ORIGINAL STUDY
Reoperations for Complications Within 90 Days After
Glaucoma Surgery
Chia-Kai Chu, MD,* Jeffrey M. Liebmann, MD,* George A. Cioffi, MD,*
Dana M. Blumberg, MD, MPH,* and Lama A. Al-Aswad, MD, MPH†
Objective: To describe reoperations in the operating room for
complications encountered within 90 days after glaucoma surgery at
a single institution over a 2-year period.
Downloaded from http://journals.lww.com/glaucomajournal by BhDMf5ePHKbH4TTImqenVHwXmMsAVI5gQnvuU7jCWhl8fle8dFPzHUEoiRAddu1c/hjpAJvgn3I= on 05/26/2020
Design: Retrospective case series.
Subjects: Adult patients who have undergone glaucoma surgery
including a tube shunt, trabeculectomy with mitomycin C, trabectome,
or transcleral cyclophotocoagulation from June 1, 2015 to August 30,
2017 at a single institution.
Methods: These patients were then examined for postoperative
complications that required reoperations within the first 90 days
including revision of the tube shunt, revision of the trabeculectomy,
drainage of the choroidal, or placement of a tube shunt.
Main Outcome Measures: Percentage of reoperations for compli-
cations within the first 90 days after glaucoma surgery and surgical
indications for these reoperations.
Results: A total of 622 glaucoma procedures were performed on 600
eyes in 525 patients over a 2-year period from June 1, 2015 to June 30,
2017 by 4 glaucoma surgeons at a single institution. Of these, 275 (44%)
were trabeculectomy with mitomycin C, 253 (41%) were the placement
of a tube shunt, 33 (5%) were cyclophotocoagulation, and 61 (10%) were
trabectome procedures. Postoperative complications requiring reopera-
tions within 90 days developed in 15 patients (2.4%) overall including 7
patients (2.5%) in the trabeculectomy with mitomycin C group and 8
patients (3.1%) in the tube shunt group. Five patients developed bleb
leaks, 3 patients developed serous choroidal effusions, 3 patients had
tube exposure, 1 patient had tube retraction, 1 patient had persistent
iritis from iris touching the tube, and 1 had encapsulation around the
tube. The rate of reoperation for complications was similar between the
tube group and the trabeculectomy group (P = 0.67, χ2 test). There were
no complications requiring reoperations in 90 days for transcleral
cyclophotocoagulation or trabectome.
Conclusions: Early postoperative complications requiring reoperations
within the first 90 days after glaucoma surgery were low and comparable
with previous studies. Common indications for reoperation within 90 days
include wound leak and tube shunt-related issues.
Key Words: glaucoma surgery, trabeculectomy, tube shunt, trabectome,
MIGS, complication rate after glaucoma surgery, return to the OR in
90 days
(J Glaucoma 2020;29:344–346)
Received for publication August 16, 2019; accepted February 11, 2020.
From the *Columbia University Medical Center, Harkness Eye Insti-
tute; and †New York University (NYU) School of Medicine, NYU
Langone Health, New York, NY.
Poster presented at the American Glaucoma Society Annual Meeting, 2018.
Disclosure: The authors declare no conflict of interest.
Reprints: Lama A. Al-Aswad, MD, MPH, Department of Ophthalmology,
New York University (NYU) School of Medicine, NYU Langone
Health, New York, NY 10017 (e-mail: lama.al-aswad@nyulangone.org).
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/IJG.0000000000001484
344 | www.glaucomajournal.com J Glaucoma  Volume 29, Number 5, May 2020
Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.
T rabeculectomy and tube shunt implantation remain the
most commonly performed glaucoma operations worldwide
while several minimally invasive glaucoma surgeries (MIGS)
have been introduced in recent years. With the expansion of
surgical options for managing glaucoma, selecting the most
appropriate glaucoma operation involves balancing the risks of
adverse events and the benefit of intraocular pressure (IOP)
reduction for an individual patient. Although lower rates of
surgical complications have been reported with MIGS compared
with traditional incisional surgery such as trabeculectomy and
tube shunt surgery, they are generally less effective in decreasing
IOP. An assessment of surgical procedures requires not only an
evaluation of efficacy but also an analysis of the incidence and
severity of associated complications.
