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.     

Midterm follow-up of necrotic bleb excision and advancement of the fornical conjunctiva

Mitomycin C has improved the success rate of glaucoma filtering surgery in patients at high risk for surgical failure. However chronic hypotony is marked by decreased vision and a late-onset leaking bleb after filtration surgery using mitomycin C. Bleb excision and conjunctival advancement is the method of choice to repair bleb leakage and chronic hypotony. Five eyes from five patients were received glaucoma filtration surgery with topical mitomycin C. All of the patients' blebs were avascular and transparent. The reasons for bleb excision were two spontaneous bleb leaks, two traumatic bleb leaks and one case of severe irritation. The mean follow-up period was 18.4 +/- 8.3 months (ten to 29 months). Cataract surgery was combined in one eye. Postoperative intraocular pressure (IOP) increased from 2.3 +/- 1.5 mmHg to 9.5 +/- 3.7 mmHg at nine months postoperatively in four eyes. It went from 28 mmHg to 40 mmHg in one patient with uveitis, for whom a second trabeculectomy with mitomycin C; 0.4 mg/ml for 3 minutes, was performed. After surgery, IOP decreased to 4 mmHg in three months. Postoperative visual acuity improved four snellen lines in three eyes. A partially avascular bleb recurred in three eyes, a corneal bleb in one eye and blepharoptosis, which disappeared spontaneously at four months postoperatively, in one eye. Necrotic bleb excision and advancement of fornical conjunctiva were useful methods to increase IOP and to improve visual acuity for the patient experiencing irritation symptoms, and for leaking blebs, and hypotonic maculopathy.     

Long-term follow up of surgical repair of late bleb leaks after glaucoma filtering surgery

PURPOSE: To study the long-term outcomes of surgical revision of leaking blebs after trabeculectomy and identify possible risk factors for failure. PATIENT AND METHODS: A retrospective, nonrandomized, noncomparative interventional study of 34 eyes with late bleb leaks after trabeculectomy that underwent bleb excision with conjunctival advancement. The primary outcome measure was successful repair and control of intraocular pressure (IOP). The other measures evaluated included change in visual acuity from baseline and complications such as recurrence of bleb leak, endophthalmitis or the need for additional antiglaucoma medication to control IOP. RESULTS: After a mean follow up of 36.2+/-23 months, the mean IOP at the last visit was 14.5+/-7.6 mm Hg. IOP in 58.8% of eyes was controlled without medication. Complications included early leaks (7/34), late recurrent or persistent leaks (1/34), and endophthalmitis (1/34). In all, 41.2% patients required additional medication at the last visit. Survival analysis at 22 months the probability of total and qualified success was 52% and 72%, respectively. However, this dropped to 10% and 15%, respectively, at 5 years. The probability of total and qualified success further dropped to 2.5% and 5% at 5 years when the IOP cut-off was lowered from 21 to 15 mm Hg. Cox regression analysis failed to identify risk factors for bleb failure. CONCLUSIONS: Surgical bleb revision seems to be effective in treating late bleb leaks with few postoperative complications. However, patients should be followed carefully as late failure of bleb function beyond 2 years is a significant possibility.     

