Outcomes of bleb excision and conjunctival advancement for leaking or hypotonous eyes after glaucoma filtering surgery

AIM: To determine outcomes of bleb excision and conjunctival advancement for leaking or hypotonous eyes after glaucoma filtering surgery. METHODS: In a retrospective case series the medical records of all patients who underwent bleb excision and conjunctival advancement surgery for bleb leaks or hypotony (defined as IOP less than 6 mm Hg, associated with reduced vision) at the Jules Stein Eye Institute and the Yale University Eye Center between January 1993 and June 2002 were reviewed. Only patients with more than 6 months of follow up were included. Complete success was defined as resolution of the pre-existing leak or hypotony, with maintenance of IOP > or =6 and < or =21 mm Hg, in the absence of further glaucoma surgery and without any glaucoma medication. Qualified success met the above criteria with or without the use of glaucoma medications. Success rates were analysed with Kaplan-Meier survival curves. RESULTS: 49 eyes were included in the study; 13 eyes had overt bleb leaks, 27 eyes had hypotony. Nineteen patients underwent resuturing of sclera and/or placement of a pericardial graft in addition to bleb excision and conjunctival advancement. Mean preoperative IOP increased from 3.2 (SD 2.4) mm Hg (range 0-10 mm Hg) to 13.8 (4.8) mm Hg (range 6-29 mm Hg) at last follow up (p<0.0001). Mean preoperative visual acuity improved from 0.6 (0.3) logMAR (range 0-2) to 0.3 (0.3) logMAR (range 0-2) at final follow up (p<0.0001). 16 eyes (40%) were classified as complete success and 17 additional eyes achieved qualified success, for a total of 33 eyes (83%) achieving at least qualified success. There was no significant difference in the rate of complete success (p = 0.95) or qualified success (p = 0.88) between the group of patients who underwent bleb excision and conjunctival advancement alone versus those who also had resuturing of sclera and/or placement of a pericardial graft. Failures included three eyes that had persistent hypotony without leak, requiring additional bleb revision, and four with uncontrolled IOP, two of whom underwent additional glaucoma surgery. CONCLUSION: Bleb excision with conjunctival advancement is a successful procedure for bleb repair. This technique provides successful resolution of leaks and hypotony, maintains glaucoma control with or without medication, and preserves vision with minimal postoperative complications in a majority of eyes.     

穹隆为基底结膜瓣可调整缝线小梁切除术探讨

目的探讨以穹隆为基底结膜瓣可调整缝线小梁切除术的效果、并发症及适应证。方法我院行抗青光眼手术的患者42例(49只眼)作为试验组,和试验组构成相近的文献报导的以角膜缘为基底可调整缝线小梁毁除术为对照组。试验组做以穹隆为基底结膜瓣可调整缝线小梁切除术,术后随访6-12月,观察眼压、滤过泡、视力、前房深度及并发症。结果眼压、滤过泡、浅前房、前房积血、低眼压、脉络膜脱离等与对照组及有关文献报导无显著差异。但试验组角膜切口轻度渗漏较多。结论以穹隆为基底结膜瓣可调整缝线与以角膜缘为基底结膜瓣可拆除缝线小梁切除术一样有效、安全,但操作更简便、省时。对大于50岁的各型原发性青光眼是适用的。为防止角结膜缘切口渗漏,第一针可调整缝线的拆除时间和眼球指压按摩时间最好在术后6天以后。     

Partial excision with a conjunctival advancement flap after a relaxing incision for a dissecting glaucoma filtering bleb

