Béjou technique: trabeculectomy with loosening sutures

This article presents a technique for trabeculectomy using relaxing sutures to close a scleral flap. Initially, a small L-shaped conjunctival incision of 4 by 2 mm is made at a distance of 1-2 mm from the limbus. This incision size provides the necessary space for creating a scleral flap. Hemostasis is performed if necessary. Next, a scleral flap of 3 by 4 mm in size is formed, its thickness is 2/3 of the sclera thickness. Using a Week-cell sponge, mitomycin-C 0.4 ml/dl is applied for 2-3 min without covering the sponge with conjunctiva. After treatment with mitomycin-C, the surgical field is washed with saline (60-80 ml). Paracentesis is performed, the scleral flap is separated anteriorly until reaching the Descemet membrane so that a valve-like incision is obtained. After opening the anterior chamber, a sclerectomy is performed using a Kelly punch for Descemet's membrane, followed by a peripheral iridectomy using Vannas scissors. The scleral flap is secured with a relaxing suture using 10-0 monofilament nylon thread. The procedure is as follows:

• needle insertion into the sclera at the temporal angle, puncture at the base of the scleral flap;
• the stitch is passed through the flap;
• the needle is inserted on the surface of the flap under the conjunctiva in the limbus area in the direction of the cornea, the needle is punctured on the transparent part of the cornea 1 mm from the limbus;
• using the same needle, make a stitch in the opposite direction (insert the needle into the transparent part of the cornea 1 mm from the limbus and bring it out superficially on the flap);
• the stitch is passed through the flap;
• needle puncture at the base of the flap, puncture on the sclera in the other corner.

As a result, the surgeon obtains three loops: two above the scleral flap, one above the cornea. The free ends of the suture are tied to the corresponding loop on the flap. using only one of the three loops, then trimmed. The conjunctiva is sutured with a mattress suture of the same 10-0 monofilament nylon thread, superficially above the flap and parallel to the limbus just below the remaining conjunctiva, closing the horizontal part of the L-shaped incision. The remainder of the incision is closed with a knot, fixing first the episclera and then the conjunctiva. Thus, the conjunctiva is sealed.

If the suture needs to be removed, the loop is cut on the corneal surface and then removed with tweezers. This procedure is performed under a slit lamp with local anesthesia and requires observation by a surgeon for at least 48 hours after the procedure or for two long observation periods.

In combined interventions (for cataract and glaucoma), a single approach is used. By modifying the technique, a partial scleral flap is formed, halving the length of the lateral incisions. A flap measuring 2 by 4 mm is obtained 2 mm from the limbus. After the application of mitomycin-C, a scleral tunnel is created using a sickle knife, continuing the previously started groove, and the scleral flap is peeled off. Then phacoemulsification with implantation of an artificial lens is performed, sclerectomy is performed using a Kelly perforator for Descemet's membrane and peripheral iridectomy. The scleral flap and conjunctiva are sutured using the previously described technique.