Autologous blood injection for late-onset filtering bleb leak

Maculopathies in Glaucoma

In the presence of glaucoma, various changes in the macula can occur during the course of the disease itself or its treatment. Maculopathies that can be observed in glaucoma include cystoid macular edema, hypotony maculopathy, and microcystic macular edema. The following article discusses the pathophysiology, causes, course, clinical presentation, and treatment of these maculopathies.

Outcomes of bleb revision with ologen following filtering glaucoma surgery

PURPOSE

This study reports long-term outcomes of bleb revision with ologen™ Collagen Matrix (Aeon Astron Europe BV, the Netherlands) for the surgical management of various bleb-related issues including persistent bleb leaks with or without associated hypotony, bleb dysesthesia, overhanging blebs, or hypotony after filtering glaucoma surgery.

MATERIALS AND METHODS

A retrospective chart review was performed for patients who underwent ologen bleb revision from 2012 to 2019 at Glaucoma Associates of Texas.

RESULTS

The study included 23 eyes of 22 patients undergoing bleb revision with the ologen implant. Mean age was 74.0 ± 11.3 years, 16 (69.6%) were female, and 13 (56.5%) were White. Indications for bleb revision included bleb leak (78.3%), dysesthesia (13.0%), and hypotony from an overfiltering bleb (8.7%). Mean preoperative intraocular pressure was 6.8 ± 4.1 mmHg and the number of medications was 0.3 ± 0.9. Median follow-up was 24 months (range: 12-84 months); all patients had at least 12 months of follow-up. At 1 year, mean intraocular pressure was 10.9 ± 4.6 mmHg on 0.2 ± 0.5 medications, and at last follow-up, mean intraocular pressure was 10.4 ± 3.6 mmHg on 0.3 ± 0.7 medications. Bleb morphology remained low, diffuse, and posterior. One patient developed kissing choroidal effusions requiring surgical drainage with subsequent stabilization of intraocular pressure and bleb function, and three patients required additional surgery due to persistent leaks or bleb failure; there were no other vision-threatening complications.

CONCLUSIONS

Use of the ologen implant during surgical bleb revision is a useful surgical technique that confers long-term improvements in bleb morphology and stability of function.

Recurrent Choroidal Detachment in Peritoneal Dialysis Patient with Hypervolemia and Dilutional Hypoalbuminemia: A Case Report

The following presents a case of recurrent choroidal detachments (CD) correlated with changes in serum albumin levels and the patient's fluid status. A 71-year-old female patient presented with a four-day history of blurry vision in her left eye. Pertinent medical history included end-stage renal disease treated with continuous ambulatory peritoneal dialysis. Previously, the patient's left eye was treated for primary angle-closure glaucoma by trabeculectomy. While this resulted in a low baseline intraocular pressure (IOP) of 2-7▒mmHg, the patient never developed any hypotony-related complications for the past six years. After examination, CD was diagnosed and treated with transscleral surgical drainage. The patient further developed two additional episodes of CD in the same eye. All episodes were also associated with bilateral pitting edema, weight gain, and hypoalbuminemia. Thus, the patient was recommended to take a protein supplement and limit her fluid intake. Additionally, the dialysis treatment regimen was altered to achieve greater daily fluid removal. After 12 weeks, there was no recurrent episode of CD, and the patient was clinically stable with a final visual acuity of 20/30 and an IOP of 3▒mmHg. The serum albumin levels improved slightly, and there were no signs of hypervolemia. In this case of recurrent CD, a possible association between the development of CD, hypoalbuminemia, and hypervolemia in patients with end-stage renal disease is demonstrated. Clinicians should be aware that these systemic factors can be tied with recurrent CDs, especially among patients with a low baseline IOP.

The feasibility of finger prick autologous blood (FAB) as a novel treatment for severe dry eye disease (DED): protocol for a randomised controlled trial

INTRODUCTION

Patients with severe dry eye disease (DED) often have limited treatment options with standard non-surgical management focused on the use of artificial tears for lubrication and anti-inflammatory drugs. However, artificial tears do not address the extraordinary complexity of human tears. Crudely, human tears with its vast constituents is essentially filtered blood. Blood and several blood-derived products including autologous serum, have been studied as tear substitutes. This study proposes to test the use of whole, fresh, autologous blood obtained from a finger prick for treatment of severe DED.

