Vol.13  No. 1,  October 2003

EARLY VERSUS LONG TERM INTRAOCULAR PRESSURE FOLLOWING RELEASABLE SUTURE TRABECULECTOMY IN ADVANCED GLAUCOMA

Dr. Jagjit S. Saini , Dr. Jaspreet Sukhija , Dr. Arun. K. Jain 

INTRODUCTION

Releasable suture surgery permits a tight initial closure of the scleral flap with an option to increase  the outflow of aqueous humor in the early post-operative period.  Interest in releasable suture was increased after Cohen and Osher1  reported their technique of exteriorizing the releasable suture over the cornea in trabeculectomy.

Aim: Behavior of IOP in  67 eyes of 52 patients with a follow-up of at least 2 years following releasable suture trabeculectomy(TRS).

MATERIAL AND METHODS

The records of all patients who underwent TRS from January 1994-2001 were reviewed.  Only those patients were included who had a follow-up of at least 2 years.  The first suture, usually the nasal one, was removed on the fifth post-operative day if there was a well-formed anterior chamber and no conjunctival leak.  IOP was measured before and after suture removal.  The second suture was removed in eyes where the IOP was > 15 mmHg after removal of the first suture.  Success was defined as final IOP of 21 mmHg or less without antiglaucoma medication and qualified success as IOP of 21 mmHg or less with antiglaucoma drugs.

RESULTS

Sixty-seven eyes ( 67 eyes) underwent trabeculectomy with releasable sutures.  There were 46 males and 21 females. The age of patients ranged from 14 years to 88 years.  The pre-operative IOP ranged from 22 mmHg to 48 mmHg ( average 26 mmHg).  The IOP recorded on follow up is shown in table- I.

IOP (mmHg)

Day of recording IOP

1st POD* eyes(%)

BRS* eyes(%)

ARS* eyes(%)

1 Week eyes(%)

3 Week eyes(%)

6 months eyes(%)

1 year eyes(%)

2 years eyes(%)

0-5

5(7)

2(3)

6(9)

0(0)

0(0)

0(0)

0(0)

0(0)

6-10

21(32)

24(36)

30(45)

22(33)

24(36)

19(29)

19(29)

18(27)

11-15

17(25)

18(27)

13(19)

22(33)

31(46)

40(60)

28(42)

33(50)

16-21

21(32)

17(25)

14(21)

17(25)

9(14)

5(7)

17(25)

13(19)

>21

3(4)

6(9)

4(6)

6(9)

3(4)

3(4)

3(4)

3(4)

Pre-suture release IOP did not differ significantly from immediate post-suture IOP(11.5 ±6.1 mmHg vs 13.4± 6 mmHg), (p> 0.05). Fifty-one (77%) eyes demonstrated IOP of  ≤ 15 mmHg at 2 years.  Sixty-four (95%) eyes had an IOP of ≤21 mmHg at 2 years.  Fifty one out of 55 eyes with 3 week post-operative IOP of  ≤15 mmHg demonstrated IOP of  ≤15 mmHg at 2 years.  Another, four out of 12 eyes with 3 weeks post-operative IOP of > 15 mmHg recorded IOP ≤15 mmHg at 2 years.  IOP measured at 3 weeks significantly correlated with IOP at 2 years ( p < 0.01). Table -II)

 

2 yrs post trab IOP (mmHg)

1 week post trab IOP (mmHg) p < .05

 

≤ 10

11-21

>21

≤ 15

19 (37%)

30 (59%)

2 (4%)

> 15

3 (19%)

9 (56%)

4 (25%)

 

3 week post trab IOP (mmHg) p < .01

≤15

22(43%)

29 (57%)

0(0.00%)

> 15

0(0.00%)

13(81%)

3(19%)

DISCUSSION

Trabeculectomy with releasable suture is generally reported safer and more successful technique than standard trabeculectomy2.  IOPs attained following TRS are reported lower3.  There is however no consensus on timing and criterion for suture release.  Some authors have described release of suture only when IOP rises above 8 or 21 mmHg 2,4.  Suture release has also been practiced at 1-21 days following the surgery3.  Pressure lowering following suture release is less effective with increasing post surgery duration. Suture release is demonstrated to be more appropriate within seven days of TRS3.  Other studies have released sutures only when IOP were adjudged  inadequate at 16 to 21 mmHg irrespective of the post surgery duration.  Thomas et al demonstrates that in a group of eyes with advanced glaucoma,  TRS is successful in attaining IOP of ≤15 mmHg in 77% of eyes at 2 years.  This IOP of ≤15 mmHg at 2 years is observed in 93% of eyes that had IOP of ≤15 mmHg demonstrated IOP of  ≤15 mmHg at 2 years.  This observation shows that IOP at 3 weeks is a reasonable predictor of IOP at 2 years.

It is appropriate to emphasize that this study was retrospective review of cases and not a randomized clinical trial.  No case of infection or keratopathy was  seen in our study.  We highlight the fact that releasable suture technique is a very effective method of controlling IOP in advanced glaucoma.  Initial IOP recordings at 3 weeks post-operative  are very important as they reflect a good correlation to the long-term control of IOP and the outcome of surgery.  Our data recommends release of sutures in the critical first week post surgery for long-term control of IOP.

REFERENCES

  1. Cohen JS, Osher RH.  Releasable scleral flap suture.  Ophthalmol Clin North America 1988; 1:187-197.

  2. Kolker AE, Kass MA, Rait JL. Trabeculectomy with releasable sutures. Arch Ophthalmol 1994; 112:62-66.

  3. Raina UK, Tuli D. Trabeculectomy with Releasable sutures.  Arch Ophthalmol 1988; 116: 1288-1293.

  4. Thomas R, Jacob P, Braganza A, Mermoud A, Muliyil.  Releasable suture technique for trabeculectomy. Ind J Ophthalmol 1997; 45:37 - 41.

Department of Ophthalmology, 
Post Graduate Institute of Medical Education and Research Chandigarh, 160012, India.

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