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Editors Selection IGR 22-4
Surgery: Treatment bleb dysesthesia
Comment by Jeffrey Liebmann on:
22374 Surgical reduction of dysesthetic blebs, Lloyd M; Giegengack M; Morrison JC, Archives of Ophthalmology, 2008; 126: 1759-1764
Successful glaucoma filtering surgery is characterized by the development of a filtering bleb. While the clinical presentation of filtering blebs varies widely, they share the common feature of elevation above the episcleral surface. This elevation, sometimes accompanied by dissection into the interpalpebral fissure, may result in bleb dysesthesia, which is most often described by patients as intermittent dryness, photophobia or foreign body sensation, and may be associated with periodic epiphora, ocular hyperemia, or delle formation. In extreme cases, patient discomfort may be so severe as to be disabling. In general, bleb dysesthesia symptoms are usually more apparent in eyes with blebs of greater height, which results in tear film abnormalities on the bleb surface or adjacent cornea. Surgical techniques to avoid very elevated, localized blebs should be used to prevent their occurrence. Occasionally, however, palliative treatments such as frequent ocular lubrication fail and surgeons are forced to return to the operating room to reduce bleb height or circumferential flow. In the current article, Lloyd et al. (1755) have described their approach for bleb reduction to eliminate or minimize bleb dysesthesia. Their article carefully describes the surgical technique of bleb limitation to reduce bleb height by limiting the region of aqueous flow, while at the same time advocating removing subconjunctival scar tissue. This technique resulted in amelioration of symptoms in almost all patients, although several patients required re-operation. Careful attention to detail at the time of the initial surgery may reduce the frequency of bleb dysethesia. Fornix-based conjunctival flaps and wide (rather than focal) application of mitomycin-C have been advocated to encourage the development of broad, shallow, filtration blebs that are less prone to later discomfort and the need for a return trip to the operating room.
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