Opportunistic posterior uveal infections in renal transplant patients.

AIMS: To describe the cases of opportunistic posterior uveal infection diagnosed in renal transplant recipients at a single center over a 10-year period. METHODS: The study involved 1156 patients who underwent renal transplantation. Five of the recipients were diagnosed with posterior uveal infection. The specific diagnoses were acute retinal necrosis (two cases), cytomegalovirus retinitis (one case), nocardial chorioretinitis (one case), or tuberculoid granuloma (one case). RESULTS: The five patients were aged 27 to 55 years, and the interval from renal transplantation to uveal infection ranged from 7 months to 16 years. All patients were receiving immunosuppressive treatment at the time of the posterior uveal infection. Acute retinal necrosis was diagnosed in cases I and II at 2 and 3 years after transplantation, respectively. In both cases, fundus examination revealed moderate vitritis and yellow-white lesions representing confluent retinitis. In case III (cytomegalovirus retinitis), 7 months after transplantation the patient developed extensive hemorrhage and confluent white exudates, periphlebitis, and perivascular sheathing in the right eye. In case IV, culture of a fine-needle aspirate from a well-demarcated, white-yellow, elevated choroidal lesion in the superotemporal region of the macula revealed nocardial infection. Fundus examination of the right eye of case V revealed a small, hypopigmented choroidal lesion superior to the optic disc. The lesion was identified as a choroidal tuberculoid granuloma. CONCLUSIONS: Opportunistic chorioretinal infections can occur at any time after renal transplantation. So it is important that every kidney recipient undergo regular ophthalmic examinations throughout his or her lifetime.

[Hemicentral retinal artery occlusion associated with moyamoya syndrome]. / Hemizentralarterienverschluss bei Moyamoya-Syndrom.

Moyamoya syndrome is a rare cerebrovascular disorder characterized by bilateral progressive supraclinoidal stenosis or occlusion of the internal carotid artery and development of collateral vessels in the lenticulostriate region. The syndrome manifests itself in association with another disease or other clinical symptoms. We present the case of a 12-year-old girl with hemicentral retinal artery occlusion due to moyamoya syndrome associated with clinical and laboratory findings of presumed systemic lupus erythematosus.

Referral patterns of uveitis in a tertiary eye care center.

OBJECTIVE: To analyze the referral patterns and diagnosis of uveitis during the past decade in a large tertiary eye center. DESIGN: The records of 1237 patients with uveitis referred to the Immunology Service of the Massachusetts Eye and Ear Infirmary from 1982 to 1992 were classified and analyzed. Data regarding sex, race, nationality, referral site, ages at presentation and onset of uveitis, ocular involvement, clinical characteristics, ocular condition, and systemic disease associations were obtained. RESULTS: The mean age at onset of uveitis was 37.2 years; the male-to-female ratio was 1:1.4. Most patients were white (85.8%), born in the United States (83.1%), and referred from within New England (84.7%). Anterior uveitis was most common (51.6%), followed by posterior uveitis (19.4%), panuveitis (16.0%), and intermediate uveitis (13.0%). Chronic (58.3%), nongranulomatous (77.7%), and noninfectious (83.1%) were the most frequent types of uveitis. The most common entities included idiopathic (34.9%), seronegative spondyloarthropathies (10.4%), sarcoidosis (9.6%), juvenile rheumatoid arthritis (5.6%), systemic lupus erythematosus (4.8%), Behçet's disease (2.5%), and the acquired immunodeficiency syndrome (2.4%). CONCLUSION: The appearance of new uveitic entities, such as the acute retinal necrosis syndrome, multifocal choroiditis and panuveitis, birdshot retinochoroidopathy, and acquired immunodeficiency syndrome-related uveitis, and the reemergence of the classic infectious causes of uveitis, tuberculosis and syphilis, have changed the way we approach the diagnosis and management of posterior and panuveitis at the Massachusetts Eye and Ear Infirmary.

Penetrating keratoplasty in atopic keratoconjunctivitis.

