eMedicine Specialties > Ophthalmology > Conjunctiva
Filtering Bleb Complications
Updated: Jul 18, 2007
Introduction
Background
The consequences of bleb-associated complications include the following, listed in order of potential morbidity: predisposition to or cause of infection, unsatisfactory bleb function (ie, intraocular pressure [IOP] too low, IOP too high), dysesthesia, decreased visual acuity, and/or loss of the globe, which can be the final outcome.
Pathophysiology
The goal of glaucoma filtering surgery is to reduce IOP with surgery. The pressure can be too high or too low following the surgery.
Frequency
United States
Uncommon
Mortality/Morbidity
Bleb complications can be classified according to their vision-threatening potential and impact on quality of life.
All bleb-related complications have infection/endophthalmitis as a possible consequence, with high morbidity. Also, bleb failure with consequent rise in IOP is a possible consequence.
The cost for the individual and the community in terms of discomfort, unplanned care, loss of work time, direct medical expenses, and decrease in visual function cannot be estimated and may be high.
Race
No racial predisposition exists.
Sex
No sexual influence exists.
Age
No influence of age exists.
Clinical
History
History includes previous filtration surgery for the management of glaucoma. Presentation varies remarkably depending on the complication being observed.
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.
Causes
- Buttonholes and tears, dehiscence, or retraction
- Conjunctival buttonholes and tears, dehiscence, or retraction of the conjunctival incision are usually a result of suboptimal surgical techniques.
- 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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References
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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].
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].
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].
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].
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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].
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].
Parrish R, Minckler D. "Late endophthalmitis"--filtering surgery time bomb?. Ophthalmology. Aug 1996;103(8):1167-8. [Medline].
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].
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].
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].
Yarangumeli A, Koz OG, Kural G. Encapsulated blebs following primary standard trabeculectomy: course and treatment. J Glaucoma. Jun 2004;13(3):251-5. [Medline].
Further Reading
Keywords
buttonhole, tear, dehiscence, retraction, infection, blebitis, endophthalmitis, leakage, dysesthesia, encapsulated bleb, failing bleb, glaucoma
