Autologous Conjunctival Resurfacing ofLeaking Filtering Blebs

Lindsey D. Harris, MD1, George Yang, MD,1 Robert M. Feldman, MD1,2, Ronald L. Fellman, MD,3

Richard J. Starita, MD,3 John Lynn, MD,3 Alice Z. Chuang, PhD1

Purpose: To present a case series of a new technique to repair late bleb leaks.Design: Retrospective, noncomparative, consecutive case series.Participants: Forty-seven autologous conjunctival resurfacings of late bleb leaks were performed by four

surgeons at two institutions.Methods: Autologous conjunctival grafts were placed over existing de-epithelialized leaking blebs.Main Outcome Measures: Leak-free, Seidel-negative blebs and controlled glaucoma.Results: After a mean follow-up of 14 6 12 months, one patient continued to have bleb leak at the last

follow-up, and one frank leak resolved with aqueous suppression. Intraocular pressure increased from 6.6 6 4.4mmHg (0.13 glaucoma medications) to 11.9 6 4.1 mmHg (0.41 glaucoma medications).

Conclusions: Conjunctival resurfacing with autologous tissue is an effective technique to repair late blebleaks. Ophthalmology 2000;107:1675–1680 © 2000 by the American Academy of Ophthalmology.

With the introduction of antifibrotic regimens, includingmitomycin C (MMC) and 5-fluorouracil (5-FU), late blebleaks have increased in frequency.1–6 Management of latebleb leaks is difficult but important. Leaks predispose tohypotony,7 hypotony maculopathy,7 choroidal effusions,7,8

blebitis,7,9 and endophthalmitis.7–11Many methods are usedto repair late bleb leaks. As is generally the case whenmultiple procedures exist, none is universally successful.Aqueous suppression,12 autologous blood patch,8 fibringlue,13 collagen shields,14 argon lasers,15,16and continuous-wave neodymium:yttrium–aluminum–garnet (Nd:YAG) la-ser treatment17,18 have been used with variable success.More invasive surgical methods are commonly required,such as hood procedures, free conjunctival patch grafts withremoval of the existing bleb,12 and scleral grafts7 to limitflow through the sclerostomy. The purpose of this paper isto report the results of a new surgical technique to repair latebleb leaks while maintaining adequate filtration.

Patients and Methods

Charts of all patients who underwent autologous conjunctival blebresurfacing (ACBR) for persistent conjunctival bleb leaks fromAugust 1994 through October 1998 were identified by review ofsurgical logs of four of the authors (RMF, RLF, RJS, JL). Chartswere reviewed for demographics; visual acuity, intraocular pres-sure (IOP) measurements, and medications used before trabecu-lectomy; adjuvants applied during trabeculectomy; visual acuity,IOP measurements, and medications used on the date of bleb leak;number of months between trabeculectomy and bleb leak; priorfailed attempts to repair bleb leak; date of ACBR; and complica-tions of ACBR. Additionally, charts were reviewed for visualacuity, IOP measurements, medications used, recurrence of blebleak, and any interventions to the eye on postoperative days 1, 7,30, 90, and at the last postoperative follow-up. The data werecollected by two of the authors (LDH, GY) and entered directlyinto a computerized database.

Statistical Analysis

All computation was performed using SAS for Windows (SAS,North Carolina) NT version 6.12. AP value less than 0.05 wasconsidered statistically significant. The demographics of sex andrace were calculated based on the number of patients in the study.All other calculations were based on the number of eyes. Data arereported as mean plus or minus standard deviation for the age attrabeculectomy, time interval between trabeculectomy and date ofleak, duration of follow-up, and IOP before trabeculectomy (whereavailable), on the day of the leak, and after surgery on days 1, 7,30, 90, and at the last follow-up visit. Frequency is reported for thenumber of leaks at days 1, 7, 30, 90, and the last follow-up visit.A one-way analysis of variance was used to compare amongsurgeons the change in IOP before surgery with that after surgeryat 90 days and at the last follow-up. A Fisher exact test carried outthe comparison among surgeons for the number of leaks andincidence of recurrent leak at each visit.

