ORIGINAL STUDY

The Effect of Trabeculectomy on Astigmatism

Heleen Delbeke, MD, Ingeborg Stalmans, MD, PhD, Evelien Vandewalle, MD, PhD,
and Thierry Zeyen, MD, PhD
Purpose: To investigate the change in corneal astigmatism after
trabeculectomy.
Patients and Methods: Between January and April 2012, patients
who underwent a primary trabeculectomy were enrolled in this
prospective study. We measured the visual acuity, automated keratorefractometry, and the intraocular pressure preoperatively and
postoperatively at 1, 3, and 6 months. Changes in astigmatism were
quantied using the vector analysis described by Cravy. A Friedman test and a linear model for longitudinal measures were used to
compare changes in the refraction and the intraocular pressure. A
binomial test was used to compare the proportion of eyes with a
shift in astigmatism with or against-the-rule.
Results: A total of 47 eyes (47/48 patients) were included for analysis.
The mean ( SD) intraocular pressure decreased from 17.5
5.4 mmHg preoperatively to 9.8 4.0 mmHg after 6 months
(P < 0.001). At this time-point, 32/47 eyes showed a shift in astigmatism with-the-rule (P = 0.02), with a median dierence in cylinder
of + 0.50 D (range, 0 to 4 D) (P = 0.004). The mean ( SD) axis of
the positive cylinder changed from 169 148 to 135 146 degrees
after 6 months (P = 0.12) and the mean ( SD) spherical equivalent
changed from
0.47 2.27 to
0.07 1.93 D (P = 0.15). The
mean ( SD) logMAR was 0.17 0.22 preoperatively and 0.14
0.14 after 6 months (P = 0.9).
Conclusions: Trabeculectomy induced a small but statistically signicant shift in astigmatism with-the-rule after 6 months. The
spherical equivalent did not change compared with the preoperative value. Most often, glasses will not need to be changed
after trabeculectomy.
Key Words: glaucoma, trabeculectomy, astigmatism, intraocular
pressure

(J Glaucoma 2015;00:000000)

laucoma is a multifactorial, chronic optic neuropathy

characterized by progressive retinal ganglion cell
death, optic disc cupping, and corresponding visual eld
loss mostly due to an abnormally high intraocular pressure
(IOP).1
When maximal pressure-lowering medical treatment
does not suciently lower the pressure or there is progression of the visual eld, a switch to laser treatment or
ltering surgery such as trabeculectomy with or without
mitomycin-C (MMC) is necessary.
Corneal astigmatism after cataract surgery has been
investigated extensively. Much less research has been
devoted to corneal astigmatism after trabeculectomy, and
the reported results are conicting. Hugkulstone and
Received for publication April 16, 2014; accepted January 8, 2015.
From the Department of Ophthalmology, University Hospitals
Leuven, Leuven, Belgium.
Disclosure: The authors declare no conict of interest.
Reprints: Heleen Delbeke, MD, Kapucijnenvoer 33, Leuven B-3000,
Belgium (e-mail: heleendelbeke@hotmail.com).
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/IJG.0000000000000236

J Glaucoma

Volume 00, Number 00, 2015

colleagues were the rst to investigate the changes in corneal astigmatism after trabeculectomy without MMC. They
found, unlike after cataract surgery, a reduction in the
vertical corneal radius after trabeculectomy, inducing
astigmatism with-the-rule (WTR). Their investigation was
limited by the number of patients (9) and a short follow-up
(7 wk).2 Kook and colleagues studied the eect of MMCaugmented trabeculectomy on corneal astigmatism in 2001.
They included 16 patients who were followed until 12
months postoperatively. Corneal astigmatism after trabeculectomy with MMC was WTR up to 3 months postoperatively, followed by an against-the-rule (ATR) shift
until 12 months after surgery.3
The change in astigmatism after trabeculectomy can
lead to a decrease in the visual acuity in some patients and it
would be useful to know when refraction stabilizes and
when new glasses can be prescribed safely. The aim of our
study was to examine the change in refraction and in particular in corneal astigmatism after trabeculectomy, and to
look for correlations with the decrease in IOP.

