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 hyperaemia 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 endopthalmitis; 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.
Pathophysiology
Pathogenesis
- The pathogenesis of blebitis is characterized by the infiltration of staphylococcus and streptococcus bacteria into the bleb following trabeculectomy.[2]
- The removal of the trabecula and adjacent structures creates a point of infiltration for pathogenic bacteria.[3]
- The prolonged use of anti-metabolites following trabeculectomy increases the risk of bleb infection.[4]
- A cystic bleb is formed with greater predisposition to infection.
- Epithelial thinning occurs following anti-metabolite therapy and heightening the risk of infiltration.[5]
- 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.[6]
- 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.[5]
- On microscopic histopathological analysis, goblet cell-depletion and epithelial thinning are characteristics of blebitis.[7]
- Observation of the basement layer of conjunctival epithelial cells will show potential thinning, missing sections, or total absence.
Causes
- Blebitis may be caused by bacterial infection, predominantly Staphylococcus aureus and strains of Streptococcus.[8]
- The occular bleb's predisposition to infection occurs due to exposure and vulnerability following a trabeculectomy to treat glaucoma.[5]
- Blebitis is a rare complication of trabeculectomy.
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.[9]
| Disease | Findings |
|---|---|
| Bleb-associated 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-associated 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.[10] |
Epidemiology and Demographics
- From 2007-2011, the incidence of blebitis in the United States was approximately 550 per 100,000 individuals.[11]
Age
- Blebitis patients are usually younger, less than 40 years old.[12]
- 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 rates of incidence of the precursory glaucoma.
Gender
- Males are more commonly affected with blebitis than females.[13]
Race
- African-Americans are more commonly affected with blebitis than other races.[13]
- Inuit are more prone to blebitis due to the higher incidence of glaucoma.[14]
Risk Factors
- Common risk factors in the development of Blebitis include the following:[13]
- Undergoing trabeculectomy for glaucoma
- Experiencing a bleb-leak
- Persistent use of anti-fibrotic topical agents
- Being male
- Being young
- Being African-American
- Experiencing recurrent bacterial conjunctivitis
- Inferior location of the filtering bleb
- Use of contact lenses
- Immunocompromise[2]
Natural History, Complications and Prognosis
Natural History
- Blebitis will require topical antibiotic therapy to resolve.[15]
- 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.[16]
- 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.[17]
- 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 endophthalmitis.[8]
Diagnosis
Symptoms
- Symptoms of blebitis may include the following:[18]
- Ocular pain of the filtering bleb
- Excessive sensitivity to light[19]
- Vision loss
- Intraocular pressure
- Fluid discharge[5]
Physical Examination
- Physical examination may be remarkable for:
- Hyperaemia in the affected eye
- Erythema of the affected eye due to presence of hypopyon[18]
- Thinning of the bleb epithelium
- Whitening of the bleb[1]
- Presence of maculopathic purulent infiltrate
Laboratory Findings
- A positive test for staphylococcus or streptococcus bacteria is diagnostic of blebitis.[2]
- This is obtained via a culture and gram stain of the aqueous humor, swabbed from the surface of the bleb.
- Polymerase chain reaction (PCR) testing of the aqueous humor will reveal bacterial infection.
Imaging Findings
- Microscopic examination of the bleb may reveal histopathological indications of blebitis, including the following:[7]
- Goblet cell depletion
- Erosion or absence of the basement layer of the bleb epithelium
- Thinning of the epithelial layers
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:[9]
- Topical corticosteroids are often used in conjunction with antimicrobrial therapy.
Surgery
- Surgery is rarely indicated for blebitis for cases such that the bleb displays positive Seidel-test results for leakage.[9]
- 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.[2]
- 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.[6]
References
- ↑ 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.
- ↑ 2.0 2.1 2.2 2.3 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.
- ↑ 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.
- ↑ 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.
- ↑ 5.0 5.1 5.2 5.3 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.
- ↑ 6.0 6.1 Caronia RM, Liebmann JM, Friedman R, Cohen H, Ritch R (1996). "Trabeculectomy at the inferior limbus". Arch. Ophthalmol. 114 (4): 387–91. PMID 8602774.
- ↑ 7.0 7.1 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.
- ↑ 8.0 8.1 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.
- ↑ 9.0 9.1 9.2 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.
- ↑ 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.
- ↑ 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.
- ↑ "Facts About Glaucoma | National Eye Institute".
- ↑ 13.0 13.1 13.2 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Poulsen EJ, Allingham RR (2000). "Characteristics and risk factors of infections after glaucoma filtering surgery". J. Glaucoma. 9 (6): 438–43. PMID 11131749.
- ↑ 18.0 18.1 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.
- ↑ Feldman, Robert (2013). Complications of glaucoma surgery. Oxford: Oxford University Press. ISBN 978-0-19-538236-5.