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Kaplan-Meier estimation of bleb survival without development of late-onset leakage. Bleb leaks occurred more frequently in eyes that had received mitomycin C (P=.008, log-rank test).

Kaplan-Meier estimation of bleb survival without development of late-onset leakage. Bleb leaks occurred more frequently in eyes that had received mitomycin C (P=.008, log-rank test).

Table 1. 
Demographics of 525 Eyes in 525 Patients*
Demographics of 525 Eyes in 525 Patients*
Table 2. 
Characteristics of 525 Eyes in 525 Patients*
Characteristics of 525 Eyes in 525 Patients*
Table 3. 
Clinical Characteristics and Bleb Appearance in Eyes With and Without Leakage*
Clinical Characteristics and Bleb Appearance in Eyes With and Without Leakage*
Table 4. 
Clinical Characteristics and Bleb Appearance in Eyes With 5-Fluorouracil vs Mitomycin C Trabeculectomy*
Clinical Characteristics and Bleb Appearance in Eyes With 5-Fluorouracil vs Mitomycin C Trabeculectomy*
1.
Baum  MWeiss  HS Argon laser closure of conjunctival bleb leak. Arch Ophthalmol. 1993;111438Article
2.
Wilson  MRKotas-Neumann  R Free conjunctival patch for repair of persistent late bleb leak. Am J Ophthalmol. 1994;117569- 574
3.
Susanna  R  JrTakahashi  WNicolela  M Late bleb leakage after trabeculectomy with 5-fluorouracil or mitomycin C. Can J Ophthalmol. 1996;31296- 300
4.
Smith  MFMagauran  RG  IIIBetchkal  JDoyle  JW Treatment of postfiltration bleb leaks with autologous blood. Ophthalmology. 1995;102868- 871Article
5.
Smith  MFMagauran  RG  IIIDoyle  JW Treatment of postfiltration bleb leak by bleb injection of autologous blood. Ophthalmic Surg. 1994;25636- 637
6.
Hennis  HLStewart  WC Use of the argon laser to close filtering bleb leaks. von Graefe's Arch Clin Exp Ophthalmol. 1992;230537- 541Article
7.
Keller  CTo  K Bleb leak with hypotony after laser suture lysis and trabeculectomy with mitomycin C [letter]. Arch Ophthalmol. 1993;111427Article
8.
Schwartz  ALWeiss  H Bleb leak with hypotony after laser suture lysis and trabeculectomy with mitomycin C. Arch Ophthalmol. 1992;1101049Article
9.
Melamed  SAshkenazi  IBelcher  CD  IIIBlumenthal  M Donor scleral graft patching for persistent filtration bleb leak. Ophthalmic Surg. 1991;22164- 165
10.
Fourman  SWiley  L Use of a collagen shield to treat a glaucoma filter bleb leak. Am J Ophthalmol. 1989;107673- 674
11.
Graham  SLGoldberg  I Cyanoacrylate adhesive closure of wound leaks following fornix-based trabeculectomy with adjunct 5-fluorouracil. J Glaucoma. 1993;2297- 302Article
12.
Grady  FJForbes  M Tissue adhesive for repair of conjunctival buttonhole in glaucoma surgery. Am J Ophthalmol. 1969;68656- 658
13.
Kajiwara  K Repair of a leaking bleb with fibrin glue. Am J Ophthalmol. 1990;109598- 599
14.
Weber  PABaker  ND The use of cyanoacrylate adhesive with a collagen shield in leaking filtering blebs. Ophthalmic Surg. 1989;20284- 285
15.
Ritch  RSchuman  JSBelcher  CD  III Management of the leaking filtration bleb. J Glaucoma. 1993;2114- 118
16.
Katz  GJHigginbotham  EJLichter  PR  et al.  Mitomycin C versus 5-fluorouracil in high risk glaucoma filtering surgery: extended follow-up. Ophthalmology. 1995;1021263- 1269Article
17.
Fluorouracil Filtering Surgery Study Group, Fluorouracil filtering surgery study one-year follow-up. Am J Ophthalmol. 1989;108625- 635
18.
Fluorouracil Filtering Surgery Study Group, Three-year follow-up of the fluorouracil filtering surgery study. Am J Ophthalmol. 1993;11582- 92
19.
Fluorouracil Filtering Surgery Study Group, Five-year follow-up of the fluorouracil filtering surgery study. Am J Ophthalmol. 1996;121349- 366
20.
Franks  WAHitchings  RA Complications of 5-fluorouracil after trabeculectomy. Eye. 1991;5385- 389Article
21.
