Thin Bleb Research Articles

Compression sutures with autologous blood injection for leaking trabeculectomy blebs

Leaks may follow trabeculectomy surgery, particularly where antimetabolite useage has resulted in thin or avascular filtration blebs. Leaking blebs are associated with endophthalmitis, low intraocular pressure (IOP), hypotony maculopathy and...

Ultrasound Biomicroscopy and Optical Coherence Tomography Imaging of Filtering Blebs after Deep Sclerectomy with New Collagen Implant

To identify the clinical and anatomic characteristics of filtering blebs after glaucoma surgery with a new biodegradable collagen implant, Ologen, using ultrasound biomicroscopy (UBM) and Visante anterior segment optical coherence tomography (OCT). The authors conducted a prospective interventional case series in 15 eyes with openangleglaucoma. The authors performed limbal-based deep sclerectomy with Ologen implantation in the scleral bed. UBM, Visante anterior segment OCT, and a complete ophthalmic examination were performed at each follow-up visit, at 1 day, and 1, 4, and 12 weeks postoperatively. Intraocular pressure (IOP) was significantly reduced (p<0.001) from a mean preoperative value of 24.2-/+6.8 mmHg (n=2.82 glaucoma medications) to a mean postoperative value of 8.1-/+1.2 (n=0), 8.5-/+1.3 (n=0), 11.7-/+3.2 (n=0), and 14.2-/+3.9 mmHg (n=0.33) at 1 day, and 1, 4, and 12 weeks, respectively. Lower IOP correlated with bleb height and low trabeculocorneal membrane thickness (r=0.79, p<0.01, r=0.91, p<0.001) based on UBM examination. Lower IOP correlated with thin bleb wall, large subconjunctival fluid spaces, and low bleb tissue reflectivity (r=0.81, p<0.01, p<0.001, and p<0.001) based on OCT examination. No postoperative complications were reported. UBM and OCT examinations are useful methods to evaluate outflow mechanisms after glaucoma surgery. Deep sclerectomy with Ologen implantation seems to be an effective and well-tolerated method to reduce IOP.

Control of filtering bleb scarring trough tissue bioengineering

Abstract Purpose To evaluate the effects on intraocular pressure (IOP) reduction and bleb morphology of a new biodegradable collagen implant iGen TM, a porous matrix reducing scar formation after glaucoma surgery. Methods We conducted a prospective interventional case series in 18 eyes of 18 patients with uncontrolled primary open‐angle glaucoma. We performed limbal‐based deep‐sclerectomy with implantion of the device in the scleral bed. We performed a complete ophtalmic examination, ultrasound biomicroscopy (UBM) and Visante anterior segment Optical Coherence Tomography (OCT) at each follow up visit, scheduled 1 day, 1 week, 4 and 12 weeks post‐operatively. Results Postoperative IOP decreased significantly (p &lt; 0.001) from a preoperative mean value of 25.1 ± 5.9 mm Hg (n = 2.73 glaucoma medications) to a postoperative mean value of 8.0 ± 1.1 (n = 0), 8.3 ± 1.2 (n = 0), 11.5 ± 3.0 (n = 0) and 14.1 ± 3.7 mm Hg (n = 0.28) at 1 day, 1week, 4 and 12 weeks respectively. Characteristic imaging parameters of successful bleb were frequently observed (14/18 patients): high and hypoechoic bleb with UBM; thin and hyporeflective bleb wall, multiple subconjunctival fluid spaces and hyporeflective deep bleb tissue with OCT. Bleb height and trabeculocorneal membrane thickness are correlated with low IOP (r = 0.91 p &lt; 0.01, r = 0.90 p &lt; 0.001) with UBM examination. Thin bleb wall, large subconjunctival fluid spaces and low reflectivity of bleb tissue are associated with lower IOP (r = 0.81 p &lt; 0.01, p &lt; 0.001 and p &lt; 0.001) with OCT examination. No post‐operative complications were reported. Conclusion In our series, deep‐sclerectomy with iGen TM implantation seems to be an effective and well‐tolerated method to lower IOP and avoid conjunctival scarring.

