The ideal option was a treatment that was readily Sir available and could be delivered safely and effectively in Safe management of a late-onset bleb leak with a the recumbent position. Argon laser photocoagulation needling technique via the indirect ophthalmoscope was therefore our Bleb leaks may occur as an early or late complication of procedure of choice. We found the procedure quick, glaucoma filtering surgery, and are often recalcitrant to effective and inexpensive. It is also easily performed by therapy. Spontaneous late bleb leaks occur more ophthalmologists experienced in the use of argon laser frequently in glaucoma filtering surgery following photocoagulation via the binocular indirect adjunctive use of the antimetabolites mitomycin C1 or 5- ophthalmoscope. We propose that similar patients can be fluorouracil, and with full-thickness procedures. We treated by this method before referral to a vitreoretinal describe a new 'repair technique' in a patient with a late­ surgeon for vitrectomy. onset leaking bleb. Dellaporta5 described a similar procedure in which evacuation of subretinal haemorrhage was achieved by Case report perforation of the retina using direct argon laser photocoagulation delivery with good results. Sahu and A 48-year-old woman with primary open angle 6 co-workers described a stretch burn technique which glaucoma in the right eye had undergone trabeculectomy apparently reduces the size and energy level requirement with an antiproliferative agent 31/z years previously. of the penetrating burn. We did not find this procedure Trabeculectomy was performed with a limbal-based flap. necessary; however, we suspect that more than one A cellulose sponge containing mitomycin C 0.2 mg! dl penetrating burn is required to enable the blood to flow was applied to the eye between the sclera and into the vitreous cavity. conjunctiva for 3 min. After the application of a second The relative ease and apparent efficacy of this sponge, the conjunctiva was irrigated with at least 250 ml technique are encouraging; however, in bilateral macular balanced salt solution. A 4 mm lamellar scleral flap was haemorrhages the patient may find it difficult to fixate prepared at a uniform depth of approximately one-half and thus require a local anaesthetic to reduce ocular of scleral thickness. After entering the anterior chamber, movement and hence inadvertent retinal burns. Possible a Kelly-Descemet punch (Stortz Instruments, St Louis, complications of our method of treatment include MO) was used to excise the trabeculum, cornea and choroidal haemorrhage, inadvertent foveal burns, retinal scleral tissue. A peripheral iridectomy at the same site breaks and persistent vitreous haemorrhage which may was performed. Five 10-0 nylon sutures were used to be further complicated by a tractional retinal detachment close the scleral flap. The conjunctival incision was or proliferative vitreous retinopathy. Further research is closed with running locked 10-0 nylon sutures. The post­ therefore necessary before this technique is adopted as a operative intraocular pressure was well controlled at safe alternative in the treatment of subhyaloid macular approximately 15 mmHg in the operated eye for 2 years haemorrhage regardless of the underlying cause. after the operation. The post-operative best corrected visual acuity was 20/20 with a refractive error of -9.0 D. The visual acuity and visual field defects were References unchanged after surgery. 1. Terson A. De l'hemorrhagie dans Ie corps vitre au cors de Two years later, the patient suddenly complained of l'hemorrhagie cerebrale. Clin Ophtalmol 1990;6:309. blurred vision and epiphora in the right eye, which 2. Garfinkle AM, Danys IR, Nicolle DA, Colohan AR, Brem S. lasted for a few days. In the right eye, intraocular Terson's syndrome: a reversible cause of blindness following 5 sub-arachnoid haemorrhage. J Neurosurg 1992;76:766-71. pressure was mmHg. Low intraocular pressure 3. Pfusler B, Belel R, Metzler R, Mohsenipour I, Schmutzhard E. continued for about 2 weeks. Choroidal and retinal folds Terson's syndrome in spontaneous subarachnoid were found at fundoscopy and hypotonic maculopathy haemorrhage: a prospective study in 60 consecutive patients. was diagnosed. Slit-lamp examination showed a slightly J Neurosurg 1996;85:392-4. shallow anterior chamber and a positive Seidel test from 4. Iijima H, Satoh S, Tsukahara S. Nd:YAG laser photo­ disruption for pre-retinal haemorrhage due to retinal the inferior portion of the bleb (Fig. 1). Despite initial macroaneurysm. Retina 1998;18:430-4. prescription of aqueous suppressant eye drops to reduce 5. Dellaporta AN. Evacuation of sub-retinal haemorrhage. Int leakage and permit surface epithelialisation and Ophthalmol 1994;18:25-31. initiation of eye patching (including tamponade 6. Sahu DK, Namperrumalsamy P, Kim R, Ravindran RD. glaucoma shell), aqueous leakage from the filtering bleb Argon laser treatment for premacu.lar haemorrhage. Retina 1998;18:79-82. persisted. Intrableb injections of autologous blood