Skuta  GLBeeson  CCHigginbotham  EJ Intraoperative mitomycin versus postoperative 5-fluorouracil in high-risk glaucoma filtering surgery. Ophthalmology. 1992;99438- 444Article
22.
Ticho  UOphir  A Late complications after glaucoma filtering surgery with adjunctive 5-fluorouracil. Am J Ophthalmol. 1993;115506- 511
23.
Cheung  JCWright  MMUrali  SPederson  JE Intermediate-term outcome of variable dose mitomycin C filtering surgery. Ophthalmology. 1997;104143- 149Article
24.
Khaw  PTDoyle  JWSherwood  MBGrierson  ISchultz  GMcGorrey  S Prolonged localized tissue effects from 5-minute exposures to fluorouracil and mitomycin C. Arch Ophthalmol. 1993;111263- 267Article
25.
Khaw  PTDoyle  JWSherwood  MBSmith  MFMcGorrey  S Effects of intraoperative 5-fluorouracil or mitomycin-C on glaucoma filtration surgery in the rabbit. Ophthalmology. 1993;100367- 372Article
26.
Mietz  HBrunner  RAddicks  KKrieglstein  GK Histopathology of an avascular filtering bleb after trabeculectomy with mitomycin-C. J Glaucoma. 1993;2266- 270Article
27.
Shields  MBScroggs  MWSloop  MWSimmons  RB Clinical and histopathologic observations concerning hypotony after trabeculectomy with adjunctive mitomycin-C. Am J Ophthalmol. 1993;116673- 683
28.
Nuyts  RMMAFelton  PCPels  E  et al.  Histopathologic effects of mitomycin C after trabeculectomy in human glaucomatous eyes with persistent hypotony. Am J Ophthalmol. 1994;118225- 237
29.
Greenfield  DSParrish  RK  II Bleb rupture following filtering surgery with mitomycin-C: clinicopathologic correlations. Ophthalmic Surg Lasers. 1996;27876- 877
30.
Lamping  KABellows  ARHutchinson  BTAfran  SI Long-term evaluation of initial filtration surgery. Ophthalmology. 1986;9391- 101Article
31.
Caronia  RMLiebmann  JMFriedman  R  et al.  Trabeculectomy at the inferior limbus. Arch Ophthalmol. 1996;114387- 391Article
32.
Prata  JA  JrNeves  RAMinckler  DS  et al.  Trabeculectomy with mitomycin C in glaucoma associated with uveitis. Ophthalmic Surg. 1994;25616- 620
33.
Singh  JO'Brien  CChawla  HB Success rate and complications of intraoperative 0.2 mg/mL mitomycin C in trabeculectomy surgery. Eye. 1995;9460- 466Article
34.
Belyea  DADan  JAStamper  RL  et al.  Late onset of sequential multifocal bleb leaks after glaucoma filtration surgery with 5-fluorouracil and mitomycin C. Am J Ophthalmol. 1997;12440- 45
35.
Katz  NRFinger  PTMcCormick  SA  et al.  Ultrasound biomicroscopy in the management of malignant melanoma of the iris. Arch Ophthalmol. 1995;1131462- 1463Article
36.
Berestka  JSBrown  SVL Limbus- versus fornix-based conjunctival flaps in combined phacoemulsification and mitomycin C trabeculectomy surgery. Ophthalmology. 1997;104187- 196Article
37.
Lederer  CM  Jr Combined cataract extraction with intraocular lens implant and mitomycin-augmented trabeculectomy. Ophthalmology. 1996;1031025- 1034Article
38.
Carlson  DWAlward  WLMBarad  JP  et al.  A randomized study of mitomycin augmentation in combined phacoemulsification and trabeculectomy. Ophthalmology. 1997;104719- 724Article
39.
Belyea  DADan  JALieberman  MFStamper  RL Midterm follow-up results of combined phacoemulsification, lens implantation, and mitomycin-C trabeculectomy procedure. J Glaucoma. 1997;690- 98Article
40.
Suñer  IJGreenfield  DSMiller  MPPalmberg  PF Hypotony maculopathy following filtering surgery with mitomycin C: incidence and treatment. Ophthalmology. 1997;104207- 215Article
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Greenfield  DSSuñer  IJMiller  MP  et al.  Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol. 1996;114943- 949Article
Clinical Sciences
April 1998

Late-Onset Bleb Leaks After Glaucoma Filtering Surgery

Author Affiliations

From the Departments of Ophthalmology (Drs Greenfield, Liebmann, Jee, and Ritch) and Neurology (Dr Greenfield), The New York Eye and Ear Infirmary, New York, and New York Medical College, Valhalla.

