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Human pericardium graft in the management of bleb's complication performed in childhood: a case report
© Papaconstantinou et al; licensee BioMed Central Ltd. 2011
Received: 5 May 2011
Accepted: 20 September 2011
Published: 20 September 2011
To report a case with hypotony due to late leakage of the filtering bleb performed during childhood and treated surgically using human pericardium graft.
A man with hypotony related to bleb's leakage in his right eye was presented. During his childhood trabeculectomy was performed to manage ocular hypertension due to pediatric glaucoma. Biomicroscopy revealed choroidal tissue incarcerated in the sclerectomy under the conjunctiva. Bleb revision was performed. Human pericardium graft was used to cover the sclerectomy and a new bleb with controlled outflow was created. The intraocular pressure (IOP) and Seidel test represent the main outcomes. Intraoperative and postoperative complications were recorded. Fifteen days postoperatively the IOP was of 7 mmHg and the bleb seemed to filter properly. Five months later the IOP was 9 mmHg and no complications were noticed. During the follow up time, the Seidel test was negative.
We used human pericardium graft with no complications in a case of bleb leakage performed for pediatric glaucoma.
Congenital glaucoma is the major cause of blindness in children, despite its low incidence (1:10,000 births) . Several surgical procedures have been advocated to restore the aqueous humor pathway and to lower the elevated intraocular pressure (IOP) .
Trabeculectomy has been proposed as a valuable procedure, to facilitate the outflow of aqueous humor, but is not very effective in congenital glaucoma. This feature has been attributed to the inherent tendency that young tissues have toward excessive scarring . The intraoperative use of adjunctive antimetabolites, like 5-fluorouracil (5FU) and mitomycin C (MMC), has been proposed to enhance the final outcomes of trabeculectomy, in pediatric glaucoma patients .
Antimetabolites, especially MMC, increment the risk of vision-threatening complications such as cystic and blebs leakage, ocular hypotony, maculopathies, choroidal hemorrhage and infections like blebities and endophthalmities. Late bleb leakage occurs more often in thin, avascular blebs and correlates with full thickness surgical procedures and use of antimetabolites .
We report our surgical approach to control the hypotony in a case with leaking filtering bleb, which occurred years after the trabeculectomy.
We decided to correct surgically the filtering bleb and the correlated hypotony, following the guidelines of the declaration of Helsinki and obtaining approve by the Ethics Committee of G.N.A. "G. Geminnatas" University Athens hospital. A 7-0 silk corneal traction suture was used to fixate and infraduct the globe, increasing exposure of the surgical site. A fornix-based conjunctival flap on the superotemporal side of the right eye was performed and the conjunctiva and tenon's capsule were separated from the sclera. Once the sclera was uncovered, we confirmed the absence of the scleral flap and the presence of choroidal tissue incarcerated in the sclerectomy. Human pericardium graft (sterile human tissue allograft, New World Medical, Rancho Cucamonga, California, USA) was used to cover the sclerectomy. Four 10-0 nylon sutures were placed to the graft in its four angles, over the sclerectomy and 8-0 Vicryl sutures were used to suture the conjunctiva above the graft. A new filtering bleb was created, with human pericardium graft, instead of a scleral flap, covering the sclerectomy. No antimetabolites were used intraoperatively.
Fifteen days postoperatively the BCVA was of light perception, the intraocular pressure (IOP) was of 7 mmHg, the cornea had Descemet membrane folds and the anterior chamber was narrow. The bleb filtered properly, the pericardium graft could be seen under the conjunctiva and the Seidel test was negative.
Late bleb leakage (LBL) occurs months to years after glaucoma filtering surgery (GFS), with an incidence of about 1 to 10% .
Our patient probably underwent a full thickness trabeculectomy, without a scleral flap protection . We don't know if antifibrotic agents were used during or after surgery, and also if the scleral flap was performed as usual and has been melted or became inadequate through years. We decided to use human pericardium graft sutured over the sclerectomy, as a substitute of the missing scleral tissue. A new bleb, covered with conjunctiva, was easily performed with no complications. The use of human pericardium over donor scleral graft presents several advantages, because it is available commercially, has a long shelf life and is very easy to handle intraoperatively.
We have not found references concerning the use of human pericardium graft for the repair of late onset leakage of a bleb performed for pediatric glaucoma.
This method does not require a special learning curve and it creates a new system of controlled humor aqueous' outflow.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
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