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Autologous blood injection for late-onset filtering bleb leak
evaluation and treatment in the Macular Photocoagulation Study. Arch Ophthalmol 1991;109:1242–1257. 4. Stur M, Ansari-Shahrezaei S. The effect of axial length on laser spot size and laser irradiance. Arch Ophthalmol 2001; 119:1323–1328.
However, considering the very small sample size in our series, no concrete recommendation can be drawn. We therefore want to know from the authors if they have any experience on this. Once again, we congratulate the authors for bringing up this important issue. ANITA PANDA, MRC(OPHTH), FICS SANJEEV NAINIWAL, MD, DNB, MNAMS, MIMSA MAYANK S. PANGTEY, MD
Autologous Blood Injection for Lateonset Filtering Bleb Leak
RAJEEV SUDAN, MD
New Delhi, India
EDITOR: THE RECENT ARTICLE BY BURNSTEIN AND ASSOCIATES
(Am J Ophthalmol 132:132–139, 2001) is commendable. The authors have rightly supported the view of other authors that liberal use of antifibrotic agents in glaucoma filtration surgery has certainly increased the incidence of spontaneous bleb leaks by creating a thin and avascular bleb.1 The problem is enormous with that of mitomycin C. Subsequently, this may lead to bleb infection.2 Management of such complications is painstaking and not free of ophthalmic hazards. While elaborating the good and poor results reported in the literature, the authors have described the limited outcome of autologus blood injection in treating late-onset filtering bleb leak in a much larger series than has ever been reported in the literature. While considering several factors before the repair, the important comment was on nature of leak. They have rightly commented that brisk leaks and small slow leaks are not ideal indications for the blood injection. However, they have not quantified the leak. In this context, we would like to share our experience, which was carried out in a quantified way (Table 1). Although our series is very small (only two eyes in each group), we feel our proposed management option may provide a better clue for precise management (Table 1). Furthermore, although no untoward effects after autologous blood injection occurred, we felt multilayered amniotic membrane transplantation offered quicker results in terms of adequate intraocular pressure control and maintenance of a clear anterior chamber. We feel amniotic membrane transplantation would be a better choice over autologous blood injection because of the above factors and no fear of transformation to a nonfunctional bleb from a leaking bleb.
REFERENCES
1. Greenfield DS, Liebmann JM, Ritch R. Late onset bleb leaks after glaucoma filtering surgery. Arch Ophthalmol 1998;116: 443– 447. 2. Mochizuki K, Jikihaze S, Ando Y, Hori Yamamoto T, Kitazawa Y. Incidence delayed onset infection after trabeculectomy with mitomycin C or 5 fluorouracil treatment. Br J Ophthalmol 1997;81:877– 883.
AUTHOR REPLY WE THANK DR. PANDA AND ASSOCIATES FOR THEIR COM-
ments and for their description of their experience with filtering bleb leak management. They should be commended for proposing a management regimen based on a quantitative assessment of the leak. We have not attempted such an assessment ourselves, but we have found that, in general, bleb revision with conjunctival advancement is more effective than nonincisional measures in repairing bleb leaks.1 We do not have any experience with amniotic membrane transplantation, but others have found it less effective than bleb revision surgery.2 We would encourage Dr. Panda and associates to expand their study and report their data as an article in a peer-reviewed journal. DARRELL WUDUNN, MD, PHD LOUIS B. CANTOR, MD
Indianapolis, Indiana TABLE 1. Management Option of Late-Onset Filtering Bleb on the Basis of the Seidel Test REFERENCES
Time of Onset of Clearance of Dye in Seconds
Management Option
0–5 6–10 6–10 11–15 ⬎15
Patching/cyanoacrylate glue Autologous blood injection Amniotic membrane transplant Amniotic membrane transplant Bleb revision
VOL. 133, NO. 6
1. Burnstein AL, WuDunn D, Knotts SL, Catoira Y, Cantor LB. Conjunctival advancement versus nonincisional treatment for late-onset glaucoma filtering bleb leaks. Ophthalmology 2002; 109:71–75. 2. Budenz DL, Barton K, Tseng SC. Amniotic membrane transplantation for repair of leaking glaucoma filtering blebs. Am J Ophthalmol 2000;130:580 –588.
