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Sylvia L. Groth, E R. Craven, William E. Sponsel; Conjunctival Advancement Flap For Restoration Of Visual Function While Conserving Filtration In Dysfunctional Antimetabolite Blebs. Invest. Ophthalmol. Vis. Sci. 2012;53(14):2500.
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Mitomycin-C has been used to reduce fibrovascular failure of glaucoma filtering blebs, but in some patients these blebs may develop diffuse epithelial incontinence or full-thickness leaks, with associated dysesthesia and hypotony. Aside from the resultant loss of visual function with hypotony-associated corneal and macular edema, bleb incontinence can leave the eye vulnerable to endophthalmitis. Various methods exist for effective repair of bleb leaks, but most sacrifice bleb function. We investigated the long-term efficacy of a fornix-based conjunctival advancement flap over the bleb to close leaks and relieve hypotony.
This study was conducted at 2 centers in patients with 1) a Seidel-positive bleb leak, 2) persistent dysesthesia, or 3) ischemic migrating bleb. Westcott dissection from the posterior bleb margin toward the sulcus was used to free the conjunctival flap, which was then advanced over the cautery-de-epithelialized bleb and secured to the cornea using multiple 10-0 nylon mattress sutures. Outcome measures were number of glaucoma meds, acuity and IOP up to 3 years.
55 consecutive qualifying patients (mean age 71.5 ±1.65(sem) yrs, 3.24 ±0.53 years since trabeculectomy) were evaluated for 25.3 ±1.8 mo. Six blebs (11%) required additional surgical revision within the follow-up period. Among all eyes, mean acuity increased from 0.376 ± 0.036 pre-op to 0.529 ±0.044 at 6 months (p< 0.0001), and this was sustained. Pre-operatively, 0.16 ± 0.07 meds were used, 0.35 ± 0.11 at 6 mo, and 0.28 ± 0.10 at 1 yr. Mean pre-op IOP was 5.1 ± 0.56 mmHg; 1 mo post-op 15.6 ±0.93, 6 mo 11.4 ±0.67, 1 yr 12.1 ±0.88, 2 yrs 11.1 ±0.79, and 3 yrs 13.2 ±0.75, all highly significant differences (p<0.0001). Of interest was a significant drop in IOP between 1 and 6 months (4.2 mmHg, p=0.001) not associated with any change in medication (R2 = 0.08).
The conjunctival advancement flap procedure as described is very effective at closing bleb leaks and maintaining IOP at a safe and protective level through three years. Visual acuity significantly improved and number of medications required remained minimal. Healing phenomena may be responsible for the initial mid-normal range IOP at 1 month decreasing and remaining in the low-normal range at all subsequent intervals.
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