Outcomes of bleb revision with ologen following filtering glaucoma surgery

Purpose This study reports long-term outcomes of bleb revision with ologen™ Collagen Matrix (Aeon Astron Europe BV, the Netherlands) for the surgical management of various bleb-related issues including persistent bleb leaks with or without associated hypotony, bleb dysesthesia, overhanging blebs, or hypotony after filtering glaucoma surgery. Materials and methods A retrospective chart review was performed for patients who underwent ologen bleb revision from 2012 to 2019 at Glaucoma Associates of Texas. Results The study included 23 eyes of 22 patients undergoing bleb revision with the ologen implant. Mean age was 74.0 ± 11.3 years, 16 (69.6%) were female, and 13 (56.5%) were White. Indications for bleb revision included bleb leak (78.3%), dysesthesia (13.0%), and hypotony from an overfiltering bleb (8.7%). Mean preoperative intraocular pressure was 6.8 ± 4.1 mmHg and the number of medications was 0.3 ± 0.9. Median follow-up was 24 months (range: 12–84 months); all patients had at least 12 months of follow-up. At 1 year, mean intraocular pressure was 10.9 ± 4.6 mmHg on 0.2 ± 0.5 medications, and at last follow-up, mean intraocular pressure was 10.4 ± 3.6 mmHg on 0.3 ± 0.7 medications. Bleb morphology remained low, diffuse, and posterior. One patient developed kissing choroidal effusions requiring surgical drainage with subsequent stabilization of intraocular pressure and bleb function, and three patients required additional surgery due to persistent leaks or bleb failure; there were no other vision-threatening complications. Conclusions Use of the ologen implant during surgical bleb revision is a useful surgical technique that confers long-term improvements in bleb morphology and stability of function.

Bleb reconstruction using donor scleral patch graft for late bleb leak and hypotony

Purpose Bleb dysfunction may occur as a late complication following glaucoma filtration surgery. Over-filtering, thinning and cystic blebs can lead to hypotony, leak and corneal dellen. We report our surgical management and outcomes of this specific entity using donor scleral patch grafts. Methods This is a 10-year non-comparative, retrospective interventional case series. Bleb reconstruction involved excision of encysted conjunctiva and sclera to identify the original fistula. A functioning donor scleral patch graft was sited over this with fixed and releasable sutures and the conjunctiva advanced. Intraocular pressure, visual acuity and post-operative issues were assessed. Results A total of 18 eyes of 17 patients with mean age 65 years (standard deviation 13.5) were included. Trabeculectomy was the primary procedure in 72% ( n = 13) and deep sclerectomy in 28% ( n = 5). Bleb leak accounted for 61% ( n = 11), hypotony 33% ( n = 6) and corneal dellen 6% ( n = 1). Mean pre-operative intraocular pressure was 7 mm Hg (standard deviation 4.6) which increased to 18.5 mm Hg (standard deviation 12) at day 1 ( p < 0.001), 11.8 mm Hg (standard deviation 4.6) at 3 months ( p < 0.05), 12.1 mm Hg (standard deviation 4.2) at 1 year ( p < 0.01) which was maintained at 12.1 mm Hg (standard deviation 5.3) at last follow-up ( p < 0.001). Post-operative interventions included bleb needling, re-suturing, suture removal, further glaucoma management, bleb leak and cataract surgery. Visual acuity also improved post-operatively and was maintained. Conclusion Reconstruction of the filtering bleb architecture with donor sclera results in improved intraocular pressure while maintaining visual acuity. Post-operative care is required to support the restored bleb function. Our findings support the use of scleral patch graft as an effective and safe method for the long-term management of hypotony and bleb leak as a late complication of glaucoma filtration surgery.

Intracameral Air and Fibrin Glue for the Management of Late Bleb Leak following Glaucoma Surgery

Background and Objectives: To report a case of delayed-onset bleb-associated endophthalmitis (BAE) with bleb leak successfully managed with pars plana vitrectomy, intravitreal antibiotics, intracameral air, and fibrin glue. Patient and Methods: A 66-year-old pseudophakic female presented with BAE and bleb leak. A 25-gauge pars plana vitrectomy, cultures, and intravitreal antibiotics and steroid injections were performed. The infusion was switched to air filling the anterior chamber and bleb with air. Fibrin glue (Tisseel®) was applied over the leaking bleb. Results: BAE and bleb leak resolved with return of visual acuity to 20/25 and a functioning bleb with no recurrence of bleb leak after 1 year of follow-up. Conclusion: The combination of intracameral air and fibrin glue may have a role in the management of bleb leaks.