TRABECULECTOMY WITH RELEASABLE

SUTURES*

BY Allan E. Kolker; MD, Michael A. Kass, MD, AND

(BY INVITATION) Julian L. Rait, MD

INTRODUCTION

OVER THE PAST 25 YEARS, TRABECULECTOMY HAS BECOME THE MOST

commonly performed drainage operation for glaucoma, primarily because it
produces fewer postoperative complications than any of the full-thickness
filtering procedures.'-9 During trabeculectomy the surgeon attempts to
balance two conflicting goals: The scleral flap sutures should be loose
enough to permit aqueous humor outflow, but tight enough to prevent
postoperative hypotony, anterior chamber shallowing, and choroidal detach-
ment. A number of investigators have dealt with these conflicting goals by
using the argon laser to disrupt scleral flap sutures.10-15 This technique
permits a tight initial closure of the scleral flap with an option to increase
aqueous humor outflow in the early postoperative period. An alternative to
this technique is placement of scleral flap sutures with slipknots that can be
released without the need for an argon laser.'5-'8 We have used the slipknot
technique in recent years and here present a retrospective analysis of our
results from a 1-year period compared with results from the preceding year
when a nearly identical procedure was employed with permanent scleral
flap sutures.

MATERIALS AND METHODS

STANDARD TRABECULECTOMY TECHNIQUE

A limbal-based conjunctival flap was created when the conjunctiva and
Tenon's capsule were incised at least 8 mm posterior to the limbus. The
dissection was carried to the limbal zone. Superficial bleeding vessels were

'From the Department of Ophthalmology and Visual Sciences,

Washington University School of Medicine, St Louis. This study was supported in part by a
grant from Research to Prevent Blindness Inc., New York.
132 Kolker et al
cauterized lightly with a monopolar cautery. One surgeon (AEK) created a
rectangular scleral flap 4 mm wide by 2 mm deep. The other surgeon
(MAK) created a triangular scleral flap with 4-mm sides. Both surgeons
dissected the scleral flap to approximately 50% depth. After performing a
paracentesis, a 3 x 1-mm opening into the anterior chamber was made with
a disposable blade and either a Kelly Descemet's punch or a Vannas scissors.
An iridectomy was made slightly wider than the opening of the sclerectomy.
The scleral flap was closed with interrupted 10-0 nylon sutures. Two sutures
were used for the rectangular flap and three sutures for the triangular flap.
The anterior chamber was re-formed through the paracentesis. Suture
tension was adjusted so that the anterior chamber remained formed and a
slow leak of aqueous humor was detected at the margins of the scleral flap.
Tenon's capsule was closed with a running 9-0 polyglactin suture on a
tapered vascular needle. The conjunctival incision was closed as a separate
layer in identical fashion. Additional fluid was injected through the paracen-
tesis. If a leak was seen along the conjunctival incision, interrupted sutures
of 9-0 polyglactin were added. At the end of surgery, topical atropine was
instilled and subconjunctival dexamethasone, 4 mg, was injected. Postopera-
tive care included administration of topical prednisolone acetate, 1%; topi-
cal atropine, 1%; and topical tobramycin, 0.3%. Topical corticosteroids were
administered for a minimum of 6 weeks.
RELEASABLE SUTURE TECHNIQUE
The releasable suture technique was identical except for closure of the
scleral flap. The releasable sutures were placed using the technique of
Cohen and Osher.18 The needle of a 10-0 nylon suture was passed first into
the sclera and then through the scleral flap (Fig 1). The needle was next
passed through the base of the scleral flap, beneath the conjunctival inser-
tion, and finally through the peripheral cornea. The releasable sutures were
tied with a quadruple-throw slipknot tightened until there was minimal
aqueous humor flow at the edges of the scleral flap (Fig 2). The surgeon who
used a rectangular scleral flap closed with two releasable sutures (Fig 3).
The surgeon who used a triangular scleral flap used one permanent suture at
the apex and two releasable sutures, one on each side of the triangle (Fig 4).
The releasable sutures were later removed at the slit lamp with a jeweler's
forceps. The first suture was removed when the anterior chamber was deep
and intraocular pressure reached 8 or 10 mm Hg (usually 1 to 10 days after
surgery). Suture removal usually produced an immediate increase in filtra-
tion with enlargement of the filtering bleb and a fall in intraocular pressure.
The second suture was removed one to several days later. If the sutures had
 Trabeculectomy 133

Lo/

FIGURE 1
Needle is passed into sclera and through flap. Needle is then passed through base of scleral
flap, beneath conjunctival insertion, and finally through peripheral cornea.

