Conjunctival management during trabeculectomy: All “Frills,” nothing fancy

Background: Trabeculectomy is commonly performed using a fornix-based conjunctival flap, and at the end of the procedure, the conjunctiva is sutured back to the corneo-scleral junction. [1] However, early bleb leaks from the conjunctival edge remain a common complication of this procedure (incidence ranging from 8–56%). [2-7] An alternative technique is the limbus-based conjunctival flap, where the conjunctiva is incised posteriorly and dissected anteriorly up to the limbus; at the end of the procedure, the two conjunctival edges are sutured to each other. [4,5] Although the incidence of bleb leaks is less common, this technique is associated with a “ring of steel” formation around the bleb and, hence, is not preferred due to the restricted posterior flow of aqueous. [4-7] Purpose: The purpose of this video is to demonstrate a modified fornix-based conjunctival flap (frill peritomy) closed with a continuous, horizontal mattress suture during a trabeculectomy and discuss the incidence of bleb leaks with this technique. Synopsis: In this technique, a fornix-based peritomy is made 1–1.5 mm posterior to the limbus, similar to that described by Wise in 1993. [8-10] At the end of the procedure, the conjunctival flap is sutured to the conjunctival frill at the limbus using a continuous, horizontal mattress suture (meandering suture). The suturing of anatomically similar tissues ensures faster healing. Also, the meandering suture tends to cause mild eversion of the edges of the peritomy, which counteracts the natural tendency of the conjunctiva to roll inwards and promotes healing. In a retrospective study of 100 patients who underwent trabeculectomy using the frill peritomy, the incidence of bleb leaks was found to be only 2%. The mean post-operative intraocular pressure in these eyes at 1 year was 13.3 ± 3.8 mmHg. Highlights: The frill peritomy combines the benefits of limbus-based flaps (water-tight closure of anatomically similar tissues) and fornix-based flaps (diffuse posterior blebs) in a single procedure. Video Link: https://youtu.be/rQzSjj_PKMQ