Haemophilus aphrophilus bleb infection after a mitomycin trabeculectomy

Background: Haemophilus aphrophilus is a rare cause of ocular infection. It has been reported once as a cause of late-onset endophthalmitis in a patient with an inadvertent bleb after cataract surgery. We present a case of Haemophilus aphrophilus bleb infection after a mitomycin trabeculectomy.
Methods: A 56-year-old woman presented with a bleb infection 10 weeks after a mitomycin C augmented trabeculectomy at a University tertiary referral practice of one of the authors (GET). The causative organism was Haemophilus aphrophilus , identified by the Toronto Public Health Laboratory, Ontario, Canada.
Results: The bleb infection resolved following topical, subconjunctival and intravenous antibiotic therapy. A formal bleb revision was required to repair a persistent bleb leak.
Conclusion: Patients who have had trabeculectomies augmented with mitomycin C may be predisposed to bleb infection with unusual organisms. Prompt diagnosis and treatment is necessary to control the infection. Increased awareness and communication with laboratory personnel may increase the isolation of this fastidious organism.     

Mitomycin C trabeculectomy in eyes with cicatricial conjunctiva

PURPOSE: To demonstrate favorable outcome of mitomycin C–augmented trabeculectomy in eyes with broad cicatricial conjunctiva created by previous surgeries.METHODS: Forty-six eyes (40 patients) with extensive conjunctival scarring that had undergone mitomycin C trabeculectomy were reviewed retrospectively.RESULTS: After a mean follow-up ± SD of 13.7 ± 7.8 months (range, 6 to 36 months), intraocular pressure was well controlled, below or equal to 16 mm Hg and 21 mm Hg, respectively, in 33 (72%) and 44 (96%) of the 46 eyes. In all eyes, a functional filtering bleb was present during the follow-up periods.CONCLUSION: Mitomycin C trabeculectomy after dissection of conjunctival scar tissue may be useful for treating refractory glaucoma.     

Recurrent bleb infections

AIM—To report the patient characteristics, causative organisms, and clinical outcomes in patients with recurrent bleb related ocular infections.
METHODS—The medical records of all patients diagnosed with bleb related ocular infection at the New York Eye and Ear Infirmary over a 10 year period were reviewed. Recurrent bleb infection was defined as at least two episodes of bleb purulence with or without associated intraocular inflammation separated by a quiescent period of at least 3 months.
RESULTS—Recurrent bleb infections developed in 12 eyes of 12 patients (10 men, two women) a mean of 16.3 (SD 17.9) months (range 3-51 months) after the initial infection. Two patients developed a third episode 3 and 20 months, respectively, after the second infection, yielding a total of 14 recurrent infection episodes. Recurrent infection developed after trabeculectomy in 11 eyes (adjunctive 5-fluorouracil, nine eyes; mitomycin C, one eye; no antifibrosis agent, one eye) and following cataract extraction with inadvertent bleb formation in one eye. Four (36.4%) of the filtered eyes had undergone trabeculectomy at the inferior limbus. The mean follow up time from filtering surgery to the first bleb related infection was 28 months for the nine patients treated with 5-fluorouracil and 14 months for the single patient treated with mitomycin C. 11 (78.6%) cases had a documented bleb leak in the 4 week period before or at the time of recurrent infection. Topical, prophylactic antibiotics had been used in 7/14 (50%) cases. The same organism was cultured from the initial and recurrent infections in 2/14 (14.3%) cases.
CONCLUSION—Eyes that have been successfully treated for bleb related infection remain at risk for recurrent infection. No apparent correlation exists between organisms responsible for the initial and recurrent infections. The increased rate of recurrent bleb related infection in patients receiving adjunctive 5-fluorouracil compared to mitomycin C may have been related to the longer follow up of the 5-fluorouracil eyes.