METHODS AND ANALYSIS

The research team at the two participating sites will approach patients with severe DED for this study. Recruitment will take place over 12 months and we expect to recruit 60 patients in total. The primary outcome of this feasibility study is to estimate the proportion of eligible patients approached who consent to and comply with study procedures including treatment regimen and completion of required questionnaires. The secondary outcome measures, although not powered for in this feasibility, include corneal inflammation (assessed by the Oxford corneal staining guide), patient pain and symptoms scores (assessed by the Ocular Surface Disease Index Score), and objective signs of DED as indicated by visual acuity (assessed by Schirmer's test, tear break-up time, lower and/or upper tear meniscus height measurement). Other secondary outcomes include patients' quality of life (assessed using the validated EQ-5D-5L Questionnaire), cost to the National Health Service (NHS) and patient (assessed via use of NHS services and privately purchased over-the-counter treatment related to DED) and safety measure of pressure within the eye (assessed by the Intraocular Pressure (IOP) Score).

ETHICS AND DISSEMINATION

This protocol and any subsequent amendments, along with any accompanying material provided to the participant in addition to any advertising material used in this trial have been approved by the East of England - Cambridgeshire and Hertfordshire Research Ethics Committee (REC reference: 17/EE/0508). Written approval from the committee was obtained and subsequently submitted to the respective Trust's Research and Development (R&D) office with final NHS R&D approval obtained. Data obtained from this study will be published in a suitable peer-review journal and will also presented at international ophthalmic conferences including the American Academy of Ophthalmology, the Royal College of Ophthalmology Annual Congress, the Association for Research and Vision and Ophthalmology, and the European Society of Cataract and Refractive Surgery. Information will be provided to patient groups and charities such as the Sjogren's Society and the Royal National Institute of Blind People. This will also be shared with the study participants as well as with relevant patient groups and charities.

TRIAL REGISTRATION NUMBER

NCT03395431; Pre-results.

Treatment of chronic and extreme ocular hypotension following glaucoma surgery with intraocular platelet-rich plasma: A case report

PURPOSE

To report a new approach for the treatment of severe ocular hypotony secondary to glaucoma filtering surgery with mitomycin C by injecting autologous eye platelet-rich plasma (E-PRP) in the anterior chamber to block excessive diffuse filtration through an abnormally thinned sclera.

METHODS

A 49-year-old patient with the Axenfeld-Rieger syndrome and severe chronic hypotony and corneal edema following filtering glaucoma surgery with mitomycin C received an isolated injection of 0.3 mL of autologous platelet-rich plasma in the anterior chamber.

RESULTS

Intraocular pressure measured by Goldman's applanation tonometry 6 h after the procedure improved to 18 mmHg. Intraocular pressure remained stable along the full follow-up period of 6 month. No filtration or hypotony or any other complications were observed.

CONCLUSION

Intracameral platelet-rich plasma (E-PRP) injection was an effective, rapidly effective, and safe procedure for treatment of severe chronic ocular hypotony following glaucoma filtrating surgery.

Shallow Anterior Chamber After Trabeculectomy: Risk Reduction by Use of Removable Compression Sutures

PURPOSE

To evaluate the risk of shallow anterior chamber after trabeculectomy with removable compression sutures.

METHODS

A total of 263 eyes affected by primary open-angle glaucoma that was unresponsive to medical treatments were divided into 2 groups: 126 eyes were treated with conventional trabeculectomy (group A) and 137 with a modified surgery technique using 3 removable compression 10-0 nylon sutures (group B). All the participants received intraoperative antimetabolites (mitomycin 0.04%). Increased intraocular pressure (IOP) of >14 mm Hg in the eyes of group B patients was followed by removal of compression sutures. Best corrected visual acuity, slit lamp examination, IOP, and anterior chamber depth were evaluated 1, 7, 30, 60, 90, and 180 days after surgery.

