Bleb Leak With Hypotony After Laser Suture Lysis and Trabeculectomy With Mitomycin C
procedures. He underwent trabeculectomy inferotemporally. For 15 weeks after sur¬ gery, intraocular pressure ranged between 2 and 15 mm Hg. An uninflamed avascular bleb
present. Sixteen weeks after surgery, intraocular pressure increased to 22 mm Hg, and two flap-sutures were cut because it was thought unlikely that cutting only one suture would be beneficial so late after surgery. A Hoskins lens was used and set for a power of 700 mW, a duration of 0.1 second, and spot size of 50 µ for four applications. Intraoc¬ ular pressure decreased to 6 mm Hg, and there were two leaks at the laser application sites. Initially, both leaks healed; one then recurred, with fluctuating vision and pres¬ sure during a period of 3 weeks. Manage¬ ment included application of a collagen shield; use of betaxalol hydrochloride, acetazolamide, topical trimethoprim sulfate, and polymyxin sulfate; and cessation of topical steroids. After the leak resolved, his intraoc¬ ular pressure was 11 mm Hg, but macular changes reduced visual acuity to 20/200 for an additional 4 weeks. Eleven weeks after ALSL, visual acuity had improved to 20/30, and his intraocular pressure was 14 mm Hg. Comment.—These two cases indicate was
We describe two cases of persistent bleb leak with hypotony after argon laser suture lysis (ALSL). One case occurred 16 days after trabeculectomy using intraoperative mitomycin C, and the other, 16 weeks after trabeculectomy. We wish to alert other practitioners to the slowed healing of conjunctiva after trabeculectomy involving
mitomycin C.1-3 In each patient, a cellulose sponge soaked in a 0.5-mg/mL solution of mitomycin C was placed between the episclera and the conjunctiva for 4 minutes after the trabeculectomy flap had been outlined, but
before it had been dis-
sected.
See also pp
1069, 1072, and 1150.
Report of Cases.\p=m-\Case1.\p=m-\A60-year-old
had sustained blunt trauma with displacement of the superior haptic of the posterior chamber intraocular lens, angle recession, and sustained elevation of intraocular pressure that was unresponsive to maximum medical therapy. Three weeks after the injury, he underwent trabeculectomy with repositioning of the lens haptic. His intraocular pressure was 4 to 7 mm Hg during the first week after surgery and 12 to 13 mm Hg during the second week after sur¬ gery. Sixteen days after surgery, his intraoc¬ ular pressure had risen to 15 mm Hg, and, because of this continuing trend, one flapsuture was cut using a Hoskins lens set for a power of 650 mW, a spot size of 50 µ , and a duration of 0.2 second for four applications. Results of examination after laser surgery revealed a bleb leak at the site of the laser application through the avascular bleb. In¬ traocular pressure varied between 1 and 4 mm Hg for 3 weeks after ALSL with persis¬ tent leaking despite treatment with a colla¬ gen shield, topical 0.5% timolol maléate, and tobramycin, acetazolamide, and cessation of topical steroids. After 3 weeks, the bleb be¬ came more vascular, and the leaking site healed. Four months after ALSL, a low bleb was present, his visual acuity was was 20/25, and his intraocular pressure was 16 mm Hg in the absence of medications. CASE 2.—A 60-year-old man had uncon¬ trolled exfoliation glaucoma despite maxi¬ mum medical therapy, 360° argon laser, trabeculoplasty, and two prior filtering man
the potency of mitomycin C. Sixteen weeks after surgery, ALSL was not only effective, but also caused a conjunctival leak that did not heal sponta¬ neously. We have used ALSL for more than 175 trabeculectomies without mit¬ omycin C and have never had a persis¬ tent leak or persistent hypotony. Be¬ cause of this potential problem, one must be particularly careful when using ALSL in patients undergoing glaucoma surgery involving mitomycin C. One should minimize the power and duration of applied laser energy and avoid superimposing laser applications. Also, conjunctiva should be blanched with topical phenylephrine hydrochlo¬ ride with direct pressure from the Hoskins lens to minimize the amount of laser energy necessary. Finally, one should avoid laser application through a fluorescein-coated bleb because the fluorescein may enhance conjunctival ab¬ sorption of laser energy. Arthur L. Schwartz, MD Howard S. Weiss, MD, MPH Washington, DC Reprints requests to Suite 950,5454 Wisconsin Ave, Chevy Chase, MD 20815 (Dr Schwartz). 1. Palmer SS. Mitomycin as adjunct chemotherapy with trabeculectomy. Ophthalmology. 1991;98: 317-321.
Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015
2. Skuta GL, Higginbotham EJ, Lichter PR, Musch DC, Bergstrom TJ. Randomized clinical trial of intraoperative subconjunctival mitomcyin-C versus postoperative 5-fluorouracil. Invest Ophthalmol Vis Sci. 1990;32(suppl):2220. Abstract. 3. Yamamoto T, Vavani J, Soong HK, Lichter PR. Effects of 5-fluorouracil and mitomycin-C on cultured rabbit subconjunctival fibroblasts. Oph-
thalmology. 1990;97:1204-1210.
Hypotony Maculopathy Following Trabeculectomy With Mitomycin C Although hypotony occurs frequently after glaucoma filtration surgery, decreased visual acuity due to macular changes is rare. We report a case of hypotony maculopathy with marked decrease in visual acuity following an otherwise uncomplicated trabeculectomy using intraoperative mitomycin C. Report of a Case.\p=m-\A29-year-old white with myopia and a history of bilateral penetrating keratoplasties 10 years previously for congenital hereditary endothelial dystrophy was referred with elevated in traocular pressure despite receiving maximum tolerated medical therapy. Best corrected visual acuity was 20/300 OD with a man
-11.00+2.00X130 and 20/60 OS with a -14.00+4.75X161. Intraocular pressure ranged from 32 to 44 mm Hg OU. Slit-lamp examination revealed clear corneal grafts in
Fig 1.—Left eye 5 weeks after surgery. Fun¬ dus photograph shows pronounced folding of the retina and choroid, which is particularly prominent in the center of the macula. The retinal arterioles and venules are tortuous.
Trabeculectomy with simultaneous topical application of mitomycin-C in refractory glaucoma. J Ocul Pharmacol. 1990;6:175-182.
Corneal-Graft Dehiscence
Secondary to Suction-Cup
Device Use for Contact Lens Removal
Dehiscence following penetrating keratoplasty (PK) occurs most commonly as
result of blunt trauma.1,2 We report a of graft dehiscence associated with a suction-cup device (SCD) used to remove contact lenses (CLs). a
Fig 2.—B-scan vertical section with the sound beam directed thickened macula (arrow) and posterior retinochoroid layer. both eyes, deep anterior chambers in botheyes, normal irides, and clear crystalline lenses. The angles were wide open and without peripheral anterior synechiae. Funduscopic examination disclosed a tilted disc with an inferior notch in the right eye and a tilted disc with a vertical cup-to-disc ratio of 1.0 in the left eye. Automated perimetry showed nasal visual field loss threatening fixation in the right eye and decreased sen¬ sitivity inferiorly in the left eye.
See also pp
1069, 1072,
and 1150.
An uncomplicated limbus-based trabe¬ culectomy was performed in the left eye. Because of the patient's young age, topical mitomycin C (0.4 mg/mL) was applied to the ocular surface for 5 minutes during surgery. One day afterafter surgery visual acuity was
20/200 OS and intraocular pressure was 3 mm Hg, with a formed anterior chamber and no choroidal detachment. Three weeks after surgery visual acuity was 20/400 OS and in¬ traocular pressure was 1 mm Hg. There was marked folding of the macula with tortuo¬ sity of the retinal vasculature (Fig 1). The bleb was pale, highly elevated, and extended for 360° of the limbus. The anterior chamber was formed, and no bleb leak, cyclodialysis cleft, choroidal detachment, or retinal holes or breaks were seen. Neither oral prednisone treatment nor a 15-mm soft contact lens to tamponade the bleb improved the condition. Cryotherapy (four applications of -80°C for 15 seconds each) applied to the surface of the filtration bleb 7 weeks after the trabeculectomy succeeded in raising the intraocular pressure to 11 mm Hg during the next 4 weeks. Two months after cryo¬ therapy, however, the best corrected vi¬ sual acuity remained at 20/400 OS, and the macula continued to have marked fold¬ ing and vascular tortuosity. Ultrasonography revealed diffuse thickening of the retinochoroid layer posteriorly with marked thickening in the region of the macula (Fig 2). No choroidal detachment was detected.