Trabeculectomy with mitomycin C, tube shunt surgery,
transcleral cyclophotocoagulation, and trabectome each have
its own well-researched set of complications that may occur,
however, the unexpected early postoperative complications
requiring additional surgical intervention have not been well
characterized.1–4 An unplanned return to the operating room
for complications may have social, occupational, and financial
consequences to the patient while also increasing the surgical
cost and clinical burden for any glaucoma service, especially
within the first 90 days, which is the time frame most insurance
companies consider as the postoperative “global period.”
Furthermore, unplanned reoperations have also been proposed
as a criterion to evaluate surgical quality.5,6 In a retrospective
case series, Hsia et al7 reported an overall reoperation rate of
3.9% within 90 days after resident-performed glaucoma surgery
but noted that there were no published data on the reoperation
rate in attending-performed glaucoma surgeries to serve as a
benchmark for comparison. This study seeks to describe the
real-world rate of reoperations in the operating room for
unplanned complications encountered within 90 days after
glaucoma surgery at a single institution over a 2-year period.
METHODS
This retrospective study was approved by the Institutional
Review Board of Columbia University Medical Center. Elec-
tronic medical records on computerized patient record system
were retrospectively reviewed of adult patients who had under-
gone glaucoma surgery performed by 1 of 4 glaucoma surgeons
followed by an unplanned reoperation for postoperative com-
plication within the first 90 days at the Edward S. Harkness Eye
Institute at Columbia University Medical Center between June 1,
2005 and June 1, 2007. Glaucoma surgeries included were tube
shunt placement, trabeculectomy with mitomycin C, and trans-
cleral cyclophotocoagulation. The only MIGS procedure
included in the study was trabectome. Tube shunt placement
included both Baerveldt glaucoma implant (Johnson & Johnson
Surgical Vision, Santa Ana, CA) or Ahmed glaucoma valve
implant (New World Medical Inc, Rancho Cucamonga, CA).
J Glaucoma  Volume 29, Number 5, May 2020 Reoperations within 90 Days after Glaucoma Surgery

In the present study, we focused on unplanned reoperations

as the primary outcome measure. We defined an unplanned TABLE 1. Demographics and Preoperative Characteristics of
Patients Who Underwent Reoperation Within 90 Days After
reoperation as any surgical complication requiring a return to the Glaucoma Surgery
operating room including revision of the tube shunt, revision of
the trabeculectomy, drainage of the choroidal effusion, and Total number of patients 15
placement of a tube shunt as a result of a complication directly Mean age, years (range) 70 (29-88)
Sex: male/female 9 (60%)/6 (40%)
related to the index operation performed. Cyclophotocoagulation
Glaucoma subtype, n (%)
or surgery for further IOP lowering was not specifically consid- Primary open-angle glaucoma 11 (73)
ered a reoperation for surgical complications. Interventions per- Combined-mechanism glaucoma 1 (7)
formed at the slit lamp, such as needling procedures, laser suture Uveitic glaucoma 2 (13)
lysis, and anterior chamber reformation, were also not included. Traumatic glaucoma 1 (7)
Data abstracted from medical records included patient Lens status, n (%)
demographics, glaucoma subtype, lens status, concurrent Pseudophakic 6 (40)
ocular history, previous intraocular surgeries, IOP, number Phakic 9 (60)
of glaucoma medications, type of glaucoma surgery, time Previous intraocular surgery with scarring, 7 (47)
interval between reoperation, and type of surgical compli- n (%)
1 prior surgery 4 (27)
cation requiring reoperation. Univariate comparisons 2 prior surgeries 2 (13)
between treatment groups were made by the χ2 test. 3 prior surgeries 1 (13)
A P-value of ≤ 0.05 was considered statistically significant. Preoperative IOP control
Mean IOP, (range) (mm Hg) 27.5 ± 6.4 (18-39)
Mean number of glaucoma medications 3.9 ± 1.1 (4)
RESULTS (median)
A total of 622 glaucoma procedures were performed on Combined intraocular surgery, n (%) 7 (47)
600 eyes in 525 patients over a 2-year period from June 1, Cataract extraction with lens implantation 5 (33)
Pars plana vitrectomy 1 (7)
2015 to June 30, 2017 by 4 glaucoma surgeons at a single
Trabeculectomy revision 1 (7)
institution. Of these, 275 (44%) were trabeculectomy with
mitomycin C, 253 (41%) were the placement of a tube shunt, IOP indicates intraocular pressure.
