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Surgical management of glaucoma offers a means of effective disease control. A gel stent that facilitates drainage to the subconjunctival space offers intraocular pressure (IOP) reduction similar to traditional glaucoma filtering surgeries in a less invasive manner. However, like all subconjunctival filtering procedures that result in a bleb, fibrosis can present as a cause of elevated IOP. The following proposed techniques and recommendations for managing elevated IOP due to bleb fibrosis after gel stent implantation are based on the clinical experience of the authors. The goal of this paper is to improve outcomes following gel stent surgery by providing guidance on assessment of bleb function and strategies for bleb enhancement.

This study aimed to design and evaluate a novel trans-bleb device (TBD) for draining aqueous humor trapped within fibrotic blebs following Ahmed glaucoma valve (AGV) implantation in dogs. Two clinically normal, purpose-bred Beagles underwent AGV implantation surgery in one eye. When a bleb was formed with increased intraocular pressure (IOP), the TBD was inserted through a fenestration created in the bleb. IOP measurements, slit-lamp biomicroscopic and ultrasound biomicroscopic (UBM) evaluations were performed during follow-up. Results showed that IOP in the eyes undergoing AGV surgery was significantly lower than in the contralateral normal eye ( P  < .001). After 3 weeks, the IOP increased, and the UBM examination confirmed the presence of a bleb wall and an underlying cavity. After TBD application surgery, a significant decrease in IOP was observed ( P  < .001). Histological findings indicated that the TBD effectively penetrated the fibrotic membrane surrounding the AGV, with observed mild inflammatory cell infiltration, neovascularization, and myofibroblast differentiation, suggesting filtering bleb formation. The TBD may offer a novel approach to address bleb fibrosis-related failure following glaucoma surgery, restoring aqueous humor flow, and thus reducing IOP. Further research is needed to validate its effectiveness, optimize its design, and assess long-term outcomes.

Purpose To identify the risk factors for a recurrence of a bleb-related infection (BRI). Study design Retrospective cohort study. Methods The medical records of all patients diagnosed with BRI at Gifu University Hospital between January 1989 and December 2020 were reviewed. The time when conjunctival hyperemia could not be detected and when the anterior chamber was quiet were defined as the resolution time of the BRI. The primary endpoint was a recurrence of a BRI. Kaplan-Meier estimation and the Cox proportional hazards model were used to determine the risk of a recurrence from the initial onset data of each eye. Bacteriological studies were performed to determine the pathogen causing the BRI. Results There were 108 eyes of 103 patients followed for at least 3 months after the initial BRI. A recurrent bleb infection developed in 21 (19.4%) eyes of 21 patients (13 men, 8 women). Log-rank test at the 10-year follow-up examination revealed that hypotony at the onset of the BRI ( P =0.004), the prophylactic use of topical antibiotics at the onset of the BRI ( P =0.046), and bleb leakage after the resolution of the BRI ( P =0.021) were significantly associated with a BRI recurrence. Cox proportional hazards model showed that ocular hypotony at the onset of the BRI (unadjusted, P =0.007; adjusted for bleb leakage, P =0.015) and bleb leakage after the resolution of the BRI (unadjusted, P =0.027; adjusted for hypotony, P =0.024) were significantly associated with a BRI recurrence. Other factors were not significantly associated with the recurrence of a BRI. Conclusion We recommend close observations when a bleb leakage is detected after the BRI has resolved.

Purpose To distinguish functioning from failed filtration blebs (FBs) implementing a deep learning (DL) model on slit-lamp images. Methods Retrospective, cross-sectional, multicenter study for development and validation of an artificial intelligence classification algorithm. The dataset consisted of 119 post-trabeculectomy FB images of whom we were aware of the surgical outcome. The ground truth labels were annotated and images splitted into three outcome classes: complete (C) or qualified success (Q), and failure (F). Images were prepared implementing various data cleaning and data transformations techniques. A set of DL models were trained using different ResNet architectures as the backbone. Transfer and ensemble learning were then applied to obtain a final combined model. Accuracy, sensitivity, specificity, area under the ROC curve, and area under the precision-recall curve were calculated to evaluate the final model. Kappa coefficient and P value on the accuracy measure were used to prove the statistical significance level. Results The DL approach reached good results in unraveling FB functionality. Overall, the model accuracy reached a score of 74%, with a sensitivity of 74% and a specificity of 87%. The area under the ROC curve was 0.8, whereas the area under the precision-recall curve was 0.74. The P value was equal to 0.00307, and the Kappa coefficient was 0.58. Conclusions All considered metrics supported that the final DL model was able to discriminate functioning from failed FBs, with good accuracy. This approach could support clinicians in the patients’ management after glaucoma surgery in absence of adjunctive clinical data.