as
Comment.—Hypotony maculopathy, described by Gass,1 is characterized
through the lens toward
the
by infolding of the choroid and retina and vascular tortuosity and engorge¬
ment. Choroidal detachment and cystoid macular edema are generally ab¬ sent. Hypotony maculopathy is a rare complication of trabeculectomy. Gass reported one case following a fullthickness glaucoma procedure and one case2 has been reported following a tra¬ beculectomy with fluorouracil. Chen et al3 referred to two patients with hypot¬ ony and macular disease following tra¬ beculectomy with mitomycin C. Mitomycin C is a new agent for im¬ proving filtration surgery success in eyes at high risk for surgical failure. By promoting formation of a large bleb, mitomycin C may have contributed to the marked hypotony leading to macu¬ lopathy in our patient. Whether youth and myopia are predisposing factors is unknown. Unfortunately, the maculopathy has not resolved to date despite restoration of physiologic intraocular pressure. The literature suggests that the visual acuity does not always improve with resolution of the hypotony.1 As the use of mitomycin C in filtration surgery becomes more common, it will be im¬ portant that both surgeons and pa¬ tients be aware of this visually signifi¬ cant and potentially irreversible
complication.
Henry D. Jampel, MD Louis R. Pasquale, MD Cathy Dibernardo Baltimore, Md Reprint requests to Maumenee B-110, The Johns Hopkins Hospital, Baltimore, MD 21205 (Dr Jampel). 1. Gass JDM. Hypotony maculopathy. In: Bellows JG, ed. Contemporary Ophthalmology: Honoring Sir Stewart Duke-Elder. Baltimore, Md: Williams & Wilkins; 1972:343-366. 2. Whiteside-Michel J, Liebmann JM, Ritch R. Initial 5-fluorouracil trabeculectomy in young patients. Ophthalmology. 1992;99:7-13. 3. Chen C-W, Huang H-T, Bair J-S, Lee C-C.
Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015
case
Report of a Case.\p=m-\An85-year-old man underwent repeated PK in the left eye in June 1989 for pseudophakic bullous keratopathy. The postoperative course was unremarkable and all sutures were removed by July 1991. Due to irregular astigmatism, best visual acuity with eyeglasses was 20/200 OS. A rigid gas-permeable CL was prescribed and visual acuity improved to 20/60. After two instruction sessions the patient was able to insert the lens, but removal could not be mastered, and his 79-year-old wife was given instructions on use of the SCD. On the day he went home wearing his CL, the patient returned, complaining of pain and poor visual acuity. He reported that his wife had difficulty trying to remove the CL. Examination of the left eye revealed a clear graft, with dehiscence from the 2 o'clock to 7 o'clock positions (Fig 1). The CL was on the inferotemporal bulbar conjunc¬ tiva, partially in the anterior chamber. The wound was closed with interrupted 10-0 ny¬ lon sutures using topical anesthesia. Four months later, the graft remained clear, but the postoperative course was complicated by cystoid macular edema. Comment.—Late wound dehiscence
following PK has been reported to occur as long as 13 years after surgery, most commonly from blunt trauma,1,2 and in one case following digital massage for
glaucoma.3 In our case, the interval be¬ tween PK and dehiscence months.
