Glyxambi
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 110
  • Home
  • Print this page
  • Email this page


 
   Table of Contents      
ORIGINAL ARTICLE
Year : 2001  |  Volume : 49  |  Issue : 4  |  Page : 247-54

Management of the late leaking filtration blebs. A report of seven cases and a selective review of the literature.


VST Centre for Glaucoma Care, L V Prasad Eye Institute, Hyderabad, India

Correspondence Address:
A K Mandal
VST Centre for Glaucoma Care, L V Prasad Eye Institute, Hyderabad
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 12930117

Rights and PermissionsRights and Permissions
  Abstract 

PURPOSE: To describe the outcome of various treatment modalities in the management of late bleb leaks after glaucoma filtering surgery (GFS). MATERIALS AND METHODS: Seven consecutive patients treated for late bleb leaks (Seidel's positive) between July 1990 and June 1999 were were enrolled in the study. The management strategy consisted of initial conservative therapy, and tailored surgery, if necessary. The surgical technique employed was either conjunctival-Tenon's advancement flap, hinged scleral flap, or fistulectomy with direct suturing. The main outcome measures were bleb characteristics and postoperative intraocular pressure (IOP). The secondary outcome measure was visual acuity. RESULTS: One patient responded to conservative therapy (aqueous suppressants, bandage contact lens) and six patients needed surgery. The successful surgical technique was conjunctivo-Tenon's advancement flap in three, hinged scleral flap in two, and fistulectomy-direct suturing to the wound (combined with cataract surgery and intraocular lens implantation) in one patient. The bleb leak stopped in all cases and 5 of the 6 surgical patients sustained functioning filtering blebs. Follow-up ranged from 8 to 56 months (mean = 20.4 +/- 16.2 months). Visual acuity improved to 6/12 or better in 4 cases, 6/36 in 2 cases and it remained at light perception in one case. None of the patients had any intraoperative or postoperative complications. CONCLUSIONS: Late leaking blebs after GFS can be treated successfully. The management decision and selection of surgical technique should be based on the clinical condition.

Keywords: Aged, Female, Filtering Surgery, adverse effects, Glaucoma, surgery, Humans, Male, Middle Aged, Postoperative Complications, pathology,


How to cite this article:
Mandal A K. Management of the late leaking filtration blebs. A report of seven cases and a selective review of the literature. Indian J Ophthalmol 2001;49:247

How to cite this URL:
Mandal A K. Management of the late leaking filtration blebs. A report of seven cases and a selective review of the literature. Indian J Ophthalmol [serial online] 2001 [cited 2019 Oct 16];49:247. Available from: http://www.ijo.in/text.asp?2001/49/4/247/14693



Click here to view


Click here to view


Click here to view


Click here to view
Bleb leaks have been recognised as a complication of glaucoma filtering surgery (GFS) ever since Elliot first described the procedure of limbal trephination in 1909. [1,2] Bleb leaks develop more frequently after full-thickness filtering surgery than after trabeculectomy.[3-6] The widespread adjunctive use of antimetabolites such as 5-Fluorouracil (5-FU) and Mitomycin-C (MMC) with trabeculectomy has significantly increased the occurrence of bleb leaks.[7-13] In eyes treated with 5-FU or MMC bleb leaks may occur in as many as 5 - 30% of patients. [8, 9, 11, 14-19] Late bleb leaks may develop months to years after the initial surgical procedure. [3, 4, 20, 21] Complications of leaking bleb include hypotony, shallow or flat anterior chamber, hypotony maculopathy,[22] choroidal detachment,[23] cataract formation, epithelial downgrowth, chronic inflammation, and filtration bleb failure. A leaking bleb may predispose the patient to infection and endophthalmitis, [7, 9, 12, 24-30] leading to loss of the eye. These complications can be avoided with appropriate management. This article describes the management strategies used in seven late leaking blebs with different treatment modalities.


  Materials and Methods Top


We reviewed the medical records of all patients who underwent therapy for late bleb leaks between July 1990 and June 1999. A total of 7 eyes of 7 patients who underwent therapy for late bleb leaks were included in the study. The diagnosis of bleb leaks was confirmed by a positive Seidel's sign. An individualised approach was used to manage the late bleb leaks.

The first line of therapy was conservative. This consisted of aqueous suppressants like β-adregeneric blocking agent used twice a day in combination with carbonic anhydrase inhibitor. In addition, topical gentamicin was used four times a day to incite conjunctival inflammation and stimulate healing. A large diameter bandage contact lens (BCL) 18-22 mm in diameter, depending on the location of the leak, was placed on the eye. The BCL was left undisturbed for at least one week to facilitate epithelial healing. Failing this, cyanocrylate tissue adhesive with large diameter BCL was attempted. When non-surgical methods of bleb leak management failed, one of the following described surgical techniques were performed. The choice of the surgical procedure depended on the location and size of the leak, and the briskness of the aqueous leak, the nature of the conjunctival and scleral tissues adjacent to the leaking bleb. All surgeries were performed by the author after having obtained informed consent from the patients.