A 65-year-old male patient developed dissecting glaucoma filtration bleb following trabeculectomy with mitomycin-C (MMC). Surgical partial excision of the bleb was performed and the tissue was subjected to histopathological evaluation. The bleb area was covered by a conjunctival flap that was advanced with the help of a relaxing incision in the superior conjunctiva fornix. The dissecting bleb was successfully managed by controlling intraocular pressure, and the patient became asymptomatic without any medication. The light microscopic examination of the bleb showed irregularly arranged collagen bundles and hypocellularity of the subconjunctival tissue with places of nodular configuration of the fibroblast in the periphery. Surgical partial excision of the dissecting glaucoma filtering bleb is a reliable, simple, and precise method. Advancing the conjunctival flap by a superior conjunctival relaxing incision facilitates easy mobilization of the flap, ensures healthy resurfacing of the bleb, and prevents postoperative transconjunctival leakage. Histopathology of the bleb is compatible with the use of MMC during original filtering surgery.     

经下穹隆部小切口义眼座二期植入临床观察

目的探讨经下穹隆部小切口进行植入羟基磷灰石义眼座二期植入的手术效果。方法对38例（38眼）行眼内容摘除术（或眼球摘除术）2～23年的患者。采用经下穹隆小切口进行羟基磷灰石义眼座二期植入的手术方法，观察其疗效。结果术后眼眶饱满，义眼座活动度良好。随访3～8月，无一例发生义眼座移位、脱出或眶内感染等。结论经下穹隆部小切口进行羟基磷灰石义眼座二期植入和常规手术相比有手术损伤小、义眼座暴露率低及活动度好等优点。     

Revision of dysfunctional filtering blebs by conjunctival advancement with bleb preservation

PURPOSE: To assess the outcome of advancing a conjunctival flap with preservation of the bleb in eyes undergoing filtration bleb revision after trabeculectomy. METHODS: A retrospective review of cases from a university-based referral practice identified 30 eyes of 30 patients that had undergone bleb revision after trabeculectomy by advancement of a conjunctival flap over the de-epithelialized bleb. Success was defined as resolution of the bleb-associated complication necessitating the revision (leak, hypotony, discomfort) with maintenance of intraocular pressure greater than or equal to 6 and less than or equal to 21 mm Hg without glaucoma medications. Qualified success met the above criteria but with the use of glaucoma medications. Summary data including visual acuity were obtained. RESULTS: On the 30 eyes, 30 conjunctival advancement procedures were performed. Seventeen were for bleb leaks, 10 for prolonged hypotony without bleb leak, and three for dysesthetic bleb. Eighteen eyes (60%) were classified as a complete success and 24 eyes (80%) achieved at least a qualified success. Cumulative probability of at least qualified success was 77% at 2 years. Failures included inadequate intraocular pressure control (one eye), recurrent bleb leak (three eyes), and hypotony without bleb leak (two eyes). The mean preoperative intraocular pressure for all eyes increased from 4.4 +/- 3.7 mm Hg to 12.3 +/- 6.2 mm Hg (P <.00001) at the final visit with a mean follow-up of 18.9 +/- 15.5 months. Visual acuity improved or remained within 1 line of preoperative acuity in all but five patients. Complications included two patients with mild ptosis and four patients with hypertropia. CONCLUSION: Advancement of a conjunctival flap with preservation the preexisting bleb often provides successful resolution of bleb-associated complications.     

Results of autografting of marginal conjunctiva in pterygium excision

PURPOSE: To investigate and compare the efficiency of autografting of marginal conjunctiva (autograft of marginal conjunctiva technique, AMCT) and the bare sclera technique (BST) in pterygium excision. MATERIALS AND METHODS: In this study, 51 eyes of 51 patients who underwent pterygium surgery using the AMCT (group 1) were compared to 45 eyes of 45 patients who underwent pterygium excision using the BST (group 2), with regard to epithelialisation, recurrence and complication of the procedures. Patients were followed up for 15.37 +/- 12.01 months in group 1 and for 18.57 +/- 10.42 months in group 2. RESULTS: Postoperative epithelialisation was completed in 4.34 +/- 1.27 days in group 1 and in 5.61 +/- 1.71 days in group 2. Epithelialisation was completed earlier in group 1 than group 2 (p < 0.05). Recurrences were detected in 7 eyes (13.73%) of group 1 and in 17 eyes (37.78%) of group 2. The difference between the groups was statistically significant (p < 0.01). No postoperative complications were seen in either of the groups. CONCLUSIONS: The AMCT was found to be a more efficient procedure than the BST. Autografting of marginal conjunctiva may be a useful alternative treatment in pterygium surgery due to higher success and lower recurrence rates.     