Keywords: blebs; ocular infections; 5-fluorouracil; mitomycin C     

Supraciliochoroidal fluid in the eyes indicates good intraocular pressure control despite absence of obvious filtering bleb after trabeculectomy

PURPOSE: To examine the presence of supraciliochoroidal fluid (SCF) by ultrasound biomicroscopy in posttrabeculectomy eyes that show good intraocular pressure (IOP) control despite the absence of an obvious filtering bleb. PATIENTS AND METHODS: Eyes were selected retrospectively according to the following criteria: IOP < 15 mm Hg, no antiglaucoma medication, no filtering bleb or a flattened bleb without microcystic spaces, and no ophthalmoscopic choroidal detachment after trabeculectomy with mitomycin C. The SCF was examined using 50-MHz ultrasound biomicroscopy (Zeiss-Humphrey). RESULTS: Ultrasound biomicroscopy detected SCF in five (63%) of eight eyes that met the study criteria. The extent of SCF in two of the eyes was four quadrants and one or two quadrants in three eyes. CONCLUSION: The presence of the SCF may explain increased uveoscleral outflow and may represent an IOP-lowering mechanism after trabeculectomy with mitomycin C, especially when IOP control is good and a filtering bleb is not obvious.     

Foreign body granulomas secondary to retained sponge fragment following mitomycin C trabeculectomy

Background: Bleb related inflammation following trabeculectomy is usually seen in the late post operative period and is unusual in the first 6 months after surgery We report the clinical findings and course of two patients with early bleb related inflammation secondary to retained cellulose sponge fragments used to apply mitomycin C on the scleral surface. Methods: Retrospective review of medical records of two patients and pathology from one patient. Results: Both patients developed bleb related inflammation four months after a combined fornix based trabeculectomy and cataract procedure in which mitomycin C was applied using filter paper discs (Whatman filter paper #1). Material suggestive of cellulose fragments was noted in the filtering bleb in both patients. Patient 1 had a bleb leak at time of presentation and pathologic examination of foreign body material obtained from the site of the leak demonstrated a granulomatous reaction surrounding cellulose fibers. The foreign body material was removed in both patients. This led to resolution of the bleb leak in the first patient and at one year following the procedure both patients had functioning blebs in the affected eye. Conclusions: Retention of sponge fragments is rare but may be a cause of bleb inflammation as a result of a foreign body granulomatous reaction. The choice of sponge material that does not shred may help in avoiding this unusual complication.     

Combination of autologous blood injection and bleb compression sutures to treat hypotony maculopathy

PURPOSE: To report successful use of a combination of autologous blood injection and bleb compression sutures to treat overfiltration with hypotony maculopathy after trabeculectomy with mitomycin C. METHODS: Two patients underwent the combined procedure and were followed until visual acuity and intraocular pressure (IOP) were stable over three consecutive visits (4 to 9 months). RESULTS: Both patients experienced improvement in visual acuity both subjectively and objectively, and both patients had an elevation in IOP that persisted over three consecutive visits. CONCLUSIONS: Combination autologous blood injection and bleb compression suture placement may be an effective means of treating hypotony maculopathy after trabeculectomy with mitomycin C.     

Late bleb-related endophthalmitis after trabeculectomy with mitomycin C

To present two cases of delayed-onset postoperative endophthalmitis following trabeculectomy combined with mitomycin C for secondary glaucoma after penetrating keratoplasty. We retrospectively evaluated two patients with late endophthalmitis after trabeculectomy combined with intraoperative mitomycin C application. Both patients underwent trabeculectomy for uncontrolled glaucoma following penetrating keratoplasty and they developed thin-walled cystic blebs. Intraocular pressure was normal, and grafts remained clear postoperatively. Severe endophthalmitis with hypopyon developed at 3 and 7 months postoperatively. Both patients had concomitant bleb infection. They underwent vitreous sampling and intravitreal injection of vancomycin and amikacin and were given topical fortified and systemic antibiotic therapy. Intravitreal injection was repeated once in both patients. Cultures grew Streptococcus pneumonias in one and Staphylococcus aureus in the other. Although the treatment of endophthalmitis was successful in both patients, only one of them achieved useful vision (20/40). For the other patient who had been infected with S. pneumoniae, vision was light perception. Delayed-onset endophthalmitis following trabeculectomy with mitomycin C application is a severe and vision threatening complication. It seems that the development of thin cystic filtering blebs secondary to intraoperative mitomycin C application may be a predisposing factor for bleb-related late endophthalmitis.     