Clinical effect of phacoemulsification combined with trabeculectomy in glaucoma patients

目的 探讨可调节缝线在晶状体超声乳化及人工晶状体植入术联合小梁切除术及术中应用丝裂霉素(MMC)的临床效果.方法 66例(66眼)行透明角膜切口超声乳化及人工品状体植入,标准小梁切除术,术中应用丝裂霉素和经透明角膜可调节缝线,术后观察眼压、视力及并发症,随访时间>6月.结果 平均随访(10.22±3.13)月.术后视力提高者占66.67%,不变24.24%,下降9.09%.术前平均眼压(26.43±12.75)mmHg(1mmHg=0.133kPa).术后随访期末眼压<2lmmHg占94.33%.功能性滤过泡(Ⅰ型和Ⅱ型)89.39%,非功能性滤过泡(Ⅲ型)6.06%,薄壁滤过泡4.55%.并发症包括角膜水肿,浅前房,前房渗出等.结论 可调节缝线在晶状体超声乳化及人工晶状体植入术联合小梁切除术及丝裂霉素,操作简单,不引起刺激症状,减少术后早期并发症。

010 Drainage angulaire uvéal par implant biologique non absorbant en cas de glaucome réfractaire

Different shunts have been used in cases of refractory glaucoma. A lot of complications were connected with the excess of fluid filtration. To estimate the efficiency of the insertion of the biological implant from osteal collagen (DCA) saturated with glucosaminoglycans (registered certificate of RF) into the anterior chamber angle was the purpose of the investigation. 22 eyes: uveal glaucoma–2, neovascular-6, pigmentary-10, closed-angle – 4, (2 years of follow-up). Previously all patients had 1 to 5 different antiglaucomatous procedures. The implant has porpous structure (pors size from 50 to 700 mkm). Drainage is elastic and it's size can be changed by surgeon, usually 3×1,5×0,8 mm. DCA was implanted 1,0 mm into the anterior chamber under the superficial scleral flap, on the surface of the ciliary body. There was no inflammatory reaction in the experimental part of the work, in patients in the early post-op or in late follow-up period. In late follow-up period there was no iris destruction or corneal edema in the places of contact with the implant. DCA prevent the excess filtration from the anterior chamber, there was no post-op athalamia. At the final follow-up visit, IOP was 6-15 mm Hg (10,1 ± 0.5) (before surgery 32-45 mm Hg). After 2 years 3 patients were without medications, 17 eyes – 1-2 medications a day. One eye had thin bleb, in 19 cases - flat blebs with good vessels. The use of new drain can reduce the number of complications in such difficult category of patients, as those with refractory glaucoma. This is an advantage in comparison with other shunts. The new biological implant from osteal collagen is stable for biodestruction. It doesn’t provoke any inflammatory reaction. The antiglaucoma procedures with this biological implant is safe and effective in patients with refractory glaucoma.

ERRATUM

Birt-Hogg-Dubé (BHD) syndrome is a rare inherited genodermatosis characterized by distinctive cutaneous lesions, an increased risk of renal and colonic neoplasia, and the development of pleuropulmonary blebs and cysts. Although the pathology of renal and cutaneous manifestations of BHD has been well described, few reports have detailed the pathologic features of pulmonary involvement. Herein we present the pathologic findings from biopsies of 2 BHD patients with spontaneous pneumothorax: 1 with known BHD and another clinically suspected to have lymphangioleiomyomatosis. Histologic features included basilar cysts comprised of intraparenchymal collections of air surrounded by normal parenchyma or a thin fibrous wall and blebs consisting of collections of air within the pleura. Although these histologic findings are not specific to BHD, their predominantly basilar location contrasts with the apical distribution of other more well-recognized causes of spontaneous pneumothorax, such as emphysematous bullae and idiopathic blebs. It is important for pathologists to be aware of this rare cause of spontaneous pneumothorax because BHD can radiographically simulate other causes of pulmonary cysts and the lung and pleura may be the initial sites of involvement. Patients with BHD are at increased risk for renal neoplasia and may benefit from periodic surveillance. Pathologists should raise the possibility of BHD in nonapical lung biopsies from young or middle-aged patients that show blebs or cysts.

