- Email: [email protected]
Repair of a Leaking Bleb With Fibrin Glue
Letters to the Journal
Vol. 109, No.5
these early time points, it is reasonable to expect that a significant amount of the drug measured is intact fluorescein. We believe topical ocular fluorescein is absorbed systemically and crosses into a mother's breast milk. Even though fluorescein has low potential for toxicity, these data suggest that a nursing mother should be notified not to breast feed for 8 to 12 hours after topical fluorescein administration. These findings become more important when a hundredfold larger oral or intravenous dose of fluorescein is administered to a patient. An assessment of the benefit to the mother and risk to the infant should be undertaken in each individual case.
References 1. Blair, N. P., Evans, M. A., Lesar, T. S., and Zeimer, R. c.: Fluorescein and fluorescein glucuronide pharmacokinetics after intravenous injection. Invest. Ophthalmol. Vis. Sci. 27:1107,1986. 2. Lund-Andersen, H., Krogsaa, B., and Jensen, P. K: Fluorescein in human plasma in vivo. Acta Ophthalmol. 60:709, 1982. 3. Larsen, M., Loft, S., Hommel, E., and LundAndersen, H.: Fluorescein and fluorescein glucuronide in plasma after intravenous injection of fluorescein. Acta Ophthalmol. 66:427, 1988. 4. Blair, N. P., Evans, M. A., Lesar, T. S., and Willett, M.: Plasma fluorescein and fluorescein glucuronide in patients with selected eye diseases. Graefes Arch. Clin. Exp. Ophthalmol. 227:114, 1989. 5. Shekleton, P., Fridler. J., and Grimwade, J.: A case of benign intracranial hypertension in pregnancy. Br. J. Obstet. Gynaecol. 87:345, 1980.
Repair of a Leaking Bleb With Fibrin Glue Kazuto Kajiwara, M.D. Department of Ophthalmology, Keio University School of Medicine. Inquiries to Kazuto Kajiwara, M.D., 2-16-2 Tsurumaki, Setagaya-ku, Tokyo 154, Japan. A postoperative regimen of daily subconjunctival injections of 5-fluorouracil markedly improved the success rate of filtering operations in patients with intractable glaucoma. I In addition to the adverse effects on the corneal epitheli-
599
um," the inhibitory effect of 5-fluorouracil on conjunctival wound healing may lead to aqueous leakage and the collapse of the anterior chamber." I used fibrin glue to close a dehisced conjunctival wound through which slight aqueous leakage persisted despite resuturing. A monocular 67-year-old woman with uncontrollable glaucoma underwent an uncomplicated trabeculectomy through a corneoscleral limbus-based conjunctival flap. A 9-0 silk running suture was used for conjunctival wound closure. On the first postoperative day, the anterior chamber was maintained by injected sodium hyaluronate. The intraocular pressure, as measured by applanation tonometry, was 5 mm Hg. A regimen of daily subconjunctival injections of 5-fluorouracil was begun. Intraocular pressure on the second postoperative day was 2 mm Hg, with no wound leakage detected on Seidel testing. On the third postoperative day, the anterior chamber was flat. Seidel testing showed slight but continuous leakage through the conjunctival wound and suture holes. Despite successful resuturing with no leakage on the sixth postoperative day, the anterior chamber collapsed again on the next day, also with slight but continuous leakage. A pressure patch was only effective in anterior chamber formation while it was being applied. The patient complained of the complete blindness resulting from eye patching, so it was decided that the wound should be sealed by some other method. On the eighth postoperative day, cyanoacrylate was applied from a 27 -gauge needle over the conjunctival wound. After 5 minutes, the filtering bleb had expanded; 20 minutes later, increased depth of the anterior chamber was noted. The next morning, however, coagulated cyanoacrylate was found to have spontaneously detached in a thin plate, and again the anterior chamber had collapsed. Another attempt was made, which also resulted in failure. On the 13th postoperative day, fibrin glue was applied over the wound after the conjunctiva had been dried as much as possible. Fibrinogen solution and thrombin solution were then applied, three times each, alternately, from a 27-gauge needle tip (Fig. 1, left). I used Beriplast P (Hoechst Japan, Behring Welke AG), which includes highly condensed fibrinogen and thrombin solutions reinforced with factor XlII and aprotinino No leakage was detected by Seidel testing, and the depth of the anterior chamber increased within half an hour. The next morning, the anterior chamber was as deep as in the