(
I

FIGURE 2
Releasable suture is tied with quadruple-throw slipknot.
134 1Kolker et al

I,1

7 FIGURE 3
Rectangular scleral flap is closed with two releasable sutures.

I
I
I I
I I
I

FIGURE 4
Triangular scleral flap is closed with one permanent suture at apex and one releasable suture on
each side.
 Trabeculectomy 135

not been removed by 14 days, they were routinely removed at this time to
prevent them from becoming adherent and breaking. Suture removal after
10 to 14 days had little effect on bleb appearance or intraocular pressure.
We reviewed the charts of all 258 patients who had filtering operations
performed between July 1, 1988, and June 30, 1990. One hundred twenty-
eight of these procedures (124 patients) were performed prior to the
introduction of releasable sutures (July 1, 1988, to June 30, 1989), and 146
procedures (134 patients) were performed between July 1, 1989, and June
30, 1990, during which time the releasable suture technique was used
exclusively. A standard form was created to review the medical record of
each patient and was used to collect demographic data and details concern-
ing postoperative progress. Clinical data, including the type and duration of
glaucoma as well as the preoperative intraocular pressure, were also gath-
ered by chart review. The prevalence of prior surgery within the two groups
was examined, as were the effects of factors such as the operating surgeon,
intraoperative use of viscoelastic agents, and postoperative use of subcon-
junctival 5-fluorouracil. Prior surgery was defined as a procedure that
included a conjunctival incision. Thus, laser trabeculoplasty and laser iridot-
omy were not included as prior surgeries.
Depth of the anterior chamber, intraocular pressure, and use of medica-
tions were also recorded from the patients' charts. We defined a flat anterior
chamber as one with complete apposition of the iris to the cornea up to and
including the pupil margin. Shallow anterior chambers were defined as all
other cases where notes in the chart indicated that the anterior chamber
appeared to be reduced in depth, including those where there was periph-
eral iridocorneal contact.
For statistical analysis of continuous variables, a two-tailed t-test was
performed. Nominal data were analyzed by a two-tailed Fisher's exact test.
RESULTS

The control and study groups were similar with respect to most demo-
graphic and disease parameters (Table I). Sixty-five of the operations in the
control group without releasable sutures were performed by the surgeon
who used a scleral flap of 4 x 2 mm. Another 63 procedures were performed
by the surgeon who used a 4-mm triangular scleral flap. This differed from
the study group where the numbers were 85 and 61, respectively (P = .05).
There was also a statistically significant difference in the number of black
patients between the two groups (P = .0001), with a greater number of black
patients included in the study group.
Forty-two of the 128 control eyes (32.8%) had some shallowing of the
136 1Kolker et al

