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Abstract #5518 Published in IGR 1-2
Cases in Controversy: Management of late bleb leaks
Wilsom MR; Chen PP; Rothman RFJournal of Glaucoma 1999; 8: 263-266
In this 'Cases in Controversy' series, a 71-year-old Asian man is presented with a pseudophakia who had advanced chronic angle-closure glaucoma. A Baerveldt implant was placed in the left eye and the right eye had an uncomplicated trabeculectomy with mitomycin-C three years previously. This eye now has a focal thin-walled bleb with a central leak adjacent to the limbus. The IOP is 8 mmHg. The visual acuity is good in this eye while the other eye has a visual acuity of 20/200. Comments are given by Chen and Rothman. Chen started by stating the known vision-threatening complications of bleb leaks such as decreased vision because of maculopathy, choroidal effusions and bleb-related infections. In this particular patient the visual acuity is still good. He does not recommend simple observation. Conservative treatment is an option including aqueous suppression. He also demonstrates how successful he is with this method. Next there is patching or large soft contact lenses. The author is not very enthusiastic about trichloroacetic acid, Argon lasers and autologous fibrin glue. Topical antibiotics to incite inflammation are rarely successful. This author could be convinced to follow the patient indefinitely. He points out that we lack good data to follow either a conservative or a aggressive course. If aggression is needed he likes autologous blood injection. Compression sutures seem to be associated with frequent leak recurrence. If surgical intervention is needed this author will do an excision of the cystic bleb with advancement of the conjunctiva. With this method he finds that approximately half the patients required additional anti-glaucoma medications, but less than 10% needed filtering glaucoma surgery. Rothman feels that observation under circumstances may be considered provided the patient is educated to the signs and symptoms of early bleb-related infection. Application of prophylactic antibiotics has not been shown to reduce the rate of infection in these eyes. In this monocular patient, Rothman would elect to initiate therapy. His conservative approach would also include aqueous suppressants. Next would be a bandage contact lens. He has not been happy with laser photocoagulation or autologous blood injections. Basically he would then proceed to excision of the bleb with advancement of the conjunctiva or the use of free conjunctival autografts. The editor of the series, Wilson, also warrants for the risk of endophthalmitis. Often the price of the successful treatment of the leak is reduction of glaucoma control. The choice of conservative versus aggressive management is determined by size and character of the bleb, perceived risk of endophthalmitis and stage of glaucomatous damage. He feels that diffuse transudation responds more favorably than frank holes. Autologous blood injections may be good for diffuse transudation where compression sutures may be OK for holes. He feels that the success of conservative treatment is often transitory.
M.R. Wilson, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178; USA
Classification:
12.8.11 Complications, endophthalmitis (Part of: 12 Surgical treatment > 12.8 Filtering surgery)