Angle Surgery: Trabeculotomy

  • Beth EdmundsEmail author
  • Allen D. Beck
  • Esther Hoffmann
  • Franz Grehn


In this section, we address the role and execution of ab externo trabeculotomy in pediatric glaucoma. We provide an in-depth comparison of different techniques with detailed descriptions of traditional trabeculotomy with metal trabeculotome, ab externo circumferential trabeculotomy with either an illuminated microcatheter or blunted suture filament, and trabeculotomy combined with filtration surgery such as combined trabeculectomy-trabeculotomy and filtering trabeculotomy. For each there are sections on preoperative preparation, execution of the relevant surgery (with tips for problem-solving and avoiding complications), and postoperative management of the child. In addition, there is a comprehensive review of the literature to date, describing the evolution of trabeculotomy in the management of the pediatric glaucomas, and the evidence base for variations in technique, surgical preferences, and outcomes.


Trabeculotomy Pediatric glaucoma Circumferential (360) trabeculotomy Combined trabeculectomy-trabeculotomy Filtering trabeculotomy Complications Outcomes 

Supplementary material

Video 5.1

Conventional trabeculotomy with metal trabeculotome (Courtesy of Professor Nader Bayoumi, Alexandria University, Egypt) (MP4 10860 kb)

Video 5.2

Circumferential trabeculotomy, ab externo, with illuminated microcatheter (Courtesy of Beth Edmunds, MBChB, FRCOphth, MD) (MP4 80191 kb)

Video 5.3

Circumferential trabeculotomy, ab externo, with blunted suture (Courtesy of Allen D. Beck, MD) (MPG 95372 kb)

Video 5.4

Filtering trabeculotomy (Courtesy of Franz Grehn, MD, PhD) (MP4 153032 kb)

Video 5.5

Combined trabeculectomy-trabeculotomy (CTT) (Courtesy of Professor Nader Bayoumi, Alexandria University, Egypt) (MP4 178733 kb)


