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Gan L, Tang F, Liao J, Xiang H, Tang L. Modified superior bleb needling of rare hypertrophic bleb after trabeculectomy: A case series. Eur J Ophthalmol 2024:11206721241256689. [PMID: 38767136 DOI: 10.1177/11206721241256689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Hypertrophic bleb is a rare complication of glaucoma filtration surgery characterized by an elevated bleb extended through the nasal 180 degrees of the eye and usually with a normal IOP. Currently, there is little experience and no existing standardized treatment. We describe a new method called modified superior bleb needling and evaluate the clinical outcomes in affected eyes. METHODS In this retrospective, consecutive interventional case series, patients who developed hypertrophic blebs after trabeculectomy from November 2015 to August 2020 at West China Hospital were enrolled. We innovatively adopted a modified superior bleb needling to allow aqueous humor to outflow into the superior subconjunctival space. Repeat needlings were performed if necessary. The technical and clinical success rate and complications were reported. RESULTS At the time of the last follow-up, complete success was achieved in 8/10 patients, qualified success was achieved in 9/10 patients, and failure was achieved in 1/10 patients. Eight patients had a low filtering bleb and IOP ≤21 mmHg. There was no statistically significant difference between the preneedling and postneedling IOP (p > 0.05). CONCLUSION Modified superior bleb needling is effective for hypertrophic blebs after trabeculectomy, and there was no significant impact on anterior chamber depth or IOP, making it a viable or preferred alternative option. It is worthy of further study and wider usage.
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Affiliation(s)
- Lu Gan
- Ophthalmology, Sichuan University, West China Hospital, ChengDu, China
- Ophthalmology, Sichuan University, West China School of Public Health and West China Fourth Hospital, ChengDu, China
| | - Fei Tang
- Ophthalmology, ShangjinNanfu Hospital, Chengdu, China
| | - Jinying Liao
- Ophthalmology, Sichuan University, West China Hospital, ChengDu, China
| | - Haotian Xiang
- Ophthalmology, Sichuan University, West China Hospital, ChengDu, China
| | - Li Tang
- Ophthalmology, Sichuan University, West China Hospital, ChengDu, China
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Pillai MR. Commentary: Long term outcomes of blebs repaired with scleral patch graft and conjunctival advancement in late-onset leak post-trabeculectomy. Indian J Ophthalmol 2021; 69:2501-2502. [PMID: 34427252 PMCID: PMC8544053 DOI: 10.4103/ijo.ijo_1643_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Manju R Pillai
- Consultant, Glaucoma Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
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Pathak Ray V, Badakere SV. Long-term outcomes of blebs repaired with scleral patch graft and conjunctival advancement in late-onset leak post-trabeculectomy. Indian J Ophthalmol 2021; 69:2496-2501. [PMID: 34427251 PMCID: PMC8544101 DOI: 10.4103/ijo.ijo_148_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Vanita Pathak Ray
- Department of Glaucoma, Centre for Sight, Hyderabad, Telangana, India
| | - Swathi V Badakere
- VST Centre for Glaucoma, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
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Surgical Management for Refractory Bleb Dysesthesia. J Ophthalmol 2020; 2020:7570454. [PMID: 32832139 PMCID: PMC7424410 DOI: 10.1155/2020/7570454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/25/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose To present long-term results of modified bleb-limiting conjunctivoplasty as a successful treatment for intractable bleb dysesthesia and to review the literature on the surgical management of dysesthetic bleb. Methods Consecutive case series and literature review. We present four cases of surgically reduced painful blebs. Our technique consisted of the following steps: (1) conjunctival, radial incision to the bare sclera in the desired limit of the bleb; (2) suturing with buried, interrupted sutures at the nearest edge of the filtering bleb; (3) lower limbal peritomy including unwanted area of the extended bleb; (4) dissection and removal of the underlying fibrous tissue when present; (5) conjunctival and resorbable sutures. In addition, a systematic literature review was performed. Only reports presenting outcomes of surgical treatment of bleb dysesthesia after filtering procedure were included in review. Results Four eyes were included consecutively in the study in a period of 4 years. On average, they developed circumferential bleb dysesthesia 9.3 ± 4.7 months after uneventful combined phacotrabeculectomy with Mitomycin C as primary procedure. Surgical reduction was decided after failure of lubricants in controlling ocular discomfort. Two cases showed a dense fibrous tissue beneath the conjunctiva that was excised to ensure filtration. In all cases, a rapid disappearance of symptoms with very good aesthetic and functional outcome was observed. After 12-month follow-up, patients remained asymptomatic and maintained intraocular pressure of 10.7 ± 1.2 mmHg without treatment. A systematic review of the literature obtained 15 eligible case series (n = 123) with rates of success within 46-100%, favoring less aggressive approaches to reduce bleb size. Conclusion Bleb dysesthesia is a rare complication of filtering glaucoma surgery. This modified bleb-limiting conjunctivoplasty technique (with removal of subjacent fibrous tissue if present) is able to target the underlying etiology providing ocular discomfort relief while maintaining bleb function and may be considered as first-choice surgical treatment.
