Leaking glaucoma filtering blebs with scleral perforation were successfully repaired in two patients using amniotic membrane transplantation. The amniotic membrane was placed into the subconjunctival space to cover the perforated scleral area. The edge of the limbal conjunctiva was sutured to the peripheral cornea with conjunctival advancement over the amniotic membrane. The bleb leaks were successfully closed. In addition, good and functioning filtration was maintained during a follow-up period of 12 months in both cases. Amniotic membrane transplantation may be effective for the surgical management of high risk of leaking glaucoma blebs with scleral perforation.
Amniotic Membrane Transplantation for Repair of Leaking Glaucoma Filtering Blebs with Scleral Perforation
From the Department of Ophthalmology, School of Medicine, University of Occupational and Environmental Health, Japan.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Hiromi Okada, MD, Department of Ophthalmology, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan.
Accepted: November 03, 2008
Posted Online: March 09, 2010
Bleb leaks often occur as a late complication of glaucoma filtration surgery.1 Bleb leaks may result in serious consequences, thus it is important to treat these leaks properly. Although various non-surgical treatments have been employed to try to close bleb leaks,2,3 successful closure often requires surgical intervention.2 Direct suturing, advancement of conjunctiva from the adjacent conjunctiva4–7 and free conjunctival autografts8,9 are usually employed for surgical treatments. These procedures, however, are technically difficult or impossible when the leaking filtering blebs are near the corneal limbus accompanied by a scleral perforation. Kee et al.10 recently reported the amniotic membrane, which has been proven to be effective for ocular surface reconstruction,11–14 to be useful for treating bleb leaks. Preserved human amniotic membranes are an attractive alternative to conjunctiva in the reconstruction of leaking glaucoma filtering blebs. This report describes two cases with leaking glaucoma filtering blebs associated with a scleral perforation, which were treated successfully using amniotic membranes.
A 55-year-old man who had undergone glaucoma surgery in both eyes about 40 years previously developed a conjunctival injection with discharge caused by bleb leaks with blebitis in his right eye in August 2005. His best-corrected visual acuity was 20/15 in the right eye and blindness in the left. The intraocular pressure (IOP) was 14 mm Hg in the right and 18 mm Hg in the left eye. The filtering bleb was cystic and localized with a thin wall and a Seidel test revealed 2 small points of bleb leaks in his right eye, although blebitis had been controlled by systemic and local antibiotics. (Fig. 1A) There was no hypotony or shallow anterior chamber. Infiltration with the blebs was present. The blebs seemed to have a high risk of recurrent infection; therefore a bleb revision was performed.
Figure 1. Slit-Lamp Photographs of the Right Eye in Case 1. (A) Before Surgery, the Filtering Bleb Is Cystic and Localized with Leaks Shown by a Seidel Test. (B) One Month After the Amniotic Membrane Transplantation. A Well-Functioning Filtering Bleb Was Formed with No Leakage.
After the limbal incision, a scleral perforation probably made by a previous glaucoma operation was found near the corneal limbus. The amniotic membrane was placed with its epithelium inside in the subconjunctival space to cover the scleral perforated area, and then sutured to the peripheral cornea using 10-0 nylon recurrent sutures. The leaking blebs were completely excised. After relaxing the conjunctiva by a fornix incision, the edge of the limbal conjunctiva was sutured to the peripheral cornea to cover the amniotic membrane with the advanced conjunctiva (Fig. 2). Twelve months after the surgery, the IOP remained lower than 18 mm Hg with antiglaucoma drops (Fig. 1B).
Figure 2. Schematic Drawings of the Amniotic Membrane Transplantation in Case 1. (A) After the Limbal Incision, a Scleral Perforation Is Located Close to the Corneal Limbus. (B) An Amniotic Membrane Is Placed with Its Epithelium Inside in the Subconjunctival Space and Sutured to the Peripheral Cornea. The Arrow Indicates Relaxing Incision of the Fornical Conjunctiva. (C) The Limbal Conjunctival Edge Is Sutured to the Peripheral Cornea for Conjunctival Advancement.
