Turkiye Klinikleri Journal of Ophthalmology

.: ORIGINAL RESEARCH
Ocular Surface After Trabeculectomy: Association Between Bleb and Dry Eye Disease: Cross Sectional Study
Trabekülektomi Sonrası Oküler Yüzey: Bleb ve Kuru Göz Hastalığı Arasındaki İlişki: Kesitsel Çalışma
İbrahim UZARa , İhsan ÇAKIRa , Gülay YALÇINKAYA ÇAKIRa , Çiğdem ALTANa , Seren PEHLİVANOĞLUa , Tekin YAŞARa
aUniversity of Health Sciences Beyoğlu Eye Training and Research Hospital, Department of Ophthalmology İstanbul, Türkiye
Turkiye Klinikleri J Ophthalmol. 2024;33(4):210-8
doi: 10.5336/ophthal.2024-103210
Article Language: EN
Full Text
ABSTRACT
Objective: To evaluate the frequency of dry eye disease (DED) and the relationship between the morphology of the filtering bleb and ocular surface instability in patients with functional filtering blebs. Material and Methods: Patients who had undergone trabeculectomy and had a functional filtering bleb and healthy individuals were included in the study and control groups, respectively. The bleb morphology, tear break-up time (TBUT), meibomian gland dysfunction, fluorescein corneal staining, Schirmer's test, and results of an ocular symptom questionnaire were evaluated. The coexistence of TBUT<10 seconds and superficial punctate keratitis was considered DED. Results: Thirty-seven eyes with functional filtering blebs and 40 healthy eyes were analyzed. TBUT was significantly lower (p=0.01) and the corneal staining score was significantly higher in the study group (p=0.01). Schirmer's test were similar in both groups (p=0.30). DED was more prevalent in the study group (p=0.02). The study group exhibited higher occurrences of dryness (p=0.007), feeling grittiness (p=0.005), watering and tearing (p=0.04), and itching (p=0.02). The height of bleb and microcystic structure scores were significantly higher in the DED group (p=0.03 and p<0.001, respectively). Microcystic structure in the bleb and height of bleb were positively correlated with the presence of DED (r=0.590, p=0.009 and r=0.355, p=0.03, respectively). Conclusion: DED is more common in eyes with functional filtering bleb following trabeculectomy and is associated with the height of the bleb and microcystic structure. The evaluation of the patients in terms of ocular surface and DED may be more important in eyes with these types of blebs.

Keywords: Bleb morphology; corneal staining; dry eye disease; ocular surface; trabeculectomy
ÖZET
Amaç: Fonksiyonel filtran blebi olan hastalarda kuru göz hastalığı (KGH) sıklığını ve filtran bleb morfolojisi ile oküler yüzey instabilitesi arasındaki ilişkiyi değerlendirmek. Gereç ve Yöntemler: Trabekülektomi geçirmiş ve fonksiyonel filtran blebi olan hastalar ve sağlıklı bireyler sırasıyla çalışma grubuna ve kontrol gruplarına dâhil edildi. Bleb morfolojisi, gözyaşı kırılma zamanı (GKZ), meibomian bez disfonksiyonu, floresein kornea boyama, Schirmer testi ve oküler semptom anketinin sonuçları değerlendirildi. GKZ<10 sn ve yüzeyel punktat keratit birlikteliği KGH olarak kabul edildi. Bulgular: Fonksiyonel filtran blebi olan 37 göz ve 40 sağlıklı göz analiz edildi. GKZ çalışma grubunda anlamlı derecede düşüktü (p=0,01) ve korneal boyanma skoru anlamlı derecede yüksekti (p=0,01). Schirmer testi her iki grupta benzerdi (p=0,30). KGH çalışma grubunda daha yaygındı (p=0,02). Çalışma grubunda kuruluk (p=0,007), kumlu his (p=0,005), sulanma ve yaşarma (p=0,04) ve kaşıntı (p=0,02) daha sık görüldü. Bleb yüksekliği ve mikrokistik yapı skorları KGH grubunda anlamlı derecede yüksekti (sırasıyla p=0,03 ve p<0,001). Blebdeki mikrokistik yapı ve bleb yüksekliği KGH varlığı ile pozitif korelasyon gösterdi (sırasıyla r=0,590, p=0,009 ve r=0,355, p=0,03). Sonuç: KGH, trabekülektomi sonrası fonksiyonel filtran blebi olan gözlerde daha yaygındır ve bleb yüksekliği ve mikrokistik yapı ile ilişkilidir. Bu tip blebleri olan hastaların oküler yüzey problemleri ve KGH açısından değerlendirilmesi önemlidir.