Penetrating keratoplasty (PK) may be required for visual rehabilitation or tectonic purposes in patients with severe keratopathy due to atopic keratoconjunctivitis (AKC). The outcome of PK is often poor in such patients because of adnexal and ocular surface abnormalities. We studied nine AKC patients requiring PK and evaluated the visual outcome and prognostic factors in 11 eyes. The mean follow-up was 87.2 months (range, 30-180 months). Preoperatively all patients had visual acuity of hand motion to 20/200. Eighteen grafts were performed. Final visual acuity was 20/40 or better in 46% of the eyes. Ten eyes retained clear grafts and improved an average of 4.5 Snellen acuity lines.

The role of Igh-1 disparate congenic mouse T lymphocytes in the pathogenesis of herpetic stromal keratitis.

The corneal destruction associated with herpes simplex keratitis (HSK) is primarily the result of the host's immune response to herpes simplex virus type-1 (HSV-1) infection. We examined the role of T cells and T cell subsets in the pathogenesis of HSK. Naive and immune T cells and HSV-1 immune CD4+ and CD8+ subsets from Igh-1 disparate BALB/c congenic mice were adoptively transferred into athymic BALB/c nude mice, which normally do not develop HSK. The results demonstrated that while the transfer of naive T cells from either HSK-susceptible C.AL-20 (Igh-1d) or HSK-resistant C.B-17 (Igh-1b) mice had little influence on HSK development, transfer of either CD3+ or CD4+ HSV-1 immune T cells from C.AL-20 mice resulted in the development of severe HSK in all of the recipients. Transfer of the same cell populations from C.B-17 mice resulted in the development of only a mild keratitis in 50% of the recipients. Transfer of CD8+ cells from either donor strain did not result in stromal disease in any recipient mouse. These results clearly demonstrate the pivotal role of CD4+ T cells in the development of necrotizing herpes stromal keratitis, and further demonstrate that CD8+ T cells are not essential in HSK development in the BALB/c system.

Efficacy of low-dose and long-term oral acyclovir therapy after penetrating keratoplasty for herpes simplex heratitis.

PURPOSE: To evaluate the efficacy of long-term and low-dose prophylactic oral acyclovir therapy in preventing the recurrence of herpetic infection and increasing graft survival in patients who undergo penetrating keratoplasty (PK) for herpes simplex keratitis (HSK). PATIENTS AND METHODS: Nineteen patients were included in the study, who underwent PK for herpes keratitis from July 1993 to November 1995, received oral acyclovir, and were followed at least 12 months. Group 1 included 12 patients with corneal scarring without perforation. These patients were free of inflammation for a mean of 4.1+/-2.2 months preoperatively, and received oral acyclovir 400 mg/day postoperatively for one year. Seven patients (Group 2) who developed corneal perforation due to necrotizing keratitis were treated with tissue adhesives, therapeutic contact lenses, and topical antiviral and oral acyclovir therapy for the resolution of active inflammation followed by PK after a mean of 3.8+/-2.1 months follow-up. They received oral acyclovir 400 mg/day postoperatively for one year in addition to standard postoperative therapy. The control group consisted of 16 patients (Groups 3 and 4) who underwent PK for herpes simplex keratitis and did not receive oral acyclovir. The indication for PK was corneal opacity and impaired visual acuity in 12 patients (Group 3) and corneal perforation in four (Group 4). RESULTS: After an average of 25 months follow-up, there was only one recurrence (8.3%) in Group 1 and two cases (28.6%) of herpetic recurrence in Group 2. Recurrence occurred at two months in one patient while he was taking oral acyclovir. Two of these recurrences followed the withdrawal of oral acyclovir therapy after one year of therapy. In contrast, in control groups there were four cases of herpetic recurrence (33.3%) in Group 3 and two (50%) in Group 4 after a mean of 30.5 months postoperative follow-up. In the study groups, a rejection episode was seen in three patients (15.8%) which was successfully treated with medical therapy. One patient from Group 2 developed bacterial keratitis which subsequently resulted in graft failure. All grafts remained clear in the other patients (94.7%). In the control groups, rejection developed in seven patients. Three rejection episodes were treated successfully. The other four developed graft failure in spite of intensive medical therapy. CONCLUSIONS: Our results suggest that postoperative oral acyclovir therapy is effective in preventing the recurrence of herpetic infection. However, the recurrence may develop after cessation of oral acyclovir therapy, especially in patients who underwent PK for corneal perforation due necrotizing HSK.