Arch Ophthalmol. 1998;116(4):443-447. doi:10.1001/archopht.116.4.443
Abstract

Objective  To determine the incidence of focal, late-onset, conjunctival bleb leaks after glaucoma filtering surgery.

Design  Prospective, cross-sectional analysis.

Setting  Tertiary care outpatient referral center.

Patients  Consecutive patients who underwent glaucoma filtering surgery prior to June 1996 presenting for evaluation from September 2, 1996, through November 15, 1996. Five hundred twenty-five eyes of 525 consecutive patients were enrolled in the study.

Intervention  Bleb height (elevated or flat), area (diffuse or localized), and wall thickness (thin, thick, or encapsulated) were classified. Each bleb was tested for focal leakage using a moistened fluorescein strip, cobalt blue illumination, and slit-lamp biomicroscopy. Diffuse transconjunctival aqueous flow did not qualify as a focal leak.

Main Outcome Measure  Seidel-positive aqueous leakage.

Results  Bleb leakage occurred in 14 eyes following trabeculectomy (mitomycin C treatment, 10 eyes; 5-fluorouracil treatment, 3 eyes; no antifibrosis agent, 1 eye) and in 1 eye following combined cataract and glaucoma surgery with adjunctive mitomycin C therapy. Bleb leakage occurred more frequently in eyes that received mitomycin C (10 [3.7] of 273 eyes) than 5-fluorouracil (3 [1.4] of 213 eyes) or no antifibrosis agent (1 [2.6] of 39 eyes), using Kaplan-Meier estimates (P=.008, log-rank test). Conjunctival blebs were significantly thinner after trabeculectomy with mitomycin C than with 5-fluorouracil (P=.001). Bleb wall thickness was greater following combined cataract and glaucoma surgery than following trabeculectomy alone (P=.008). Age (P=.84), sex (P=.68), race (P=.77), duration of mitomycin C exposure (P=.62), number of antiglaucoma medications (P=.16), and total 5-fluorouracil dose (P=.85) were not associated with late-onset leaks.

Conclusions  The risk of late-onset focal bleb leakage increases following trabeculectomy with mitomycin C therapy. Late leakage after combined cataract and glaucoma surgery is infrequent.

AQUEOUS leakage from a conjunctival filtering bleb may occur as an early or late complication of glaucoma filtration surgery. If the leakage is left untreated, vision-threatening complications may result, including ocular hypotony and maculopathy, shallowing of the anterior chamber, peripheral anterior synechiae, cataract formation, corneal decompensation, choroidal effusion, suprachoroidal hemorrhage, and endophthalmitis. Although many treatment options have been proposed,115 successful closure of late bleb leaks following glaucoma filtering surgery remains a controversial and challenging management problem.

The reported rate of bleb leakage after filtration surgery varies widely and is affected by study sample size, surgical technique, duration of follow-up, and definition of aqueous leakage. Many reports do not distinguish the incidence of early perioperative wound leaks from late-onset leakage, which is associated with a thin, avascular conjunctiva. In addition, Susanna et al3 reported markedly different rates of aqueous leakage in a study comparing spontaneous bleb leakage with leakage after provocation using ocular digital massage (0% and 31%, respectively).

Although the conjecture is unproven, bleb leakage is thought to be more frequent in eyes that have received perioperative antifibrosis agents. Bleb leaks in eyes treated with 5-fluorouracil or mitomycin C may occur in 5% to 30% of patients.1623 Leaks in these eyes may take longer to heal because of the thin, avascular tissue and associated abnormal fibrovascular response.24,25 Histopathological examination of blebs after trabeculectomy with mitomycin C treatment reveals irregularities in the conjunctival epithelium, breaks in the basement membrane, and conjunctival and subconjunctival hypocellularity, each of which may predispose to bleb leaks.2629 We performed a prospective, cross-sectional study to determine the incidence of and associated clinical factors for late bleb leakage in patients after trabeculectomy.

