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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
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