Management of blebitis in the United Kingdom: a survey: Table 1

A Review on Pathogens and Necessary Diagnostic Work for Bleb-Related Infections (BRIs)

At the present time, as newer techniques and minimally invasive procedures gain popularity among anterior segment surgeons for regulating intraocular pressure, trabeculectomy still has a leading role in glaucoma surgery. Trabeculectomy retains a highly successful and safe profile; however, one of the major complications includes bleb-related infections (BRIs). To date, the most common pathogens remain Gram-positive cocci, but the list of pathogens that have been identified in the literature includes more than 100 microorganisms. Because antibiotic use is more widespread than ever before and our ability to identify pathogens has improved, the pathogen spectrum will broaden in the future and more pathogens causing BRIs will be described as atypical presentations. The scope of this review was to identify all pathogens that have been described to cause bleb-related infections to date, as well as focus on the risk factors, clinical presentation, and various available diagnostic tools used for an appropriate diagnostic workup.

Efficacy of predetermined therapeutic measures against bleb-related infection in the Collaborative Bleb-related Infection Incidence and Treatment Study

PURPOSE

To report the efficacy of the predetermined treatment protocol of the Collaborative Bleb-related Infection Incidence and Treatment Study (CBIITS) for bleb-related infection (BRI) patients.

METHODS

A prospective, observational cohort study was conducted at 34 clinical centres in Japan. Nineteen eyes from 19 patients that developed BRI were treated using the CBIITS protocol at 34 clinical centres. The visual acuity (VA) and intraocular pressure (IOP) were monitored for 6 and 12 months after treatment with the predetermined protocol.

RESULTS

The logMAR was 0.623 ± 0.748 (mean ± standard deviation) before the infection developed. It was 1.054 ± 1.156 and 0.950 ± 1.168 at 6 months and 12 months post-infection, respectively. However, in subgroup analyses, there was no significant decrease in post-infection logMAR in stages I and II. In contrast, decimal VA was decreased ≥2 lines in all four cases in stage III. The IOP did not change after infection. It was 10.2 ± 5.0 mmHg (range, 3-22 mmHg) before the infection developed, and 12.9 ± 5.2 mmHg (5-24 mmHg) and 10.7 ± 4.7 mmHg (3-18 mmHg) at 6 months and 12 months after infection, respectively.

CONCLUSION

Because of the small number of BRI patients, the superiority of the treatment was not definitively determined. However, VA was almost maintained in stages I and II, and the IOP did not change after infection. Although further study is necessary, the treatment protocol shown in the study might be a valuable treatment regime.

Bleb-related infection revisited: a literature review

Bleb-related infection (BRI) is one of the serious complications of glaucoma filtering surgery. This literature review is aimed at the evaluation of recent studies related to BRI. The review presented and discussed risk factors, and clinical and laboratory diagnosis emphasizing advances in diagnostic techniques to detect and distinguish the disease as well as to initiate immediate intensive antibacterial treatment. Clinical features of recognized prognostic factors of visual outcome were also presented. The studies showed that the prognosis of blebitis is usually good, unless infection has progressed to endophthalmitis that would signify a poorer prognosis. Despite prompt and intensive treatment of patients with bleb-related endophthalmitis, the outcomes remain unsatisfactory especially with virulent organisms and low initial visual acuity. It has been recommended that early detection and treatment of risk factors and thorough patient education are indispensable in ensuring best prognosis in post-trabeculectomy patients.

Nocardia exalbida blebitis: a case report

PURPOSE

To report the first documented case of Nocardia exalbida blebitis.

METHODS

A 57-year-old immunocompetent African American man with a long-standing history of open-angle glaucoma in both eyes treated with trabeculectomy presented with a diffusely hyperemic, thin, cystic, leaky bleb with no discharge in his left eye. The patient underwent bleb revision using an amniotic membrane patch graft followed by 1 month of antibiotics. He presented second time with an inflamed eye and brisk leakage and underwent a second bleb revision. His cultures remained negative. Two months after this second surgery, an anterior staphyloma had formed within the bleb area, and visible leakage of purulent material and a dense hypopyon was noted. Gram stain of the material showed rare long-branching rods. The material was sent to an outside laboratory for culture and identification.

RESULTS

All 6 cultures were positive for N. abscessus complex and N. exalbida. The patient underwent 6 months of Bactrim therapy with topical sulfonamide and amikacin, leading to the disappearance of the hypopyon and an inflammation-free eye.

CONCLUSIONS

N. exalbida is a newly identified Nocardia species that must be considered as a possible infectious agent in immunocompetent patients with blebitis refractive to initial topical antibiotic therapy. Delay in diagnosis and initiation of appropriate antibiotic regimen can result in an aggressive inflammatory process and vision loss.

OLOGEN(®) implant in the management of glaucoma in an unusual case of Axenfeld-Rieger syndrome

We report an unusual case of Axenfeld–Rieger Syndrome with secondary glaucoma managed with Ologen^® implant. A 35-year-old male presented with complaints of decreased vision in both eyes of 22 years duration. His best corrected visual acuity (BCVA) was no perception of light in right eye and 20/30 in left eye. Gonioscopy revealed anterior insertion of iris into trabecular meshwork, prominent iris processes and broad-based synechiae with prominent Schwalbe's line along the angle circumference with cord-like structures taking its origin at the level of Schwalbe's line in both eyes. Fundus examination revealed total glaucomatous optic atrophy in right eye with 0.9:1 cup disc ratio with bipolar notch in left eye. Humphrey visual field analysis showed superior and inferior arcuate scotoma in left eye. Intraocular pressure measured by Goldman applanation tonometry was 30 mmHg and 26 mmHg in right and left eye, respectively. After an unsuccessful medical management, he underwent trabeculectomy with Ologen^® implant under local anesthesia in his left eye. Postoperatively, at the end of one year, intraocular pressure (IOP) in his left eye was controlled without medication. This case highlights the management of secondary angle closure glaucoma in Axenfeld–Rieger syndrome with Ologen^® implant.

Recurrent endophthalmitis after trabeculectomy for glaucoma: importance of timely filtering bleb coverage for the conjunctiva

Purpose

To report the occurrence of endophthalmitis after trabeculectomy for glaucoma that was treated by vitrectomy without bleb closure and recurred 3 times after an initial clinically inapparent period of about 2 years.

Methods

Interventional case report and short review of the pertinent literature.

Results

A 73-year-old Caucasian female underwent trabeculectomy (without mitomycin) for glaucoma. Four years after the trabeculectomy, an endophthalmitis with Staphylococcus epidermidis as the causative organism occurred and was treated with a pars plana vitrectomy (20-gauge) and a combined antibiotic and anti-inflammatory drug regimen. The bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus. As the filtering bleb healed nicely and the filtering function was restored, the filtering bleb was left as it was, and best-corrected visual acuity initially recovered to 0.8. After 22 months, the endophthalmitis recurred, this time with Enterococcus faecalis as the causative organism. Its treatment required a total of four further vitrectomies (23-gauge), each accompanied by the same antibiotic and anti-inflammatory drug regimen that had been applied previously. However, the visual acuity could not be preserved, and the eye is blind with defective light projection.

Conclusions

The literature suggests an aggressive surgical approach to endophthalmitis, and the present case report confirms this. Since the visual prognosis of eyes after endophthalmitis is poor, the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis rather than address glaucoma symptoms and therefore include safe bleb leak coverage.