Inferior trabeculotomy and trabeculectomy for refractory pediatric glaucomas.

Dear Editor,

We read the article by Mandal et al., with interest.[1] We have successfully practiced Mandal's technique of trabeculotomy and trabeculectomy (T and T) since 5 years. However, the problem comes when there is a failure.

Mandal has chosen mitomycin-C (MMC)-augmented trabeculectomy over Ahmed glaucoma valve. In our experience, even when MMC is used for a short duration at a low concentration, blanching of the conjunctiva and the resultant avascular bleb is common in children [Fig. 1]. Use of a “ring of steel technique”[2] or an inferior T and T [Fig. 2] could be useful alternatives.

Figure 1

Diffuse illumination digital photograph of the left eye showing an avascular, thin-walled, cystic bleb after mitomycin C-augmented trabeculotomy and trabeculectomy in a child with infantile glaucoma

Figure 2

Serial photographs showing (a) a child with infantile glaucoma following a failed trabeculotomy and trabeculectomy (T and T), (b) position of the surgeon for an inferior T and T, (c) scarred superior conjunctiva, (d) dissection of scleral flap and explored Schlemm's canal inferiorly, (e) inferior trabeculotomy in progress, (f) inferior peripheral iridectomy, (g) diffuse inferior bleb postoperatively, (h) microscopic view of the well-formed anterior chamber with a wide base inferior peripheral iridectomy and air bubble in the anterior chamber and (i) 1-month postoperative appearance of the eye

There are several studies where MMC or 5-fluorouracil were used with inferior trabeculectomy in adults resulting in a high incidence of bleb-related infections.[34] Vesti et al.[5] have reported inferior trabeculectomy without antifibrotics to be a safe and effective procedure in adults. However, the follow-up was short (<12 months). We want to know from Mandal, between the MMC-augmented trabeculectomy at superior limbus and an inferior T and T procedure without antifibrotics, which would be a lesser evil and which one has a higher efficacy?