33 (5%) were cyclophotocoagulation, and 61 (10%) were
trabectome procedures. The total number of procedures
performed over this 2-year span includes eyes that under-
went multiple glaucoma-related procedures for further IOP DISCUSSION
lowering but does not include any unplanned reoperations In this retrospective study, we reviewed the rates of
for complications within 90 days. reoperation and complication within 90 days of attending-
There were 15 patients who required a return to the oper- performed tube shunt placement, trabeculectomy with mito-
ating room in the first 90 days to address postoperative compli- mycin C, transcleral cyclophotocoagulation, and trabectome
cations resulting in an overall reoperation rate of 2.4%. There at the Edward S. Harkness Eye Institute at Columbia Uni-
were 7 patients (2.2%) who required reoperation in the trabecu- versity Medical Center. Among the 622 glaucoma surgeries
lectomy with mitomycin C group and 8 patients (3.1%) in the performed, postoperative complications requiring reoperations
tube shunt group. The rate of reoperation for complications was within 90 days developed in 15 patients resulting in an overall
similar between the tube group and the trabeculectomy group reoperation rate of 2.4% with a similar rate of reoperation
(P = 0.67, χ2 test). There were no complications requiring reop- between patients who underwent trabeculectomy with mito-
erations in 90 days for transcleral cyclophotocoagulation or mycin C and tube shunt placement. This overall rate is also
trabectome. low and comparable with previous studies. To our knowledge,
Clinical characteristics of the 15 patients requiring reop- this is the first study reporting the real-world rate of unplanned
eration are summarized in Table 1. The mean age was 70 years. return to the operating room within the 90-day postoperative
The indications for the initial glaucoma surgery were: primary period after attending-performed glaucoma surgery.
open-angle glaucoma (11 patients, 73%), uveitic glaucoma Several studies have reported on the serious complication
(2 patients, 13%), traumatic glaucoma (1 patient, 7%), and rate after surgery requiring reoperation, including the tube
combined-mechanism glaucoma (1 patient, 7%). Six patients
were pseudophakic and 7 patients had previous intraocular
surgery other than cataract surgery. Seven patients had com-
bined intraocular surgery at the time of glaucoma surgery, TABLE 2. Type of Complication Requiring Reoperation on the
Basis of Type of Surgery
including 5 with concurrent cataract extraction.
The indications for reoperation were wound leaks n (%)
(5 patients), serous choroidal effusion (3 patients), bleb encap-
sulation (2 patients), and tube-related issues (5 patients). Specif- Complication After After
ically, 3 patients had tube exposure, 1 patient had tube retrac- Requiring Tube Shunt Trabeculectomy
tion, and 1 patient had persistent iritis from the iris touching Reoperation (N = 253) (N = 275)
the tube. No subject required an anterior chamber washout for Tube exposure 3 (1.2) 0
hyphema. Mean (SD) time to reoperation in the immediate Tube retraction 1 (0.4) 0
postoperative period was 6.4 (3.1) weeks. The type of compli- Bleb encapsulation 1 (0.4) 1 (0.4)
cation requiring reoperation on the basis of the type of surgery is Chronic iritis 1 (0.4) 0
summarized in Table 2. There was no aqueous misdirection, Wound leak 0 5 (1.8)
Serous choroidal effusion 2 (0.8) 1 (0.4)
suprachoroidal hemorrhage, blebitis, or endophthalmitis within Total 8 (3.2) 7 (2.5)
the 90-day postoperative period in our study.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. www.glaucomajournal.com | 345
Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.