PATIENTS AND METHODS

All patients filtered prior to June 1996 and seen in the private practices of D.S.G., J.M.L., and R.R. at The New York Eye and Ear Infirmary, New York, from September 2, 1996, to November 15, 1996, were enrolled in the study. Each patient had undergone previous trabeculectomy (with or without antifibrosis agents) or combined trabeculectomy (with or without antifibrosis agents), cataract extraction, and intraocular lens implantation by 1 of the aforementioned surgeons. If both eyes had undergone filtering surgery, the right eye was enrolled.

Trabeculectomy was performed at the superior limbus using either a limbus-based or fornix-based approach following regional anesthesia and povidone-iodine preparation. Meticulous hemostasis was achieved with light bipolar cautery. A half-thickness scleral flap was outlined at the surgical limbus. Intraoperative mitomycin C (0.5 mg/mL) or 5-fluorouracil (50 mg/mL) was applied to eyes at risk for trabeculectomy failure for variable intervals using a saturated surgical spear (Weck-Cel, Weck Ophthalmics, Jacksonville, Fla) placed between the scleral flap and Tenon fascia, after which copious irrigation with balanced salt solution was performed. A clear corneal paracentesis track was made at 90° from the filtration site. Using a 0.75-mm Kelly Descemet punch (Storz Ophthalmics, St Louis, Mo), an internal block of clear corneal and trabecular meshwork tissue was removed. A peripheral iridectomy was performed and the scleral flap was sutured with 2 to 4 interrupted 10-0 monofilament nylon sutures. Limbus-based conjunctival incisions were closed with either a running 10-0 nylon suture on a CU-5 (Alcon Surgical, Alcon Laboratories, Ft Worth, Tex) needle or a 9-0 polyglactin suture on a vascular needle. Fornix-based conjunctival incisions were closed with 2 to 3 10-0 nylon sutures. Additional balanced salt solution was injected into the anterior chamber to re-form the filtering bleb and to verify that the wound was watertight. Subconjunctival injections of gentamicin sulfate (20 mg) and methylprednisolone sodium succinate (20 mg) were administered and the eyes were patched after topical application of a combined steroid and antibiotic ointment of neomycin sulfate, polymyxin B sulfate, and 0.1% dexamethasone. When 5-fluorouracil was used, variable numbers of subconjunctival injections (5 mg per injection) were administered (a 30-gauge needle attached to a 1-mL tuberculin syringe) 180° away from the filtering site during the first 2 postoperative weeks.

Combined cataract and glaucoma surgery was performed using a fornix-based conjunctival incision. In eyes undergoing phacoemulsification, a 3.5-mm wide, half-thickness scleral groove was made approximately 1 mm posterior to the limbus and a scleral tunnel was dissected. In eyes undergoing extracapsular cataract extraction, a half-thickness scleral flap was outlined at the surgical limbus and a 180° superior limbal incision was created. In most eyes, mitomycin C (0.5 mg/mL) or 5-fluorouracil (50 mg/mL) was applied to the surface of the scleral bed for variable intervals. Postoperative subconjunctival infections were administered as previously described.

The clinical examination procedure included characterization of bleb appearance and assessment for bleb leakage, as follows. Under cobalt blue slitlamp illumination, a moistened sterile fluorescein strip was applied to the bleb surface. A leak was defined as a spontaneous focal-point source of aqueous leakage from an area of interrupted conjunctival tissue occurring at least 3 months postoperatively. Diffuse transconjunctival aqueous flow, or "bleb sweat," did not qualify as a leak. No eyes in this investigation underwent digital massage to enhance visualization of conjunctival leakage.

Blebs were classified by height (elevated or flat), area (diffuse or localized), and wall thickness by 1 of 3 investigators (D.S.G., J.M.L., and R.R.) who were masked to the patients' surgical histories. Thin-walled blebs were defined as blebs with a transparent conjunctiva where it was possible to visualize the scleral flap or nylon suture. Thick-walled blebs were defined as blebs with a nontransparent conjunctiva. Tenon capsule cysts were classified as encapsulated blebs.