两种结膜瓣在复合式小梁切除术后对形成功能性滤过泡的影响

目的比较穹隆部为基底的球结膜瓣和角膜缘为基底的球结膜瓣在青光眼复合式小梁切除术后对形成功能性滤过泡的影响。方法将45例（55眼）原发性青光眼并接受复合小梁切除术者随机分成2组：A组：27眼以角膜缘为基底的球结膜瓣;B组：28眼以穹隆部为基底的球结膜瓣。术后观察2组患眼眼压、滤泡、前房深度。全部患者术后观察6个月。结果2种结膜瓣的复合式小梁切除术均有显著降眼压效果（P〈0．01）;功能性滤过泡的形成率差异也无统计学意义（P〉0．05）;术后早期眼球按摩促进滤泡形成中出现被动性滤泡渗漏B组多于A组。结论2种结膜瓣的复合小梁切除术治疗青光眼都有相同良好的效果。鉴于穹隆部为基底的球结膜瓣在眼球按摩中有较高被动性滤泡渗漏,因此角膜缘为基底球结膜瓣的复合小梁切除术更安全。     

小梁切除术不同结膜瓣滤过泡的形成分析

目的：探讨小梁切除术两种不同结膜瓣术后功能性滤过泡形成情况。方法：比较372例（372只眼）原发性青光眼不同结膜瓣小梁切除术术后功能性滤过泡形成情况，其中以角巩缘为基底的结膜瓣165只眼，以穹窿部为基底的结膜瓣207只眼。结果：术后1周对所有患者进行了观察，3个月时只有127只跟进行了随访。以角巩缘为基底的结膜瓣手术组术后1周滤过泡成功率为83．03％，3个月时为78．69％。以穹窿部为基底的结膜瓣手术组术后1周滤过泡成功率为55．07％，3个月时为53．03％。两组比较有明显差别。结论：本组研究发现，传统的以角巩缘为基底的结膜瓣术后滤过泡成功率高于以穹窿部为基底的结膜瓣，其术后降压效果相应亦较好。     

Revision of dysfunctional filtering bleb by conjunctival advancement with bleb preservation: A simple choice for massive choroidals with hypotony following trabeculectomy

A 65-year-old diabetic and hypertensive male presented with a sudden diminution of vision after sustaining a trivial fingernail injury to his only good-seeing (right) eye. The patient underwent phacotrabeculectomy with posterior chamber intraocular lens (PCIOL) implantation 22 years previously. In his right eye visual acuity at presentation was counting fingers at 1.5 m with an accurate projection of light. Intraocular pressure (IOP) was 4 mmHg. The anterior chamber was uniformly shallow with a peripheral iridocorneal touch. Angle details could not be visualized. The bleb was avascular, thin and cystic with a positive forced Seidel test. Fundus examination showed 360° choroidal detachments. B-scan ultrasound revealed massive choroidals. Revision of dysfunctional filtering bleb by conjunctival advancement with bleb preservation and anterior chamber reformation with healon was performed. Postoperatively, the first day visual acuity improved to 6/36, the anterior chamber was deep, bleb was well covered with conjunctiva, the IOP was 10 mmHg and fundus examination revealed resolving choroidals. At the final follow up at 4 months, the patient did not require medication and visual acuity was 6/12, the bleb was functioning well with an IOP of 14 mmHg. Examination of the fundus revealed a cup-to-disc ratio of 0.5 with moderate non-proliferative diabetic retinopathy changes. The patient has been advised to maintain a strict glycemic control and return for routine follow up after 3 months.     