TABLE I: PATIENT, DISEASE, AND SURGICAL CHARACTERISTICS

CONTROL GROUP STUDY GROUP
(128 EYES, 124 (146 EYES, 134
PATIENTS)' PATIENTS)+ P VALUE

Age (ys, mean ± SD) 68 ± 16.6 63 ± 13.0 .11

Race 115 white/9 black 113 white/21 black .0001
Sex (F:M) 59:65 66:68 .35
Glaucoma duration (yr, 11.0 ± 5.9 9.8 ± 6.4 .18
mean ± SD)
Preoperative IOP (mm 31.0 ± 9.5 27.0 ± 8.2 .07
Hg, mean ± SD)
Primary open-angle 111 (86.7%) 116 (79.5%) .1
glaucoma
Prior surgery involving 51 (39.8%) 48 (32.7%) .23
conjunctival incision
Surgeon
AEK
MAK
65
63
85
61
05
Viscoelastic drugs used 49 (38.3%) 55 (37.7%) .9
during surgery
Postoperative 5-fluo- 48 (37.5%) 47 (32.2%) .36
rouracil
*With permanent scleral flap sutures.
tWith releasable scleral flap sutures.
anterior chamber in the immediate postoperative period. Fifteen of the eyes
in the study group had shallow anterior chambers, and an additional six eyes
had shallow anterior chambers after removal of one or both releasable
sutures. Thus, 21 of the 146 eyes (14.4%) in the study group had shallow
anterior chambers, which was significantly less than the control group (P =
.0003). Flat anterior chamber, defined as iridocorneal touch to the pupil
margin, occurred in 11 control eyes (8.6%), but in only 2 eyes (1.4%) that
had releasable sutures (P = .0078). Surgical intervention to drain supra-
choroidal fluid and re-form the anterior chamber was required in eight
control eyes (6.2%), but only one study eye (0.7%) (P = .014).
Intraocular pressure was higher in the group with releasable sutures for
the first few days following trabeculectomy (Table II). Intraocular pressure
was similar in the two groups from day 7 to 1 year. On postoperative day 1,
an intraocular pressure less than 5 mm Hg was noted in 82 of 116 eyes
(71%) in the control group, compared with 54 of 136 eyes (39.7%) in the
study group (P = .001). On the second postoperative visit (days 2 to 5), the
corresponding numbers were 70 of 126 eyes in the control group (55.6%)
versus 58 of 144 eyes in the study group (40.3%) (P = .005).
The rate of success of trabeculectomy in terms of intraocular pressure
control was similar in the two groups. If success is defined as an intraocular
 Trabeculectomy 137

TABLE II: INTRAOCULAR PRESSURE AFTER TRABECULECTOMY

CONTROL GROUP STUDY GROUP
(128 EYES, 124 PATIENTS)f (146 EYES, 134 PATIENTS)t
TIME NO. OF EYES IOP ± SD (mm Hg) NO. OF EYES IOP ± SD (mm Hg) P VALUE

1 day 116 4.4 ± 3.9 136 9.0 ± 7.9 .001

2-5 days 126 6.8 ± 5.2 144 8.9 ± 7.0 .005
6-10 days 123 7.0 ± 4.7 146 7.4 ± 4.5 .43
14-21 days 128 10.5 ± 5.4 146 10.0 ± 5.3 .41
1 mo 128 14.8 ± 5.4 144 14.2 ± 6.9 .43
3 mo 120 13.5 ± 4.7 133 13.3 ± 5.6 .83
6 mo 111 13.1 ± 4.2 125 13.6 ± 6.8 .50
12 mo 100 13.2 ± 3.0 114 13.8 ± 3.6 .24
'The 3-, 6-, and 12-month data do not include patients who failed or were lost to follow-up.
fWith permanent scleral flap sutures.
tWith releasable scleral flap sutures.

pressure less than 20 mm Hg at 1 year without use of medication, then 86 of

the 109 control eyes (78.9%) and 92 of the 120 study eyes (76.7%) can be
considered a success (Table III). If a qualified success is defined as an
intraocular pressure less than 20 mm Hg at 1 year with use of postoperative
medication, then 14 of 109 control eyes (12.8%) and 16 of 120 study eyes
(13.3%) can be considered a qualified success.
COMPLICATIONS
In 9 of 146 eyes (6%) where releasable sutures were used, the anterior
chamber shallowed following suture removal. There were no cases of flat
anterior chamber following suture removal, and surgical re-formation of the
anterior chamber was not required. One eye had a small aqueous humor
leak along the suture tract after suture removal. This eye had received
subconjunctival injections of 5-fluorouracil. The leak healed spontaneously
within 3 days.
Superior corneal epithelial abrasions that appeared to be related to the
releasable sutures developed in 12 eyes (8%). All of these eyes were
receiving 5-fluorouracil injections. Suture breakage on attempted removal
occurred in six eyes (4.1%). One suture broke at 10 days postoperatively and
four at 14 days, and another broke when removal was deferred until 30 days
because of persistently low intraocular pressure. No damage to the con-
junctival insertion or the lens was documented in this series of cases, nor
were any corneal or suture tract infections noted.
138 K0lker et al

TABLE III: SUCCESS OF TRABECULECTOMY AT 1 YEAR

CONTROL GROUP STUDY GROUP
(PERMANENT (RELEASEABLE
SCLERAL FLAP SCLERAL FLAP
SUTURES SUTURES) P VALUE

Success' 86/109 (78.9%) 92/120 (76.7%) 0.68

Qualified successt 14/109 (12.8%) 16/120 (13.3%) 1.00
Failure 9/109 (8.3%) 12/120 (10.0%) .65
Loss to follow-up 19/128 (14.8%) 26/146 (17.8%) .50
prior to 1 year
Total 128 eyes 146 eyes
°IOP < 20 mm Hg without medication.
fIOP < 20 mm Hg with medication but no additional surgery.