Data abstracted from the patients' medical records included demographics, glaucoma diagnosis, date and type of glaucoma filtration surgery, previous ocular surgery, type and dose of antifibrosis agent (if applicable), concurrent antiglaucoma medication, and intraocular pressure (IOP). Evaluation of continuous variables was achieved using a Student t test. Categorical variables were evaluated with χ2, Fisher exact test, or Spearman rank correlation when appropriate. Statistical significance was determined at P=.05. Each potential confounding variable was screened for association with the outcome. Only those confounding variables that were statistically associated were eligible for the potential final multivariate model.

RESULTS

Five hundred twenty five eyes of 525 patients were enrolled. Patient demographic data is summarized in Table 1. Bleb leaks were detected in 15 eyes (2.9%). There were no differences in age (P=.84), sex (P=.67), ethnicity (P=.46), glaucoma diagnosis (P=.56), length of postoperative follow-up (P=.27), number of previous conjunctival incisions (P=.25), number of concurrent antiglaucoma medications (P=.13), duration of mitomycin C exposure (P=.79), and total 5-fluorouracil dose (P=.85) in the leaking and nonleaking blebs (Table 2 and Table 3).

Bleb leakage occurred in 14 eyes following trabeculectomy (mitomycin C treatment, 10 eyes; 5-fluorouracil treatment, 3 eyes; no antifibrosis agent, 1 eye) and in 1 eye following combined trabeculectomy with mitomycin C, cataract extraction, and intraocular lens implantation. Bleb leakage occurred more frequently in eyes that received mitomycin C (10 [3.7] of 273 eyes) than those that received 5-fluorouracil (3 [1.4] of 213 eyes) or no antifibrosis agent (1 [2.6] of 39 eyes), using Kaplan-Meier estimates (P=.008, log-rank test) (Figure 1). The clinical characteristics and bleb appearance in eyes with and without aqueous leakage are described in Table 3. Mean±SD IOP was significantly lower in eyes with bleb leaks (9.5±4.5 vs 15.4±6.9 mm Hg, P=.001, Student t test). Five (33.3%) of 15 eyes with leaks had an IOP of 14 mm Hg or more.

Compared with nonleaking blebs, leaking blebs were more likely to be characterized as localized and thin-walled (P=.007 [Fisher exact test] and .02 [χ2 test], respectively). Leaks occurred in 12 (5.2%) of 231 blebs classified as thin, in 3 (1.1%) of 278 blebs classified as thick, and in 0 of 16 blebs classified as encapsulated. Bleb wall thickness was greater following combined surgery than following trabeculectomy (P=.008).

One hundred eighty-one eyes underwent trabeculectomy with 5-fluorouracil treatment and 170 eyes underwent trabeculectomy with mitomycin C treatment (Table 4). Conjunctival blebs were significantly thinner after trabeculectomy with mitomycin C than with 5-fluorouracil (P=.001, χ2 test). The incidence of bleb leakage was significantly greater in eyes after trabeculectomy with mitomycin C than with 5-fluorouracil (5.9% vs 1.7%, P=0.05), despite the fact that follow-up was significantly longer in eyes after trabeculectomy with 5-fluorouracil (P<.001). Age, sex, ethnicity, IOP, number of antiglaucoma medications, bleb height, and bleb area were similar both in the eyes that had undergone 5-fluorouracil trabeculectomy and in those that had undergone mitomycin C trabeculectomy.

Bleb leak management included observation (5 eyes); placement of a large-diameter bandage contact lens (4 eyes); combined bandage contact lens placement, autologous blood injection, and compression suture repair (3 eyes); bleb excision and conjunctival advancement (2 eyes); and argon laser treatment following application of methylene blue dye (1 eye).

COMMENT

Aqueous leakage from a conjunctival filtering bleb may be classified as early or late. Early-onset bleb leaks, largely dependent on technical aspects of wound closure, generally occur within the first 3 postoperative months. Late-onset leaks are typically associated with thin, cystic, avascular blebs and occur months to years after surgery. In our study, we defined late-onset bleb leaks as those that develop at least 3 months after filtering surgery.