and fibrin glue were also tried twice to close the button hole Yinka Osoba � of the leaking bleb without any success. Manchester Royal Eye Hospital Finally, a previously reported transconjunctival bleb Oxford Road needling technique was carried out? This technique Manchester M13 9WH, UK involves elevation of the conjunctiva off the surface of the Mark Talbot globe with balanced salt solution and anaesthetic using a Royal Preston Hospital 27 Fulwood gauge needle. The underlying episcleral-Tenon's Preston PR29 9HT, UK capsule scarring was then incised extensively with a small gauge needle far away from the ischaemic bleb. We 802 Fig. 1. Left: a thin cystic ischaemic bleb after trabeculectomy. Right: staining of the bleb leak with 2% fluorescein. took care not to perforate the thin-walled, avascular and reported for management of late-onset leakage in thin friable bleb. Slight subconjunctival haemorrhage was avascular blebs. The purpose of needling the late-onset noted after treatment. A fibronectin eye drop was bleb leak in this case is decompression of the internal instilled in addition to promote closure of the leaking bleb pressure. Late-onset bleb leak is thought to be 3 bleb. Five days later, the bleb closed and a Seidel test was caused by narrowing of the effective bleb space by negative, as shown in Fig. 2. The needling technique subconjunctival adhesions that reduce the size of the bleb induced a much more diffuse bleb and improved the and cause it to become thin-walled. Thus, there is high bleb so as to prevent any leakage from the conjunctiva. pressure within a narrow bleb space that causes thinning Therefore, the leaks were repaired successfully, and bleb of the bleb. The aim of the needling revision is to increase function was maintained. No symptoms of leakage from the size of bleb and thereby decompress it. For this the filtering bleb were noted ll1z years following surgery. reason, 'needling' may be a reasonable technique to repair late-onset bleb leaks. The main advantages of this procedure are its ease, safety and lack of major Comment complications. Furthermore, the technique can be Many conservative methods of closing leaks in filtering repeated if necessary. It should be considered before 3 4 blebs have been reported, , but few are consistently surgical management of a leaking bleb. useful in the management of late-onset leaks in thin, Fibronectin adhesives were used adjunctively to close avascular blebs. Meanwhile, although surgical revision the bleb leak. The use of topical fibronectin or epidermal 5 of leaking bleb is a successful and a reliable procedure growth factor (EGF), which is currently under for closing filtering blebs, uncontrolled intraocular investigation,6-8 increases the tensile strength of rabbit pressure elevation can occur after revision due to tight and primate corneal wounds. Fibronectin can also induce closure of the conjunctiva over the scleral flap. When healing of bleb microholes. Topical fibronectin is there is severe subconjunctival scarring over a considered to be useful for closing late-onset bleb leaks. widespread area or a thin-walled ischaemic bleb exists, However, there is a need for further studies on this issue. bleb revision becomes technically difficult. Needling Transconjunctival needling has minimal revision is the generally accepted method of complications. In selected cases, this minimally invasive management of poorly functioning encapsulated or slit-lamp needling procedure provides successful closure flattened blebs. However, this technique has not been of a late-onset bleb leak. Fig. 2. Left: an ishaemic bleb after the needling technique. A slight subconjunctival haemorrhage was noted. Right: a negative Seidel test in this patient after the needling procedure. 803 4 References thickening from cystalline deposits. We describe a case of infantile cystinosis which has resulted in progressive 1. Budenz DL, Chen PP, Weaver YK. Conjunctival advancement for late-onset filtering bleb leaks: indications blindness from retinal deposition of cystine at an earlier and outcomes. Arch Ophthalmol 1999;117:14-9. than expected age. 2. Mardelli PG, Lederer CM Jr, Murray PL, Pastor SA, Hassanein KM. Slit-lamp needle revision of failed filtering blebs using mitomycin C. Ophthalmology 1996;103:1946-55. Case report 3. Greenfield DS, Liebmann JM, Jee J, Ritch R. Late-onset bleb A 5-year-old Asian boy with infantile cystinosis was leaks after glaucoma filtering surgery. Arch Ophthalmol 1998;116:443-7. referred to the regional paediatric team due to 4. Chen PP, Palmberg PF. Needling revision of glaucoma progressive visual failure. At about 2 years of age his drainage device filtering blebs. Ophthalmology visual acuity by Kay pictures was 6/12. Over the 1997;104:1004-10. following 2-3 years his vision deteriorated to 1/60 in the 5. Kosmin AS, Wishart PK. A full-thickness scleral graft for the right and 3/60 in the left eye. Initially his visual failure surgical management of a late filtration bleb leak. Ophthalmic Surg Lasers 1997;28:461-8.