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

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          Abstract

          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.

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          Most cited references26

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          Incidence of late-onset bleb-related complications following trabeculectomy with mitomycin.

          N. G. Heatley, Lyndia Brumback, Ronald W DeBry … (2002)
          To determine the incidence of late-onset bleb-related complications following trabeculectomy with mitomycin and to report the management and outcome of bleb leaks following trabeculectomy with mitomycin. A retrospective medical record review of all patients who underwent trabeculectomy with mitomycin from June 1, 1991, through April 30, 1998, at our institution was performed. The Kaplan-Meier survival method was used to estimate the probability of (1) endophthalmitis, (2) blebitis, (3) a bleb leak, and (4) the combined outcome (the first occurrence of a bleb leak, blebitis, or endophthalmitis). This survival analysis included only the first trabeculectomy in an eye, with at least 3 months of follow-up during the study period. A separate description of bleb leak management and outcome was performed. Two hundred thirty-nine eyes of 198 patients were included in the survival analysis. The average follow-up was 2.7 (range, 0.3-7.3) years. Twenty eyes (8%) from 19 patients experienced a bleb leak; the adjusted incidence was 3.2% per patient-year. Five eyes (2%) had an episode of blebitis. Eight eyes (3%) experienced an episode of endophthalmitis; the follow-up adjusted incidence (number of events per patient-year) was 1.3%. Twenty-seven eyes (11%) from 26 patients had at least 1 of the complications of a bleb leak, blebitis, or endophthalmitis; the adjusted incidence was 4.4% per patient-year. A Kaplan-Meier analysis estimated the 5-year probability of developing a bleb leak, blebitis, or endophthalmitis to be 17.9%, 6.3%, and 7.5%, respectively. Two hundred fifty-eight trabeculectomies in 242 eyes of 198 patients were included in the description of bleb leak management and outcome. Bleb leaks occurred in 22 eyes (9% of the 258 trabeculectomies). Seventeen eyes were successfully treated with office-based measures, and 4 ultimately underwent surgical bleb revision. One eye without infection continued to leak after 11 months of office-based therapy. There is significant morbidity associated with a trabeculectomy with mitomycin. The incidence of a bleb leak or an infection continues at a fairly constant rate over time, such that at 5 years, up to 23% of all patients might develop one of these complications. An isolated bleb leak seems to be a relatively benign condition, as three quarters resolve with office-based methods.
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            Fibrin glue in ophthalmology

            Anita Panda, Sandeep Kumar Singh, Abhiyan Kumar … (2009)
            Suturing is a time consuming task in ophthalmology and suture induced irritation and redness are frequent problems. Postoperative wound infection and corneal graft rejection are examples of possible suture related complications. To prevent these complications, ophthalmic surgeons are switching to sutureless surgery. A number of recent developments have established tissue adhesives like cyanoacrylate glue and fibrin glue as attractive alternatives to sutures. A possible and promising new application for tissue adhesives is to provide a platform for tissue engineering. Currently, tissue glue is being used for conjunctival closure following pterygium and strabismus surgery, forniceal reconstruction surgery, amniotic membrane transplantation, lamellar corneal grafting, closure of corneal perforations and descematoceles, management of conjunctival wound leaks after trabeculectomy, lid surgery, adnexal surgery and as a hemostat to minimise bleeding. The purpose of this review is to discuss the currently available information on fibrin glue.
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              Endophthalmitis after filtering surgery with mitomycin.

              Harry Flynn, I Suñer, P Palmberg … (1996)
              To identify the incidence, causative organisms, and clinical outcomes of eyes with bleb-associated endophthalmitis after glaucoma filtering procedures with adjunctive mitomycin. Retrospective analysis of 773 consecutive eyes that underwent glaucoma filtering surgery at the Bascom Palmer Eye Institute, Miami, Fla. The course of 609 eyes from 485 patients with a minimum of 3 months of follow-up were reviewed. Mean follow-up was 16.0 +/- 11.5 months (range, 3-48 months). Of the 609 eyes, 13 (2.1%) developed bleb-associated endophthalmitis an average of 18.5 +/- 13.2 months after surgery (range, 1-45 months). The incidence of bleb-associated endophthalmitis was significantly greater after inferior trabeculectomy (7.8% per patient-year) than after superior trabeculectomy (1.3% per patient-year) by Kaplan-Meier estimates (P = .02, log rank test). The cumulative incidence was 13% for inferior limbal blebs and 1.6% for superior limbal blebs. Nine (69.2%) of the 13 eyes were culture positive. Streptococcus sanguis and Haemophilus influenzae (6/13 [46.2%]) were the most frequent causative organisms. The mean increase in intraocular pressure after endophthalmitis treatment was 1.2 mm Hg, with a mean decrease in visual acuity of 1.42 logMAR units. Eight (61.5%) of the 13 eyes had a final acuity of 20/400 or better. The incidence of bleb-associated endophthalmitis after guarded filtering surgery performed with adjunctive mitomycin is higher than the reported rate in eyes undergoing filtering surgery without the use of antifibrotic agents (0.2%-1.5%). Inferior limbal trabeculectomy carries the highest risk of infection. Eyes with mitomycin blebs maintained excellent filtration capacity. However, after treatment of the infection, the visual outcomes were generally poor.
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                Author and article information

                Journal
                Journal ID (publisher-id): COP
                Journal ID (pmc): COP
                Journal ID (doi): 10.1159/issn.1663-2699
                Title: Case Reports in Ophthalmology
                Publisher: S. Karger AG
                ISSN (Electronic): 1663-2699
                Publication date Subscription-year: 2019
                Publication date Collection: January - April 2019
                Publication date (Electronic): 24 January 2019
                Volume: 10
                Issue: 1
                Pages: 47-52
                Affiliations
                [_a] aUniversity of Illinois College of Medicine, Peoria Campus, Peoria, Illinois, USA
                [_b] bIllinois Retina and Eye Associates, Peoria, Illinois, USA
                Author notes
                *Kamal Kishore, MD, Illinois Retina and Eye Associates, 4505 N Rockwood Drive, Suite 1, Peoria, IL 61615 (USA), E-Mail Kamal.kishore1963@gmail.com
                Author information
                https://orcid.org/0000-0002-0339-3351
                Article
                Publisher ID: 496383 Pmcid ID: PMC6489093 Other ID: Case Rep Ophthalmol 2019;10:47–52
                DOI: 10.1159/000496383
                PMC ID: PMC6489093
                PubMed ID: 31097944
                SO-VID: 53ef9b12-51d9-4cdd-ab8a-40f5ca790aa8
                Copyright © © 2019 The Author(s). Published by S. Karger AG, Basel
                License:

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 10 September 2018
                Date accepted : 16 December 2018
                Page count
                Figures: 2, Pages: 6
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Vision sciences,Ophthalmology & Optometry,Pathology
                Keywords: Fibrin glue,Intracameral air,Glaucoma,Bleb leak,Bleb-associated endophthalmitis
                Data availability:
                ScienceOpen disciplines: Vision sciences, Ophthalmology & Optometry, Pathology
                Keywords: Fibrin glue, Intracameral air, Glaucoma, Bleb leak, Bleb-associated endophthalmitis

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