600
May, 1990
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Kajiwara). Left, Applied fibrin glue is fluorescein-stained (arrows). Right, The extent of the applied glue was reduced over the time course, but wound dehiscence and suture holes were firmly sealed, without leakage, on the 19th postoperative day. preoperative state, and an exuberant, diffuse bleb was noted. The extent of the applied fibrin glue gradually reduced over the time course (Fig. 1, right), possibly because of physical abrasion by eyelid movement, but the wound itself was firmly sealed. The patient was discharged on the 15th postoperative day with an anterior chamber of normal depth (Fig. 2) and no aqueous leakage. The intraocular pressure was kept at 5 to 6 mm Hg for the next ten months. Cyanoacrylate was successfully used by
Grady and Forbes" in the repair of fistulas after glaucoma surgery. In my patient, however, an attempt to arrest wound dehiscence with cyanoacrylate failed twice. This was possibly because of failure to accomplish complete dryness before application. After a filtering operation, it is almost impossible to dry the wound edges, suture holes, and surrounding tissue completely because of aqueous leakage. In contrast, fibrin glue can coagulate even in wet conditions, as Zauberman and Hemo have reported." and has a longer sealing effect with the tissue after coagulation. It has been applied as a physiologic tissue glue to prevent postoperative fluid leakage and oozing hemorrhage after neurosurgery, lung surgery, cardiovascular surgery, and other surgical procedures. Additionally, human-derived fibrinogen is less irritative to the tissue.
References
Fig. 2 (Kajiwara). The patient was discharged with a normal-depth anterior chamber and intraocular pressure of 5 mm Hg.
1. Heuer, D. K., Parrish, R. K., II, Gressel, M. G., Hodapp, E., Desjardins, D. c.. Skuta, G. L., Palmberg, P. F., Nevarez, J. A., and Rockwood, E. J.: 5-Fluorouracil and glaucoma filtering surgery. III. Intermediate follow-up of a pilot study. Ophthalmology 93:1537, 1986. 2. Knapp, A., Heuer, D. K., Stern, G. A., and Driebe. W. T., [r.: Serious corneal complications of
Vol. 109, No.5
601
Letters to the Journal
glaucoma filtering surgery with postoperative 5-fluorouracil. Am. J. Ophthalmol. 103:183, 1987. 3. Rockwood, E. J., Parrish, R. K., II, Heuer, D. K., Skuta, G. L., Hodapp, E., Palmberg, P. F., Gressel, M. G., and Feuer, W.: Glaucoma filtering surgery with 5-fluorouracil. Ophthalmology 94:1071, 1987. 4. Grady, F. J., and Forbes, M.: Tissue adhesive for repair of conjunctival buttonhole in glaucoma surgery. Am. J. Ophthalmol. 68:656, 1969. 5. Zauberman, H., and Hemo, I.: Use of fibrin glue in ocular surgery. Ophthalmic Surg. 19:132, 1988.
Inhibition of Exercise-Induced Pigment Dispersion in a Patient With the Pigmentary Dispersion Syndrome William L. Haynes, M.D., A. Tim Johnson, M.D., and Wallace L. M. Alward, M.D. Department of Ophthalmology, University of Iowa Hospitals and Clinics. Inquiries to William L. Haynes, M.D., Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242. Pigmentary dispersion syndrome is thought to result from the rubbing of the iris pigment epithelium on the anterior packets of zonules.' Strenuous exercise may precipitate episodes of pigment dispersion in some patients.v" We treated a patient who consistently developed pigment dispersion and increased intraocular pressure after playing basketball. Both the pigment dispersion and the pressure rise could be inhibited by treatment with topical 0.5% pilocarpine before exercise. A 29-year-old myopic man had blurred vision and halos around lights after playing basketball. Slit-lamp examination showed Krukenberg spindles, midperipheral iris transilluminattion defects, and marked pigmentation of the trabecular meshwork in both eyes. The optic disks and visual fields were normal. After obtaining informed consent, we examined the patient 30 minutes before and 30 to 60 minutes after strenuous exercise (playing basketball for approximately two hours) on several different days. Intraocular pressure was measured by pneumotonometry, and anterior chamber pigment was graded on a modified Mitsui scale.' There was no pretreatment for the initial trial. Intraocular pressure was R.E.: 19