PurposeTo evaluate the long-term outcome of ‘bleb-sparing epithelial exchange’ surgery for dysfunctional filtering blebs in paediatric and adult eyes.MethodsPatients who had undergone bleb revision ≥ 5 years back and were on regular follow-up were included. Age, ocular diagnosis, details of primary filtering surgery including mitomycin-C (MMC) usage, indication and year of bleb revision were recorded. After bleb revision, the mean intraocular pressure (IOP), glaucoma medications and best corrected visual acuity (BCVA) up to 5 years were noted. On last review, clinical details, bleb characteristics and swept source anterior segment tomographic (SSOCT) assessment of bleb were recorded. Comparative analysis of paediatric and adult eyes was performed.Main outcome measuresChange in IOP and BCVA. ‘Complete success’ was defined as IOP ≥ 6 to ≤ 18mmHg without use of any topical glaucoma medications and ‘Qualified success’ when ≥ 1 topical glaucoma medication(s) was required.ResultsA total of 51 eyes of 51 consecutive patients were studied, among which 22 were children. The mean duration between filtering surgery and bleb revision was 4.54 ± 1.53 years in paediatric and 6.48 ± 3.5 years in the adult group, p = 0.04. Children underwent trabeculotomy + trabeculectomy with 0.04% MMC, while adults underwent trabeculectomy with 0.02% MMC. The mean pre-revision IOP was 6.38 ± 2.80 and 6.51 ± 2.78 mmHg in the paediatric and adult group respectively, p = 0.86. At 3 months post-revision, it increased to 11.81 ± 3.48 and 12.75 ± 3.52 mmHg respectively (p < 0.001). At final review, mean IOP of paediatric group was 10.90 ± 2.59 and adult group was 11.86 ± 2.66 mmHg, p = 0.20. At 5 years, complete success was 68.18% and 72.41%, and qualified success was 31.87% and 27.59% in the former and latter group respectively, p = 0.49. No failures were seen. Kaplan-Meier probability at 5 years for IOP target ≤ 18, ≤ 15 and ≤ 12 in children was 95.45%, 63.64% and 50% and in adults 93.10%, 65.52% and 41.38% respectively. BCVA improved up to 1 year in paediatric group, with continued improvement in adults up to 3 years. SSOCT measured bleb height was 0.88 ± 0.37 and 1.32 ± 0.49mm in children versus adults (p = 0.006) and wall thickness, 0.35 ± 0.22 and 0.58 ± 0.24mm respectively, p = 0.008.ConclusionBleb-sparing epithelial exchange is an equally safe and effective technique with good long-term success in both paediatric and adult dysfunctional blebs.

Two patients with history of trabeculectomy presented with uncontrolled intraocular pressure (IOP) postoperatively. The first patient had a flat and vasularized bleb 10 weeks after the surgery, and the second subject developed encapsulated bleb 3 months postoperatively. Both patients were taken to the operating room and intraoperative optical coherence tomography (OCT) guided bleb needling was performed to restore aqueous egress into the subconjunctival space. Postoperatively, IOP of the operated eyes ranged 14-18 mmHg at week 6 and month 3. None of the eyes had any intraoperative or postoperative complications. This novel application of the intraoperative OCT for bleb needling facilitates precision surgery under direct visualization and reduces the risk of complications.

The nuclear lamina is an intermediate filament meshwork adjacent to the inner nuclear membrane (INM) that plays a critical role in maintaining nuclear shape and regulating gene expression through chromatin interactions. Studies have demonstrated that A- and B-type lamins, the filamentous proteins that make up the nuclear lamina, form independent but interacting networks. However, whether these lamin subtypes exhibit a distinct spatial organization or whether their organization has any functional consequences is unknown. Using stochastic optical reconstruction microscopy (STORM) our studies reveal that lamin B1 and lamin A/C form concentric but overlapping networks, with lamin B1 forming the outer concentric ring located adjacent to the INM. The more peripheral localization of lamin B1 is mediated by its carboxyl-terminal farnesyl group. Lamin B1 localization is also curvature- and strain-dependent, while the localization of lamin A/C is not. We also show that lamin B1’s outer-facing localization stabilizes nuclear shape by restraining outward protrusions of the lamin A/C network. These two findings, that lamin B1 forms an outer concentric ring and that its localization is energy-dependent, are significant as they suggest a distinct model for the nuclear lamina—one that is able to predict its behavior and clarifies the distinct roles of individual nuclear lamin proteins and the consequences of their perturbation.

