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

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 (r(s)) correlating duration of hypotony and BCVA at both 6 and 12 months was significant (P = .015 and r(s) = 0.426, P = .028 and r(s) = 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

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 13.61.8 mm Hg (with a mean of 0.7 glaucoma medications) pre-operatively to 11.70.9 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