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Closure of Fornix-based Posttrabeculectomy Conjunctival Wound Leaks With Autologous Fibrin Glue
LETTERS TO THE JOURNAL Closure of Fornix-based Posttrabeculectomy Conjunctival Wound Leaks With Autologous Fibrin Glue Stuart L. Graham, M.B.B.S., Barbara Murray, and Ivan Goldberg, M.B.B.S. Departments of Ophthalmology (S.L.G., I.G.) and Haematology (B.M.), Prince of Wales Hospital and University of New South Wales. Inquiries to Stuart L. Graham, M.B.B.S., Department of Ophthalmology, Prince of Wales Hospital, High St., Randwick, NSW, 2031, Australia. Posttrabeculectomy 5-fluorouracil injections have been associated with an increased inci dence of conjunctival wound leaks. 1 With a fornix-based conjunctival flap, these leaks can be particularly troublesome, predisposing not only to failure of the bleb but to the complica tions associated with a flat anterior chamber and hypotony. We successfully treated five patients who de veloped postoperative wound leaks with autol ogous fibrin glue. In four of these patients, the leak had not responded to conservative mea sures (pressure-patching, bandage soft contact lens, and Simmons' shell). In one patient the leak was a rapid one that was evident on the first postoperative day. Another patient had an area of devitalized conjunctiva causing a leak that did not seal despite two applications of the glue. In the five successful cases, the bleb remained functional and the 5-fluorouracil injections
were able to be recommenced after two to three days. No complications were observed from the applications and the glue was well tolerated. Currently, the mean follow-up is 4.2 months (range, 2.5 to 6.0 months), with a mean intraoc ular pressure of 14.8 mm Hg (range, 12 to 18 mm Hg) with no treatment. The 5-fluorouracil was administered in doses of 5 mg per injec tion. The mean cumulative 5-fluorouracil dose was 31 mg (range, 20 to 40 mg). In four pa tients, only one application of glue was re quired, whereas in the fifth patient a second application was made the next day. Four pa tients were treated with combined procedures (trabeculectomy with extracapsular cataract ex traction and intraocular lens), and one patient was treated with a trabeculectomy. The autologous glue was prepared using the ammonium sulfate precipitation technique. 2 Bovine thrombin (Thrombostat, Parke-Davis, Sydney, Australia) was the activator, with aminocaproic acid added to prevent fibrinolysis. We withdrew 36 ml of blood from each patient. From this the fibrinogen was extracted and was divided into two separate vials and frozen. Each vial yielded more than was required for an application. The second vial was stored frozen, to be available for a second application if the first was unsuccessful, or if the leak recurred during the 5-fluorouracil injections. For appli cation, the fibrinogen was thawed to 37 C in a water bath. The technique for application was as follows. With the patient in a supine position, an eyelid speculum was placed and the patient was asked to fixate inferiorly. The superior limbal region
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of THE JOURNAL. Letters must be typewritten, double-spaced, on 8 1/2 x 11-inch bond paper with 1 1/2-inch margins on all four sides. (See Instructions to Authors.) An original and two copies of the typescript and figures must be sent. The letters should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped or reducible to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, THE JOURNAL does not publish correspondence concerning previously published letters.
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was dried with a Stroll sponge (Defries Indus tries, Dandenong, Australia). Excess aqueous was expressed from the bleb edge with a cot ton-tip applicator. Both fibrinogen and activa tor were drawn into separate 1-ml syringes with 30-gauge needles. A row of drops of the activa tor was placed along the limbal wound margin, followed by an equal amount of fibrinogen. This combination was repeated for three layers. No manual mixing of the two solutions was required. The glue rapidly set, forming a gel like film over the wound. A drop of 2% fluorescein disclosed whether the leak had been sealed (Seidel's test) and staining the glue disclosed its extent. Extrane ous glue was removed by lifting it with nontoothed forceps and trimming with spring scis sors. A soft bandage contact lens was then applied to prevent displacement by eyelid movement. The eye was padded overnight and reexamined the next day. In all cases, the glue had dissolved in 24 hours, leaving only a thin film in the limbal groove. Conjunctival wound leaks have been sealed with cyanoacrylate adhesive, 3 and with com mercial pooled fibrin glue. 4 The advantages of fibrin glue over cyanoacrylate are that it sets in a wet field, it is well tolerated by the patient, and it is nontoxic. Using autologous fibrin glue rather than the commercial variety has the further advantage of avoiding the risk of trans mission of infections such as acquired immuno deficiency syndrome and hepatitis. The preparation time for the glue is about one hour. Advance preparation is possible if prob lems are anticipated. One patient received glue that had been prepared six weeks earlier (as a result of a temporary postponement of surgical procedures), with good bonding results. We were concerned that the fibrinogen could stimulate bleb fibrosis and thus reduce the sur gical success rate. To date we have seen no evidence of this, with no reduction in the suc cess of filtration. We therefore propose autolo gous fibrin glue as a useful alternative to resuturing in the management of fornix-based conjunctival wound leaks after trabeculectomy.