Leaks occur infrequently after trabeculectomy without antifibrosis agents but have been reported in 3.3% of eyes after full-thickness procedures.30 The reported rate of late-onset bleb leakage after glaucoma filtering surgery using mitomycin C and 5-fluorouracil is highly variable and dependent upon individual wound-healing response, surgical procedure (ie, trabeculectomy vs combined cataract extraction and trabeculectomy), and surgical technique. Differences in sample size, length of follow-up, definition of aqueous leakage, spontaneous or provoked leak detection, and filtering bleb location also affect reported leak rates. The Fluorouracil Filtering Surgery Study Group18 reported late-onset leaks in 7.0% of eyes after 3 years of follow-up. Caronia et al31 reported a 12.9% rate of late leakage in eyes with filtering blebs after trabeculectomy with 5-fluorouracil at the inferior limbus. In eyes after trabeculectomy with 5-fluorouracil or mitomycin C, Susanna et al3 reported an increased rate of late-onset leak detection when digital ocular massage was performed. Others32,33 have reported an incidence of late leakage ranging between 4.2% and 10% after trabeculectomy with mitomycin C.

Study design (retrospective or prospective) will also affect the detection rate. Leaks are often only sought in eyes with hypotony, anterior chamber shallowing, choroidal detachment, or suspected infection. As such, retrospective reporting will underestimate the true incidence of leakage. Belyea et al34 retrospectively reviewed 385 consecutive eyes undergoing trabeculectomy with 5-fluorouracil or mitomycin C treatment and reported a 1.8% overall incidence of late-onset sequential multifocal leaks (5 eyes received 5-fluorouracil, 2 eyes received mitomycin C). Histopathological examination of 3 eyes demonstrated epithelial breakdown, hypocellularity, and stromal collagen necrosis in the bleb. To determine more clearly the incidence of late-onset leakage, we performed a prospective cross-sectional analysis of late-onset leakage among a consecutive series of eyes with filtration blebs with a minimum of 3 months postoperative follow-up.

In this cross-sectional series, we found that bleb leaks occurred 3 times more commonly following trabeculectomy with mitomycin C treatment than with 5-fluorouracil treatment, despite the fact that the duration of follow-up was significantly greater in the 5-fluorouracil–treated group than in the mitomycin C–treated group (P<.001). If these blebs become thinner over time, one would have expected a greater rate of late leakage in those eyes with longer follow-up. In contrast, others34,35 have retrospectively reported a greater incidence of late leakage after trabeculectomy with 5-fluorouracil. Belyea et al34 reported a slightly greater rate after filtering surgery with 5-fluorouracil treatment (2.6%) compared with surgery with mitomycin C treatment (1.0%). Katz et al35 reported 2 (11%) of 19 eyes with late-onset bleb leaks after trabeculectomy with 5-fluorouracil treatment compared with 1 (5%) of 20 eyes with mitomycin C treatment. It is unclear whether a greater number of leaks might have been identified if each patient in these series had been sequentially tested at every follow-up visit.

We found that, in contrast with early-onset bleb leakage, many eyes with late-onset leaks had normal IOP and elevated blebs. Five eyes (33%) with leaks had IOP of 14 mm Hg or greater, implying that IOP alone cannot predict which eyes will have leaks or determine which eyes should be tested for leaks. The value of routine Seidel testing, however, remains unclear. Although bleb leaks have been associated with endophthalmitis, a true causative relationship between the two has yet to be proven. In addition, the management of late bleb leakage is both complex and controversial. The risk-benefit ratio of closing conjunctival leaks, with the attendant risks of IOP elevation and visual loss, needs to be validated in a prospective, randomized fashion.

Bleb leakage was uncommon after combined glaucoma and cataract surgery in our study. Others3639 have reported low rates of leakage after combined procedures. This is consistent with the infrequent development of hypotony and late endophthalmitis following combined cataract and glaucoma surgery, and reflects the thicker bleb walls present in these eyes.40,41 As expected, localized, thin-walled blebs in this series were more prone to leakage than diffuse blebs with thicker walls. Furthermore, bleb leakage in our series was almost 3 times more common in eyes that had undergone primary filtering surgery (3.7%) compared with eyes that had had prior conjunctival incisional surgery (1.3%), although this difference was statistically insignificant.

In conclusion, these data suggest that the risk of late-onset focal bleb leakage increases following trabeculectomy with adjunct mitomycin C therapy and occurs in as much as 6% of eyes. Localized, thin-walled blebs develop leaks more frequently than diffuse blebs with thicker walls. As such, late leakage after combined cataract and glaucoma surgery is infrequent.

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Article Information

Accepted for publication December 19, 1997.

This study was supported in part by the New York Glaucoma Research Institute, New York.

Presented as a scientific exhibit at the Annual Meeting of the Association for Research in Vision and Ophthalmology, Ft Lauderdale, Fla, May 15, 1997.