  Surgical Technique Top


A. Conjunctival-Tenon's advancement flap

A fornix-based conjunctivo-Tenon flap is made just behind the leaking bleb. The flap is undermined and pulled towards the limbal region to assess closure of the fistulous opening by the flap. Superficial necrotic tissue around the fistulous track is removed and the intensity of leakage assessed. Three double-armed fixation sutures are applied between the Tenon's capsule and the posterior aspect of the fistulous opening using 8-0 vicryl sutures. A superficial incision is made at the anterior limbal region and debridement of the epithelial lining behind the incision line is performed. Watertight closure is achieved by suturing conjunctiva at the incision with 10-0 nylon suture. Abrasion of the corneal margin helps facilitate the adherence between tissues while fixation sutures at the base of the fistula ensure stability of the conjunctival-Tenon's flap and prevent postoperative retraction of the flap.

B. Hinged partial thickness scleral flap

An eyelid speculum is placed and a stay suture is passed through the superior rectus muscle insertion to expose the leaking bleb and adjacent area. A fornix-based conjunctivo-Tenon flap is dissected just behind the leaking bleb. The site of the fistula is identified. If the fistula is judged to be draining excessively and if hooding by sliding conjunctival-Tenon flap is judged inadequate, a hinged scleral flap is performed. A partial thickness quadrangular scleral flap is raised just behind the leaking fistula. The scleral flap is raised with its attached margin at the posterior border of the leaking fistula. The necrotic tissue around the fistulous opening is debrided and a very superficial incision is made at the anterior limbal region and the epithelial lining is scraped off using a Beaver blade. The partial thickness scleral flap is then overturned and sutured at the anterior limbal region covering the fistula by the superficial surface of the dissected scleral flap. The scleral flap is sutured in place using interrupted 10-0 nylon suture. No sutures are applied on the sides of the scleral flap in anticipation that some filtration would continue to maintain the intraocular pressure (IOP) at a safe level even when the leaking bleb is successfully repaired. The conjunctival flap is sutured to the anterior limbus to create a watertight closure.


  Case Reports Top


Two representative case reports are described below.


  Case report 1 Top


A 52-year-old year male (Case 1) presented to the glaucoma department on January 1997 with pain, redness and watering in his right eye. He had been diagnosed to having bleb infection with endophthalmitis. He had absolute glaucoma in the left eye. He had undergone iridencleisis in his right eye 20 years ago with good IOP control and had recorded visual acuity of 6/9 until December, 1996. He developed in the following month acute red eye and reduction in vision. There was bleb infection with 5 mm hypopyon and vitreous exudates. He received intravitreal antibiotics after vitreous tap at the Institute. Subconjunctival antibiotic was also injected. Culture was negative till 7 days of incubation. The patient responded to this treatment regimen and regained visual acuity of 6/9 within a month which was maintained till February 1998. After 3 months, in May 1998, he presented with sudden decrease in vision. The IOP was unrecordably low and Seidel test was positive. The patient was diagnosed to have late bleb leak. A trial of cyanoacryalate tissue adhesive and BCL failed. The patient underwent sliding conjunctivo-Tenon flap for revision of the fistula as described previously [Figure - 1].


  Case report 2 Top


A 71-year-old male (Case 2) underwent trabeculectomy in the right eye in September, 1988. He underwent extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (PC IOL) implantation in January 1991. The vision was 6/9. He maintained normal IOP in his right eye without any medication until February 1996, when a routine examination disclosed an IOP of 2 mmHg and a positive Seidel test. An attempt at primary closure of the fistula by cyanoacrylate tissue adhesive and BCL failed. The patient underwent hinged partial thickness scleral flap for revision of the leaking filtering bleb associated with excessively draining fistula 3 weeks later. Postoperatively there were no complications such as retraction of the flap or releakage. At the last follow-up at 56 months, his visual acuity was 6/9, the IOP was 14 mmHg without any medication and the filtration bleb appeared functioning [Figure - 2].


  Results Top


Patient data and clinical summaries are presented in [Table - 1]. Six of 7 patients were male, the mean age was 61.4 9.4 years (range, 46-71 years). The interval between filtration surgery and bleb leak ranged from 1.5 years to 16 years (mean 8.7 5.7 years). The primary surgery was thermal sclerostomy in one patient, iridencleisis in 3 patients, trabeculectomy in 2 patients and glaucoma triple procedure in one patient. No patient had a history of adjunctive antimetabolite therapy.

