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.     

Autologous conjunctival resurfacing of leaking filtering blebs

PURPOSE: To present a case series of a new technique to repair late bleb leaks. DESIGN: Retrospective, noncomparative, consecutive case series. PARTICIPANTS: Forty-seven autologous conjunctival resurfacings of late bleb leaks were performed by four surgeons at two institutions. METHODS: Autologous conjunctival grafts were placed over existing de-epithelialized leaking blebs. MAIN OUTCOME MEASURES: Leak-free, Seidel-negative blebs and controlled glaucoma. RESULTS: After a mean follow-up of 14 +/- 12 months, one patient continued to have bleb leak at the last follow-up, and one frank leak resolved with aqueous suppression. Intraocular pressure increased from 6.6 +/- 4.4 mmHg (0.13 glaucoma medications) to 11.9 +/- 4.1 mmHg (0.41 glaucoma medications). CONCLUSIONS: Conjunctival resurfacing with autologous tissue is an effective technique to repair late bleb leaks.     

Surgical management of a dysfunctional filtering bleb

This case report presents a patient who developed a large overhanging bleb following antimetabolite trabeculectomy surgery 6 years prior. Complaints included decreasing vision and foreign body sensation for several months. Successful excisional surgery with placement of compression sutures was performed. Visual acuity and intraocular pressure were maintained with the resolution of symptoms.     

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     

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.     

Histopathology in a dissecting conjunctival filtering bleb

CASE REPORT: Four years after trabeculectomy, a patient developed unilateral tearing and presented with an ipsilateral conjunctival filtering bleb that had dissected into the cornea. The corneal portion of the bleb was excised for symptomatic relief. Histopathological examination disclosed dissection of the conjunctival filtering bleb into the cornea between Bowman's layer and the corneal epithelium. The internal portion of the bleb consisted of loose stromal tissue lacking any internal epithelial lining. COMMENTS: A conjunctival bleb dissecting into the cornea is a well-described late complication of trabeculectomy; however, its pathophysiology remains controversial. The subepithelial dissection plane in this specimen supports the concept that the conjunctival filtering bleb may dissect into, as well as "overhang", the limbal cornea.     

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.     

青光眼滤过术后异常滤过泡的临床治疗观察

目的 探讨青光眼滤过术后异常滤过泡的特点及处理方法.方法 对我院2006年1月至2007年12月青光眼滤过术后26例(26只眼)异常滤过泡进行回顾性分析.结果 25只眼异常滤过泡经治疗后转化为功能性滤过泡(眼压控制在正常水平).结论 青光眼术后滤过泡功能障碍通过及时正确处理,可使大部分非功能性滤过泡转化为功能性滤过泡,提高手术成功率.     

丝裂霉素C结膜下注射联合针拨治疗功能不良滤过泡

目的：探讨丝裂霉素C（ mitomycin C,MMC）结膜下注射联合针拨治疗青光眼小梁切除术后功能不良滤过泡的疗效。方法：对36例39眼因青光眼行小梁切除术后2～12 wk滤过泡功能不良者进行MMC 0．1mL（0．2mg／mL）结膜下注射联合针拨治疗,平均治疗1．31±0．58次,观察眼压、滤过泡和并发症．并随访3 mo。
　　结果：治疗后3mo时平均眼压为15．8±6．6mmHg,显著低于治疗前平均眼压27．4±5．7 mmHg;成功滤过泡32眼,成功率为82．1％。结膜下出血7眼,浅前房低眼压1眼,无伤口渗漏和脉络膜渗漏等并发症。
　　结论：MMC结膜下注射联合针拨治疗小梁切除术后功能不良滤过泡是安全、简单、有效的方法。     

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.     

针拨联合球结膜下注射丝裂霉素C治疗功能不良滤过泡

目的 探讨针拨联合丝裂霉素C(mitomycin C,MMC)球结膜下注射治疗青光眼患者小梁切除术后早期功能不良滤过泡的疗效.方法 对47例(50眼)小梁切除术后2～8周滤过泡功能不良青光眼患者行针拨联合MMC 0.2 mL(0.04 mg)结膜下注射,术后所有患者随访3～6个月,观察患者眼压、滤过泡形态和并发症.结果 小梁切除术后2～8周,低平、限局、肥厚、充血型滤过泡32眼、包囊型囊样滤过泡18眼.针拨联合MMC结膜下注射治疗后3～6个月,46眼的滤过泡转为功能性的,轻度膨隆弥散型31眼,多腔或薄壁型15眼,限局肥厚型或无滤过泡4眼.治疗前患眼的平均眼压为(28.5±6.5)mmHg(1 kPa=7.5 mmHg),随访3～6个月平均眼压为(16.3±2.9)mmHg,与注射前比较二者差异有统计学意义(P<0.05).46眼没有用抗青光眼药物或用一种抗青光眼药物眼压控制在21 mmHg以下,成功率占92%.治疗后视物模糊10眼,结膜下出血6眼,角膜上皮点状脱落2眼,无低眼压、伤口渗漏和前房变浅等并发症.结论 针拨联合MMC结膜下注射治疗小梁切除术后早期功能不良滤过泡是安全、有效、简单的方法.     