Originally received: October 25, 1999.Accepted: April 27, 2000. Manuscript no. 99521.1 Hermann Eye Center, University of Texas Health Sciences Center atHouston, Houston, Texas.2 Center for Health Care, Memorial Hermann Hospital Systems, Houston,Texas.3 Glaucoma Associates of Texas, Dallas, Texas.

Presented in part at the joint meeting of the American Academy ofOphthalmology and the Congress of the Pan-American Association ofOphthalmology, Orlando, Florida, October 1999.

Supported by grants from the Hermann Eye Fund; the National EyeInstitute (Core Grant); and Research to Prevent Blindness, New York, NewYork (grant no.: 5).

The authors have no proprietary interest in the products or devices men-tioned herein.

Reprint requests to Robert M. Feldman, MD, Hermann Eye Center, 6411Fannin Street, 7th Floor, Houston, Texas 77030.

1675© 2000 by the American Academy of Ophthalmology ISSN 0161-6420/00/$–see front matterPublished by Elsevier Science Inc. PII S0161-6420(00)00280-3

Surgical Technique

The surgical technique, with minor variations among the surgeons,is as follows. A superior traction suture is placed, and the eye isrotated downward. The border of the ischemic bleb is then dis-sected from healthy surrounding conjunctiva and Tenon’s capsulewith sharp Wescott scissors. The host tissue is lightly underminedapproximately 2 to 4 mm. A persistent cuff of hypertrophic ele-vated conjunctiva at the perimeter of the avascular bleb is carefullyremoved with Vannas scissors (SAS, North Carolina). Absolutealcohol is then wiped across the epithelium of the bleb using alightly soaked cellulose sponge until no viable epithelium remains.Care is taken to not allow alcohol to touch the free edge of healthyconjunctiva. The area is then profusely irrigated with balanced saltsolution. A shallow lamellar keratectomy is fashioned at the lim-bus, creating a space for suturing the patch. Any portion of the blebanterior to the limbus is excised. If the bleb is dysesthetic or if theeye is hypotonous, light cautery is applied to shrink the bleb. Theavascular bleb is then measured with a caliper both horizontallyand vertically, and an additional 1 to 2 mm in both directions isadded to allow for postoperative shrinkage of the bleb. The tractionsuture is temporarily released, and an additional inferotemporalcorneal traction suture placed, if needed, to expose the inferotem-poral conjunctiva. The appropriate area of conjunctiva is measuredand outlined with a marking pen. The conjunctiva and underlyingTenon’s capsule are harvested, the inferior traction suture is re-moved, and the denuded sclera is left untouched. The eye is againrotated downward, the limbal edge of the harvested conjunctiva isplaced at the limbus over the lamellar keratectomy site, and thepatch is lined up with the rest of the avascular bleb. The anteriorcorners of the patch are sutured to the cornea using 9-0 nylon ona VAS 100 needle (Ethicon 5890 New Jersey) so the corners of thegraft approximate the free edges of the conjunctiva. The twoposterior corners are similarly sutured to healthy conjunctiva. Ifthe eye is hypotonous, the anterior chamber is filled with eitherviscoelastic or balanced salt solution to aid in suturing. A runninghorizontal mattress suture (9-0 nylon) is extended from the limbusposteriorly along each side of the graft until meeting along theposterior margin, where they overlap and are tied down. The graftepithelial edges are approximated to the edges of the healthy hosttissue. Great care is taken to keep the running suture continuallytaut. The anterior margin of the conjunctiva is carefully suturedinto the lamellar keratectomy using the technique reported byWise.19 Balanced salt solution is injected into the anterior chamberthrough a preplaced paracentesis, and the suture line is checked forleaks. If leaks are present, additional interrupted 9-0 nylon suturesare placed to close the leaks. Antibiotic ointment is placed in theeye after removal of the traction suture.

Postoperative Treatment Regimens

Postoperative treatment includes 7 days of topical antibiotics andtopical corticosteroids for 3 weeks, then tapered.

