C L I N I C A L A N D E X P E R I M E N TA L

REVIEW

Post-trabeculectomy ocular biometric changes

Clin Exp Optom 2016 DOI:10.1111/cxo.12477

Mohammad Pakravan* MD Trabeculectomy is the most common surgical procedure for the management of glau-
Azam Alvani* MSc coma, which may significantly influence ocular biometry. Axial length and anterior cham-
Hamed Esfandiari* MD ber depth tend to decrease, while crystalline lens and choroidal thickness increase post-
Elham Ghahari* MD operatively. An increase in with-the-rule astigmatism is also observed after the procedure.
Mehdi Yaseri† PhD Such biometric changes affect intraocular lens power calculation even years after the pro-
*Ophthalmic Epidemiology Research Center, Shahid cedure. Non-contact biometric methods and postponing cataract surgery after trabeculect-
Beheshti University of Medical Sciences, Tehran, Iran omy could reduce calculation errors associated with surgically induced alterations in
†
Department of Epidemiology and Biostatistics,
ocular biometrics.
School of Public Health, Tehran University of
Medical Sciences, Tehran, Iran
E-mail: [email protected]

Submitted: 28 January 2016

Revised: 11 May 2016
Accepted for publication: 19 May 2016

Key words: anterior chamber depth, axial length, choroidal thickness, keratometry, lens thickness, trabeculectomy

Trabeculectomy remains the most common (IOP of zero to four mmHg) had AL
AXIAL LENGTH CHANGES
surgical procedure for long-term reduction reductions almost three times greater than
of intraocular pressure (IOP) in glaucoma, Nemeth and Horoczi4 first reported those without hypotony, which further
which bypasses the conventional outflow changes in ocular dimensions following tra- emphasises the association between a lower
pathway by creating a corneoscleral fistula beculectomy and observed a reduction in post-operative IOP and a greater reduction
into the subconjunctival space.1,2 A diffuse AL four days after surgery. Further studies in AL.7
elevated functioning bleb is the key factor have reported a significant and persistent Dissimilar methods for AL measurement
for a successful outcome. Intraoperative reduction in AL at all visits after trabecu- could explain the disparity between studies.
application of antimetabolites ensures bet- lectomy up to 60 months post- Ultrasonic biometry used in some studies
ter surgical outcomes, especially in those at operatively.4–11 Using non-contact biome- led to a more pronounced reduction in AL
higher risk of surgical failure.3 In addition try, a reduction of 0.10 to 0.18 mm in AL in comparison to non-contact techni-
to the significant IOP reduction, a number has been reported, which appears to stabi- ques.5,6,8 This difference is because of
of changes in ocular biometrics occur post- lise almost three months after surgery.7,9–11 avoiding globe indentation and deforma-
trabeculectomy. While axial length Antimetabolite use during the procedure tion with the non-contact method, in con-
(AL) and anterior chamber depth (ACD) to minimise scar tissue formation and bleb trast to contact ultrasonic biometry that
decrease corresponding to the amount of failure typically yields lower post-operative tends to deform and underestimate AL in
IOP reduction, lens thickness (LT), choroi- IOPs and a greater reduction in AL.5 Stud- post-trabeculectomy soft eyes. In such a set-
dal thickness (CT) and with-the-rule (WTR) ies that use applanation ultrasound also ting, AL may be underestimated because of
astigmatism typically increase. These post- report larger reductions in AL after trabe- scleral collapse or choroidal oedema, espe-
trabeculectomy biometric changes have the culectomy.5,6,8 Kook, Kim and Lee6 cially with contact methods.
potential to influence intraocular lens reported a significant reduction in AL Figure 1 compares the AL changes after
(IOL) power calculations in cases requiring (0.83  1.00 mm) after trabeculectomy trabeculectomy in measurement with con-
cataract surgery alone or in combination with the antimetabolite mitomycin-C tact and non-contact methods based on the
with filtering surgery. This is of particular (MMC), three months after the operation, combined results of various studies.6–11 In
concern, considering the increased fre- whereas in more recent studies that use contrast to contact biometric methods, in
quency of coexisting glaucoma and cataract non-contact methods (IOL Master and measurement with non-contact methods
in elderly people. The aim of this review is Lenstar), the reduction in AL (0.10 to there is a small but significant reduction in
to summarise the evidence concerning the 0.18 mm) was significantly lower compared AL that remained unchanged from week
changes in ocular biometrics following to applanation techniques (Figure 1).7,9–11 one post-operative follow-up until the last
trabeculectomy. However, patients who developed hypotony visit at month six.7,9–11

