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Blurred Vision and Itchy Eyes

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A patient with glaucoma presented with a complaint of blurred vision for approximately 1 to 2 weeks. He had undergone trabeculectomy a year earlier and had been seen in the office 3 months prior with an IOP of 10 mm Hg at that time. Upon questioning, he admitted to fairly constant eye rubbing in response to itching caused by seasonal allergies.

Diagnosis

This patient has hypotony with a massive choroidal effusion extending to the disc and choroidal folds through the macula. Bleb examination revealed a conjunctival defect with maceration of the underlying scleral flap.

Hypotony, usually defined as an IOP of 5 to 6 mm Hg or less,^1,2,3 is always a concern immediately after trabeculectomy or tube-shunt procedures. Causes include wound leak, overfiltration, ciliary body shutdown, inadvertent cyclodialysis and inflammation. Persistent hypotony can cause choroidal effusion, choroidal folds, maculopathy, disc swelling, corneal edema, cataract formation, and a shallow anterior chamber with peripheral anterior synechiae.

This patient exemplifies that the failure to treat comparatively minor conditions, such as allergies or dry eyes, can lead to serious complications after glaucoma surgery.

Figure

Choroidals extending to the optic nerve
Source: Odette Callender, MD

Click here for a larger view of this image.

Management

Aqueous suppressants can treat overfiltration, and intense topical or periocular steroids can treat significant inflammation. Options for treating a wound leak include bandage contact lens, patching, aqueous suppressants, autologous blood injection, and surgical modification of the conjunctiva or sclera. Cycloplegia, photocoagulation, cryotherapy, diathermy and ciliary body suturing may resolve a cyclyodialysis cleft, but no remedy exists for ciliary body shutdown.^3,4

Surgical revision of the trabeculectomy site resolved the wound leak with subsequent resolution of hypotony and choroidal effusion.

References

1. Late Hypotony. Expert Consult Web site. http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-0-7020-2978-3..00083-1&isbn=978-0-7020-2978-3. Accessed September 8, 2011.
2. Farhi P. Hypotony Maculopathy. OSNSupersite Ophthalmic Hyperguide Web site. 2008. /notfound.aspx?item=web%3a%7bCA69EF13-C3D5-4767-9F8F-DF80E27BFEFD%7d%40en. Accessed September 8, 2011.
3. Sanders SP. Ocular Hypotony. Medscape Reference Web site. http://emedicine.medscape.com/article/1207657. Accessed September 8, 2011.
4. Saha N, MacNaught AI, Gale RP. Closure of cyclodialysis cleft using diode laser. Eye. 2003;17:527–528.