Success Criteria

Success criteria are no bleb leaks later than 1 month after surgeryand, with adequate IOP, no further surgical intervention for glau-coma.

Results

Forty-seven eyes of 45 patients were identified. Two patients hadbilateral ACBRs. Forty-five charts were reviewed. At the time of

review, all patients were at least 90 days past the ACBR procedure.All 47 ACBRs were performed without intraoperative complica-tions.

The demographics for the group are shown in Table 1. Sixteeneyes (34%) had undergone attempts before ACBR to stop the blebleak. Eight were treated with aqueous suppression, three with laserremodeling, three with autologous blood patches, one with sutures,and one with bandage contact lenses. Data were available for 3months after surgery on 43 of 47 eyes. Thirty-seven eyes hadpostoperative data past 90 days. The mean interval of follow-upwas 146 12 months. The four patients lost to follow-up at 90 daysreturned to the referring physician for follow-up care; one patientreturned to the surgeon after 1 week, and three patients returnedmore than 1 month after surgery. None were referred again forrecurrent leak.

Table 2 shows recurrence of bleb leaks after ACBR. Early leaksare defined as frank Seidel-positive leaks occurring at or before 30days after surgery, which are not considered failures unless theleak did not resolve by postoperative day 30. At postoperative day1, two leaks occurred; by postoperative day 7, eight leaks hadoccurred; but by postoperative day 30, only four leaks occurred.On postoperative day 1, one patient had a hole in the graft that wasresutured. The hole was also sutured on postoperative days 2, 5, 8,and 12. Subsequently, the eye was leak free and had an uncom-plicated, successful postoperative course. Between 7 days and 30days after surgery, 10 eyes were resutured. One of the eyes wasjust described. One eye was leak free, but was resutured to replacea broken suture. Six were resutured once, and two of the sixreceived additional aqueous suppression. These patients remainedleak free throughout the follow-up. Two eyes were sutured twiceduring this interval, and both received aqueous suppression. Oneleak resolved completely, but one continued to leak after 30 days.

Two eyes had frank leaks at 90 days after surgery. The eyedescribed above, that was treated with sutures twice and aqueoussuppression, continued to leak at 90 days after surgery. However,the leak resolved, and the eye was still leak free at the lastfollow-up at 31 months. The second eye, which had a frank leak at90 days after surgery, began leaking at this time. It was treated

Table 1. Demographics

SexFemale 23 (51.1%)Male 22 (48.9%)

RaceWhite 29 (64.4%)Black 16 (35.6%)

AgeMean 61.2 6 19.4 yearsRange 12.6 to 90.3 years

Adjuvants in previous trabeculectomyMMC 27 (57.4%)5-FU 10 (21.3%)None 4 (8.5%)Unknown 6 (12.8%)

No. that had prior attempts to stop bleb leakNo 31 (66%)Yes 16 (34%)

Time between trabeculectomy and bleb leakMean 6.3 6 13.7 yearsRange 0.2 to 28.1 years

Table 1 describes the demographics of the study’s patient population. Sexand race were calculated based on the number of patients. All othercalculations were based on the number of eyes treated with ACBR.Calculations include mean 6 standard deviation.

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with aqueous suppression. It continued to leak until the last visit at16 months after surgery.

Table 2 shows the mean IOPs for the group. Mean IOP on theday of diagnosis of bleb leak was 6.66 4.4 mmHg (0.13 glaucomamedications), which increased by the last visit to an IOP of 11.964 mmHg (0.41 glaucoma medications). No surgical interventionswere used to decrease IOP after ACBR. The number of postoper-ative leaks between surgeons was significant at day 1, but insig-nificant at days 7, 30, 90, and at the last follow-up. The differenceamong surgeons in the change in IOP before surgery to that aftersurgery on day 90 and at the last follow-up was not significant.

Figure 1 shows an ischemic leaking bleb before ACBR wasperformed. Figure 2 shows the avascular bleb on postoperative day1. After surgery, the bleb began to vascularize by postoperativeday 3. Vascularization continued until it was complete by 1 monthafter surgery. Figure 3 shows a fully vascularized bleb on postop-erative day 90.

