Measuring Health-Related Quality of Life in Thyroid Eye Disease.

Health-related quality of life (HQOL) is a concept that aims to understand the totality of an individual's experience of their disease state. This can include the physical, psychosocial, emotional, and psychological effects of a disease state. A complex and multifactorial concept, HQOL can be challenging to measure accurately and reliably. Thyroid eye disease (TED), as a multifaceted physically debilitating and facial disfiguring disorder, presents unique challenges and opportunities in the measurement of HQOL. Multiple distinct tools have been developed for this purpose, each has been constructed, assessed, and utilized. This discussion surveys the landscape of TED-related QOL measurement and presents challenges for the future. Clinicians and clinical researchers should implement TED-related QOL measurement as part of routine TED care and as a primary outcome in TED clinical trials. We recommend utilizing the Graves' ophthalmopathy (GO)-QOL routinely in clinical practice and as a primary outcome in TED clinical trials. If the GO-QOL is too time-consuming or in mild TED, a faster alternative is the TED-QOL.

The success rate of TED upper eyelid retraction reoperations.

Although reoperation rates for upper lid retraction surgery for thyroid eye disease (TED) typically range between 8% and 23%, there is little literature describing the outcomes of these second operations. In this retrospective observational cohort study, all patients that underwent surgery for upper eyelid retraction over a 14-year period at a single institution were included. Cases were included if a second eyelid retraction surgery was performed during the study period. Success of surgery was defined as a marginal reflex distance (MRD1) of 2.5 to 4.5 mm in each eye and less than 1 mm difference in MRD1 between the eyes. Overcorrection and undercorrection were defined as above and below these bounds, respectively. 72 eyes in 49 patients were included in the study. The mean age was 56.6 (±11.5) years. By definition, all patients had at least 1 lid lengthening surgery for upper eyelid retraction, and at least 1 subsequent surgery. For this second surgery, 61 eyes (85%) underwent retraction surgery and 11 eyes (15%) underwent ptosis surgery. After this second operation, 31% were undercorrected and 33% were overcorrected. A third surgery was performed in 19 eyes (25%), 12 had surgery for residual retraction and 7 for ptosis. After the third operation 10% of eyes were under corrected and 11% were over corrected. Four patients underwent a fourth surgery: one for retraction and three for ptosis. Success was noted in 35% after the second surgery and 44% after the third. Surgical success in eyelid retraction surgery increases from a second to a third consecutive surgery, and residual asymmetry was roughly equally distributed between over- and undercorrection.

Long-Term Evaluation of Eyebrow Soft Tissue Expansion in Thyroid Eye Disease.

PURPOSE: To evaluate the long-term transformation of lateral eyebrow soft tissue in a group of patients with known thyroid eye disease. METHODS: A retrospective review of all patients with a known diagnosis of thyroid eye disease with clinical photos available from both their initial diagnosis visit and at least 7 years following their initial visit was performed. Age at diagnosis, sex, disease activity, previous orbital, and eyelid surgery were noted, as was history of treatment with radioactive iodine, steroids, and external beam radiation. The area between the upper eyebrow and upper eyelid crease was evaluated in standardized photographs by a panel of 4 expert, independent, masked observers utilizing a previously published visual grading key. RESULTS: One hundred and four patients met inclusion criteria. Fifteen participants were male and 89 were female. The mean patient age was 50.6 years (±1.21 years), and the mean follow up duration was 10.0 years (±0.23 years). The mean initial photo grade (1.24) was significantly higher than the mean follow up photo grade (1.00; p < 0.01). In logistic regression analyses, only the initial photograph grade was significantly associated with improvement in eyebrow soft tissue appearance (p < 0.01). Medical and surgical treatments were not significantly associated with changes in eyebrow soft tissue appearance (all p > 0.05). CONCLUSIONS: Expansion of eyebrow soft tissue may improve over time in patients with thyroid eye disease. This change was not affected by age, sex, disease activity, surgery, or medical therapy.

Localization and Retrieval of an Eyelid Metallic Foreign Body With an Oscillating Magnet and High-Resolution Ultrasonography.

A patient was found to have a metallic foreign body in the left anterior orbit on CT imaging, but the foreign body was not evident on clinical examination. On high-resolution ultrasonography, an object was identified in the left upper eyelid; however, the typical shadow with metallic foreign bodies was not seen. A high-power oscillating magnet was then applied to the eyelid, which revealed a subcutaneous metallic foreign body in the left upper eyelid. When used in conjunction, the high-resolution ultrasound and oscillating magnet successfully localized and facilitated retrieval of the metallic foreign body from the left upper eyelid.