RESULTS

On the first postoperative day, 12 eyes from group A (9.5%) exhibited a shallow anterior chamber with marked hypotony and no eyes in group B showed flat anterior chamber at any control evaluation (P<0.001). The day after surgery, group A showed a mean IOP of 5.3 mm Hg (± 2.02), whereas group B had a mean of 7.4 mm Hg (± 2.10). At 7 days postoperation, the values for IOP were 10.95 (± 1.55) and 11.7 mm Hg (± 1.66) in groups A and B, respectively. One month later, mean IOP was 11.05 mm Hg (± 1.08) for group A and 13.9 mm Hg (± 3.26) for group B. The surgeon removed the compression sutures from all eyes with IOP>14 mm Hg (90%). The day after suture removal, mean IOP decreased to 10.45 mm Hg (± 1.37). There was no significant statistical difference in visual acuity between the 2 groups at any point during follow-up (P>0.001). At 180 postoperative days the difference in mean IOP between the 2 groups was statistically significant (P<0.001).

CONCLUSIONS

The application of removable corneoscleral compression sutures during trabeculectomy reduced the risk of postoperative shallow anterior chamber and allowed for safe IOP control after the procedure giving further postoperative chance to reduce the intraocular pressure.

Bleb revision for resolution of hypotony maculopathy following primary trabeculectomy

PURPOSE

To describe a surgical method of bleb revision for hypotony maculopathy, to evaluate its long-term efficacy, and to define the relationship between the duration of hypotony maculopathy and visual acuity (VA) outcomes.

DESIGN

Noncomparative retrospective case series.

METHODS

Medical records of 33 patients with hypotony maculopathy who underwent primary bleb revision between June 1999 and September 2012 by a single surgeon at an academic medical center were reviewed. Hypotony maculopathy was characterized by the presence of a decrease in VA, retinal striae, and macular edema in the setting of decreased intraocular pressure (IOP) after glaucoma filtering surgery. The main outcome measure was final logMAR VA after bleb revision at 6 and 12 months.

RESULTS

Thirty-three eyes of 33 patients were followed for 4.68 ± 3.56 years (range 0.55-12.69 years). Mean duration of hypotony maculopathy was 4.98 ± 8.93 months. LogMAR VA improved from 0.78 ± 0.40 at baseline to 0.34 ± 0.34 (P < .001) 6 months after bleb revision and to 0.45 ± 0.55 (P < .001) 12 months after bleb revision. Spearman rank coefficient (rs) correlating duration of hypotony and BCVA at both 6 and 12 months was significant (P = .015 and rs = 0.426, P = .028 and rs = 0.416, respectively). Mean IOP increased from 3.51 ± 2.27 mm Hg to 12.06 ± 4.06 mm Hg (P < .001) at 12 months. Fifty-two percent were on no antiglaucoma medications at last follow-up. Five eyes (15%) required a second bleb revision to correct persistent hypotony maculopathy.

CONCLUSION

Surgical repair for hypotony maculopathy provided a significant improvement in VA at 6 and 12 months. Surgical bleb revision is associated with good long-term control of IOP and improved VA in eyes with hypotony maculopathy after previous glaucoma filtering surgery.

Secondary subconjunctival implantation of a biodegradable collagen-glycosaminoglycan matrix to treat ocular hypotony following trabeculectomy with mitomycin C

AIM

Biodegradable collagen glycosaminoglycan matrices (CGM) have been introduced to glaucoma filtration surgery in order to prevent scarring of the filtering bleb. In this retrospective case series, we describe a new surgical concept for treating symptomatic ocular hypotony following filtration surgery with mitomycin C by a secondary subconjunctival implantation of a CGM.

METHODS

Depending on bleb morphology, a CGM implant with a diameter of 6 or 12 mm was placed subconjunctivally on the scleral flap in 12 eyes displaying symptomatic ocular hypotony with (n=2) or without (n=10) bleb leakage. Median period between trabeculectomy and this intervention was 4.5 months (range, 1-72 months).

RESULTS

Mean intraocular pressure significantly increased from 4.4±1.4 mm Hg to 9.9±2.8 mm Hg (p<0.0001) over a median follow-up of 6 months (range, 2-18 months). Mean visual acuity improved significantly (p=0.0012). Postoperative complications included implant re-exposure in one eye and persistent choroidal detachment requiring resurgery in another eye.

CONCLUSIONS

Subconjunctival implantation of CGM may present an additional surgical tool in the treatment of symptomatic ocular hypotony after filtering surgery. The mechanism of action may be counter-pressure to the scleral flap and secondary wound healing around the CGM scaffold. Long-term observations are needed to fully evaluate this new surgical concept.