DISCUSSION

Most authorities agree that trabeculectomy produces fewer postoperative

complications than full-thickness filtering procedures.1-9 In a recent review
of the filtering surgery performed between 1984 and mid-1990 in Medicare
beneficiaries aged 65 and older, Sastry and associates19 reported that 0.5%
of patients were rehospitalized within 14 days of trabeculectomy for anterior
chamber re-formation compared with 1.0% of patients after full-thickness
filtering procedures. Hypotony and flat anterior chamber following filtering
surgery are not benign events and may be associated with development of
cataract, suprachoroidal hemorrhage, corneal endothelial cell loss, and pe-
ripheral anterior synechiae.
Some surgeons have attempted to reduce posttrabeculectomy complica-
tions by suturing the scleral flap tightly and then cutting the sutures with an
argon laser as needed.1-15 This is a very useful approach but one that has
some limitations. Not all ophthalmologists have ready access to an argon
laser. In some cases, the scleral flap sutures can be obscured by hemor-
rhage, edema, or scar tissue in the bleb area, or by a swollen, tender upper
eyelid. Finally, argon laser suture lysis can be associated with complica-
tions.13,20 Savage and co-workers13 reported that 3 of 38 eyes that had
undergone argon laser suture lysis required surgical re-formation of the
anterior chamber. Two other eyes had substantial conjunctival wound leaks,
and three additional eyes had minor conjunctival leaks following the pro-
cedure.
Trabeculectomy with the use of scleral sutures with slipknots has been
reported previously.'15-8 However, none of these reports included a de-
tailed presentation of results or complications. In the present series, we
noted a marked decrease in the incidence of shallow and flat anterior
chambers following trabeculectomy with releasable sutures. In addition,
 Trabeculectomy 139

fewer eyes required surgical re-formation of the anterior chamber and

drainage of suprachoroidal fluid. Because of the retrospective nature of this
study, we did not have adequate data to report on the incidence of choroidal
detachment, cataract, or formation of peripheral anterior synechiae. Use of
releasable sutures did not affect the ultimate outcome of filtering surgery in
terms of mean intraocular pressure or percentage of eyes with controlled
intraocular pressure 1 year following surgery. At 1 year, 108 of 120 study
eyes (90%) had intraocular pressures less than 20 mm Hg with or without
medication. This is very similar to the control group and also similar to a
number of other reports in the literature.1-9
Complications associated with use of releasable sutures were few and
relatively minor. Six eyes had shallow anterior chambers after a suture was
released. All re-formed spontaneously without the need for surgical inter-
vention. Six eyes had superior corneal abrasions from the free end of the
suture. All of these eyes were receiving postoperative injections of 5-fluo-
rouracil. We have recently employed an altered technique to prevent this
problem. After the suture emerges from the cornea, a second pass is made
in the cornea. The end of the suture is cut flush with the corneal surface
(Fig 5). This leaves an exposed loop, but no free suture end to abrade the
corneal epithelium. The incidence of corneal abrasions has been reduced
with this refinement of the technique.
No cases of endophthalmitis or corneal infection were encountered in
this series. Nonetheless, an exposed suture could serve as a wick for infec-
tion. We use topical antibiotics until all releasable sutures are removed and
the corneal epithelium is intact.
We found that suture removal after 10 to 14 days had no noticeable effect
on bleb size or intraocular pressure. This was true whether 5-fluorouracil
was used or not. None of the eyes in this series were treated with stronger
antimetabolites such as mitomycin C. It is possible that mitomycin C alters
healing sufficiently that the time of suture removal may need to be length-
ened in some eyes.

