Filtering bleb activation in the early post-operative period after fistulizing surgery

Abstract

The article presents a case report of a patient with a cystic bleb in the early postoperative period after trabeculectomy. Patient complained of discomfort in a recently (4 weeks) operated eye. Medical regimen administered previously had been taken irregularly. Biomicroscopy revealed a high, encapsulated cystic bleb with thin walls and hyperemia. Intraocular pressure at the moment of examination was 27 mmHg. Local hypotensive therapy had been neglected by the patient. A local anti-inflammatory (tobramycin / dexamethasone fixed combination) and hypotensive (brimonidine / timolol fixed combination) therapy was administered. 24 hours later, when intraocular pressure decreased to 20 mmHg, a needle revision procedure was conducted for partial bleb wall destruction and subconjunctival injection of dexamethasone, fluorouracil and ranibizumab. During the next day examination the bleb was diffuse, with less hyperemia and an abundance of conjunctival microcysts in the central bleb’s zone. Intraocular pressure was 10.2 mmHg. No choroidal detachment was noted during ophthalmoscopy and OCT examination. The patient continued anti-inflammatory therapy. Another needling procedure with the same drug combination was repeated two weeks after due to an increased hyperemia. At the end of the four-week follow-up period the filtering bleb remained diffuse and the intraocular pressure was 13.2 mmHg. Dexamethasone drops were prescribed to be instilled 1‑2 times a day for a month. This case report demonstrates the method of restoring a functioning filtering bleb by the needle revision with antiinflammatory, cytostatic and anti-VEGF therapy for prolonging the hypotensive effect of a trabeculectomy in the presence of wound healing.

Keywords

• trabeculectomy
• bleb
• Wuerzburg bleb classification score
• dexamethasone
• fluorouracil
• VEGF-inhibitor
• bleb needling