结膜瓣切口大小对小梁切除术后滤过泡形成的影响

目的探讨不同大小切口的以穹隆为基底的结膜瓣,对小梁切除术后功能性滤过泡形成的影响。方法选择于我院施行小梁切除术的患者62名68只眼,依据穹隆为基底的“L”形切口结膜瓣的大小不同随机分为三组,A组结膜瓣切口为5mm×10mm,B组结膜瓣切口5mm×7mm,C组为A组基础上辅以角膜缘连续缝合。对术后功能泸过泡进行密切观察随诊,干预治疗,比较三种方法对眼压控制的效果。结果术后滤过道瘢痕形成A、C二组为0,B组31.81%;术后早期滤过过强A组30.40%>B组9.0%>C组8.70%。术后稳定期功能性滤过泡的保存率C组91.30%>A组86.96%>B组63.64%。结论以角膜缘连续缝合的以穹隆为基底的大切口结膜瓣联合调整缝线术可以提高小梁切除术后功能性滤过泡形成率。     

羊膜和细胞外基质对兔眼小梁切除术后滤过泡的影响

目的探讨羊膜和结膜细胞外基质（ECM）对兔眼小梁切除术后滤过泡的影响。方法对27只新西兰白兔右眼后房注射α-糜蛋白酶,制备青光眼动物模型。将兔随机分为对照组、羊膜组、结膜ECM组,每组9只兔,行右眼手术。对照组行单纯小梁切除术,羊膜组行小梁切除联合羊膜移植术,结膜ECM组行小梁切除联合ECM移植。术后第1、7、14、21、28、35、42、56天观察小梁滤过泡形态及功能并测量术眼眼压,光学显微镜下观察小梁滤过泡下细胞的形态。结果对照组术前平均眼压（34．59±4．44）mmHg（1mmHg=0．133kPa）,术后第1、7、14、28、42、56天眼压分别为（11．31±2．76）mmHg、（19．20±5．17）mmHg、（21．17±4．36）mmHg、（22．22±1．39）mmHg、（23．90±1．97）mmHg、（23．67±1．73）mmHg。羊膜组术前平均眼压（34．38±4．20）mmHg,术后第1、7、14、28、42、56天眼压分别为（10．48±2．45）mmHg、（12．80±3．41）mmHg、（13．50±2．25）mmHg、（16．17±1．73）mmHg、（17．22±1．32）mmHg、（16．71±1．52）mmHg。结膜ECM组术前平均眼压（34．66±4．49）mmHg,术后第1、7、14、28、42、56天眼压分别为（10．94±2．75）mmHg、（11．29±2．40）mmHg、（13．93±3．55）mmHg、（15．63±3．54）mmHg、（15．70±2．44）mmHg、（15．12±3．65）mmHg。术后对照组与羊膜组和结膜ECM组眼压比较,差异有统计学意义（P〈0．01）;羊膜组与结膜ECM组眼压比较,差异无统计学意义（P〉0．05）。羊膜组、结膜ECM组术后第42、56天滤过泡轻微隆起并弥散,有较好的滤过功能。对照组术后第14、21天滤过泡区瘢痕形成,滤过功能差。组织学切片观察显示羊膜组、结膜ECM组滤过泡未形成瘢痕,成纤维细胞少,但有炎性细胞浸润。结论羊膜和结膜ECM能改善小梁切除术后滤过泡功能,减少瘢痕形成。     

翼状胬肉切除联合自体球结膜瓣移植术的临床分析

目的：探讨显微镜下施行翼状胬肉切除联合下方游离自体球结膜瓣移植术的疗效。方法：对93例97眼翼状胬肉施行翼状胬肉切除联合下方游离自体球结膜瓣移植术,观察术后恢复情况。结果：术后随访6～18mo,3眼复发（3%）,1眼并发炎性息肉（1%）,无其他并发症。结论：显微镜下翼状胬肉切除联合下方游离自体球结膜瓣移植术是治疗翼状胬肉的有效方法,具有术后复发率低且不影响白内障、青光眼手术切口选择的优点。     