References 1. The Fluorouracil Filtering Surgery Study Group: Fluorouracil Filtering Surgery Study one year follow-up. Am J. Ophthalmol. 108:625, 1989. 2. Siedentop, K. H., Harris, D. M., Ham, K., and
August, 1992
Sanchez, B.: Extended experimental and preliminary surgical findings with autologous fibrin tissue adhe sive made from patient's own blood. Laryngoscope 96:1062, 1986. 3. Grady, F. J., and Forbes, M.: Tissue adhesive for repair of conjunctival buttonholes in glaucoma sur gery. Am. J. Ophthalmol. 68:656, 1969. 4. Kajiwara, K.: Repair of a leaking bleb with fibrin glue. Am. J. Ophthalmol. 109:599, 1990.
Mucogenic Glaucoma Caused by an Epithelial Cyst of the Iris Stroma Darren Lee Albert, M.D., S e y m o u r B r o w n s t e i n , M.D., and Barry S. Kattleman, M.D. Departments of Ophthalmology and Pathology, McGill University, Royal Victoria Hospital (D.L.A., S.B.); and Department of Ophthalmology, McGill University, Sir Mortimer B. Davis Jewish General Hospital (B.S.K.). Inquiries to Seymour Brownstein, M.D., Department of Ophthalmology, Royal Victoria Hospital, 687 Pine Ave. W., Suite E4.61, Montreal, Quebec, Canada H3A 1A1. Iris cysts have been classified into primary and secondary groups and may appear as con genital or acquired lesions. 1 We recently exam ined and treated an adult patient who had unilateral open-angle glaucoma associated with a mucus-producing epithelial cyst of the iris stroma of unknown origin. A 21-year-old woman had two months of blurred vision in her right eye at initial exami nation. Ocular and medical history were noncontributory, including history for previous trauma. She had not been taking any medica tions, including no eyedrops. Her best-correct ed visual acuity was 20/20 in both eyes and the intraocular pressure was R.E.: 30 mm Hg and L.E.: 14 mm Hg. Slit-lamp examination of her right eye disclosed that the anterior chamber was filled mostly with transparent material of a higher density than aqueous, described as be ing "reminiscent of vitreous," which contained several suspended flecks of pigment. A slightly elevated lesion, measuring 1.5 mm in diameter, with raised edges and a shallow, gray, indis tinct central crater was noted at the 9:30 o'clock meridian on the anterior surface of the periph eral iris (Fig. 1). Gonioscopy disclosed a few peripheral anterior synechiae that extended from the temporal margin of the lesion to the trabecular meshwork and a grade 4 (35 to 45 degrees) open angle elsewhere (nearly 360 de-
were able to be recommenced after two to three days. No complications were observed from the applications and the glue was well tolerated. Currently, the mean follow-up is 4.2 months (range, 2.5 to 6.0 months), with a mean intraoc ular pressure of 14.8 mm Hg (range, 12 to 18 mm Hg) with no treatment. The 5-fluorouracil was administered in doses of 5 mg per injec tion. The mean cumulative 5-fluorouracil dose was 31 mg (range, 20 to 40 mg). In four pa tients, only one application of glue was re quired, whereas in the fifth patient a second application was made the next day. Four pa tients were treated with combined procedures (trabeculectomy with extracapsular cataract ex traction and intraocular lens), and one patient was treated with a trabeculectomy. The autologous glue was prepared using the ammonium sulfate precipitation technique. 2 Bovine thrombin (Thrombostat, Parke-Davis, Sydney, Australia) was the activator, with aminocaproic acid added to prevent fibrinolysis. We withdrew 36 ml of blood from each patient. From this the fibrinogen was extracted and was divided into two separate vials and frozen. Each vial yielded more than was required for an application. The second vial was stored frozen, to be available for a second application if the first was unsuccessful, or if the leak recurred during the 5-fluorouracil injections. For appli cation, the fibrinogen was thawed to 37 C in a water bath. The technique for application was as follows. With the patient in a supine position, an eyelid speculum was placed and the patient was asked to fixate inferiorly. The superior limbal region
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of THE JOURNAL. Letters must be typewritten, double-spaced, on 8 1/2 x 11-inch bond paper with 1 1/2-inch margins on all four sides. (See Instructions to Authors.) An original and two copies of the typescript and figures must be sent. The letters should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped or reducible to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, THE JOURNAL does not publish correspondence concerning previously published letters.