Purpose The success of XEN Gel Stent (XEN) and Preserflo MicroShunt (Preserflo) implantation depends mainly on the development of bleb fibrosis. This study aimed to describe the histological findings of bleb fibrosis after XEN and Preserflo surgery. Methods This retrospective study included patients with different types of glaucoma who underwent revision surgery after XEN or Preserflo implantation. The available clinical information and histological samples of removed fibrotic tissue were analyzed. Results Thirty-six patients were included. Revision surgery was performed at a median of 195 (range = 31–1264) days after primary surgery. The mean intraocular pressure changed from 29.1 (± 10.3) mmHg at baseline to 18.3 (± 8.7) mmHg (− 37%; p  < 0.0001) and 16.2 (± 4.2) mmHg (− 45%; p  < 0.0001) after 6 and 12 months, respectively. Histological analysis revealed an increase in activated fibroblasts and macrophages in all specimens and a parallel orientation of fibroblasts in a minor part of the probe in 60% of the specimens. No pronounced inflammatory reaction in the form of lymphocytic or granulocytic infiltration was observed. The comparison of specimens from uveitic glaucoma and primary open-angle glaucoma patients revealed no significant differences. Conclusions The histological analysis of fibrotic blebs from the XEN and Preserflo implants did not show any pronounced immune or foreign-body reaction and revealed a similar histological pattern of failed blebs after trabeculectomy.

Purpose To track changes in the morphology of hyperemic blebs in eyes undergone trabeculectomy with mitomycin C 0.02% (MMC) after triamcinolone acetonide (TA) injection. Methods A total of 30 eyes of 30 patients with localized or diffuse hyperemia after trabeculectomy with MMC were enrolled in this prospective interventional case series. Two milligrams of TA were injected at the site of maximal injection. Bleb morphology was graded using Indiana Bleb Appearance Grading Scale (IBAGS), and the Moorfields Bleb Grading System (MBGS) 1 week, 1 month, 3 months, 6 months, and 1 year after injection. Failure was defined as intraocular pressure (IOP) more than predefined target IOP for each eye, need for an additional surgical procedure, IOP less than 6 mmHg, and loss of Light Perception (LP) vision. Results A total of 27 patients completed a 1-year follow-up period and were included in the final analysis. The mean time interval from trabeculectomy to injection of TA was 5.98 ± 2.57 weeks. The bleb height and vascularity in the IBAGS system decreased significantly after the intervention ( p  < 0.05), with an increase in bleb extension ( p  = 0.006). Using MBGS, the bleb area did not change significantly following TA injection ( p  = 0.056) but its height and vascularity significantly decreased in both central and peripheral areas and the surrounding conjunctiva ( p  = 0.032). The development of a mature cataract was the only complication that could be attributed to TA injection. Conclusion Injection of TA in hyperemic failing blebs improves bleb morphology by decreasing vascularity and height while increasing the extent with an acceptable safety profile.

Purpose We report a new bleb lining technique with Tenon’s patch graft for late-onset leakage from large ischemic bleb with severe conjunctival scarring and impractical conjunctival mobilization after trabeculectomy. Study design Retrospective case series. Methods This study includes six cases with late-onset leakage from large ischemic blebs. Small Tenon’s tissue is dissected from the incisional site or a previously made inferior incision for Tenon’s anesthesia. A passage is created from the small incision to the leaking area of the bleb using a bleb knife or micro scissors. The Tenon’s tissue, stained with indocyanine green, is inserted under the ischemic bleb’s conjunctiva. A transconjunctival compression suture is placed across the leaking point to fix the Tenon patch graft positionally. Results In all cases, bleb leakage was completely sealed immediately after surgery. In 4 cases, the closure of the bleb leakage was maintained after surgery during the follow-up period (6–17 months). In two cases, bleb leakage recurred from different leaking points 7 or 9.5 months after the surgery; however, repeated tenon’s patch lining revisions successfully closed these leakages. The intraocular pressure at the final visit was 5–13 mmHg (median, 10 mmHg) without glaucoma medication or additional glaucoma surgery. Conclusion Tenon’s patch-lining technique is a promising method for bleb leakage with large ischemic bleb and impractical conjunctival mobilization.