced salt solution, a rectangle of material (approximately 2?mm larger and wider than the trabeculectomy flap) is cut out, and the cover is sutured into place, with at least one 10-0 nylon suture to each corner of the material. Postoperatively, these sutures may be lysed using an argon laser to increase drainage as desired, so secure closure on the operating table is warranted ( Fig. 243-5 ).
Especially in pseudophakes after complicated cataract extraction or in aphakes, the surgeon may encounter vitreous prolapse after the iridectomy. Careful clearance
Figure 243-4 Repair of disinserted flap.
Figure 243-5 Donor dura flap to replace disinserted flap.
from the sclerotomy of all vitreous is key because vitreous is a very effective sclerotomy plug. A limited vitrectomy with a combination of scissors dissection, cellulose sponge, and automated vitrector should be performed. The goal is no vitreous present at the sclerotomy when checked using a cellulose sponge. Extra care is required in these eyes to avoid a postoperative shallow anterior chamber because this may bring further vitreous forward to block the sclerotomy. Therefore, consider the placement of extra releasable sutures (or sutures that may be lasered) to prevent early overdrainage.
Excess bleeding from the iris root and/or ciliary body after iridectomy must be addressed because blood may also cause sclerotomy blockage. Cold balanced salt solution, dripped slowly over several minutes, with or without low-concentration epinephrine added, usually results in stoppage of the bleeding. Alternatively, a monopolar wet-field 23gauge cautery may be applied carefully to the bleeding vessel if the site can be visualized. It is rare for these areas to rebleed postoperatively, but if they do, it is usually in situations with hypotony; again, a tight closure with extra releasable sutures is considered. Viscoelastic material can be left in the eye at the conclusion of surgery to act as a “tamponade” and also to help avoid postoperative hypotony.
Suprachoroidal hemorrhage (SCH) is the other type of intraoperative bleeding. In these cases the eye should be closed as quickly as possible. Avoidance is paramount because an expulsive
SCH is disastrous. Preoperative intravenous mannitol (100?ml of 20% solution over 15 minutes), with Foley catheter placement, may be considered in eyes that undergo trabeculectomy with a preoperative IOP >40?mmHg (5.3?kPa). Theoretically, less chance exists of SCH if eye pressure at the time of internal sclerotomy does not suddenly drop from 45?mmHg (6.0?kPa) to zero. In addition, the paracentesis may be performed earlier to decompress the eye gradually prior to internal block removal.
Usually effusions develop postoperatively, not intraoperatively. However, patients who have Sturge-Weber syndrome or markedly elevated episcleral venous pressure may develop effusions intraoperatively. Their occurrence is signaled by sudden anterior chamber shallowing. Management consists of drainage via inferior linear sclerotomies, located 5–6?mm from the limbus. If the plan is to carry out surgery on the second eye of a patient who has developed intraoperative choroidal effusions in the first eye (the disease is bilateral), placement of a preliminary posterior sclerotomy prior to internal block removal may be considered.
Early Postoperative Complications
In the early postoperative period, initial underdrainage, not associated with sclerotomy blockage, is addressed effectively by sequential release of scleral flap sutures. If so-called permanent sutures have been placed, the 10-0 nylon may be lysed with the argon laser and a Hoskins (or Ritch) lens. Krypton red (or blue-green argon), 50?µm spots, at 300?mW are usually effective. Rarely, a nylon suture cannot be visualized, secondary to overlying subconjunctival hemorrhage or thick Tenon’s tissue. To avoid this occurrence, place at least half of the scleral flap sutures using a “releasable”-suture technique.  This involves tying the suture with a slip knot that may be released easily with a pull on the cornealized free suture end ( Fig. 243-6 ). Because endophthalmitis has been reported to develop from a freely moving, cornealized releasable suture, the externalized suture end must be buried in clear cornea. The superficial unburied segment of the suture is epithelialized quickly, which decreases risk of endophthalmitis and still allows the surgeon easy assess. To maintain expansion of the subconjunctival space with fluid (aqueous) in the early postoperative period, and when it is too early to lyse a stitch, another option is local scleral compression. This involves gentle application of pressure over the conjunctiva using a moistened cotton-tip applicator, just at the edge of the scleral flap. Such pressure “burps” free an aliquot of aqueous, which lowers IOP. Gonioscopy is recommended to check that the internal sclerostomy is not blocked by vitreous, iris, and so forth.
A blocked sclerotomy is handled differently. If fibrin or blood blocks outflow, tissue plasminogen activator may be helpful. 
Figure 243-6 Releasable sutures (arrow).