Surgical repair of leaking filtering blebs

PURPOSE: To report the surgical management of leaking filtering blebs occurring after blebitis or persistent hypotony. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two eyes of 20 patients with late bleb leak, blebitis or endophthalmitis, hypotony maculopathy, or bleb dysesthesia on presentation to the glaucoma service who required surgical bleb revision from 1990 through 1999. INTERVENTION: Pedicle flap, partial excision, and advancement or free conjunctival autologous graft techniques for surgical bleb revision. Type of bleb revision was dependent on the dimensions of the bleb and quality of surrounding conjunctiva. MAIN OUTCOME MEASURES: Preoperative and postoperative intraocular pressure (IOP), status of bleb leak, reoperation for glaucoma, or requirement for postrevision glaucoma medical therapy, with success defined as the need for two or fewer glaucoma medications after revision. RESULTS: Eighty-six percent (19/22) of eyes that underwent surgical bleb revision had resolution of leak and IOP control using two or fewer medications after one or more bleb revisions. The preoperative IOP (mean +/- standard deviation) was 3.7 +/- 2.6 mmHg (range, 0-8 mmHg). After an average follow-up of 21 months (range, 8-108 months), the IOP was 11.0 +/- 4.4 mmHg for patients taking 0.6 +/- 1.0 glaucoma medications. Eighteen percent (4/22) of eyes required two or more bleb revisions. In one eye, an IOP spike of 36 mmHg developed after revision, which required laser suture lysis on two occasions before the IOP was significantly lowered. The three failures were: one eye that required three or more medications for IOP control, a patient whose eye had a persistent leak after revision and who was not mentally competent to undergo repeat revision, and one eye that required combined glaucoma and cataract surgery after revision. CONCLUSIONS: Surgical bleb revision has a high success rate of closing late bleb leaks, maintaining glaucoma control, and preserving vision, with few postoperative complications. The appropriate surgical procedure for revision must be based on the individual clinical situation and can result in successful bleb revision.     

Free conjunctival autologous graft for bleb repair and bleb reduction after trabeculectomy and nonpenetrating filtering surgery

PURPOSE: To describe methods and outcomes of excisional revision of a filtering bleb (bleb revision) using free conjunctival autologous graft either for bleb repair or for bleb reduction after trabeculectomy and deep sclerectomy with an implant. METHODS: Retrospective medical records were reviewed for a consecutive non-comparative case series comprising patients who underwent excisional revision of a filtering bleb between May 1998-January 2001. Excisional revision using free conjunctival autologous graft (bleb revision) was performed either for bleb repair, to treat early and late leaks and hypotony with maculopathy, or for bleb reduction, to improve ocular pain, discomfort, burning, foreign body sensation, tearing, and fluctuations of visual acuity. The revision consisted of bleb excision and free conjunctival autologous graft. The bleb histopathology was analyzed in patients who underwent bleb repair. RESULTS: Sixteen patients were included in the study, consisting of nine patients who had a trabeculectomy and seven patients who had a deep sclerectomy with an implant. Bleb revision was necessary in 14 patients due to leaking filtering bleb (bleb repair), and in 2 patients due to bleb dysesthesia (bleb reduction). After a follow-up of 15.1 +/- 8.4 months, the mean intraocular pressure (IOP) rose from 7.8 +/- 6.3 mm Hg to 14.3 +/- 6.5 mm Hg, and the visual acuity from 0.4 +/- 0.3 to 0.7 +/- 0.3, with a P value of 0.008 and 0.03, respectively. The complete success rate at 32 months, according to the Kaplan-Meier survival curve, was 38.3%, and the qualified success rate was 83.3%. Four patients (25%) required additional suturing for persistent bleb leak. To control IOP, antiglaucoma medical therapy was needed for six patients (37.5%) and repeated glaucoma surgery was needed for one patient. CONCLUSION: Free conjunctival autologous graft is a safe and successful procedure for bleb repair and bleb reduction. However, patients should be aware of the postoperative possibility of requiring medical or surgical intervention for IOP control after revision.     