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Ocular biometric changes after trabeculectomy Pakravan, Alvani, Esfandiari, Ghahari and Yaseri

Time surgery and reaches the minimum post-

0
Week 1 Month 1 Month 3 Month 6 Month 12 operative depth two to three days following
surgery.17,18 Thereafter, the ACD begins to
Mean change of axial length (mm)

-0.20
increase gradually, reaching 83 to 91 per
cent of its preoperative value by day
-0.40
14;17–19 however, the ACD remains almost
0.11  0.22 mm shorter than preoperative
-0.60 values, even years after surgery.8 Con-
versely, some studies, using non-contact
-0.80 instruments, have demonstrated that ACD
is not affected by the procedure, at least at
-1.00 three weeks after trabeculectomy.20,21 In a
Non-contact Contact
recent study, we evaluated ACD changes
-1.20 after MMC trabeculectomy with both con-
tact and non-contact biometry and found
Figure 1. Axial length changes (mm) after trabeculectomy measured by contact and no significant differences between the two
non-contact biometry during one year follow-up6–11 methods. Six months after the surgery, we
observed 0.10  0.12 and 0.07  0.10 mm
reductions in ACD, for contact and non-
Using non-contact biometry, post- however, all these studies have consistently
contact biometry, respectively.22
operative changes in AL appear to stabilise shown that along with IOP and AL reduc-
Similar to AL, post-trabeculectomy ACD
after three months and continue to remain tion, CT increases significantly after trabecu-
changes correlate with the level of IOP
the same up to five years.8,11 Fluctuations lectomy. These changes occur rapidly in the
reduction after surgery, particularly in
in AL are greater in the immediate post- first days after trabeculectomy and may con-
patients with primary open-angle glau-
operative period (up to three months) tinue at least up to six months post-opera-
coma.8 Patients with primary open-angle
compared to longer-term follow up, most tively.9,10,14,15 Although no associations were
glaucoma have thinner and less rigid sclera
likely due to fluctuations in IOP.8 observed between the change in IOP and
and they have more fluctuations in ACD
Risk factors for a significant AL reduction CT in short-term studies, longer studies have
post-operatively than those with primary
after trabeculectomy include: high pre- reported a high correlation between CT and
angle-closure glaucoma.8
operative IOP, low post-operative IOP, IOP changes; a 3.4 μm increase in CT per
younger age, exposure to antimetabolites, 1.0 mmHg decrease in IOP (1.7 per cent
myopic refractive errors and surgical com- increase in CT per 1.0 mmHg decrease in LENS THICKNESS CHANGES
plications such as choroidal detachment IOP).9,10,14,15 Similarly, there is a positive
Despite the importance of LT in IOL
and hypotonic maculopathy.5–7 Hypotony is and significant correlation between the
power calculation with the latest genera-
a common complication of trabeculectomy changes in CT and changes in ocular perfu-
tions of IOL power formulae, there are few
with an estimated incidence of 10 to 37 per sion pressure (OPP), which increases signifi-
studies on LT changes after trabeculect-
cent.12 The proposed mechanism of AL cantly (31.4 per cent) following
omy. Cunliffe and colleagues19 partially
reduction after trabeculectomy includes trabeculectomy.9 The choroid contains pro-
attributed a post-operative myopic shift and
choroidal and ocular wall thickness increase fuse non-vascular smooth muscle and as
shallow anterior chamber to possible
associated with IOP reduction.4,6,13 The such, the choroid thins when these muscles
changes in the crystalline lens. They
direct relationship between the amount of contract and expands once they relax.
hypothesised that a post-operative shallow
IOP reduction and increased CT and AL Therefore, lowering the IOP drastically
anterior chamber causes the ciliary body to
reduction has been demonstrated in several might cause choroidal expansion.16 More
move forward, which combined with ciliary
studies.9,14 In primary open-angle glaucoma importantly, an increase in OPP could cause
spasm, would release tension on the
a 1.0 mmHg decrease in IOP results in a the increase in CT.9 Further research is
zonules and lead to thickening and ante-
0.01 mm decrease in AL.8 Post- needed to determine the exact mechanism
rior displacement of the crystalline lens;
trabeculectomy open-angle glaucoma cases of CT changes and its effect on visual func-
however, LT or lens position changes were
appear to be more sensitive to AL changes tion. The changes in CT may underlie
not measured in their study. More recently,
and experience greater fluctuations in AL observed changes in AL, as instruments such
a significant increase in LT
in comparison to angle-closure glaucoma.8 as IOL Master, Lenstar and A-scan measure
(0.07  0.1 mm) was reported six months
AL as the distance from the anterior cornea
after trabeculectomy with MMC.22 These
to the internal limiting membrane (ILM) or
CHOROIDAL THICKNESS CHANGES small changes may indicate early cataract
retinal pigment epithelium (RPE).
formation or progression, which is a common
Recently several studies have evaluated CT complication after trabeculectomy.6,23–26 An
changes after trabeculectomy.9,10,14,15 As ANTERIOR CHAMBER DEPTH increase in LT may be partly responsible for
most of these studies have investigated the CHANGES the reported ACD reduction after trabeculect-
change in CT at one post-operative time, the omy. More studies are needed to evaluate the
persistence or time course of such changes Using contact biometric devices, the ante- effect of trabeculectomy on LT and its associa-
after trabeculectomy remains unknown; rior chamber becomes shallow soon after tion with ACD.

