Results from a modified bleb needling procedure with continuous infusion performed in the operating room

Purpose: Needling of a scarred trabeculectomy bleb is often performed in the office using a slit-lamp microscope as an alternative to additional surgery to lower intraocular pressure (IOP). However, the success rate in an office setting is highly variable, with reported success rates as low as 13%. We report a retrospective assessment of an intraoperative needling technique for reviving failed blebs. Design: A retrospective chart review. Participants: Patients undergoing the intraoperative modified bleb revision technique in the setting of a failed trabeculectomy due to scarring at the Wilmer Eye Institute, Johns Hopkins Hospital between August 16, 2010 and August 29, 2012. Methods: Patients with uncontrolled IOP were operated on using a modified bleb needling technique. In this technique, a 25-G infusion cannula is placed in the anterior chamber and fibrotic adhesions within the bleb are lysed with a 25-G needle. The continuous infusion of balanced salt solution from the anterior chamber causes bleb elevation, which helps to guide the endpoint of lysis for the procedure. A subconjunctival injection of 5-fluorouracil is given at the conclusion of each case. Main Outcome Measures: IOP reduction and number of glaucoma medications at postoperative day 1, week 1, month 1, month 3, month 6, and month 12. Results: A total of 33 eyes of 30 patients were included. At the visit before the procedure, the mean (±SD) IOP was 22.1±9.2 (range, 11 to 58) and subjects were using an average of 2.3±1.4 (range, 0 to 4) glaucoma medications. The mean IOP reduction was 8.7mm Hg [95% confidence interval (CI), 5.6-11.8] at postoperative day 1, 8.1mm Hg (95% CI, 4.0-12.3) at week 1, 8.9mm Hg (95% CI, 5.3-12.5) at month 1, 8.1mm Hg (95% CI, 4.2-12.0) at month 3, 8.2mm Hg (95% CI, 3.9-12.5) at month 6, and 6.2mm Hg (95% CI, 3.6-8.7) at month 12. IOP was reduced about 30% to 40% compared with baseline at each time point (P<0.05). The average reduction in medications used was 1.7 at day 1, 1.0 at month 1, 1.2 at month 3, 1.5 at month 6, and 0.5 at month 12. Seven patients underwent repeat needling. Overall, 64% of subjects maintained IOP at or below their target after 12 months. Conclusions: A modified bleb needling procedure performed in the operating room can successfully lower IOP in the setting of a previous trabeculectomy in over 60% of subjects a year after the procedure.