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O'Rourke M, Moran S, Collins N, Doyle A. Bleb reconstruction using donor scleral patch graft for late bleb leak and hypotony. Eur J Ophthalmol 2020; 31:1039-1046. [PMID: 32450728 DOI: 10.1177/1120672120924343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Bleb dysfunction may occur as a late complication following glaucoma filtration surgery. Over-filtering, thinning and cystic blebs can lead to hypotony, leak and corneal dellen. We report our surgical management and outcomes of this specific entity using donor scleral patch grafts. METHODS This is a 10-year non-comparative, retrospective interventional case series. Bleb reconstruction involved excision of encysted conjunctiva and sclera to identify the original fistula. A functioning donor scleral patch graft was sited over this with fixed and releasable sutures and the conjunctiva advanced. Intraocular pressure, visual acuity and post-operative issues were assessed. RESULTS A total of 18 eyes of 17 patients with mean age 65 years (standard deviation 13.5) were included. Trabeculectomy was the primary procedure in 72% (n = 13) and deep sclerectomy in 28% (n = 5). Bleb leak accounted for 61% (n = 11), hypotony 33% (n = 6) and corneal dellen 6% (n = 1). Mean pre-operative intraocular pressure was 7 mm Hg (standard deviation 4.6) which increased to 18.5 mm Hg (standard deviation 12) at day 1 (p < 0.001), 11.8 mm Hg (standard deviation 4.6) at 3 months (p < 0.05), 12.1 mm Hg (standard deviation 4.2) at 1 year (p < 0.01) which was maintained at 12.1 mm Hg (standard deviation 5.3) at last follow-up (p < 0.001). Post-operative interventions included bleb needling, re-suturing, suture removal, further glaucoma management, bleb leak and cataract surgery. Visual acuity also improved post-operatively and was maintained. CONCLUSION Reconstruction of the filtering bleb architecture with donor sclera results in improved intraocular pressure while maintaining visual acuity. Post-operative care is required to support the restored bleb function. Our findings support the use of scleral patch graft as an effective and safe method for the long-term management of hypotony and bleb leak as a late complication of glaucoma filtration surgery.
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Affiliation(s)
- Michael O'Rourke
- Department of Ophthalmology, 58010Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - Sarah Moran
- Department of Ophthalmology, 58010Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - Niamh Collins
- Department of Ophthalmology, 58010Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - Aoife Doyle
- Department of Ophthalmology, 58010Royal Victoria Eye and Ear Hospital, Dublin, Ireland
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Yu JTS, Au L. Conjunctival bleb compression as a treatment for hypotony post XEN45 implant in uveitic glaucoma. Eur J Ophthalmol 2019; 30:217-220. [DOI: 10.1177/1120672119836339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: Over-filtration and subsequent hypotony are recognised complications of penetrating glaucoma procedures, especially when augmented with antimetabolites. Patients with uveitis are especially at risk of hypotony and this can reduce the final acuity achieved, compromise surgical outcomes and adversely affect the inflammatory status. The incidence of hypotony following XEN45 implant insertion is higher for uveitic patients and we present a method of surgically addressing this hypotony with transconjunctival compression sutures that are placed over the overdraining XEN45 implant. Methods: We present a retrospective case series of consecutive uveitic glaucoma patients who had conjunctival compression sutures between 2015 and 2018 following XEN45 insertion, at the Manchester Royal Eye Hospital, UK. Two 9/0 nylon sutures were placed in a horizontal figure-of-eight conformation transconjunctivally across the overdraining bleb: one directly over the XEN45 implant and one at the posterior limit of the implant in order to restrict flow. Results: Three patients underwent conjunctival compression sutures following XEN45 implant-related hypotony and all three had successful resolution of their hypotony and visual symptoms. No patients required long-term topical agents to control their intraocular pressure. Conclusion: Conjunctival compression sutures are an effective option for addressing persistent hypotony following XEN45 implant insertion in patients with uveitic glaucoma.
