Elsevier

Ophthalmology

Volume 107, Issue 9, September 2000, Pages 1681-1687
Ophthalmology

Surgical repair of leaking filtering blebs☆

Presented in part at the American Academy of Ophthalmology annual meeting, Orlando, Florida, October 1999.
https://doi.org/10.1016/S0161-6420(00)00282-7Get rights and content

Abstract

Purpose

To report the surgical management of leaking filtering blebs occurring after blebitis or persistent hypotony.

Design

Retrospective, noncomparative case series.

Participants

Twenty-two eyes of 20 patients with late bleb leak, blebitis or endophthalmitis, hypotony maculopathy, or bleb dysesthesia on presentation to the glaucoma service who required surgical bleb revision from 1990 through 1999.

Intervention

Pedicle flap, partial excision, and advancement or free conjunctival autologous graft techniques for surgical bleb revision. Type of bleb revision was dependent on the dimensions of the bleb and quality of surrounding conjunctiva.

Main outcome measures

Preoperative and postoperative intraocular pressure (IOP), status of bleb leak, reoperation for glaucoma, or requirement for postrevision glaucoma medical therapy, with success defined as the need for two or fewer glaucoma medications after revision.

Results

Eighty-six percent (19/22) of eyes that underwent surgical bleb revision had resolution of leak and IOP control using two or fewer medications after one or more bleb revisions. The preoperative IOP (mean ± standard deviation) was 3.7 ± 2.6 mmHg (range, 0–8 mmHg). After an average follow-up of 21 months (range, 8–108 months), the IOP was 11.0 ± 4.4 mmHg for patients taking 0.6 ± 1.0 glaucoma medications. Eighteen percent (4/22) of eyes required two or more bleb revisions. In one eye, an IOP spike of 36 mmHg developed after revision, which required laser suture lysis on two occasions before the IOP was significantly lowered. The three failures were: one eye that required three or more medications for IOP control, a patient whose eye had a persistent leak after revision and who was not mentally competent to undergo repeat revision, and one eye that required combined glaucoma and cataract surgery after revision.

Conclusions

Surgical bleb revision has a high success rate of closing late bleb leaks, maintaining glaucoma control, and preserving vision, with few postoperative complications. The appropriate surgical procedure for revision must be based on the individual clinical situation and can result in successful bleb revision.

Section snippets

Patients and methods

A retrospective review was conducted of consecutive patients who underwent surgical revision of their filtering blebs from June 1990 through February 1999 and who had at least 6 months of follow-up. The study included 22 eyes of 20 patients who required 29 surgical procedures, of which 11 were pedicle flaps, 15 were conjunctival advancement flaps, and three were free autologous conjunctival grafts. Timing was contingent on the nature of the presentation; eyes with hypotony maculopathy underwent

Results

The mean ± standard deviation age of all patients at time of surgical revision was 64.3 ± 15.2 years (range, 28–85 years; Table 1). Of the 20 patients, 12 patients were male and eight were female; all patients were white. The diagnoses before the filtering surgeries were as follows: open-angle glaucoma, 14 patients; low-tension glaucoma, one patient; juvenile open-angle glaucoma, two patients; pigmentary glaucoma, one patient; pseudoexfoliative glaucoma, one patient; and elevated episcleral

Discussion

Thin, cystic, avascular blebs are likely to develop a late, chronic leak.2, 3, 4 The recognition of a leaky bleb, often heralded by increased tearing, particularly at night or on awakening, coupled with profound hypotony and a positive leak demonstrated by 2% fluorescein, is very important in glaucoma management. A thin-walled avascular bleb occurs after full-thickness drainage procedures2 and the use of adjunctive antimetabolites.3, 4 Lamping et al2 reported an incidence of 3.3% of late bleb

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    ☆

    The authors have no proprietary or financial interest in the subject matter or materials discussed in the article.

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    Copyright © 2000 American Academy of Ophthalmology, Inc. Published by Elsevier Inc. All rights reserved.