mm Hg and L.E.: 21 mm Hg before exercise with trace anterior chamber pigment in both eyes. After exercise, intraocular pressures increased to 47 mm Hg in both eyes with severe anterior chamber pigment. In subsequent tria... either the left eye only or the right eye only was treated with 0.5% pilocarpine (one drop 30 minutes before exercise) or 0.5% thymoxamine (one drop Ph hours and 30 minutes before exercise). When either eye was pretreated with pilocarpine, the intraocular pressure actually decreased after exercise in the treated eye, and there was minimal or no increase in anterior chamber pigment. When either eye was left untreated or was pretreated with thymoxamine, a marked increase in both intraocular pressure and anterior chamber pigment (similar to that seen in the initial trial) occurred after exercise. In two previously reported cases of symptomatic pigment dispersion.V both patients described symptoms that most commonly occurred after playing basketball. One patient was given pilocarpine to use prophylactically. This reportedly relieved the symptoms, but it is not clear whether it inhibited pigment release or intraocular pressure increase since no measurements were made just before exercise." Our patient also exhibited pigment dispersion and intraocular pressure increase after 90 minutes of jumping exercises but not after comparable periods of jogging or bicycling. Jumping exercises may be more likely to cause iris-zonule contact. In our patient, 0.5% pilocarpine clearly inhibited exercise-induced dispersion of pigment and increase in intraocular pressure while 0.5% thymoxamine (an alpha adrenergic inhibitor) did not. Though pilocarpine increases aqueous outflow and thus lowers intraocular pressure, this mechanism would not explain inhibition of pigment release. The greater pupillary constriction achieved with pilocarpine may more effectively inhibit iris-zonule contact. Pilocarpine may be clinically useful when given prophylactically before exercise in patients subject to exercise-induced pigment dispersion.
References 1. Campbell, D. G.: Pigmentary dispersion and glaucoma. Arch. Ophthalmol. 97:1667, 1979. 2. Epstein, D. L., Boger, W. P., II, and Grant, W. M.: Phenylephrine provocative testing in the pigmentary dispersion syndrome. Am. J. Ophthalmol. 85:43, 1978.
Vol. 109, No.5
these early time points, it is reasonable to expect that a significant amount of the drug measured is intact fluorescein. We believe topical ocular fluorescein is absorbed systemically and crosses into a mother's breast milk. Even though fluorescein has low potential for toxicity, these data suggest that a nursing mother should be notified not to breast feed for 8 to 12 hours after topical fluorescein administration. These findings become more important when a hundredfold larger oral or intravenous dose of fluorescein is administered to a patient. An assessment of the benefit to the mother and risk to the infant should be undertaken in each individual case.
References 1. Blair, N. P., Evans, M. A., Lesar, T. S., and Zeimer, R. c.: Fluorescein and fluorescein glucuronide pharmacokinetics after intravenous injection. Invest. Ophthalmol. Vis. Sci. 27:1107,1986. 2. Lund-Andersen, H., Krogsaa, B., and Jensen, P. K: Fluorescein in human plasma in vivo. Acta Ophthalmol. 60:709, 1982. 3. Larsen, M., Loft, S., Hommel, E., and LundAndersen, H.: Fluorescein and fluorescein glucuronide in plasma after intravenous injection of fluorescein. Acta Ophthalmol. 66:427, 1988. 4. Blair, N. P., Evans, M. A., Lesar, T. S., and Willett, M.: Plasma fluorescein and fluorescein glucuronide in patients with selected eye diseases. Graefes Arch. Clin. Exp. Ophthalmol. 227:114, 1989. 5. Shekleton, P., Fridler. J., and Grimwade, J.: A case of benign intracranial hypertension in pregnancy. Br. J. Obstet. Gynaecol. 87:345, 1980.