改进的结膜瓣转位术治疗翼状胬肉的临床观察

目的评价改进翼状胬肉的手术方法降低复发率的效果。方法原发性翼状胬肉60例（78眼）,在手术显微镜下广泛切除变性的眼球筋膜囊组织联合自体舌形球结膜瓣转位修复方法,以最小的手术损伤,尽可能修复角膜缘上皮（干细胞）的屏障功能。结果术后随访12～24个月,平均18个月,2眼复发（2．56％）,视力明显提高。结论作者设计的改进显微手术切除联合舌形球结膜瓣转位术,手术操作简单,术后复发率低。     

平阳霉素注射手术切除及带蒂结膜瓣转移治疗复发性翼状胬肉

目的探讨复发性翼状胬肉的治疗方法。方法对98例（98眼）复发性翼状胬肉先行平阳霉素注射,1个月后再行翼状胬肉切除联合带蒂结膜瓣转移术,术毕在其根部再次注射平阳霉素;术后滴用含皮质类固醇和玻璃酸钠的抗生素滴眼液。术后每3个月复诊观察,随访2年。结果98眼中,3眼再次复发（3．06％）,95眼无复发,恢复良好（96．94％）。结论先行平阳霉素注射后再行手术治疗,术后滴用含皮质类固醇和玻璃酸钠的抗生素眼液是治疗复发性翼状胬肉的安全有效的方法,大大降低再次复发的可能。     

Reconstruction of conjunctiva with amniotic membrane after excision of large conjunctival melanoma: a long-term study

PURPOSE: To evaluate, on a long- term basis, the role of amniotic membrane in the reconstruction of large conjunctival defects after excision of large conjunctival melanoma. METHODS: Four consecutive patients with diffuse conjunctival melanoma involving both bulbar and palpebral conjunctiva were studied. Conjunctival melanoma was completely excised (with wide clinically disease-free margins) and amniotic membrane immediately sutured to the surrounding conjunctiva and sclera to cover the conjunctival defect. Minimum follow-up was 48 months. RESULTS: Successful conjunctival surface reconstruction and physiologic fornical depth were achieved in all patients within 6 weeks. No recurrence of primary melanoma was observed during long-term follow-up. CONCLUSIONS: Amniotic membrane transplantation is an effective alternative in ocular surface repairing surgery after removal of large conjunctival tumors.     

Leiomyosarcoma of the conjunctiva

The clinical, light microscopic, immunohistologic, and ultrastructural findings of a leiomyosarcoma of the conjunctiva are presented. This tumor was diagnosed after a 26-year history and is the first to be adequately documented as having arisen in the conjunctiva.     

Amyloidosis of the conjunctiva

Background: Amyloid of the eyelid conjunctiva is an extremely rare condition which may result in chronic discomfort and multiple surgeries.
Methods: A retrospective study of four patients from Moorfields Eye Hospital is presented to assess the clinical features and results of surgical treatment.
Results: Three patients had persistent ocular irritation and required multiple surgical procedures for recurrent amyloid. However, one patient has been followed for nearly 30 years with relatively few symptoms, and has required only infrequent surgical intervention. All patients underwent debulking and ptosis surgery at least once. The more severe clinical course was not related to the type of amyloid protein present. Shave excision of recurrent tarsal conjunctival arnyloid with split-thickness mucous membrane grafting was successfully tried in one patient in order to minimise postoperative cicatrisation of the posterior lamella.
Conclusion: The clinical course of patients with eyelid amyloid may vary greatly. Management should be conservative when possible, but surgery is an integral part of management since debulking of amyloid deposits and ptosis surgery was required in all patients in this series.