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January 2003
Surgically Revising Bleb Leaks After
Trabeculectomy
Advice on how to maintain filtration long-term.
By MARLENE R. MOSTER, MD, AND AUGUSTO AZUARA-
BLANCO, MD, PHD

E-MAIL PRINT BOOKMARK

Bleb leaks can occur early in the postoperative period or months to years a"er
filtration surgery. An inadvertent buttonhole or tear in the conjunctiva during a
filtering procedure or a wound leak through the conjunctival incision can be
responsible for an early leaking bleb. The usual cause for conjunctival
buttonholes and tears is penetration of the tissue by the tip of a sharp
instrument (eg, needle, scissors, blade) or the teeth of a forceps. This RELATED NEWS
complication is more likely in cases with extensive conjunctival scarring. Early
leaking can lead to hypotony, a shallow or flat anterior chamber, choroidal
e#usion, and subconjunctival-to-episcleral fibrosis that will jeopardize a Ocugen Reports Positive Phase 2 Clinical
satisfactory long-term filtration. Results Demonstrating Proof-of-Concept for
its Novel Combination Therapy for Dry Eye
Late bleb leaks are more frequently encountered in thin, avascular blebs that were exposed to Disease
antifibrotic agents at the time of surgery.1-5 Leakage of the filtering bleb can be associated Ocugen announced positive results from its
phase 2 proof-of-concept clinical trial of
with hypotony and increases the chances for bleb-related infection and endophthalmitis.3,5,6 OCU310, a novel combination of brimondine
A surgeon must be able to differentiate between a bleb leak (ie, through a hole in the bleb) tartrate and a corticosteroid, loteprednol etab…

and bleb ooze (also known as a sweating bleb), which represents transconjunctival flow
NanoViricides Drug Candidates to be Tested
commonly seen in ischemic, thin blebs. in Animal Models of Dermal, Ocular, and
Genital Herpes Virus Infection at the
Bleb leaks may resolve spontaneously, and late bleb leaks may leak intermittently from new
University of Wisconsin
sites. NanoViricides has announced that it has
expanded its in vivo testing agreement with the
DIAGNOSIS University of Wisconsin to encompass testing its
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A Seidel sign will detect a leaking bleb (Figure 1). The surgeon applies a fluorescein strip to
the inferior tarsal conjunctiva or, very gently, directly to the bleb. Without applying pressure, pSivida Announces FDA Acceptance For
he should examine the eye under cobalt blue illumination. If there is a leak, he will see Filing of New Drug Application for Durasert
3-Year Treatment for Posterior Segment
unstained aqueous humor flowing into the tear film. If there is no spontaneous leakage, the
Uveitis
ophthalmologist should gently apply pressure to the globe or bleb while examining the pSivida announced that its new drug application
suspicious area. (NDA) for Durasert 3-year treatment for
posterior segment uveitis has been accepted by
the FDA for filing. The acceptance of th…

Figure 1. A Seidel sign detects a leaking bleb.

EARLY BLEB LEAKS

Management
The need for and timing of surgical intervention depends on the severity of the leakage and
presence of complications. A brisk leak associated with a flat filtering bleb, ocular hypotony,
and a shallow-to-flat anterior chamber merits prompt treatment. If the leak is mild, however,
with an elevated bleb, an acceptable IOP, and a deep anterior chamber, it is permissible to
observe the patient in order to allow time for the leak possibly to close spontaneously. In this
case, it is advisable to discontinue or reduce the amount of topical steroids that the patient
receives.

Therapeutic modalities to treat early leaking blebs include pressure patching, a bandage
contact lens, Simmon’s shell, a symblepharon ring, fibrin tissue glue, cyanoacrylate glue, and
surgical revision.7 The last option is the most efficient.8

Surgical Techniques for Repair

If the leak is located in the center of the conjunctival flap, the surgeon may attempt a purse-
string closure either internally on the undersurface of the conjunctiva or externally overlying
the flap, if the flap has already been reapproximated. A 10–0 or 11–0 nylon on a tapered
(“vascular”) needle should be used. When the conjunctival buttonhole or tear occurs at the
limbus, it may be sutured directly to the cornea, which should be de-epithelialized. A
mattress suture or, if large, a running suture with 10–0 nylon is appropriate. When the
buttonhole or tear occurs near the incised edge of a limbal-based conjunctival flap, the
surgeon may place sutures to close the conjunctival incision anterior to the tear to close it as
well.

LATE BLEB LEAKS

Management
The need for and timing of intervention for late bleb leaks depends on several factors. For
instance, monocular individuals with leaking blebs who have had previous episodes of bleb-
related infections, persistent ocular hypotony, a persistently shallow-to-flat anterior chamber,
or reduced vision should receive prompt treatment. In the absence of complications, the leak
may not require therapy, such as in patients who have focal small leaks with formed blebs,
normal IOP, good central vision, and no previous episodes of bleb-related infection.
Sometimes, an observation period will permit the leak sufficient time to close spontaneously.
Treatment with pharmacological agents that decrease aqueous secretion may facilitate this
closure by reducing the flow of aqueous through the fistula. Prophylactic broad-spectrum
antibiotic coverage that involves alternating different antibiotics is recommended. The
prompt diagnosis and management of bleb-related ocular infection depends upon educating
patients regarding its symptoms.

