- Email: [email protected]
Efficacy of Autologous Blood Injection for Treating Overfiltering or Leaking Blebs After Glaucoma Surgery
2. Webster RG Jr. Corneal trauma. In: Smolin G, Thoft RA, editors. The cornea. Boston: Little, Brown and Company, 1994:605-633. 3. Roper-Hall M. Thermal and chemical burns. Trans Ophthalmol Soc U K 1965;85:631-640. 4. Dunnebier EA, Kok JHC. Treatment of an alkali burninduced symblepharon with a megasoft bandage lens. Cornea 1993;12:8-9.
Efficacy of Autologous Blood Injection for Treating Overfiltering or Leaking Blebs After Glaucoma Surgery Saira A. Choudhri, MD, Leon W. Herndon, MD, Karim F. Damji, MD, R. Rand Allingham, MD, and M. Bruce Shields, MD PURPOSE: To evaluate the efficacy of autologous blood injections for treating overfiltering or leak ing blebs after glaucoma surgery. METHOD: Retrospective review of ten eyes of ten patients who received intrableb autologous blood injections for hypotonous maculopathy. RESULTS: After intrableb blood injection, average intraocular pressure increased from 4.3 mm Hg to 6.4 mm Hg, and average visual acuity improved from 20/88 to 20/77. These results, however, were not statistically significant. CONCLUSION: Our results with autologous blood injection are less favorable than those of previous reports, although further study with a larger case series is needed.
H
YPOTONY ASSOCIATED WITH EXCESSIVE FILTERING
blebs or bleb leakage after glaucoma surgery is difficult to manage. Treatment of such blebs has included aqueous suppression, trichloroacetic acid, bandage soft contact lens, cryotherapy, and surgical revision. In 1993, Wise1 described the injection of autologous blood into the filtering bleb as an alterna tive treatment for overfiltering and leaking blebs. Other investigators have reported the benefits of this Accepted for publication Nov 13, 1996. Duke University Eye Center. Inquiries to Leon W. Herndon, MD, Box 3802, Durham, NC 27710; fax: (919) 684-2230; e-mail: [email protected]
554
procedure.2'4 Because our results have been less en couraging, we report our experience with autologous blood injection in overfiltering or leaking blebs. Ten eyes of ten patients were treated with autolo gous blood injection. Indications for the treatment included hypotony associated with overfiltration in seven eyes and with bleb leakage in three eyes. All procedures were performed after the administration of retrobulbar anesthesia with 4 ml of lidocaine 4% and bupivacaine 0.75% in equal parts with hyaluronidase. The first two procedures were performed at the slit lamp. Both were complicated by hyphema, and the remainder of the procedures were performed in a minor operating room with the patient in a supine position under an operating microscope. In the latter cases, the anterior chamber was filled with sodium hyaluronate. In all patients, venous blood was with drawn from the arm; the needle was changed to a 30 gauge, and a small quantity of blood was injected subconjunctivally adjacent to the filtering bleb and then into the bleb (Figure). After checking intraocu lar pressure, the eye was dressed with erythromycin ointment and patched. The ten patients included five men and five women. The ages of the patients ranged from 43 to 81 years (mean ± SD, 67.4 ± 12.5 years). Eight patients were diagnosed with chronic open-angle glaucoma, one patient with low-tension glaucoma, and one with traumatic glaucoma. Nine eyes had undergone trabeculectomy (five with mitomycin C, one with 5-fluorouracil, and three with no antimetabolite), and one eye had undergone posterior lip sclerotomy. Three eyes had had prior unsuccessful bleb interventions, includ ing trichloroacetic acid application in two eyes and suturing of the scleral flap in one eye. Follow-up ranged from 7 to 56 weeks (mean, 27.4 ± 17.1 weeks). The average intraocular pressure after autolo gous blood injection increased from 4.3 ± 2.5 mm Hg to 6.4 ± 5.1 mm Hg on the final visit. After treatment, intraocular pressure change ranged from - 3 mm Hg to 16 mm Hg. The logMAR visual acuity increased from a mean of 1.46 ± 1.01 to a mean of 1.32 ± 1.08. The mean preinjection and postinjection intraocular pressure and visual acuity were ana lyzed using the paired t test and the Wilcoxon signed rank test. The differences in mean preinjection and postinjection intraocular pressure and visual acuity
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL 1997
REFERENCES 1. Wise JB. Treatment of chronic postfiltration hypotony by intrableb injection of autologous blood. Arch Ophthalmol 1993;111:827-830. 2. Nuyts RM, Greve EL, Geijssen HC, Langerhorst CT. Treat ment of hypotonous maculopathy after trabeculectomy with mitomycin C. Am J Ophthalmol 1994;118:322-331. 3. Leen MM, Moster MR, Katz LJ, Terebuh AK, Schmidt CM, Spaeth GL. Management of overfiltering and leaking blebs with autologous blood injection. Arch Ophthalmol 1995; 113:1050-1055. 4. Smith MF, Magauran RG III, Betchkal J, Doyle JW. Treatment of postfiltration bleb leaks with autologous blood. Ophthal mology 1995;102:868-871.
