Safe Excision of a Large Overhanging Cystic Bleb Following Autologous Blood Injection and Compression Suture
A 64-year-old man with history of chronic angle closure glaucoma underwent right eye trabeculectomy with mitomycin C 4 years prior, followed by phacoemulsification with intraocular lens implant 2 years prior, presented with a 6-month history of a foreign body sensation, epiphora, and blurring. Previous right eye best corrected visual acuity was 20 / 30 after cataract surgery and was reduced to 20 / 80 at presentation. Goldman applanation intraocular pressure (IOP) was 8 mmHg. Slit-lamp examination revealed a large, superior overhanging cystic bleb encroaching onto the corneal surface (). Ultrasound biomicroscopy revealed multiple loculations within the bleb (). The septa between the loculated compartments within the bleb appeared thin and a high risk of injury was anticipated with simple partial excision of the overhanging portion.\nIndocyanine green (ICG) 0.25% (25 mg dissolved in 1 mL of aqueous solution, then into 9 mL of basic salt solution) was injected into the overhanging portion of the cystic bleb using a 30-guage needle. The ICG remained predominantly in the overhanging portion and did not extend to the superior portion of the bleb. A tourniquet was placed around an arm by an assistant and 1 mL of blood was withdrawn from the antecubital vein using a 5 mL syringe with a sterile 25-gauge needle. The surgeon held a 1 mL syringe with another 30-gauge needle and withdrew blood from the assistant's syringe. Autologous blood was gently injected into the overhanging portion of the bleb. An 8-0 Vicryl stitch was placed over the horizontal boundary between the overhanging and original portions of the bleb with the spatulated needles passing through partial-thickness of cornea just anterior to the limbus on both sides adjacent to the overhanging bleb ().\nBlood remained in the overhanging portion of the bleb and no hyphema was observed in the immediate post-operative period. The IOP was maintained in the low teens and the overhanging portion slightly reduced in size and appeared more firm, due to fibrosis, over time. The patient deferred a second operation until 6 weeks later, and partial excision of the overhanging portion of the bleb was performed. Injection of ICG was attempted, but failed as the overhanging portion of the bleb was very firm due to fibrosis. The anterior border of the bleb was elevated from the cornea with a Took's knife, followed by excision of the overhanging portion with Wescott scissors. The compression stitch was removed and no leak was evident from the edge. The patient's best corrected visual acuity returned to 20 / 40 at 3-month follow-up (). IOP was maintained in the low teens, and the bleb remained well situated without exuberance throughout 9 months of follow-up.