针拨联合丝裂霉素C结膜下注射治疗抗青光眼术后失败滤过泡

目的:观察利用针拨联合丝裂霉素C结膜下注射治疗抗青光眼术后失败滤过泡的效果。方法:对抗青光眼小梁手术后3~22wk失败滤过泡34例(35眼)用针拨联合丝裂霉素C滤过泡旁注射,并随访6mo以上,观察滤过泡重新形成和眼压下降情况。结果:成功29例(29眼),手术前平均眼压为23.74±6.2mmHg,手术后眼压平均为13±4.3mmHg。其中3例(3眼)重复针拨、注射。随访期结束后统计针拨前后眼压具有显著性差异,Kaplan-Meier生存分析2a滤过泡成功率82.9%±6.4%。针拨术中有4眼前房出血,2眼低眼压,未见丝裂霉素的其它毒性反应。结论:针拨联合丝裂霉素C结膜下注射可以重新建立功能性滤过泡,有效地控制眼压,减少青光眼患者再次手术的痛苦。它是挽救抗青光眼术后失败滤过泡的一种良好的方法,具有毒性小、安全可重复的特点。     

丝裂霉素C结膜下注射治疗青光眼小梁切除术后功能不良滤过泡的临床观察

目的观察丝裂霉素C(MMC)结膜下注射对青光眼小梁切除术后早期功能不良的滤过泡的临床效果。方法对114例(122只眼)青光眼患者术后1～8周内滤过功能不良的滤过泡行丝裂霉素C(MMC)结膜下注射,每天结膜下注射一次,共3～7次,MMC浓度为0.004%,配合每天眼部按摩2～3次,观察滤过泡弥散隆起的情况,前房深浅的变化,随访3～6个月。结果122只眼丝裂霉素C(MMC)结膜下注射前:低平限局肥厚充血型92只眼、包囊型囊样30只眼。MMC结膜下注射后滤过泡外观形态:轻度膨隆弥散型84只眼,多腔或薄壁型24只眼,限局肥厚型或无滤过泡14只眼。结膜下注射前患眼的眼压为(28.6±2.1)mmHg,结膜下注射后患眼的眼压为(15.1±2.3)mmHg。结论对于青光眼小梁切除术后早期功能不良的滤过泡采用结膜下注射丝裂霉素C(MMC)联合眼部按摩是安全、有效及简便的处理方法。     

丝裂霉素C联合针刺分离治疗无功能滤过泡的疗效

目的 对青光眼滤过术后功能不良滤过泡行丝裂霉素C(mitomycin C,MMC)球结膜下注射联合针刺分离术,观察其疗效.方法 对25例(27眼)青光眼术后滤过功能不良患者行MMC球结膜下注射联合针刺分离术,观察眼压、滤过泡及不良反应.结果 术后随访6～48个月,平均(23.0±9.7)个月.术后3个月眼压均有下降(P<0.01),其中16眼达到成功标准,成功率59.3%,7眼为部分成功,占25.9%,4眼失败,占14.8%.结论 球结膜下注射MMC联合针刺分离术对青光眼小梁切除术后功能不良滤过泡是一种安全、有效及相对简便的处理方法 .(中国眼耳鼻喉科杂志,2009,9:150-152)     

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.     

Results of medical management and mitomycin C-augmented excisional bleb revision for encapsulated filtering blebs

BACKGROUND AND OBJECTIVE: To assess the outcome of medical management and mitomycin C (MMC)-augmented excisional bleb revision (EBR) for encapsulated filtering blebs. PATIENTS AND METHODS: The author conducted a retrospective study of 503 patients who had undergone trabeculectomy performed over a 5 year period, followed up for at least one year, in order to identify the encapsulated filtering blebs. Mitomycin C-augmented (0.4mg/ml for 3 minutes) EBR was performed in cases of failed medical therapy for managing encapsulated blebs consisting of antiglaucoma medications, topical steroids, and digital compression. RESULTS: An encapsulated bleb developed in 18 eyes (3.6%) of 503 patients. Identification of bleb encapsulation occurred at a mean follow-up time of 24.2 +/- 10.4 days after surgery. The mean intraocular pressure (IOP) at that point was 30.4 +/- 11.7 mmHg in the affected eyes. Fifteen (83.3%) of 18 eyes responded to conservative management and 3 eyes (16.7%) required MMC augmented EBR. The mean IOP reduced from 30.4 +/- 11.7 mmHg to 14.2 +/- 4.2 mmHg after a mean follow-up of 37.6 +/- 11.4 months in the conservative management group, while it reduced from 37.3 +/- 23.4 mmHg to 12.0 +/- 4.4 mmHg after a mean follow-up of 42 +/- 6 months in the surgically treated group. None of the surgically treated eyes developed MMC-related complications. CONCLUSION: Conservative management is very effective in the treatment of encapsulated filtering blebs. The intraoperative use of MMC is a safe and effective adjunct in EBR in cases where conservative management has failed.     