The role of tissue resection length in the determination of post-operative eyelid position for Muller's muscle-conjunctival resection surgery.

PURPOSE: To investigate the relationships between pre-operative marginal reflex distance (MRD), tissue resection length, phenylephrine response, and change in MRD with surgery for a cohort of individuals undergoing Muller's muscle conjunctival resection (MMCR) surgery. METHODS: All cases of MMCR surgery performed over a 13-year period at a single institution were screened for entry. Individuals with adequate photographic documentation and follow up were included. Patients with previous or concurrent upper eyelid, orbital or eyebrow disease of surgery were excluded. Marginal reflex distance (MRD) was calculated based on photographs utilizing public domain software. Data was plotted for inspection and appropriate statistical tests were performed. RESULTS: During the study period 198 eyes fit criteria for analysis. A loose association between tissue resection length and change in MRD with surgery was found (r = 0.176, p < 0.05); this relationship was not significant in ANOVA analysis (p = 0.367). There was a strong association between MRD change with surgery and pre-operative MRD (r = 0.498, p < 0.01). Approximately 28% of the sample responded to 2.5% phenylephrine drop instillation with a greater than 2 mm increase in MRD. The response to phenylephrine was strongly associated with pre-operative MRD (r = -0.441, p < 0.01). A regression on change in MRD with surgery with tissue resection, phenylephrine response >2 mm and pre-operative MRD as variables revealed a model with pre-operative MRD as the only significant predictor (p < 0.01). CONCLUSION: Tissue resection length and phenylephrine response play small roles relative to pre-operative MRD in the determination of change in MRD with MMCR surgery.

Ocular surface, fornix, and eyelid rehabilitation in Boston type I keratoprosthesis patients with mucous membrane disease.

PURPOSE: To understand the efficacy of various approaches for ocular surface reconstruction in eyes with implanted Boston Type I keratoprosthesis. METHODS: All eyes implanted with a Boston Type I keratoprosthesis over a 9-year period by a single surgeon were reviewed. Any case in which mucosal rehabilitation was performed was included in the study sample. The type, number, approach, and outcome for all eyelid and ocular surface procedures were assessed. RESULTS: A total of 22 mucosal surface surgeries were performed before, concurrent with, and after implantation of 11 keratoprostheses and 1 penetrating keratoplasty (after keratoprosthesis removal) in 9 eyes of 9 patients. Most of the ocular surface reconstructive surgeries (81.8%; 18/22) were performed at the time of or following keratoprosthesis implantation, with the most common indication being corneal stromal necrosis (44.4%; 8/18). Free grafting and simple advancement resulted in graft retraction for each case, and pedicle or bucket handle flaps resulted in a stable vascularized graft for half of the cases. Graft retraction occurred in 6 of the 9 eyes in this study, including in all 5 eyes of patients with Stevens Johnsons syndrome (SJS). CONCLUSIONS: Free grafting and simple advancement flaps do not appear to be effective for rehabilitation in these eyes. However, even vascularized pedicle and bucket handle flaps retracted 50% of the time. Individuals with SJS were more likely to both require conjunctival rehabilitation after keratoprosthesis surgery and develop graft retraction in the course of management.

Does the Tyndall effect describe the blue hue periodically observed in subdermal hyaluronic acid gel placement?

BACKGROUND: The blue hue of skin overlying injected hyaluronic acid (HA) fillers in certain cases has been hypothesized in the literature as related to the Tyndall effect. This investigation aims to understand the relevant optical concepts and to discuss the plausibility of this assertion. METHODS: Theoretic and physical aspects of relevant optical theories including the Tyndall effect, the Raleigh criterion and the Mie Solution are discussed, with simple examples. The physical properties of the system (both HA and subcutaneous tissue) are explored. Alternate concepts of dermal hue generation are discussed. RESULTS: The Tyndall effect (and Rayleigh criterion) describe optical phenomenon that occur as light passes through colloidal solutions containing uniform spherical particles of sizes less than the length of a wavelength of visible light. HA fillers are complex, large, non-spherical, cross-linked hydrogels, and thus are not well characterized by these theories.Skin is a complex optical surface in which shorter wavelengths of light are selectively filtered at superficial depths. Light passing through to subdermal HA would have low blue light amplitude, minimizing what light could be preferentially scattered. Further, should blue hues be 'generated' subdermally, the same skin filters work in reverse, making the blue light poorly detectable by an external observer. CONCLUSIONS: The Tyndall effect is unlikely to cause dermal hue changes in HA filler instillation. Optical and perceptual processes explaining superficial vein coloration may better describe subdermal HA hue changes. Vein coloration is thought to be related to three processes: the reflective properties of the skin, the absorptive properties of blood and the perceptive properties of an observer's eyes. Subdermal HA may simulate these phenomena by a number of undetermined, yet plausible mechanisms.