Excisional bleb revision to correct overfiltration or leakage

OBJECTIVES: To evaluate the effectiveness of excisional revision of filtering blebs for hypotony or leakage when more conservative measures have failed. PATIENTS AND METHODS: Retrospective review of all patients who underwent excisional revision of a filtering bleb for hypotony (intraocular pressure [IOP] < 5 mm Hg) or leakage during a 3 year period. The revision consisted of excision of the avascular bleb, mobilization of the surrounding conjunctiva, and suturing of the conjunctiva at the limbus. RESULTS: Sixteen patients were included in the study. The average age was 66.3 +/- 14.8 years (range, 39-83). Revision followed trabeculectomy in 11 cases, combined phacoemulsification-trabeculectomy in three cases, and inadvertent blebs in two cases. Five cases had bleb leaks without hypotony, four cases had hypotony alone, and seven cases had both hypotony and a bleb leak. Average follow-up after bleb revision was 25 +/- 11 months (range, 9-43). Average IOP increased from 3.8 +/- 5.6 mm Hg (range, 0-22) to 11.9 +/- 4.1 mm Hg (range, 3-18), with an average of 1.1 +/- 1.1 medication (range, 0-3). The IOP at the last visit was < 15 mm Hg in all but two patients, with 10 of the 16 patients requiring medications. At the last follow-up examination, visual acuity had improved > or = two lines in nine patients and was reduced two lines in one patient. Five patients had early postoperative limbal wound leaks; resuturing was required in one case. CONCLUSIONS: Excisional bleb revision is an effective technique to correct hypotony or leakage after filtering surgery when other methods have failed. Intraocular pressure control is often maintained with the use of medications.     

Prognostic outcome of leaking filtering blebs reconstruction with rotational conjunctival flaps

PURPOSE: Late bleb leaks may follow months to years after filtering surgery especially with the use of antimetabolites. Complications related to beb leaks may lead to a decrease in visual acuity through complicated hypotony or ocular infection. Our retrospective study reports the anatomical and functional results of bleb reconstruction involving the resection of the bleb associated with the covering of the trabeculectomy site with a rotational conjunctival flap. MATERIAL: and methods: Twelve eyes of eleven patients with filtering bleb leaks occurring 3 months to 5 years after successful trabeculectomy (58.3% with adjunct of antimetabolites) underwent bleb surgical reconstruction between november 1995 and June 1999 and were followed until March 2000. Surgical bleb reconstruction was indicated because of persistent or a recurring bleb leak despite conservative medical treatment and blood bleb injections in seven cases. Complications associated with bleb leaks were chronical hypotony (9 cases), athalamy (1 case), hypotony maculopathy (1 case), and endophtalmitis with athalamy (1 case). Three patients had normal IOP but a bleb leak responsible for epiphora. All eyes were treated surgically through bleb excision and conjunctival closure was performed by rotational conjunctival flap. RESULTS: Mean (+/- SD) preoperative IOP was 5.1+/-3.5mmHg (range: 2 to 14mmHg). Mean (+/- SD) postoperative IOP evaluated before any other operation for uncontrolled IOP was 12.7+/-3.1mmHg (range: 6 to 15mmHg). Mean follow-up was 26.7+/-16.9 months (range: 9 to 64 months). All the complications related to the bleb leak resolved after bleb reconstruction. Surgery definively stopped the leak in 10 cases (83.3%) and allowed IOP control without treatment in 50.0% of the cases. Chronic recurring bleb leaks without hypotony occurred in two eyes and required surgery with conjunctival graft which led to a refractory increase in IOP responsible for loss of vision in one case. CONCLUSION: Bleb resection associated with the covering of the trabeculectomy site with a rotational conjunctival flap is a safe and effective procedure for the treatment of a late bleb leak and its complications. In most of the cases (83.3%), long-term IOP control can be expected without, medical treatment in 50% of the cases. Patients must be aware of the possibility of a recurring Seidel; however, the incidence of this complication remains low.     