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Affiliation(s)
- Jonathan Thur Sian Yu
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Leon Au
- Manchester Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Yu JT, Mercieca K, Au L. Conjunctival bleb compression sutures: An effective method of addressing hypotony after trabeculectomy or trabeculectomy-related procedures. Eur J Ophthalmol 2018; 28:731-734. [PMID: 29888614 DOI: 10.1177/1120672118777100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE: Over-filtration is a well-known complication of trabeculectomy and related procedures, especially with adjunctive antimetabolites. Secondary hypotony can result in reduced visual acuity and compromise long-term surgical success. Persistent hypotony requires intervention and we describe an effective adaptation of placing conjunctival compression sutures directly over the scleral flap. METHODS: A retrospective consecutive case series of all patients who underwent conjunctival compression suturing from 2012 to 2014 at Manchester Royal Eye Hospital, UK. Under sub-tenon's anaesthesia, two 9/0 nylon figure-of-eight transconjunctival sutures were placed horizontally across the bleb: the first over the anterior flap/ostium and the second over the posterior flap edge to reduce flow through the trabeculectomy flap. RESULTS: A total of 10 patients underwent conjunctival compression suturing, and all patients had successful reversal of hypotony and symptom resolution within 1 week with corresponding clinical improvement. Intraocular pressure control was maintained without topical pressure-lowering agents in seven patients (median = 10 mmHg, range = 7-12 mmHg) with a median follow-up of 35.9 months (range = 11-61 months). Two patients required topical therapy to maintain intraocular pressure ≤ 14 mmHg and one patient's hypotony returned after 10 months but remained untreated due to pre-existing poor vision. No patients required a return to theatre. CONCLUSION: This series demonstrates that conjunctival compression sutures can successfully provide long-term control of trabeculectomy-bleb-related hypotony. This technique offers an effective alternative for glaucoma surgeons in addressing post-trabeculectomy hypotony.
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Affiliation(s)
- Jonathan Ts Yu
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Karl Mercieca
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Leon Au
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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B Scoralick AL, Almeida I, Ushida M, T Dias D, Dorairaj S, S Prata T, N Kanadani F. Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017; 11:58-62. [PMID: 28924340 PMCID: PMC5577121 DOI: 10.5005/jp-journals-10028-1224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/02/2017] [Indexed: 11/25/2022] Open
Abstract
Aim To investigate surgical outcomes and success predictors of transconjunctival scleral flap resuturing for the management of hypotony due to overfiltration following trabeculectomy with mitomycin C. Materials and methods Noncomparative, retrospective, interventional case series in which all glaucoma patients from two glaucoma services undergoing transconjunctival scleral flap resuturing between May 2012 and July 2016 were enrolled. Included eyes had to have hypotony [intraocular pressure (IOP) < 6 mm Hg] and/or hypotony maculopathy caused by excessive filtration following trabeculectomy. Key exclusion criteria were wound/bleb leaking and postoperative ocular trauma or infection. Preoperative and postoperative IOP, best-corrected visual acuity (BCVA), fundus imaging, surgical complications, and any subsequent related events or procedures were recorded. Rates of postsurgical hypotony and/or maculopathy resolution and possible success predictors were investigated. Results A total of 22 patients (22 eyes) with a mean age of 56.4 ± 15.2 years were included. Median follow-up was 245 days [interquartilerange (IR); 120-817 days] and mean IOP was increased from 2.9 ± 1.5 mm Hg (1-6 mm Hg) to 8.5 ± 3.1 mm Hg (2-16 mm Hg) at the last follow-up visit (p < 0.01). Approximately 75% of the cases (16 out of 22) had an IOP between 7 and 18 mm Hg at the end of the follow-up period. Median BCVA (log MAR) at last follow-up visit [0.1 (IR; 0.0- 0.3)] was significantly better than preoperative BCVA [0.4 (IR; 0.11.0); p < 0.01]. Hypotony resolved in 81% of the cases, while maculopathy resolution was found in 85% of the cases. Time interval between trabeculectomy and flap resuturing was the only factor significantly associated with patient’s IOP at last follow-up visit (R2 = 0.23; p = 0.036). Success rates (IOP > 6 mm Hg at last follow-up visit) were halved in those left untreated for more than 6 months. No serious adverse event was recorded. Conclusion Our findings support the use of transconjunctival scleral flap resuturing as an effective and safe alternative for hypotony management due to overflitration following trabeculectomy. As time interval seems to influence the odds of hypotony resolution, early intervention is recommended. How to cite this article Scoralick ALB, Almeida I, Ushida M, Dias DT, Dorairaj S, Prata TS, Kanadani FN, Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017;11(2):58-62.