Discussion

Cystic, thin-walled avascular bleb leaks are increasinglycommon with long-term follow-up of trabeculectomies per-formed with adjunctive 5-FU or MMC.1–6 5-Fluorouraciland MMC inhibit fibroblast proliferation and result in thin-ner, more friable blebs. The Fluorouracil Filtering SurgeryStudy1–3reported a higher incidence of late-onset bleb leakscompared with the control group at 1-, 3-, and 5-yearfollow-ups. At the 1-year and 3-year follow-ups, seven of105 eyes (7%) treated with 5-FU had bleb leaks, comparedwith zero of 108 eyes in the control group. The number oflate bleb leaks increased at the 5-year follow-up, with nine

of 105 eyes (9%) treated with 5-FU experiencing bleb leakscompared with two of 108 eyes (2%) in the control group.Tsai et al4 reported the incidence of bleb leaks occurringafter trabeculectomy for neovascular glaucoma with adjunc-tive 5-FU to be one of 34 eyes (3%), with a median

Table 2. Total Number of Leaks and IOP

No. Leaks Intraocular PressuresGlaucoma

Medications

Pretrabeculectomy0 Mean 26.1 6 11 mmHg

Range 11 to 58 mmHgDay of indication47 Mean 6.6 6 4.4 mmHg

Range 0 to 18 mmHg0.13

Day 12 Mean 10.6 6 5.4 mmHg

Range 0 to 24 mmHg0.00

Day 78 Mean 10.2 6 5.4 mmHg

Range 0 to 29 mmHg0.09

Day 304 Mean 14.4 6 7.4 mmHg

Range 4 to 40 mmHg0.33

Day 902 Mean 13.6 6 5.5 mmHg

Range 4 to 36 mmHg0.37

Last post-op follow-up1 Mean 11.9 6 4.1 mmHg

Range 4 to 22 mmHg0.41

Table 2 describes the number of leaks and the IOP pretrabeculectomy, onthe day bleb leak was initially seen by the surgeon, and on postoperativedays 1, 7, 30, 90 and last follow-up visit. IOP calculations include mean 6standard deviation. The number of glaucoma medications is also includedand was calculated as a mean.

Figure 1. Thin, ischemic leaking bleb.Figure 2. Autologous conjunctival bleb resurfacing on postoperative day1. An avascular bleb is shown.Figure 3. Autologous conjunctival bleb resurfacing on postoperative day90. A fully vascularized bleb is shown.

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follow-up of 12.5 months. In a study by Belyea et al5 of 385eyes treated with 5-FU and MMC, the incidence of blebleaks was 1.8%, with a mean follow-up of 20.4 months(range, 9–44 months). One hundred ninety-three eyes(50.1%) were treated with 5-FU (total dose range, 12.5–40mg), with only five leaks occurring. Meanwhile, of the 192eyes (49.9%) treated with MMC (total dose range, 0.25–0.5mg/ml for 3–4.5 minutes), only two leaks were recognized.A study of 525 eyes by Greenfield et al6 reported bleb leaksoccurring more commonly in MMC-treated eyes, with 10bleb leaks occurring in 273 eyes (3.7%), with a meanfollow-up of 1.7 6 1.3 years compared with 5-FU–treatedeyes, in which three bleb leaks occurred in 213 eyes (1.4%),with a mean follow-up of 3.66 2.6 years and comparedwith the group without antifibrotics, in which one of 39 eyes(2.6%) experienced bleb leaks. The results of Perkins etal’s20 2- to 3-year follow-up of 68 patients who had under-gone trabeculectomy with adjuvant MMC showed a 4%occurrence of late bleb leaks. Complications of bleb leaksinclude hypotony with or without subsequent macularedema, shallow anterior chamber, choroidal detachment,blebitis, and endophthalmitis. In a recent series of 12 eyeswith recurrent multiple bleb infection,9 11 had undergonetrabeculectomy with antimetabolites or alkylating agents.Since introduction of 5-FU and MMC into trabeculectomy,doses commonly used have decreased from 140 mg total for5-FU and 0.5 mg/ml of MMC in place for 5 minutes to morecommonly less than 10 mg of 5-FU and 0.2 mg/ml of MMCin place for 2 minutes or less.21,22 This may reduce thefrequency of late leaks, which occurred in this study onaverage of 6 years after the initial surgery.