Surgical revision of failed filtration surgery with mitomycin C augmentation

AIM: The aim of the study was to assess the outcomes of surgical revision with reopening of the scleral flap in eyes with failed glaucoma surgery and adjunctive mitomycin C (MMC). METHODS: Retrospective, noncomparative, interventional case series. Fifty-four eyes of 54 consecutive patients with previously failed trabeculectomy or deep sclerectomy who underwent formal surgical revision (23 with concurrent phacoemulsification) were included. MMC, 0.2 mg/mL for 2 to 3 minutes, was applied under a fornix-based conjunctival flap. The preexisting scleral flap was dissected open to reestablish filtration. RESULTS: Mean follow-up was 39.5+/-10 months. Kaplan-Meier survival analysis showed that the probability (with 95% confidence intervals) of maintaining an intraocular pressure (IOP) between 5 and 18 mm Hg and 20% decrease from preoperative IOP was 64% (47% to 76%) with medications and/or needle revision and 38% (26% to 53%) without, 3 years after surgery. Mean IOP before surgery was 23.6+/-7.2 mm Hg and 14.4+/-6.0 three years after surgery (last IOP before further glaucoma procedure carried forward). Needle revision for bleb failure or high IOP was carried out in 23 eyes (42.5%) and further glaucoma surgery in 5 eyes (9.3%). Patients were on an average of 2+/-1.1 glaucoma medications before surgery. At last follow-up, the number of medications had decreased to 0.8+/-1.2 (P<0.000), with 23 eyes (42.5%) requiring medications to control IOP. Significant complications included delayed suprachoroidal hemorrhage (3 eyes, 5.6%), delayed bleb leaks (5 eyes, 9.3%), hypotony (2 eyes, 3.7%), and blebitis (2 eyes, 3.7%). CONCLUSIONS: There is a progressive increase in IOP with time after surgical revision of failed glaucoma surgery with adjunctive MMC. A significant proportion of eyes will eventually require a needle revision procedure and/or glaucoma medications to further lower IOP. Also, there is a significant incidence of complications associated with this procedure.     

Filtering bleb revision. Techniques and outcome

BACKGROUND: The surgical management and outcome of bleb-related complications such as leaking blebs,overfiltration and blebitis are reported. METHODS: A retrospective analysis was carried out of 35 patients who underwent surgical repair of the filtering bleb in our hospital between 1991 and 2000. RESULTS: Surgical techniques used were autologous blood injection, fibrin glue injection, conjunctival suturing, resuturing of the trabeculectomy flap, bleb excision, conjunctival advancement, lyodura and tenon patching. In the eyes with leaking blebs the mean preoperative intraocular pressure (IOP) was 11.6+/-10.3 mmHg.After an average followup of 12 months the IOP was 11.9+/-3.3 mmHg. In the eyes with overfiltration the mean IOP was 2.4+/-1.5 mmHg and after an average follow-up of 18 months the mean IOP increased to 13.5+/-3.7 mmHg. In 77.1% the IOP was regulated between 8 and 21 mmHg without glaucoma medication. Mean visual acuity improved by 3.6+/-5.9 lines postoperatively. CONCLUSION: Surgical bleb revision has a high success rate with regard to maintaining a functioning filtering bleb and to preserving vision.     

Filtering bleb modification with a THC:YAG (Holmium) laser

OBJECTIVE: To present a method for remodeling oversized blebs using the THC:YAG laser and describe its use in treating hypotony and bleb leaks. METHODS: Retrospective medical record review of 13 patients who underwent holmium laser bleb revision. RESULTS: Thirteen eyes of 13 patients were analyzed. All the patients had an oversized bleb and 2 patients presented an associated late-onset leaking bleb. Mean preoperative IOP was 4.1 mm Hg. THC:YAG laser energy was applied to the bleb to remodel and/or close the leak. After a mean follow up of 17.3 months, the mean IOP was 7.84 mm Hg +/- 2.3. Postsurgery complications included hyphema and the inadvertent rupture of a conjunctival microcyst. Visual acuity improved in 9 of the eyes and remained stable in 4 of the eyes. CONCLUSION: The THC:YAG laser can be used effectively to sculpt large blebs, reduce symptoms associated with large blebs, increase IOP in hypotonous eyes, and under specific circumstances, close bleb leaks.     

Conjunctival advancement versus nonincisional treatment for late-onset glaucoma filtering bleb leaks.

