Transcript Bleb leak characteristics and success of repair following

Bleb leak characteristics and
success of repair following
trabeculectomy with Mitomycin C
Amy Hennessy, MD MPH
Harold Bernstein, MD
Medical College of Virginia
Richmond, VA
Authors have no financial interests to disclose
Background
• Mitomycin C and 5-fluorouracil are the most
common adjunctive agents used in filtering
surgery today
– Blebs may be thinner with more irregular
epithelium, breaks in basement membrane,
fewer goblet cells, and atrophic and avascular
stroma 1,2,3,4,5
– Thin, avascular, leaking blebs commonly
associated with blebitis or endophthalmitis 1,2,3,4
Bleb leaks are relatively common
and can be potentially serious
• 4.2-10% incidence of late bleb leak after trabeculectomy with
MMC 5
• Risk of bleb leak, blebitis or endophthalmitis during the first 5
years after trabeculectomy is 4.4% per year 1
• 3 times greater incidence of bleb leak in eyes treated with
MMC compared with eyes treated with 5-FU (5.9% vs 1.7%) 5
• In a group of 123 eyes of POAG patients followed for 6.8
years after trabeculectomy, 9 with bleb leak, 4 with blebitis 6
• In 258 trabeculectomies DeBry and colleagues identified 9%
incidence of bleb leak; 2% blebitis, 3% endophthalmitis 1
• Infection 25 times greater in eyes with bleb leaks compared to
those without leak 7
Bleb leak management
Goal:
• Eliminate leak and hypotony while
preserving filtration function and maintaining target
IOP 2,7,8
Surgical bleb leak management:
• Conjunctival advancement with or without excision of the
existing bleb, free conjunctival graft, scleral patch graft,
amniotic membrane graft 2,3,4,7,9
• 2 most frequent techniques: free conjunctival graft and
advancement of adjacent conjunctiva 4,7,9
• Best surgical approach unclear 2
Purpose of Study
• Characterize a population of patients who
experience bleb leaks following trabeculectomy
with mitomycin C
• Determine predictors of successful outcome of
surgical repair by 1 surgeon
• Determine outcomes (visual acuity, IOP, Seidel
status) before and after typical conjunctival
advancement repair of bleb leak
Methods
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Retrospective medical record review of 16 patients with
documented bleb leaks found over a 3 year period
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At least 1 month of post-operative follow-up
2 with associated blebitis
SAS statistical program used to analyze data
Initial conservative treatment (aqueous suppression,
bandage contact lens, topical antibiotic, eye shield)
followed by surgical repair: 2 possibilities
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If mobile conjunctiva and bleb not extending onto cornea, then
conjunctival advancement with cautery to de-epithelialize thin
conjunctiva (10/16)
If need for bleb excision or patch graft required, more difficult
repair performed, sometimes including entry into anterior
chamber (6/16)
Definition of successful repair
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No blebitis, no endophthalmitis, no bleb dysesthesia
Resolution of leak
No further surgery
< 1 additional IOP-lowering med
IOP maintained between 6 and 21
• Grading success:
– “Complete” success:
• All criteria met; no surgery or medical problems post-op
– “Partial” success:
• No return to surgery, no infection, no dysesthesia but additional meds
required to maintain IOP between 6 and 21
– Failure:
• Return to surgery
• Need for 2 or more medications for IOP control
Results
• 16 patients with bleb leak
– 9 male (56.25%), 9 white (56.25%)
– Average age at initial surgery 66.6 (+9) years
• 15 POAG, 1 unintentional filtering bleb (ICCE)
– 14 trab, 1 combined procedure
– All 15 received MMC with initial trabeculectomy
• Mean concentration 0.5mg/cc
• Mean duration 1.8 minutes
• 68.75% limbal-based flap, 3 unknown, 1 fornix-based
– Average age at leak 74.3 (+7.9) years
• Mean of 95.4 months (~8 years) from initial surgery to leak
• Surgical repair 6.1 months after leak noted
– Range 21 days-21 months
– Given 2-3 office visits with non-surgical measures
– Large range of delayed repair due to patient issues
• Refused surgery, not medically stable
Results
• Mean follow-up after repair: 8.1 months +/4.7 (range 1 month to >12 months)
• Intraocular pressure significantly increased
(p<0.0001)
– Pre-op IOP 5.3 + 4.1 (range 0-15)
– Post-op IOP 12.6 + 3.4 (range 6-21)
• Visual acuity improved (p=0.09)
– Mean pre-op logMAR 0.56 (VA 20/70)
– Mean final post-op logMAR 0.33 (VA 20/40)
Success of repair
• Complete success:
– 11/16 (68.75%)
• At least “Partial” success:
– 14/16 (87.5%)
• Failure: 2/16 (12.5%)
– IOP 27 on 4 medications
– Persistent leak
• No clinical factors predicted success or failure
• 5-FU not given in post-op period may be associated
with failure (OR 4.8, CI 0.4-58.0) (p=0.21)
Conclusions
• Bleb leak is an infrequent yet significant problem
complicating filtering surgery
• This small study on bleb leak repair shows similar
results to studies by Catoira 2 and Tannenbaum 8
• Bleb repair by conjunctival advancement appears
successful in correcting bleb leak, maintaining
IOP, improving visual acuity and preventing blebrelated infection when other methods have failed
• It may be that 5-FU given in post-operative period
affects the outcome of bleb leak repair
References
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1. DeBry PW, Perkins TW, Heatley G, Kaufman P, Brumback LC. Incidence of late-onset
bleb-related complications following trabeculectomy with mitomycin. Arch Ophthalmol. 2002
Mar; 120: 297-300.
2. Catoira Y, WuDunn D, Cantor, LB. Revision of Dysfunctional filtering blebs by
conjunctival advancement with bleb preservation. Am J Ophthalmol. 2000; 130: 574-579.
3. Wadhwani RA, Bellows AR, Hutchinson BT. Surgical repair of leaking filtering blebs.
Ophthalmology. 2000 Sep; 107(9): 1681-1687.
4. Budenz DL. Barton K, Tseng SCG. Amniotic membrane transplantation for repair of
leaking glaucoma filtering blebs. Am J Ophthalmol 2000; 130: 580-588.
5. Greenfield DS Liebman JM Jee J Ritch R. Late Onset bleb leaks after glaucoma filtering
surgery. Arch Ophthalmol. 1998 April; 116: 443-447.
6. Shigeeda T, Tomidokoro A, Chen YN, Shirato S, Araie M. Long-term follow-up of initial
trabeculectomy with mitomycin C for primary open angle glaucoma in Japanese patients. J
Glaucoma. 2006 Jun; 15(3): 195-199.
7. Burnstein AL, WuDunn D, Knotts SL, Catoira Y, Cantor LB. Conjunctival advancement
versus nonincisional treatment for late-onset filtering bleb leaks. Ophthalmology. 2002 Jan;
109(1):71-75.
8. Tannenbaum DP, Hoffman D, Greaney MJ, Caprioli J. Outcomes of bleb excision and
conjunctival advancement for leaking or hypotonous eyes after glaucoma filtering surgery.
Br J Ophthalmol. 2004 Jan; 88(1): 99-103.
9. Budenz DL, Chen PP, Weaver YK. Conjunctival advancement for late-onset filtering bleb
leaks: indications and outcomes. Arch Ophthalmol. 1999 Aug; 117(8):1014-1019.