A 65-year-old male presented in September 2006 for the management of chronic angle-closure glaucoma in both of his eyes. He had a 20-year history of the disease and had undergone laser iridotomy bilaterally. The patient was being treated with maximally tolerated medical therapy, and he had an IOP of 18 mm Hg OD and 19 mm Hg OS. Central corneal thickness measured 495 µm OD and 479 µm OS. There was almost a complete absence of neuroretinal rim in both of his eyes (Figure 1).
Figure 1. In this optic disc photograph of the patient's right eye, advanced neuroretinal rim loss is present in all sectors of the optic disc.
Visual field testing showed a dense superior arcuate defect threatening central fixation (Figure 2), and scanning laser polarimetry showed marked loss of the retinal nerve fiber layer in the patient's right eye (Figure 3). A fornix-based trabeculectomy with an adjunctive antifibrotic agent was performed on the patient's right eye on December 11, 2006. The surgeon applied mitomycin C (0.4 mg/mL) via a cellulose sponge to the operative site for 1.5 minutes and then irrigated with balanced salt solution. During the procedure, the conjunctiva was noted to be extremely thin and friable with minimal Tenon's capsule. The scleral flap was soft and required more sutures than usual to obtain a tight closure. The surgeon closed the conjunctiva and Tenon's capsule with 10–0 nylon.
Figure 2. Visual field testing with standard automated perimetry shows a dense superior hemifield defect threatening central fixation in the patient's right eye.
Figure 3. Analysis with scanning laser polarimetry (GDx ECC; Carl Zeiss Meditec, Inc.) shows diffuse loss of the retinal nerve fiber layer in the patient's right eye.
The closure was secure 1 day after surgery. On postoperative day 3, a slow leak was noted along the conjunctival suture tracks. On the next day, the conjunctival suture tracks had expanded, and each had an associated wound leak.
Comments on Management
RNW: Dr. Lerner, how would you manage this patient?
FL: Early postoperative leaks may be due to a defective closure or tissue-related problems. They are more common when intraoperative antimetabolites are used. In this case, the suture was well placed, and it fully covered the fornix-based wound. It is not unusual for thin, friable conjunctiva and Tenon's tissue to be associated with a postoperative leak. A compressive patch may be attempted in the early postoperative period. Topical cycloplegics and antibiotics could be administered. The frequency of the administration of topical corticosteroids is usually reduced. Limited success also has been observed with a variety of other approaches, including the use of large-diameter soft contact lenses, biologic glue, and amniotic membrane.1 If conservative management is not successful or if a flat chamber with corneal/lenticular contact develops, a surgical approach is indicated.
FAM: Would you consider an autologous blood injection in this patient?
FL: Autologous blood injection into the bleb has limited success, although it may have a better outcome when combined with compression sutures.2
RNW: Dr. Lerner, what would be your surgical options if conservative management failed?
FL: Either a conjunctival flap advancement or an autologous conjunctival graft technique could be used.3-5 During conjunctival flap advancement, the anterior border of the bleb is incised. The leaking (often avascular) tissue can be excised and the conjunctiva advanced anteriorly following a blunt dissection of the posterior subconjunctival space. Alternatively, the posterior margin of the bleb can be incised and the posterior conjunctiva advanced following blunt dissection. After removing the epithelium on the surface of the limbus with a sharp blade, the surgeon can suture the conjunctiva to the limbus. If the area of the bleb that is going to be resected cannot be covered by conjunctival advancement, an autologous conjunctival graft could be obtained that is approximately 1 to 2 mm larger than the area of the bleb. Care should be taken in maintaining the orientation of the tissue.
RNW: In this case, the conjunctival suture tracks continued to enlarge, and the patient was taken to the OR for revision of the trabeculectomy. Generally, I prefer to excise leaking tissue and to perform conjunctival advancement in eyes with a leaking bleb. I was concerned, however, that the advanced conjunctiva also would subsequently leak. Intraoperatively, the conjunctiva posterior to the functioning bleb was unusually mobile. This tissue was pulled anteriorly from 8 mm posterior to the limbus and was resutured over the preexisting bleb with a continuous closure. Conjunctival epithelium was not removed. At the conclusion of surgery, the wound was secure, and it remained so during the next several weeks. The patient has done remarkably well postoperatively with IOPs consistently between 8 and 10 mm Hg. The resulting bleb has a diffuse microcystic appearance (Figure 4).
Figure 4. The filtering bleb had this appearance after revision of the trabeculectomy.
CONCLUSION
This case illustrates an eye with an early postoperative wound leak following trabeculectomy that underwent revision consisting of conjunctival advancement without the removal of the leaking tissue and epithelium. The use of conjunctival advancement without the excision of tissue is an alternative approach to the repair of a leaking bleb.
Section editors Felipe A. Medeiros, MD, and Robert N. Weinreb, MD, are glaucoma specialists at the Hamilton Glaucoma Center, University of California, San Diego. Dr. Medeiros is Assistant Professor, and Dr. Weinreb is Distinguished Professor of Ophthalmology and Director. They acknowledged no financial interest in the product or company mentioned herein. Dr. Medeiros may be reached at fmedeiros@eyecenter.ucsd.edu, and Dr. Weinreb may be reached at weinreb@eyecenter.ucsd.edu.
Sushma Rai, MD, is a fellow in glaucoma at the Hamilton Glaucoma Center, University of California, San Diego. She acknowledged no financial interest in the product or company mentioned herein. Dr. Rai may be reached at srai1234@yahoo.com.
S. Fabian Lerner, MD, is Director, Glaucoma Section, Postgraduate Department, University Favaloro School of Medicine, Buenos Aires, Argentina. He acknowledged no financial interest in the product or company mentioned herein. Dr. Lerner may be reached at +54 11 4961 9258; fabianlerner@fibertel.com.ar.
1. Crichton A, Condon GP, Trope GE. Management of the leaking bleb. In: Trope GE, ed. Glaucoma Surgery. Boca Raton, LA: Taylor & Francis; 2005:217-224.
2. Burnstein AL, WuDunn D, Knotts SL, et al. Conjunctival advancement vs non-incisional treatment for late-onset glaucoma filtering bleb leaks. Ophthalmology. 2002;109:71-75.
3. Choudhri SA, Herndon LW, Damji KF, et al. Efficacy of autologous blood injection for treating overfiltering or leaking blebs after glaucoma surgery. Am J Ophthalmol. 1997;123:554-555.
4. Myers JS, Yang CB, Herndon LW, et al. Excisional bleb revision to correct overfiltration or leakage. J Glaucoma. 2000;9:169-173.
5. Tannenbaum DP, Hoffman D, Greaney MJ, et al. Outcomes of excisional bleb revision and conjunctival advancement for leaking or hypotonous eyes after glaucoma filtering surgery. Br J Ophthalmol. 2004;88:99-103.