Atopic keratoconjunctivitis.

Atopic keratoconjunctivitis (AKC) is a potentially blinding disease characterized by a bilateral chronic keratoconjunctivitis associated with atopic dermatitis. The disease usually manifests as severe itching and burning, excessive tearing, foreign body sensation, and mucoid discharge. The clinical characteristics of AKC show a broad spectrum including lid dermatitis, chronic blepharitis, cicatrizing conjunctivitis with fornix foreshortening and symblepharon formation, punctate epithelial keratitis, persistent epithelial defects, corneal scarring and neovascularization, lipid keratopathy, conjunctivalization of peripheral cornea, and peripheral ulcerative keratitis. The underlying pathophysiologic mechanism in AKC involves a combination of type-I IgE-mediated, and type-IV delayed hypersensitivity reactions. The immunoregulatory defect responsible for the overproduction of allergen-specific IgE antibody, the key component responsible for antigen binding, and subsequent mast cell degranulation, is probably multifactorial. The histopathologic characteristics of the conjunctiva in AKC include a mast cell and eosinophil invasion of the epithelium, epithelial pseudotubule formation, and prominent mast cell and mononuclear cell infiltration of the substantia propria. A number of ocular conditions have been reported to be associated with AKC, including keratoconus, herpes simplex keratitis, and cataracts. Successful long-term control of this potentially blinding disease requires a multidisciplinary approach involving systemic and environmental aspects. Scrupulous long-term environmental control of allergens is the single most important aspect in the management of patients with AKC. Systemic anti-histamine therapy, and long-term topical mast cell stabilizing therapy are also mandatory. Topical steroids should be reserved for exacerbations of the disease.

Optic disk neovascularization in a patient with cytomegalovirus retinitis associated with renal transplantation.

PURPOSE: To report the development of optic nerve head neovascularization during the recovery phase of cytomegalovirus (CMV) retinitis in a renal allograft recipient. CASE REPORT: A 46-year-old male renal allograft recipient developed CMV retinitis seven months after transplantation. At the time of the diagnosis, the patient was being immunosuppressed with prednisone, cyclosporine, and azathioprine, and was treated with repeated intravitreal and intravenous ganciclovir. Six weeks after the initiation of therapy, optic disk neovascularization developed. This was confirmed by fluorescein angiography, which showed no areas of retinal capillary nonperfusion. At this stage, active retinal lesions were partially resolved. Apart from intraocular inflammation, no other cause of neovascularization was detected. Over the following six months, optic disk neovascularization regressed spontaneously without causing vitreous hemorrhage or visual loss. There was no recurrence of CMV retinitis during follow-up. CONCLUSION: Optic disk neovascularization may develop in the healing phase of CMV retinitis in renal transplant recipients.

Clinical features and keratoplasty results in keratoconus complicated by acute hydrops.

PURPOSE: Acute hydrops develops when Descemet's membrane and the endothelium of the ectatic cornea separates to allow aqueous humor to enter the stroma. The current study was done to determine if penetrating keratoplasty (PK) in keratoconus patients with resolved hydrops has a poor prognosis. METHODS: A retrospective chart review of 35 eyes of 35 patients with keratoconus who underwent PK after the resolution of acute hydrops (Group 1) and of 74 eyes of 69 patients who had PK without a previous history of acute hydrops (Group 2) was performed. The chi-square test was used for statistical analysis. RESULTS: The mean age in Group 1 was 21.1+/-11. 0 years. The mean age in Group 2 was 23.2+/-14.4 years. Vernal keratoconjunctivitis was present in 11 patients in Group 1 (31%) and in 12 (17.4%) patients in Group 2. Loose sutures were present in two patients (6%) in Group 1; both resulted in loose suture-related corneal neovascularization. Loose sutures developed in five patients (7%) in Group 2. In Group 1, three patients (9%) had microbial keratitis. Microbial keratitis was seen in five patients (7%) in Group 2. Two patients (6%) in Group 1 developed late endothelial graft failure. In Group 2, one eye (1%) developed early and one eye (1%) late epithelial graft rejection; five eyes (7%) developed late endothelial graft rejection. There was no statistically significant difference between the two groups with respect to the incidence of graft rejection. At the last examination, 34 eyes in Group 1 had clear grafts; in the second group, graft clarity was achieved in 71 eyes. CONCLUSION: Penetrating keratoplasty in hydrops is successful in terms of graft clarity and visual outcome in patients with keratoconus after the resolution of hydrops. The patients should have preoperative and postoperative anti-allergic treatment and close follow-up for possible complications.

