Sometimes a complication of a trabeculectomy surgery is having a thin cystic bleb which leaks. This needs surgical repair and our guest professor Dr Ramesh Ayyala shows us his technique. This patient with a leaky cystic bleb, which is not an uncommon situation seen following trabeculectomy with mitomycin-C (MMC). When the bleb becomes leaky there is increased risk of hypotony maculopathy and more importantly infection which is termed blebitis. Once diagnosed, we should aim to fix it before these complications occur. While several techniques have been described, the one that Prof. Ayyala shows gives the best results which covers the bleb nicely with fresh conjunctiva while maintaining the IOP below 15 . Other techniques like excision of bleb may result in the return of high pressures that leads to another surgery. Covering the bleb with only amniotic membrane leads to recurrent leaks within 3 months in most cases. And covering only with conjunctiva can lead to conjunctival erosion. In his technique, step 1: de-epithelialize the bleb epithelium with gentle dry weck cell sponge followed by draping it with amniotic membrane graft (AMG) followed by conjunctival advancement. The AMG provides the sticky glue to bind the conjunctiva to the underlying cystic bleb. Step 2: During initial conjunctival dissection, it is important to dissect only conjunctiva while leaving the Tenon’s intact as it contains the draining blood vessels from the bleb running posteriorly. Step 3: Make sure the conjunctiva is relaxed with the relaxing incisions in the superior fornix so as to not induce ptosis. This technique routinely gives IOP below 15 mmHg in the majority of patients and rarely do they develop recurrence.
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