  1. 1.
    Barkan O. Operation for congenital glaucoma. Am J Ophthalmol. 1942;25(5):552–68.CrossRefGoogle Scholar
  2. 2.
    SD MP Jr, McFarland D. External trabeculectomy for developmental glaucoma. Ophthalmology. 1980;87(4):302–5.CrossRefGoogle Scholar
  3. 3.
    Dietlein TS, Jacobi PC, Krieglstein GK. Prognosis of primary ab externo surgery for primary congenital glaucoma. Br J Ophthalmol. 1999;83(3):317–22.CrossRefGoogle Scholar
  4. 4.
    Akimoto M, Tanihara H, Negi A, Nagata M. Surgical results of trabeculectomy ab externo for developmental glaucoma. Arch Ophthalmol. 1994;112(12):1540–4.CrossRefGoogle Scholar
  5. 5.
    Luntz MH, Livingston DG. Trabeculotomy ab externo and trabeculectomy in congenital and adult-onset glaucoma. Am J Ophthalmol. 1977;83(2):174–9.CrossRefGoogle Scholar
  6. 6.
    Beck AD, Lynch MG. 360 degrees trabeculotomy for primary congenital glaucoma. Arch Ophthalmol. 1995;113(9):1200–2.CrossRefGoogle Scholar
  7. 7.
    Sarkisian SR Jr. An illuminated microcatheter for 360-degree trabeculotomy [corrected] in congenital glaucoma: a retrospective case series. J AAPOS. 2010;14(5):412–6.CrossRefGoogle Scholar
  8. 8.
    Grover DS, Godfrey DG, Smith O, Feuer WJ, Montes de Oca I, Fellman RL. Gonioscopy-assisted transluminal trabeculotomy, ab interno trabeculotomy: technique report and preliminary results. Ophthalmology. 2014;121(4):855–61.CrossRefGoogle Scholar
  9. 9.
    Maul E, Strozzi L, Munoz C, Reyes C. The outflow pathway in congenital glaucoma. Am J Ophthalmol. 1980;89(5):667–73.CrossRefGoogle Scholar
  10. 10.
    Sampaolesi R. Congenital glaucoma: long-term results of surgery. Dev Ophthalmol. 1987;14:166–76.CrossRefGoogle Scholar
  11. 11.
    Mandal AK, Naduvilath TJ, Jayagandan A. Surgical results of combined trabeculotomy-trabeculectomy for developmental glaucoma. Ophthalmology. 1998;105(6):974–82.CrossRefGoogle Scholar
  12. 12.
    Biedner BZ, Rothkoff L. Combined trabeculotomy-trabeculectomy compared with primary trabeculotomy for congenital glaucoma. J Pediatr Ophthalmol Strabismus. 1998;35(1):49–50.PubMedGoogle Scholar
  13. 13.
    Mandal AK, Prasad K, Naduvilath TJ. Surgical results and complications of mitomycin C augmented trabeculectomy in refractory developmental glaucoma. Ophthalmic Surg Lasers. 1999;30(6):473–80.PubMedGoogle Scholar
  14. 14.
    Mullaney PB, Selleck C, Al-Awad A. Combined trabeculotomy and trabeculectomy as an initial procedure in uncomplicated congenital glaucoma. Arch Ophthalmol. 1999;117(4):457–560.CrossRefGoogle Scholar
  15. 15.
    al-Hazmi A, Awad A, Zwaan J. Correlation between surgical success rate and severity of congenital glaucoma. Br J Ophthalmol. 2005;89(4):449–53.CrossRefGoogle Scholar
  16. 16.
    Zhang X, Du S, Fan Q, Peng S, Yu M, Ge J. Long-term surgical outcomes of primary congenital glaucoma in China. Clinics (Sao Paulo, Brazil). 2009;64(6):543–51.CrossRefGoogle Scholar
  17. 17.
    Jalil A, Au L, Khan I, Ashworth J, Lloyd IC, Biswas S. Combined trabeculotomy–trabeculectomy augmented with 5-fluorouracil in paediatric glaucoma. Clin Exp Ophthalmol. 2011;39(3):207–14.CrossRefGoogle Scholar
  18. 18.
    Dubey S, Agrawal A, Chauhan L, Mukherjee S, Douglas G. Combined trabeculotomy-trabeculectomy with antimetabolite and releasable suture: outcome with primary congenital glaucoma in a north Indian population. Nepal J Ophthalmol. 2015;7(1):16–25.CrossRefGoogle Scholar
  19. 19.
    Harms H, Dannheim R. Epicritical consideration of 300 cases of trabeculotomy 'ab externo'. Trans Ophthalmol Soc U K. 1969;89:491–9.Google Scholar
  20. 20.
    Elder MJ. Combined trabeculotomy-trabeculectomy compared with primary trabeculectomy for congenital glaucoma. Br J Ophthalmol. 1994;78(10):745–8.CrossRefGoogle Scholar
  21. 21.
    Mandal AK, Matalia JH, Nutheti R, Krishnaiah S. Combined trabeculotomy and trabeculectomy in advanced primary developmental glaucoma with corneal diameter of 14 mm or more. Eye (Lond). 2006;20(2):135–43.CrossRefGoogle Scholar
  22. 22.
    al-Hazmi A, Zwaan J, Awad A. Effectiveness and complications of mitomycin C use during pediatric glaucoma surgery. Ophthalmology. 1998;105(10):1915–20.CrossRefGoogle Scholar
  23. 23.
