New Glaucoma Insights: Case ReportsSurgical Advancement of Tenon’s Layer During Trabeculectomy Improves Bleb MorphologyRoddy, Gavin W. MD, PhD; Sit, Arthur J. SM, MD Author Information Department of Ophthalmology, Mayo Clinic, Rochester, MN Mayo Foundation for Medical Education and Research (G.W.R. and A.J.S.) and National Eye Institute grant EY031758 (G.W.R.). Disclosure: The authors declare no conflict of interest. Reprints: Arthur J. Sit, SM, MD, Department of Ophthalmology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905 (e-mail: [email protected]). Journal of Glaucoma: June 2022 - Volume 31 - Issue 6 - p e32-e36 doi: 10.1097/IJG.0000000000002032 Buy Metrics Abstract Trabeculectomy surgery remains the gold standard incisional glaucoma surgical procedure in many practices, particularly for patients requiring intraocular pressure (IOP) in the low teens or below. However, trabeculectomy surgery is associated with complications including leakage, over filtration, or fibrosis of the surgical bleb. Morphology of the surgical bleb is an important predictor of surgical success defined as long-term IOP reduction with minimal to no complications. There have been many, often subtle, variations in the surgical technique in hopes of improving long-term IOP reduction. However, fewer changes have been implemented specifically to modify bleb morphology. In our surgical practice, we began performing a thorough dissection and advancement of Tenon’s layer with incorporation into the conjunctival closure in a 2-layered manner. This technique allowed flow of aqueous to a delineated potential space between sclera and Tenon’s layer. Our clinical observations were improved bleb morphology characterized by diffuse, low-lying blebs with nonischemic overlying conjunctiva compared with those performed with a more traditional trabeculectomy technique. Since we incorporated this change into our practice at a defined time, we have a small number of patients in our practice that had a more traditional trabeculectomy technique in the fellow eye. Therefore, in our surgical practice, a small number of patients had trabeculectomy in 1 eye before implementation of this new technique, and then had trabeculectomy in the fellow eye after this technique was adopted, providing opportunity for comparison of bleb morphology with and without Tenon advancement. In series we present two representative, index cases and describe our surgical technique. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.