CORRESPONDENCE
859
However, considering the very small sample size in our series, no concrete recommendation can be drawn. We therefore want to know from the authors if they have any experience on this. Once again, we congratulate the authors for bringing up this important issue. ANITA PANDA, MRC(OPHTH), FICS SANJEEV NAINIWAL, MD, DNB, MNAMS, MIMSA MAYANK S. PANGTEY, MD
Autologous Blood Injection for Lateonset Filtering Bleb Leak
RAJEEV SUDAN, MD
New Delhi, India
EDITOR: THE RECENT ARTICLE BY BURNSTEIN AND ASSOCIATES
(Am J Ophthalmol 132:132–139, 2001) is commendable. The authors have rightly supported the view of other authors that liberal use of antifibrotic agents in glaucoma filtration surgery has certainly increased the incidence of spontaneous bleb leaks by creating a thin and avascular bleb.1 The problem is enormous with that of mitomycin C. Subsequently, this may lead to bleb infection.2 Management of such complications is painstaking and not free of ophthalmic hazards. While elaborating the good and poor results reported in the literature, the authors have described the limited outcome of autologus blood injection in treating late-onset filtering bleb leak in a much larger series than has ever been reported in the literature. While considering several factors before the repair, the important comment was on nature of leak. They have rightly commented that brisk leaks and small slow leaks are not ideal indications for the blood injection. However, they have not quantified the leak. In this context, we would like to share our experience, which was carried out in a quantified way (Table 1). Although our series is very small (only two eyes in each group), we feel our proposed management option may provide a better clue for precise management (Table 1). Furthermore, although no untoward effects after autologous blood injection occurred, we felt multilayered amniotic membrane transplantation offered quicker results in terms of adequate intraocular pressure control and maintenance of a clear anterior chamber. We feel amniotic membrane transplantation would be a better choice over autologous blood injection because of the above factors and no fear of transformation to a nonfunctional bleb from a leaking bleb.
REFERENCES
1. Greenfield DS, Liebmann JM, Ritch R. Late onset bleb leaks after glaucoma filtering surgery. Arch Ophthalmol 1998;116: 443– 447. 2. Mochizuki K, Jikihaze S, Ando Y, Hori Yamamoto T, Kitazawa Y. Incidence delayed onset infection after trabeculectomy with mitomycin C or 5 fluorouracil treatment. Br J Ophthalmol 1997;81:877– 883.
AUTHOR REPLY WE THANK DR. PANDA AND ASSOCIATES FOR THEIR COM-
ments and for their description of their experience with filtering bleb leak management. They should be commended for proposing a management regimen based on a quantitative assessment of the leak. We have not attempted such an assessment ourselves, but we have found that, in general, bleb revision with conjunctival advancement is more effective than nonincisional measures in repairing bleb leaks.1 We do not have any experience with amniotic membrane transplantation, but others have found it less effective than bleb revision surgery.2 We would encourage Dr. Panda and associates to expand their study and report their data as an article in a peer-reviewed journal. DARRELL WUDUNN, MD, PHD LOUIS B. CANTOR, MD
Indianapolis, Indiana TABLE 1. Management Option of Late-Onset Filtering Bleb on the Basis of the Seidel Test REFERENCES
Time of Onset of Clearance of Dye in Seconds
Management Option
0–5 6–10 6–10 11–15 ⬎15
Patching/cyanoacrylate glue Autologous blood injection Amniotic membrane transplant Amniotic membrane transplant Bleb revision
VOL. 133, NO. 6
1. Burnstein AL, WuDunn D, Knotts SL, Catoira Y, Cantor LB. Conjunctival advancement versus nonincisional treatment for late-onset glaucoma filtering bleb leaks. Ophthalmology 2002; 109:71–75. 2. Budenz DL, Barton K, Tseng SC. Amniotic membrane transplantation for repair of leaking glaucoma filtering blebs. Am J Ophthalmol 2000;130:580 –588.
CORRESPONDENCE
859