All the patients presented with reduced visual acuity; 3 of them presented with epiphora and intermittent blurred vision. One patient (Case 1) had history of bleb infection and endophthalmitis, successfully treated with topical and intravitreal antibiotics. All the patients had positive Seidel's test. The results of therapy are summarised in [Table - 1]. One patient (Case 3) responded to conservative therapy with BCL application for one week. This patient had a pinpoint leak and had undergone a trabeculectomy for chronic angle closure glaucoma (CACG) by the author 3 years before the diagnosis of bleb leak. This is the only patient on whom the original surgery was performed in the institute; others had been referred to the institute.

Three patients (Cases 1, 6, 7) received conjunctival-Tenon's advancement flap, two patients (Cases 2,4) received hinged partial thickness scleral autograft and one patient (Case 5) needed fistulectomy and direct suturing of the corneo-scleral wound combined with ECCE and PC IOL. The mean IOP at presentation was 3.3 + 3.2 mmHg (range, 0 to 9 mmHg) and at the last follow-up visit it was 15 2.9 mmHg (range, 12 - 20 mmHg). There was significant visual improvement (6/12 or greater) in 3 patients (Cases 1, 2, 3, 4) and IOP was under control in all patients without any medication. The bleb appearance was satisfactory in all patients except in Case 5. In this eye there was no bleb, but the IOP was under control. The bleb appearance remained unchanged in Case 3; it was managed conservatively. The mean follow-up was 20.4 16.2 months (range: 8 - 56 months).


  Discussion Top


Late bleb leak is a recognised complication that may occur months or years after initial surgery. [3, 4, 20, 21] The reported rate of late bleb leakage after glaucoma filtering surgery varies widely. This complication develops more frequently following full-thickness filtration procedures than after trabeculectomies.[3-6] Bleb leakage is thought to be more frequent in eyes that have received perioperative antifibrotic agents such as 5-FU and MMC. [8, 9, 11, 14-19] Late onset sequential multifocal bleb leaks as part of the complication after GFS with 5-FU and MMC have also been described.[31]

Interestingly, none of our patients received any antifibrotic agents during or after filtering surgery. This may be related to referral bias. In a series reported by Kosmin and Wishart,[32] two of 8 patients with late filtration bleb leak had adjunctive 5-FU therapy. Wilson and Kotas-Newman[33] had 4 patients with persistent late bleb leaks, of whom 2 had trabeculectomy with 5-FU therapy and 2 had full thickness filtering procedures. Susanna et al[34] also reported late bleb leaks after trabeculectomy with 5-FU or MMC. In our series of the 7 eyes three had iridencleisis, one had thermal sclerostomy, two had trabeculectomy without any antimetabolite therapy and one eye had glaucoma triple procedure. Similarly, Tomlinson et al[35] described 11 patients and Buxton et al[36] reported 5 patients in whom late bleb leaks or thinning occurred without use of any antimetabolite therapy during the primary filtering surgery.

Aqueous humour has lytic properties, and is known to inhibit subconjunctival fibroblasts [37,38] and its flow through the epithelial track presumably keeps the fibroblasts from growing over to fill the hole, leading to persistent leaking bleb in free filtering surgery. In guarded filtration surgery, the partial thickness scleral flap may get thinner with the passage of time by the lytic properties of the aqueous and may resemble full-thickness filtering surgery which is prone to developing late bleb leaks. It is reasonable to conjuncture that the process is further enhanced with the adjunctive antimetabolite therapy.

A variety of treatment modalities have been advocated for management of late leaking filtering blebs. In our series, only one (Case 3) of 7 patients responded to conservative therapy. This consisted of aqueous suppressants, BCL and topical gentamicin therapy. The Seidel's test was negative after 10 days of treatment. The mechanism of conservative therapy has been well established in the literature. Aqueous suppressants decrease production of aqueous humour and reduce bulk flow through the leak thereby allowing epithelial proliferation; BCL facilitates epithelial migration; and topical aminoglycoside (eg. gentamicin) incites mild conjunctival inflammation and stimulates wound healing.[35] The author believes that conservative therapy may help some patients. Indeed, this may even the sole therapy required as seen in one of our patients. Despite the reservations expressed by Sinnreich et al,[39] conservative treatment should be considered. This includes patching, [21, 25, 27, 28, 40] aqueous suppressants, [27,40] BCL,[41] collagen shield,[42] glaucoma tamponade shell [43,44] and symblepharon ring.[45]

Tissue adhesive is a valuable non-surgical adjunct in the management of late leaking blebs. [46,48] The use of autologous fibrin tissue glue has also been reported to successfully seal both early and late postoperative bleb leaks.[49-52] Other modalities include injection of autologous blood [53,54] and a variety of laser therapies.[55-57] Cyanocryalate tissue adhesives were tried in 4 of our cases (Cases 1, 2, 4, 5), but were not successful.