Clinical and Experimental Optometry 2016 © 2016 Optometry Australia

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 Ocular biometric changes after trabeculectomy Pakravan, Alvani, Esfandiari, Ghahari and Yaseri

KERATOMETRIC CHANGES significant difference between the magni- like and total aberrations increase signifi-
tude of astigmatism 12 months after trabe- cantly at one month post-trabeculectomy
Most studies on keratometric changes after culectomy compared to one week before but return to normal levels by three
trabeculectomy have revealed induced surgery. months.36 The corneal coma-like and total
WTR astigmatism with a mean of To further analyse the probable causes aberrations remain unchanged during the
0.81  1.08 D at three months that tends of keratometric changes, some investigators first three post-operative months and there
to resolve within one year.6,27–30 These ker- have evaluated the degree of induced WTR is no significant correlation between the
atometric changes were especially signifi- astigmatism after mini-trabeculectomy, two ocular and corneal coma-like aberrations
cant with the earlier five by five scleral flap by two scleral flap, which induced less astig- and between the ocular and corneal total
trabeculectomy.31 matism and resolved more rapidly.29 In aberrations at one month post-trabeculect-
In comparison to keratometry, corneal contrast, using antimetabolites at the time omy.36 These results suggest that changes
topography can reveal post-operative cor- of surgery is a risk factor for the duration in the internal optics, thickness and posi-
neal curvature changes in greater detail.32 of induced WTR astigmatism post-opera- tion of the crystalline lens or subtle
Topographic assessment of corneal tively.6,33 Other suggestions to explain changes in foveal morphology, are respon-
changes after trabeculectomy showed that induced astigmatism include, tight scleral sible for the increase in higher-order aber-
the majority of the post-operative changes flap suturing, ‘posteriorly placed wound rations. Karasheva and colleagues21
are found in the superior semimeri- gape’ from the internal sclerostomy and measured the thickness of the macula
dian.28,32 There are two broad patterns of extensive cauterisation;19,27,31 however, the using optical coherence tomography and
topographic variations; most patients most obvious explanation may be the found that foveal thickening was most evi-
develop superior corneal steepening, while reduction in IOP and consequently, a more dent one month after surgery, indicating
some experience superior corneal flatten- pronounced effect of eyelid pressure. Del- the presence of subclinical macular
ing. Despite these differences in superior beke and colleagues34 reported that after oedema due to the sudden change in pres-
topographical changes, both groups mani- one month, there was a significant correla- sure after filtration surgery. After three
fest an increase in WTR astigmatism. Coex- tion between the change in astigmatism months, foveal thickness had returned to
istence of inferior corneal steepening in and IOP reduction; the lower the IOP, the preoperative levels. In addition, it is possi-
the superior corneal flattening group more the WTR astigmatism; however, this ble that faint changes in the anterior or
causes an overall increase in the vertical correlation disappeared after six months. posterior corneal curvature that were unde-
keratometric values and WTR Figure 2 shows the trends of post- tectable by videokeratography or even
astigmatism.32 operative changes of induced WTR astig- change in corneal thickness affect the ocu-
Although the magnitude of WTR astig- matism based on the combined results of lar aberrations; however, the correlation of
matism is high in the early post-operative various studies.6,27–30,35 WTR astigmatism increased higher order aberrations with
period, it tends to resolve and reach its demonstrated a continuous descending the above factors has not been explored.
preoperative values one year after sur- trend during a one-year follow-up after tra-
gery.6,19,28 Cunliffe and colleagues19 beculectomy, while most of this reduction THE EFFECT OF POST-OPERATIVE
observed that significant WTR astigmatism has occurred during the first month after PROCEDURES/MEDICATIONS
at two months post-operatively had resolved the surgery.
by month 10. Similarly, Kook, Kim and Along with corneal steepening, higher Severe complications after trabeculectomy
Lee6 demonstrated that there was no order aberrations including ocular coma- are rare37 and patients with such complica-
tions almost always are excluded from bio-
3 metric studies; however, patients may need
post-operative interventions, such as digital
Mean induced with-the-rule astigmatism (dioptre)

