Abstract
The aim of this study was to introduce a reproducible algorithm for the surgical management of late-onset (>2 months) bleb complications after trabeculectomy with mitomycin C. We performed a retrospective review of eyes treated using a reproducible algorithm approach by a single surgeon for the surgical management of late-onset bleb complications from July 2006 to April 2014. Exclusion criteria were bleb revision with less than 3 months of follow-up or bleb revision combined with other glaucoma procedures at the time of surgery. Success was evaluated using the Kaplan-Meier survival method and defined as achieving all of the following criteria: primary surgery indication resolved, no additional surgery required for decreasing the intraocular pressure (IOP), and IOP of ≥6 mmHg and ≤18 mmHg. Twenty-three eyes from 20 patients were evaluated. Indications for bleb revision were hypotonic maculopathy (47.8%), bleb leak (30.4%), and dysesthetic bleb (21.7%). The overall primary outcome success rate calculated using the Kaplan-Meier survival method was 65.2% at 48 months. When the IOP target was changed to ≤15 mmHg, the bleb survival rate was 47.8% at 48 months. At the most recent postoperative visit, 95.7% of eyes had an IOP of ≤15 mmHg and 56.5% were being treated with an average of one medication per eye. One eye (4.3%) required a second bleb revision for persistent hypotony and two eyes required glaucoma surgery to reduce IOP during follow-up. An algorithm approach for the surgical management of late-onset bleb complications with a success rate similar to those reported in specialized literature is proposed. Randomized trials are needed to confirm the best surgical approach.
Highlights
In the surgical management of glaucoma, trabeculectomy is commonly performed as the initial procedure for lowering the intraocular pressure (IOP)
We report the outcomes of patients with various indications for bleb revision, including bleb leak, hypotony, and bleb dysesthesia, who were treated using a reproducible algorithm approach for surgical management by a single surgeon
One eye was excluded because the follow-up period was less than 3 months, and four eyes were excluded because an Ahmed valve was implanted simultaneously with bleb revision
Summary
In the surgical management of glaucoma, trabeculectomy is commonly performed as the initial procedure for lowering the intraocular pressure (IOP). The introduction of antifibrotic agents as an adjunct to trabeculectomy has led to lower intraoperative pressures but higher long-term complications These complications are more frequent in patients with thin-walled, avascular, or cystic blebs[1,2,3,4], and a cumulative frequency of 26% at 20 years has been reported[5]. Some of these complications, such as late-onset bleb leak, can be managed with bandage contact lenses, cyanoacrylate glue, or autologous blood injection. Late-onset bleb complications, such as hypotony, bleb dysesthesia, and bleb leak, are frequently managed with revision surgery[6]
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