Many therapeutic modalities have been proposed to treat late leaks, including lubrication,
pressure patching, a bandage contact lens, a glaucoma tamponade shield, a symblepharon
ring, the injection of autologous blood cryopexy, thermal Nd:YAG laser, cyanoacrylate glue,
and fibrin tissue glue.7 Overall, the long-term success rate of these techniques has been less
than 50%, and surgical revision provides a better outcome.9,10

Surgical Techniques for Repair

When treating a late bleb leak, it is important to attempt to save the established, initial
filtration site. Due to the conjunctiva’s friable nature, it is often impossible to close the defect
directly with sutures, so healthy conjunctival tissue is needed. The most commonly used
technique consists of placing healthy autologous conjunctiva over the bleb, using either
advancement of the conjunctiva (with or without Tenon’s layers)11-17 or a free conjunctival
autograft.18,19

Conjunctival Advancement
Following this method, the surgeon uses a corneal traction suture (7–0 silk or polyglactin
910) to rotate the globe inferiorly. He then creates a paracentesis, after which he may inject
viscoelastic into the anterior chamber. Next, at both sides of the filtering bleb, the surgeon
performs a conjunctival peritomy that extends approximately 1 or 2 clock hours at each side.
He extends the conjunctival incision surrounding the avascular filtering bleb and dissects the
bleb from the healthy, surrounding conjunctiva, which is undermined posteriorly with blunt
dissection. A posterior conjunctival relaxing incision may be made at the fornix, parallel to
the limbus, creating a pedicle flap to facilitate the advancement of the conjunctiva.20

The surgeon subsequently denudes the ischemic, thin-walled bleb tissue and the limbus of
conjunctival and limbal epithelium by blade debridement (No. 67 Beaver blade) and wet-
field cautery to allow the long-term adherence of the grafted conjunctiva.17,20 While we
prefer this technique, a cellulose sponge lightly soaked in alcohol may also be used to
eliminate the epithelium.21 Alternatively, some surgeons excise the whole, thin, avascular
bleb wall.12,15,16,22 If there is excessive outflow through the scleral flap, placing additional
flap sutures may help. If the scleral flap is too friable to allow suturing, a scleral23,24 or
pericardium patch graft20 may be used.

Figure 2. In this revised bleb, healthy conjunctiva and Tenon’s has been brought to the limbus. Multiple
mattress sutures of 10–0 nylon make the incision watertight.

Next, the surgeon mobilizes the dissected fresh conjunctiva adjacent to the bleb in order to
cover it and sutures this conjunctiva over to the previously abraded peripheral cornea. A
sclerocorneal groove can facilitate watertight healing. The surgeon may secure the advanced
conjunctiva with temporal and nasal mattress sutures (10–0 nylon or 8–0 polyglactin
sutures)14 and/or a running suture (10–0 nylon) (Figures 2 and 3). Figure 4 illustrates the
different steps involved in conjunctival advancement.

Figure 3. One day postoperatively, the bleb is elevated and without leakage.

Free Autologous Conjunctival Graft

When severe scarring or a large bleb size results in severe tension on the advanced
conjunctiva, ptosis and hyperopia may occur. In these cases, bleb revision with a free
conjunctival autograft may be a better choice than conjunctival advancement.18,19,25 First, the
surgeon should use a caliper to measure the area of the avascular bleb both horizontally and
vertically and add 1 to 2 mm in both directions in order to allow for the postoperative
shrinkage of the bleb. After rotating the globe superiorly with an inferior corneal traction
suture, the surgeon measures the appropriate area of inferior conjunctiva and outlines it with
a marking pen. The surgeon then harvests the conjunctiva and sutures the free conjunctival
graft into place, covering the avascular bleb, with the limbal edge of the harvested
conjunctiva sutured at the limbus with mattress sutures (9–0 nylon, on a BV100 needle
[ETHICON, Somerville, NJ]) at the nasal and temporal edges. Finally, the surgeon secures
the remainder of the graft with running or interrupted sutures of 9–0 or 10–0 nylon.
Figure 4. The technique of repairing late leaking blebs is demonstrated. The surgeon identifies the
leaking bleb with a fluorescein strip (A). After outlining and demarcating the bleb, the surgeon uses
Vannas and/or Westcott scissors to cut open the conjunctiva and Tenon’s layer while leaving the limbus
intact (B). The surgeon widely undermines the conjunctiva and Tenon’s layer posterior to and around the
bleb so that there is sufficient tissue to bring down to the limbus (C). Next, the surgeon lifts the original
edge of the bleb, pulls it toward the limbus, and amputates it there with a Vannas scissors while leaving
the scleral bed intact (D). The surgeon brings healthy conjunctiva and Tenon’s tissue to the limbus and
sews it carefully with 10–0 individual mattress sutures. Alternatively, a running suture may be used (E).
If there is too much tension on the conjunctiva/Tenon’s flap, a relaxing incision in the fornix may be
created. The surgeon may suture the anterior edge with 9–0 VICRYL (ETHICON) (F).

