Main Article Content
Purpose: To evaluate the resultsof bleb needling revision with adjunctive 5-fluorouracil (5-FU) in chronic filtering bleb failure over 6 months post-trabeculectomy.
Method: A prospective study in failed trabeculectomyseen in a glaucoma clinic between November 2017 andApril 2019 were treated with bleb needling revision with 5-FU injection by one glaucoma specialist and same technique. Chronic filtering bleb failure was defined as inadequately lowered intraocular pressure (IOP)less than 21 mmHg with anti-glaucoma medication or more than 21 mmHg with or without anti-glaucoma medication over 6 months post-trabeculectomy as well as presence of a bleb that was encysted, fibrosed or flat.A 27 gauge needle was used to achieve multiple punctureof subconjunctival fibrosis or encystment, proceeding if necessaryto attempted elevation of the scleral flap. In all cases, 0.1 ml of 50 mg/ml of 5-FU was then injected subconjunctivally superiorto the re-formed bleb, and topical prednisolone acetate and moxifloxacin were prescribed. Success was definedas target IOP achieved and maintained less than 21 mmHg without anti-glaucoma medication at 12 months after first needling. Patients were followed up and re-needled asrequired.
Results: Needling was attempted on 51 eyes of 51 consecutive patients (30 eyes of POAG, 18 eyes of PACG and 3 eyes of secondary glaucoma). The mean number of needling was 1.88 (range 1-10). Needling had been successful in 41 (80.4 %) eyes. The average pre-needling IOP was 24.8 ± 12.6 mmHg and the average post needling IOP was 13.5 ± 7.4 mmHg (p < 0.001) at 12 months after first needling. The mean number of medications pre-needling was 2.6 ± 1.4 and post-needing was 0.3± 0.5 (p < 0.001). The mean time since the trabeculectomy was 68 months (range 6- 120 months). Prognostic factors for failure of needling revision were a pre- needling IOP > 25 mmHg (HR =3.1, p= 0.0003), needling revision ≥ 3 times (HR = 2.6, p = 0.0012) and history of repeated filtration surgery before performed this procedure (HR = 1.8, p = 0.011). Ten eyes (19.6 %) did not respond to needling; 6 eyes of POAG, 3 eyes of PACG and and 1 eye of secondary glaucoma which required revised trabeculectomy, glaucoma drainage device implantation and anti-glaucoma medication. Three eyes had complications; 2 hyphema and 1 hypotony and no other procedures were required.
Conclusion: Late bleb needling revision with 5-FU injection is still an effective and lasting treatment for the majority of failed trabeculectomy and avoid further surgery included Thai patients. More than one needling is frequently necessary to achieve target IOP. The procedure is relatively safe, with a short operating time and is minimally invasive with less complications.
Conflicts of interest: The author report no conflicts of interest
Key Words: 5-fluorouracil, needling revision, trabeculectomy bleb
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
1. De Fendi LI, Arruda GV, Scott IU, Paula JS. Mitomycin C versus 5-fluorouracil as an adjunctive treatment for trabeculectomy: a meta-analysis of randomized clinical trials. Clin Experiment Ophthalmol 2013;41(8):798-806.
2. Suzuki R, Dickens CJ, Iwach AI, et al. Long-term follow-up of initially successful trabeculectomy with 5-fluorouracil injections. Ophthalmology.2002; 109: 1921–1924.
3. HusainR,ClarkeJC,SeahSK,KhawPT. A review of trabeculectomy in East Asian people-the influence of race. 2005;19(3):243-252
4. AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS):9. Comparison of glaucoma outcomes in black and white patients within treatment groups. 2001;132(3):311-320
5. Suzuki R, Susanna-Jr R. Early transconjunctival needling revision with 5-fluorouracil versus medical treatment in encapsulated blebs: a 12-month prospective study. Clinics. 2013;68(10):1376-1379.
6. The Flurouracil Filtering Surgery Study Group. Fluorouracil Filtering Surgery Study one-year follow-up. Am J Ophthalmol.1989;108:625–635.
