Bleb Needling for Reviving a Failed Filter

Restoring function while preserving future surgical options.

Oluwatosin Smith, MD, and Matthew E. Emanuel, MD

Glaucoma Today

Key Takeaways Bleb needling is a safe, repeatable, and highly effective method for restoring function after the failure of traditional subconjunctival filtration surgery, including trabeculectomy and Ex-Press shunt placement. A careful assessment of bleb morphology, the thoughtful selection of surgical approach, the appropriate use of antifibrotic and antiinflammatory adjuncts, and meticulous postoperative management can produce durable reductions in IOP while delaying or avoiding the implantation of a glaucoma drainage device. Before proceeding to additional glaucoma surgery, bleb needling merits consideration whenever a previously functioning filtration procedure can be salvaged. Bleb needling, or revision, is an age-old technique for restoring function when subconjunctival filtration surgery fails. A colleague once jokingly remarked, “Why don’t we just perform primary trabeculectomies, let them fail, and then needle them, since the outcomes after needling seem better than the primary surgery?” Although said in jest, this comment highlights that bleb needling is an effective method of revitalizing a previously functional filtration procedure while preserving future surgical options. For that reason, bleb needling has become our preferred intervention before proceeding to the implantation of a glaucoma drainage device. This article focuses on bleb needling after traditional subconjunctival filtration procedures, including trabeculectomy and Ex-Press glaucoma filtration device (Alcon) surgery. FACTORS INFLUENCING SUCCESS Successful bleb needling depends on several important considerations: Bleb appearance and configuration; Choice of needling technique (ab interno vs ab externo); Use of antifibrotic agents and corticosteroids intra- and postoperatively; Use of a spacer such as an OVD; Selection of the appropriate setting (slit lamp vs OR); and Postoperative management and patient expectations. How much time has passed since the original filtration surgery may also influence outcomes. The biology of wound healing changes over time.

Metabolic Syndrome, GLP-1 Use, and NAION

This patient encounter supports a growing body of research that establishes a correlation among the three.

Jonathan Hamilton, OD, Rawan Abumohsen, OD

Modern Optometry

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