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Affiliation(s)
- Ana Luiza B Scoralick
- Staff specialist, Department of Ophthalmology, Instituto de Olhos Ciencias Medicas, Belo Horizonte, Brazil
| | - Izabela Almeida
- Postgraduate Student, Department of Ophthalmology, Glaucoma Service, Federal University of Sao Paulo, Brazil; Glaucoma Unit Hospital Medicina dos Olhos, Osasco, Brazil
| | - Michele Ushida
- Staff specialist, Glaucoma Unit, Hospital Medicina dos Olhos, Osasco, Brazil
| | - Diego T Dias
- Postgraduate Student, Department of Ophthalmology, Glaucoma Service, Federal University of Sao Paulo, Brazil; Glaucoma Unit Hospital Medicina dos Olhos, Osasco, Brazil
| | - Syril Dorairaj
- Assistant Professor, Department of Ophthalmology, Mayo Clinic, Jacksonville Florida, USA
| | - Tiago S Prata
- Associate Professor, Department of Ophthalmology, Glaucoma Service, Federal University of Sao Paulo, Brazil; Glaucoma Unit Hospital Medicina dos Olhos, Osasco, Brazil; Department of Ophthalmology Glaucoma Service, Sorocaba Ophthalmology Hospital, BOS Sorocaba, Brazil
| | - Fábio N Kanadani
- Associate Professor, Department of Ophthalmology, Instituto de Olhos Ciencias Medicas, Belo Horizonte, Brazil
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Fakhraie G, Mohajernezhad-Fard Z, Moghimi S, Vahedian Z, Eslami Y, Zarei R. Lens Extraction for Management of Coexisting Cataract and Post-filtering Surgery Ocular Hypotony. J Ophthalmic Vis Res 2016; 10:385-90. [PMID: 27051482 PMCID: PMC4795387 DOI: 10.4103/2008-322x.176908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Purpose: To evaluate the safety and efficacy of phacoemulsification for management of post-filtering ocular hypotony. Methods: This prospective interventional case series study recruited 21 consecutive patients with an established diagnosis of ocular hypotony with or without maculopathy. Clear corneal incision phacoemulsification was done for all patients. Nineteen cases that completed a follow-up of at least 6 months were considered for final analysis. Results: Mean baseline intraocular pressure (IOP) was 2.95 ± 1.43 mm Hg, which increased to 8.84 ± 4.67 mm Hg at 6 months (P < 0.001). Hypotony was resolved in 13 cases (68%) at 6 months while 6 cases (32%) showed persistent hypotony at this time point. Postoperative IOP change at all follow-up time points was not correlated with patient age, time interval between filtering surgery and phacoemulsification, baseline IOP, baseline anterior chamber depth and IOP on the first postoperative day. Three cases (16%) showed filtering bleb failure with dramatic IOP rise around the first postoperative month and required glaucoma medication for IOP control. No significant intra- or postoperative complications were noted. Conclusion: Cataract surgery alone seems promising in resolving hypotony in patients with post-filtering ocular hypotony, and can be considered as an effective treatment modality before proceeding to more complicated procedures.