was
26
Suction-cup devices are commonly used to aid in the removal of rigid CLs. Our patient's description of the event and the ocular appearance on initial ex¬ amination led us to postulate that the SCD was inadvertently placed directly on the corneal graft and pulled anteri¬ orly, leading to dehiscence. We tested enucleated eye and a commonly used SCD (the type used by our patient) in a our hypothesis using a normotensive tensiometer (Fig 2). We were surprised to find that the SCD could consistently tolerate 1.86 to 1.96 (0.19 to 0.20 kg) before losing contact with the corneal surface. To our knowledge, this is the first re-
procedures. He underwent trabeculectomy inferotemporally. For 15 weeks after sur¬ gery, intraocular pressure ranged between 2 and 15 mm Hg. An uninflamed avascular bleb
present. Sixteen weeks after surgery, intraocular pressure increased to 22 mm Hg, and two flap-sutures were cut because it was thought unlikely that cutting only one suture would be beneficial so late after surgery. A Hoskins lens was used and set for a power of 700 mW, a duration of 0.1 second, and spot size of 50 µ for four applications. Intraoc¬ ular pressure decreased to 6 mm Hg, and there were two leaks at the laser application sites. Initially, both leaks healed; one then recurred, with fluctuating vision and pres¬ sure during a period of 3 weeks. Manage¬ ment included application of a collagen shield; use of betaxalol hydrochloride, acetazolamide, topical trimethoprim sulfate, and polymyxin sulfate; and cessation of topical steroids. After the leak resolved, his intraoc¬ ular pressure was 11 mm Hg, but macular changes reduced visual acuity to 20/200 for an additional 4 weeks. Eleven weeks after ALSL, visual acuity had improved to 20/30, and his intraocular pressure was 14 mm Hg. Comment.—These two cases indicate was
We describe two cases of persistent bleb leak with hypotony after argon laser suture lysis (ALSL). One case occurred 16 days after trabeculectomy using intraoperative mitomycin C, and the other, 16 weeks after trabeculectomy. We wish to alert other practitioners to the slowed healing of conjunctiva after trabeculectomy involving
mitomycin C.1-3 In each patient, a cellulose sponge soaked in a 0.5-mg/mL solution of mitomycin C was placed between the episclera and the conjunctiva for 4 minutes after the trabeculectomy flap had been outlined, but
before it had been dis-
sected.
See also pp
1069, 1072, and 1150.
Report of Cases.\p=m-\Case1.\p=m-\A60-year-old
had sustained blunt trauma with displacement of the superior haptic of the posterior chamber intraocular lens, angle recession, and sustained elevation of intraocular pressure that was unresponsive to maximum medical therapy. Three weeks after the injury, he underwent trabeculectomy with repositioning of the lens haptic. His intraocular pressure was 4 to 7 mm Hg during the first week after surgery and 12 to 13 mm Hg during the second week after sur¬ gery. Sixteen days after surgery, his intraoc¬ ular pressure had risen to 15 mm Hg, and, because of this continuing trend, one flapsuture was cut using a Hoskins lens set for a power of 650 mW, a spot size of 50 µ , and a duration of 0.2 second for four applications. Results of examination after laser surgery revealed a bleb leak at the site of the laser application through the avascular bleb. In¬ traocular pressure varied between 1 and 4 mm Hg for 3 weeks after ALSL with persis¬ tent leaking despite treatment with a colla¬ gen shield, topical 0.5% timolol maléate, and tobramycin, acetazolamide, and cessation of topical steroids. After 3 weeks, the bleb be¬ came more vascular, and the leaking site healed. Four months after ALSL, a low bleb was present, his visual acuity was was 20/25, and his intraocular pressure was 16 mm Hg in the absence of medications. CASE 2.—A 60-year-old man had uncon¬ trolled exfoliation glaucoma despite maxi¬ mum medical therapy, 360° argon laser, trabeculoplasty, and two prior filtering man
the potency of mitomycin C. Sixteen weeks after surgery, ALSL was not only effective, but also caused a conjunctival leak that did not heal sponta¬ neously. We have used ALSL for more than 175 trabeculectomies without mit¬ omycin C and have never had a persis¬ tent leak or persistent hypotony. Be¬ cause of this potential problem, one must be particularly careful when using ALSL in patients undergoing glaucoma surgery involving mitomycin C. One should minimize the power and duration of applied laser energy and avoid superimposing laser applications. Also, conjunctiva should be blanched with topical phenylephrine hydrochlo¬ ride with direct pressure from the Hoskins lens to minimize the amount of laser energy necessary. Finally, one should avoid laser application through a fluorescein-coated bleb because the fluorescein may enhance conjunctival ab¬ sorption of laser energy. Arthur L. Schwartz, MD Howard S. Weiss, MD, MPH Washington, DC Reprints requests to Suite 950,5454 Wisconsin Ave, Chevy Chase, MD 20815 (Dr Schwartz). 1. Palmer SS. Mitomycin as adjunct chemotherapy with trabeculectomy. Ophthalmology. 1991;98: 317-321.
Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015
2. Skuta GL, Higginbotham EJ, Lichter PR, Musch DC, Bergstrom TJ. Randomized clinical trial of intraoperative subconjunctival mitomcyin-C versus postoperative 5-fluorouracil. Invest Ophthalmol Vis Sci. 1990;32(suppl):2220. Abstract. 3. Yamamoto T, Vavani J, Soong HK, Lichter PR. Effects of 5-fluorouracil and mitomycin-C on cultured rabbit subconjunctival fibroblasts. Oph-
thalmology. 1990;97:1204-1210.
Hypotony Maculopathy Following Trabeculectomy With Mitomycin C Although hypotony occurs frequently after glaucoma filtration surgery, decreased visual acuity due to macular changes is rare. We report a case of hypotony maculopathy with marked decrease in visual acuity following an otherwise uncomplicated trabeculectomy using intraoperative mitomycin C. Report of a Case.\p=m-\A29-year-old white with myopia and a history of bilateral penetrating keratoplasties 10 years previously for congenital hereditary endothelial dystrophy was referred with elevated in traocular pressure despite receiving maximum tolerated medical therapy. Best corrected visual acuity was 20/300 OD with a man
-11.00+2.00X130 and 20/60 OS with a -14.00+4.75X161. Intraocular pressure ranged from 32 to 44 mm Hg OU. Slit-lamp examination revealed clear corneal grafts in
Fig 1.—Left eye 5 weeks after surgery. Fun¬ dus photograph shows pronounced folding of the retina and choroid, which is particularly prominent in the center of the macula. The retinal arterioles and venules are tortuous.
Trabeculectomy with simultaneous topical application of mitomycin-C in refractory glaucoma. J Ocul Pharmacol. 1990;6:175-182.
Corneal-Graft Dehiscence
Secondary to Suction-Cup
Device Use for Contact Lens Removal
Dehiscence following penetrating keratoplasty (PK) occurs most commonly as
result of blunt trauma.1,2 We report a of graft dehiscence associated with a suction-cup device (SCD) used to remove contact lenses (CLs). a
Fig 2.—B-scan vertical section with the sound beam directed thickened macula (arrow) and posterior retinochoroid layer. both eyes, deep anterior chambers in botheyes, normal irides, and clear crystalline lenses. The angles were wide open and without peripheral anterior synechiae. Funduscopic examination disclosed a tilted disc with an inferior notch in the right eye and a tilted disc with a vertical cup-to-disc ratio of 1.0 in the left eye. Automated perimetry showed nasal visual field loss threatening fixation in the right eye and decreased sen¬ sitivity inferiorly in the left eye.
See also pp
1069, 1072,
and 1150.
An uncomplicated limbus-based trabe¬ culectomy was performed in the left eye. Because of the patient's young age, topical mitomycin C (0.4 mg/mL) was applied to the ocular surface for 5 minutes during surgery. One day afterafter surgery visual acuity was
20/200 OS and intraocular pressure was 3 mm Hg, with a formed anterior chamber and no choroidal detachment. Three weeks after surgery visual acuity was 20/400 OS and in¬ traocular pressure was 1 mm Hg. There was marked folding of the macula with tortuo¬ sity of the retinal vasculature (Fig 1). The bleb was pale, highly elevated, and extended for 360° of the limbus. The anterior chamber was formed, and no bleb leak, cyclodialysis cleft, choroidal detachment, or retinal holes or breaks were seen. Neither oral prednisone treatment nor a 15-mm soft contact lens to tamponade the bleb improved the condition. Cryotherapy (four applications of -80°C for 15 seconds each) applied to the surface of the filtration bleb 7 weeks after the trabeculectomy succeeded in raising the intraocular pressure to 11 mm Hg during the next 4 weeks. Two months after cryo¬ therapy, however, the best corrected vi¬ sual acuity remained at 20/400 OS, and the macula continued to have marked fold¬ ing and vascular tortuosity. Ultrasonography revealed diffuse thickening of the retinochoroid layer posteriorly with marked thickening in the region of the macula (Fig 2). No choroidal detachment was detected.