A 49-year-old man underwent glaucoma surgery twice in his right eye in 1973 and 1996. A trabeculectomy with mitomycin C was performed on the right eye in March, 2004 because the IOP was not medically controlled. About 1 year after the surgery, blebitis developed in the right eye. The blebitis was controlled by antibiotics; however, conservative treatments including patching and injection of autologous blood for the bleb leaks were not successful. Therefore he was referred to our hospital for the bleb revision. His best-corrected visual acuity was 20/250 in the right eye and 20/1000 in the left. His IOP was 13 mm Hg in the right and 20 mm Hg in the left. The filtering bleb was thin, cystic and localized, and Seidel test revealed a bleb leak point near the limbus in his right eye. There was no hypotony or shallow anterior chamber. Infiltration with the blebs was present (Fig. 3A).
Figure 3. Slit-Lamp Photographs of the Right Eye in Case 2. (A) The Bleb Leakage Appeared in the Perforated Area of the Scleral Flap. (B) One Year After the Amniotic Membrane Transplantation. A Healthy Conjunctiva Covers the Leaking Area and the Well-Functioning Filtering Bleb Is Formed with No Leakage
A perforation in the scleral flap associated with previous glaucoma surgery was confirmed near the limbus during the operation. There was intense conjunctival scaring around the leaking area. The amniotic membrane was placed with its epithelium outside to cover the leaking conjunctiva and then sutured to the peripheral cornea and conjunctiva continuously using 10-0 nylon sutures. A mass of amniotic membrane was stuffed in the scleral perforated lesion under the amniotic membrane patch (Fig. 4). After the surgery, a filtering bleb was observed without any leaks in the right eye. Three months after the surgery, the membrane graft had less height and could not be observed under a slit lamp examination. There was a healthy conjunctiva covering the leaking area with a well-functioning bleb. Twelve months after the surgery, the right IOP was 10 mm Hg with antiglaucoma medications (Fig. 3B).
Figure 4. Schematic Drawings of Amniotic Membrane Transplantation in Case 2. (A) The Amniotic Membrane Is Placed with Its Epithelium Outside to Cover the Leaking Bleb and Sutured to the Peripheral Cornea. (B) A Mass of Amniotic Membrane Is Stuffed into the Scleral Perforated Lesion and the Covering Amniotic Membrane Is Sutured to the Conjunctiva Around the Bleb.
In these 2 cases, the blebs were thin, avascular and localized with the cicatricial conjunctiva. In addition, the scleral perforation was located close to the corneal margin. These factors are associated with difficulties in repairing bleb leaks. Therefore, an amniotic membrane was used for revision of the leaking blebs.
An amniotic membrane was used for the reconstruction of the ocular surface by grafting, patching and stuffing.15,16 Amniotic membrane grafting is used as a surrogate basement membrane for a defective corneal or conjunctival surface to promote the proliferation and differentiation of epithelial cells on the amniotic membrane. Amniotic membrane patching is used to cover the inflammed ocular surface, especially when it is associated with epithelial defects. Deep ulcerations or small perforations of the cornea and sclera can be treated by stuffing small pieces of amniotic membrane into the stromal defects.
In case 1, the bleb leaks were treated using an amniotic membrane with the epithelium inside to cover the perforated scleral area. This method might also improve the outcome of filtration by preventing scar formation. A previous report17 showed that the amniotic membrane graft improves the outcome of filtration following a trabeculectomy for glaucoma patients at a high risk for filtration surgery. In case 2, the scleral perforation was treated using the amniotic membrane with the epithelium outside as stuffing and a graft. This method was used to promote the conjunctiva covering the leaking area. In this case, the healthy conjunctiva seemed to cover the leaking area accompanied by the formation of a well-functioning bleb three months after the surgery. Kee et al.10 covered bleb leaks with an amniotic membrane without any excision of the conjunctival flap to successfully stop the leak with a well-functioning bleb after the amniotic membrane spontaneously fell off. An amniotic membrane was used as a patch in case 1, because the advanced conjunctiva could completely cover the leaking area. In case 2, the conjunctiva could not completely cover the leaking area because of intense conjunctival scaring. Therefore an amniotic membrane was used as a graft. The present study suggests that amniotic membrane transplantation could be an alternative method for repairing leaking blebs accompanied by a scleral perforation.