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Affiliation(s)
- Ghasem Fakhraie
- Department of Ophthalmology, Glaucoma Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Mohajernezhad-Fard
- Department of Ophthalmology, Glaucoma Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sasan Moghimi
- Department of Ophthalmology, Glaucoma Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zakieh Vahedian
- Department of Ophthalmology, Glaucoma Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Yadollah Eslami
- Department of Ophthalmology, Glaucoma Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Zarei
- Department of Ophthalmology, Glaucoma Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Begum S, Bobat H, Kirwan JF. Bleb compression and autologous blood for relief of bleb dysaesthesia. Does it work? Clin Exp Ophthalmol 2016; 44:528-9. [PMID: 26844817 DOI: 10.1111/ceo.12710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/09/2016] [Indexed: 12/01/2022]
Affiliation(s)
| | - Hannaa Bobat
- Queen Alexandra Hospital, Portsmouth, Hampshire, UK
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Repair of eyelid retraction due to a trabeculectomy bleb: case series and review of the literature. Ophthalmic Plast Reconstr Surg 2013; 30:e32-5. [PMID: 23645356 DOI: 10.1097/iop.0b013e318291665c] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Superior limbal trabeculectomy remains a common surgical treatment for glaucoma. Positional effects on the overlying upper eyelid-both ptosis and retraction-have been associated with the procedure. More than 1 mechanism may explain retraction; however, the eyelid may elevate mechanically due to the underlying raised superior bulbar conjunctiva.
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Long-term results after transconjunctival resuturing of the scleral flap in hypotony following trabeculectomy. Am J Ophthalmol 2013; 155:864-9. [PMID: 23394904 DOI: 10.1016/j.ajo.2012.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 12/06/2012] [Accepted: 12/10/2012] [Indexed: 11/23/2022]
Abstract
PURPOSE To present the 4-year follow-up results in the surgical treatment of hypotony following trabeculectomy with mitomycin C in glaucoma patients with additional flap sutures. DESIGN Retrospective interventional case series. METHODS Since 2006, 53 patients with hypotony maculopathy attributable to overfiltration following glaucoma surgery (trabeculectomy with mitomycin C) were included in this institutional study. We were able to follow up intraocular pressure (IOP) and distance-corrected visual acuity in 33 (62%) over 4 years, whereas all were followed over 2 years. To elevate IOP, we placed tangential transconjunctival sutures through the scleral flap and connected them to the adjacent sclera in all 53 patients. RESULTS Mean IOP prior to surgery was 3.55 mm Hg (± 2.05; range 0-8 mm Hg), 20.08 mm Hg (± 12.48) on the first postoperative day, 10.69 mm Hg (± 4.73) after 1 month, 10.12 mm Hg (± 3.95) after 6 months, 10.42 mm Hg (± 4.17) after 2 years, and 9.5 mm Hg (± 3.93) after 4 years. Mean visual acuity (VA) improved from 0.8 logarithm of minimal angle of resolution (logMAR) preoperatively to 0.5 after 1 month, and remained stable after 6 months at 0.3. Macular folds resolved in all patients and choroidal detachment in 51 patients (96%) after 6 months. IOP increase and vision improvement were statistically significant (<.05). CONCLUSION Even 4 years after resuturing of the scleral flap through the intact conjunctiva, there is evidence that this surgical method is an effective and simple technique to treat hypotony maculopathy after glaucoma surgery.
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Faingold D, Kasner OP. Expanded indications for transconjunctival trabeculectomy flap suturing: postoperative choroidal effusion and dysesthesia. Can J Ophthalmol 2012; 47:291-5. [PMID: 22687310 DOI: 10.1016/j.jcjo.2012.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 03/09/2012] [Accepted: 03/22/2012] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the efficacy of transconjunctival trabeculectomy flap suturing (TTFS) in improving choroidal effusions and bleb dysesthesia resulting from overfiltration after trabeculectomy. DESIGN Retrospective review. PARTICIPANTS The study involved 15 eyes of 15 patients. METHODS Patients underwent TTFS for choroidal effusions and bleb dysesthesia following trabeculectomy using mitomycin C. The scleral flap was sutured through the conjunctiva as an outpatient clinic procedure. RESULTS There were 11 patients who had choroidal effusions and 4 patients were identified with dysesthesia. The average duration of choroidal effusion prior to TTFS was 2.1 ± 2.3 months and 3 ± 2 months in the dysesthesia group. At the final follow-up (25 ± 17 months) the mean intraocular pressure improved from 4.1 ± 2.1 mm Hg before suturing to 8.1 ± 3.6 mm Hg (p < 0.007) for the patients with choroidal effusion and from 4.2 ± 0.6 mm Hg to 8. 7 ± 3.5 mm Hg (p = 0.05) for the patients with dysesthesia. In both groups, resolution of the signs and symptoms was achieved in all cases. The mean time to resolution of choroidal effusions was 5.5 ± 8.6 weeks and the mean time to resolution of dysesthesia was 2 ± 0.8 weeks. None of the patients had serious complications such as failure of the trabeculectomy or visual loss. CONCLUSIONS Transconjunctival suturing of the trabeculectomy scleral flap is a simple and effective surgical method for the treatment of cases of choroidal effusions or dysesthesia resulting from trabeculectomy.