Reprints: Robert Ritch, MD, Department of Ophthalmology, The New York Eye and Ear Infirmary, 310 E 14th St, New York, NY 10003 (e-mail: ritch@inx.net).

References
1.
Baum  MWeiss  HS Argon laser closure of conjunctival bleb leak. Arch Ophthalmol. 1993;111438Article
2.
Wilson  MRKotas-Neumann  R Free conjunctival patch for repair of persistent late bleb leak. Am J Ophthalmol. 1994;117569- 574
3.
Susanna  R  JrTakahashi  WNicolela  M Late bleb leakage after trabeculectomy with 5-fluorouracil or mitomycin C. Can J Ophthalmol. 1996;31296- 300
4.
Smith  MFMagauran  RG  IIIBetchkal  JDoyle  JW Treatment of postfiltration bleb leaks with autologous blood. Ophthalmology. 1995;102868- 871Article
5.
Smith  MFMagauran  RG  IIIDoyle  JW Treatment of postfiltration bleb leak by bleb injection of autologous blood. Ophthalmic Surg. 1994;25636- 637
6.
Hennis  HLStewart  WC Use of the argon laser to close filtering bleb leaks. von Graefe's Arch Clin Exp Ophthalmol. 1992;230537- 541Article
7.
Keller  CTo  K Bleb leak with hypotony after laser suture lysis and trabeculectomy with mitomycin C [letter]. Arch Ophthalmol. 1993;111427Article
8.
Schwartz  ALWeiss  H Bleb leak with hypotony after laser suture lysis and trabeculectomy with mitomycin C. Arch Ophthalmol. 1992;1101049Article
9.
Melamed  SAshkenazi  IBelcher  CD  IIIBlumenthal  M Donor scleral graft patching for persistent filtration bleb leak. Ophthalmic Surg. 1991;22164- 165
10.
Fourman  SWiley  L Use of a collagen shield to treat a glaucoma filter bleb leak. Am J Ophthalmol. 1989;107673- 674
11.
Graham  SLGoldberg  I Cyanoacrylate adhesive closure of wound leaks following fornix-based trabeculectomy with adjunct 5-fluorouracil. J Glaucoma. 1993;2297- 302Article
12.
Grady  FJForbes  M Tissue adhesive for repair of conjunctival buttonhole in glaucoma surgery. Am J Ophthalmol. 1969;68656- 658
13.
Kajiwara  K Repair of a leaking bleb with fibrin glue. Am J Ophthalmol. 1990;109598- 599
14.
Weber  PABaker  ND The use of cyanoacrylate adhesive with a collagen shield in leaking filtering blebs. Ophthalmic Surg. 1989;20284- 285
15.
Ritch  RSchuman  JSBelcher  CD  III Management of the leaking filtration bleb. J Glaucoma. 1993;2114- 118
16.
Katz  GJHigginbotham  EJLichter  PR  et al.  Mitomycin C versus 5-fluorouracil in high risk glaucoma filtering surgery: extended follow-up. Ophthalmology. 1995;1021263- 1269Article
17.
Fluorouracil Filtering Surgery Study Group, Fluorouracil filtering surgery study one-year follow-up. Am J Ophthalmol. 1989;108625- 635
18.
Fluorouracil Filtering Surgery Study Group, Three-year follow-up of the fluorouracil filtering surgery study. Am J Ophthalmol. 1993;11582- 92
19.
Fluorouracil Filtering Surgery Study Group, Five-year follow-up of the fluorouracil filtering surgery study. Am J Ophthalmol. 1996;121349- 366
20.
Franks  WAHitchings  RA Complications of 5-fluorouracil after trabeculectomy. Eye. 1991;5385- 389Article
21.
Skuta  GLBeeson  CCHigginbotham  EJ Intraoperative mitomycin versus postoperative 5-fluorouracil in high-risk glaucoma filtering surgery. Ophthalmology. 1992;99438- 444Article
22.
Ticho  UOphir  A Late complications after glaucoma filtering surgery with adjunctive 5-fluorouracil. Am J Ophthalmol. 1993;115506- 511
23.
Cheung  JCWright  MMUrali  SPederson  JE Intermediate-term outcome of variable dose mitomycin C filtering surgery. Ophthalmology. 1997;104143- 149Article
24.
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