Anahtar Kelimeler: Bleb morfolojisi; korneal boyanma; kuru göz hastalığı; oküler yüzey; trabekülektomi
REFERENCES:
  1. Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo CK, et al. TFOS DEWS II definition and classification report. Ocul Surf. 2017;15(3):276-83. [Crossref]  [PubMed] 
  2. Rouen PA, White ML. Dry eye disease: prevalence, assessment, and management. Home Healthc Now. 2018;36(2):74-83. [Crossref]  [PubMed] 
  3. Miura M, Inomata T, Nakamura M, Sung J, Nagino K, Midorikawa-Inomata A, et al. Prevalence and characteristics of dry eye disease after cataract surgery: a systematic review and meta-analysis. Ophthalmol Ther. 2022;11(4):1309-32. [Crossref]  [PubMed]  [PMC] 
  4. Dohlman TH, Lai EC, Ciralsky JB. Dry eye disease after refractive surgery. Int Ophthalmol Clin. 2016;56(2):101-10. [Crossref]  [PubMed] 
  5. Ji H, Zhu Y, Zhang Y, Li Z, Ge J, Zhuo Y. Dry eye disease in patients with functioning filtering blebs after trabeculectomy. PLoS One. 2016;11(3):e0152696. [Crossref]  [PubMed]  [PMC] 
  6. Neves Mendes CR, Hida RY, Kasahara N. Ocular surface changes in eyes with glaucoma filtering blebs. Curr Eye Res. 2012;37(4):309-11. Erratum in: Curr Eye Res. 2012;37(8):759. [Crossref]  [PubMed] 
  7. Ono T, Yuki K, Ozeki N, Shiba D, Tsubota K. Ocular surface complications after trabeculectomy: incidence, risk factors, time course and prognosis. Ophthalmologica. 2013;230(2):93-9. [Crossref]  [PubMed] 
  8. Koike KJ, Chang PT. Trabeculectomy: a brief history and review of current trends. Int Ophthalmol Clin. 2018;58(3):117-33. [Crossref]  [PubMed] 
  9. Güven Yılmaz S, Değirmenci C, Palamar M, Yağcı A. Evaluation of filtering bleb function after trabeculectomy with mitomycin C using biomicroscopy, anterior segment optical coherence tomography and in vivo confocal microscopy. Turk J Ophthalmol. 2015;45(4):132-7. [Crossref]  [PubMed]  [PMC] 
  10. Budenz DL, Hoffman K, Zacchei A. Glaucoma filtering bleb dysesthesia. Am J Ophthalmol. 2001;131(5):626-30. [Crossref]  [PubMed] 
  11. Shigeeda T, Tomidokoro A, Chen YN, Shirato S, Araie M. Long-term follow-up of initial trabeculectomy with mitomycin C for primary open-angle glaucoma in Japanese patients. J Glaucoma. 2006;15(3):195-9. [Crossref]  [PubMed] 
  12. Lin PY, Tsai SY, Cheng CY, Liu JH, Chou P, Hsu WM. Prevalence of dry eye among an elderly Chinese population in Taiwan: the Shihpai Eye Study. Ophthalmology. 2003;110(6):1096-101. [Crossref]  [PubMed] 
  13. Klink T, Schrey S, Elsesser U, Klink J, Schlunck G, Grehn F. Interobserver variability of the Würzburg bleb classification score. Ophthalmologica. 2008;222(6):408-13. [Crossref]  [PubMed] 
  14. Jie Y, Xu L, Wu YY, Jonas JB. Prevalence of dry eye among adult Chinese in the Beijing Eye Study. Eye (Lond). 2009;23(3):688-93. [Crossref]  [PubMed] 
  15. Rossi GC, Pasinetti GM, Scudeller L, Raimondi M, Lanteri S, Bianchi PE. Risk factors to develop ocular surface disease in treated glaucoma or ocular hypertension patients. Eur J Ophthalmol. 2013;23(3):296-302. [Crossref]  [PubMed] 
  16. Wolffsohn JS, Arita R, Chalmers R, Djalilian A, Dogru M, Dumbleton K, et al. TFOS DEWS II Diagnostic Methodology report. Ocul Surf. 2017;15(3):539-74. [Crossref]  [PubMed] 
  17. Mengher LS, Bron AJ, Tonge SR, Gilbert DJ. Effect of fluorescein instillation on the pre-corneal tear film stability. Curr Eye Res. 1985;4(1):9-12. [Crossref]  [PubMed] 
  18. Su TY, Ho WT, Lu CY, Chang SW, Chiang HK. Correlations among ocular surface temperature difference value, the tear meniscus height, Schirmer's test and fluorescein tear film break up time. Br J Ophthalmol. 2015;99(4):482-7. [Crossref]  [PubMed] 
  19. Inoue K, Okugawa K, Kato S, Inoue Y, Tomita G, Oshika T, et al. Ocular factors relevant to anti-glaucomatous eyedrop-related keratoepitheliopathy. J Glaucoma. 2003;12(6):480-5. [Crossref]  [PubMed] 
  20. Küsbeci T, Öztürk F, Yavaş G, Aktepe F, Ermiş SS, İnan ÜÜ. Topikal travoprost % 0,004 ve bimatoprost % 0,03 kullanımının oküler yüzey üzerine etkisi [The effect of travoprost 0,004% and bimatoprost 0,03% on ocular surface]. Turk J Ophthalmol. 2007;37(5):359-66. [Link] 
  21. Hoskins HD, Kass M. Introduction and classification of the glaucomas. In: Klein EA, ed. Becker-Shaffers Diagnosis and Therapy of the Glaucomas. 6th ed. Baltimore: The CV Mosby Company; 1989. p.1-9.