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Affiliation(s)
- Dana Faingold
- Henry C. Witelson Ocular Pathology Laboratory, McGill University, Montreal, Que
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Abstract
PURPOSE To describe a simple method and outcomes of remodeling dysesthetic, oversized filtering blebs. PATIENTS AND METHODS Retrospective chart review of the initial consecutive patients who had undergone "bleb window"-pexy (BWP) over a 1-year period. Patients with symptomatic, oversized, and dysmorphic blebs that did not show signs of spontaneous resolution were candidates for the technique, regardless of the intraocular pressure. Under topical anesthesia, a conjunctival window was created in the filtering bleb at the palpebral fissure (nasal or temporal) using Westcott scissors. The cut edges of conjunctiva and Tenon capsule were then glued to the underlying bare sclera using autologous fibrin tissue glue. In the case of extended (360 degrees) blebs (2 patients), 2 conjunctival windows were performed (nasal and temporal). Main outcome included symptomatic relief, restoration of bleb architecture, and preservation of filtration. RESULTS Six eyes from 6 patients underwent BWP. The mean follow-up period was 6.6+/-1.7 months (3.5 to 8.3 mo). All patients documented a rapid symptomatic relief within the first postoperative day. All had successful reduction in bleb size and adequate filtration without further antiglaucoma medications or surgery. Best corrected visual acuity improved 2 Snellen lines in 1 eye. Lens status remained unchanged in all cases. No complications or recurrences were noted. CONCLUSIONS Early results showed that BWP is safe, easy, and minimally invasive technique for the rapid relief of dysesthesia symptoms from dysmorphic filtering blebs. A larger sample size with longer follow-up is necessary to confirm the clinical utility.
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Quaranta L, Pizzolante T. Endophthalmitis After Compression Sutures for Enlarged Conjunctival Filtration Bleb Following Trabeculectomy. Ophthalmic Surg Lasers Imaging Retina 2009; 40:432-3. [DOI: 10.3928/15428877-20096030-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Dysesthetic blebs can complicate filtration surgery. Lubrication often reduces symptoms; however, some cases require surgical intervention. Limited conjunctivoplasty reduces the symptoms of dysesthetic blebs without sacrificing control of intraocular pressure (IOP). However, this may not sufficiently lower these blebs, particularly if the bleb is thick and dense. We describe a modified conjunctivoplasty technique that includes removal of subconjunctival scar tissue within the interpalpebral fissure and provide a 1-year follow-up of 13 eyes treated in this manner. All patients reported rapid, complete symptom resolution. The IOP was controlled in all 13 eyes following conjunctivoplasty; 3 required topical antiglaucoma therapy. Subconjunctival scar tissue may contribute to the formation of dysesthetic blebs owing to its thickness and by encouraging local dissection of aqueous humor. Our report demonstrates that removal of this tissue does not compromise IOP control when performed with conjunctivoplasty.
