Early cystic bleb needling revision after glaucoma filtering surgery with toxic keratopathy

Clinical case of high thin-wall cystic limited filtering bleb needling revision in the early post-op period after trabeculectomy with sinusotomy accompanied by toxic keratopathy is presented. Optical coherence tomography (OCT) demonstrated that filtering bleb height was 2700 μm and bleb wall thickness was 70 μm. Bleb needling revision with its lateralwall dissection and subconjunctival injection of dexamethasone, fluorouracil, and ranibizumab near to the bleb site was performed. In 1.5 hours after the procedure, bleb height decreased to 550 μm (by 5 times) while bleb wall thickness increased up to 100 μm. Topical antibacterial, steroid, and non-steroid anti-inflammatory therapy was recommended. The next day IOP level reduced from 11 mm Hg to 4.5 mm Hg. It was accompanied by choroidal effusion that was managed conservatively with cycloplegic agents (drops and injections) for 3 days. On day 6, central corneal edema affecting all layers, Descemet’s membrane folds, and ocular hypertension were revealed. Metabolic therapy resolved corneal edema within 3 days. Re-needling bleb revision decreased IOP level to 6.2 mm Hg. This resulted in transient Descemet’s membrane folds. This paper describes filtering bleb needling revision with its lateral wall dissection and anti-inflammatory, cytostatic, and anti-VEGF agents use to prolong glaucoma filtering surgery effect in excessive scarring. The procedure was accompanied by toxic corneal endothelium decompensation with corneal edema and Descemet’s membrane folds treated with active metabolic therapy.

1. Petrov S. Yu. Bleb classification. National Journal glaucoma. 2014; 13 (3): 85‑98. (in Russ.).

2. Wells A. P., Crowston J. G., Marks J., Kirwan J. F., Smith G., Clarke J. C., et al A pilot study of a system for grading of drainage blebs after glaucoma surgery. J Glaucoma 2004; 13 (6): 454‑460.

3. Shmyreva V. F., Petrov S. Yu., Antonov A. A., Pimenidi M. K. Controlled cytostatic therapy in the early postoperative period after glaucoma surgery (preliminary report). Herald of ophthalmology. 2007; 1: 12‑14. (in Russ.).

4. Shmyreva V. F., Petrov S. Yu., Makarova A. S. Causes of long-term decrease of glaucoma surgery hypotensive effect and possibilities of its enhancement. Glaucoma. 2010. 2: 43‑49. (in Russ.).

5. How A., Chua J. L., Charlton A., Su R., Lim M., Kumar R. S., Crowston J. G., Wong T. T. Combined treatment with bevacizumab and 5‑fluorouracil attenuates the postoperative scarring response after experimental glaucoma filtration surgery. Invest. Ophthalmol. Vis. Sci. 2010; 51 (2): 928‑932.

6. Camejo L., Noecker R. J. Bleb Needling. Glaucoma Today 2007; 1: 57‑60.

7. Sengupta S., Venkatesh R., Ravindran R. D. Safety and Efficacy of Using Off-label Bevacizumab Versus Mitomycin C to Prevent Bleb Failure in a Single-site Phacotrabeculectomy by a Randomized Controlled Clinical Trial. J. Glaucoma. 2012; 21 (7): 450‑459.

8. Klettner A., Roider J. Comparison of bevacizumab, ranibizumab, and pegaptanib in vitro: efficiency and possible additional pathways. Invest Ophthalmol Vis Sci. 2008; 49 (10): 4523‑4527.

9. Horsley M. B., Kahook M. Y. Anti-VEGF therapy for glaucoma. Curr Opin Ophthalmol. 2010; 21 (2): 112‑117.

10. Kahook M. Y. Bleb morphology and vascularity after trabeculectomy with intravitreal ranibizumab: a pilot study. Am J Ophthalmol. 2010; 150 (3): 399‑403.

11. Petrov S. Yu., Novikov I. A., Dugina A. E. Methods for assessing the functional state of the filtering bleb after glaucoma surgery. RU patent 2423069. 19.11.2009. (in Russ.).

12. Freiberg F. J., Matlach J., Grehn F., Karl S., Klink T. Postoperative subconjunctival bevacizumab injection as an adjunct to 5‑fluorouracil in the management of scarring after trabeculectomy. Clin Ophthalmol. 2013; 7: 1211‑1217.

13. Walters T., Raizman M., Ernest P., Gayton J., Lehmann R. In vivo pharmacokinetics and in vitro pharmacodynamics of nepafenac, amfenac, ketorolac, and bromfenac. J Cataract Refract Surg. 2007; 33 (9): 1539‑1545.

14. Brkovic A., Sirois M. G. Vascular +permeability induced by VEGF family members in vivo: Role of endogenous PAF and NO synthesis. J Cell Biochem. 2007; 100 (3): 727‑737.

15. Ferrara N. Molecular and biological properties of vascular endothelial growth factor. J Mol Med. 1999; 77: 527‑543.

16. Gavard J., Gutkind J. S. VEGF controls endothelial-cell permeability by promoting the beta-arrestin-dependent endocytosis of VE-cadherin. Nat Cell Biol. 2006; 8: 1223‑1234.

17. Avetisov S. E., Budzinskaya M. V., Kazaryan E. E., Gyrova I. V. Diagnostic value of lifetime retinal morphometry in patients with subretinal neovascularization. Herald of ophthalmology. 2007; 1: 3‑7. (in Russ.).

18. Budzinskaya M. V., Pogoda T. V., Strelkova I. D., Chikun E. A., Schegoleva I. V., Kazaryan E. E., Galoyan N. S. The impact of genetic mutations on the subretinal neovascularization clinical picture. Report № 2. The role of HTRA и VEGF genetic polymorphism. Herald of ophthalmology. 2011; 4: 9‑16. (in Russ.).

19. Karp J. E., Broder S. Molecular foundations of cancer: new targets for intervention. Nat. Med. 1995; 4 (1): 309‑320.

20. Bochmann F., Kaufmann C., Becht C. N., Guber I., Kaiser M., Bachmann L. M., Thiel M. A. ISRCTN12125882 — Influence of topical anti-VEGF (Ranibizumab) on the outcome of filtration surgery for glaucoma — Study Protocol. BMC Ophthalmol. 2011; 11: 1.

21. Singh R. P., Goldberg I., Mohsin M. The efficacy and safety of itraoperative and / or postoperative 5‑fluorouracil in trabeculectomy and phacotrabeculectomy. Clin. Experiment. Ophtalmol. 2001; 29 (5): 296‑302.

22. Knapp A., Heuer D. K., Stern G. A., Driebe W. T. Jr. Serious corneal complications of glaucoma filtering surgery with postoperative 5‑fluorouracil. Am J Ophthalmol. 1987; 103 (2): 183‑187.

23. Thomas R., Jacob A., Raju R., Gieser S. C., Sen S. Incidence of complications following 5‑fluorouracil with trabeculectomies. Indian J Ophthalmol. 1993; 41 (4): 185‑186.

24. Heur D. K., Parrish R. K., Gressel M. G., et al. 5‑Fluorouracil and glaucoma filtering surgery. II: A pilot study. Ophthalmology 1984; 91: 384‑394.

25. Heur D. K., Parrish R. K., Gressel M. G., et al. 5‑Fluorouracil and glaucoma filtering surgery: intermediate follow-up of a pilot study. Ophthalmology 1986; 93:1537‑1546.

26. Weinreb R. N. Adjusting the dose of 5‑Fluorouracil after filtration surgery to minimize side effects. Ophthalmology 1987; 94: 564‑570.