Doses of 6–25?µl have been injected into the anterior chamber safely, with resumption of flow through the sclerotomy. Because recurrent bleeding is a risk with tissue plasminogen activator use, lower doses, 6–12?µl, are now recommended. Also, fibrin frequently recurs unless high-dose corticosteroids, topical, subconjunctival, and/or oral, are used to reduce inflammation.
THE SHALLOW ANTERIOR CHAMBER.
If a shallow anterior chamber is present, the reason for shallowing—overdrainage or some other process—must be ascertained. Overdrainage is associated with low IOP, which usually results from inadequate scleral flap closure (with a high bleb present) or from a bleb leak (no or low bleb present).
Overdrainage with no bleb leak can be tedious to manage. If the bleb is high and no corneal-lens touch or “kissing” choroidal effusion occurs, observation with cycloplegic prescription is appropriate. However, if anterior chamber shallowing is progressive, early placement of an oversized, bandage soft contact lens may help to prevent later, more difficult problems.  Such lenses seem to limit excessive bleb extension and/or excess bleb transconjunctival aqueous flow ( Fig. 243-7 ). Usually, their use may be discontinued after 1–2 weeks. Alternatively, a Simmon’s shell may be applied to the eye. The shell has a plate that can be positioned over the sclerotomy site for maximum tamponade. However, patients may tolerate it poorly, and daily ocular examination is required. Also, corneal epithelial defects occur frequently.
Another option some surgeons use in these cases is gentle pressure patching, in which pressure is applied directly over the trabeculectomy flap to limit outflow. One concern with this option is that, when the patient looks up (or exhibits Bell’s phenomenon, with sleep), the pressure patch may transfer pressure over the cornea, which results in lens-corneal touch. Sometimes, injection of viscoelastic material into the anterior chamber may provide sufficient time (24–48 hours) to allow the eye to “catch up” with itself. We have found greater viscosity viscoelastic to be particularly useful in such cases. This is best attempted early, rather than late, in the course. Finally, if overdrainage continues with the development of choroidal effusions that touch, or of lens-corneal touch, the surgeon may need to return the patient to the operating room for further flap closure, anterior chamber reformation, and effusion drainage.
Initial overdrainage with bleb leak is frequently the result of a buttonhole missed at the time of surgery. Postoperatively, a buttonhole is far more difficult to manage. As already noted, suture repair at this time is often ineffective, especially if intraoperative antimetabolites were used and/or the conjunctiva is cystic or excessively thinned. Suturing at this time may result in a larger hole. Patching, bandage soft contact lenses, and Simmon’s shell may be used, with variable results. The surgeon must watch the bleb carefully because the preceding “solutions” often fail to
Figure 243-7 A 17?mm contact lens compresses an overdraining bleb. Edge of bandage contact lens indicated by arrows.
seal the leak and only act to exacerbate episcleral/conjunctival healing and adhesion. Other alternatives include autologous fibrin tissue glue, autologous blood injection (see Fig. 243-8 ),   and cyanoacrylate glue with contact lens application.  Most of these alternatives seem to work better on small, late-postoperative bleb leaks. A large, early-postoperative bleb leak may require a return to the operating room and development of a new conjunctival flap from “buttonhole-free” conjunctiva.
Remaining causes of an early-postoperative shallow chamber, other than overdrainage, are basically five, one with low IOP and four with high IOP. Most rarely, the ciliary body may shut down secondary to intense postoperative inflammation. Such eyes have flat blebs, no bleb leaks, shallow anterior chambers, low IOP, and occasionally inflammatory choroidal effusions. High-dose topical, peribulbar, and systemic corticosteroids may be helpful in these cases. Postoperative 5-fluorouracil injections should be considered because they may help prevent conjunctival-episcleral adhesions in the period before aqueous flow restarts.
A shallow anterior chamber associated with a high IOP results from one of four causes only:
• Pupillary block
• Aqueous misdirection malignant glaucoma
• Ring choroidal effusion (rare)
If a full-thickness iridectomy was made at the time of surgery, pupillary block can be ruled out. However, if doubt exists with regard to the surgical iridectomy patency and the preceding scenario exists, the surgeon must perform another (laser) iridectomy as soon as possible. Only then can pupillary block be ruled out. Once pupillary block is excluded, the surgeon must examine for the presence of an SCH, which is more likely to occur in elderly, vitrectomized, aphakic, hypotonous eyes. Usually, diagnosis is made easily by indirect ophthalmoscopy, with observation of the characteristic dark choroidal swellings and the patient’s history of pain, nausea, and vomiting. If ophthalmoscopy is impossible, a B-scan ultrasound examination is carried out ( Fig. 243-9 ). If SCH is diagnosed, therapeutic options include observation and corticosteroid prescription if the patient is not too uncomfortable and there is no choroidal or lens-corneal touch. Again, 5-fluorouracil injections may be considered to prevent scarring of the sclerotomy while the SCH resolves. Otherwise, it may be best to return the patient to the operating room for evacuation of the SCH. This is best accomplished no sooner than postoperative day 7–10, at which time clot lysis has usually begun, which allows easier SCH drainage.