SUMMARY

We attempted to reduce some of the postoperative complications of tra-

beculectomy by using releasable scleral flap sutures. This technique allows
an initial tight closure of the scleral flap with the option to increase aqueous
humor outflow in the early postoperative period. We reviewed our experi-
ence with trabeculectomy and releasable sutures in 146 eyes (134 patients)
and compared these cases with a prior series of 128 eyes (124 patients) that
underwent trabeculectomy with permanent scleral flap sutures. In the
140 1Kolker et al

FIGURE 5
A second pass ofthe needle is made into peripheral cornea. End of suture is cut flush to corneal
surface, leaving exposed loop but no free end to abrade corneal epithelium.

control group, 42 eyes (32.8%) had clinically detectable shallowing of the

anterior chamber in the postoperative period. In contrast, shallow anterior
chamber was noted in 21 eyes (14.4%) in the group with releasable sutures
(P = .0003). Flat anterior chamber, defined as iridocorneal touch to the
pupil margin, occurred in 11 control eyes (8.6%) but in only 2 eyes (1.4%)
with releasable sutures (P = .0078). Surgical intervention to drain supra-
choroidal fluid and re-form the anterior chamber was required in eight
control eyes (6.2%) but in only one study eye (0.7%) (P = .014). At 1 year of
follow-up, the two groups were similar in terms of mean intraocular pres-
sure, the need for ocular hypotensive medications, and failure rate.

REFERENCES
1. Drance SM, Vargas E: Trabeculectomy and thermosclerostomy: A comparison of two
procedures. Can J Ophthalmol 1973; 8:413-415.
2. Spaeth GL, Joseph NH, Fernandes E: Trabeculectomy: A reevaluation after three years
and a comparison with Scheie's procedure. Trans Am Acad Ophthalmol Otolaryngol 1975;
79:349-361.
3. Schwartz PL, Ackerman J, Beards J, et al: Further experience with trabeculectomy. Ann
Ophthalmol 1976; 8:207-217.
 Trabeculectomy 141
4. Watkins PH Jr, Brubaker RF: Comparison of partial-thickness and full-thickness filtration
procedures in open-angle glaucoma. Am J Ophthalmol 1978; 86:756-761.
5. Shields MB: Trabeculectomy vs full-thickness filtering operation for control of glaucoma.
Ophthalmic Surg 1980; 11:498-505.
6. Spaeth GL: A prospective, controlled study to compare the Scheie procedure with Wat-
son's trabeculectomy. Ophthalmic Surg 1980; 11:688-694.
7. Blondeau P, Phelps CD: Trabeculectomy vs thermosclerostomy: A randomized prospective
clinical trial. Arch Ophthalmol 1981; 99:810-816.
8. Spaeth GL, Poryzees E: A comparison between peripheral iridectomy with thermal
sclerostomy and trabeculectomy: A controlled study. Br J Ophthalmol 1981; 65:783-789.
9. Kietzman B: Glaucoma surgery in Nigerian eyes: A five-year study. Ophthalmic Surg 1976;
7:52-58.
10. Lieberman MF: Suture lysis by laser and goniolens. Am J Ophthalmol 1983; 95:257-258.
11. Hoskins GD Jr, Migliazzo C: Management of failing filtering blebs with the argon laser.
Ophthalmic Surg 1984; 15:731-733.
12. Salamon SM: Trabeculectomy flap suture lysis with endolaser probe. Ophthalmic Surg
1987; 18:506-507.
13. Savage JA, Condon GP, Lytle RA, et al: Laser suture lysis after trabeculectomy. Ophthal-
mology 1988; 95:1631-1638.
14. Melamed S, Askhenazi I, Glovinski J, et al: Tight scleral flap trabeculectomy with post-
operative laser suture lysis. Am J Ophthalmol 1990; 109:303-309.
15. Chopra H, Goldenfeld M, Krupin T, et al: Early postoperative titration of bleb function:
Argon laser suture lysis and removable sutures in trabeculectomy. J Glaucoma 1992;
1:54-57.
16. McAllister JA, Wilson RP: Glauconma. Boston, Butterworths 1986, pp 243-250.
17. Shin DH: Removable-suture closure of the lamellar scleral flap in trabeculectomy. Ann
Ophthalmol 1987; 19:51-55.
18. Cohen JS, Osher RH: Releasable scleral flap suture. Ophthalmol Clin North Am 1988;
1:187-197.
19. Sastry SM, Street DA, Javitt JC: National outcomes of glaucoma surgery: Complications
following partial and full-thickness filtering procedures. J Glaucoma 1992; 1:137-140.
20. Schwartz AL, Weiss HS: Bleb leak with hypotony after laser suture lysis and trabeculec-
tomy with mitomycin C. Arch Ophthalnol 1992; 110:1049.