PATIENTS AND METHODS

This prospective study was registered on clinicaltrials.gov (NCT01711190) and approved by the Institutional Review Board of the University Hospitals, Leuven.
All consecutive eligible patients who agreed to participate
in the study signed an informed consent before enrollment.
All the enrolled patients underwent a primary MMCenhanced trabeculectomy for glaucoma that was not adequately controlled with maximal tolerated medical therapy
and/or laser therapy.
All the surgeries were performed by 2 surgeons (I.S.
and E.V.) between January 2012 and April 2012 at the
University Hospitals Leuven, Belgium.
Indications for surgery were based on the following
factors: (1) IOP associated with a high probability of
glaucoma progression, (2) glaucomatous visual eld loss
and/or changes of the optic disc indicative of progressive
glaucoma damage, or (3) allergy or intolerance to current
maximal topical therapy.
We included only white patients with primary openangle glaucoma, normal-tension glaucoma, pseudoexfoliation glaucoma, or pigment dispersion glaucoma.
We excluded patients below 18 years of age, patients
with other ocular diseases besides glaucoma, those with a
refractive error more than 6.00 D or a visual acuity <1.3
logarithm of the minimum angle of resolution values (logMAR), and those with signicant corneal opacities inducing
irregular astigmatism. Patients who underwent laser treatment for glaucoma or clear corneal small incision cataract
surgery more than 6 months before the trabeculectomy were
not excluded. All other intraocular surgeries were a
contraindication.
The surgeons used a modied Moorelds trabeculectomy technique.4 One hour before surgery, topical pilocarpine (Pilo 2%; Meda Pharma, Brussels, Belgium) was
www.glaucomajournal.com |

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.

Delbeke et al

J Glaucoma

instilled. Anesthesia was induced by general anesthesia or

retrobulbar injection of a mixture of bupivacaine (Marcaine
2%; Astra Zeneca, London, UK) and lidocaine (Linisol 2%;
B Braun Medical, Diegem, Belgium). Immediately before
the surgery, apraclonidine (Iopidine; Alcon, Puurs,
Belgium) eye drops were applied to provide blanching of the
conjunctiva. A silk 8-0 corneal traction suture was placed
and a fornix-based conjunctival ap was dissected in 1
quadrant, followed by gentle diathermy for hemostasis with
a wet bipolar cauter (Innity Vision System; Alcon,
Novartis, Vilvoorde, Belgium or Eva; DORC, Zuidland,
The Netherlands). A scleral ap measuring 54 mm with
side incisions at 0.5 mm from the cornea was consequently
delineated with a 30-degree blade (Micro Feather; Feather
Safety Razor Co., Osaka, Japan). The ap was dissected
half-thickness 1 mm into the clear cornea with a crescent
knife (Alcon, Puurs, Belgium), without prolonging the lateral incisions. Sponges soaked in MMC (0.2 mg/mL) were
applied for 2 minutes underneath the conjunctival and
scleral ap. Subsequently, the subconjunctival space was
abundantly rinsed. Two xed diagonal sutures (nylon 10-0)
were preinstalled at the edges of the scleral ap. A corneal
paracentesis was made at the 3 or the 9 oclock position
using a 30-degree blade (Micro Feather; Feather Safety
Razor Co.). In order to maintain the anterior chamber (AC)
depth, a viscoelastic (Viscoat; Alcon) was injected to ll half
of the AC. The trabeculectomy was performed using the
Khaw titanium punch of 0.5 mm (No. 7-102: Duckworth
and Kent; Hertfordshire, UK) followed by a peripheral
iridectomy. The 2 xed ap sutures were closed with gentle
tension on the scleral ap. The conjunctiva was closed with
2 nylon 10-0 sutures (2 purse string sutures at the edges) at
the limbus, and the side port was hydrated at the end of the
surgery. Finally, a subconjunctival injection of betamethasone (Celeston chronodose; Schering-Plough NV/SA,
Brussels, Belgium) was administered and all phakic eyes
received a drop of atropine sulfate 1% (Atropine Sulphate
Minims; Chauvin Pharmaceuticals, Brentwood, Essex, UK).
A topical preparation containing tobramycin and
dexamethasone (Tobradex; Alcon) was applied as an ointment at the end of the surgery and consequently continued
in the form of drops 4 times daily for 8 weeks and then
tapered over 3 weeks. In case of allergy to benzalkonium
chloride, preservative-free dexamethasone (Dexamethasone
Monofree; Thea Pharma, Wetteren, Belgium) and ooxacin
(Traoxal Edo; Dr Mann Pharma, Berlin, Germany) were
prescribed. In the rst postoperative days, gentle bleb
massage was performed if the IOP was elevated. The xed
sutures were cut between the rst and the second weeks with
the 532-nm laser to reach the preset target IOP. Encapsulated blebs associated with an increase in IOP were treated
with needling. Failing ltering blebs were treated by subconjunctival 5-uorouracyl and/or bevacizumab injections
and/or by needling revision, if the scleral ap was visible,
lifting the scleral ap and, if necessary, penetrating the AC.
Before surgery, a comprehensive ophthalmological
examination was performed including automated keratorefractometry (AR) (Autorefractokeratometer NIDEK;
Aichi, Japan), visual acuity depicted in logMAR, and IOP
measurement by Goldmann applanation tonometry. We
included only patients with a reliability coecient Z7 on
AR. When AR was not available, it was replaced by a
subjective refraction test. These investigations were
repeated at 1, 3, and 6 months after surgery.