Another cause of a shallow anterior chamber, with associated high IOP, is aqueous misdirection. Once called malignant glaucoma, it is indeed a malignant process to treat. Aqueous misdirection
Figure 243-8 Peribleb autologous blood injection for leak.
(as discussed in Chapter 229 ) is the syndrome characterized by marked anterior displacement of the lens-iris diaphragm with a high IOP, presumably as a result of trapped misdirected posterior aqueous. If prompt treatment is initiated, perhaps 50% of mild cases resolve with intensive cycloplegic therapy (i.e., atropine 1%, one drop every 5 minutes for a total of three drops, four times a day). Also, to relieve the buildup of what is believed to be misdirected aqueous trapped behind the vitreous face, many surgeons recommend aqueous suppressants and/or osmotics. Other useful medical adjuncts include phenylephrine 2.5% four times a day and prednisolone acetate every 2 hours for inflammation. If this is unsuccessful and the patient is aphakic or pseudophakic, laser therapy is an option.
Finally, although rare, anterior ring choroidal effusion has been described as a cause of shallow anterior chamber associated with high IOP. B-scan confirms this diagnosis.
Although classical posterior choroidal effusions often occur in conjunction with a shallow anterior chamber and low IOP, they may also occur in eyes that have full-depth chambers and low IOPs. Management usually consists of cycloplegia, topical corticosteroids, and observation. As long as the effusions do not touch, drainage is not required. If touch does occur centrally, because of the danger of retinal adhesion formation, many surgeons choose to perform effusion drainage via posterior sclerotomies inferiorly. The scleral flap may be revised at the time of choroidal drainage to prevent further hypotony and a recurrence of the effusions. Several permanent or releasable sutures may be enough to reduce leakage in the short term.
In this era of antimetabolite use, an increased incidence of corneal epithelial toxicity and even defects occurs after 5-fluorouracil injections. Very early temporary punctal occlusion using collagen plugs optimizes the corneal wetting. Preservative-free tears are helpful. One group also reported that bandage contact lens application increased comfort and decreased inflammation.
Late Postoperative Complications
LATE BLEB FAILURE.
Late bleb failure may result from heavy vascularization and healing around the bleb. Digital pressure applied by the patient to the inferior globe through the inferior lid may be useful in such cases, as this helps maintain flow through the drain and keeps the subconjunctival space expanded. If this is insufficient, needling revision of the bleb may reestablish effective filtration. The needling process alone rarely establishes long-term filtration in eyes not exposed to antimetabolites. However, if needling is followed with 5-fluorouracil injections,
Figure 243-9 B-scan of suprachoroidal hemorrhage following trabeculectomy.
Figure 243-10 Neodymium:yttrium-aluminum-garnet laser bleb remodeling for bleb leak. (Courtesy of Mary Lynch, MD.)
up to an 80% success rate is possible. Also, needling may help revive a failing bleb after trabeculectomy using intraoperative mitomycin.
TENON’S CYST FORMATION.
A Tenon’s cyst is a high-domed, taut encapsulation of the bleb, which limits aqueous percolation. It must be differentiated from vascularized bleb failure. Once reported to occur in up to 15% of postsurgical eyes during the first postoperative month, it seems to be much less common in eyes that have received 5-fluorouracil or mitomycin. If the acute rise in IOP associated with these cysts is managed medically, with or without corticosteroid use, most of these blebs (up to 90%) continue to function later, as the bleb tissue remodels itself. If failure seems imminent (lower bleb, higher IOP), needling of the cyst, with postoperative 5-fluorouracil injections, may be helpful.
LATE BLEB LEAKS.
Initial management of these leaks involves patching, aqueous suppressants, and antibiotics. Additional management includes modalities already referred to, such as bandage contact lenses, autologous fibrin or blood, and glue. Trichloroacetic acid application and carefully applied cryotherapy may also be attempted. If these modalities fail and further management is felt necessary, neodymium:yttrium-aluminum-garnet laser bleb remodeling may be tried. The laser is tuned to the continuous-wave multimode, carefully retrofocused 1.0?mm behind the bleb to the underlying sclera, and then applied in a grid pattern (3.0?J/shot) over the bleb area ( Fig. 243-10 ). Inflammation and discomfort may be intense, but up to 80% of leaks seal. Other alternatives include a return to the operating room, where free conjunctival patch grafts may be applied over the sclerotomy after excision of the cystic leaking bleb.   Or, if scarring is minimal, local revision using conjunctival rotation may be attempted.