Surgical repair of late bleb leak is a more definitive therapy. We used conjunctivo-Tenon's flap and hinged partial thickness scleral flaps in the majority of our cases; fistulectomy and the leaking site was directly sutured in one patient. There have been several successful reports of rotational or sliding conjunctival Tenon's flap to cover the previous filtration site.[21-23,58-60] O'Connor et al[23] described a method of repairing leaking filtering blebs by mobilising conjunctival-Tenon's fascia using large horizontal relaxing incisions at the junction of the palpebral and bulbar conjunctiva. The posterior margin of the Tenon's and the conjunctiva were tacked in the sclera using interrupted 9-0 polygalactin (vicryl) sutures.[23]

In two cases (Cases 2 and 4), hinged partial thickness scleral flap was performed as the size of the leak was large and the aqueous leakage was brisk and the adjacent conjunctival and scleral texture were healthy. The partial thickness scleral flap was overturned and secured tightly to limit flow of aqueous past its anterior margins, but no suture was applied on the lateral boundaries, simulating a trabeculectomy with a well guarded sclerostomy. As expected, IOP was controlled without any medication and the bleb appearance was satisfactory in both cases. If the scleral flap had been sewn down on the sides, the scleral flap would have closed the sclerostomy, causing flattening of the bleb leading to an increase in IOP. Singh et al[61] have treated two cases using this technique, but were not successful.

Scleral patch graft is a good surgical alternative in difficult situations. There have been several successful reports of donor scleral patch graft using both full thickness [32, 62, 63] and partial thickness sclera.[64] Preserved and processed cadaver tissues such as fascia lata,[65] pericardium and meninges may also proven suitable for patch graft in excessively draining fistulas. Fascia lata is an effective, safe and inexpensive alternative to alcohol-preserved donor sclera. [65,66] However, glycerine preserved donor sclera (not alcohol preserved donor sclera) has the added risk of viral infection transmission.[67] Full thickness corneal allografts have been used to seal persistent limbal wound leaks[68] and half-thickness stromal corneal patch graft has been used for an incompetent scleral flap following trabeculectomy.[69] Morris et al[70] recently reported the use of autologous Tenon's capsule and partial thickness scleral patch graft for revision of excessively draining fistulas with leaking filtering blebs. In their first case, a piece of Tenon's tissue was dissected away from the adjacent sclera leaving a pedicle attachment abutting the fistula site. The Tenon's flap was rotated and sutured to close the fistulas and the conjunctival flap was sutured at the anterior limbus. In the second case, a 2.5 x 2mm rectangular 1/3 thickness sclera was dissected from an adjacent area approximately 3 - 4mm superotemporally to the fistula and sutured in place over the fistula using interrupted 10-0 nylon sutures. This technique requires a relatively larger incision and extensive scleral dissection. Our technique in Cases 2 and 4 required less dissection and Tenon's manipulation as this scleral flap was dissected just behind the site of the fistula. Overturning of the attached flap also required fewer sutures as the anterior end of the flap was sutured to the limbus. We feel the technique described in the present study is simple and easier to perform. The Morris technique is suitable when the adjacent sclera is friable following use of antimetabolites like MMC.

The autologous hinged scleral flap or patch graft may be difficult to obtain in repair of bleb leaks associated with thin-walled exuberant filtering blebs spread over a wide area as seen in MMC - augmented trabeculectomy. In such situations, full thickness and partial thickness donor sclera, pericardium, meninges and fascia lata may prove to be useful for patch grafting, and the hooding can be made by free conjunctival autograft from the same or contralateral eye. Recently, Budenz et al[71] reported conjunctival advancement as a successful procedure for closing late-onset filtering bleb leaks. In their series, 22 of 26 eyes had MMC and one eye had 5-FU application at primary surgery. In our series, cases 1, 6 and 7 were managed by conjunctival advancement flap. No patient had received adjunctive antimetabolite therapy in primary surgery in our cases.

