Original article
Risk of Endophthalmitis and Other Long-Term Complications of Trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS)

https://doi.org/10.1016/j.ajo.2012.10.017Get rights and content

Purpose

To report the risk of endophthalmitis and other long-term complications in patients randomized to trabeculectomy in the Collaborative Initial Glaucoma Treatment Study.

Design

A longitudinal cohort study using data collected from a multicenter, randomized clinical trial.

Methods

Long-term postoperative complications in the 300 patients randomized to trabeculectomy in the Collaborative Initial Glaucoma Treatment Study were tabulated. Kaplan-Meier analyses were used to estimate the time-related probabilities of blebitis, hypotony, and endophthalmitis.

Results

Two hundred eighty-five patients were included in the final trabeculectomy cohort after accounting for declining treatment assignment and other early events. Patients were followed up for an average of 7.2 years. One hundred sixty-three patients (57%) received 5-fluorouracil during surgery. Of the 247 patients with at least 5 years of follow-up, 50 required further treatment for glaucoma. Cataract extraction was performed in 57 patients (20%). Forty patients (14%) required bleb revision at least once. Bleb-related complications included bleb leak (n = 15), blebitis (n = 8), and hypotony (n = 4). Three patients were noted to have endophthalmitis, although the diagnosis in 2 patients was presumptive. The occurrences of blebitis, hypotony, or endophthalmitis were not significantly associated with 5-fluorouracil use. The Kaplan-Meier calculated risks of blebitis and hypotony at 5 years were both 1.5%, whereas the risk of endophthalmitis was 1.1%.

Conclusions

The potential efficacy of trabeculectomy must be weighed against the long-term risk of complications, especially endophthalmitis, when selecting treatments for patients with open-angle glaucoma. We report a low 5-year risk of endophthalmitis (1.1%) and other bleb-related complications in the trabeculectomy cohort of the Collaborative Initial Glaucoma Treatment Study.

Section snippets

Methods

The CIGTS was approved by the University of Michigan Institutional Review Board as well as by the institutional review board at each of the 14 clinical centers. The detailed methodology of the CIGTS has been described previously.9, 20 Briefly, the CIGTS involved 36 surgeons at 14 clinical centers and was approved by the institutional review boards at each site; written informed consent was obtained from all participants. The study enrolled 607 patients with newly diagnosed open-angle glaucoma

Patients

Three hundred of the 607 CIGTS patients were randomized to intervention with trabeculectomy. After randomization, 10 patients changed their minds and chose not to undergo initial trabeculectomy. Eight of these patients underwent ALT as the first intervention, whereas 2 patients opted for medications. Four patients had no follow-up either because of death or drop-out before or shortly after treatment, whereas 1 patient had only 9 months of follow-up after a several-year delay in undergoing

Discussion

For surgical approaches to treating open-angle glaucoma with the potential for infectious complications, an adequate assessment of risks and benefits is critical. There is a theoretically reduced risk of infection in nonpenetrating glaucoma surgery, given the lack of complete ocular penetration when compared with conventional trabeculectomy. Reported infectious complications in nonpenetrating glaucoma surgery have been limited to isolated reports of fungal and bacterial keratitis and blebitis.21

Sarwar Zahid is a fourth year medical student at the University of Michigan Medical School, Ann Arbor, Michigan. Given his immense interest in ophthalmology, he pursued a one-year research fellowship with the retinal dystrophy team at the Kellogg Eye Center, Ann Arbor, Michigan. His long-term career goal is to further build on his research training in order to become an excellent clinical and academic ophthalmologist.

References (37)

  • E. Mendrinos et al.

    Bacterial keratitis after nonpenetrating glaucoma surgery

    J Cataract Refract Surg

    (2008)
  • D.C. Musch et al.

    Intraocular pressure control and long-term visual field loss in the Collaborative Initial Glaucoma Treatment Study

    Ophthalmology

    (2011)
  • S.Y. Jea et al.

    Ab interno trabeculectomy versus trabeculectomy for open-angle glaucoma

    Ophthalmology

    (2012)
  • R. Bindlish et al.

    Efficacy and safety of mitomycin-C in primary trabeculectomy: five-year follow-up

    Ophthalmology

    (2002)
  • P.T. Zacharia et al.

    Ocular hypotony after trabeculectomy with mitomycin C

    Am J Ophthalmol

    (1993)
  • E.J. Higginbotham et al.

    Bleb-related endophthalmitis after trabeculectomy with mitomycin C

    Ophthalmology

    (1996)
  • P.Y. Ramulu et al.

    Utilization of various glaucoma surgeries and procedures in Medicare beneficiaries from 1995 to 2004

    Ophthalmology

    (2007)
  • M.C. Grieshaber

    Ab externo Schlemm's canal surgery: viscocanalostomy and canaloplasty

    Dev Ophthalmol

    (2012)
  • Cited by (104)

    • Personalising surgical treatments for glaucoma patients

      2021, Progress in Retinal and Eye Research
      Citation Excerpt :

      Recent results from a retrospective multicentre study in the UK performed on 428 eyes showed that at 2 years trabeculectomy with MMC or 5FU, with releasable or adjustable sutures and performed by trained glaucoma specialists, resulted in an IOP of ≤21 mmHg and a 20% reduction of baseline IOP without medication in 80% of cases (Kirwan et al., 2013). However, even with improvements in the surgical technique and better use of antifibrotics, this procedure still accounts for a significant number of post-operative manipulations and minor as well as major complications (Gedde et al., 2012; Kirwan et al., 2013; Zahid et al., 2013). Since the early 1990s, newer surgical techniques have emerged as a safer alternative to conventional filtration surgery.

    View all citing articles on Scopus

    Sarwar Zahid is a fourth year medical student at the University of Michigan Medical School, Ann Arbor, Michigan. Given his immense interest in ophthalmology, he pursued a one-year research fellowship with the retinal dystrophy team at the Kellogg Eye Center, Ann Arbor, Michigan. His long-term career goal is to further build on his research training in order to become an excellent clinical and academic ophthalmologist.

    View full text