Management of bleb leaks is challenging. Typically,initial treatment is aqueous suppression, prophylactic anti-biotics, and observation. This is inadequate as a long-termsolution because these leaks spontaneously resolve and re-appear elsewhere within the ischemic bleb. Furthermore, avery thin bleb is still present, allowing easy penetration ofbacteria into the bleb. Other techniques used are: autologousblood injections,12 glue,13 argon laser,15,16and continuous-wave Nd:YAG laser.17,18Autologous blood injections wereperformed on six patients in a case series by Smith et al,8

which were successful after 4 to 12 months of follow-up infour of the six patients. Others believe that results have beendisappointing, even after multiple blood patches. Anotherrecent case series by Gammon et al13 on autologous fibringlue showed success in one of three patients. In Hennis andStewart’s15 case series, 15 bleb leaks were treated withargon laser. Thirteen of the 15 leaks closed, but complica-tions of conjunctival fenestration and pitting occurred inthree eyes and corneal stromal opacities occurred in one eyeafter applying the argon laser at the conjunctival–cornealinterface. Lynch et al’s17 case series of bleb leaks andhypotony treated with continuous-wave Nd:YAG laser hadfour of five bleb leaks to be closed at last follow-up (mean,10.5 months). In the one failed eye, another leak, an iatro-genic leak, occurred after closure of the first bleb leak. Itwas retreated using the laser, and a larger leak formed in anarea of pigmentation made by the first treatment procedure.After aqueous suppression and patching, the leak healed.Disadvantages included iatrogenic leaks, the pigmentation

precipitated by the laser treatment that can affect futurelaser treatment, and pupil flattening or peaking. In a subse-quent recent case series on Nd:YAG laser conducted byGeyer,18 five of five eyes with leaking blebs healed afterlaser treatment. However, in all five, iatrogenic leaks devel-oped that healed with aqueous suppression and patching,and in two eyes pupil retraction developed. The continuous-wave Nd:YAG laser is not readily available to most sur-geons and is expensive. Thus no long-term data are avail-able.

More invasive surgical procedures have also been triedto manage bleb leaks. In 1964, Iliff23 described closing aconjunctival fistula with a conjunctival flap moved fromabove over the pre-existing bleb. More recently, in 1992,O’Connor et al24 modified this with excision of the bleb andrelaxing incision in the superior fornix to bring Tenon’sfascia and conjunctiva down over the filtration area. Theyreported success in five patients. However, long-term fol-low-up and IOPs were not reported. Six years ago, Wilsonand Kotas-Neumann12 reported using a free conjunctivalpatch to repair bleb leaks after bleb excision. They reportedsuccessful bleb leak closure in four patients. One patientwas leak free at 1 year, whereas three patients were leak freeat 2 months. One half of the patients used glaucoma med-ication to maintain adequate IOP. In 1997, Kosmin andWishart7 reported using full-thickness scleral graft afterbleb excision to stop bleb leaks in eight eyes. They success-fully repaired eight bleb leaks and had adequate follow-up.However, two of eight patients (25%) experienced IOPspikes after surgery that were treated by loosening suturesthat held the scleral graft in place. Three of the eight eyes inthe study required glaucoma medication to maintain IOPless than 22 mmHg. This may be a good option for over-filtration through the fistula rather than for bleb leaks.

Amniotic membrane transplantation is currently underinvestigation for conjunctival resurfacing. A case series byTseng et al25 recently reported on efficacy of amnioticmembrane transplantation in seven eyes after removal oflarge conjunctival lesions and in nine eyes after removal ofconjunctival scars or symblepharon. With a mean follow-upof 10.9 6 9 months, 11 eyes were reported as successfulwithout recurrence, and two eyes were reported as partiallysuccessful because of conjunctival inflammation. However,three eyes failed and showed recurrent scarring. Althoughthe indication for intervention in this case series was notbleb leak, it did show questionable efficacy of the proce-dure.