One patient (Case 5) with a pin-point leak presented 6 years after iridencleisis. He had a significant cataract, which was managed by fistulectomy combined with ECCE - PC IOL and direct suturing of cataract surgery wound along with closure of the fistula. The visual acuity improved from counting fingers at 2 meters to 6/26. This patient had glaucomatous disc damage. There were no high IOP spikes, but the patient had 12 months' follow-up only. To my knowledge, this is the first reported case of late leaking bleb, wherein repair of the bleb and cataract surgery was performed in a single operative session. Clune et al[64] has reported a patient in whom cataract extraction with IOL implantation was performed in addition to revision of an exuberant non-leaking filtering bleb. This patient had hypotony maculopathy and complicated cataract following trabeculectomy with MMC. In suitable cases, cataract surgery and IOL implantation can be combined with repair of the leaking bleb in the absence of bleb infection.

All 7 patients in our series had successful restoration of leaking bleb. Six of the 7 patients underwent repair of the leaking bleb, and all sustained functioning filtering blebs. The technique described in the present study using conjunctival Tenon's advancement flap or hinged partial thickness scleral flap or autograft should be considered in cases where the leaking bleb is to be managed surgically. The literature report of surgical techniques for bleb repair and revision of bleb are summarised in [Table - 2]. The choice of surgical approach should depend on site or size of leaking fistula, briskness of leakage, health of adjacent sclera or conjunctiva, and availability of donor tissues from eye banks or commercial sources.[78]

 
  References Top

1.
Elliot RH. A preliminary note on a new operative procedure for the establishment of a filtering cicatrix in the treatment of glaucoma. Ophthalmoscope 1909;7:804.  Back to cited text no. 1
    
2.
Elliot RA. Sclero-Corneal Trephining in the Operative Treatment Of Glaucoma. New York: Paul B.Hoeber;1914.  Back to cited text no. 2
    
3.
Blondeau P, Phelps CD. Trabeculectomy vs thermosclerostomy : A randomised prospective clinical trial. Arch Ophthalmol 1981;99:810-16.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.
Lamping KA, Bellows AR, Hutchinson BT, Afran SI. Long term evaluation of initial filtration surgery. Ophthalmology 1986;93:91-101.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.
Speath GL. A prospective, controlled study to compare the Scheie procedure with Watsons trabeculectomy. Ophthalmic Surg l980;11:688-93.  Back to cited text no. 5
    
6.
Wilson MR. Posterior lip sclerostomy vs trabeculectomy in West Indian blacks. Arch Ophthalmol 1989;107:1604-8.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.
Khaw PT, Doyle JW, Sherwood MB, Smith F, McGorray S. Effects of intraoperative 5-fluorouracil or mitomycin-C on glaucoma filtration surgery in the rabbit. Ophthalmology 1993;100:367-72.  Back to cited text no. 7
    
8.
Schuman JS, Zaltas MM. Management of the leaking bleb. In: Ritch R, Shields MB, Krupin T, editors. The Glaucomas. 2nd edition. St.Louis; C.V. Mosby Company 1996, pp 1737-44.  Back to cited text no. 8
    
9.
Ticho U, Ophir A. Late complications after glaucoma filtering surgery with adjunctive 5-fluorouracil. Am J Ophthalmol 1993;115:506-10.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.
Gressel MG, Parrish RK II, Folberg R. 5-Fluorouracil and glaucoma filtering surgery. I. An animal model. Ophthalmology 1984;91:378-83.  Back to cited text no. 10
    
11.
The Fluorouracil Filtering Surgery Study Group : Three-year follow-up of the Fluorouracil Filtering Surgery Study. Am J Ophthalmol 1993;115:82-92.  Back to cited text no. 11
    
12.
Whiteside-Michel J, Liebmann JM, Ritch R. Initial 5-fluorouracil trabeculectomy in young patients. Ophthalmology 1992;99:7-13.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.
Schwartz AL, Weiss HS. Bleb leak with hypotony after laser suture lysis and trabeculectomy with mitomycin C. Arch Ophthalmol 1992;110:1049.  Back to cited text no. 13
[PUBMED]  [FULLTEXT]  
14.
Katz GJ, Higginbotham EJ, Lichter PR, Skuta GL, Musch DC, Bergstrom TJ, et al. Mitomycin C versus 5-fluorouracil in high risk glaucoma filtering surgery: Extended follow-up. Ophthalmology 1995;102:1263-69.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.
Fluorouracil Filtering Surgery Study Group. Fluorouracil filtering surgery study one-year follow up. Am J Ophthalmol 1989;108:625-35.  Back to cited text no. 15
    
16.
Fluorouracil Filtering Surgery Study Group. Five-year follow-up of the fluorouracil filtering surgerystudy. Am J Ophthalmol 1996;121:349-66.  Back to cited text no. 16
    
