Blebitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Overview

Blebitis is the inflammation of the ocular bleb as a result of bacterial infection. It is a possible complication of a trabeculectomy performed to treat glaucoma. The causative pathogens are usually Staphylococcus or Streptococcus bacteria. Trabulectomy creates a point of possible infiltration in the bleb; the prolonged use of anti-metabolites following trabeculectomy increases the risk of bleb infection via cyst formation, epithelial wall thinning and erosion, and goblet cell depletion and decreased mucin production. Membrane deterioration, in conjunction with an inferior location for the bleb, creates a flow pathway for bacterial infiltration through the bleb's aqueous humor. Symptoms of blebitis include ocular pain, photophobia and loss of vision, intraocular pressure, and fluid discharge. Physical examination may reveal erythema and hyperemia of the affected eye, as well as thinning and whitening of the bleb. The presence of maculopathic purulent infiltrate can also be found upon physical exam. The mainstays of therapy for blebitis are fortified topical antimicrobial and antibacterial agents, as well as topical corticosteroids. With treatment, the prognosis for blebitis is good. Without treatment, blebitis can result in bleb-related endophthalmitis, leading to a much worse prognosis, including permanent vision loss and death. Blebitis is very rare; the incidence in the United States was estimated to be 550 per 100,000 individuals (.55%) from 2007-2011.

Historical Perspective

Blebitis was officially identified by Dr. R.H. Brown in 1994 to classify bleb-infection not associated with the vitreous.[1]

Classification

There is no diagnostic classification schema for blebitis. However, blebitis is considered Stage I of the bleb-related infection classification system.[2][3][4][5]

Bleb-related Infection Classification

Stage Description
Stage I Blebitis - infection confined to the bleb itself
Stage II Bleb-related endophthalmitis mainly involving the anterior chamber
Stage IIIa Bleb-related endophthalmitis with mild vitreous involvement
Stage IIIb Bleb-related endophthalmitis with marked vitreous involvement

Pathophysiology

Pathogenesis

The pathogenesis of blebitis is characterized by the infiltration of staphylococcus and streptococcus bacteria into the bleb following trabeculectomy.[6] The removal of the trabecula and adjacent structures creates a point of infiltration for pathogenic bacteria.[7] The prolonged use of anti-metabolites following trabeculectomy increases the risk of bleb infection. Anti-metabolite drug use results in epithelial thinning, which heightens the risk of infiltration.[8][9].

Additional pathogenic factors include:

  • Post-operative goblet cell depletion decreases the amount of protective mucin.
  • Inferior placement of the bleb heightens the risk of infection by the increased risk of leakage, providing a flow pathway for pathogenic bacteria to travel from the lacrimal lake to the bleb[10].
    • Lack of protection from the eyelid for inferior bleb placements contributes to infection risk.

Gross Pathology

On gross pathology, maculopathic purulent infiltrate, edematous erythema, hyperaemia and hypopyon are characteristics of blebitis.[9]

Microscopic Pathology

On microscopic histopathological analysis, goblet cell-depletion and epithelial thinning are characteristic of blebitis.[11] Observation of the basement layer of conjunctival epithelial cells may demonstrate thinning, missing segments, or total absence.

Causes

Blebitis may be caused by bacterial infection, predominantly Staphylococcus spp. and Streptococcus spp.[5][12] [9] Less commonly,Corynebacterium, Pseudomonas aeruginosa, and Nocardia have been isolated in cases of blebitis.[13][14]

Differentiating Blebitis from Other Diseases

Blebitis must be differentiated from other diseases that cause ocular erythema and hyperaemia, as well as pain, pressure, loss of vision, and photophobia.[15]

Disease Findings
Bleb-related endophthalmitis An ocular disease that results from the spread of bleb-infection extends beyond the anterior chamber. Presents with similar symptoms to blebitis, including ocular pain, photophobia, hyperaemia, and bleb-leakage. Primarily Differentiates from blebitis by the presence of infection and inflammation in the vitreous. There is also increased conjunctivitis in bleb-related endophthalmitis. Symptoms are more severe, with near-total vision loss common in the absence of treatment. Primarily caused by Streptococcus infection; aggressive intravitreal vancomycin and broad spectrum antibiotics are necessary to prevent vision morbidity.[16]

Epidemiology and Demographics

From 2007-2011, the incidence of blebitis in the United States was approximately 550 per 100,000 individuals.[17]

Age

Blebitis patients are usually less than 40 years old.[18] Blebitis is also commonly seen in African American patients older than 40 years old and Mexican Americans older than 60 years old, due to the higher incidence of the precursory glaucoma surgery.