    Jalil A, Au L, Khan I, Ashworth J, Lloyd IC, Biswas S. Combined trabeculotomy-trabeculectomy augmented with 5-fluorouracil in paediatric glaucoma. Clin Exp Ophthalmol. 2011;39(3):207–14.CrossRefGoogle Scholar
  24. 24.
    Matlach J, Hipp M, Wagner M, Heuschmann PU, Klink T, Grehn F. A comparative study of a modified filtering trabeculotomy and conventional trabeculectomy. Clin Ophthalmol. 2015;9:483–92.CrossRefGoogle Scholar
  25. 25.
    ElSheikha OZ, Abdelhakim MA, Elhilali HM, Kassem RR. Is viscotrabeculotomy superior to conventional trabeculotomy in the management of Egyptian infants with congenital glaucoma? Acta Ophthalmol. 2015;93(5):e366–71.CrossRefGoogle Scholar
  26. 26.
    Tamcelik N, Ozkiris A, Sarici AM. Long-term results of combined viscotrabeculotomy-trabeculectomy in refractory developmental glaucoma. Eye (Lond). 2010;24(4):613–8.CrossRefGoogle Scholar
  27. 27.
    Mandal AK. Primary combined trabeculotomy-trabeculectomy for early-onset glaucoma in Sturge-Weber syndrome. Ophthalmology. 1999;106(8):1621–7.CrossRefGoogle Scholar
  28. 28.
    Beck AD, Lynch MJ, Crandall J, Mobin-Uddin O. Surgical outcomes with 360-degree suture trabeculotomy in poor-prognosis primary congenital glaucoma and glaucoma associated with congenital anomalies or cataract surgery. J AAPOS. 2011;15:54–8.CrossRefGoogle Scholar
  29. 29.
    Shi Y, Wang H, Yin J, Zhang X, Li M, Xin C, et al. Outcomes of microcatheter-assisted trabeculotomy following failed angle surgeries in primary congenital glaucoma. Eye (Lond). 2017;31(1):132–9.CrossRefGoogle Scholar
  30. 30.
    Alward WL. Chapter 11, Primary congenital glaucoma. Version 1.0. 28 Sep 2015. Iowa Glaucoma Curriculum. Accessed 12 Mar 2018.
  31. 31.
    Lim ME, Neely DE, Wang J. Comparison of 360 degree with traditional trabeculotomy in pediatric glaucoma. J AAPOS. 2015;19(2):145–9.CrossRefGoogle Scholar
  32. 32.
    Gloor BR. Gefahren der 360 degrees-Fadentrabekulotomie [Risks of 360 degree suture trabeculotomy]. Ophthalmologe. 1998;95(2):100–3. [Article in German]CrossRefGoogle Scholar
  33. 33.
    Neely DE. False passage: a complication of 360 degrees suture trabeculotomy. J AAPOS. 2005;9(4):396–7.CrossRefGoogle Scholar
  34. 34.
    Wise J, Toygar O, Correa ZM, Miller DM, Sisk RA. Subretinal cannulation as a complication of suture trabeculotomy surgery in a pediatric patient. Retin Cases Brief Rep. 2017;11(1):79–82.CrossRefGoogle Scholar
  35. 35.
    Luntz MH. Congenital, infantile, and juvenile glaucoma. Ophthalmology. 1979;86(5):793–802.CrossRefGoogle Scholar
  36. 36.
    Quigley HA. Childhood glaucoma: results with trabeculotomy and study of reversible cupping. Ophthalmology. 1982;89(3):219–26.CrossRefGoogle Scholar
  37. 37.
    Debnath SC, Teichmann KD, Salamah K. Trabeculectomy versus trabeculotomy in congenital glaucoma. Br J Ophthalmol. 1989;73:608–11.CrossRefGoogle Scholar
  38. 38.
    Elder MJ. Congenital glaucoma in the West Bank and Gaza Strip. Br J Ophthalmol. 1993;77(7):413–6.CrossRefGoogle Scholar
  39. 39.
    Meyer G, Schwenn O, Pfeiffer N, Grehn F. Trabeculotomy in congenital glaucoma. Graefes Arch Clin Exp Ophthalmol. 2000;238(3):207–13.CrossRefGoogle Scholar
  40. 40.
    Tamcelik N, Ozkiris A. Long-term results of viscotrabeculotomy in congenital glaucoma: comparison to classical trabeculotomy. Br J Ophthalmol. 2008;92:36–9.CrossRefGoogle Scholar
  41. 41.
    Yalvac IS, Satana B, Suveren A, Eksioglu U, Duman S. Success of trabeculotomy in patients with congenital glaucoma operated on within 3 months of birth. Eye (Lond). 2007;21(4):459–64.CrossRefGoogle Scholar
  42. 42.
    Papadopoulos M, Edmunds B, Chiang M, Mandal A, Grajewski AL, Khaw PT. Glaucoma surgery in children. In: Weinreb RN, Grajewski A, Papadopoulos M, Grigg J, Freedman S, editors. Childhood glaucoma, WGA consensus series 9. Amsterdam: Kugler Publications; 2013. p. 95–134.Google Scholar
  43. 43.
    Shi Y, Wang H, Yin J, Li M, Zhang X, Xin C, et al. Microcatheter-assisted trabeculotomy versus rigid probe trabeculotomy in childhood glaucoma. Br J Ophthalmol. 2016;100(9):1257–62.CrossRefGoogle Scholar
  44. 44.