17.
Franks WA, Hitchings RA. Complications of 5-fluorouracil after trabeculectomy. Eye 1991;5:385-89.  Back to cited text no. 17
    
18.
Cheung JC, Wright MM, Urali S, Pederson JE. Intermediate-term outcome of variable dose mitomycin C filtering surgery. Ophthalmology 1997;104:143-49.  Back to cited text no. 18
[PUBMED]  [FULLTEXT]  
19.
Greenfield DS, Liebmann JM, Jee J, Ritch R. Late-onset bleb leaks after glaucoma filtering surgery. Arch Ophthalmol 1998;116:443-47.  Back to cited text no. 19
[PUBMED]  [FULLTEXT]  
20.
Fitzgerald, JR, McCarthy JL. Surgery of the filtering bleb. Arch Ophthalmol 1962;68:453-67.  Back to cited text no. 20
    
21.
Sugar HS. Complications, repair, and reoperation of antiglaucoma filtering blebs. Am J Ophthalmol 1967:63:825-33.  Back to cited text no. 21
    
22.
Newhouse RP, Beyrer C. Hypotony as a late complication of trabeculectomy. Ann Ophthalmol 1982;14:685-86.  Back to cited text no. 22
[PUBMED]  [FULLTEXT]  
23.
O'Connor DJ, Tressler CS, Caprioli J. A surgical method to repair leaking filtering blebs. Ophthalmic Surg 1992;23:336-38.  Back to cited text no. 23
    
24.
Dunnington JH, Regan EF. Late fistulization of operative wounds. Arch Ophthalmol 1950;43:407-18.  Back to cited text no. 24
    
25.
Shaffer's Diagnosis and Therapy of the Glaucomas. 6th ed. St.Louis: C.V.Mosby Company; 1989. pp. 598-604.  Back to cited text no. 25
    
26.
Wolner B, Liebmann JM, Sassai JW, Ritch R, Speaker M, Marmor M. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5-fluorouracil. Ophthalmology 1991;98:1053-60.  Back to cited text no. 26
    
27.
Ritch R, Shields MB, Krupin T., editors. The Glaucomas. St.Louis: C.V.Mosby Company; 1989. pp.282-290.  Back to cited text no. 27
    
28.
Shields MB. Textbook of Glaucoma. 3rd ed. Baltimore: Williams and Wilkins; 1992. pp.600-11.  Back to cited text no. 28
    
29.
Katz LJ, Cantor LB, Spaeth GL. Complications of surgery in glaucoma. Early and late bacterial endophthalmitis following glaucoma filtering surgery. Ophthalmology 1985;92:959-63.  Back to cited text no. 29
    
30.
Ashkenazi I, Melamed S, Avni I, Bartov E, Blumenthal M. Risk factors associated with late infection of filtering blebs and endophthalmitis. Ophthalmic Surg 1991;22:570-74.  Back to cited text no. 30
    
31.
Belyea DA, Dan JA, Stamper RL, Lieberman MF, Spencer WH. Late onset of sequential multifocal bleb leaks after glaucoma filtration surgery with 5-fluorouracil and mitomycin C. Am J Ophthalmol 1997;124:40-45.  Back to cited text no. 31
    
32.
Kosmin AS, Wishart PK. A full-thickness scleral graft for the surgical management of a late filtration bleb leak. Ophthalmic Surg Lasers 1997;28:461-68.  Back to cited text no. 32
    
33.
Wilson MR, Kotas-Neumann R. Free conjunctival patch for repair of persistent late bleb leak. Am J Ophthalmol 1994;117:569-74.  Back to cited text no. 33
    
34.
Susanna R Jr, Takahashi W, Nicolela M. Late bleb leakage after trabeculectomy with 5-fluorouracil or mitomycin C. Can J Ophthalmol 1996;31:296-300.  Back to cited text no. 34
    
35.
Tomlinson CP, Belcher CD III, Smith PD, Simmons RJ. Management of leaking filtration blebs. Ann Ophthalmol 1987;19:405-11.  Back to cited text no. 35
    
36.
Buxton JN, Lavery KT, Liebmann JM, Buxton DF, Ritch R. Reconstruction of filtering blebs with free conjunctival autografts. Ophthalmology 1994;101:635-39.  Back to cited text no. 36
    
37.
Herschler J, Claflin AJ, Fiorentino G. The effects of aqueous humor on the growth of subconjunctival fibroblasts in tissue cultures and its implications for glaucoma surgery. Am J Ophthalmol 1980;89:245-49.  Back to cited text no. 37
    
38.
Radius RL, Herschler J, Claflin A, Fiorentino G. Aqueous humor changes after experimental filtering surgery. Am J Ophthalmol 1980;89:250-54.  Back to cited text no. 38
    