Amniotic membrane transplantation

Amniotic membrane may be used instead of conjunctiva.26,27 A prospective, randomized trial
comparing amniotic membrane transplantation with conjunctival advancement reported a
better outcome with the latter technique, however.27

RESULTS OF SURGICAL BLEB REVISION

After revision, the bleb is typically thicker with variable vascularization. The IOP is usually
the same as preoperative levels or slightly raised, and the patient may need increased medical
therapy. Occasionally, some cases may experience a failure of filtration, but the overall
success rate of these techniques is approximately 80%.9,10

Marlene R. Moster, MD, is Professor of Clinical Ophthalmology at Thomas Jefferson School

of Medicine and Attending Surgeon on the Glaucoma Service, Wills Eye Hospital,
Philadelphia. She holds no financial interest in the products mentioned herein. Dr. Moster
may be reached at (610) 949-9788; moster@willsglaucoma.org.

Augusto Azuaro-Blanco, MD, PhD, is Consultant Ophthalmic Surgeon and Honorary

Clinical Senior Lecturer at the Department of Ophthalmology, Aberdeen Royal Infirmary,
University of Aberdeen in Aberdeen, United Kingdom. He holds no financial interest in the
products mentioned herein. Dr. Azuaro-Blanco may be reached at +44 12 24 55 32 17;
aazblanco@aol.com.

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Ophthalmol. 2002;120:297-300.

2. Uchida S, Suzuki Y, Araie M, et al. Long-term follow-up of initial 5-fluorouracil trabeculectomy in primary open-angle glaucoma in Japanese
patients. J Glaucoma. 2001;10:458-465.

3. Belyea DA, Dan JA, Stamper FL, et al. Late onset of sequential multifocal bleb leaks after glaucoma filtering surgery with 5-fluorouracil and

mitomycin-C. Am J Ophthalmol. 1997;124:40-45.

4. The Fluorouracil Filtering Surgery Study Group. Five-year follow-up of the Fluorouracil Filtering Surgery Study. Am J Ophthalmol.

1996;121:349-366.

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Ophthalmol. 2000;118:412-413.

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9. Burnstein AL, WuDunn D, Knotts SL, et al. Conjunctival advancement versus nonincisional treatment for late-onset glaucoma filtering bleb leaks.

Ophthalmology. 2002;109:71-75.

10. Lynch MG. Surgical repair of leaking filtering blebs. Discussion. Ophthalmology. 2000;107:1687.

11. Iliff CE. Flap perforation in glaucoma surgery sealed by a tissue patch. Arch Ophthalmol. 1964;71:215-218.

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13. Cohen JS, Shaffer RN, Hetherington J Jr, Hoskins HD Jr. Revision of filtration surgery. Arch Ophthalmol. 1977;95:1612-1615.

14. Galin MA, Hung PT. Surgical repair of leaking blebs. Am J Ophthalmol. 1977; 83:328-333.

15. O'Connor DJ, Tressler CS, Caprioli J. A surgical method to repair leaking filtering blebs. Ophthalmic Surg. 1992;23:336-338.

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1999;117:1014-1019.

17. Catoira Y, Wudunn D, Cantor LB. Revision of dysfunctional filtering blebs by conjunctival advancement with bleb preservation. Am J

Ophthalmol. 2000;130:574-579.

18. Buxton JN, Lavery KT, Liebmann JM, et al. Reconstruction of filtering blebs with free conjunctival autografts. Ophthalmology. 1994;101:635-

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20. Wadhwani RA, Bellows AR, Hutchinson BT. Surgical repair of leaking filtering blebs. Ophthalmology. 2000;107:1681-1687.

21. Harris LD, Yang G, Feldman RM, et al. Autologous conjunctival resurfacing of leaking filtering blebs. Ophthalmology. 2000;107:1675-1680.

22. Myers JS, Yang CB, Herndon LW, et al. Excisional bleb revision to correct overfiltration or leakage. J Glaucoma. 2000;9:169-173.

23. Hyams S. Repair of a leaking filtering bleb after trabeculectomy. Glaucoma. 1988;10:148-150.

24. Melamed S, Ashkenazi I, Belcher DC III, Blumenthal M. Donor scleral graft patching for persistent filtration bleb leak. Ophthalmic Surg.

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25. Schnyder CC, Shaarawy T, Ravinet E, et al. Free conjunctival autologous graft for bleb repair and bleb reduction after trabeculectomy and

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26. Kee C, Hwang JM. Amniotic membrane graft for late-onset glaucoma filtering leaks. Am J Ophthalmol. 2002;133:834-835.

27. Budenz DL, Barton K, Tseng SC. Amniotic membrane transplantation for repair of leaking glaucoma filtering blebs. Am J Ophthalmol.

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