Incision-Free Minimally Invasive Conjunctival Surgery (MICS) for Late-Onset Bleb Leaks After Trabeculectomy (An American Ophthalmological Society Thesis)

Abstract

This study describes an incision-free minimally invasive conjunctival surgical (MICS) technique to repair late-onset leaking blebs after trabeculectomy. METHODS: A surgical technique to repair leaking blebs without incision or excision of conjunctiva is described. This is followed by retrospective review of all patients treated at the Glaucoma Unit at St. Michael's Hospital for bleb leaks repaired with MICS from 2012 to 2017. With Research Ethics Board approval, clinical data obtained from the charts included demographic information, vision, intraocular pressure (IOP) data before and after surgery, need for additional medication, and complications. Resolution of the bleb leak without the need for additional therapy or intervention for glaucoma control was considered a success. RESULTS: The MICS approach was applied to 14 eyes of 13 consecutive patients with a leaking bleb. Mean age of presentation was 70.2 ± 14.8 years, and all patients had a history of mitomycin use at the time of glaucoma surgery. The onset of bleb leak following trabeculectomy ranged from 7 months to 16.3 years. Mean pre-operative IOP was 4.5 ± 2.8 mm Hg; IOP measured 12.3 ± 3.0 mm Hg immediately after the procedure. Complete resolution of the bleb leak was observed following surgery in all cases. The follow-up period ranged from 2 weeks to 61 months (10.2 ± 18.1). Recurrent bleb leak was reported in 1 patient 2 years following initial surgery. In all cases, the initially repaired filtering blebs remained functional at last followup, and no additional medications were required. CONCLUSIONS: The MICS procedure is an effective option for treating late-onset leaking blebs without cutting or excising conjunctival tissue. The minimal requirements of this method make it additionally accessible to low-resource settings. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Surgical Treatment of a Patient with Recurrent Bleb Leak and Glaucoma: Bleb Excision Combined with Gonioscopy-Assisted Transluminal Trabeculotomy

“…Non-surgical procedures, considered the first-line treatment, include aqueous suppressant drugs and large-diameter BCLs. 2,9 Generally, incisional methods are used in cases where non-surgical interventions are ineffective or leakage cannot be eliminated completely. Surgical procedures include conjunctival advancement or transplantation, scleral or corneal patch, amniotic membrane transplantation, and material or pericardium/dura patch applications to the leaking area.…”

“…1 However, patients who undergo one of these methods require close follow-up because of the high possibility of leakage recurrence and subsequent IOP elevation. 9 As a result, bleb leaks are sometimes difficult to manage. Furthermore, resuming anti-glaucoma drug therapy is necessary to control IOP in most cases.…”

Bleb plication: a minimally invasive repair method for a leaking ischemic bleb after trabeculectomy

“…Both conjunctival advancement 18 and MICS 28 attempt to cover an ischemic bleb with the non-ischemic conjunctiva. However, surgeons are often faced with a shortage of conjunctiva after the removal of the ischemic conjunctiva.…”

“…In addition, it is much less invasive than conjunctival advancement because the ischemic conjunctiva is not removed. Besides, Gupta et al proposed incision-free minimally invasive conjunctival surgery (MICS) to seal a bleb leakage 28 . There are shared aspects between our bleb plication method and MICS; both attempt to seal bleb leakage by covering the ischemic bleb with the conjunctiva from the fornix side, without removing the ischemic conjunctiva.…”

Combined minimally invasive conjunctival surgery with lens repositioning for traumatic bleb leak with dislocated intraocular lens

“…Traditional conjunctival advancement approaches for bleb revision in the setting of persistent bleb leaks typically involve extensive conjunctival incisions and dissections that often lead to slow visual recovery. Minimally invasive conjunctival surgery (MICS) was recently described as a less invasive alternative for repair of bleb leaks [ 1 ]. This underutilized approach may be particularly useful when concurrently performing other ophthalmic procedures requiring extensive manipulation of the eye, which is often needed for management of ocular trauma.…”