  22. Cho P, Yap M. Schirmer test. I. A review. Optom Vis Sci. 1993;70(2):152-6. [Crossref]  [PubMed] 
  23. Belmonte C, Acosta MC, Gallar J. Neural basis of sensation in intact and injured corneas. Exp Eye Res. 2004;78(3):513-25. [Crossref]  [PubMed] 
  24. Begley CG, Chalmers RL, Abetz L, Venkataraman K, Mertzanis P, Caffery BA, et al. The relationship between habitual patient-reported symptoms and clinical signs among patients with dry eye of varying severity. Invest Ophthalmol Vis Sci. 2003;44(11):4753-61. [Crossref]  [PubMed] 
  25. Rosenthal P, Borsook D. The corneal pain system. Part I: the missing piece of the dry eye puzzle. Ocul Surf. 2012;10(1):2-14. [Crossref]  [PubMed] 
  26. Lemp MA, Baudouin C, Amrane M, Ismail D, Garrigue JS, Buggage RR. Poor correlation between dry eye disease signs and symptoms in a phase III randomized clinical trial. Invest Ophthalmol Vis Sci. 2011;52(14):3821. [Link] 
  27. Shields MB, Scroggs MW, Sloop CM, Simmons RB. Clinical and histopathologic observations concerning hypotony after trabeculectomy with adjunctive mitomycin C. Am J Ophthalmol. 1993;116(6):673-83. [Crossref]  [PubMed] 
  28. Morita K, Gao Y, Saito Y, Higashide T, Kobayashi A, Ohkubo S, et al. In vivo confocal microscopy and ultrasound biomicroscopy study of filtering blebs after trabeculectomy: limbus-based versus fornix-based conjunctival flaps. J Glaucoma. 2012;21(6):383-91. [Crossref]  [PubMed] 
  29. Francis BA, Du LT, Najafi K, Murthy R, Kurumety U, Rao N, et al. Histopathologic features of conjunctival filtering blebs. Arch Ophthalmol. 2005;123(2):166-70. [Crossref]  [PubMed] 
  30. Kessing SV. Mucous gland system of the conjunctiva. A quantitative normal anatomical study. Acta Ophthalmol (Copenh). 1968:Suppl 95:1+. [PubMed] 
  31. Palmberg P. Surgery for complications. In: Albert DM, ed. Ophthalmic Surgery: Principles and Techniques. Vol 1. London: Blackwell Science; 1999. p.476-91.
  32. Binotti WW, Bayraktutar B, Ozmen MC, Cox SM, Hamrah P. A review of imaging biomarkers of the ocular surface. Eye Contact Lens. 2020;46 Suppl 2(Suppl 2):S84-S105. [Crossref]  [PubMed]  [PMC] 
  33. Uzunosmanoglu E, Mocan MC, Kocabeyoglu S, Karakaya J, Irkec M. Meibomian gland dysfunction in patients receiving long-term glaucoma medications. Cornea. 2016;35(8):1112-6. [Crossref]  [PubMed] 
  34. Kitazawa Y, Kawase K, Matsushita H, Minobe M. Trabeculectomy with mitomycin. A comparative study with fluorouracil. Arch Ophthalmol. 1991;109(12):1693-8. [Crossref]  [PubMed] 
  35. Mohammadi SF, Ashrafi E, Norouzi N, Abdolahinia T, Mir-AbouTalebi M, Jabbarvand M. Effects of mitomycin-C on tear film, corneal biomechanics, and surface irregularity in mild to moderate myopic surface ablation: preliminary results. J Cataract Refract Surg. 2014;40(6):937-42. [Crossref]  [PubMed] 

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