The ACBR procedure described in this article effectivelystopped leaks with minimal interference with bleb filtration.Of the two late frank leaks that recurred, one healed withaqueous suppression after 90 days after surgery and contin-ued to remain leak free at 31 months after surgery. The onelate frank leak that did not resolve was performed on apatient with malformed lids that traumatized the ACBR.The procedure initially resulted in a leak-free state, but thebleb dried out and releaked, which could be attributed to thelid’s configuration. The bleb continued to leak at 16 monthsafter surgery.

The sutures that were placed within the early intervalafter surgery stopped early leaks, yet aqueous suppression

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also helped in reaching leak-free status in four of the nineeyes. These leaks were at suture lines and not within isch-emic blebs, with the exception of one patient. This patientrequired multiple resuturing of the graft after experiencing astretch hole within the graft. Resuturing is not performedroutinely. Aqueous suppression is the recommended man-agement of early leaks occurring after ACBR.

Autologous conjunctival bleb resurfacing may be suc-cessful because it places autologous conjunctiva over thebleb (no excision is performed), stopping the bleb fromleaking immediately and then providing new cells, nutri-ents, chemotactic factors, growth factors, and vascularity,which work to provide epithelialization of the bleb even ifthe graft retracts. Intraocular pressure is maintained withthis procedure because the size of the bleb is not reduced,and even though the bleb is slightly thickened, it is stillrelatively thin. Because only one of these two parameters isaffected, adequate filtration of the bleb is still maintainedwith only a small increase in IOP. In this study, the IOPlevels increased from 6.66 4.4 mmHg before surgery to11.9 6 4.1 mmHg at the last follow-up visit, which arehealthy IOP measurements. Additionally, the change in IOPbetween preoperation, postoperative day 90, and at the lastfollow-up was insignificant among the surgeons. The num-ber of glaucoma medications used to help maintain lowerIOP did increase slightly from 0.13 to 0.41 medications.However, the number of glaucoma medications used aftersurgery in this case series was still less than that reported inother studies. Thus this procedure has the potential to allowfor long-term, leak-free, glaucoma control.

This is the largest series (47 procedures) of a singletechnique to repair late bleb leaks. Autologous conjunctivalbleb resurfacing procedures in this series were performed byfour surgeons using similar techniques, indicating that theprocedure is reproducible and that its results should begeneralizable. In comparing the number of leaks that oc-curred among surgeons, theP value was only significant atday 1. Although thisP value was significant, the patients ofonly two surgeons experienced one leak. This small numberof leaks indicates that this may not be a real phenomenon.Additionally, a broad distribution of patient demographics,including patients with 5-FU and MMC adjuvants and somewithout antiproliferative regimens, are included in thestudy, indicating that it is effective regardless of antifibroticregimen use. The cases were consecutive, and all patientswere accounted for at the end of the study.

Weaknesses of the study include possible misclassifica-tion by the surgeons of a bleb leak versus an ooze. Bleb leakcan be defined as fluid flowing through a hole in the bleb ascompared with an ooze, which is normally present in isch-emic filtering blebs and represents transconjunctival flow.Also, follow-up and evaluation for leaks with Seidel testingwas not performed at every postoperative visit becausepostoperative follow-up criteria specifying Seidel testingwas not delineated at the time of surgery, which is attrib-utable to the retrospective nature of this chart review. Thenatural history of this disorder remains unclear. Some casesundergo spontaneous resolution, continued leakage, and in-termittent leakage from new sites.

In conclusion, in patients with late-leaking filtering blebs

who are at risk for infection, ACBR is an effective initialsurgical treatment.

References

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2. Three-year follow-up of the Fluorouracil Filtering SurgeryStudy. The Fluorouracil Filtering Surgery Study Group. Am JOphthalmol 1993;115:82–92.

3. Five-year follow-up of the Fluorouracil Filtering SurgeryStudy. The Fluorouracil Filtering Surgery Study Group. Am JOphthalmol 1996;121:349–66.

