Inadvertent Filtering Bleb Research Articles

Inadvertent Filtering Bleb Due to Corneal Stromal Wick Syndrome

We report a unique case in which an inadvertent filtering bleb was created after a complicated cataract surgery through an unusual mechanism: an internal fragment of corneal stroma, which was still attached at one end of the clear corneal wound, was pushed into the anterior chamber, became inadvertently entrapped in the wound, and served as a wick to prevent complete healing.

DELAYED-ONSET BLEB-ASSOCIATED ENDOPHTHALMITIS (1996–2008)

The purpose of this study was to report the clinical features, organisms, and outcomes of patients with delayed-onset bleb-associated endophthalmitis. Retrospective consecutive case series. Patients who were treated for delayed-onset bleb-associated endophthalmitis between January 1, 1996, and July 1, 2008, at a single institution were included. Information on visual acuities, clinical characteristics, causative organisms, and treatment outcomes were collected. Infections within 1 month of glaucoma filtering surgery, inadvertent filtering blebs after cataract surgery, and patients with glaucoma drainage devices were excluded. A total of 71 eyes from 68 patients were identified. An adjunctive antifibrotic agent was used in 48 eyes (68%). The mean time between surgery and endophthalmitis was 4.8 years (range, 0.1-16; standard deviation, 3.6). The average follow-up time after initial treatment was 37 months (range 1-144; standard deviation, 41). At presentation, 17 eyes (24%) had a bleb leak. Fifty-seven eyes (83%) were culture positive. The most common causative organisms were Streptococcus species in 20 eyes (30%), gram-negative organisms in 19 eyes (28%), and coagulase-negative Staphylococcus in 12 eyes (18%). All gram-positive isolates were sensitive to vancomycin. Nine eyes (13%) eventually underwent evisceration or enucleation secondary to pain and/or poor vision. The main outcome measure was best-corrected visual acuity at the last follow-up examination. Final visual acuities in the initial tap/inject group (n = 45) versus the initial vitrectomy group (n = 24) were as follows: ≥ 20/40 (29% vs. 4.2%), 20/50 to 20/400 (36% vs. 29%), and <5/200 (36% vs. 62%). Streptococcus species and gram-negative organisms were the most common causative isolates identified in this case series of delayed-onset bleb-associated endophthalmitis. Despite treatment of the infection, visual outcomes were generally poor.

Microbiologic Identification of Bleb-related Delayed-onset Endophthalmitis Caused by Moraxella Species

To report the clinical presentation and outcome of delayed-onset endophthalmitis caused by Moraxella species and to evaluate the eubacterial polymerase chain reaction (PCR) in aqueous humor samples for the microbiologic diagnosis. Seven patients with bleb-related delayed onset-endophthalmitis caused by Moraxella were included in a prospective multicenter study (FRIENDS group, 2004 to 2005). Eubacterial PCR followed by direct sequencing and conventional cultures were carried out on aqueous humor samples taken before the first intravitreal antibiotic injection and on vitreous samples taken during pars plana vitrectomy. All cases were postoperative (5 after filtering surgery and 2 inadvertent filtering blebs). The mean delay of onset of endophthalmitis was 41.3 months+/-30.4 (SD) (range, 2.4 to 84.8) after surgery. Initial visual acuity was limited to light perception for 3 patients, hand motions for 2 patients, count fingers for 1 patient, and 20/125 for 1 patient. Functional recovery was variable with final visual acuity ranging from no light perception to 20/25. The eubacterial PCR carried out on aqueous humor provided microbiologic identification in all cases, whereas the cultures were negative in 6 of 7 cases. The eubacterial PCR performed on vitreous samples of 3 vitrectomized patients, after 2 intravitreal injections of antibiotics, identified Moraxella in 2 patients, whereas cultures were negative in all cases. Delayed-onset endophthalmitis caused by Moraxella occurs predominantly after a bleb-related infection. PCR is a more sensitive technique for the microbiologic diagnosis in this context than conventional culture.