Granulomatous anterior uveitis in a patient with CREST syndrome.

The CREST syndrome is a variant form of progressive systemic sclerosis. Apart from the occurrence of keratoconjunctivitis sicca, other types of ocular involvement associated with this variant are quite rare. We present the case of a 73-year-old woman with the CREST variant of progressive systemic sclerosis who developed unilateral granulomatous anterior uveitis. Systemic and laboratory testing failed to suggest evidence for any other associated systemic disease as a possible cause of the granulomatous uveitis. The inflammation was successfully controlled with topical steroids and mydriatics. While a small number of cases of uveitis have been reported in other variant forms of progressive systemic sclerosis, to date there have been no descriptions of uveitis associated with the CREST syndrome.

Fleck dystrophy of the cornea; a report of cases from three generations of a family.

Fleck dystrophy of the cornea is characterized by numerous, tiny, small opacities scattered throughout the entire corneal stroma. The mode of inheritance is autosomal dominant, and this dystrophy is considered to be bilaterally symmetric. This report describes five members from three-generations of the same family with corneal fleck dystrophy. Their clinical features and genetic inheritance pattern are discussed. Visual acuity in all patients was normal and the density of opacities were similar except for two patients with less density. Except for one who presented with mild photophobia all patients were asymptomatic. The inheritance pattern appeared as autosomal dominant with variable expression.

Glare disability in patients with hydrophilic and hydrophobic acrylic intraocular lens implants.

PURPOSE: To compare glare disability test results in patients with hydrophilic and hydrophobic acrylic intraocular lenses (IOL). METHODS: Sixty eyes of 60 patients were studied in three groups of 20. Each eye in Group 1 had a single-piece hydrophilic acrylic (Bioacryl, Biotech, France) IOL implant, and each eye in Group 2 had a three-piece hydrophobic acrylic (AcrySof, Alcon, USA) IOL implant. Group 3 was the control group, and consisted of eyes without cataracts. Glare disability was tested using the Ophthimus glare sensitivity test (Ophthimus, Sweden). For each eye, we determined log contrast sensitivity values without exposure to glare source and with exposure to glare source. The difference between these values was recorded as the threshold contrast increase. An infrared camera was used to measure pupil diameter during glare disability testing, and pupil diameter greater than 4 mm was used as an exclusion criterion to eliminate edge design as a potential contributor to glare disability. RESULTS: The respective mean log contrast sensitivity scores for Groups 1, 2, and 3 in the absence of the glare source were 0.80 +/- 0.03, 0.81 +/- 0.04, and 0.79 +/- 0.08. The corresponding findings with glare source were 0.84 +/- 0.07, 0.89 +/- 0.07, and 0.84 +/- 0.03. The threshold contrast increase in Group 2 (0.070 +/- 0.035) was significantly higher than that in both Group 1 (0.043 +/- 0.040) and the control group (0.045 +/- 0.026) (p < 0.05 for both comparisons). There were no significant differences between Group 1 and the control group regarding log contrast sensitivity values with glare source and threshold contrast increase (p > 0.05 for both comparisons). CONCLUSIONS: The eyes with hydrophilic acrylic IOL showed better glare disability results than those with hydrophobic acrylic IOL. The superior performance of the hydrophilic acrylic IOL could be related to their lower refractive index and equi-convex design.

Refractive outcome of single running suture adjustment in penetrating keratoplasty.