4. Tsai JC, Feuer WJ, Parrish RK, Grajewski AL. 5-Fluorouracilfiltering surgery and neovascular glaucoma. Long-term fol-low-up of the original pilot study. Ophthalmology 1995;102:887–92; discussion 892–3.

5. Belyea DA, Dan JA, Stamper RL, et al. Late onset of sequen-tial multifocal bleb leaks after glaucoma filtration surgery with5-fluorouracil and mitomycin C. Am J Ophthalmol 1997;124:40–5.

6. Greenfield DS, Liebmann JM, Jee J, Ritch R. Late-onset blebleaks after glaucoma filtering surgery. Arch Ophthalmol 1998;116:443–7.

7. Kosmin AS, Wishart PK. A full-thickness scleral graft for thesurgical management of a late filtration bleb leak. OphthalmicSurg Lasers 1997;28:461–8.

8. Smith FM, Magauran RG III, Betchkal J, Doyle JW. Treat-ment of postfiltration bleb leaks with autologous blood. Oph-thalmology 1995;102:868–71.

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10. Kangas TA, Greenfield DS, Flynn HW Jr, et al. Delayed-onsetendophthalmitis associated with conjunctival filtering blebs.Ophthalmology 1997;104:746–52.

11. Phillips WB II, Wong TP, Bergren RL, et al. Late onsetendophthalmitis associated with filtering blebs. OphthalmicSurg 1994;25:88–91.

12. Wilson MR, Kotas-Neumann R. Free conjunctival patch forrepair of persistent late bleb leak. Am J Ophthalmol 1994;117:569–74.

13. Gammon RR, Prum BE Jr, Avery N, Mintz PD. Rapid prep-aration of small-volume autologous fibrinogen concentrateand its same day use in bleb leaks after glaucoma filtrationsurgery. Ophthalmic Surg Lasers 1998;29:1010–2.

14. Fourman S, Wiley L. Use of a collagen shield to treat aglaucoma filter bleb leak [letter]. Am J Ophthalmol 1989;107:673–4.

15. Hennis HL, Stewart WC. Use of the argon laser to closefiltering bleb leaks. Graefes Arch Clin Exp Ophthalmol 1992;230:537–41.

16. Baum M, Weiss HS. Argon laser closure of conjunctival blebleak [case report]. Arch Ophthalmol 1993;111:438.

17. Lynch MG, Roesch M, Brown RH. Remodeling filtering blebswith the neodymium:YAG laser. Ophthalmology 1996;103:1700–5.

18. Geyer O. Management of large, leaking, and inadvertent fil-tering blebs with the neodymium:YAG laser. Ophthalmology1998;105:983–7.

19. Wise JB. Mitomycin-compatible suture technique for fornix-based conjunctival flaps in glaucoma filtration surgery. ArchOphthalmol 1993;111:992–7.

20. Perkins TW, Gangnon R, Ladd W, et al. Trabeculectomy with

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mitomycin C: intermediate-term results. J Glaucoma 1998;7:230–6.

21. Singh J, O’Brien C, Chawla HB. Success rate and complica-tions of intraoperative 0.2 mg/ml mitomycin C in trabeculec-tomy surgery. Eye 1995;9:460–6.

22. Dietze PJ, Feldman RM, Gross RL. Intraoperative applicationof 5-fluorouracil during trabeculectomy. Ophthalmic Surg1992;23:662–5.

23. Iliff CE. Flap perforation in glaucoma surgery sealed by atissue patch. Arch Ophthalmol 1964;71:215–8.

24. O’Connor DJ, Tressler CS, Caprioli J. A surgical method torepair leaking filtering blebs. Ophthalmic Surg 1992;23:336–8.

25. Tseng SCG, Prabhasawat P, Lee SH. Amniotic membranetransplantation for conjunctival surface reconstruction. Am JOphthalmol 1997;124:765–74.

Historical Image

Text and images courtesy of John Kearney, MD and Stephen Tanaka, MD, Hayward, California.

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