Amniotic membranes have been used to treat intractable corneal epithelial defects18 due to their anti-inflammatory, anti-fibrotic and epithelializing effects. Previous experiments19,20 using rabbits demonstrated that the survival time associated with conjunctival blebs made by a trabeculectomy could be prolonged by subconjunctival amniotic membranes, probably due to their anti-fibrotic and anti-inflammatory effects. In the present cases, the amniotic membranes may have acted not only as a patch covering the leaking scleral hole to preserve the filtering route (case 1), but also as a graft leading to rapid epithelialization of the conjunctiva to cover the leaking conjunctiva16 (case 2). However, further studies are needed to confirm that these 2 techniques are reasonable for repairing bleb leaks near the corneal limbus accompanied by a scleral perforation.
In conclusion, bleb leaks that were present after a trabeculectomy were repaired successfully while maintaining their function by using amniotic membranes. These techniques may therefore be effective for the surgical management of high-risk leaking blebs.
- Greenfield DS, Liebmann JM, Lee J, et al. Late-onset bleb leaks after glaucoma filtering surgery. Arch Ophthalmol. 1998;116:443–447.
- Ritch R, Schuman JS, Belcher CD. Cases in controversy, management of the leaking filtration bleb. J Glaucoma. 1993;2:114–118.
- Azuara-Blanco A, Katz LJ. Dysfunctional filtering blebs. Surv Ophthalmol. 1998;43:93–126. doi:10.1016/S0039-6257(98)00025-3 [CrossRef]
- Wilensky JT. Management of late bleb leaks following glaucoma filtering surgery. Tr Am Ophthalmol Soc. 1992;90:161–168.
- O’Connor DJ, Tressler CS, Caprioli J. A surgical method to repair leaking filtering blebs. Ophthalmic Surg. 1992;23:336–338.
- Budenz DL, Chen PP, Weaver YK. Conjunctival advancement for late-onset filtering bleb leaks: Indications and outcomes. Arch Ophthalmol. 1999;117:1014–1019.
- Harris LD, Yang G, Feldman RM, et al. Autologous conjunctival resurfacing of leaking filtering blebs. Ophthalmology2000;107:1675–1680. doi:10.1016/S0161-6420(00)00280-3 [CrossRef]
- Buxton JN, Lavery KT, Liebmann JM, et al. Reconstruction of filtering blebs with free conjunctival autografts. Ophthalmology. 1994;101: 635–639.
- Wilson MR, Kotas-Neumann R. Free conjunctival patch for repair of persistent late bleb leak. Am J Ophthalmol. 1994;117:569–574.
- Kee C, Hwang J-M. Amniotic membrane graft for late-onset glaucoma filtering leaks. Am J Ophthalmol. 2002;133:834–835. doi:10.1016/S0002-9394(02)01415-0 [CrossRef]
- Prabhasawat P, Barton K, Burkett G, et al. Comparison of conjunctival autografts and amniotic membrane grafts for pterygium excision. Ophthalmology. 1997;104:974–985
- Tsubota K, Satake Y, Ohyama M, et al. Surgical reconstruction of the ocular surface in advanced cicatricial pemphigoid and Stevens-Johnson Syndrome. Am J Ophthalmol. 1996;122:38–52.
- Tseng SCG, Prabhasawat P, Lee S. Amniotic membrane transplantation for conjunctival surface reconstruction. Am J Ophthalmol. 1997;124:765–774.
- Shimazaki J, Yang H, Tsubota K. Amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns. Ophthalmology. 1997;104:2068–2076.
- Shimazaki J. Clinical Applications of Amniotic Membrane Transplantation. Jpn J Ophthalmic Surg. 2002;15:25–29 (Japanese).
- Zarbin M, Chu D. The amniotic membrane in Ophthalmology. Surv Ophthalmol. 2004;49:51–77. doi:10.1016/j.survophthal.2003.10.004 [CrossRef]
- Fujishima H, Shimazaki J, Shinozaki N, et al. Trabeculectomy with the use of amniotic membrane for uncontrollable glaucoma. Ophthalmic Surg Lasers. 1998;29:428–431.
- Lee S, Tseng SCG. Amniotic membrane transplantation for persistent epithelial defects with ulceration. Am J Ophthalmol1997;123:303–312.
- Barton K, Budenz DL, Khaw PT, et al. Glaucoma filtration surgery using amniotic membrane transplantation. Invest Ophthalmol Vis Sci. 2001;42:1762–1768.
- Demir T, Turgut B, Akyol N, et al. Effects of amniotic membrane transplantation and mitomycin C on wound healing in experimental glaucoma surgery. Ophthalmologica. 2002;216:438–442. doi:10.1159/000067550 [CrossRef]