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Affiliation(s)
- Michael Lloyd
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
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Maruyama K, Shirato S. Efficacy and safety of transconjunctival scleral flap resuturing for hypotony after glaucoma filtering surgery. Graefes Arch Clin Exp Ophthalmol 2008; 246:1751-6. [PMID: 18751993 DOI: 10.1007/s00417-008-0924-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 07/23/2008] [Accepted: 07/26/2008] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND To evaluate the efficacy and safety of transconjunctival scleral flap resuturing for the management of hypotony-associated excess filtration after glaucoma filtering surgery. METHODS Fifty-six eyes of 55 patients with hypotony maculopathy and/or choroidal detachment caused by excess filtration after glaucoma filtering surgery underwent transconjunctival scleral flap resuturing directly through the conjunctiva, using a 10-0 nylon suture with a round tapered needle. Intraocular pressure (IOP) after suture, best-corrected visual acuity, rate of resolution of hypotony maculopathy and choroidal detachment, rate of complication, and rate of supplemental surgical treatment were assessed. RESULTS IOP (mean +/- SD) was 2.9 +/- 1.4 mmHg before suture, and elevated significantly to 7.3 +/- 4.5 mmHg at 1 week after suture, 7.2 +/- 3.5 mmHg at 1 month, 8.4 +/- 4.1 mmHg at 1 year, and 8.1 +/- 3.5 mmHg at the last follow-up (mean of 23 months). The best-corrected visual acuity was improved. Hypotony maculopathy was resolved in 92% and choroidal detachment in 100% of the patients. None of the patients required supplemental surgical treatment, because transconjunctival scleral flap resuturing failed to increase IOP. Suture removal was performed in 14 eyes that showed high IOP after suture. Of these eyes, six required needle revision and one required surgical bleb revision. In two eyes, aqueous humor leak after suture was controlled by wearing contact lenses. No bleb-associated infection was observed. CONCLUSION Even though additional treatments such as repeated suture, suture removal, and needle revison were necessary in some cases, transconjunctival scleral flap resuturing is a simple and minimally invasive procedure that improves hypotony after glaucoma filtering surgery, with no serious complication.
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Affiliation(s)
- Katsuhiko Maruyama
- Department of Ophthalmology, Tokyo Medical University, 6-7-1, Nishi-shinjuku, Shinjuku, Tokyo, 160-0023, Japan.
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19
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Eha J, Hoffmann EM, Wahl J, Pfeiffer N. Flap suture--a simple technique for the revision of hypotony maculopathy following trabeculectomy with mitomycin C. Graefes Arch Clin Exp Ophthalmol 2008; 246:869-74. [PMID: 18389274 DOI: 10.1007/s00417-007-0694-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Revised: 08/07/2007] [Accepted: 09/12/2007] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND A serious complication following trabeculectomy with mitomycin C (MMC) is intraocular hypotony with hypotony maculopathy, papilledema, flattening of the anterior chamber, corneal decompensation and a decrease in visual acuity. We describe a new simple surgical technique for the treatment of hypotony maculopathy following trabeculectomy with MMC. METHODS In a prospective consecutive case study, 16 patients with hypotony maculopathy following trabeculectomy with MMC were included. Through the intact conjunctiva, additional 10.0 nylon sutures were placed through the scleral flaps into the adjacent sclera. Assessment of visual acuity, intraocular pressure (IOP) measurement and fundoscopy were performed on the 1st and 7th day postoperatively and 1, 3 and 6 months postoperatively. Photography of the bleb and the posterior pole and optical coherence tomography imaging of the posterior pole were performed. RESULTS Before surgery (flap suture), the mean IOP was 2.8 mmHg (+/-1.1; range from 1 to 4 mmHg). It was 24.9 +/- 11.7 mmHg (range; 9-48 mmHg) on the 1st postoperative day, 15.7 +/-8.1 mmHg (range; 5-35 mmHg) on day 7, 11.1 +/-4.1 mmHg (range; 5-20 mmHg) 1 month after surgery, 9.3 +/-3.9 mmHg (range; 2-20 mmHg) after 3 months, and 9.6 +/-4.2 mmHg (range; 2-20 mmHg) after 6 months. The best corrected mean visual acuity was 20/50 before trabeculectomy and 20/160 before flap suture. It improved to 20/63 at 6 months postoperatively. Clinical signs of hypotony maculopathy disappeared in all patients. No bleb leakage was observed in any patient during follow-up. CONCLUSION Resuturing the scleral flap through the intact conjunctiva is an effective and minimally invasive method to treat hypotony maculopathy following trabeculectomy with MMC. Thus, opening the conjunctiva can be avoided.
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Affiliation(s)
- Judith Eha
- Department of Ophthalmology, Johannes Gutenberg-University, Langenbeckstr. 1, 55101 Mainz, Germany.
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