Prospective study of surgical outcomes and bleb morphology using indocyanine green as a surgical dye in trabeculectomy with mitomycin C

Background: To investigate the effect of adding indocyanine green to mitomycin C in augmented trabeculectomy. Design: A prospective, non‐comparative interventional case series. Participants: A total of 37 eyes of 37 patients followed up for 1 year. Methods: A solution containing 12.5 mg/mL of indocyanine green was added to mitomycin C, resulting in an mitomycin C concentration of 0.2–0.4 mg/mL, which was applied to bare sclera and Tenon's capsule for 3 min during trabeculectomy. Main Outcome Measures: Visual acuity, intraocular pressure, bleb morphology, Moorfields Bleb Grading System scores and complications. Results: Indocyanine green could be visualized on clinical examination for all eyes on the first postoperative day. Mean intraocular pressure decreased from 22.9 ± 6.2 mmHg to 12.1 ± 4.4 mmHg postoperatively (P < 0.001) at 1 year. Thirty‐four eyes (91.9%) achieved an intraocular pressure of less than 21 mmHg at final visit without additional topical intraocular pressure‐lowering medications. Three eyes (8.1%) developed bleb failure andrequired Baerveldt device implantation. There were no cases of blebitis or late bleb leak. No adverse effects attributable to indocyanine green could be identified postoperatively. Conclusion: The addition of indocyanine green during trabeculectomy improves the visibility of antimetabolites intraoperatively and allows for the estimation of antimetabolite treatment area intraoperatively and postoperatively. It appears to have no adverse effect on surgical outcomes and complication rates, while improving safety of antimetabolite use.     

Late-onset blebitis/endophthalmitis: incidence and outcomes with mitomycin C.

PURPOSE: To assess the outcomes of patients who had late infections after undergoing filtering surgery with mitomycin C with respect to treatment, resultant vision, and maintenance of intraocular pressure. METHODS: A retrospective review of 233 eyes that underwent trabeculectomy with mitomycin C with or without coincident cataract extraction and intraocular lens insertion from August 1993 to June 1997 was undertaken. Records were examined for postoperative infection occurring at least 6 months after filtering surgery. Age, sex, date, and type of surgery were reviewed and entered into a computerized database. RESULTS: Bleb infections occurred in 6 of 233 (2.6%) eyes that underwent mitomycin C filtering surgery. Four of these developed endophthalmitis. The average postoperative time until infection was 24.7 months. Two patients had bleb leaks, one of which progressed to endophthalmitis. On resolution of infection, all blebs remained functional, and vision returned to preblebitis acuities in 67%. CONCLUSION: Aggressive topical antibiotic therapy with daily observation may be appropriate in selected cases of late-onset blebitis and endophthalmitis. Eyes may continue to have good visual outcomes and functioning filters without need for additional surgery or hospitalization. Early recognition and appropriate management of infections may play a role in these outcomes.     

Repair of a leaking bleb filtration with conjunctival and amniotic membrane transplantation

CLINICAL CASE: A 71-year-old woman presented with a leaking bleb after a combined phacotrabeculectomy performed 13 years ago. To construct a new filtering bleb, the necrotic area was fully excised. The amniotic membrane was inserted over the scleral flap underneath healthy conjunctiva edges. A conjunctiva-Tenon autograft from the contralateral eye was sutured and was sealed with fibrin adhesive. DISCUSSION: We propose a new surgical technique to repair late leak failures after trabeculectomy with mitomycin C in blebs with a large avascular area. Transplantation of amniotic membrane and conjunctival autograft may be used to repair late leak failures with inadequate conjunctiva to advance.     

Occlusion of the retinal vasculature after trabeculectomy with mitomycin C

A 45-year-old male underwent a trabeculectomy with mitomycin C for a secondary glaucoma after complicated cataract surgery. Because of early bleb failure a needling procedure with subconjunctival injection of mitomycin C was performed. Five days postoperatively the patient developed an occlusion of both the arterial and venous retinal vasculature. A relation between the diffusion of mitomycin C into the vitreous cavity and the development of retinal toxicity is suggested.     