Long-term outcomes of blebs repaired with scleral patch graft and conjunctival advancement in late-onset leak post-trabeculectomy

Purpose:To report long-term outcomes in eyes that developed late-onset bleb leak post trabeculectomy, with or without hypotony and/or maculopathy, due to a scleral melt/fistula and who required a scleral patch graft and conjunctival advancement for repair.Methods:Retrospective, non-comparative, interventional case series over a decade (2010–2019), presenting with late bleb leak post-filtration-surgery. All cases required a scleral patch graft and conjunctival advancement for management via a standard technique, performed by an experienced glaucoma surgeon.Results:A total of 18 eyes were included. Mean age was 51.5 ± 10.2 years (95% CI [46.4–56.7]) and were followed up after repair for 52.4 ± 26.9 months, 95%CI [39.1–65.8]. 66.7% eyes (n = 12) had IOP ≦6 mmHg and also had hypotony maculopathy. None of the eyes presented with blebitis. 44.5% (n = 8) eyes underwent phacoemulsification as significant cataract was present. LogMAR best-corrected visual acuity (BCVA) was 0.8 ± 0.7 (95% CI [0.4–1.1]) prior to intervention and improved to 0.4 ± 0.6 (95% CI[0.1–0.6], P = 0.004). 22.3% (n = 4) eyes had persistent choroidal folds but BCVA was improved. Mean pre-intervention intraocular pressure (IOP) was 6.3 ± 3.8 mmHg (95% CI 4.4–8.2]) which increased to 12.1 ± 2.9 mmHg (95%CI[10.6–13.5], (P < 0.001). 27.8% (n = 5) eyes needed laser suture lysis post repair to control IOP; two needed further surgical intervention. Number of anti-glaucoma medications at last follow-up was 0.4 ± 0.9 (95% CI [−0.1–0.8], P = 0.09). No serious complications were encountered.Conclusion:Scleral patch graft and conjunctival advancement is a useful technique for repair of a scleral fistula post-filtering surgery, and this is recommended not only for the restoration of anatomy for prevention of infection and control of IOP, but also for visual rehabilitation.     

Conjunctival vasculature patterns influencing the filtering bleb shape following trabeculectomy with limbal-based conjunctival flaps

Purpose  

To investigate the correlation between conjunctival vasculature factors and two types of functional bleb shape, cystic and diffuse, formed after trabeculectomy with limbal-based conjunctival flaps.     

Efficacy of autologous conjunctival flap on repairing the late-onset filtering bleb leakage

AIM: To evaluate the effectiveness of autologous conjunctival flap surgery for repairing the late-onset filtering bleb leakage after trabeculectomy. METHODS: This study retrospectively reviewed 106 eyes from 106 patients with late-onset filtering bleb leakage after trabeculectomy who received autologous conjunctival flap surgery at the Zhongshan Ophthalmic Centre from 2005 to 2015. The basic information was recorded, and the interval time between trabeculectomy and autologous conjunctival flap surgery as well as related risk factors, intraocular pressure (IOP), anterior chamber depth (ACD) and best corrected visual acuity (BCVA) were analysed. Moreover, 41 patients who completed the 1-year follow up were analysed to determine the IOP and BCVA changes and long-term success rates. RESULTS: The 50 male and 56 female subjects (average age 39.13±17.96y) included 47 (44.34%) and 33 (31.13%) cases of primary open angle and primary angle-closure glaucoma. The mean interval between trabeculectomy and repair surgery was 60.60±56.92 (3-264)mo. The mean mitomycin (MMC) concentration during trabeculectomy was 0.27±0.04 (0.12-0.4) mg/mL in the fornix-based conjunctival flap group (68 patients) and 0.28±0.04 (0.20-0.33) mg/mL in the limbal-based conjunctival flap group (11 patients). After bleb leakage, the patients'' vision remained stable while the IOP decreased from 10.25±4.76 (3-20.86) to 9.44±4.33 (2-21) mm Hg (P<0.01). In the 41 analysed patients, the IOP was controlled at 15.68±5.11 (7-40) mm Hg in the 1st year after autologous conjunctival flap surgery and recurrence was not observed, for a long-term success rate of 100%. CONCLUSION: Autologous conjunctival flap repairing surgery is an effective technique for sealing filtering bleb leakages and controlling IOP postoperatively.