Outcomes of a Modified Trabeculectomy Closure Technique Moon Jeong Lee, BS,* Rohan P. Bajaj, BS,* Aleksandra Mihailovic, MS,* Jayant V. Iyer, MD,† Henry D. Jampel, MD, MHS,* and David S. Friedman, MD, MPH, PhD* Precis: A modiﬁed closure for trabeculectomy in which the con- junctiva is incised posterior to the limbus and reapproximated using 2 nylon sutures, provided similar surgical outcomes to the standard trabeculectomy closure technique. Purpose: To examine the surgical outcomes of a modiﬁed trabecu- lectomy closure technique in which the conjunctiva is incised pos- terior to the limbus and reapproximated using 2 sutures, burying the posterior conjunctiva under an anterior lip of conjunctiva. Materials and Methods: This retrospective review included 73 eyes that underwent trabeculectomies between 2015 and 2017 at Johns Hopkins Hospital by a single surgeon. We analyzed traditional closures used from January 2015 to May 2016, and modiﬁed clo- sures used from July 2016 to March 2017. The main outcome measures were a reduction in intraocular pressure at 3, 6, and 12 months, reduction in the number of medications at 12 months, and total number of postoperative complications. Results: There was no difference in reduction of intraocular pressure at 3 months (9.9 ± 8.2 vs. 10.5 ± 8.7 mm Hg), 6 months (10.8 ± 9.6 vs. 10.6 ± 8.3 mm Hg), or 12 months (12.2 ± 8.9 vs. 10.0 ± 9.3 mm Hg) in the standard (n = 44) and modiﬁed groups (n = 29), respectively. There was a similar reduction in the use of glaucoma medications in the standard group (1.2 ± 1.5 vs. 1.0 ± 1.1) compared with the modiﬁed group and no difference in the number of postoperative complications (25.0% vs. 17.2%, respectively) (P > 0.05 for all). Conclusions: The modiﬁed closure provided similar results to the standard closure for trabeculectomy. Further studies are needed to determine whether the 2 techniques differ in surgical outcomes over a longer follow-up or other surgical parameters (eg, ease, surgical time, learning curve). Key Words: glaucoma, trabeculectomy, ﬁltering glaucoma surgery (J Glaucoma 2019;28:584–587) T rabeculectomy remains a frequently performed glaucoma surgery to lower intraocular pressure (IOP) because of its effectiveness in treating glaucoma refractory to medical and procedural interventions. 1,2 There are several variations in the surgical steps performed in a trabeculectomy; however, the overall goal remains to permit aqueous humor outﬂow from the anterior chamber to sub-Tenon space. 2,3 The surgical effective- ness and safety of variations in technique are still debated and have included the use of antibiotics during surgery (5-ﬂuorouracil and mitomycin C), the thickness and shape of the scleral ﬂap, and various conjunctival ﬂap constructions (limbus-based or fornix-based conjunctival ﬂap) and closures. 4–8 A well-functioning bleb is critical to the success of a trabeculectomy, and surgeons must balance poor aqueous outﬂow potentially leading to higher IOP, with excessive ﬂow, which can lead to a number of complications including hypotony and suprachoroidal hemorrhage. 9–11 The con- junctival opening and closure plays an essential role in ﬁltra- tion and can affect the ﬂow of aqueous humor and resulting IOP. 12 Thus, many trabeculectomy modiﬁcation techniques have focused on alterations of the conjunctival steps. Here, we examined the surgical outcomes of a modiﬁed trabeculectomy closure technique in which the conjunctiva is incised 3 to 4 mm posterior to the limbus and is reap- proximated using 2 nylon sutures without a central mattress suture, burying the posterior conjunctiva under an anterior lip of conjunctiva at the limbus (Fig. 1). MATERIALS AND METHODS The Johns Hopkins Medicine Institutional Review Board approved all study protocol. Participants A retrospective chart review was conducted on patients who underwent a trabeculectomy by a single surgeon (D.S.F.) at the Wilmer Glaucoma Center of Excellence at Johns Hopkins Hospital between January 2015 and March 2017. The standard closure technique was performed between January 2015 and May 2016 and in July 2016, the surgeon transitioned to the modiﬁed closure technique. Results through March 2017 were reviewed. It was decided a priori to exclude the ﬁrst 5 modiﬁed closure procedures performed to allow for learning. Trabe- culectomies performed in conjunction with cataract sur- geries, patients with less than 3 months of follow-up, and patients with previous tube shunt placements were also excluded. In advance of data collection, patients with a diagnosis of uveitis and patients with previous trabeculec- tomies were deemed to be at high risk for trabeculectomy failure and thus were excluded from the analysis. 13 Eyes that required additional IOP-lowering surgery (ie, tube shunt, cycloablative procedures) following the initial trabeculec- tomy were censored from analysis at the time of second surgery and recorded as failures. Data Collection Preoperative variables abstracted included: glaucoma diagnosis, IOP, lens status, glaucoma medication use, and Doi: 10.1097/IJG.0000000000001263 Received for publication November 30, 2018; accepted April 6, 2019. From the *Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD; and †Glaucoma Department, Singa- pore National Eye Center, Singapore, Singapore. M.J.L. and R.P.B. contributed equally (co-ﬁrst authors). Disclosure: The authors declare no conﬂict of interest. Reprints: David S. Friedman, MD, MPH, PhD, Johns Hopkins Hos- pital, 600 N. Wolfe Street, Wilmer 120, Baltimore, MD 21287 (e-mail: David.Friedman@jhu.edu). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website, www. glaucomajournal.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ORIGINAL STUDY 584 | www.glaucomajournal.com J Glaucoma  Volume 28, Number 7, July 2019 Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.