Trabeculectomy with mitomycin C in the treatment of post-traumatic angle-recession glaucoma

目的 观察小梁切除术术中联合应用丝裂霉素C(Mitomycin C,MMC)治疗外伤性房角退缩性青光眼的效果.方法 小梁切除术联合术中应用MMC治疗外伤性房角退缩性青光眼22例(22眼).术后对眼压、视力和并发症进行了分析.以Kaplan-Meier寿命表判断成功率.结果 成功标准为:不用或用局部抗青光眼药物,眼压在6～21 mmHg之间;不需要再进行抗青光眼手术;并且未发生严重的并发症.6月累积成功率为86.36%(n=22),12月为78.57%(n=14),18月为66.67%(n=6).术后视力与术前相同或稍有提高17例(77.27%),视力下降5例(22.73%).并发症包括浅前房6眼、薄壁滤过泡3眼、低眼压1眼和白内障1眼.结论 小梁切除术联合MMC是治疗外伤性房角退缩性青光眼一种有效的方法.术后大部分病人眼压被控制,保存了有用的视力。

Determinants of Bleb Morphology in Minimally Invasive, Clear-Cornea Micropenetrating Glaucoma Surgery with Mitomycin C

Antimetabolites, especially mitomycin C (MMC), increase the incidence of late bleb-related endophthalmitis in trabeculectomy. This is related to a higher incidence of avascular, thin, cystic, translucent blebs, which may be caused by a toxic effect on conjunctival tissue. An MMC dose-response study was carried out focusing on bleb morphology and function. In a retrospective, comparative case series study, 2 successive groups of patients with complicated glaucoma were compared 2 years after a special, minimally invasive, filtering procedure (intrastromal holmium laser keratostomy). Preoperative local subconjunctival injections of a fixed MMC dose (4 microg) were used in group A, and lower MMC doses, calculated individually (1 or 2 microg), were used in group B. Bleb vascularity and morphology were evaluated by masked grading of photomicrographs. Bleb function was evaluated by intraocular pressure (IOP). Total bleb avascularity occurred in 63% of the blebs in group A and 0% in group B (P < 0.01). In eyes with IOP < or = 20 mmHg without medical treatment, the mean IOP was significantly lower in group 1 (8 vs 15 mm Hg, P < 0.002). A translucent cystic bleb without conjunctival stroma was observed in only 1 eye in group A. An optimal spongy stromal bleb was observed in all other eyes (96%) despite the different MMC doses. The numbers of complications in the 2 groups were nearly equal. Bleb avascularity after 4 microg MMC could be avoided by the use of 1 or 2 microg MMC on the basis of preoperative prognosticators for failure, but at the expense of some of the IOP-lowering effect. This indicates that the therapeutic index (clinical safety margin) of MMC seems to be narrow. An MMC dose-response relation was not observed for the thin, cystic, and translucent bleb. The low incidence of this bleb (4%) indicates that the operative technique, apart from the vascularity, may be the most essential determinant of bleb morphology.

Trabeculectomy with mitomycin C in the treatment of pediatric glaucoma

目的 观察小梁切除术联合丝裂霉素C(MMC)治疗儿童青光眼的疗效和安全性.方法小梁切除术联合MMC治疗儿童青光眼32例(32眼)年龄3～14岁.术后随访时间6～40月(平均18.07±5.81月),对眼压、视力和并发症进行了分析,以Kaplan-Meier寿命表判断成功率.结果相对成功率标准为:眼压6～21 mmHg,不用或用抗青光眼药物,不需要再进行抗青光眼手术,并且未发生严重的并发症.6月累积成功率为85.47%(n=32),12月为76.32%(n=25),24月为64.29%(n=12).并发症包括浅前房6眼、薄壁滤过泡5眼、滤过泡渗漏3眼、囊样滤过泡2眼、低眼压2眼、滤过泡炎1眼、白内障1眼和视网膜脱离1眼.结论小梁切除术联合MMC可能是治疗儿童青光眼一种有效的方法.然而,MMC术后薄壁滤过泡和滤过泡相关的感染以及其他问题尚需长期随访。

Histopathologic Features of Conjunctival Filtering Blebs

To characterize and compare the histological features of conjunctiva obtained during the repair of trabeculectomy and inadvertent blebs and to assess the effects of antifibrotic agents. We used routine paraffin processing and light microscopy to examine conjunctival specimens from 28 eyes undergoing late bleb revision: 19 leaking trabeculectomy blebs, 5 nonleaking trabeculectomy blebs, and 4 inadvertent blebs. Quantitative analysis of histological characteristics included conjunctival epithelial thickness, stromal vascularity, squamous metaplasia, stromal inflammatory cell infiltrate, and goblet cell density. The type of surgery, presence of leaks, prior topical medication, and antifibrotic use were correlated with histological findings. Trabeculectomy blebs (leaking and nonleaking) showed decreases in overall epithelial thickness (P<.02), goblet cell density (P<.001), and vascularity (P<.001) compared with inadvertent bleb controls. Conjunctiva exposed to antifibrotics had fewer layers of epithelial cells than those with no prior exposure (P<.05). Histological analysis of thin blebs excised following trabeculectomy demonstrated decreases in epithelial thickness and goblet cell density compared with inadvertent blebs. Both leaking and nonleaking trabeculectomy blebs exhibited decreases in localized stromal vascularity and increases in surrounding stromal vascularity compared with normal conjunctiva.