Trabeculectomy with mitomycin C for post-keratoplasty glaucoma

AIM: To investigate the effect of trabeculectomy with and without mitomycin C in post-keratoplasty glaucoma. METHODS: A retrospective study was performed on patients who underwent trabeculectomy for glaucoma after penetrating keratoplasty. 34 eyes of 32 patients were included in this study. 26 eyes received trabeculectomy with mitomycin C and eight eyes without mitomycin C. The procedure was deemed successful if the intraocular pressure was maintained below 21 mm Hg with or without use of additional antiglaucoma medication (mean follow up time 22.3 (SD 10.3) months). RESULTS: At the last examination trabeculectomy was successful in 19 of 26 eyes (73.0%) with mitomycin C (+) and two of eight (25.0%) without (p=0.0219). When the prognosis was analysed by Kaplan-Meier curve, the mitomycin C (+) group showed a better prognosis (p=0.0182). Mean intraocular pressure and average number of glaucoma medications improved in the group with mitomycin C without severe side effects on the graft. Graft rejection after trabeculectomy was seen in two eyes in the mitomycin C group. Final graft clarity rate was 69.2% (18/26) in the mitomycin C (+) group and 37.5% (3/8) in the mitomycin C (-) group. Complications such as persistent epithelial defect, cystoid macular oedema, choroidal detachment, leakage from bleb were seen in four eyes in the mitomycin C (+) group and in one eye in the mitomycin C (-) group. CONCLUSIONS: Trabeculectomy with mitomycin C showed better results for glaucoma following keratoplasty.     

小梁切除联合丝裂霉素治疗外伤继发性青光眼

目的观察小梁切除手术联合丝裂霉素治疗外伤继发性青光眼的临床效果。方法对19例（19眼）外伤继发性青光眼应用小梁切除术治疗,术中联合应用丝裂霉素。术后随访眼压、滤泡形态,视力,以及手术并发症。结果术后眼压均低于术前,滤泡在术后3～7d形成,形态良好。视力较术前有不同程度改善。并发症包括前房积血、浅前房,未出现严重的并发症。结论小梁切除术联合丝裂霉素治疗外伤继发性青光眼是一种安全、有效的治疗方法,在药物治疗无法控制眼压时,可以考虑应用该方法治疗。     

Needle bleb revision of encapsulated filtering bleb with bevacizumab.

The utility of needle bleb revision with bevacizumab in a patient with a failing bleb following trabeculectomy is explored. The patient had previously failed needle bleb revision with mitomycin C. After needling and injection of 1 mg of bevacizumab, the bleb was noted to be more diffuse with a decrease in surface neovascularization. Bevacizumab may be an effective medication for rescuing failing filtering blebs that exhibit neovascularization.     

Amniotic membrane graft for late-onset glaucoma filtering leaks

PURPOSE: To evaluate the effectiveness and safety of amniotic membrane graft in the management of late-onset filtering bleb leaks after trabeculectomy with mitomycin C. DESIGN: Prospective, noncomparative, interventional case reports. METHODS: Two eyes of two patients with late-onset filtering bleb leak received an amniotic membrane graft. RESULTS: In both patients, bleb leaks were closed successfully with amniotic membrane graft, and bleb function was maintained during the follow-up period of 34 and 14 months, respectively. CONCLUSION: Amniotic membrane graft may be considered an alternative method for treating late-onset filtering bleb leaks while maintaining bleb function. As the number of cases was small, more cases need to be accumulated to verify the usefulness of this technique.     

Conjunctival dysfunction and mitomycin C-induced hypotony

PURPOSE: To determine the role of a physically intact conjunctiva in the development of chronic hypotony after mitomycin C-enhanced trabeculectomy. METHOD: Three patients with mitomycin C-related hypotonic maculopathy, but without a leak on Siedel test, had a thorough evaluation of the bleb area and an anterior segment fluorescein angiography. The bleb was excised and a pedicle flap, rotated from the temporal conjunctiva, was sutured to cover the defect superiorly. The scleral flap and its sutures were not disturbed. The excised bleb was subjected to light and electron microscopy. RESULTS: The Seidel test result was negative in all patients, but late phases of the anterior segment angiography showed a generalized seepage of aqueous from the bleb. After revision of the bleb, there was a gradual increase in the intraocular pressure, a reversal of the hypotonic maculopathy, and consequent improvement in visual acuity in all three patients, stable up to a minimum follow-up of 18 months. On histopathologic examination, the basement membrane was thickest under thin areas of the epithelium and thinnest below thicker epithelial layers. CONCLUSION: A dysfunctional conjunctival barrier, as evidenced by the "sweating" of the bleb and histopathologic alterations in the epithelial barrier, could be responsible for the hypotonic maculopathy in these patients. Excision of the conjunctiva alone and replacement by a pedicle conjunctival graft offers a safe and effective method of treating chronic hypotony after mitomycin C-augmented trabeculectomy in such patients.     