DISCUSSION
DR ALAN L. ROBIN. This interesting retrospective study compares two sequential
groups of patients undergoing trabeculectomy. The manuscript examines one pri-
mary variable: the type of knot used to tie the scleral flap suture. In the first
treatment group, permanent sutures were used to secure the scleral flap; in the
second, releasable sutures were used. The releasable sutures are initially secure,
causing a tight flap with a minimal amount of aqueous leaving the wound. They are
later removed, creating a full-thickness filter. In this series, the removal, or release,
was done between 1 and 10 days after the trabeculectomy. Despite the flaws
inherent in any retrospective study, this review finds that the type of knot thrown in a
single suture can drastically influence the outcome and complications associated with
filtration surgery.
This timely manuscript leads us to consider two concepts. The first is that there is
no generic form of filtration surgery. That is, when evaluating the success and
complications of any particular study involving surgical intervention, one must have a
142 Kolker et al
full knowledge of all details concerning the type of surgery performed. The second is
that problems exist with conventional filtration surgery and still need to be over-
come. Many unresolved issues need to be addressed before an ideal filtration
operation is created.
Eyes undergoing filtration surgery were much more difficult to manage until the
last two decades. Full-thickness filtering surgery was successful at lowering intraocu-
lar pressure (IOP). Inherent in this type of procedure is a "point of no return"; that
is, once a full-thickness scleral hole is made, there is no longer any simple anatomic
method of preventing overfiltration, with subsequent flat anterior chambers. Flat
and shallow anterior chambers are the bane of full-thickness filtering surgery. Flat
chambers predispose to cataract formation, the development of posterior and ante-
rior synechiae, and corneal decompensation. These problems are not benign and
frequently necessitate further invasive intraocular surgery. Large choroidal detach-
ments are often associated with shallow anterior chambers. These choroids often
require drainage. Drainage of suprachoroidal fluid itself can lead to the progression
of cataracts. Even a relatively simple procedure such as the drainage of a choroidal
effusion increases inflammation and jeopardizes the initial filter through scarring.
Likewise, if cataracts requiring surgical intervention form because of a shallow
anterior chamber, the inflammation associated with subsequent cataract surgery may
then cause the initial filter to fail. If this occurs, one is now faced with a second
filtering operation in an eye with a scarred limbus and pseudophakia. The chance of
this filter succeeding is reduced.
Earlier surgeons were concerned about the consequences of full-thickness filtra-
tion surgery. The likelihood of complications often instilled an aura of apprehension
that caused an overly conservative attitude toward the surgical management of
glaucoma. They hoped that the natural history of pressure-sensitive glaucomatous
optic neuropathy would deteriorate slowly, so that the patient would still retain visual
function until his death, rather than surgically intervene and attempt to maintain
visual function at its present level. Many surgeons procrastinated, trying to avoid
surgery and surgically-induced complications. Many patients have suffered extensive
visual field loss, and have progressed to losing fixation, because of the fear of
complications associated with full-thickness filtering surgery.
Ophthalmologists became more surgically aggressive when guarded filtration
become popular in the 1970s. Trabeculectomy was viewed as a wonderful compro-
mise. There were less initial flat chambers. Regrettably, after a period of follow-up, it
was realized that the final IOP lowering was less than that found with full-thickness
filtering surgery. In many series, the mean finalIOP was 6 mm Hg further decreased
in eyes that had undergone full-thickness surgery when compared with eyes that had
undergone trabeculectomy. The IOP lowering associated with full-thickness filtering
surgery was equivalent to that of partial-thickness surgery plus the addition of an
IOP-lowering medication (eg, a beta-blocker). Different techniques were tried and
evolved to optimize the IOP lowering and the eventual success of the bleb, without
sacrificing the safety aspects that were afforded by a more guarded filtration surgery.
Surgeons changed the size and shape of the scleral flap, the size of the internal
 Trabeculectomny 143

