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Editors Selection IGR 11-2

Surgical Treatment: Trabeculectomy outcome after blebleak

Comment by Tony Wells on:

23901 Early bleb leak after trabeculectomy and prognosis for bleb failure, Alwitry A; Rotchford A; Patel V et al., Eye, 2009; 23: 858-863

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Early leakage of trabeculectomy blebs occurring via an unsealed conjunctival incision, or conjunctival buttonhole, is a commonly described occurrence after trabeculectomy. The consequences of such leaks may be potentially serious and include infection via direct access to the intracameral spaces, and collapse of the bleb with adhesion of the inner walls with eventual bleb fibrosis and failure. Alwitry et al. (901) retrospectively analyzed the effect of bleb leak within the first month after surgery on the outcomes of mitomycin trabeculectomy in 119 eligible consecutive eyes, with at least one year of follow up. Surgical technique and postoperative management was similar to current approaches at many centers. There were both limbus- and fornix-based approaches, large dissection areas, 0.1 to 0.4 mg/ml MMC for 1 to 4 minutes, a 5x4 mm trapezoidal scleral flap secured with at least two releaseable 10-0 nylon sutures, and iridectomy. Conjunctival wound closure was assessed using topical 2% fluorescein and insufflating the anterior chamber with balanced salt; detected leaks were closed intraoperatively. Postoperative interventions included massage, suture release, subconjunctival 5-FU and needling with adjunctive 5-FU. Low-flow leaks detected during follow up were managed conservatively, larger leaks without hypotony were managed with bandage contact lenses, surgical repair for leaks with hypotony, or shallow anterior chamber. Of the 119 procedures, 22.7% had an early bleb leak and the outcomes of these eyes were compared to the remainder that did not. It was found that early leaks, which occurred more commonly in fornix-based conjunctival flap procedures, had little impact on clinical outcomes. The authors mention that the difference between this and previous data, e.g., from the Fluorouracil Filtering Study, could be MMC providing mitigation of adhesion of transiently collapsed inner walls of blebs.

Conservative management of small conjunctiv al leaks and more interventional management of larger ones seems to be reasonable and not to adversely affect trabeculectomy outcomes

The authors make the assumption that low IOP in the early days after surgery is due to the bleb leak, although it is the closure of scleral flap that is the main determinant of early postoperative IOP since the conjunctiva provide minimal resistance to flow initially. Limitations of this study include those that might be expected in a retrospective study; notably, lack of a predetermined protocol for intervention, absence of additional information that might have been relevant, such as bleb morphology, and details of the nature of the leak and potential variability on Seidel testing. The authors present the information and address the limitations of the study well. They should be commended for limiting the patient group to those with at least one year of follow-up, and restricting the study to a discrete range of procedures. While all leaks could and should be avoided by meticulous closure at the time of surgery, it is reassuring that conservative management of small conjunctival leaks and more interventional management of larger ones seems to be reasonable and not to adversely affect trabeculectomy outcomes.

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