Adalimumab as steroid-sparing treatment of inflammatory-stage thyroid eye disease.

PURPOSE: Steroids are often used as medical therapy for active thyroid eye disease (TED). While high-dose steroids have been shown to be effective in reducing the severity of TED symptoms, the side effects of steroids can be severe. As the pathogenesis of TED is thought to involve the upregulation of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), it has been postulated that anti-TNF agents may be used as steroid-sparing agents in the treatment of TED. This retrospective study was conducted to examine the efficacy of adalimumab, a subcutaneously administered TNF-α antagonist, in treating the inflammatory symptoms of active TED. METHODS: All patients in the inflammatory phase of TED who were treated with adalimumab at the Jules Stein Eye Institute over a 2-year period were reviewed. Data concerning visual acuity, optic nerve function, extraocular motility restriction, binocular visual fields, and proptosis were extracted from patient charts. Clinical photographs from baseline and 3-month follow-up visits were reviewed by masked orbital specialists. Each photograph was graded on the severity of conjunctival injection, chemosis, eyelid erythema, and eyelid edema on a scale from 1 to 4. An inflammatory score was calculated as the sum of these 4 elements. Groups were compared using paired t tests. RESULTS: Six of 10 patients showed a decrease in inflammatory score while on adalimumab, whereas 3 showed an increase and 1 stayed the same. One patient experienced a significant complication (hospital admission for sepsis). Eight patients received concomitant tapering steroids during the first 6 weeks of therapy as the adalimumab reached maximum efficacy. When data from all 10 subjects were analyzed together, there was no significant change in inflammatory index after 3 months of treatment with adalimumab. However, when the 5 patients with a high baseline inflammatory index (>4) were considered separately, there was a significant improvement (mean decrease of 5.2±2.7; p<0.01) after adalimumab treatment. Four of 5 patients also reported a subjective improvement in symptoms while on adalimumab. CONCLUSIONS: This study suggests that adalimumab may have a role in the treatment of active TED with prominent inflammatory symptoms. The use of adalimumab and other immunosuppressive agents in the treatment of TED may help to mitigate some of the metabolic and psychiatric side effects of pulsed steroid treatment. A future randomized controlled study will be necessary to determine the efficacy of adalimumab as a primary therapy for TED.

Cavernous venous malformations of the orbit (so-called cavernous haemangioma): a comprehensive evaluation of their clinical, imaging and histologic nature.

PURPOSE: The purpose of this investigation is to describe the clinical, imaging, histologic and flow dynamic characteristics of orbital cavernous haemangioma. METHODS: In this clinicopathologic series, clinical features were obtained from patient records. All imaging studies were reviewed. All specimens were reviewed with haematoxylin and eosin, and 10 were subject to a staining protocol including: Movat Pantachrome, periodic acid Schiff, D2-40, CD31, GLUT-1, Ki-67, vascular endothelial growth factor receptor 1 (VEGF-r1) (flt-1), VEGF-r2 (Flk-1), VEGF, anti-smooth muscle actin (SMA), CD20, CD4, CD8 and CD68. Imaging and pathology were reviewed in a systematic fashion. RESULTS: Clinically, lesions were more common in middle-aged females presenting with axial proptosis and pain. One-third demonstrated signs of optic nerve dysfunction. Dynamic imaging revealed focal early and diffuse late enhancement. Lesions demonstrated slow growth at 0.2 cm3/year. Histologically, all lesions demonstrated large vascular channels with mature-appearing endothelium and abundant stroma. Three salient features were noted and characterised: thrombosis, nests of perivascular hypercellularity and expanded stromal elements. Acute thrombosis was a feature of each specimen (<10% of channels). Fibrin clots were lined by a layer of CD31+ endothelium. Perivascular hypercellular areas stained uniformly with CD31 and less so with VEGFr2. Additionally, focal areas of Ki67+ and CD68+ cells were found in these regions. Expanded stroma contained CD31+ microcapillary networks and stained diffusely with anti-SMA. CONCLUSIONS: Cavernous haemangioma demonstrate clinical features and growth characteristics of a benign mass. Dynamic imaging highlights their slow flow vascular nature. Histologically, the hypercellularity and stromal changes identified can be understood within the pathogenic context of thrombosis and recanalisation in an organised lesion.