39.
Sinnreich Z, Barishak R, Stein R. Leaking filtering blebs. Am J Ophthalmol 1978;86:345-49.  Back to cited text no. 39
    
40.
Minckler DS, Van Buskirk EM. Glaucoma. Color Atlas of Ophthalmic Surgery. Philadelphia: J.B. Lippincott; 1992. pp.114-15.  Back to cited text no. 40
    
41.
Blok MD, Kok JH, van Mil, C, Greve EL, Kijlstra A. Use of Megasoft Bandage Lens for treatment of complications after trabeculectomy. Am J Ophthalmol 1990;110:264-68.  Back to cited text no. 41
    
42.
Fourman S, Wiley L. Use of a collagen shield to treat a glaucoma filter bleb leak. Am J Ophthalmol 1989;107:673-74.  Back to cited text no. 42
    
43.
Melamed S, Hersh P, Kerste D, Lee DA, Epstein DL. The use of glaucoma shell tamponade in leaking filtration blebs. Ophthalmology 1986;93:839-42.  Back to cited text no. 43
    
44.
Joiner DW, Liebmann JM, Ritch R. A modification of the use of the glaucoma tamponade shell. Ophthalmic Surg 1989;20:441-42.  Back to cited text no. 44
    
45.
Hill RA, Aminlari A, Sassani JW, Michalski M. Use of symblepharon ring for treatment of over-filtration and leaking blebs after glaucoma filtration surgery. Ophthalmic Surg 1990;21:707-10.  Back to cited text no. 45
    
46.
Grady FJ, Forbes M. Tissue adhesive for repair of conjunctival buttonhole in glaucoma surgery. Am J Ophthalmol1969;68:656-58.  Back to cited text no. 46
    
47.
Zalta AH, Wieder RH. Closure of leaking filtering blebs with cyanoacrylate tissue adhesive. Br J Ophthalmol 1991;75:170-173.  Back to cited text no. 47
    
48.
Leahey AB, Gottsch JD, Stark WJ. Clinical experience with N-butyl cyanoacrylate (Nexacryl) tissue adhesive. Ophthalmology 1993;100:173-80.  Back to cited text no. 48
    
49.
Kajiwara K. Repair of leaking bleb with fibrin glue. Am J Ophthalmol 1990;109:599-601.  Back to cited text no. 49
    
50.
Asrani SG, Wilesky JT. Management of bleb leaks after glaucoma filtering surgery: Use of autologous fibrin tissue glue as a alternative. Ophthalmology 1996;103:294-98.  Back to cited text no. 50
    
51.
Gammon RR, Prum BE, Avery N, Mintz PD. Rapid preparation of small-volume autologous fibrinogen concentrate and its same day use in bleb leaks after glaucoma filtration surgery. Ophthalmic Surg Lasers 1998;29:1010-12.  Back to cited text no. 51
    
52.
Graham SL, Murray B, Goldberg I. Closure of fornix-based posttrabeculectomy conjunctival wound leaks with autologuous fibrin glue. Am J Ophthalmol 1992:221-22.  Back to cited text no. 52
    
53.
Smith MF, Magauran R, Doyle JW. Treatment of postfiltration bleb leak injection of autologous blood. Ophthalmic Surg 1994;25:636-37.  Back to cited text no. 53
    
54.
Leen MM, Moster MR, Katz LJ, Terebuh AK, Schmidt CM, Spaeth GL. Management of overfiltering and leaking blebs with autologous blood injection. Arch Ophthalmol 1995;113:1050-55.  Back to cited text no. 54
    
55.
Fink AJ, Boys-Smith JW, Brear R. Management of large filtering blebs with the argon laser. Am J Ophthalmol 1986;101:695-96.  Back to cited text no. 55
    
56.
Lynch MG, Roesch M, Brown RH. Remodeling filtering blebs with the neodymium : YAG laser. Ophthalmology 1996;103:1700-705.  Back to cited text no. 56
    
57.
Geyer O. Management of large leaking and inadvertent filtering blebs with the neodymium: YAG laser. Ophthalmology 1998;105:983-87.  Back to cited text no. 57
    
58.
Galin MA, Hung PT. Surgical repair of leaking blebs. Am J Ophthalmol 1977;83:328-33.  Back to cited text no. 58
    
59.
Hyams S. Repair of a leaking filtering bleb after trabeculectomy. Glaucoma 1988;10:148-50.  Back to cited text no. 59
    
60.
Petursson GJ, Fraunfelder FT. Repair of an inadvertent buttonhole of leaking filtering blθb. Arch Ophthalmol 1979;97:926-27.  Back to cited text no. 60
    