as
Comment.—Hypotony maculopathy, described by Gass,1 is characterized
through the lens toward
the
by infolding of the choroid and retina and vascular tortuosity and engorge¬
ment. Choroidal detachment and cystoid macular edema are generally ab¬ sent. Hypotony maculopathy is a rare complication of trabeculectomy. Gass reported one case following a fullthickness glaucoma procedure and one case2 has been reported following a tra¬ beculectomy with fluorouracil. Chen et al3 referred to two patients with hypot¬ ony and macular disease following tra¬ beculectomy with mitomycin C. Mitomycin C is a new agent for im¬ proving filtration surgery success in eyes at high risk for surgical failure. By promoting formation of a large bleb, mitomycin C may have contributed to the marked hypotony leading to macu¬ lopathy in our patient. Whether youth and myopia are predisposing factors is unknown. Unfortunately, the maculopathy has not resolved to date despite restoration of physiologic intraocular pressure. The literature suggests that the visual acuity does not always improve with resolution of the hypotony.1 As the use of mitomycin C in filtration surgery becomes more common, it will be im¬ portant that both surgeons and pa¬ tients be aware of this visually signifi¬ cant and potentially irreversible
complication.
Henry D. Jampel, MD Louis R. Pasquale, MD Cathy Dibernardo Baltimore, Md Reprint requests to Maumenee B-110, The Johns Hopkins Hospital, Baltimore, MD 21205 (Dr Jampel). 1. Gass JDM. Hypotony maculopathy. In: Bellows JG, ed. Contemporary Ophthalmology: Honoring Sir Stewart Duke-Elder. Baltimore, Md: Williams & Wilkins; 1972:343-366. 2. Whiteside-Michel J, Liebmann JM, Ritch R. Initial 5-fluorouracil trabeculectomy in young patients. Ophthalmology. 1992;99:7-13. 3. Chen C-W, Huang H-T, Bair J-S, Lee C-C.
Downloaded From: http://archopht.jamanetwork.com/ by a UQ Library User on 06/19/2015
case
Report of a Case.\p=m-\An85-year-old man underwent repeated PK in the left eye in June 1989 for pseudophakic bullous keratopathy. The postoperative course was unremarkable and all sutures were removed by July 1991. Due to irregular astigmatism, best visual acuity with eyeglasses was 20/200 OS. A rigid gas-permeable CL was prescribed and visual acuity improved to 20/60. After two instruction sessions the patient was able to insert the lens, but removal could not be mastered, and his 79-year-old wife was given instructions on use of the SCD. On the day he went home wearing his CL, the patient returned, complaining of pain and poor visual acuity. He reported that his wife had difficulty trying to remove the CL. Examination of the left eye revealed a clear graft, with dehiscence from the 2 o'clock to 7 o'clock positions (Fig 1). The CL was on the inferotemporal bulbar conjunc¬ tiva, partially in the anterior chamber. The wound was closed with interrupted 10-0 ny¬ lon sutures using topical anesthesia. Four months later, the graft remained clear, but the postoperative course was complicated by cystoid macular edema. Comment.—Late wound dehiscence
following PK has been reported to occur as long as 13 years after surgery, most commonly from blunt trauma,1,2 and in one case following digital massage for
glaucoma.3 In our case, the interval be¬ tween PK and dehiscence months.
was
26
Suction-cup devices are commonly used to aid in the removal of rigid CLs. Our patient's description of the event and the ocular appearance on initial ex¬ amination led us to postulate that the SCD was inadvertently placed directly on the corneal graft and pulled anteri¬ orly, leading to dehiscence. We tested enucleated eye and a commonly used SCD (the type used by our patient) in a our hypothesis using a normotensive tensiometer (Fig 2). We were surprised to find that the SCD could consistently tolerate 1.86 to 1.96 (0.19 to 0.20 kg) before losing contact with the corneal surface. To our knowledge, this is the first re-