221
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AMERICAN JOURNAL OF OPHTHALMOLOGY
was dried with a Stroll sponge (Defries Indus tries, Dandenong, Australia). Excess aqueous was expressed from the bleb edge with a cot ton-tip applicator. Both fibrinogen and activa tor were drawn into separate 1-ml syringes with 30-gauge needles. A row of drops of the activa tor was placed along the limbal wound margin, followed by an equal amount of fibrinogen. This combination was repeated for three layers. No manual mixing of the two solutions was required. The glue rapidly set, forming a gel like film over the wound. A drop of 2% fluorescein disclosed whether the leak had been sealed (Seidel's test) and staining the glue disclosed its extent. Extrane ous glue was removed by lifting it with nontoothed forceps and trimming with spring scis sors. A soft bandage contact lens was then applied to prevent displacement by eyelid movement. The eye was padded overnight and reexamined the next day. In all cases, the glue had dissolved in 24 hours, leaving only a thin film in the limbal groove. Conjunctival wound leaks have been sealed with cyanoacrylate adhesive, 3 and with com mercial pooled fibrin glue. 4 The advantages of fibrin glue over cyanoacrylate are that it sets in a wet field, it is well tolerated by the patient, and it is nontoxic. Using autologous fibrin glue rather than the commercial variety has the further advantage of avoiding the risk of trans mission of infections such as acquired immuno deficiency syndrome and hepatitis. The preparation time for the glue is about one hour. Advance preparation is possible if prob lems are anticipated. One patient received glue that had been prepared six weeks earlier (as a result of a temporary postponement of surgical procedures), with good bonding results. We were concerned that the fibrinogen could stimulate bleb fibrosis and thus reduce the sur gical success rate. To date we have seen no evidence of this, with no reduction in the suc cess of filtration. We therefore propose autolo gous fibrin glue as a useful alternative to resuturing in the management of fornix-based conjunctival wound leaks after trabeculectomy.
References 1. The Fluorouracil Filtering Surgery Study Group: Fluorouracil Filtering Surgery Study one year follow-up. Am J. Ophthalmol. 108:625, 1989. 2. Siedentop, K. H., Harris, D. M., Ham, K., and
August, 1992
Sanchez, B.: Extended experimental and preliminary surgical findings with autologous fibrin tissue adhe sive made from patient's own blood. Laryngoscope 96:1062, 1986. 3. Grady, F. J., and Forbes, M.: Tissue adhesive for repair of conjunctival buttonholes in glaucoma sur gery. Am. J. Ophthalmol. 68:656, 1969. 4. Kajiwara, K.: Repair of a leaking bleb with fibrin glue. Am. J. Ophthalmol. 109:599, 1990.
Mucogenic Glaucoma Caused by an Epithelial Cyst of the Iris Stroma Darren Lee Albert, M.D., S e y m o u r B r o w n s t e i n , M.D., and Barry S. Kattleman, M.D. Departments of Ophthalmology and Pathology, McGill University, Royal Victoria Hospital (D.L.A., S.B.); and Department of Ophthalmology, McGill University, Sir Mortimer B. Davis Jewish General Hospital (B.S.K.). Inquiries to Seymour Brownstein, M.D., Department of Ophthalmology, Royal Victoria Hospital, 687 Pine Ave. W., Suite E4.61, Montreal, Quebec, Canada H3A 1A1. Iris cysts have been classified into primary and secondary groups and may appear as con genital or acquired lesions. 1 We recently exam ined and treated an adult patient who had unilateral open-angle glaucoma associated with a mucus-producing epithelial cyst of the iris stroma of unknown origin. A 21-year-old woman had two months of blurred vision in her right eye at initial exami nation. Ocular and medical history were noncontributory, including history for previous trauma. She had not been taking any medica tions, including no eyedrops. Her best-correct ed visual acuity was 20/20 in both eyes and the intraocular pressure was R.E.: 30 mm Hg and L.E.: 14 mm Hg. Slit-lamp examination of her right eye disclosed that the anterior chamber was filled mostly with transparent material of a higher density than aqueous, described as be ing "reminiscent of vitreous," which contained several suspended flecks of pigment. A slightly elevated lesion, measuring 1.5 mm in diameter, with raised edges and a shallow, gray, indis tinct central crater was noted at the 9:30 o'clock meridian on the anterior surface of the periph eral iris (Fig. 1). Gonioscopy disclosed a few peripheral anterior synechiae that extended from the temporal margin of the lesion to the trabecular meshwork and a grade 4 (35 to 45 degrees) open angle elsewhere (nearly 360 de-