BLEBITIS VERSUS LATE ENDOPHTHALMITIS.
As many as 1 per 100 patients/year may develop infection of the bleb. The cystic thin blebs seen after antimetabolite application are believed to be at higher risk. When a bleb is present, the surgeon needs to treat any red eye emergency with antibiotics. Blebitis is differentiated from conjunctivitis by the presence of a murky, opalescent bleb, often with an associated bleb leak, in addition to conjunctiva injected diffusely with associated discharge ( Fig. 243-11 ). The key here is analysis of the vitreous response. If the vitreous is quiet, prompt treatment with hourly topical antibiotics may save the bleb and the eye. Topical corticosteroids after 48 hours of treatment are useful to treat the inflammation. However, if endophthalmitis is diagnosed with vitreous involvement, intravitreal cultures and antibiotics are required and eye
Figure 243-11 Blebitis.
Figure 243-12 Intrableb injection of autologous blood for hypotony.
salvage is rare. Organisms frequently seen in these eyes include hemophilus, streptococci, and staphylococci. Thus, coverage is best initiated with fortified topical cefazolin or vancomycin and tobramycin. Alternatively, topical fluoroquinolones, perhaps in combination with systemic fluoroquinolone prescription, may cover many of these cases. Intravitreal antibiotic injections of choice are vancomycin and amikacin.
Antimetabolites have introduced a somewhat new entity, late hypotony, to the list of late postoperative trabeculectomy complications. Whereas an IOP <5?mmHg (<0.67?kPa) on a long-term basis used to be unheard of, now such eyes are not infrequent. Most commonly, the history is of high-dose mitomycin use with loose scleral flap closure, although this entity has also been seen after 5-fluorouracil injections. Characteristically, vision is decreased, the eyes are soft, blebs are large, thin, and totally avascular, retinal folds are seen in the macula (with or without the aid of fluorescein angiography), retinal vessels are tortuous, and the nerve head may be swollen. Useful treatments, as with bleb leaks, include intrableb autologous blood injection ( Fig. 243-12 ) and neodymium:yttrium-aluminum-garnet bleb treatment. Sometimes, a return to the operating room to revise the thin bleb and/or resuture the flap is indicated. A donor “cover” (as already discussed) may be necessary to limit aqueous egress. Alternatively, if a symptomatic cataract is present, the cataract extraction-associated inflammation frequently slows filtration through bleb healing and resolves the hypotony. Some surgeons
Figure 243-13 Exposure of tube in drainage seton (arrow).
have expressed concern that if such eyes are left untreated for many months, the retinal folds may not resolve, even after successful pressure adjustment. One report exists of such an eye, finally successfully treated with pars plana vitrectomy and liquid perfluorocarbon liquid.
No chapter on glaucoma surgical complications is complete without at least a mention of some of the unique problems seen with setons. Usually, with proper placement, extrusion of the plate(s) and uncontrolled intraocular inflammation are not seen. Initial hypotony may be seen with some of the valved implants. If proper tube blockage, with either a “stent” or external suture, is used with the unvalved implants, hypotony may be avoided with these devices, even after the “plug” is removed or dissolved. The most frequent problems with these devices are melting of the patch graft that overlies the extraocular tube, with tube exposure ( Fig. 243-13 ), and intraocular rotation of the tube anteriorly into cornea. Melting of the graft may be monitored if conjunctival coverage is maintained. If not maintained, a new graft must be placed and conjunctiva mobilized to cover it. The other problem, tube migration, is especially common in children and young adults. At the first hint of corneal compromise (endothelial cell counts may be helpful), the tube is repositioned more posteriorly to avoid corneal failure.
1. Riley SF, Smith TJ, Simmons RJ. Repair of a disinserted scleral flap in trabeculectomy. Ophthalmic Surg. 1993;24:349–50.
2. Brown SV. Management of a partial thickness scleral flap buttonhole during trabeculectomy. Ophthalmic Surg. 1994;25:732–3.
3. Riley SF, Lima FL, Smith TJ, Simmons RJ. Using donor sclera to create a flap in glaucoma filtering procedures. Ophthalmic Surg. 1994;25:117–18.
