Conjunctival Leaks Research Articles

Short-Term Outcomes of a Modified Safer Surgery Trabeculectomy Technique

Abstract Purpose: To determine the short-term outcomes of a modified Moorfields Safer Surgery System technique of trabeculectomy. Methods: This is a prospective interventional study. Trabeculectomy was performed according to the author’s modification of Moorfields Safer Surgery System. This method allows titrating the opening pressure of trabeculectomy by varying the side cuts, varying the ostium size, and adjusting the tightness of the sutures. Forty-four eyes of 43 patients were included. Main outcome measures include postoperative intraocular pressure (IOP), incidence of intra and postoperative complications, and success up to 6 months after surgery. Results: The mean preoperative and postoperative IOP at 6 months were 20.97 ± 7.93 mmHg and 12.69 ± 4.76 mmHg, respectively (n = 44). 70.5% of the patients had absolute success at 6 months, and the overall success was 88.6%. None of the patients had hypotony and there were no intraoperative complications noted. Forty-two out of 44 eyes (95.5%) had diffuse formed blebs without leak on the 1st postoperative day. The most common postoperative complication (13.6%) was a conjunctival leak that was detected on fluorescein staining. In all these patients, the anterior chamber was deep, and the bleb well formed. These leaks were resolved with conservative measures. Many of these leaks would have been missed if not intentionally looked for. Excluding this complication, we had a complication rate of 9.1%. Conclusion: The authors’ modification of the Moorfields Safer Surgery System technique may allow the surgeon to optimize aqueous flow through trabeculectomy while mitigating complications.

Outcomes of conjunctival compression sutures for hypotony after glaucoma filtering surgery

To evaluate the outcomes of conjunctival compression sutures (CCS) for enlarged overfiltering blebs associated with ocular hypotony after uncomplicated trabeculectomy with mitomycin C (TM). A retrospective analysis of consecutively recruited patients with enlarged conjunctival bleb associated with hypotony who had undergone CCS was performed. Patients were considered for CCS if they had enlarged overfiltering bleb for at least 4 weeks, following an uncomplicated TM, with no sign of resolution. Only patients with hypotony, defined as intraocular pressure (IOP) <6 mm Hg associated with a reduced vision of at least 2 lines, were included. Success was defined as an IOP >6 mm Hg 6 months after surgery. A total of 45 eligible patients were identified. In 29 eyes of 45 patients (64.4%), success in providing resolution of the preexisting hypotony (postoperative IOP mean ± standard deviation 13.4 ± 1.8 mm Hg, range 10-16 mm Hg) was obtained. Out of these 29 eyes, 9 eyes had a conjunctival bleb diffusion over 180 degrees, 19 eyes overfiltering bleb over 270 degrees, and 1 eye over 360 degrees. Complications from CCS included a transient spike of IOP in the first postoperative week (8 patients); a bleb rupture associated with conjunctival leaks and hypotony was observed in one eye. The placement of CCS is a safe and effective technique for managing overfiltering blebs associated with hypotony. The present study suggests that CCS are not effective for dealing with circumferential blebs extending over 360 degrees.

Our experience of fibrin sealant-assisted implantation of Ahmed glaucoma valve

Dear Editor, While I commend the work by Dr Nikhil and team for their innovative use of fibrin glue for scleral patch graft in Ahmed glaucoma valve implantation,[1] I have a few queries and comments. The size of the graft stated to have been used was 4–5 mm. I wonder if this size would suffice to achieve a good seal of the patch graft over the tube with fibrin glue as there would be less flat surface for good apposition. A larger graft can overcome this. Scleral patch graft is thicker than Tutoplast used by Kahook and Noecker[2] and one can expect this to get lifted off the tube easily. Please clarify on this. The authors discuss about tube blockage, tube cornea touch, conjunctival erosion that are not directly related to the use of glue but failed to mention about patch graft migration. Kindly clarify. Was the risk of infection increased due to use of glue on donor scleral graft? This is not mentioned in the article. As much more dissection of conjunctiva is required for a shunt versus trabeculectomy, more sutures are required to achieve conjunctival closure. So it would not be unreasonable to use glue rather than sutures, which would definitely reduce the discomfort. The authors explain that conjunctival fibrosis experienced in their cases prevented them from considering glue for conjunctival closure. But in such a situation, even conjunctival suturing would be challenging (can cause buttonholing). At least glue besides apposing the conjunctiva would achieve a good seal and prevent leak. Preventing conjunctival leak is equally important in a shunt procedure. Please comment. In scleral thinning as seen in one of the cases with anterior staphyloma, suturing the patch graft would not be a viable option and there, glue outscores. This could be a real indication. The authors comment that fibrin sealant-assisted implantation takes less time than sutures. I am afraid this might not be true. The preparation and waiting time for the glue to set in would be similar or slightly more than suturing (four sutures). Please comment. This is only yet another indication for use of fibrin blue. In the Indian context, use of glue does not give any added advantage but in contrast, only increases the cost of surgery given the fact that implants are expensive. If one plans to use fibrin sealant then it should be utilized for conjunctival closure as well.

Multifocal conjunctival leaks due to the use of mitomycin C mimicking the normal drainage of the tear from the lacrimal excretory ducts

Multifocal conjunctival leaks due to the use of mitomycin C mimicking the normal drainage of the tear from the lacrimal excretory ducts Burak Turgut1, Murat Kaya1, Tamer Demir1, Orhan Aydemir1, Beng&uuml; &Ccedil;obanog˘lu21Fırat University School of Medicine, Department of Ophthalmology, Elazig, Turkey; 2Fırat University School of Medicine, Department of Pathology, Elazig, TurkeyAbstract: A 20-year-old male patient underwent trabeculectomy with mitomycin C (MMC) because of glaucoma secondary to the use of corticosteroid drops. There were three conjunctival holes, which had a positive Seidel test, near the superior fornix three weeks after surgery. Because of hypotony and choroidal effusion in the operated eye, the patient was hospitalized and medical treatment carried out. Despite medical treatment, the leak continued for ten days. The conjunctiva was then partially excised and the tissue was subjected to histopathological evaluation. The conjunctiva and Tenon&rsquo;s capsule were sutured and the Seidel test was negative, intraoperatively. The histopathological examination of the tissue showed necrosis due to MMC. The excising of conjunctival necrotic tissue provided successful control of intraocular pressure and the patient became asymptomatic at six months follow-up. It should be considered that a leak from superotemporal conjunctiva near the fornix after trabeculectomy with MMC may be confused with orifices of the lacrimal gland ducts.Keywords: trabeculectomy with MMC, conjunctival necrosis, leak

DETECTION OF CONJUNCTIVAL LEAKS FOLLOWING FILTRATION SURGERY

DETECTION OF CONJUNCTIVAL LEAKS FOLLOWING FILTRATION SURGERY