Repair of a Leaking Bleb With Fibrin Glue Kazuto Kajiwara, M.D. Department of Ophthalmology, Keio University School of Medicine. Inquiries to Kazuto Kajiwara, M.D., 2-16-2 Tsurumaki, Setagaya-ku, Tokyo 154, Japan. A postoperative regimen of daily subconjunctival injections of 5-fluorouracil markedly improved the success rate of filtering operations in patients with intractable glaucoma. I In addition to the adverse effects on the corneal epitheli-
599
um," the inhibitory effect of 5-fluorouracil on conjunctival wound healing may lead to aqueous leakage and the collapse of the anterior chamber." I used fibrin glue to close a dehisced conjunctival wound through which slight aqueous leakage persisted despite resuturing. A monocular 67-year-old woman with uncontrollable glaucoma underwent an uncomplicated trabeculectomy through a corneoscleral limbus-based conjunctival flap. A 9-0 silk running suture was used for conjunctival wound closure. On the first postoperative day, the anterior chamber was maintained by injected sodium hyaluronate. The intraocular pressure, as measured by applanation tonometry, was 5 mm Hg. A regimen of daily subconjunctival injections of 5-fluorouracil was begun. Intraocular pressure on the second postoperative day was 2 mm Hg, with no wound leakage detected on Seidel testing. On the third postoperative day, the anterior chamber was flat. Seidel testing showed slight but continuous leakage through the conjunctival wound and suture holes. Despite successful resuturing with no leakage on the sixth postoperative day, the anterior chamber collapsed again on the next day, also with slight but continuous leakage. A pressure patch was only effective in anterior chamber formation while it was being applied. The patient complained of the complete blindness resulting from eye patching, so it was decided that the wound should be sealed by some other method. On the eighth postoperative day, cyanoacrylate was applied from a 27 -gauge needle over the conjunctival wound. After 5 minutes, the filtering bleb had expanded; 20 minutes later, increased depth of the anterior chamber was noted. The next morning, however, coagulated cyanoacrylate was found to have spontaneously detached in a thin plate, and again the anterior chamber had collapsed. Another attempt was made, which also resulted in failure. On the 13th postoperative day, fibrin glue was applied over the wound after the conjunctiva had been dried as much as possible. Fibrinogen solution and thrombin solution were then applied, three times each, alternately, from a 27-gauge needle tip (Fig. 1, left). I used Beriplast P (Hoechst Japan, Behring Welke AG), which includes highly condensed fibrinogen and thrombin solutions reinforced with factor XlII and aprotinino No leakage was detected by Seidel testing, and the depth of the anterior chamber increased within half an hour. The next morning, the anterior chamber was as deep as in the
600
May, 1990
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Kajiwara). Left, Applied fibrin glue is fluorescein-stained (arrows). Right, The extent of the applied glue was reduced over the time course, but wound dehiscence and suture holes were firmly sealed, without leakage, on the 19th postoperative day. preoperative state, and an exuberant, diffuse bleb was noted. The extent of the applied fibrin glue gradually reduced over the time course (Fig. 1, right), possibly because of physical abrasion by eyelid movement, but the wound itself was firmly sealed. The patient was discharged on the 15th postoperative day with an anterior chamber of normal depth (Fig. 2) and no aqueous leakage. The intraocular pressure was kept at 5 to 6 mm Hg for the next ten months. Cyanoacrylate was successfully used by
Grady and Forbes" in the repair of fistulas after glaucoma surgery. In my patient, however, an attempt to arrest wound dehiscence with cyanoacrylate failed twice. This was possibly because of failure to accomplish complete dryness before application. After a filtering operation, it is almost impossible to dry the wound edges, suture holes, and surrounding tissue completely because of aqueous leakage. In contrast, fibrin glue can coagulate even in wet conditions, as Zauberman and Hemo have reported." and has a longer sealing effect with the tissue after coagulation. It has been applied as a physiologic tissue glue to prevent postoperative fluid leakage and oozing hemorrhage after neurosurgery, lung surgery, cardiovascular surgery, and other surgical procedures. Additionally, human-derived fibrinogen is less irritative to the tissue.
References
Fig. 2 (Kajiwara). The patient was discharged with a normal-depth anterior chamber and intraocular pressure of 5 mm Hg.
