GLAUCOMA 58 EWAP MARCH 2022 A patient may be at risk for a bleb leak after trabeculectomy, either in the early postop period or years after surgery. Meenakshi Chaku, MD, shared considerations for this potential complication, how she monitors patients, and what to do if a bleb leak does occur. Dr. Chaku noted that the likelihood of a bleb leak occurring varies. Management of this issue would depend on when it occurs and if an infection is present at the time of occurrence. One of the most important things to do, she said, is to watch the patient for infection. Occasionally, bleb leaks can occur early in the postoperative period, especially if the patient has poor tissue healing. However, she noted that any glaucoma specialist could encounter a late onset bleb leak. It can happen for any patient with prior trabeculectomy, especially if the tissue is more ischemic and thinner over the surgery site. Thus, it’s important to check for evidence of a bleb leak each time patients with a previous trabeculectomy come into the clinic. Comorbidities and considerations In terms of specific comorbidities to be aware of that could increase the instance of a bleb leak after surgery, Dr. Chaku said to be cautious of patients with a thinner conjunctiva. Other risk factors include older age, previous history of inflammation, or long-term use of topical hypotensive medications, which can decrease tissue quality over time. When performing the trabeculectomy, Dr. Chaku said the way you open the conjunctiva also plays a role. A limbus-based approach tends to have less chance of a bleb leak than a fornix-based approach because it’s more posterior. Additionally, she mentioned that the use of an antimetabolite, like mitomycin-C, could increase the risk of poor healing and bleb leak, but it is necessary to help in the success of the surgery. The problem, she said, is “we want patients to heal at their surgery site, but we don’t want them to scar down. We want a functioning bleb; that’s why we use mitomycin-C, but using it puts them at a higher risk later on for bleb leaks.” Dr. Chaku said that if surgeons are using sponges for mitomycin-C administration, she recommends making sure they’re more posterior and not touching the edge of conjunctiva that you’re going to close with at the limbus. Dr. Chaku has experience using sponges for mitomycin-C administration but also uses injection of mitomycin-C to administer the antimetabolite more posterior. Physicians should make sure to have a good conjunctival closure to prevent any leak. Dr. Chaku likes to use a running mattress suture when she closes a trabeculectomy to make sure the closure is tight. She also suggested using a thinner vascular needle so it doesn’t create a suture track during the closure. This is especially helpful if the conjunctiva is delicate and Handling bleb leaks by Ellen Stodola Editorial Co-Director This article originally appeared in the December 2021 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Chaku: MEENAKSHI.CHAKU@lumc.edu .ate onset DNeD NeaM. Source\ New 9ork Eye and Ear Infirmary of Mount Sinai
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