Interventions for late trabeculectomy bleb leak

BACKGROUND

Late trabeculectomy bleb leaks are a common complication after filtering glaucoma surgery. Although asymptomatic, late bleb leaks may lead to hypotony and are associated with bleb related infections.

OBJECTIVES

To assess the effects of interventions for late trabeculectomy bleb leak.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), MEDLINE (January 1946 to July 2012), EMBASE (January 1980 to July 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 18 July 2012.

SELECTION CRITERIA

We included randomised and quasi-randomised trials in which any treatments for eyes with late bleb leak (interventional and non-interventional) were compared with each other.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors when additional information was needed.

MAIN RESULTS

The review included one multicentre trial based in the USA with 30 eyes of 30 participants. The trial compared two surgical procedures (conjunctival advancement and amniotic membrane transplant) to cover a filtering bleb leak. Conjunctival advancement has been shown to be more effective in sealing filtering bleb leaks.

AUTHORS' CONCLUSIONS

Although a variety of treatments have been proposed for bleb leaks, there is no evidence of their comparative effectiveness.The evidence in this review was provided by a single trial that compared two surgical procedures (conjunctival advancement and amniotic membrane transplant). The trial did show a superiority of conjunctival advancement, which was regarded as standard treatment, to amniotic membrane transplantation. There is a need for more randomised trials to validate the findings of this single trial and provide more information on the different types of interventions, especially non-surgical treatments compared to surgical procedures. We recommend that any intervention should be compared to a standard procedure, which is to date conjunctival advancement.

Complications of inadvertent filtering blebs after cataract extraction

We report 2 cases of inadvertent filtering blebs that developed vision-threatening complications many years after uneventful cataract extraction with scleral incisions. These inadvertent blebs can create complications similar to the intentionally produced blebs from trabeculectomy surgery; thus, follow-up and management should be handled in a similar manner.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Effect of excision of avascular bleb and advancement of adjacent conjunctiva for treatment of hypotony

PURPOSE

To evaluate the efficacy of excision of avascular bleb and advancement of adjacent conjunctiva (EBAC) for treatment of hypotony after trabeculectomy with mitomycin C (MMC).

METHODS

Fifteen patients (17 eyes) who received EBAC for correction of hypotony between September 1996 and October 2008 were reviewed retrospectively. The main outcomes were intraocular pressure (IOP) and postoperative complications.

RESULTS

Hypotony (IOP <6 mmHg) of eight eyes (47.1%, seven patients) was caused by bleb perforation. Of these, two eyes (two patients) had a history of trauma. Hypotony appeared at 33.9+/-30.8 months, and EBAC was performed at 48.2+/-35.3 months after trabeculectomy with MMC. The mean follow-up period was 38.3+/-29.8 months. The qualified success rate of EBAC was 100% at 51 months after EBAC, and the complete success rate of EBAC was 76.5% at six months and 70.6% at 51 months, as determined by Kaplan-Meier analysis. Post-EBAC complications included blepharoptosis in four eyes (23.5%) and bleb perforation in one (5.9%). The blepharoptosis resolved within one month after EBAC in two patients. However, in the other patients, mild blepharoptosis remained at 17 and 22 months postoperatively.

CONCLUSIONS

EBAC was found to be an effective method for treatment of hypotony after trabeculectomy with MMC, and postoperative blepharoptosis was a major complication.

Surgical revision of dysfunctional filtration blebs with bleb preservation, sliding conjunctival flap and fibrin glue

PURPOSE

The introduction of anti-metabolite regimens to glaucoma filtration surgery has improved post-operative intraocular pressure (IOP) control; however, it has also increased the frequency of dysfunctional blebs. In this study, we report a surgical technique for the repair of trabeculectomy blebs using bleb preservation, a sliding conjunctival flap, and fibrin glue.

METHODS

This study is a retrospective, non-comparative, consecutive case series involving 10 eye samples collected from 10 patients (6 M : 4 F) with one or a combination of bleb overfiltration, dysesthesia, thinning, leak, or blebitis, in which a conjunctival flap was advanced over the failing bleb and secured in place using fibrin glue and sutures.