Zig Zag versus Top Hat configuration in IntraLase-enabled penetrating keratoplasty.

AIM: To compare the outcomes with IntraLase-enabled keratoplasty using (IEK) Top Hat (TH) versus Zig Zag (ZZ) configuration. METHODS: Retrospective comparative series of 24 eyes that underwent TH and 10 eyes that underwent ZZ IEK. RESULTS: There were no significant differences in LogMar Best-spectacle corrected visual acuity (TH- IEK=0.3; ZZ-IEK=0.18, p=0.18), spherical equivalent (TH-IEK=-3.55±3.7 dioptres (D); ZZ-IEK=-2.69±4.85 D, p=0.60), manifest cylinder (TH- IEK=3.79±2.43 D; ZZ- IEK=4.61±3.29 D, p=0.45), topographic astigmatism (TH-IEK=3.67±2.34 D; ZZ-IEK=4.26±1.1 D, p=0.63), total higher-order aberrations (TH- IEK=8.26±3.53; ZZ-IEK=8.1±4.71, P=0.92), endothelial cell density change from baseline (TH- IEK= -41.55%±15.86; ZZ-IEK=-25.45%±30.66, p=0.22) or time to suture removal in months (TH- IEK=7.48±4.07; ZZ- IEK=6.93±2.71, p=0.75). There was no difference in requirements for astigmatic keratectomy (TH-IEK=54.2%±13; ZZ-IEK=50%±5, OR=1.18) or complications (TH-IEK=25%±6; ZZ-IEK=30%±3, OR=0.78). CONCLUSIONS: TH-IEK and ZZ-IEK have comparable visual and refractive outcomes, wound healing and endothelial cell counts at 1-year.

Predictors of treatment failure for pneumatic retinopexy.

OBJECTIVE: The purpose of this study was to define the overall anatomic success rate in pneumatic retinopexy and to identify morphologic features that may be predictive of treatment failure in pneumatic retinopexy. DESIGN AND PARTICIPANTS: Prospective consecutive interventional case series of patients with new-onset primary rhegmatogenous retinal detachments treated with pneumatic retinopexy. METHODS: In this interventional case series, consecutive patients with new-onset primary rhegmatogenous retinal detachments were treated with pneumatic retinopexy and followed prospectively. Morphologic data were collected on 3-colour fundus drawings. The primary outcome measure was treatment failure, defined as requirement for scleral buckle or vitrectomy within the follow-up period. Rates of failure for each morphologic feature were compared and a logistic regression model was fit. RESULTS: A total of 113 eyes were included in the study. Anatomic success was achieved in 69.6% of patients. Morphologic criteria including the position and number of breaks, position and extent of lattice degeneration, size of the detached area, and macular status were all found not to be significantly related to failure. In multivariate analysis, only 3 predictors, pseudophakic status (p < 0.05, odds ratio [OR] 2.9, 95% CI, 1.06-7.88), presence of retinal break greater than 1 clock-hour (p < 0.05, OR 3.41, 1.06-11.02), and presence of grade C or D proliferative vitreoretinopathy (PVR) (p < 0.01, OR 31.83, 95% CI, 3.59-282.24), gained statistical significance. CONCLUSIONS: Only pseudophakia, a large retinal break, and/or PVR was associated with an increased likelihood of failure.

Post-LASIK ectasia treated with intrastromal corneal ring segments and corneal crosslinking.

Corneal ectasia is a serious complication of laser in situ keratomileusis (LASIK). We report the case of a 29-year-old man who underwent LASIK in both eyes and in whom corneal ectasia developed in the left eye 3 years after surgery. He was treated sequentially with intraocular pressure-lowering medication, intrastromal corneal ring segment (ICRS) implants, and collagen cross-linking. Vision improved and the ectasia stabilized following treatment. Combined ICRS implantation and collagen cross-linking should be considered early in the management of post-LASIK ectasia.