2 | www.glaucomajournal.com

Volume 00, Number 00, 2015

A mid-term follow-up was chosen for analysis of the

results as we postulated that postoperative astigmatism was
expected to stabilize after 3 to 6 months on the basis of the
available literature,57 and the patients may benet from a
prescription of new glasses after a couple of months.
We gave all patients a letter, whereupon the ophthalmologist could complete the results, together with a
stamped envelope addressed to our department. Ophthalmologists who did not reply were called to collect the
information.

Statistical Methodology
Changes in astigmatism were quantied using the
vector analysis described by Cravy.8 A Friedman test and a
linear model for longitudinal measures were used to compare the changes in refraction and IOP. A binomial test was
used to compare the proportion of eyes with a shift in
astigmatism WTR or ATR.

RESULTS
In total, 52 eyes of 51 patients were enrolled in this
prospective study. Sixteen eyes had missing or unreliable
data at 1, 3, and/or 6 months. At 6 months, we excluded 5
eyes because of missing data. Forty-seven eyes (47/48
patients) were included for the nal analysis at 6 months.
Baseline characteristics are summarized in Table 1.
There were no intraoperative complications. Postoperative
complications and interventions are summarized in
Tables 2 and 3.
The mean SD spherical equivalent changed from
0.47 2.27 D preoperatively to 0.07 1.93 D after 6
months (P = 0.15). Six months after trabeculectomy, 20/47
eyes showed a shift toward myopia (mean,
0.70
0.49 D), 26/47 eyes showed a shift toward hyperopia (mean,
1.06 1.02 D), and 1 patient had no shift in refraction. The
preoperative visual acuity (logMAR) changed from
0.17 0.22 to 0.14 0.14 after 6 months (P = 0.9).
Tables 4 and 5 summarize changes in astigmatism and
refraction after trabeculectomy.
On the basis of Cravys vector analysis,8 32/47 (68%)
eyes showed a shift in astigmatism WTR (P = 0.02) after 6
months. Using this analysis, the mean ( SD) change in
astigmatism (combination of axis and cylinder) was
0.35 1.11 D after 1 month (P = 0.05) and 0.18 0.75 D
TABLE 1. Baseline Characteristics
Age [mean (range)]
No. eyes
Preoperative visual acuity (log MAR) (SD)
Mean spherical equivalent preoperatively (SD)
Women [N (%)]
Right eyes [N (%)]
Anesthesia [N (%)]
Local
General
No. myopic eyes preoperatively [N (%)]
No. hyperopic eyes preoperatively [N (%)]
Primary open-angle glaucoma [N (%)]
Normal-tension glaucoma [N (%)]
Pseudoexfoliation glaucoma [N (%)]
No prior laser or phacoemulsication [N (%)]
Laser trabeculoplasty [N (%)]
YAG laser iridotomy [N (%)]
Phacoemulsication [N (%)]

Copyright

67.5 (47-85)
52
0.2 ( 0.2)
0.5 D ( 2.27)
30 (57.7)
25 (48)
46
6
25
27
28
18
6
34
9
3
10

(88.5)
(11.5)
(48)
(52)
(53.9)
(34.6)
(11.5)
(65.4)
(17.3
(5.8)
(19.2)

2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.