RESULTS

All patient eyes had symptom resolution post-operatively. There were no bleb leaks or hypotonous eyes after an average follow-up of 15.2 months (range: 6-31 months). Three patients required needling augmented with 5-fluorouracil needling to maintain IOP control. IOP decreased from a mean of 13.6+/-1.8 mm Hg (with a mean of 0.7 glaucoma medications) pre-operatively to 11.7+/-0.9 mm Hg (with a mean of 0.9 glaucoma medications).

CONCLUSION

Conjunctival flap advancement with bleb preservation and adjunctive fibrin glue is a successful technique used for the treatment of bleb dysfunction. The major advantages compared with other techniques are preservation of IOP control and reduced post-operative complications, such as wound leak and the need for re-suturing.

Outcomes of surgical bleb revision for complications of trabeculectomy

OBJECTIVE

To describe the results of revision surgery for complications of trabeculectomy in a case series from an academic glaucoma service.

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 177 eyes of 167 adult patients who underwent revision of trabeculectomy at the Wilmer Eye Institute between 1994 and 2007.

METHODS

Three indications for surgery were identified: hypotony without leak, bleb leak, and bleb dysesthesia. Revision was deemed successful when all of the following were true: the primary indication was eliminated, further intraocular pressure (IOP)-lowering surgery was not required, no major complication occurred, and a new bleb-related problem did not develop. Patients with less than 3 months of follow-up were excluded unless failure occurred earlier. Surgical procedures included variations on excision of thin or leaking conjunctiva with advancement.

MAIN OUTCOME MEASURES

Change in IOP, change in visual acuity, need for further IOP-lowering surgery, and complications after bleb revision.

RESULTS

Subjects' mean age was 67+/-14 years, 54% were female, and mean follow-up was 2.8+/-2.7 years, with a mean interval from trabeculectomy to revision of 3.5+/-3.7 years. Overall success rate was 63% (112/177), which was slightly higher for leak repair (65%; 64/98) and hypotony (63%; 32/51) than for dysesthesia (57%; 16/28) indications. By Kaplan-Meier analysis, overall cumulative success rates at 1, 2, 5, and 10 years after bleb revision were 80%, 75%, 50%, and 41%, respectively. IOP and visual acuity improved significantly in both hypotony and leak groups (P values ranging from 0.004 to <0.0001). Additional IOP-lowering surgery was required in 9%. In multivariate regression analysis adjusting for age, gender, and number of prior surgeries, patients with glaucoma other than primary open-angle glaucoma were twice as likely to have failed bleb revision.

CONCLUSIONS

Surgical bleb revision often provides successful resolution of bleb-related complications. Most patients maintain IOP control without need for further IOP-lowering surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Long-term results of amniotic membrane transplantation-assisted bleb revision for leaking blebs

BACKGROUND

To report long-term results of amniotic membrane transplantation (AMT)-assisted bleb revision for intractable late-onset bleb leak.

METHODS

Retrospective medical record review of six consecutive patients who underwent AMT-assisted bleb revision for late-onset bleb leak at the Kobe University hospital between December 2001 and March 2004.

RESULTS

The median (range) of age was 60 (20-77) years. All patients had a history of trabeculectomy with adjunctive use of 0.4 mg/ml mitomycin C. The median (range) of interval between the prior trabeculectomy and bleb leak was 15 (4-54) months. Preoperative intraocular pressure (IOP) was lower than 10 mmHg in two cases, while it was 25 mmHg or higher in three patients, who had a localized, ischemic, thin-wall leaking bleb circumscribed with extensively scarred tissue. The median (range) of follow-up after the AMT-assisted bleb revision was 49 (41-67) months. Postoperative IOP was well controlled in all patients without medication or with a maximum of three glaucoma medications. No patients presented recurrence of the bleb leak or AMT-related complications during entire follow-up. All patients showed at final visit a diffuse bleb which extended posteriorly beyond the conjunctival incision line.

CONCLUSION

AMT-assisted bleb revision successfully treated intractable late-onset bleb leak. Further comparative studies are needed to confirm the present result.

Use of topical human amniotic fluid in the treatment of acute ocular alkali injuries in mice

PURPOSE

To evaluate the efficacy of topical human amniotic fluid (HAF) in the treatment of ocular acute alkali burns in mice.