Gender

Males are more commonly affected with blebitis than females.[19]

Race

African-Americans are more commonly affected with blebitis than other races.[19] Inuit are more prone to blebitis due to the higher incidence of glaucoma in that population.[20]

Risk Factors

Common risk factors in the development of Blebitis include:[19]

Natural History, Complications and Prognosis

Natural History

Blebitis will require topical antibiotic therapy to resolve.[21] Without treatment, blebitis may lead to bleb leakage and bleb-related endopthalmitis. Recurrence of infection and blebitis is likely without treatment.

Complications

Without treatment, a possible complication of blebitis is endophthalmitis.[22] Endophthalmitis is caused when the pathogen causing blebitis, previously limited to the bleb, spreads past the anterior chamber of the eye and into the vitreous body.

Prognosis

With treatment, the prognosis for blebitis is good.[23] Risk of permanent vision loss is minimal with effective therapy. Without treatment, the prognosis for blebitis is worse due to the increased risk of developing bleb-related endophthalmitis.[12]

Diagnosis

Symptoms

Symptoms of blebitis may include:[24]

Physical Examination

Physical examination may be remarkable for:

Laboratory Findings

A positive test for staphylococcus or streptococcus bacteria is diagnostic of blebitis.[6]

Imaging Findings

There are no imaging findings associated with blebitis.

Other Diagnostic Studies

Physical examination and microscopic histopathological analysis of suspected blebitis is sufficient for diagnosis.

Treatment

Medical Therapy

The mainstays of therapy for blebitis are fortified topical antimicrobial and antibacterial agents:[15]

Topical corticosteroids are often used in conjunction with antimicrobial therapy.

Surgery

Surgery is rarely indicated for blebitis for cases such that the bleb displays positive Seidel-test results for leakage.[15]

  • Surgery will be performed to repair the bleb but is only indicated when the chance of reinfection is eliminated.

Prevention

Effective measures for the primary prevention of blebitis include those that minimize the possibility of ocular bacterial infection following a trabeculectomy:

  • Minimizing use of topical corticosteroids to prevent bleb-leakage that predisposes blebitis.[6]
  • Avoiding prolonged use of topical antibiotics beyond the prescribed time period post-trabeculectomy.
  • Avoiding inferior or nasal placement of the bleb to reduce the risk of leakage.[10]