7. Kapasai MS, Bert CM. The Efficacy of 5-Fluorouracil Bleb Needling Performed 1 Year or More Posttrabeculectomy: a retrospecive study. J Glaucoma 2009; 18(2):144-148
8. Ewing RH, Stamper RL. Needle revision with and without 5-fluorouracil for the treatment of failed filtering blebs. 1990;110(3): 254-259.
9. Tatham A,Sarodia U,Karwatowski W. 5-Fluorouracil augmented needle revision of trabeculectomy:does the location of outflow resistance make a difference? J Glaucoma 2013;22(6):463-467.
10. Ung CT, VonLany H,Claridge KG. Late bleb needling. Br J Ophthalmol 2003;87(11):1430-1431.
11. Makornwattana M. Efficacy and Safety of Multiple Needle Revisions and 5-FU Injections in Over 14-month.Thammasat Thai Journal of Ophthalmology.2009;4:23-29.
12. Prutthipongsit A, Kochakrai D. Outcome of needle revision with subconjunctival 5-Fluoruracil in filtration blebs. EyeSEA 2019;14(1): 50-57.
13. Fagerli M, Kjell TL, Tor E. Needling revision of failed filtering blebs after trabeculectomy: a retrospective study. Acta Ophthalmol Scand. 2003;81:577–582.
14. Broadway DC, Bloom PA, Bunce C, Thiagarajan M, Khaw PT. Needle revision of failing and failed trabeculectomy blebs with adjunctive 5-fluorouracil: survival analysis. Ophthalmology 2004;111(4):665-673.
15. Pasternack JJ, Wand M, Shields MB, et al. Needle revision of failed filtering blebs using 5-Fluorouracil and a combined abexterno and ab-interno approach. J Glaucoma. 2005;14:47–51.
16. Rotchford AP, King AJ. Needling revision of trabeculectomies bleb morphology and long-term survival. Ophthalmology 2008;115:1148. e4–53.e4.
17. Zheng L, Arvind H, Wechsler D. Outcomes: Trabeculectomy Bleb Needle Revision With 5-Fluorouracil. J Glaucoma. 2016 Mar;25(3):317-23.
18. Chang SH, Hou CH. Needling revision with subconjunctival 5-fluorouracil in failing filtering blebs. Chang Gung Med J 2002;25: 97–103.
19. Dong H Shin, Yong Y Kim, Savita Y Ginde, Paul H Kim, Anup K Khatana. Risk Factors for Failure of 5-Fluorouracil Needling Revision for Failed Conjunctival Filtration Blebs. Am J Ophthalmol 2001;132:875-880.
20. Khaw PT, Sherwood MB, MacKay SL, Rossi MJ, Schultz G. Five-minute treatments with fluorouracil, floxuridine, and mitomycin have long-term effects on human Tenon’s capsule fibroblasts. Arch Ophthalmol 1992;110:1150–1154.
21. Tsai AS, Boey PY, Htoon HM, Wong TT. Bleb needling outcomes for failed trabeculectomy blebs in Asian eyes: a 2-year follow up. Inj J Ophthalmol2015;8(4): 748-753.
22. Hawkins AS, Flanagan JK, Brown SV. Predictors for success of needle revision of failing filtration blebs. Ophthalmology 2002;109:781–5.
23. Wong MH, Husain R, Ang BC, Gazzard G, Foster PJ, Htoon HM, Wong TT, Oen FT, Khaw PT, Seah SK, Aung T. The Singapore 5-fluorouraciltrial: intraocular pressure outcomes at 8 years. Ophthalmology 2013;120(6):1127-1134.
24. YS Lee, SC Wu, HJ Tseng, WC Wu, SHL Chang. The relationship ogf bleb morphology and the outcome of needle revision with 5-fluorouracil in failing bleb. Medicine (2016) 95:36(e4546).
25. Mercieca K, Drury B, Bhargava A, et al. Br J Ophthalmol 2018;102:1244–1247.