Long term growth arrest of human Tenon’s fibroblasts following single applications of β radiation

AIMS/BACKGROUNDAntimetabolites are increasingly used to manipulate the healing response after filtration surgery, but problems with thin cystic blebs have been encountered with the liquid agents commonly used such as 5-fluorouracil...

Conjunctival impression cytology of the filtering bleb.

Impression cytology was used to evaluate the conjunctival surface change after filtering surgery and its association with bleb type and mitomycin C. Impression cytology were obtained at least ten (mean, 20.4) months after surgery from 22 eyes of 19 patients who had undergone trabeculectomy, and were graded according to a previously described system. Blebs were divided into thin cystic and thick diffuse types. Abnormal impressions, demonstrated as disturbed epithelial and goblet cell morphology and a decrease in the numbers of both cells, were found in nine eyes (40.9%). With regard to the prevalence of abnormal impressions, there were statistically significant differences between bleb type and between the use or non-use of mitomycin C (p = 0.040, 0.013); these related more to the use of mitomycin C than to bleb type. This study reveals that filtering surgery causes long-term damage to the conjunctival epithelium overlying a filtering bleb, especially in a patient with a thin cystic bleb or one has been treated with mitomycin C. This change in the conjunctival surface may lead to the occurrence of late hypotony and bleb-related infection.

Topical Dorzolamide-lnduced Hypotony and Ciliochoroidal Detachment in Patients With Previous Filtration Surgery

We describe 2 patients who have undergone glaucoma filtration surgery in whom delayed hypotony and ciliochoroidal detachment developed following treatment with topical dorzolamide hydrochloride, 2%. Report of Cases. Case 1. A 76-year-old woman was examined 9 months after undergoing cataract extraction combined with trabeculectomy in the right eye. Her intraocular pressure was 31 mm Hg. Biomicroscopy revealed a thin flat bleb and a deep and quiet anterior chamber. Apraclonidine hydrochloride, 0.5%, was prescribed for the patient. Her intraocular pressure stabilized at 18 mm Hg, but further intraocular pressure reduction was indicated and dorzolamide hydrochloride, 2%, was prescribed. Two weeks later, the patient described having a 6-day history of decreased vision and pain in her right eye. An examination revealed a reduction of visual acuity from 20/70 to counting fingers. The intraocular pressure was 5 mm Hg. The conjunctiva was 3+ injected with a flat, Seidel-negative bleb. The anterior chamber was

Treatment of Postfiltration Bleb Leaks with Autologous Blood

Managing filtration surgery bleb leaks can be difficult as well as frustrating. Treatment options traditionally have included aqueous suppressants, patching, and bleb compression devices. Previously, if conservative management failed, surgical revision was considered. Six patients with thin avascular blebs and discrete leaking holes (2 had had full-thickness procedures, 4 had had trabeculectomy with mitomycin C) underwent subconjunctival injection of approximately 1 ml of whole autologous blood. Injections were made just lateral and just medial to the domed cystic elevation of the blebs. Five of six eyes were leak-free by the second day after the procedure. No complications occurred. After 4 to 12 months of follow-up, four eyes are currently leak-free. In these eyes, intraocular pressure is between 8 and 12 mmHg. Subconjunctival peribleb injection of autologous blood may be a safe and helpful adjunct in treating selected postfiltration surgery bleb leaks.