PURPOSE: To evaluate the effectiveness of single running suture adjustment in reducing postoperative astigmatism and improving visual acuity in patients who have undergone penetrating keratoplasty. METHODS: Eighteen eyes of 18 patients who underwent penetrating keratoplasty at the Department of Ophthalmology, Baskent University between May 1997 and December 2000 and who had an astigmatism over 2 diopters (D) at the fourth postoperative week were included. All eyes underwent suture adjustment at the fourth week and eight eyes with residual astigmatism above 3 D underwent a second adjustment at the eighth week. Final astigmatism and visual acuity findings were evaluated 28 weeks postoperatively. RESULTS: The mean postoperative keratometric and refractive astigmatism were 5.76 +/- 0.88 D (range=4.50-7.76) and 5.22 +/- 0.78 D (range=4.0-7.0) at the fourth week, which were decreased to 2.82 +/- 0.99 D (range=1.25-4.62, p=0.0001) and 2.61 +/- 1.01 D (range= 1.0-4.5, p=0.0001) after suture adjustment, respectively. In eight eyes at the eighth week, a second suture adjustment reduced the average keratometric and refractive astigmatism from 3.86 +/- 0.65 D (range=2.75-4.62) and 3.81 +/- 0.44 D (range=3.25-4.50) to 2.33 +/- 0.91 D (range=0.87-3.50, p=0.012) and 2.06 +/- 0.68 D (range=1.0-2.75, p=0.011), respectively. At the 28th week, the average keratometric and refractive astigmatism levels for the entire cohort, which were 2.39 +/- 1.06 D (range=1.0-3.50) and 2.25 +/- 0.96 D (range=1.0-3.25), respectively, showed a statistically significant decrease when compared with the levels before the first suture adjustment (p=0.0001 for both data). The mean best-corrected visual acuity was 20/25 on the Snellen chart at the 28th week. CONCLUSIONS: Postoperative adjustment of single running suture is a safe and effective way of reducing postkeratoplasty astigmatism.

Scleromalacia following trabeculectomy with intraoperative mitomycin C.

PURPOSE: To report the development of scleromalacia in pediatric age as a complication of trabeculectomy with the adjunctive use of intra-operative mitomycin C. PATIENTS: Reported are 2 patients who developed scleromalacia following trabeculectomy combined with intra-operative 0.4 mg/ml mitomycin C application for 5 minutes for refractory glaucoma in aphakic bullous keratopathy and penetrating keratoplasty. RESULTS: Scleromalacia localised in the surgical area developed in 2 young patients. Scleromalacia remained stable in both patients after 6 and 24 months follow-ups. CONCLUSIONS: It is suggested that this procedure be done more selectively, especially in young patients, with a shorter application time and using a lower concentration.

Cataract surgery in patients with Fuchs' heterochromic iridocyclitis.

PURPOSE: To evaluate the results of cataract extraction and posterior chamber intraocular lens (IOL) implantation in patients with Fuchs' heterochromic iridocyclitis (FHI). METHODS: We studied the records of 35 patients with FHI who underwent cataract extraction. Extracapsular cataract extraction (ECCE) was performed by phacoemulsification through a scleral flap in 9 patients and by manual delivery of the nucleus through a corneal section in 26 patients. RESULTS: After a mean follow-up time of 24 (3-60) months, the visual acuity in 21 eyes (60%) was 20/20, and all eyes had 20/40 or better vision. Six eyes with implanted regular PMMA IOL developed a marked anterior uveitis, which was resolved within 3 weeks with topical steroids. Only 1+ or 2+ cellular reaction was observed postoperatively in patients with heparin-coated lens implantation and patients who underwent phacoemulsification. Biomicroscopic evidence of giant cell activity was observed in two patients with heparin-coated IOL and in 11 with regular PMMA IOLs after ECCE (two after phacoemulsification). Four eyes developed intraocular pressure elevation that reverts to normal within 24 weeks with medical therapy. CONCLUSIONS: These results indicate that the surgical outcomes of FHI patients after cataract surgery appear to be better when the phacoemulsification technique is used or when heparin-coated lenses are implanted.

Retinal tears associated with panuveitis and Behçet's disease.

