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Journal Français d'Ophtalmologie
Volume 41, n° 1
pages e47-e49 (janvier 2018)
Doi : 10.1016/j.jfo.2016.11.030
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A new technique for encapsulated filtration blebs: Vitrector assisted cystectomy
Une nouvelle technique pour les bulles de filtration encapsulée : kystectomie à l’aide de la sonde de vitrectomie
 

G. Gulkilik, S. Karaman Erdur , M.S. Kocabora, O. Balci, M. Eliacik, M. Odabasi, M. Ozsutcu
 Istanbul Medipol University, Department of Ophthalmology, Bagcilar, 34214 Istanbul, Turkey 

Corresponding author.

We introduce a new technique for the management of encapsulated non filtering blebs which are unresponsive to needling procedure.

A 21 year-old man with a visual acuity of 20/30 presented with encapsulated bleb in the left eye 4 weeks after a successful trabeculectomy operation with adjunctive mitomycin C for medically uncontrolled glaucoma. The internal ostium was patent on gonioscopic examination. Intraocular pressure was 35mmHg despite multiple therapies with bimatoprost, brimonidine, and dorzalomide-timolol fixed combination. He underwent two consecutive bleb needling procedures with adjunctive subconjunctival 5-fluorouracil (5-FU) injections which were successful initially but encapsulated bleb recurred. The 5-FU augmented bleb needling was performed at the slit lamp after cleaning the patient's eyelid and periorbital skin with 10% providone iodine followed by instillation of a drop of 5% providone iodine. Needling of the bleb was performed using a 27-gauge needle. The aim was to remove episcleral scarring which was obstructing the intrascleral pathway. This was followed by an injection of 0.1mL of 5-FU solution (50mg/mL) along the far posterior margins of the bleb area.

Anterior segment OCT analysis demonstrated that there was a thick walled Tenon cyst without any filtration (Figure 1). Finally he was scheduled for vitrector assisted cystectomy. After explaining the benefits of the procedure informed consent was obtained and he was scheduled for vitrector assisted cystectomy. It was explained to the patient that conventional surgical cystectomy may still be necessary despite the procedure.



Figure 1


Figure 1. 

Preoperative OCT analysis demonstrated the encapsulated bleb with a thick wall made up of Tenon's capsule. There was not any filtration of fluid beyond the cyst.

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The surgical technique for vitrector assisted cystectomy was as follows. Under retrobulbar anesthesia with lidocaine 2%, a lid speculum was inserted. An 8/0 vicryl traction suture was placed at 12 o’clock position in the cornea. A 28 gauge needle attached to 1mL syringe filled with lidocaine was used to make an incision on the conjunctiva temporal to the bleb and lidocaine was injected aiming to create a dissection plane between the conjunctiva and the bleb wall. Also cyst wall was ruptured with the needle without injecting lidocaine into the cyst. Then a 25-gauge viscoelastic cannula was inserted through the incision and 1.6% Na Hyaluronate was injected between the conjunctiva and cyst wall, and also under the cyst wall so two spaces were created with viscoelastic (Figure 2). One of the spaces was between the conjunctiva and cyst wall and the other between the cyst wall and the scleral flap. These spaces were made to protect conjunctiva and scleral flap during cystectomy. Finally a 23-gauge vitrectomy probe connected to Alcon Constellation Vision System (Alcon, Forth Worth, TX, USA) was introduced subconjunctivally and cystectomy (fibrous capsule was removed) was performed at multiple points while paying attention not to damage conjunctiva and scleral flap (Figure 3). Vitrectomy device parameters were 300mmHg vacuum and 2000cut/min. A single 8/0 vicryl suture was placed at the incision site.



Figure 2


Figure 2. 

A 25-gauge viscoelastic cannula was inserted through the conjunctival incision and 1.6% Sodium Hyaluronate was injected between the conjunctiva and cyst wall, and also under the cyst wall.

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Figure 3


Figure 3. 

A 23-gauge vitrectomy probe was introduced subconjunctivally and fibrous capsule of the cyst was removed at multiple points.

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Surgical procedure was completed successfully. Visual acuity was stable during the follow up period. There was no need for antiglaucomatous medication and IOP was within normal limits. On postoperative day 1 after cystectomy, IOP was 12mmHg and bleb was functional. OCT demonstrated multiple defects in the cyst wall made by the vitrector. Sclerotomy site was open and multiple fluid pockets were seen both inside the Tenon's capsule and subconjunctivally (Figure 4). On month 1 and 12 bleb was functional IOP were 16mmHg and 14mmHg respectively without any antiglaucomatous medication. OCT analysis at 12months also demonstrated that cyst was resolved as drainage of aqueous was subconjunctival (Figure 5).



Figure 4


Figure 4. 

Anterior segment OCT analysis on postoperative day 1. Multiple defects on the cyst wall could be seen. Multiple fluid pockets and functional scleral flap (asterisk) indicate drainage of the aqeous subconjunctivally.

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Figure 5


Figure 5. 

Anterior segment OCT analysis on postoperative month 12. Drainage of the aqeous was through the scleral flap to subconjunctival area. Multiple fluid pockets were still present in the Tenon's capsule and subconjuctivally.

Zoom

Bleb related complications may have negative impact on the success rates of trabeculectomy, which is the gold standard surgical procedure for medically uncontrolled glaucoma [1, 2]. Encapsulated bleb is a complication of trabeculectomy, and usually develops 2 to 6 weeks postoperatively [3]. They are characterized by highly elevated, dome shaped blebs with open sclerostomy on gonioscopy and reported to occur with an incidence of 13.7% to 29% [2, 3, 4]. Intraocular pressure is usually elevated and highly elevated bleb may cause mechanical discomfort or dellen, necessitating management of this condition [3].

Medical therapy alone, medical therapy associated with digital massage, and transconjunctival needling with and without adjunctive antimetabolite drugs had been previously described for the treatment of encapsulated blebs [1, 5, 6, 7]. These measures are not always successful even after multiple interventions and surgical cystectomy may be necessary [1].

Several methods had been described previously for the management of encapsulated blebs. Initially it can be managed medically but IOP control may take some time and this is not acceptable for the eyes that already have advanced optic nerve damage. Currently needling of the encapsulated bleb with or without adjunctive antimetabolite is the primary procedure, and surgical bleb revision is advocated if the needling fails [8].

There some limitations of this report. As the vitrector technique has been associated with a large visco-dissection of the subconjunctival tissues with NA hyaluronate injection it is possible that the effect observed on the IOP may also be secondary to this visco-dissection and also the intra-bleb manipulations more than to the vitrector ablation of the cyst wall alone. Another limitation is the need for larger comparative series with longer follow-up to show if this vitrector assisted technique is more effective than the needling. As the needling procedures are usually particularly effective in encapsulated blebs, it is possible that a third, careful and strong needling in this case could be also finally effective.

Although this is a single case study, the technique which we present here was successful for the management of encapsulated filtering bleb for at least 12 months. Anterior segment OCT analysis also demonstrated that bleb was functional and drainage of aqueous was through the subconjunctival space. This was probably achieved as fibrous cyst wall was removed at multiple points. Using 23-gauge probe for cystectomy enabled us to perform the procedure from a small conjunctival incision. This made the procedure relatively less invasive and safer with a shorter recovery period than conventional cystectomy.

In conclusion, vitrector assisted cystectomy can be an effective and safe for the management of encapsulated blebs when needling procedure fails. Further studies are needed to evaluate its safety and efficacy, before advocating its conventional use.

Disclosure of interest

The authors declare that they have no competing interest.


Appendix A. Supplementary data

(46.41 Mo)
  
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