OBJECTIVE: To compare the outcomes of conjunctival advancement and nonincisional management of late-onset glaucoma filtering bleb leak. DESIGN: Retrospective, nonrandomized, comparative interventional trial. PARTICIPANTS: Fifty-one eyes of 48 persons who underwent management of late-onset glaucoma filtering bleb leak from December 1986 through December 1999 were included. Thirty-seven eyes were included in the nonincisional treatment group (aqueous suppression with lubrication or patching, bandage contact lenses, cyanoacrylate glue, autologous blood injection, or a combination thereof) and 34 eyes were included in the surgical revision group (conjunctival advancement with preservation of the preexisting bleb). Twenty eyes underwent nonincisional treatment before surgical revision and were included in each treatment group. METHODS: Retrospective chart review of bleb leaks occurring at least 2 months after trabeculectomy. Successful treatment was defined as the resolution of the bleb leak, a final intraocular pressure (IOP) of 21 mmHg or less, and no significant complications such as blebitis, endophthalmitis, or bleb dysesthesia requiring a bleb revision. MAIN OUTCOME MEASURES: Cumulative success of closure of the filtering bleb leak, complications resulting from the intervention, IOP before and after treatment, and number of glaucoma medications before and after treatment. RESULTS: The Kaplan-Meier cumulative probability of success at 12 and 24 months were 0.45 and 0.42, respectively, for the nonincisional treatment group and 0.80 and 0.80, respectively, for the surgical revision group. The overall difference between the cumulative success of surgical and nonincisional treatment was statistically significant (P = 0.0001, log-rank test). In the nonincisional treatment group, only 20 of 37 eyes (54%) achieved initial sealing of the bleb leak after the treatment, and of those, almost half (8/20) eventually failed. Reasons for failure included persistent or recurrent leak (n = 21), blebitis or endophthalmitis (n = 6, including 4 with persistent leak), and bleb dysesthesia (n = 2). All eyes in the surgical group achieved closure of the leak, however 7 eventually failed because of leak recurrence (n = 2), elevated IOP (n = 3), or bleb dysesthesia (n = 2), and 11 required additional glaucoma medications. CONCLUSIONS: Patients with late bleb leaks managed with conjunctival advancement were more likely to have successful outcomes and less likely to have serious intraocular infections than those managed more conservatively.     

薄壁囊状滤过泡的结膜瓣加固术

目的　探讨改良转移结膜瓣对矫正青光眼小梁切除术后薄壁囊状滤过泡的临床效果。方法　剪开滤过泡周围的结膜（保留原滤过泡）,游离转移上方或颞侧球结膜-筋膜组织,加固覆盖于经局部冷冻的变性囊状泡表面,转移结膜瓣的前缘固定缝合于周边角膜的槽状浅沟内。转移结膜瓣不够松弛时,在穹窿部做一减张性球结膜-筋膜组织切开。结果　46例（52只眼）术后随访6个月至4年,平均眼压由术前（4.25±1.33）mmHg（1mmHg=0.133kPa）提高至术后（12.98±5.70）mmHg,差异有显著性（t=3.26,P<0.01）。51只眼仍保留滤过功能,20只眼的结膜渗漏和6只眼的黄斑水肿消失,术后视力较术前有明显改善（χ     

The efficacy of a modified ACTSEB (anterior chamber tube shunt to an encircling band) procedure