Figure. Slit-lamp appearance of eye immediately after intrableb injection of autologous blood. Intrableb blood noted by arrowhead.
were not statistically significant. Of the three blebs with leaks, one closed after blood injection. Hyphema occurred in one patient who was treated with sodium hyaluronate in the supine position, in addition to the two patients in whom hyphema occurred at the slit lamp without sodium hyaluronate. Our results in this small series of 10 patients showed a trend toward improvement in visual acuity and intraocular pressure that was not statistically significant. These findings are less favorable than results reported in other case series, which have supported the efficacy of autologous blood injection in treating overfiltering and leaking blebs. Nuyts and associates2 described their experience with the use of autologous blood injection for the treatment of hypotonic maculopathy in 22 patients and reported an increase in intraocular pressure from 4.3 mm Hg to 8.6 mm Hg and an improvement in mean logMAR visual acuity from 0.71 to 0.32 in 22 patients. Leen and associates3 reported their experience with intra bleb blood injections in 12 eyes. In seven of 12 eyes classified as successes, intraocular pressure increased by a mean of 5.1 ± 2.9 mm Hg, and visual acuity improved by a mean of 5.3 ± 2 . 1 lines. The explana tion for our poorer results is not clear, but our findings suggest the need for further studies with larger case series to establish the efficacy of autologous blood injection in the management of overfiltering or leaking blebs.
VOL.123, No. 4
Perforation Rosette of the Lens After NchYAG Laser Iridotomy Gregor Wollensak, MD, Peter Eberwein, MD, and Jens Funk, MD, PhD PURPOSE: To describe an unreported complica tion of Nd:YAG laser iridotomy. METHODS: We examined a 31-year-old patient with pigment dispersion syndrome and moderately increased intraocular pressure whose left eye had been treated prophylactically with Nd:YAG laser iridotomy and who complained of blurred vision thereafter. RESULTS: Slit-lamp examination of the left eye disclosed a typical perforation rosette of the pos terior pole of the crystalline lens with a perfora tion of the anterior lens capsule under the iridoto my site and pigment within the lens. Opacity regressed spontaneously, and vision returned to normal. CONCLUSIONS: A perforation rosette of the lens can occur after Nd:YAG laser iridotomy and should be considered a possible serious complica tion of the procedure.
T
HE ND:YAG LASER IRIDOTOMY IS A THERAPEUTIC
procedure that is often used to treat angle-closure glaucoma. It has been recently introduced as a
Accepted for publication Nov 11, 1996. Department of Ophthalmology, University of Freiburg i Br (G.W., J.F.), and Eye Hospital Gengenbach (P.E.). Inquiries to Jens Funk, MD, PhD, Department of Ophthalmology, Killianstr 5, 79106 Freiburg i Br, Germany; fax: 01149 761 270 4063; e-mail: [email protected]
BRIEF REPORTS
555
Efficacy of Autologous Blood Injection for Treating Overfiltering or Leaking Blebs After Glaucoma Surgery Saira A. Choudhri, MD, Leon W. Herndon, MD, Karim F. Damji, MD, R. Rand Allingham, MD, and M. Bruce Shields, MD PURPOSE: To evaluate the efficacy of autologous blood injections for treating overfiltering or leak ing blebs after glaucoma surgery. METHOD: Retrospective review of ten eyes of ten patients who received intrableb autologous blood injections for hypotonous maculopathy. RESULTS: After intrableb blood injection, average intraocular pressure increased from 4.3 mm Hg to 6.4 mm Hg, and average visual acuity improved from 20/88 to 20/77. These results, however, were not statistically significant. CONCLUSION: Our results with autologous blood injection are less favorable than those of previous reports, although further study with a larger case series is needed.
