Filtering Bleb Complications Clinical Presentation

  • Author: Carlo E Traverso, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 11, 2010
 

History

History includes previous filtration surgery for the management of glaucoma. Presentation varies remarkably depending on the complication being observed.

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Physical

Clinical picture varies considerably depending on the complication. These eyes show evidence of filtration surgery in common, with a range of associated glaucomatous damage.

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Causes

  • Buttonholes and tears, dehiscence, or retraction
    • Conjunctival buttonholes and tears, dehiscence of the conjunctival incision, or retraction of the conjunctival edge are usually a result of suboptimal surgical techniques. Examples of these are shown in the images below. Suboptimal suturing techniques can cause gaping ofSuboptimal suturing techniques can cause gaping of the conjunctival incision. Retraction of a fornix-based conjunctival flap. ItRetraction of a fornix-based conjunctival flap. It can progress to uncover the scleral flap.
    • Care must be taken in handling the tissues, and meticulous suturing techniques need to be used. Attention to detail is key in the prevention of these problems.
    • Dehiscence and retraction are almost unavoidable when using absorbable sutures in conjunction with antimetabolites.
    • Each of the above events can cause an entire spectrum of bleb-associated complications (see Complications).
  • The most evident risk factor for late bleb leaks, bleb ruptures, and infections is the intraoperative or postoperative use of antimetabolites. After antimetabolites, blebs tend to be more ischemic and thinner, with progressive thinning and possible spontaneous rupture.
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Contributor Information and Disclosures
Author

Carlo E Traverso, MD  Chairman, University Eye Clinic, Genova; Department of Neurosciences, Ophthalmology and Genetics, University of Genova Medical School, Italy

Carlo E Traverso, MD, is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, and European Glaucoma Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Neil T Choplin, MD  Adjunct Clinical Professor, Department of Surgery, Section of Ophthalmology, Uniformed Services University of Health Sciences

Neil T Choplin, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Association for Research in Vision and Ophthalmology, and California Medical Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

J James Rowsey, MD  Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Busbee BG, Recchia FM, Kaiser R, Nagra P, Rosenblatt B, Pearlman RB. Bleb-associated endophthalmitis: clinical characteristics and visual outcomes. Ophthalmology. Aug 2004;111(8):1495-503; discussion 1503. [Medline].

  2. Halkiadakis I, Lim P, Moroi SE. Surgical results of bleb revision with scleral patch graft for late-onset bleb complications. Ophthalmic Surg Lasers Imaging. Jan-Feb 2005;36(1):14-23. [Medline].

  3. Maruyama K, Shirato S. Efficacy and safety of transconjunctival scleral flap resuturing for hypotony after glaucoma filtering surgery. Graefes Arch Clin Exp Ophthalmol. Dec 2008;246(12):1751-6. [Medline].

  4. Azuara-Blanco A, Katz LJ. Dysfunctional filtering blebs. Surv Ophthalmol. Sep-Oct 1998;43(2):93-126. [Medline].

  5. Fluorouracil Filtering Surgery Study Group. Five-year follow-up of the Fluorouracil Filtering Surgery Study. Am J Ophthalmol. Apr 1996;121(4):349-66. [Medline].

  6. Higginbotham EJ, Stevens RK, Musch DC, Karp KO, Lichter PR, Bergstrom TJ, et al. Bleb-related endophthalmitis after trabeculectomy with mitomycin C. Ophthalmology. Apr 1996;103(4):650-6. [Medline].

  7. Hu CY, Matsuo H, Tomita G, Suzuki Y, Araie M, Shirato S, et al. Clinical characteristics and leakage of functioning blebs after trabeculectomy with mitomycin-C in primary glaucoma patients. Ophthalmology. Feb 2003;110(2):345-52. [Medline].

  8. Jonas JB, Dugrillon A, Kluter H, Kamppeter B. Subconjunctival injection of autologous platelet concentrate in the treatment of overfiltrating bleb. J Glaucoma. Feb 2003;12(1):57-8. [Medline].

  9. Kangas TA, Greenfield DS, Flynn HW, Parrish RK, Palmberg P. Delayed-onset endophthalmitis associated with conjunctival filtering blebs. Ophthalmology. May 1997;104(5):746-52. [Medline].

  10. Mochizuki K, Jikihara S, Ando Y, Hori N, Yamamoto T, Kitazawa Y. Incidence of delayed onset infection after trabeculectomy with adjunctive mitomycin C or 5-fluorouracil treatment. Br J Ophthalmol. Oct 1997;81(10):877-83. [Medline].

  11. Parrish R, Minckler D. "Late endophthalmitis"--filtering surgery time bomb?. Ophthalmology. Aug 1996;103(8):1167-8. [Medline].

  12. Sony P, Kumar H, Pushker N. Treatment of overhanging blebs with frequency-doubled Nd:YAG laser. Ophthalmic Surg Lasers Imaging. Sep-Oct 2004;35(5):429-32. [Medline].

  13. Tannenbaum DP, Hoffman D, Greaney MJ, Caprioli J. Outcomes of bleb excision and conjunctival advancement for leaking or hypotonous eyes after glaucoma filtering surgery. Br J Ophthalmol. Jan 2004;88(1):99-103. [Medline].

  14. Wolner B, Liebmann JM, Sassani JW, Ritch R, Speaker M, Marmor M. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5-fluorouracil. Ophthalmology. Jul 1991;98(7):1053-60. [Medline].

  15. Yarangumeli A, Koz OG, Kural G. Encapsulated blebs following primary standard trabeculectomy: course and treatment. J Glaucoma. Jun 2004;13(3):251-5. [Medline].

 
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Retraction of a fornix-based conjunctival flap. It can progress to uncover the scleral flap.
Suboptimal suturing techniques can cause gaping of the conjunctival incision.
Fluorescein staining of the conjunctiva shows an obvious leakage of aqueous.
After fluorescein staining, aqueous is percolating slowly, forming tiny droplets on the surface that mimic a sweating bleb.
Cystic, thick-walled bleb, defined most commonly as a Tenon cyst.
Large, extended, overfiltering bleb causes symptoms because of tear flow disturbances and ocular surface wetting.
Corneal dissecting bleb, extending forward within the corneal epithelium.
 
 
 
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