Intraoperative 5-Fluorouracil Administration in Trabeculectomy

The purpose of this study was to determine whether 5-fluorouracil administered as a single intraoperative dose beneath the conjunctival flap during trabeculectomy in patients with glaucoma would be safe and effective. This prospective case series consists of 43 eyes of 43 consecutive patients who underwent trabeculectomy with intraoperative topical administration of 5-fluorouracil. Surgical outcome and success rate of the procedure were evaluated at a 6-month follow-up period. Success was defined as a postoperative intraocular pressure (IOP) of </=21 mm Hg with a minimum 20% drop in IOP from preoperative levels and one Snellen line or less loss of visual acuity, at the end of 6 months. The overall success rate was 85.4%. Mean IOP was 31.4 +/- 11.4 preoperatively and 15.1 +/- 4.6 postoperatively. The mean number of antiglaucoma medications was reduced from 2.8 +/- 0.9 to 0.4 +/- 0.7. Success rates were 69.2% in eyes with high risk for failure and 92.9% in relatively low-risk eyes. A thin and ischemic bleb was characteristic in the immediate postoperative period and remained so in all successful eyes with the exception of five eyes (11.6%) that developed encapsulated blebs. There were no corneal epithelial complications. Intraoperative 5-fluorouracil application directly to the trabeculectomy site appears to be a safe and effective method. It can be a valuable alternative in glaucoma surgery, but may be less successful in eyes with high risk for failure.

Differentiation of Dunn osteosarcoma cells in response to dibutyryl cyclic 3',5'-adenosine monophosphate.

We investigated the effects of dibutyryl cyclic adenosine 3',5'-monophosphate (Bt2cAMP) on the differentiation of Dunn osteosarcoma cells. Flow-cytometric analysis and DNA synthesis assay showed that Bt2cAMP decreased the cell population in the S phase in a time- and dose-dependent manner. Also, the cells showed distinct morphological and functional alterations; the cell morphology changed to a fibroblast-like appearance with long and thin protoplasmic processes, the knobs or blebs on both the cell membrane and nuclear membrane disappeared and the intracellular alkaline phosphatase activity increased. Moreover, Bt2cAMP-treated cells secreted a large quantity of fibronectin, which was deposited on the extended cell surface in the culture medium. Thus, Dunn osteosarcoma cells are differentiated morphologically and functionally by Bt2cAMP, and might be transformed to benign precursor cells.

Risk Factors Associated With Late Infection of Filtering Blebs and Endophthalmitis

Late infection of filtering blebs and endophthalmitis are hazardous complications of glaucoma filtering surgery frequently associated with bleb failure and loss of functional vision. To determine possible risk factors for the development of these complications, characteristics of nine eyes of nine patients after filtering surgery in whom late endophthalmitis developed were compared with those in patients who had received a comparable operation at the same time in whom endophthalmitis did not develop. An average of 7.7 +/- 6.2 years (range, 6 months to 18 years) elapsed between the time of the filtering procedure and the initial appearance of endophthalmitis. Factors associated with increased risk were: increased axial length, thin and leaky bleb, conjunctivitis, upper respiratory infection, and the winter season.

Complications of 5—Fluorouracil after trabeculectomy

Trabeculectomy has a very high success rate, however, certain eyes are known to be at high risk of failure due to scarring of the conjunctival bleb. Such eyes include those with a previous failed filter, eyes with glaucoma secondary to uveitis and neovascularisation and the eyes of children and young adults. Trabeculectomy is generally accepted to have less successful results in patients of African race although good results are reported from some centres. The effectiveness of treatment with 5-fluorouracil in improving the results of trabeculectomy has been established in a number of pilot studies and clinical trials. Early studies used 100 mg of 5-fluorouracil in divided doses. Serious complications were recorded and lower dose regimes have been advised to improve the safety of the technique. Similar success in improving the chance of success to trabeculectomy has been found with doses of 40 mg with a lower incidence of side effects. We report complications associated with the use of 5-fluorouracil in a total dose of 50 mg in a group of 49 eyes undergoing trabeculectomy and postoperative 5-fluorouracil and describe the previously unreported increased incidence of thin cystic blebs in these eyes.

PHILADELPHIA DERMATOLOGICAL SOCIETY

<b>Congenital Ichthyosiform Erythroderma.</b>Presented byDr. John P. Scully, Reading, Pa. R. H., a white woman aged 30 years, soon after birth acquired a bullous eruption on an erythrodermic background. The bullous lesions had lessened by the end of her first year. She has had persistent dryness and scaling of the skin during her lifetime. During the past summer recurrent pruritic erythematous lesions of the lower extremities were secondarily infected at times. The blood count, sedimentation rate, fasting blood sugar, results of urinalysis and blood urea nitrogen were normal. A hemolytic Staphylococcus aureus, coagulase-positive, was cultured from the leg. The biopsy report was as follows: "The epidermis was moderately and densely hyperkeratotic. The rest of the epidermis was acanthotic and highly edematous; Spongiosis was conspicuous at some places. The significant lesion was a thin vesicle or bleb which lay at the level of the stratum granulosum and extended barely to