massage, laser suture lysis, releasable

2.5
sutures removal and bleb needling to con-
trol IOP and improve bleb appearance.
2 These procedures may further affect ocular
biometric parameters. For example, argon
laser suture lysis of scleral flap sutures in
1.5
the early period after trabeculectomy may
relieve induced WTR corneal astigmatism;
1 however, after six months, there is no dif-
ference in the amount of astigmatism
between the eyes with or without suture
0.5
lysis.34
Shallow or flat anterior chamber is a com-
0 mon complication (13.1 to 14.6 per cent) in
Day 1 Week 1 Month 1 Month 3 Month 6 Month 12 the early post-operative period, which may
Time lead to cataract formation and bleb
failure.37–41 Topical atropine is prescribed
Figure 2. Induced with-the-rule astigmatism during one year after trabeculectomy6,26–29,34 post-operatively by some ophthalmologists

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Ocular biometric changes after trabeculectomy Pakravan, Alvani, Esfandiari, Ghahari and Yaseri

to prevent shallowing or flattening of the IOP increase after phacoemulsification cor- refractive outcomes of combined phaco-
anterior chamber and to reduce anterior relate with the extent of final refractive trabeculectomy or subsequent cataract pro-
chamber inflammation by stabilising the error.50,51 This may be due to the effect of cedures. Changes in AL, ACD and kerato-
blood-aqueous barrier.42,43 Orengo-Nania contact biometric probe (that is used in all metry are of significant magnitude to affect
and colleagues44 reported a small (approxi- older studies), which could produce more the prediction of refractive outcomes post-
mately 0.1 mm) but statistically significant IOL calculation error and consequently, cataract surgery. To achieve the best refrac-
deepening of the anterior chamber in more final refractive error. Using non- tive outcome, it is recommended to delay
patients who used atropine. Atropine pre- contact biometry for AL measurements cataract surgery until AL, ACD and kerato-
vents shallowing of the anterior chamber by and using the AL of the fellow eye, if it has metric changes stabilise at approximately
relaxation of the circular ciliary muscle that not undergone trabeculectomy and the two six months post-operatively. In addition, it
results in tightening of the lens zonules and eyes have symmetric refraction or AL, is preferable to measure biometric para-
posterior displacement of lens-iris meters using non-contact optical biometry
might prevent post-cataract surgery refrac-
diaphragm.42 instead of contact ultrasonic biometry for
tive errors.
IOL power calculations in such cases. Simi-
In the case of combined cataract surgery
larly, modifications to spectacle prescrip-
with trabeculectomy (phaco-trabeculect-
REFRACTIVE SURPRISES AFTER tions should be delayed until at least three
omy), the IOP change is significantly
CATARACT SURGERY IN months post-operatively once the IOP has
higher than staged cataract surgery follow-
TRABECULECTOMY PATIENTS stabilised.
ing trabeculectomy (6.61 versus
Glaucoma and cataract are commonly 0.59 mmHg). Consequently AL decreases
coexisting diseases of the eye45,46 and and mean keratometry increases (corneal ACKNOWLEDGEMENT
patients are also at a higher risk of cataract steepening) significantly more in the com- This study was supported financially by the
formation or progression following trabe- bined procedure.52,53 In terms of AL Ophthalmic Epidemiology Research Cen-
culectomy. Consequently, many glaucoma changes, theoretically one may expect a ter, Shahid Beheshti University of Medical
patients require cataract surgery concomi- hyperopic shift after combined procedures; Sciences, Tehran, Iran.
tantly or soon after trabeculectomy. however, using non-contact biometry the
Because of biometric changes due to IOP refractive outcome of phaco-
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