J Glaucoma

Volume 00, Number 00, 2015

The Effect of Trabeculectomy on Astigmatism

TABLE 2. Postoperative Complications at Any Time-point During

the Follow-up of 6 Months

No. Eyes (%)

Positive Seidel*
Choroidal detachment
Malignant glaucoma
Endophthalmitis

3
6
0
0

(5.8)
(11.5)
(0)
(0)

TABLE 4. Shift in Astigmatism WTR and ATR 6 Months After

Trabeculectomy (47 Eyes)

Shift in Astigmatism

DISCUSSION
There are not many reports on the evolution of
astigmatism after trabeculectomy. Most of them studied a
limited number of patients and the results were sometimes
conicting. It is important, however, to know the optimal
time window to change the glasses if a change in refraction
occurs. We investigated the change in refraction,
TABLE 3. Postoperative Manipulations and Interventions

No. Eyes (%)

32
28
18
8

15
12
5
4

*All patients had a shift in astigmatism.

ATR indicates against-the-rule; WTR, with-the-rule.

after 3 months (P = 0.02), remaining stable until 6 months

(P = 0.01) (Fig. 1). There was no dierence in astigmatism
after 6 months between the group of eyes with or without
suture lysis (P = 0.179).
The median cylinder changed from + 1.00 D (range, 0 to
4.25 D) preoperatively to + 1.00 D (range, 0 to 7.50 D)
(P = 0.002), + 0.75 D (range, 0 to 4.00 D) (P = 0.030), and
+ 0.50 D (range, 0 to 4.00 D) (P = 0.004) after 1, 3, and 6
months, respectively. After 6 months, 12/47 eyes had a change
in the cylinder power of Z1 D, of which 8 eyes changed WTR.
The mean axis of the positive cylinder changed from
169 148 to 135 146 degrees after 6 months (P = 0.12); 17/
47 eyes had a change in the cylinder axis of Z45 degrees.
There was no dierence between the pseudophakic and
the phakic patients in the mean change in astigmatism
(Cravys vector analysis) or spherical equivalent after 6
months: 0.2 0.40 versus 0.2 0.81 D (P = 0.52) for
astigmatism and 0.5 1.74 versus 0.2 1.12 D (P = 0.755)
for the spherical equivalent, respectively.
The mean ( SD) IOP decreased from 17.5 5.4 mm
Hg preoperatively to 7.9 3.9, 10.1 5.6, and 9.8 4 mm
Hg at 1, 3, and 6 months, respectively, after trabeculectomy. After 1 month, there was a signicant correlation
between the change in astigmatism and the decrease in IOP
(r = 0.49, P = 0.001); the lower the IOP, the more the
astigmatism WTR (Fig. 2). This correlation disappeared
after 6 months (r = 0.07, P = 0.656) (Fig. 3).

Copyright

Shift ATR (n)

> 0 D*
Z0.25 D
Z0.5 D
Z1 D

*None of the patients had a positive Seidel beyond week 1.

Massage
Day 1 or 2
First week
Second week
1 month
Laser suture lysis of scleral ap sutures
First week
Second week
1 month
Transconjunctival scleral ap sutures for hypotony
Conjuntival sutures for positive Seidel
Needling revision of failing bleb
Needling of encapsulated bleb
Anterior chamber reformation

Shift WTR (n)

25
14
12
1

(48.1)
(26.9)
(23.1)
(1.9)

19
17
0
3
1
2
0
2

(36.5)
(32.7)
(0)
(5.8)
(1.9)
(3.8)
(0)
(3.8)

particularly in corneal astigmatism, induced by trabeculectomy with MMC over a period of 6 months in 47 eyes.
Using Cravys vector analysis,8 the majority of the
eyes (68%) developed astigmatism WTR after 6 months.
The median dierence in cylinder after 6 months was
+ 0.5 D (range, 0 to 4 D).
Watson9 was the rst to mention alteration in vision
after glaucoma ltrating surgery. Hugkulstone et al2 investigated surgically induced astigmatism as a possible cause for
a decrease in the visual acuity after trabeculectomy. He found
a decrease in the vertical radius and a concomitant increase in
the horizontal radius (WTR astigmatism) postoperatively.
The authors suggested that WTR astigmatism was the result
of the scleral ap and the posterior placement of the incisions
of the ap rather than the number of ap sutures, as there
was no dierence between scleral aps sutured with 2 or 5
stitches. However, their investigation was limited by the
number of patients (9) and by the short follow-up (7 wk).
Claridge et al10 found superior steepening of the corneal
curvature after trabeculectomy in the majority of the eyes
using computer-assisted corneal topography. This superior
steepening was attributed to contraction of the tissue around
the trabeculectomy site secondary to extensive scleral cautery.
They also suspected that a large drainage bleb or a postoperative ptosis could provoke corneal steepening. Cunlie
et al5 attributed the change in curvature to the internal sclerostomy that allowed the corneal edge of the trabeculectomy
to sink slightly, decreasing the vertical radius of the cornea.
However, from 2 months onwards, the vertical corneal radius
returned to preoperative levels, possibly because the tension
of the scleral ap sutures started to weaken, allowing the
corneal edge of the sclerostomy to resume its preoperative
position. Similarly, we found a small but signicant shift in
astigmatism WTR after trabeculectomy. This shift was also
more pronounced 1 month postoperatively and regressed
after 3 months, remaining stable until the end of the followup at 6 months (Fig. 1). This shift in WTR astigmatism could
also be explained by the pressure of the eyelid and the bleb on
the cornea, steepening the vertical meridian, especially with
lower IOPs, in the early postoperative period. This eect may
be counteracted when additional corneal incisions are used to
TABLE 5. Changes in Refraction 6 Months After Trabeculectomy
(47 Eyes)