1. Heuer, D. K., Parrish, R. K., II, Gressel, M. G., Hodapp, E., Desjardins, D. c.. Skuta, G. L., Palmberg, P. F., Nevarez, J. A., and Rockwood, E. J.: 5-Fluorouracil and glaucoma filtering surgery. III. Intermediate follow-up of a pilot study. Ophthalmology 93:1537, 1986. 2. Knapp, A., Heuer, D. K., Stern, G. A., and Driebe. W. T., [r.: Serious corneal complications of
Vol. 109, No.5
601
Letters to the Journal
glaucoma filtering surgery with postoperative 5-fluorouracil. Am. J. Ophthalmol. 103:183, 1987. 3. Rockwood, E. J., Parrish, R. K., II, Heuer, D. K., Skuta, G. L., Hodapp, E., Palmberg, P. F., Gressel, M. G., and Feuer, W.: Glaucoma filtering surgery with 5-fluorouracil. Ophthalmology 94:1071, 1987. 4. Grady, F. J., and Forbes, M.: Tissue adhesive for repair of conjunctival buttonhole in glaucoma surgery. Am. J. Ophthalmol. 68:656, 1969. 5. Zauberman, H., and Hemo, I.: Use of fibrin glue in ocular surgery. Ophthalmic Surg. 19:132, 1988.
Inhibition of Exercise-Induced Pigment Dispersion in a Patient With the Pigmentary Dispersion Syndrome William L. Haynes, M.D., A. Tim Johnson, M.D., and Wallace L. M. Alward, M.D. Department of Ophthalmology, University of Iowa Hospitals and Clinics. Inquiries to William L. Haynes, M.D., Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242. Pigmentary dispersion syndrome is thought to result from the rubbing of the iris pigment epithelium on the anterior packets of zonules.' Strenuous exercise may precipitate episodes of pigment dispersion in some patients.v" We treated a patient who consistently developed pigment dispersion and increased intraocular pressure after playing basketball. Both the pigment dispersion and the pressure rise could be inhibited by treatment with topical 0.5% pilocarpine before exercise. A 29-year-old myopic man had blurred vision and halos around lights after playing basketball. Slit-lamp examination showed Krukenberg spindles, midperipheral iris transilluminattion defects, and marked pigmentation of the trabecular meshwork in both eyes. The optic disks and visual fields were normal. After obtaining informed consent, we examined the patient 30 minutes before and 30 to 60 minutes after strenuous exercise (playing basketball for approximately two hours) on several different days. Intraocular pressure was measured by pneumotonometry, and anterior chamber pigment was graded on a modified Mitsui scale.' There was no pretreatment for the initial trial. Intraocular pressure was R.E.: 19
mm Hg and L.E.: 21 mm Hg before exercise with trace anterior chamber pigment in both eyes. After exercise, intraocular pressures increased to 47 mm Hg in both eyes with severe anterior chamber pigment. In subsequent tria... either the left eye only or the right eye only was treated with 0.5% pilocarpine (one drop 30 minutes before exercise) or 0.5% thymoxamine (one drop Ph hours and 30 minutes before exercise). When either eye was pretreated with pilocarpine, the intraocular pressure actually decreased after exercise in the treated eye, and there was minimal or no increase in anterior chamber pigment. When either eye was left untreated or was pretreated with thymoxamine, a marked increase in both intraocular pressure and anterior chamber pigment (similar to that seen in the initial trial) occurred after exercise. In two previously reported cases of symptomatic pigment dispersion.V both patients described symptoms that most commonly occurred after playing basketball. One patient was given pilocarpine to use prophylactically. This reportedly relieved the symptoms, but it is not clear whether it inhibited pigment release or intraocular pressure increase since no measurements were made just before exercise." Our patient also exhibited pigment dispersion and intraocular pressure increase after 90 minutes of jumping exercises but not after comparable periods of jogging or bicycling. Jumping exercises may be more likely to cause iris-zonule contact. In our patient, 0.5% pilocarpine clearly inhibited exercise-induced dispersion of pigment and increase in intraocular pressure while 0.5% thymoxamine (an alpha adrenergic inhibitor) did not. Though pilocarpine increases aqueous outflow and thus lowers intraocular pressure, this mechanism would not explain inhibition of pigment release. The greater pupillary constriction achieved with pilocarpine may more effectively inhibit iris-zonule contact. Pilocarpine may be clinically useful when given prophylactically before exercise in patients subject to exercise-induced pigment dispersion.
References 1. Campbell, D. G.: Pigmentary dispersion and glaucoma. Arch. Ophthalmol. 97:1667, 1979. 2. Epstein, D. L., Boger, W. P., II, and Grant, W. M.: Phenylephrine provocative testing in the pigmentary dispersion syndrome. Am. J. Ophthalmol. 85:43, 1978.