Original Investigation | Clinical Sciences

Nd:YAG Laser Goniopuncture for Late Bleb Failure After Trabeculectomy With Adjunctive Mitomycin C

Remo Susanna Jr, MD1; Carlos G. De Moraes, MD2,3; Luciana M. Alencar, MD, PhD1; Robert Ritch, MD2
[+] Author Affiliations
1Department of Ophthalmology, University of São Paulo, São Paulo, Brazil
2The Shelley and Steven Einhorn Clinical Research Center, New York Eye and Ear Infirmary, New York
3Department of Ophthalmology, New York University School of Medicine, New York,
JAMA Ophthalmol. 2014;132(3):286-290. doi:10.1001/jamaophthalmol.2013.6259.
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Importance  There is an increasing need to prolong trabeculectomy success rates with minimally invasive procedures.

Objective  To investigate the safety and efficacy of Nd:YAG laser goniopuncture (LGP) in lowering intraocular pressure (IOP) in eyes having late bleb failure following trabeculectomy with mitomycin C administration.

Design, Setting, and Participants  Prospective, noncomparative, interventional cohort at a referral glaucoma practice, including 19 eyes of 19 patients with uncontrolled glaucoma after failed trabeculectomy.

Interventions  All eyes had ischemic nonfunctioning blebs with patent internal ostia and underwent Nd:YAG LGP, followed by a 5-fluorouracil injection.

Main Outcomes and Measures  The IOP and the number of antiglaucoma medications before and after the procedure, as well as presurgical and postsurgical appearance of the blebs, using the Indiana Bleb Appearance Grading Scale classification.

Results  The mean (SD) time of LGP after trabeculectomy was 35.7 (32.3) months, and the mean (SD) follow-up period after LGP was 6.0 (1.1) months (range, 4.4-8.4 months). The mean (SD) IOP had decreased from 20.9 (4.5) mm Hg (range, 15.5-29.0 mm Hg) to 11.9 (4.1) mm Hg (range, 5.0-21.0 mm Hg) (P < .001). The only complications observed after LGP were 2 cases of hypotony, which resolved spontaneously. Compared with baseline Indiana Bleb Appearance Grading Scale classifications, 2 eyes showed an increase in bleb height and 10 eyes showed an increase in bleb extension. None of the eyes had a positive Seidel test result. The mean (SD) number of hypotensive agents per eye had decreased from 0.7 (1.1) to 0.3 (0.7) after the procedure. At the last follow-up visit, 15 eyes (79%) had achieved an IOP of 15 mm Hg or less, with a minimum IOP reduction of 20% from baseline without medication use.

Conclusions and Relevance  The Nd:YAG LGP is a safe and effective procedure for lowering IOP in eyes with ischemic nonfunctioning blebs and patent trabeculectomy ostia. This is a promising solution to rescue failed trabeculectomies and can potentially prolong trabeculectomy success rates.

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Figure 1.
Before and After Nd:YAG Laser Goniopuncture, With Indiana Bleb Appearance Grading Scale Classification

A, Failed bleb before Nd:YAG laser goniopuncture. The intraocular pressure was 24 mm Hg on a maximum tolerated medical therapy regimen. B, Gonioscopic view of the opened ostium. C, Bleb appearance at the last follow-up visit. The intraocular pressure was 8 mm Hg without medication use.

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Figure 2.
Patient Shown in the Video, Who Underwent Nd:YAG Laser Goniopuncture

A, The intraocular pressure before the procedure was 18 mm Hg on a maximum tolerated medical therapy regimen. B, One month after a session of Nd:YAG laser goniopuncture (see the Video), the intraocular pressure had dropped to 10 mm Hg without medication use.

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Nd:YAG Laser Goniopuncture Performed on the Eye Shown in Figure 2

Following visualization of the internal ostium during gonioscopy, 10 shots of Nd:YAG laser (7-8 mJ each) focused deep into the ostium, and 5-fluorouracil injection in the inferior fornix, the bleb appearance improved and enlarged, despite the baseline ischemic area and surrounding scar tissue.

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