No. Eyes (%)

Myopic shift (Z0.25 D)
Hyperopic shift (Z0.25 D)
No change in SE
Shift in SEZ1 D
Shift in axis of astigmatism Z45 degrees

2015 Wolters Kluwer Health, Inc. All rights reserved.

20
26
1
15
17

(42.6)
(55.3)
(2.1)
(31.9)
(36.2)

SE indicates spherical equivalent.

www.glaucomajournal.com |

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.

Delbeke et al

J Glaucoma

Volume 00, Number 00, 2015

FIGURE 1. Changes in astigmatism after trabeculectomy using vector analysis.8 ATR indicates against-the-rule; M, month; WTR, withthe-rule.

close the conjunctiva. Since June 2012, we used 2 purse string

and 2 mattress conjunctival sutures, all imbedded in corneal
incisions. A comparative study is ongoing to investigate the
dierence in induced astigmatism with or without corneal
incisions and extra mattress sutures.
Rosen et al11 showed that suture lysis of the scleral ap
sutures did not inuence changes in corneal curvature. This
was consistent with our study where there was no dierence
in astigmatism after 6 months between the groups with or
without suture lysis.
Hong et al12 compared the astigmatism after trabeculectomy with and without MMC. MMC inhibits broblast proliferation and improves the success rate in eyes
undergoing trabeculectomy, but it can also inuence the
severity and the duration of changes in the corneal curvature. Both groups showed a maximum shift WTR 1 month
postoperatively, but the group with MMC showed less
WTR astigmatism at that time-point ( 1.0 2.1 vs.
2.6 1.2 D). Whereas the group without MMC reached
a plateau 3 months after trabeculectomy, the group with
MMC showed a continuous ATR shift until 12 months

postoperatively. After 12 months, there was almost no

astigmatism (a mean of 0.3 1.1 D ATR) in the group with
MMC, and a mean of 1.4 2.5 D WTR in the group
without MMC. Hong and colleagues used a limbal-based
conjunctival ap technique, with a scleral ap measuring
4 4 mm. They applied MMC (0.4 mg/mL) for 1 to
5 minutes, in contrast to our study, where we used only
MMC (0.2 mg/mL) for 2 minutes. They assumed that the
continuous ATR shift after 3 months in the group with
MMC was the result of the residual MMC action on wound
healing. The lower dose and the shorter duration of application in our study can explain as to why the plateau was
reached at 3 months. Furthermore, they closed the conjunctiva and the sclera with 10-0 nylon sutures, but no
information was given about the technique of closure.
Information about the type of cauterization or the use of a
punch or not to create the trabeculectomy was also not
available.
Kook et al3 also studied the eect of MMC-augmented
trabeculectomy on corneal astigmatism, using 0.4 mg/mL
for 2 to 5 minutes. The group with MMC showed, as in the

FIGURE 2. Correlation between the change in astigmatism and the IOP after 1 month. ATR indicates against-the-rule; IOP, intraocular
pressure; N, number of patients; WTR, with-the-rule.

4 | www.glaucomajournal.com

Copyright

2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.