scleral opening, the size ratio between the scleral flap and the internal opening, the
location of the scleral flap, and the number of sutures used to tie down the scleral
flap, and used intracameral and subconjunctival viscoelastics to alter the likelihood of
a formed anterior chamber and low 1OPs. The many combinations and permutations
of these variables have led to the concept in the 1990s that there is no generic
"trabeculectomy."
Surgeons realized that increasing the number of sutures that closed the scleral flap
decreased the likelihood of a flat anterior chamber. Regrettably, "oversuturing" led
to higher final postoperative IOPs. Many surgeons began cutting the sutures with a
laser slit-lamp delivery system at various postoperative intervals to maintain a formed
chamber, and also lower lOPs. This technique afforded the safety of a partial-
thickness filter during the first few postoperative days, when there was decreased
aqueous production. However, it also allowed for the surgeon, for the first time, to
be in control of both the postoperative anterior chamber depth and final IOP. That is,
the surgeon could manipulate the timing of increased filtration depending on the
chamber depth, IOP, the presence of choroidals, and the appearance of the bleb.
Indeed, the surgeon has the prerogative of not lysing the sutures if the IOP is
adequately lowered. Surgeons created new, somewhat empiric guidelines for how
many sutures to place within the flap, how tight to tie them, and when (and if) to
remove them. This principle of noninvasive timed suture removal was a great
advance in the management of filtration surgery. However, there are many disadvan-
tages associated with laser suture lysis.
First, a laser needs to be both convenient and available. It is inconvenient and
costly (laser facility fees) if the postoperative follow-up is performed at the physi-
cian's office but the laser is located elsewhere. It is potentially time-consuming and
inefficient to take a patient to a laser. The conjunctiva over the sutures must be both
thin and transparent for the laser energy to penetrate the conjunctiva and be
absorbed by the suture. This often requires a tenonectomy in younger patients. This
tenonectomy can create conjunctival buttonholes and wound leaks. A thinner bleb
may predispose an eye to bleb ruptures and to an increased incidence of endophthal-
mitis. It is also not infrequent for a subconjunctival hemorrhage to occur within the
bleb during the immediate postoperative period. If this occurs, it is possible that the
suture could not be visualized through the opaque conjunctiva. Lasering the suture
also can lead to complications. If the conjunctiva and the suture are in close
proximity, or if there is sufficient pigmentation in the conjunctiva, there is a possi-
bility that the laser energy could cause a hole in the conjunctiva and induce a wound
leak.
No extra intraoperative manipulation of the conjunctiva is required when placing
releasable sutures. There is a decreased chance of wound leaks. Minimal equipment
is needed for the removal of releasable sutures, and this equipment is both inexpen-
sive and readily available. The surgeon needs only fine tying forceps. Sutures can be
easily removed at the slit lamp with use of topical anesthesia, without discomfort.
The use of releasable sutures appears to be a better solution than laser suture lysis to
the problem of how to best control postoperative filtration.
144 144 Kolker et al
There are few disadvantages to the use of releasable sutures. These sutures are
technically more difficult for the surgeon to place, especially in a hypotonus and soft
eye, than a conventional single-throw suture. A suture that extends from the bleb
through the cornea, onto the surface of the cornea, may act as a wick, seeding the
bleb area with bacteria and cause endophthalmitis. Although this has never been
reported, it is still technically possible.
The authors have demonstrated the advantages of this newer technique employing
the use of releasable sutures. However, the authors' paper still raises many questions
that need answering. Both surgeons used two different number of sutures. Is there
an ideal number of sutures to use? Are the number of sutures needed different
depending on the size or shape of the scleral flap?
The authors did not discuss any difficulties in scleral flap suture removal. Were
they able to remove all sutures? If not, what percentage were not removed? Could
the authors tell a priori which sutures they would have problems removing?
What are the guidelines for removing releasable sutures? In the initial postopera-
tive period, if the IOP is elevated, should digital massage be used rather than suture
removal? At what time intervals should sutures be removed? Does removal depend
on the chamber depth, the bleb appearance, the bleb vascularity, the IOP, or the
presence of choroidals? Can an algorithm be created to help ophthalmologists gauge
when to remove these sutures?