Repair of eroded glaucoma drainage devices: mid-term outcomes.

PURPOSE: Glaucoma drainage devices (GDD) are used in the surgical management of medically refractory glaucoma. One late serious complication is erosion and exposure of the tube, clip, or plate. In this study, we evaluated the effectiveness of oral buccal mucous membrane allografts with corneal lamellar grafts for the repair of GDD erosions. METHODS: Retrospective consecutive observational case series. All patients who underwent buccal membrane transplants with corneal allografts for the repair of GDD erosions between 2006 and 2010 were included in this study. Primary outcomes were categorized as: (a) success: coverage of the GDD without further repair; (b) qualified success: minor perioperative complications or additional procedures required to maintain success; or (c) failure: GDD reerosion requiring surgery. RESULTS: Nineteen eyes from 17 patients with 20 GDDs were reviewed, of which there were 19 Ahmed valves and 1 Molteno implant. There were 16 cases of tube erosion, 2 cases of plate erosion, and 2 cases of pars plana clip erosion. The mean (SD) number of ocular surgeries before the buccal membrane transplant was 4.8 (2.9). The mean (SD) time to exposure from the original GDD procedure was 4.6 (3.7) years. Analysis of tube erosions alone showed a success rate of 94% after ≥ 1 buccal membrane repairs. Buccal membrane repairs in total were considered a surgical success in 85% of cases with a mean (SD) follow-up of 1.7 (1.2) years. CONCLUSIONS: Buccal membrane transplants are particularly useful in cases of tube erosion.

Cadaveric anatomical comparison of the lateral nasal wall after external and endonasal dacryocystorhinostomy.

PURPOSE: Much literature has accumulated espousing the relative merits of endonasal and external dacryocystorhinostomy (DCR). However, there is comparatively little information on the relative anatomic differences between these 2 approaches. The purpose of this study is to investigate the anatomic relationships of the lateral nasal wall for endonasal and external DCR. METHODS: Ten cadaver half heads were used in this study. Half were subject to endonasal and half to external DCR procedures. The lateral nasal wall was then dissected and measurements were taken of ostium and anastomosis size and position relative to other landmarks on the lateral nasal wall. Relationships were compared between the 2 procedures. RESULTS: The dimensions and area of the ostium and the anastomosis were similar between the 2 procedures. The lower portion of the ostium was located more inferiorly in endonasal DCR. Additionally, the ostium was more likely to be found lateral to the axilla of the middle turbinate in endonasal DCR, when compared with anterior for external. External DCR was also more likely to involve opening the anterior ethmoid air cells than endonasal approach. CONCLUSION: Endonasal and external DCR osteomies appear to be of similar size, with the endonasal opening being located slightly lower and more posterior on the lateral nasal wall.

Psychometric properties of a new tool to assess task-specific and global competency in cataract surgery.

BACKGROUND AND OBJECTIVE: To establish and validate an assessment tool of cataract surgery performed by residents suitable for a competency-based curriculum. PATIENTS AND METHODS: A three-component evaluation tool was created based on review of the literature and was refined using a modified Delphi technique. Faculty surgeons viewed two videos of cataract surgery, performed by a novice and an expert, and completed the evaluation tool. Results were analyzed for the psychometric properties. RESULTS: Evaluators concluded the scale had excellent face validity. Construct validity showed the scale to reliably distinguish (P < .001) between novice (30.3 ± 6.1) and experienced (48.3 ± 7.2) surgeons. Internal consistency of the scale was high, with Cronbach's alpha equal to 0.981. Inter-rater reliability was high with an intraclass correlation coefficient equal to 0.811 (F(df) = 53.2 (25), P < .001). CONCLUSION: The tool has excellent face validity, content validity, and reliability. Its task-specific, global-index scale and quantitative data form make it a valuable tool to assess residents' surgical skills.

Outcomes of deep anterior lamellar keratoplasty versus intralase enabled penetrating keratoplasty in keratoconus.