J Glaucoma

Volume 00, Number 00, 2015

The Effect of Trabeculectomy on Astigmatism

FIGURE 3. Correlation between the change in astigmatism and the IOP after 6 months. ATR indicates against-the-rule; IOP, intraocular
pressure; N, number of patients; WTR, with-the-rule.

study by Hong and colleagues, a slower and longer lasting

ATR shift. Kook and colleagues also analyzed the eect of
preoperative astigmatism on the nal refractive result and
the change in the axial length postoperatively. They divided
their patients in WTR or ATR astigmatism preoperatively.
Both groups had a similar pattern of WTR shift in the early
postoperative period followed by an ATR astigmatic shift
until 12 months. At 12 months, there was a residual astigmatism of 0.7 D WTR. Eyes with ATR astigmatism preoperatively had a greater WTR astigmatic change at 6
months than those with WTR astigmatism preoperatively.
They concluded that although the amount of induced
astigmatism in their group was relatively small, as in our
study, the changes were longer lasting with the use of
MMC. The axial length was signicantly shorter at all
follow-up visits, with a mean change of 0.9 mm at 12
months. They also found emmetropization as we did in our
study.
The above-mentioned papers did not investigate the
correlation between IOP and astigmatism. We found a
signicant correlation between the change in astigmatism
and the decrease in IOP after 1 month (r = 0.49,
P = 0.001); the lower the IOP, the more the astigmatism
WTR (Fig. 2). This correlation disappeared after 6 months
(r = 0.07, P = 0.656) (Fig. 3). Probably, the eye is more
susceptible to deformation in the early postoperative weeks
when the IOP is the lowest.
We used wet bipolar cauterization in all our patients and
stopped antiaggregants 3 weeks before surgery, which probably contributed to a signicant reduction of cauterization
during surgery. The method of cauterization (wet or dry) or
the duration of discontinuing antiaggregants was rarely
specied in previous papers, although both factors may have
played an important role in the severity and the duration of
astigmatism.
Although previous reports have indicated that astigmatism stabilizes after 3 months, a longer follow-up period
in our study might have revealed additional information.
In conclusion, our study showed only a small,
although statistically signicant, shift in astigmatism WTR,
which stabilizes from 3 months onward. The spherical

Copyright

equivalent and the visual acuity did not change compared

with the values preoperatively. Most often, glasses will not
need to be changed after trabeculectomy.
ACKNOWLEDGMENT
The authors thank Steen Fieuws for his assistance with
the statistical analyses.
REFERENCES
1. Distelhorst JS, Hughes GM. Open-angle glaucoma. Am Fam
Physician. 2003;67:19371944.
2. Hugkulstone CE. Changes in keratometry following trabeculectomy. Br J Ophthalmol. 1991;75:217218.
3. Kook MS, Kim HB, Lee SU. Short-term effect of mitomycin-C
augmented trabeculectomy on axial length and corneal
astigmatism. J Cataract Refract Surg. 2001;27:518523.
4. Vandewalle E, Abegao Pinto L, Van Bergen T, et al. Intracameral bevacizumab as an adjunct to trabeculectomy: a 1-year
prospective, randomized study. Br J Ophthalmol. 2014;98:
7378.
5. Cunliffe IA, Dapling RB, West J, et al. A prospective study
examining the changes in factors that affect visual acuity
following trabeculectomy. Eye. 1992;6:618622.
6. Vernon SA, Zambarakji HJ, Potgieter F, et al. Topographic
and keratometric astigmatism up to 1 year following small flap
trabeculectomy (microtrabeculectomy). Br J Ophthalmol. 1999;
83:779782.
7. Ashai M, Ahmed A, Ahsan M, et al. The effect of
trabeculectomy on corneal astigmatism. JK-Practitioner. 2006;
13:2729.
8. Cravy TV. Calculation of the change in corneal astigmatism
following cataract extraction. Ophthalmic Surg. 1979;10:3849.
9. Watson PG. Trabeculectomy: a modified ab externo technique.
Ann Ophthalmol. 1970;2:199205.
10. Claridge KG, Galbraith JK, Karmel V, et al. The effect of
trabeculectomy on refraction, keratometry and corneal topography. Eye. 1995;9:292298.
11. Rosen WJ, Mannis MJ, Brandt JD. The effect of trabeculectomy on corneal curvature. Ophthalmic Surg. 1992;23:395398.
12. Hong YJ, Choe CM, Lee YG, et al. The effect of mitomycin-C
on postoperative corneal astigmatism in trabeculectomy and
triple procedure. Ophthalmic Surg Lasers. 1998;29:484489.

2015 Wolters Kluwer Health, Inc. All rights reserved.

www.glaucomajournal.com |

Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.