DESIGN

Experimental study.

METHODS

A chemical burn with 2 microl of sodium hydroxide 0.15 mol/l was created in one eye of 30 mice. The animals were divided into gender- and age-matched groups according to the topical treatment that was administered: group 1 was treated with preterm HAF (n = 10 mice); group 2 was treated with term HAF (n = 10 mice), and group 3 was treated with saline solution (n = 10 mice). Treatment consisted of one drop that was applied to the burned eye five times per day (week one), and three times per day (week two). The epithelial defect was photographed and measured on days two and four. Ocular burn damage was assessed at days two, seven, and 14 after a pre-established classification. On day 14, both eyes of each mouse were enucleated and assessed histopathologically.

RESULTS

Median epithelial defect (interquartile range [IQR], 25th, 75th percentile) at day four was 9.93% (IQR, 8.57, 11.27) for group 1, 7.30% (IQR, 5.96, 8.97) for group 2, and 18.92% (IQR, 11.71, 27.64) for group 3 (P < .0076). The overall change (difference in slope) in ocular burn score between days 2 and 14 was -0.127 (P = .009) in group 1 vs 3, -0.134 (P = .012) in group 2 vs 3, and 0.007 (P = .88) in group 1 vs 2. On histologic examination saline solution-treated corneas had more inflammatory cells and blood vessels than HAF-treated corneas.

CONCLUSION

Topical preterm/term HAF was an effective topical therapy for limiting the damage after acute alkali burns of the eye in this animal model.

Donor scleral patch for treating hypotony due to leaking and/or overfiltering blebs

OBJECTIVE

To report a modified technique of bleb revision with the use of a donor scleral patch in cases in which scleral melting did not allow effective suturing and closure of the aqueous leak. The suturing technique ensures tight adaptation of the scleral patch over the leaky region, and allows better-controlled aqueous flow with loose suturing of the posterior edge of the scleral patch.

METHODS

Records of patients who underwent bleb revision with donor scleral graft from 1997 to 2003 were reviewed retrospectively. Chart information including demographic and clinical data was recorded preoperatively and 1 day, 1 week, 1 month, 6 months, and at final follow-up.

RESULTS

Fifteen patients underwent this surgical procedure for bleb revision. The mean follow-up time was 22.0 +/- 24.0 months (median = 8.0 months). The mean preoperative visual acuity was 20/50 and the mean intraocular pressure (IOP) was 2.9 +/- 2.3 mm Hg, which improved to 20/30 and 14.1 +/- 3.3 mm Hg respectively, on last follow-up.

CONCLUSIONS

The scleral patch with 4-nylon sutures should be proposed in cases in which a macerated scleral bed is revealed during the revision. The loose suturing of the scleral patch at its posterior border was found to prevent intraocular pressure spikes.

Spontaneous inferior subconjunctival haemorrhages in association with circumferential drainage blebs

AIM

To describe an association of spontaneous inferior subconjunctival haemorrhages in eyes with circumferential drainage blebs following trabeculectomy.

METHODS

Observational case series. Patients with multiple episodes of spontaneous inferior subconjunctival haemorrhage following trabeculectomy (with or without antimetabolite) and circumferential blebs are presented. All patients described had multiple episodes. A possible mechanism is discussed.

RESULTS

The number of spontaneous haemorrhages ranged from two to more than 10. All individual haemorrhages resolved spontaneously without adverse sequelae

CONCLUSIONS

A new clinical presentation of inferior subconjunctival haemorrhage in association with circumferential blebs is described.

Management of late-onset bleb leaks

PURPOSE OF REVIEW

This paper reviews various methods of both medical and surgical management of late bleb leaks.

RECENT FINDINGS

The hood procedure without bleb removal may be preferred for small leaking blebs and autologous conjunctival bleb resurfacing for large leaking blebs. If hypotony is present preleak, revision of the underlying scleral flap may also be required.

SUMMARY

Blebs with late leaks are a major problem after glaucoma filtration surgery and can result in hypotony or endophthalmitis. Conservative treatment and laser therapy both have limited success in sealing the leaks and are not as effective as surgical management. Many surgical techniques are used, but none is universally successful.