Ehab Ghoneim, MD, Professor of Ophthalmology, Suez Canal University, Ismailia, 6532, Egypt
Received: 20 November, 2014; Accepted: 10 December, 2014; Published: 12 December, 2014
Ehab Ghoneim, MD, Professor of Ophthalmology, Suez Canal University, Ismailia, 6532, Egypt, Tel: +201223639848; Email:
Ghoneim E (2015) Needle Revision with Antimetabolites in Bleb Failure. J Clin Res Ophthalmol 2(1): 007-009. DOI: 10.17352/2455-1414.000008
© 2015 Ghoneim E. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Antimetabolites; Needling; Mitomycin C; 5-Fluorouracil
Bleb failure after initially successful glaucoma surgery still constitutes a major challenge in management of glaucoma patients.
Needling is considered a simple surgical technique that can solve a major problem like failure of glaucoma surgery.
The introduction of antimetabolite in ophthalmology greatly enhances the results of needling as well as the initial trabeculectomy.
Mitomycin C(MMC) and 5-Fluorouracil (5FU) used as adjunctive therapy with needling for management of bleb failure with variable success rates but the results with antimetabolites is significantly better than needling alone.
In conclusion needling augmented with antimetabolitesis simple technique, relatively safe, fast and has a high success rate, even in complicated glaucoma.
Glaucoma filtering surgery is unusual in that its goal is the creation and maintenance of a non healing fistula between two anatomic spaces that are normally not connected .
Fibroblasts, connective tissue elements, cytokines, aqueous humor and the surrounding vascular supply all influence what happens to a bleb over a long period of time.
The enemy of drainage procedure is excessive scarring .
Long-term studies showed a loss of intraocular pressure (IOP) control in a significant proportion of eyes with an initially successful trabeculectomy [2,3]. So follow up of glaucoma patients after surgery is mandatory as significant proportion develop bleb failure.
Revision of guarded filtration procedures was reported as early as 1941 by Ferrer . Needling as currently performed was described by Pederson and Smith . The combination of needling with anti metabolites (mitomycin C and 5FU) greatly improve the outcome of needling and enhance bleb survival.
Most filtering blebs contain loculations that are delimited by internal fibrous walls. In bleb development, the walls are formed from conjunctival adherence to the underlying sclera and episclera. The main loculation is formed at the sclerostomy site and may be surrounded by other, usually smaller, loculations .
Phases in life of the bleb
Formation phase.Comprise roughly the first two week, successful blebs showed common characteristics (elevation and avascularity). They may be diffuse or localized, thin walled or spongy and they differ in height, pallor and extent of conjunctival micro cystic edema.
Establishment phase: The bleb wall is elevated and the wall appears tense and cystic.
Mature phase: May be functional blebs which usually multi loculated bleb. While failed blebs are often totally flat and vascularized.
Encapsulated blebs: Defined as highly elevated, tense, thickened, dome-shaped or sausage shaped blebs occurring within 3 months after trabeculectomy. A significant proportion of these blebs resolve without surgical intervention .
The signs of bleb failure include sub conjunctival cyst disappearance, increased vascularity, decreasing area of bleb and elevated intraocular pressure (IOP) . Those patients at high risk of bleb failure are Africans, with previous ocular inflammation, prolonged topical medication (miotics and sympathomimetics) and aphakia. As there were a great tendency to subconjunctival, episcleral and scleral fibrosis . The clinical appearance of a bleb is not always an accurate predictor of functional status as a small proportion of flat blebs are functioning well, also blebs are dynamic structure and remodeling takesover time .
For successful glaucoma surgery, close follow up and early intervention is recommended to manage complications and to maintain the delicate balance between maintaining the integrity of the eye and prevention of excessive scarring [2,6].
Needling is indicated when there is inadequate IOP control with an elevated bleb with microcysts, flat bleb with visible scleral flap without micro cyst (Figure 1), postoperative need of topical ocular hypotensive medication and some eyes with encapsulated bleb .
Needling is performed by lysing or puncturing bands of fibrous tissue that define the margins of areas with good filtration from areas with little or no filtration. These bands may be in the bleb itself or may be episcleral and tightly adherent to the scleral flap .
Early intervention in case of bleb failure was supported by several studies. They recommend performingMMC needling when signs of failure are detected during the cellular phase, which starts several weeks after surgery [1,7,8].
Intra operative signs of good needling include softening of the eyeball, release of aqueous humor into the sub conjunctival space, which created a raised conjunctival bleb, and occasionally a small reflux of blood into the anterior chamber (AC) .
Poor needling response is anticipated with the need for multiple needle revision procedures.Flat bleb that tightly adherent to episclera, higher pre needling IOP and immediate post-needling IOP over 19mm Hg .
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