PURPOSE: To evaluate the efficacy of a modified anterior chamber tube shunt to an encircling band (ACTSEB) procedure for treating intractable glaucoma after scleral buckling procedure. METHODS: A retrospective review of medical records was performed on 7 eyes of 5 patients who underwent a modified ACTSEB procedure to treat intractable glaucoma after an encircling procedure. The modified ACTSEB procedure was performed using a silicone tube with its distal end inserted into the fibrous capsule around a scleral buckle and its proximal end inserted into the anterior chamber. Preoperative and postoperative intraocular pressure (IOP), number of antiglaucoma medications, visual acuity, and complications were recorded. Success was defined as a final IOP of >6 mm Hg and <21 mm Hg with or without medication. Among them qualified success was defined as a final IOP of <22 mm Hg with antiglaucoma medication, and complete success as the same IOP without medication. RESULTS: The overall success rate was 86% (6/7). Qualified success rate was 71% (5/7), and the complete success rate 14% (1/7). No case of hypotony, shallow anterior chamber, fibrous tube occlusion, tube obstruction by lens or iris, conjunctival wound leak, hyphema, or epithelial ingrowth occurred. The only complication was of inferior migration of the silicone tube into the anterior chamber in 2 cases. One of these led to corneal decompensation and subsequent tube removal due to tube migration, and the other underwent tube repositioning at 14 months postoperatively. CONCLUSIONS: The modified ACTSEB procedure provides an efficient means of treating intractable glaucoma after scleral buckling procedure.     

Surgical outcomes of combined phacoemulsification and glaucoma drainage implant surgery for Asian patients with refractory glaucoma with cataract

PURPOSE: To examine the safety and efficacy of combined phacoemulsification and glaucoma drainage implant surgery in providing reduction of intraocular pressure (IOP) and visual rehabilitation in eyes with refractory glaucoma and cataract. DESIGN: Interventional case series. METHODS: A retrospective chart review was performed on all subjects who underwent combined phacoemulsification with intraocular lens implantation and glaucoma drainage implant surgery by a single surgeon at the National University Hospital, Singapore. The implants used were the 185 mm2 Ahmed glaucoma valve and the 350 mm2 Baerveldt glaucoma implant. In terms of IOP, a complete success was defined as IOP of between 6 to 21 mm Hg without medication, qualified success as IOP between 6 to 21 mm Hg with one or more medication, and failure as a sustained IOP of >21 mm Hg or <6 mm Hg with or without one or more medication on two or more visits. RESULTS: A total of 32 combined phacoemulsification and glaucoma implant surgeries in 32 patients was performed. All patients were of Asian origin, and the mean age was 58 +/- 16 years (range, 20-78 years). The Baerveldt glaucoma implant and Ahmed glaucoma valve implant were inserted in 16 eyes each. With a mean follow-up of 13 +/- 5 months (range 6 to 22 months), IOP was reduced from a mean of 28.0 +/- 11.5 mm Hg to 15.2 +/- 6.0 mm Hg postoperatively (P <.0001), whereas the number of antiglaucoma medications decreased from a mean of 2.4 +/- 1.4 to.3 +/-.7 (P <.0001) at last follow-up. Overall, there were 24 eyes (75%) that were classified as complete successes, 4 eyes (12.5%) that were qualified successes, and 4 eyes that failed (12.5%). Twenty-three eyes (72%) had improvement of visual acuity, while only one eye had a loss of more than 1 line of Snellen acuity. There was no case that encountered an intraoperative complication, and postoperative complications occurred in 12 eyes (38%), the most common of which was hypotony (in six eyes, 19%). CONCLUSION: For subjects with refractory glaucoma and cataract, combined phacoemulsification and glaucoma drainage implant surgery provide good visual rehabilitation and control of IOP, with low incidence of complications.     

Valve implants of glaucoma pressure regulator for refractory glaucoma: own experience

PURPOSE: To present our experiences in valve implantation for refractory glaucoma. MATERIAL AND METHODS: From October 1993 to December 1996 implantations of Glaucoma Pressure Regulator Optimed were performed in 7 eyes of 7 patients. There were 4 men and 3 women aged from 32 to 65 years. There were 3 eyes with neovascular glaucoma due to diabetes mellitus, 2 eyes with posttraumatic glaucoma, including 1 case after keratoplasty, 1 eye with postkeratoplasty glaucoma and 1 eye with aphakic glaucoma. Preoperative IOPs ranged from 33 to 61 mm Hg (mean 37.6 +/- 7.2 mm Hg). RESULTS: Success was considered an IOP of less than 22 mm Hg without medication (complete success) or with medication (qualified success) without additional filtering surgery. Postoperative success was obtained in 4 out of 7 eyes after follow-up period of 37.4 +/- 17.08 months (range 16-39 months). Early complications were hyphema (1 patient, 14.3%), blockage of intracameral portion of the tube (1 patient, 14.3%), hypertony (1 patient, 14.3%). Late complications were: external conjunctival bleb failure (2 patients, 28.6%), blockage of intracameral portion of tube by fibrovascular tissue (1 patient, 14.3%). CONCLUSION: Our experiences confirm that the valve implant is still today an alternative surgical procedure for controlling IOP in eyes with refractory glaucoma that have visual potential.     