Inadvertent filtering bleb following sutureless cataract surgery

The case history of a sixty-two-year-old lady, who presented with a bleb in the upper part of her left eye following cataract surgery was studied. The patient had no prior history of any glaucoma surgery. Gonioscopy revealed fishmouthing of the internal aspect of the scleral tunnel incision. The diagnosis of post-cataract filtering bleb was made which was managed by resuturing the wound. This case highlights the use of gonioscopy to visualise and evaluate the internal wound and discusses intraoperative recognition of internal leak and its management with horizontal sutures.

Uso de membrana amniótica no tratamento de complicações pós-trabeculectomia

Methods: Four eyes of 4 patients presenting post-trabeculectomy with mitomycin-A complications (leaking blebs, 3 eyes, and inadvertent filtering bleb, 1 eye) underwent bleb reconstruction with amniotic membrane. Results: Mean follow-up time was 5.75 months (range, 2 to 9 months). Complete resolution was achieved in all cases. In one case it was necessary to add cyanoacrylate tissue adhesive and place a therapeutic contact lens. The epithelialization occurred within 14.75 days (range, 8 to 21 days). Visual acuity improved in 1 patient and did not change in the other 3 cases. Intraocular pressure remained under control in all patients with the additional use of topical antiglaucomatous medication. Conclusions: The use of amniotic membrane seems to represent a viable option for the treatment of post-trabeculectomy leaking and inadvertent filtering blebs that were resistant to conventional therapy. More cases are necessary for further analysis and to refine the technique.

Management of large, leaking, and inadvertent filtering blebs with the neodymium: YAG laser

Objective The purpose of the study was to test the efficacy of the neodymium:YAG (Nd:YAG) laser for repairing filtering blebs. Design The study design was a prospective study. Participants Five eyes of five patients with leaking blebs (group 1), five eyes of five patients with large irritating blebs (group 2), and four eyes of four patients with inadvertent filtering blebs in the surgical wound after cataract surgery (group 3) were studied. Intervention The thermal mode of the Lasag Microrupter II Nd:YAG laser was used to treat the filtering blebs. The area of the bleb targeted for treatment was “painted” with methylene blue and then exposed to Nd:YAG laser treatment with an energy level of 2.5 to 3.75 J in a grid pattern. The aiming beam was focused on the conjunctiva, but the laser beam was offset according to the height of the bleb (offset of 0.9–1.5 mm, 4–5 on the Lasag) to selectively treat the internal surface of the bleb. Main outcome measures Symptomatology, intraocular pressure (IOP), and complications were measured. Results After the laser treatment, all the leaks in group 1 were healed, all the patients in group 2 reported relief of their symptoms, and all blebs in group 3 shrank considerably. The IOP increased significantly ( P < 0.001) after laser treatment in all three groups. This elevation appeared to diminish over time, with the major increase in IOP being recorded within the first month after the laser treatment. However, satisfactory IOP control was maintained in nearly all patients (13 of 14) who received none or one antiglaucoma medication. The visual acuity of one patient decreased significantly because of cataract formation. Complications included transient pressure rise (1 eye), bleb failure (1 eye), pupillary retraction toward the bleb (6 eyes), iatrogenic bleb leak (6 eyes), and cataract (1 eye). Conclusion The continuous wave Nd:YAG laser is an effective tool for repairing bleb-related problems while maintaining successful filtration.

Haemophilus aphrophilus Endophthalmitis Associated With a Filtering Bleb

Haemophilus is an extremely rare cause of endophthalmitis in the immediate postoperative period, but it is a well-established causative agent of late-onset endophthalmitis associated with either intentional or inadvertent filtering blebs. 1,2 To our knowledge, this is the first reported case of endophthalmitis due to Haemophilus aphrophilus in a patient with an inadvertent bleb following cataract extraction. Report of a Case. —A 51-year-old white man presented with a 5-day history of a red, painful right eye associated with decreased visual acuity of approximately 48 hours' duration. His ocular history was significant for an uneventful extracapsular cataract extraction in the right eye with a posterior chamber intraocular lens placement 2 years earlier. He denied any recent history of fever, chills, local eye trauma, cardiac valvular disease, recent sinusitis, or oral soft-tissue infections. Visual acuity was light perception in the right eye and 20/20 OS. There was no evidence of an afferent