4. Hughes BA, Shin DH, Birt CM. Use of fascia lata in revision of filtration surgery. J Glaucoma. 1996;5:207–9.
5. Melamed S, Ashkenazi I, Glovinski J, Blumenthal M. Tight scleral flap trabeculectomy with postoperative laser suture lysis. Am J Ophthalmol. 1990;109:303–9.
6. Kolker AE, Kass MA, Rait JL. Trabeculectomy with releasable sutures. Arch Ophthalmol. 1994;112:62–6.
7. Burchfield JC, Kolker AE, Cook SG. Endophthalmitis following trabeculectomy with releasable sutures [letter]. Arch Ophthalmol. 1996;114:766.
8. Rosenberg LF, Siegfried CJ. Endophthalmitis associated with releasable suture [letter]. Arch Ophthalmol. 1966;114:767.
9. Lundy DL, Sidoti P, Winarko T, et al. Intracameral tissue plasminogen activator after glaucoma surgery. Indications, effectiveness, and complications. Ophthalmology. 1996;103:274–82.
10. Tripathi RC, Tripathi BJ, Park JK, et al. Intracorneal tissue plasminogen activator for resolution of fibrin clots after glaucoma filtering procedure. Am J Ophthalmol. 1991;111:247–8.
11. Smith MF, Doyle JW. Use of oversized bandage soft contact lenses in the management of early hypotony following filtration surgery. Ophthalmic Surg Lasers. 1996;27:417–21.
12. Blok MD, Kok JH, Van Mil C, et al. Use of the megasoft bandage lens for treatment of complications after trabeculectomy. Am J Ophthalmol. 1990;110:264–8.
13. Osher RH, Cionni RJ, Cohen JS. Re-forming the flat anterior chamber with Healon. J Cataract Refract Surg. 1996;22:411–15.
14. Asrani SG, Wilensky JT. Management of bleb leaks after glaucoma filtering surgery. Use of autologous fibrin tissue glue as an alternative. Ophthalmology. 1996;103:294–8.
15. Leen MM, Moster MR, Katz LJ, et al. Management of overfiltering and leaking blebs with autologous blood injection. Arch Ophthalmol. 1995;113:1050–1.
16. Smith MF, Magauran RG, Doyle JW. Treatment of postfiltration bleb leak by bleb injection of autologous blood. Ophthalmic Surg. 1994;25:636–7.
17. Smith MF, Magauran RG, Doyle JW, Betchkel J. Treatment of postfiltration bleb leaks with autologous blood. Ophthalmology. 1995;102:868–71.
18. Zalta AH, Wieder RH. Closure of leaking filtering blebs with cyanoacrylate tissue adhesive. Br J Ophthalmol. 1991;75:170–3.
19. Dugel PU, Heuer DK, Thach AB, et al. Annular peripheral choroidal detachment simulating aqueous misdirection after glaucoma surgery. Ophthalmology 1997; 104:439–44
20. Beckman RL, Solinski SJ, Greff LJ, et al. Bandage contact lens augmentation of 5-fluorouracil treatment in glaucoma filtration surgery. Ophthalmic Surg. 1991; 22:563–4.
21. Shin DH, Juzych MS, Klatana AK, et al. Needling revision of failed filter blebs with adjunctive 5-fluorouracil. Ophthalmic Surg. 1993;24:242–8.
22. Greenfield DS, Miller MP, Suner IJ, Palmberg PF. Needle elevation of the scleral flap for failing filtration blebs after trabeculectomy with mitomycin-C. Am J Ophthalmol. 1996;122:195–204.
23. Lynch MG, Roesch M, Brown RH. Remodeling filtering blebs with the neodymium:YAG laser. Ophthalmology. 1996;103:1700–5.
24. Wilson MR, Kotas-Neumann R. Free conjunctival patch for repair of persistent late bleb leak. Am J Ophthalmol. 1994;117:569–74.
25. Buxton JN, Lavery KT, Liebmann JM, et al. Reconstruction of filtering blebs with free conjunctival autografts. Ophthalmology. 1994;101:635–9.
26. Wise JB. Treatment of chronic postfiltration hypotony by intrableb injection of autologous blood. Arch Ophthalmol. 1993;111:827–30.
27. Doyle JW, Smith MF. Effect of phacoemulsification surgery on hypotony following trabeculectomy surgery. Arch Ophthalmol. 2000;118:763–5.
28. Duker JS, Schuman JS. Successful surgical treatment of hypotony maculopathy following trabeculectomy with topical mitomycin C. Ophthalmic Surg. 1994; 25:463–5.
29. Sherwood MB, Smith MF. Prevention of early hypotony with Molteno implants. Ophthalmology. 1993;100:85–90.