References

  1. 1.0 1.1 Brown RH, Yang LH, Walker SD, Lynch MG, Martinez LA, Wilson LA (1994). "Treatment of bleb infection after glaucoma surgery". Arch. Ophthalmol. 112 (1): 57–61. PMID 8285894.
  2. Yamamoto T, Kuwayama Y, Collaborative Bleb-related Infection Incidence and Treatment Study Group (2011). "Interim clinical outcomes in the collaborative bleb-related infection incidence and treatment study". Ophthalmology. 118 (3): 453–8. doi:10.1016/j.ophtha.2010.07.002. PMID 20932582.
  3. Greenfield DS (1998). "Bleb-related ocular infection". J Glaucoma. 7 (2): 132–6. PMID 9559501.
  4. Azuara-Blanco A, Katz LJ (1998). "Dysfunctional filtering blebs". Surv Ophthalmol. 43 (2): 93–126. PMID 9763136.
  5. 5.0 5.1 Yamamoto T (2012). Taiwan J of Ophthalmology. 2 (1): 2–5 http://www.sciencedirect.com/science/article/pii/S2211505611000342. Text " title:Bleb-related infection: Clinical features and management. " ignored (help); Missing or empty |title= (help)
  6. 6.0 6.1 6.2 6.3 Ramakrishnan R, Bharathi MJ, Maheshwari D, Mohideen PM, Khurana M, Shivakumar C (2011). "Etiology and epidemiological analysis of glaucoma-filtering bleb infections in a tertiary eye care hospital in South India". Indian J Ophthalmol. 59 (6): 445–53. doi:10.4103/0301-4738.86311. PMC 3214414. PMID 22011488.
  7. Zahid S, Musch DC, Niziol LM, Lichter PR (2013). "Risk of endophthalmitis and other long-term complications of trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS)". Am. J. Ophthalmol. 155 (4): 674–680, 680.e1. doi:10.1016/j.ajo.2012.10.017. PMC 3608803. PMID 23246272.
  8. Wells AP, Cordeiro MF, Bunce C, Khaw PT (2003). "Cystic bleb formation and related complications in limbus- versus fornix-based conjunctival flaps in pediatric and young adult trabeculectomy with mitomycin C". Ophthalmology. 110 (11): 2192–7. doi:10.1016/S0161-6420(03)00800-5. PMID 14597529.
  9. 9.0 9.1 9.2 9.3 Matsuo H, Tomita G, Araie M, Suzuki Y, Kaji Y, Obata H, Tanaka S (2002). "Histopathological findings in filtering blebs with recurrent blebitis". Br J Ophthalmol. 86 (7): 827. PMC 1771211. PMID 12084758.
  10. 10.0 10.1 Caronia RM, Liebmann JM, Friedman R, Cohen H, Ritch R (1996). "Trabeculectomy at the inferior limbus". Arch. Ophthalmol. 114 (4): 387–91. PMID 8602774.
  11. Mietz H, Brunner R, Addicks K, Krieglstein GK (1993). "Histopathology of an avascular filtering bleb after trabeculectomy with mitomycin-C". J. Glaucoma. 2 (4): 266–70. PMID 19920531.
  12. 12.0 12.1 Wallin Ö, Al-ahramy AM, Lundström M, Montan P (2014). "Endophthalmitis and severe blebitis following trabeculectomy. Epidemiology and risk factors; a single-centre retrospective study". Acta Ophthalmol. 92 (5): 426–31. doi:10.1111/aos.12257. PMID 24020653.
  13. Ifantides C, Batlle OR, Mushatt D, Ayyala RS (2015). "Nocardia exalbida blebitis: a case report". J Glaucoma. 24 (4): e19–21. doi:10.1097/IJG.0b013e3182a07574. PMID 25826645.
  14. Bharathi S, Raman GV, Mohan DM, Krishnan A (2014). "An unusual presentation of Pseudomonas aeruginosa blebitis following combined surgery". Indian J Ophthalmol. 62 (9): 958–60. doi:10.4103/0301-4738.143947. PMC 4244747. PMID 25370403.
  15. 15.0 15.1 15.2 Reynolds AC, Skuta GL, Monlux R, Johnson J (2001). "Management of blebitis by members of the American Glaucoma Society: a survey". J. Glaucoma. 10 (4): 340–7. PMID 11558820.
  16. Ba'arah BT, Smiddy WE (2009). "Bleb-related Endophthalmitis: Clinical Presentation, Isolates, Treatment and Visual Outcome of Culture-proven Cases". Middle East Afr J Ophthalmol. 16 (1): 20–4. doi:10.4103/0974-9233.48862. PMC 2813581. PMID 20142955.
  17. Vaziri K, Kishor K, Schwartz SG, Maharaj AS, Moshfeghi DM, Moshfeghi AA, Flynn HW (2015). "Incidence of bleb-associated endophthalmitis in the United States". Clin Ophthalmol. 9: 317–22. doi:10.2147/OPTH.S75286. PMC 4334336. PMID 25709395.
  18. "Facts About Glaucoma | National Eye Institute".
  19. 19.0 19.1 19.2 Soltau JB, Rothman RF, Budenz DL, Greenfield DS, Feuer W, Liebmann JM, Ritch R (2000). "Risk factors for glaucoma filtering bleb infections". Arch. Ophthalmol. 118 (3): 338–42. PMID 10721955.
  20. Cook C, Foster P (2012). "Epidemiology of glaucoma: what's new?". Can. J. Ophthalmol. 47 (3): 223–6. doi:10.1016/j.jcjo.2012.02.003. PMID 22687296.
  21. Waheed S, Liebmann JM, Greenfield DS, Ritterband DC, Seedor JA, Shah M, Ritch R (1998). "Recurrent bleb infections". Br J Ophthalmol. 82 (8): 926–9. PMC 1722708. PMID 9828779.
  22. Ciulla TA, Beck AD, Topping TM, Baker AS (1997). "Blebitis, early endophthalmitis, and late endophthalmitis after glaucoma-filtering surgery". Ophthalmology. 104 (6): 986–95. PMID 9186440.
  23. Poulsen EJ, Allingham RR (2000). "Characteristics and risk factors of infections after glaucoma filtering surgery". J. Glaucoma. 9 (6): 438–43. PMID 11131749.
  24. 24.0 24.1 Brown, Reay H. (1994). "Treatment of Bleb Infection After Glaucoma Surgery". Archives of Ophthalmology. 112 (1): 57. doi:10.1001/archopht.1994.01090130067019. ISSN 0003-9950.
  25. Feldman, Robert (2013). Complications of glaucoma surgery. Oxford: Oxford University Press. ISBN 978-0-19-538236-5.

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