61.
Singh J, O'Brien C, Chawla HB. Success rate and complications of intraoperative 0.2 mg/ml mitomycin-C in trabeculectomy surgery. Eye 1995;9:460-66.  Back to cited text no. 61
    
62.
Melamed S, Ashkenazi I, Belcher III DC, Blumenthal M. Donor scleral graft patching for persistent filtration bleb leak. Ophthalmic Surg 1991;22:164-65.  Back to cited text no. 62
    
63.
Haynes WL, Alward WLM. Rapid visual recovery and long-term intraocular pressure control after donor scleral patch grafting for trabeculectomy-induced hypotony maculopathy. J Glaucoma 1995;4:200-l.  Back to cited text no. 63
    
64.
Clune MJ, Shin DH, Olivier MMG, Kupin TH. Partial-thickness scleral-patch graft in revision of trabeculectomy. Am J Ophthalmol 1993;115:818-20.  Back to cited text no. 64
    
65.
Hughes BA, Shin DH, Birt CM. Use of fascia lata in revision of filtration surgery. J Glaucoma 1996;5:207-9.  Back to cited text no. 65
    
66.
Tanji TM, Lundy DC, Minckler DS, Heuer DK, Varma R. Fascia lata patch graft in glaucoma tube surgery. Ophthalmology 1996;103:1309-12.  Back to cited text no. 66
    
67.
Rosenwasser GOD, Jones RL, Greene WH. Recovery of herpes simplex virus from preserved sclera (Abstract). Invest Ophthalmol Vis Sci 1993;34:S1494.  Back to cited text no. 67
    
68.
Soong HK. Meyer RF, Wolter JR. Fistula Excision and peripheral grafts in the treatment of persistent limbal wound leaks. Ophthalmology 1988;95:31-36.  Back to cited text no. 68
    
69.
Rumelt S, Rehany U. A donor corneal patch graft for an incompetent scleral flap following trabeculectomy. Ophthalmic Surg Lasers 1996;27:878-80.  Back to cited text no. 69
    
70.
Morris DA, Ramocki JM, Shin DH, Glover BK, Kim YY. Use of autologous Tenon's capsule and scleral patch grafts for repair of excessively draining fistulas with leaking filtering blebs. J Glaucoma 1998;7:417-19.  Back to cited text no. 70
    
71.
Budenz DL, Chen PP, Weaver YK. Conjunctival advancement for late-onet filtering bleb leaks. Arch Ophthalmol 1999;117:1014-19.  Back to cited text no. 71
    
72.
Cohen JS, Shaffer RN, Hetherington J, Hoskins D. Revision of filtration surgery. Arch Ophthalmol 1977;95:1612-15.  Back to cited text no. 72
    
73.
Maumenee AE. Treatment of epithelial downgrowth and intraocular fistula following cataract extraction. Trans Am Ophthalmol Soc 1964;62:153-66.  Back to cited text no. 73
    
74.
Iliff CE. Flap perforation in glaucoma surgery sealed by a tissue patch. Arch Ophthalmol 1964;71:215-18.  Back to cited text no. 74
    
75.
Sekhar GC. Surgical management of late leaking blebs. Asian journal of Ophthalmol 2000;2:10-13.  Back to cited text no. 75
    
76.
La Borwit SE, Quigley HA, Jampel HD. Bleb reduction and bleb repair after trabeculectomy. Ophthalmology 2000;107:712-18.  Back to cited text no. 76
    
77.
Harris LD, Yang G, Feldman RM, Fellman RL, Starita RJ, Lynn J, et al. Autologous conjunctival rsurfacing of leaking filtering blebs. Ophthalmology 2000;107:1675-80.  Back to cited text no. 77
    
78.
Wadhwani RA, Bellows AR, Hutchinson T. Surgical repair of leaking filtering blebs Ophthalmology 2000;107:1681-87.  Back to cited text no. 78
    


    Figures

  [Figure - 1], [Figure - 2]
 
 
    Tables

  [Table - 1], [Table - 2]


This article has been cited by
1 Partial excision with a conjunctival advancement flap after a relaxing incision for a dissecting glaucoma filtering bleb
Mandal, A.K., Vemuganti, G.K., Ladda, N., Veenashree, M.P.
Ophthalmic Surgery and Lasers. 2002; 33(6): 497-500
[Pubmed]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  Materials and Me...
  In this article
Abstract
Surgical Technique
Case Reports
Case report 1
Case report 2
Results
Discussion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed7042    
    Printed227    
    Emailed19    
    PDF Downloaded2    
    Comments [Add]    
    Cited by others 1    

Recommend this journal