Slit-lamp needle revision of failed filtering blebs using high-dose mitomycin C

PURPOSE: To investigate the efficacy of bleb needle revision with high-dose mitomycin C in reviving failed filtering blebs after 1 year. PATIENTS AND METHODS: We reviewed the charts of 44 patients with one eye that had undergone bleb needle revision with a mixture of 0.1 mL of mitomycin (0.4 mg/mL) mixed with 0.1 mL of non-preserved 1% lidocaine. At least 12 months of follow-up were required. A successful bleb needle revision was defined as one that did not require a subsequent needling, glaucoma surgery, or medication to reach an intraocular pressure (IOP) greater than 4 mm Hg but less than 22 mm Hg. A qualified success was defined as a successful bleb needle revision that required subsequent needling or medication. RESULTS: The bleb needle revision with high-dose mitomycin was a success or qualified success after 12 months in 28 patients or 64% (95% confidence interval, 50% to 78%). The baseline IOP in these patients was 26.7 +/- 8.2 mm Hg (range 15 to 48 mm Hg) using an average of 1.5 +/- 1.5 glaucoma medications. The IOP after 1 year was 13.6 +/- 4.0 (range 6 to 21 mm Hg) with an average of 0.5 +/- 0.8 medications. Of 44 patients, 17 (39%) were successes and 11 (25%) were qualified successes. CONCLUSION: Bleb needle revision with high-dose MMC was effective in reducing the IOP in 64% of eyes with a failed filtering bleb with minimal long-term complications.     

Bleb reduction and bleb repair after trabeculectomy

OBJECTIVE: To describe methods and outcomes for repair of bleb-related complications of trabeculectomy surgery. DESIGN: Retrospective, consecutive, noncomparative case series. PARTICIPANTS: Thirty-one persons having bleb revision by two surgeons at the Wilmer Institute from 1994 to the present. INTERVENTION: One of two types of revision surgery was performed: bleb reduction to decrease symptoms from large blebs or bleb repair to improve hypotony, using conjunctival rotation flap or free conjunctival autograft. MAIN OUTCOME MEASURES: Visual acuity, intraocular pressure (IOP), reported symptoms, complications, and number of glaucoma medications at the final visit. RESULTS: The mean time from trabeculectomy to bleb revision was 4.4 years. Bleb reduction was performed because of symptomatic, high blebs in 11 eyes of 11 persons. Bleb repair was performed to end bleb leakage in 13 eyes of 13 persons and to increase IOP in 8 eyes of 7 persons with hypotony. Median visual acuity improved from 20/50 before revision to 20/30 at most recent follow-up. Mean IOP increased after treatment from 7.7+/-4.9 to 12.4+/-4.0 mmHg (P < 0.001). Symptoms that caused the revision surgery were eliminated in all cases. None of these eyes has lost IOP control, none has required repeat trabeculectomy, and only 2 of the 32 (6%) require topical glaucoma medication. More than one revision procedure was required in 8 of 32 (25%) eyes. CONCLUSIONS: Surgical bleb revisions for complications after trabeculectomy surgery are safe and effective. Bleb reduction for large, symptomatic blebs or bleb repair for leaking blebs and hypotony did not lead to loss of IOP control.     