H
YPOTONY ASSOCIATED WITH EXCESSIVE FILTERING
blebs or bleb leakage after glaucoma surgery is difficult to manage. Treatment of such blebs has included aqueous suppression, trichloroacetic acid, bandage soft contact lens, cryotherapy, and surgical revision. In 1993, Wise1 described the injection of autologous blood into the filtering bleb as an alterna tive treatment for overfiltering and leaking blebs. Other investigators have reported the benefits of this Accepted for publication Nov 13, 1996. Duke University Eye Center. Inquiries to Leon W. Herndon, MD, Box 3802, Durham, NC 27710; fax: (919) 684-2230; e-mail: [email protected]
554
procedure.2'4 Because our results have been less en couraging, we report our experience with autologous blood injection in overfiltering or leaking blebs. Ten eyes of ten patients were treated with autolo gous blood injection. Indications for the treatment included hypotony associated with overfiltration in seven eyes and with bleb leakage in three eyes. All procedures were performed after the administration of retrobulbar anesthesia with 4 ml of lidocaine 4% and bupivacaine 0.75% in equal parts with hyaluronidase. The first two procedures were performed at the slit lamp. Both were complicated by hyphema, and the remainder of the procedures were performed in a minor operating room with the patient in a supine position under an operating microscope. In the latter cases, the anterior chamber was filled with sodium hyaluronate. In all patients, venous blood was with drawn from the arm; the needle was changed to a 30 gauge, and a small quantity of blood was injected subconjunctivally adjacent to the filtering bleb and then into the bleb (Figure). After checking intraocu lar pressure, the eye was dressed with erythromycin ointment and patched. The ten patients included five men and five women. The ages of the patients ranged from 43 to 81 years (mean ± SD, 67.4 ± 12.5 years). Eight patients were diagnosed with chronic open-angle glaucoma, one patient with low-tension glaucoma, and one with traumatic glaucoma. Nine eyes had undergone trabeculectomy (five with mitomycin C, one with 5-fluorouracil, and three with no antimetabolite), and one eye had undergone posterior lip sclerotomy. Three eyes had had prior unsuccessful bleb interventions, includ ing trichloroacetic acid application in two eyes and suturing of the scleral flap in one eye. Follow-up ranged from 7 to 56 weeks (mean, 27.4 ± 17.1 weeks). The average intraocular pressure after autolo gous blood injection increased from 4.3 ± 2.5 mm Hg to 6.4 ± 5.1 mm Hg on the final visit. After treatment, intraocular pressure change ranged from - 3 mm Hg to 16 mm Hg. The logMAR visual acuity increased from a mean of 1.46 ± 1.01 to a mean of 1.32 ± 1.08. The mean preinjection and postinjection intraocular pressure and visual acuity were ana lyzed using the paired t test and the Wilcoxon signed rank test. The differences in mean preinjection and postinjection intraocular pressure and visual acuity
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL 1997
REFERENCES 1. Wise JB. Treatment of chronic postfiltration hypotony by intrableb injection of autologous blood. Arch Ophthalmol 1993;111:827-830. 2. Nuyts RM, Greve EL, Geijssen HC, Langerhorst CT. Treat ment of hypotonous maculopathy after trabeculectomy with mitomycin C. Am J Ophthalmol 1994;118:322-331. 3. Leen MM, Moster MR, Katz LJ, Terebuh AK, Schmidt CM, Spaeth GL. Management of overfiltering and leaking blebs with autologous blood injection. Arch Ophthalmol 1995; 113:1050-1055. 4. Smith MF, Magauran RG III, Betchkal J, Doyle JW. Treatment of postfiltration bleb leaks with autologous blood. Ophthal mology 1995;102:868-871.
Figure. Slit-lamp appearance of eye immediately after intrableb injection of autologous blood. Intrableb blood noted by arrowhead.
were not statistically significant. Of the three blebs with leaks, one closed after blood injection. Hyphema occurred in one patient who was treated with sodium hyaluronate in the supine position, in addition to the two patients in whom hyphema occurred at the slit lamp without sodium hyaluronate. Our results in this small series of 10 patients showed a trend toward improvement in visual acuity and intraocular pressure that was not statistically significant. These findings are less favorable than results reported in other case series, which have supported the efficacy of autologous blood injection in treating overfiltering and leaking blebs. Nuyts and associates2 described their experience with the use of autologous blood injection for the treatment of hypotonic maculopathy in 22 patients and reported an increase in intraocular pressure from 4.3 mm Hg to 8.6 mm Hg and an improvement in mean logMAR visual acuity from 0.71 to 0.32 in 22 patients. Leen and associates3 reported their experience with intra bleb blood injections in 12 eyes. In seven of 12 eyes classified as successes, intraocular pressure increased by a mean of 5.1 ± 2.9 mm Hg, and visual acuity improved by a mean of 5.3 ± 2 . 1 lines. The explana tion for our poorer results is not clear, but our findings suggest the need for further studies with larger case series to establish the efficacy of autologous blood injection in the management of overfiltering or leaking blebs.
VOL.123, No. 4
Perforation Rosette of the Lens After NchYAG Laser Iridotomy Gregor Wollensak, MD, Peter Eberwein, MD, and Jens Funk, MD, PhD PURPOSE: To describe an unreported complica tion of Nd:YAG laser iridotomy. METHODS: We examined a 31-year-old patient with pigment dispersion syndrome and moderately increased intraocular pressure whose left eye had been treated prophylactically with Nd:YAG laser iridotomy and who complained of blurred vision thereafter. RESULTS: Slit-lamp examination of the left eye disclosed a typical perforation rosette of the pos terior pole of the crystalline lens with a perfora tion of the anterior lens capsule under the iridoto my site and pigment within the lens. Opacity regressed spontaneously, and vision returned to normal. CONCLUSIONS: A perforation rosette of the lens can occur after Nd:YAG laser iridotomy and should be considered a possible serious complica tion of the procedure.
T
HE ND:YAG LASER IRIDOTOMY IS A THERAPEUTIC
procedure that is often used to treat angle-closure glaucoma. It has been recently introduced as a
Accepted for publication Nov 11, 1996. Department of Ophthalmology, University of Freiburg i Br (G.W., J.F.), and Eye Hospital Gengenbach (P.E.). Inquiries to Jens Funk, MD, PhD, Department of Ophthalmology, Killianstr 5, 79106 Freiburg i Br, Germany; fax: 01149 761 270 4063; e-mail: [email protected]
BRIEF REPORTS
555