All eyes undergoing filtration surgery have advanced optic neuropathy. The goal of
the surgery is to reduce the IOP in an effort to diminish the possibilities of further
axonal loss. Any IOP elevation is undesirable because it may further compromise the
optic nerve. Are eyes with tighter wounds more likely to experience postoperative
rise in IOP? Are such rises capable of causing further optic nerve damage? Should
these eyes be periodically observed during the first 24 hours to ensure that no
marked IOP elevation is occurring?
When should the sutures be removed? It might be silly to remove the sutures
while the chamber is still relatively shallow. However, if antimetabolites are not
used, it becomes extremely difficult to remove them after the second postoperative
week when there appears to be fibrous tissue surrounding the suture. However,
different algorithms might be applied if antimetabolites, such as mitomycin C, are
used intraoperatively. We have experienced sudden shallowing of the anterior cham-
ber associated with hypotonus maculopathy when sutures were removed up to 8
months after surgery.
In summary, the authors' manuscript is important. It demonstrates the ability of
the surgeon to manipulate the course of filtration after trabeculectomy is completed.
It demonstrates the importance of the ability to remove sutures that close the
trabeculectomy scleral flap in the immediate postoperative period. Might I suggest
that these authors, or other authors, perform prospective studies comparing the
long-term IOP lowering in eyes with both releasable and nonreleasable sutures.
Might I also suggest investigations into the number of sutures required to close a
scleral flap and timing of their release. In this way, we might be better able to control
the postoperative course, maximizing the chances of low TOPs without hypotony.
 Trabeculectomy 145.
DR GEORGE SPAETH. Some years ago we performed a prospective randomized study
of this methodology (releasable sutures), but we used a somewhat different tech-
nique suture. After a relatively small number of cases the results were similar to
those presented by Dr Kolker. We believed that it wasn't proper to continue the
study because clearly the patients who had the releasable sutures were doing so
much better short-term. We also found that the long-term results were as Dr Kolker
showed: not superior in terms of control in patients who had releasable sutures.
My question for Dr Kolker has to do with something to which Dr Robin alluded.
That is, what is his advice now that so many surgeons are using antifibrosis agents
such as 5-fluorouracil and mitomycin C. When does he release sutures in those
cases? Here it becomes quite a problem, and I wondered if he had some good
suggestions for us.
DR ALLAN KOLKER. I would like to thank Dr Robin for a delightful discussion of the
paper, and I appreciate Dr Spaeth's questions which center on a very important
aspect. Before the availability of medications such as 5-fluorouracil and mitomycin
C, the problem was easy. If we waited past 14 days, the suture became fibrosed and
was very difficult to remove. We were essentially locked into a period of 2 weeks
after the operative procedure. We had some leeway based on the appearance of the
bleb, whether the pressure was too high, and whether the scleral flap was too tightly
closed; and we could remove the sutures at will during the first two weeks. We tend
to use 10-0 nylon sutures. We tried 9-0 nylon sutures, which perhaps are a little
stronger, but use them relatively infrequently. I think there were 5 cases out of
approximately 150 in which the suture broke on attempted removal. This rarely
caused any difficulty, and in fact, I have never seen a resulting problem. If the suture
breaks, it snaps back into the cornea since these are nylon sutures that are quite
elastic. They become covered by epithelium and cause no difficulty. There is some
disadvantage in that one would like to have the suture released, as mentioned by Dr
Robin. Fortunately these are usually cases with well-formed blebs since suture
removal was delayed past the first two weeks.
The point regarding 5-fluorouracil and mitomycin C is very important. As Dr
Spaeth mentioned and Dr Robin indicated, late removal of the sutures, or cutting
sutures with a laser, even as much as 6 months after surgery may cause rapid opening
of the scleral flap and profound hypotony when fibroblast inhibitors are employed.
My real question is whether these techniques (removable sutures or suture lysis)
should be used with 5-fluorouracil or mitomycin C filters. We still use releasable
sutures, but we certainly delay their removal for prolonged periods of time due to the
hazard of hypotony. Sometimes pressures now become too low; and one can ques-
tion how low is adequate, or how low is too low. I don't have the answer.
I believe that we have largely eliminated one set of problems with filtering
surgery, (ie, early postoperative flat chambers and choroidal effusions) but have
created a new set of problems associated with hypotony and macular changes due to
the use of fibroblast inhibitors. Thank you.