Management of hypotony after trabeculectomy with mitomycin C

The purpose of this study was to determine the incidence and risk factors of hypotony and the effectiveness of medical and surgical treatment. A total 117 eyes of 103 patients that underwent trabeculectomy with mitimycin C (MMC) between 1993 and 2000 were reviewed. Hypotony was treated with the following methods in a stepwise manner: medical treatment, intrableb autologous blood injection, additional sutures to the scleral flap, necrotic bleb excision and advancement of the forniceal conjunctival flap. Hypotony developed in 30 eyes (25.6%) of 26 patients, among, which hypotonic maculopathy developed in 11 eyes (9.4%). The risk factors of hypotony were young age and primary open angle glaucoma. Because of no light sense, 6 of the 30 hypotonic eyes were not treated. Nineteen (79.2%) of the 24 treated hypotonic eyes were successfully managed. Five eyes, 3 with hypotony but maintaining visual acuity and 2 with follow-up loss, were not included in the success group. The mean intraocular pressure (IOP) before treatment, 2.5 +/- 1.2 mmHg, increased to 8.3 +/- 4.0 mmHg at 18.5 months follow-up. The stepwise treatment seems to be a useful method to manage hypotony after trabeculectomy with MMC.     

Photodynamic modulation of wound healing in glaucoma filtration surgery

AIM: To report a clinical pilot study investigating photodynamic therapy (PDT) in combination with glaucoma filtration surgery. BCECF-AM was used as the photosensitising substance. The clinical safety and tolerability of BCECF-AM, and its efficacy in controlling postoperative intraocular pressure (IOP) were assessed. METHODS: Before trabeculectomy (TE), 42 consecutive eyes of 36 glaucoma patients received one subconjunctival injection of 80 micro g BCECF-AM (2,7,-bis- (2-carboxyethyl) -5- (and-6) -carboxy-fluorescein, acetoxymethyl-ester) followed by an intraoperative illumination with blue light (lambda = 450-490 nm) for 8 minutes. Antifibrotic efficacy was established as postoperative IOP reduction of >20% and/or an IOP constantly < 21 mm Hg without antiglaucomatous medication. Follow up of the filtering bleb was documented by slit lamp examination. RESULTS: Eyes had mean 1.1 preoperative surgical interventions (filtration and non-filtration glaucoma surgery). Mean preoperative IOP was 31.6 (SD 9.7) mm Hg. Patients were followed for mean 496 days (range 3.5-31.8 months). Of the 42 eyes, 25 eyes had an IOP decreased to 15.8 (3.4) mm Hg without medication (complete success: 59.5%; p<0.001; t test). Seven eyes showed good IOP reduction < 21 mm Hg under topical antiglaucomatous medication (qualified success: 16.7%). 10 eyes failed because of scarring within 2-67 weeks (23.8%). Clinical follow up examinations revealed no local toxicity, no uveitis, and no endophthalmitis. CONCLUSIONS: This method is a new approach in modulating postoperative wound healing in human eyes undergoing glaucoma filtration surgery. The data of the first human eyes combining TE with PDT underline the clinical safety of this method and its possible potential to prolong bleb survival.     

改良小梁切除术联合生物羊膜植入治疗闭角型青光眼的临床观察

目的探讨Tenon’s筋膜切除联合生物羊膜植入的小梁切除术治疗闭角型青光眼临床疗效。方法对26例(30只眼)闭角型青光眼患者行Tenon’s筋膜切除联合生物羊膜植入的小梁切除术,术后随访1年,观察降眼压效果及其手术并发症。结果术后1周眼压(11.80±2.23)mmHg,较术前眼压(38.53±7.17)mmHg明显降低(P<0.01)。术后随访1年,眼压(17.80±4.11)mmHg,保持功能性滤泡27只眼(90%)。结论 Tenon’s筋膜切除联合生物羊膜植入的小梁切除术可作为治疗闭角型青光眼的一种有效方法,手术成功率高,长期眼压控制好,可有效地减少瘢痕组织形成。