    Neustein RF, Beck AD. Circumferential trabeculotomy versus conventional angle surgery: comparing long-term surgical success and clinical outcomes in children with primary congenital glaucoma. Am J Ophthalmol. 2017;183:17–24.CrossRefGoogle Scholar
  45. 45.
    Girkin CA, Rhodes L, McGwin G. Goniotomy versus circumferential trabeculotomy with an illuminated microcatheter in congenital glaucoma. J AAPOS. 2012;16(5):424–7.CrossRefGoogle Scholar
  46. 46.
    El Sayed Y, Gawdat G. Two-year results of microcatheter-assisted trabeculotomy in paediatric glaucoma: a randomized controlled study. Acta Ophthalmol. 2017;95(8):e713–9.CrossRefGoogle Scholar
  47. 47.
    Shakrawal J, Bali S, Sidhu T, Verma S, Sihota R, Dada T. Randomized trial on illuminated-microcatheter circumferential trabeculotomy versus conventional trabeculotomy in congenital glaucoma. Am J Ophthalmol. 2017;180:158–64.CrossRefGoogle Scholar
  48. 48.
    Temkar S, Gupta S, Sihota R. Illuminated microcatheter circumferential trabeculotomy versus combined trabeculotomy-trabeculectomy for primary congenital glaucoma: a randomized controlled trial. Am J Ophthalmol. 2015;159(3):490–7.CrossRefGoogle Scholar
  49. 49.
    Dao JB, Sarkisian SR Jr, Freedman SF. Illuminated microcatheter-facilitated 360-degree trabeculotomy for refractory aphakic and juvenile open-angle glaucoma. J Glaucoma. 2014;23(7):449–54.CrossRefGoogle Scholar
  50. 50.
    Lim ME, Dao JB, Freedman SF. 360-Degree trabeculotomy for medically refractory glaucoma following cataract surgery and juvenile open-angle glaucoma. Am J Ophthalmol. 2017;175:1–7.CrossRefGoogle Scholar
  51. 51.
    Konstas AG, Jay JL. Modification of trabeculectomy to avoid postoperative hyphaema. The 'guarded anterior fistula' operation. Br J Ophthalmol. 1992;76(6):353–7.CrossRefGoogle Scholar
  52. 52.
    Bayoumi NH. Deep sclerectomy in pediatric glaucoma filtering surgery. Eye (Lond). 2012;26(12):1548–53.CrossRefGoogle Scholar
  53. 53.
    Khan AO. Trabeculotomy versus trabeculotomy-trabeculectomy for congenital glaucoma. Br J Ophthalmol. 2006;90(1):125.CrossRefGoogle Scholar
  54. 54.
    Chang TC, Cavuoto KM. Surgical management in primary congenital glaucoma: four debates. J Ophthalmol. 2013;2013:612708.CrossRefGoogle Scholar
  55. 55.
    Mandal AK, Gothwal VK, Nutheti R. Surgical outcome of primary developmental glaucoma: a single surgeon's long-term experience from a tertiary eye care centre in India. Eye (Lond). 2007;21(6):764–74.CrossRefGoogle Scholar
  56. 56.
    Essuman VA, Braimah IZ, Ndanu TA, Ntim-Amponsah CT. Combined trabeculotomy and trabeculectomy: outcome for primary congenital glaucoma in a West Africa population. Eye (Lond). 2011;25(1):77–83.CrossRefGoogle Scholar
  57. 57.
    Campos-Mollo E, Moral-Cazalla R, Belmonte-Martinez J. Combined trabeculotomy-trabeculectomy as the initial surgical procedure of primary developmental glaucoma. Arch Soc Esp Oftalmol. 2008;83(8):479–85. [Article in Spanish]CrossRefGoogle Scholar
  58. 58.
    Khalil DH, Abdelhakim MA. Primary trabeculotomy compared to combined trabeculectomy-trabeculotomy in congenital glaucoma: 3-year study. Acta Ophthalmol. 2016;94(7):e550–e4.CrossRefGoogle Scholar
  59. 59.
    Alsheikheh A, Klink J, Klink T, Steffen H, Grehn F. Long-term results of surgery in childhood glaucoma. Graefes Arch Clin Exp Ophthalmol. 2007;245(2):195–203.CrossRefGoogle Scholar
  60. 60.
    Ghate D, Wang X. Surgical interventions for primary congenital glaucoma. Cochrane Database Syst Rev. 2015;1:CD008213.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Mandal AK, Walton DS, John T, Jayagandan A. Mitomycin C-augmented trabeculectomy in refractory congenital glaucoma. Ophthalmology. 1997;104(6):996–1003.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Beth Edmunds
    • 1
    Email author
  • Allen D. Beck
    • 2
  • Esther Hoffmann
    • 3
  • Franz Grehn
    • 4
  1. 1.Casey Eye InstituteOregon Health and Science UniversityPortlandUSA
  2. 2.Department of OphthalmologyEmory UniversityAtlantaUSA
  3. 3.Department of OphthalmologyChildhood Glaucoma Center, University Medical Center MainzMainzGermany
  4. 4.Department of OphthalmologyUniversity Hospitals WürzburgWürzburgGermany

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