Safe management of a late-onset bleb leak with a needling technique

A novel bleb revision technique: lining with tenon's patch graft for treatment of large, ischemic, leaking blebs with severe conjunctival scarring after trabeculectomy

PURPOSE

We report a new bleb lining technique with Tenon's patch graft for late-onset leakage from large ischemic bleb with severe conjunctival scarring and impractical conjunctival mobilization after trabeculectomy.

STUDY DESIGN

Retrospective case series.

METHODS

This study includes six cases with late-onset leakage from large ischemic blebs. Small Tenon's tissue is dissected from the incisional site or a previously made inferior incision for Tenon's anesthesia. A passage is created from the small incision to the leaking area of the bleb using a bleb knife or micro scissors. The Tenon's tissue, stained with indocyanine green, is inserted under the ischemic bleb's conjunctiva. A transconjunctival compression suture is placed across the leaking point to fix the Tenon patch graft positionally.

RESULTS

In all cases, bleb leakage was completely sealed immediately after surgery. In 4 cases, the closure of the bleb leakage was maintained after surgery during the follow-up period (6-17 months). In two cases, bleb leakage recurred from different leaking points 7 or 9.5 months after the surgery; however, repeated tenon's patch lining revisions successfully closed these leakages. The intraocular pressure at the final visit was 5-13 mmHg (median, 10 mmHg) without glaucoma medication or additional glaucoma surgery.

CONCLUSION

Tenon's patch-lining technique is a promising method for bleb leakage with large ischemic bleb and impractical conjunctival mobilization.

Bleb Plication for a Leaking Bleb After Trabeculectomy

PURPOSE

The purpose of this work was to report a new method for the repair of ischemic bleb leaks. Bleb leakage is a serious complication of glaucoma filtering surgery with mitomycin C. Many surgical methods have been proposed to seal the leakage from a bleb; however, this novel plication method is effective, relatively easy to perform, and safe.

METHODS

We describe the case reports of 2 patients with leakage from a bleb who were treated with the new method. The conjunctiva was lifted away from the sclera as extensively as possible around the ischemic conjunctiva toward the fornix using a bleb knife. Thereafter, 10-0 nylon sutures were applied between the nonischemic conjunctiva located just outside the ischemic conjunctiva and the corneal limbus. The ischemic conjunctiva was not removed, but covered with the nonischemic conjunctiva that was advanced toward the corneal limbus by these sutures.

RESULTS

After treatment, no recurrence of bleb leakage was observed. Moreover, no ischemic changes were observed in the advanced nonischemic conjunctiva or plicated conjunctiva.

CONCLUSION

This new method of bleb plication was effective for sealing bleb leakage.

Bleb plication: a minimally invasive repair method for a leaking ischemic bleb after trabeculectomy

Bleb leakage is a serious complication of glaucoma filtering surgery. This study describes the method and the results of a new repair method for ischemic bleb leaks. The subjects were consecutive eleven eyes of 11 patients with bleb leakage who underwent the bleb plication surgery. The bleb plication surgery consisted of two steps: 1) bleb needle redirection to float the conjunctiva away from the sclera as extensively as possible around the ischemic conjunctiva; and 2) multiple “O-shaped” sutures were applied between the non-ischemic conjunctiva just outside the ischemic conjunctiva and corneal limbus. The ischemic conjunctiva was not removed, but undermined beneath the advanced non-ischemic conjunctiva. This bleb plication method was repeated until the leakage was sealed. All patients were followed up for at least 6 months after final bleb plication. After final bleb plication, no recurrence of bleb leakage was observed. Moreover, ischemic changes were no longer observed in the advanced non-ischemic conjunctiva. Pre-operative and final intraocular pressure was 3.2 ± 4.1 and 11.9 ± 2.8 mmHg, respectively. This new repair method of bleb plication was safe and effective in sealing the leakage. The conjunctiva is not excised, and hence it does not run out.

Ocular hypotony: A comprehensive review

Ocular hypotony is an infrequent, yet potentially vision-threatening, entity. The list of differential causes is extensive, involving any condition that may compromise aqueous humor dynamics or the integrity of the globe and sometimes following medical treatments or procedures. Depending on the cause and the clinical impact, treatment options aim to correct the underlying pathology and to reestablish anatomical integrity, as well as visual function. We review the pathophysiology, clinical presentation, different causes, and associated therapeutic options of ocular hypotony.

Bleb needle redirection for the treatment of early postoperative trabeculectomy leaks: a novel approach

BACKGROUND

This study describes a technique of bleb needling as a management of early postoperative limbal bleb leaks unresponsive to conservative management. This technique redirects the aqueous into a newly formed bleb, sealing the leak easily and rapidly.

METHODS

Medical records of patients with early bleb leaks after trabeculectomy or phacotrabeculectomy between November 2004 and September 2005 were reviewed retrospectively. Patients whose bleb leaks were unresponsive to conservative management and who underwent needling procedures were identified and studied further.

RESULTS

Six of 18 patients who had early bleb leaks did not respond to conservative treatment and underwent a needle redirection of their blebs, which sealed within a few days after needling. The mean follow-up time of this group was 6 months. The mean preoperative vision was 20/50 with a mean preoperative intraocular pressure (IOP) of 27 using 2.8 medications, and this improved postoperatively and postneedling to a vision of 20/30 with a mean IOP of 11 using 0.16 medications.

INTERPRETATION

Bleb needling with subsequent redirection of aqueous into a new bleb should be considered as an option in the treatment of limbal leaks after a trabeculectomy that does not respond to conservative treatment.