Viewpoint
Blebs: Good Riddance!

One of my favorite lines from an otherwise boring meeting came more than 15 years ago when a friend was asked about a post-cataract filtering bleb from a suture tract. "If it's anything like my trabeculectomy," he shrugged, "It will be closed off by next week.

Those are fighting words to the glaucoma specialist, loosely defined as anyone who enjoys performing trabeculectomy. They live to create holes in the eye that the body cannot heal. Maybe it is an acquired skill, but probably the talent is a gift from heaven.

Consider their challenge: they have to make a hole in the eye that won't heal, not too big or the eye will become soft, but not too small or the pressure won't be low enough. They use antimetabolites, just enough to prevent scarring, but not so much that they will get an atrophic bleb. Later, they will have the pleasure of (in alphabetical order) injecting the bleb, lasering the bleb, massaging the bleb, needling the bleb, reconstructing the bleb, reforming the bleb or treating an infected bleb.

Trabs are hell, and God bless those who want to do them. I stopped years ago and don't ever want to do one again.

Which brings us to the article in this issue on endoscopic cyclophotocoagulation (ECP) and its use during cataract surgery. ECP has made combined phaco/trab obsolete in our office. We have not done one in years. Any patient who needs a cataract operation and improved glaucoma control or compliance gets a phaco/ECP, but never a phaco/filter. If the ECP is insufficient, we can repeat it. If it becomes necessary, Dr. Mike can do a trabeculectomy as an independent procedure later on.

Many Good Alternatives in Glaucoma Surgery

There are many options being developed that eliminate patient compliance as a variable in glaucoma control. In addition to the invasive ECP treatment, we also have non-invasive office laser procedures, like argon laser trabeculoplasty and selective laser trabeculoplasty. We have developed outflow-enhancing operations that do not require a filtering hole or a bleb, like viscocannalostomy and canaloplasty. Will they become as effective as a good filter and replace it as surgery of choice? Will the safety profile of these operations, even if one needs to be repeated, weigh the risk/benefit ratio in their favor? Time will tell.

Trabeculectomy is a challenging and inconsistent operation. Maybe some day we won't need it any more and it will drift away into history, just like all the other drainage operations before it.