Chu et al
versus trabeculectomy study that reported a 7% complication
after tube shunt surgery and 5% after trabeculectomy in the first
year of follow-up.7 A total of 8 patients in the tube group
underwent reoperations including 2 for aqueous misdirection, 1
for endophthalmitis, 1 to relieve obstruction of the tube by
vitreous, 1 for persistent corneal edema, 1 for drainage of a
choroidal effusion, 1 for a choroidal and retinal detachment,
and 1 for lysis of iris adhesion to tube. Five patients in the
trabeculectomy group required additional surgery for drainage
of choroidal effusion, drainage of a suprachoroidal hemorrhage,
endophthalmitis, and persistent corneal edema. Although this
study had a longer follow-up period of 1 year and did not look
specifically at reoperations within 90 days, it found the rate of
reoperation for complications over a longer time span to be
similar between the tube group and trabeculectomy group.
Conversely, in the primary tube versus trabeculectomy
study, the rate of reoperation for complications after 1 year
of follow-up was significantly higher in the trabeculectomy
with mitomycin C group compared with the tube group.8,9 A
total of 7 patients (6%) in the trabeculectomy group under-
went reoperations including 4 bleb revision for wound leaks,
2 patients with hypotony maculopathy, and 1 patient with an
8-ball hyphema. One patient (1%) in the tube group under-
went tube removal for exposure of the endplate. Our findings
also found wound leaks to be the main indication for reop-
erations after trabeculectomy with mitomycin C given the
immediate filtration of aqueous near the limbus in compar-
ison with a tube shunt surgery that produces delayed drainage
of aqueous humor to an area remote from the limbus. By the
nature of the primary tube versus trabeculectomy study, none
of the eyes had previous incisional ocular surgery. Compared
with our study, the higher rate of reoperations for compli-
cations in the tube group in our study may potentially be
attributed to the present occurrence of previous intraocular
surgeries that potentially compromises the conjunctiva and
lead to increased rates of tube complications such as tube
exposure.
There are several limitations to our study. It is not unex-
pected that retrospective case series generally report lower
complication rates than prospective studies given that they may
be overlooked unless attention is directed specifically towards
their detection. Therefore, the actual complication rate of
necessitating surgery may be higher. Similarly, patients under-
going surgical reoperation with an outside hospital provider
would not have been identified by the methods of this study,
however, it can be reasonably assumed that this would be a very
small number of patients. Finally, the shorter follow-up period
compared with previous studies may miss surgical complications
such as endophthalmitis and persistent corneal edema that are
not necessarily seen in the early postoperative time frame but
are nonetheless serious complications.
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J Glaucoma  Volume 29, Number 5, May 2020
In summary, our study was the first to report the real-world
reoperation rate for trabeculectomy with mitomycin C, tube
shunt, trabectome, and transcleral cyclophotocoagulation within
the 90-day postoperative period. The reoperation rates are
comparable between the trabeculectomy with mitomycin C and
tube shunt groups, and consistent with prior published results.
Common indications for reoperation within 90 days include
wound leak and tube-related issues. Although a full discussion on
the ways to minimize reoperation rates is beyond the scope of this
paper, consideration can be given to surgeon awareness of wound
closures in trabeculectomy with an antifibrotic agent. Meanwhile,
given that tube shunts are commonly used when there is a higher
likelihood of failure with a filtering surgery, it is not surprising
that there may be tube exposure. Such information is useful not
only in terms of what to expect or examine closely during post-
operative visits but also in terms of discussing expected outcomes
with patients. Notably, for the trabectome, there was no reported
reoperation for complications which is in line with previous
studies regarding the overall safety of MIGS procedures. To the
best of our knowledge, published data on 3-month reoperation
rates secondary to complications after glaucoma surgery are
limited.
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