JUL 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 33 of 66

July 2013 sues for patients. Bleb elevation in the interpalpebral fissure, especially when the bleb sits upon the ledge of the lower lid margin, can be the source of great discomfort that is surprisingly resistant to lubrication, punctal plugs, NSAIDs, Restasis [cyclosporine, Allergan, Irvine, Calif.], and steroids. "There are many options to alter bleb morphology, and the old adage regarding the number of treatments available versus the likelihood of success comes to mind. In the past, laser and silver nitrate solution were used as options to shrink blebs, but these are not in widespread use now. Blood injection is another option, although more than one treatment may be needed to effect sufficient change. "Delimiting the extent of the bleb to restrict it to the 10 to 2 o'clock area often is quite effective in relieving symptoms and improving appearance while maintaining adequate bleb function. Light cryo— a series of 10-second freezes placed in the interpalpebral fissure with lidocaine jelly for anesthesia—is a simple and often adequate solution. Light cautery, sometimes done in the office with a disposable unit, has also been used successfully. Compression sutures with 9-0 nylon, which are essentially mattress sutures that drape over the bleb from the cornea to the posterior sclera/episclera, work well. In a bleb with only mild elevation, I have found light cryo to be simple, effective, well tolerated, and titratable with limited potential for complications. If the interpalpebral bleb is more elevated and established, I would consider either compression sutures or a vicryl suture line to sclera along the 10 and 2 o'clock meridians to promote subconjunctival fibrosis and limitation of the filtration area." What was done It was clear to me that this patient absolutely needed a functioning filter, and I did not want to risk a successful outcome if at all possible. It was also clear to me that I would probably not get too many "at bats" to get a hit here. After treating aggressively with lubrication, punctal occlusion, etc., what I decided to try was to use mul- tiple Ellman radiofrequency energy applications in the inferior nasal and temporal conjunctiva where there was unwanted conjunctival elevation to create some shrinkage and fibrosis of the tissue. In the area where I wanted the bleb to remain up top, I left the conjunctiva alone. Within a few days the dellen was gone and within a week the temporal/inferior/nasal conjunctival elevation was pretty much gone. I've used this technique on quite a few patients now. The Ellman has many advantages over cautery. It is much easier to control the application and you can create much more shrinkage of tissue without charring and less burning. This can be done if you like without penetrating conjunctiva or causing leakage. Figures 6 and 7 show another case of bleb dysesthesia before and after treatment. In both of these cases there was no change in the IOP. I have used this method or a variation of it now in quite a few cases. Usually the applications are with a bullet-shaped electrode to the surface of the conjunctiva, however in some cases I pass a Tefloncoated needle in which only the tip is active through conjunctiva and apply radiofrequency to the undersurface of the conjunctiva to contract it, but that is a bit more of a tricky maneuver. It can be used effectively though to delineate the bleb more superiorly and cut off the flow to the sides and make a more focal bleb without damaging the bleb itself. I have used this in some cases of overfiltration. In one case where there was extreme elevation of the conjunctiva nasally and a severe progressive dellen I treated very aggressively with the radio surgical probe at the nasal conjunctiva and did a temporary nasal tarsorrhaphy (suture on bolsters) right over that area to provide tamponade and held back on steroids. The conjunctiva stuck down nicely and the patient's pressure remained well controlled. I believe that this is a promising technique for these cases of bleb dysesthesia due to overfiltration. The bleb can be remodeled in the office with relative safety and ease. If this method fails, more aggressive techniques can be considered. EW continued on page 32

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