OBJECTIVE: To compare the visual and refractive outcomes after deep anterior lamellar keratoplasty (DALK) and intralase enabled keratoplasty (IEK) for keratoconus. DESIGN: A retrospective comparative case series. PARTICIPANTS: Eighteen eyes that underwent DALK and 18 that had IEK for keratoconus. METHODS: Main outcome measures included preoperative and postoperative best spectacle corrected visual acuity (BSCVA), refraction, high-order aberrations (HOA), and complication rate were compared between the 2 groups after all suture removals. RESULTS: Mean time to all suture removal was 11.91 months for the DALK and 6.7 months for the IEK. The mean logMAR BSCVA of patients in the DALK group was 0.28 (20/38) and 0.37 (20/46) in the IEK group (p < 0.211). The final sphere was -5.62 and -0.53 in the DALK and IEK groups, respectively (p < 0.973). There was statistically significant difference in the astigmatism between the 2 groups with mean manifest cylinder of 3.13 in the DALK group and 5.78 in the IEK group (p < 0.011).Total HOA (DALK 6.11 vs IEK 9.32, p < 0.036) and total spherical aberrations (DALK 0.44 vs IEK 0.71, p < 0.041) were both significantly higher in the IEK group. A total of 44.4% of eyes underwent astigmatic keratotomy after IEK compared to 5.6% of eyes in the DALK group (p < 0.018; odds ratio = 13.6 [1.48, 125.31]). Overall complication rates were similar for DALK and IEK groups. CONCLUSIONS: BSCVA and complication rates are similar after DALK and IEK, but each technique has its advantage. IEK offered shorter time to suture removal whereas DALK offered lower postoperative astigmatism and HOA rates.

Sterile single use cover for the G-probe Transscleral Cyclodiode.

PURPOSE: Multiuse of the G-probe transscleral cyclophotocoagulation (TSCPC) device can lead to contamination. We evaluated the mechanical stability and clinical efficacy of a disposable sterile barrier for the G-probe footplate. METHODS: We measured diode laser output with and without the G-probe barrier both before and after cadaver TSCPC (18 shots at 2000 mW for 2000mS). Qualitative analyses of the laser aiming beam were made before each trial in the barrier and nonbarrier state. After each trial, the G-probe barrier was examined for microperforations and footplate for debris and/or damage. Microbiology was taken on the cadaver eye and the G-probe before and after 20 cycles. Histologic analysis after TSCPC with and without barrier was carried out on a cadaver eye. RESULTS: Qualitatively, laser focus dispersion was minimized by the G-probe cover. Mean (95% CI) laser output was measured for the nonbarrier, with barrier pre-TSCPC and with barrier post-TSCPC, respectively as 980 mW (899,1061), 1247 mW (1115, 1378), and 1240 mW (1132, 1347). The difference between the nonbarrier and barrier both preTSCPC and postTSCPC was statistically significant (df=2, F=36.26, P<0.01). No perforations in the G-probe barrier were evident and no debris or damage was detected on the G-probe. Pathology was consistent with earlier reports of TSCPC in cadaver eyes. Microbial segregation of the cadaver eye and the G-probe footplate was maintained. CONCLUSIONS: The G-probe barrier is an effective and robust method to protect consecutive patients from contamination during TSCPC. Although energy levels were slightly higher in probes with barrier, histologic differences were not evident and the clinical significance of this finding is likely limited.

Concurrence of retinitis pigmentosa and central serous retinopathy.

We describe a patient with concurrent retinitis pigmentosa and central serous chorioretinopathy. Both conditions involve dysfunction of the retinal pigment epithelium and evince distinct clinical, angiographic, and electrophysiologic features. Potential pathophysiologic connections are explored.

Buccal mucous membrane for the reconstruction of complicated leaking trabeculectomy blebs.

PURPOSE: Late onset trabeculectomy bleb leaks often require surgical repair to avoid hypotony and/or infection. Repair using local conjunctiva is typically performed. However, in cases in which local conjunctiva is limited and/or has failed, buccal mucous membrane can be used as a conjunctival substitute. METHODS: Four cases of buccal mucous membrane repair for leaking trabeculectomy blebs are reported. Surgical technique is described. RESULTS: In each case of bleb leak, multiple nonincisional techniques failed to control the leak. In 3 of 4 cases, earlier reconstruction attempts with conjunctival advancement and/or free flaps failed. Each was ultimately repaired with buccal membrane autograft. One case required additional minimally invasive procedures to control postoperative leaking. One case required a second adjacent buccal graft for leaking residual conjunctival bleb. Each graft was functioning well at most recent follow-up ranging from 1 to 17 months. DISCUSSION: Buccal membrane is an abundant and effective conjunctival substitute for the repair of recalcitrant leaking trabeculectomy blebs. It may be useful in cases in which earlier conjunctival-based repairs have failed.