Recurrent Endophthalmitis after Trabeculectomy for Glaucoma: Importance of Timely Filtering Bleb Coverage for the Conjunctiva

Purpose

To report the occurrence of endophthalmitis after trabeculectomy for glaucoma that was treated by vitrectomy without bleb closure and recurred 3 times after an initial clinically inapparent period of about 2 years.

Methods

Interventional case report and short review of the pertinent literature.

Results

A 73-year-old Caucasian female underwent trabeculectomy (without mitomycin) for glaucoma. Four years after the trabeculectomy, an endophthalmitis with Staphylococcus epidermidis as the causative organism occurred and was treated with a pars plana vitrectomy (20-gauge) and a combined antibiotic and anti-inflammatory drug regimen. The bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus. As the filtering bleb healed nicely and the filtering function was restored, the filtering bleb was left as it was, and best-corrected visual acuity initially recovered to 0.8. After 22 months, the endophthalmitis recurred, this time with Enterococcus faecalis as the causative organism. Its treatment required a total of four further vitrectomies (23-gauge), each accompanied by the same antibiotic and anti-inflammatory drug regimen that had been applied previously. However, the visual acuity could not be preserved, and the eye is blind with defective light projection.

Conclusions

The literature suggests an aggressive surgical approach to endophthalmitis, and the present case report confirms this. Since the visual prognosis of eyes after endophthalmitis is poor, the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis rather than address glaucoma symptoms and therefore include safe bleb leak coverage.Key words: Glaucoma surgery, Complications, Endophthalmitis, Vitrectomy, Filtering bleb     

小梁切除术中应用隧道刀制作巩膜瓣联合丝裂霉素C的临床观察

目的:探讨在小梁切除术中应用隧道刀制作巩膜瓣联合丝裂霉素C的临床效果。方法:对53例61眼各型青光眼患者行小梁切除术,术中应用隧道刀制作巩膜瓣,并应用0.4g/L丝裂霉素C浸泡,时间2min。结果:随访12mo。术后各时期的眼压与术前眼压比较均有明显下降;功能性滤过泡形成率为93%,无持续性浅前房及低眼压性黄斑病变等严重并发症出现。结论:隧道刀制作巩膜瓣创伤小、时间短,瓣的厚度均匀、表面光滑,联合丝裂霉素C,明显减少了术后滤过道的瘢痕粘连,提高了小梁切除术的手术成功率。     

小梁切除术后薄壁滤过泡的临床及病理分析

目的分析小梁切除术后薄壁滤过泡患者的临床和病理改变,探讨薄壁滤过泡患者低眼压等相关并发症的发生机制。设计回顾性病例系列。研究对象薄壁滤过泡相关并发症患者30例。方法收集1999年1月至2008年9月在中山眼科中心因小梁切除术后薄壁滤过泡相关并发症须行滤过泡加固术的青光眼患者30例。记录患者的眼压及眼部薄壁滤过泡相关并发症的情况,分析患者小梁切除术中丝裂霉素C（MMC）的使用情况。对其中7例患者的滤过泡壁边缘组织行组织病理检查。主要指标眼压、并发症情况、MMC使用情况,滤过泡病理结果。结果患者行滤过泡加固术时距小梁切除术时间为5个月－9年（平均49．0±33-3个月）。患眼眼压2．7～11．0mmHg,平均（4．40±4．49）mmHg。低眼压21例（70％）,滤过泡渗漏18例（60％）,浅前房2例（6．7％）,低眼压性黄斑水肿7例（23．3％）,巨大薄壁滤过泡5例（16．7％）,滤过泡赘生至角膜上皮下4例（13．3％）,滤过泡炎5例（16．7％）,眼内炎2例（6．7％）。所有患者均有小粱切除术中MMC使用史。使用较高浓度MMC（≥0．286mg/ml）的患者占53．33％。病理结果显示,滤过泡结膜上皮变性,厚薄不均,局部萎缩变薄甚至上皮缺如。上皮下纤维结缔组织变性、增生或结膜下疏松、囊腔样的纤维组织;结膜上皮内生,上皮下形成囊样腔隙。结论小梁切除术后薄壁滤过泡可引起一系列眼部严重并发症,MMC造成的局部结膜上皮变薄或缺如是其低眼压的主要原因;滤过泡结膜下组织结构的破坏及上皮内生在其低眼压的发病中起一定作用。