To report retinal tears formation in 3 eyes of 2 patients with active panuveitis and Behçet's disease. We describe 2 patients that were diagnosed and treated for Behçet's disease with active panuveitis. Retinal tears developed while the inflammation was active. The patients were treated with topical, oral steroids, and cyclosporine therapy for bilateral panuveitis. One patient presented with a retinal tear located at the periphery of the active retinal lesion. The other had multiple tears associated with active retinal lesions in both eyes. Argon laser photocoagulation was performed in both patients as soon as the tears were detected. Ocular inflammation was controlled with this therapy, and only a few mild flare-ups occurred. The patients have been followed up for 8 and 16 months, respectively. During this period no new retinal tears have developed. Although retinal tear formation is rarely associated with Behçet's panuveitis, the clinician should be aware of this as a possible complication. When structural changes are present in the vitreous, detailed ophthalmoscopy is indicated to assess for retinal tears. If a tear is detected in a patient with panuveitis and Behçet's disease, laser photocoagulation therapy should be performed immediately to prevent retinal detachment.

Phacoemulsification and intraocular lens implantation in a patient with Mooren's ulcer.

A 61-year-old man with progressive, bilateral Mooren's ulcer had subjective symptoms of pain, discomfort, and blurred vision. Biomicroscopic examination showed 360 degrees of peripheral ulceration of the cornea. There were 1+ cells in the anterior chamber, and nuclear sclerosis of the lens was present. He was treated with topical and systemic steroids, perilimbal conjunctival resection, and systemic cyclophosphamide therapy. After the complete control of inflammation, the patient remained in remission for 14 months. When a cataract developed in the right eye, reducing the visual acuity to light perception, the authors performed a scleral tunnel incision and phacoemulsification with intraocular lens implantation. After 18 months of postoperative follow-up, the vision improved to 20/30, and the eye was stable. Phacoemulsification and scleral tunnel incision with intraocular lens implantation can be successfully performed after the complete control of inflammation with medical therapy.

Microbial keratitis following penetrating keratoplasty.

PURPOSE: To investigate the prevalence of microbial keratitis, predisposing risk factors and treatment modalities in patients who developed keratitis following penetrating keratoplasty (PK). PATIENTS AND METHODS: The records of 285 patients who had undergone PK between January 1991 and December 1995 in a tertiary care center were reviewed. Patients who developed postoperative microbial keratitis were evaluated for predisposing risk factors, microbiological etiology, response to broad spectrum antibiotic therapy and subsequent PK. Patients were mainly treated with fortified topical antibiotics with or without repeat PK. RESULTS: Of the 285 patient records reviewed, microbial keratitis developed in 21 eyes of 21 patients (7.4%). Seventy-one percent of infections occurred within 6 months after grafting. Keratitis initially began from the donor-recipient border in 16 cases (76.2%) and were central or paracentral in 5 patients. Predisposing risk factors included loose or exposed suture (9), suture removal (1), persistent epithelial defect (3), graft failure (3), contact lens wear (1), Stevens-Johnson syndrome (1). Fifteen (71.4%) patients were culture-positive consisting of Streptococcus pneumoniae (7), Staphylococcus aureus (5), Pseudomonas aureginosa (2), and Hemophilus influenzae (1). Forty-three percent of patients were successfully treated with medical therapy only. Seven patients underwent second PK for visual rehabilitation and 4 for tectonic purposes. After medical and surgical therapy, graft clarity was achieved in 17 (81%) of patients. CONCLUSIONS: The microbial keratitis following PK is a major postoperative problem affecting the long term prognosis. Careful selection of patients, and preoperative and postoperative control of risk factors, may decrease the frequency of this complication. Several factors, including loose or exposed sutures, epithelial defects, ocular surface disorders, and graft failure, may predispose patients to develop microbial keratitis following PK.

Pyogenic granuloma: a rare complication of silicone punctal plugs.

To describe pyogenic granuloma formation associated with silicone punctal plugs. A 65-year-old woman with severe dry eye was treated with silicone punctal plugs in both upper and lower puncta. After 14 months of success with the plugs, the patient presented with a fleshy ampullary lesion overlying the plugged superior punctum of her right eye. It was clinically diagnosed as a pyogenic granuloma, and the silicone plug was removed. Since the lesion persisted for 1 month, it was surgically removed. Histopathologic examination confirmed the diagnosis of pyogenic granuloma. A new plug was inserted and tolerated well. The routine use of silicone plugs are recommended as long as patients are informed of possible rare complications.

Management of hypotony maculopathy and a large filtering bleb after trabeculectomy with mitomycin C: success with argon laser therapy.

We report a patient with postkeratoplasty glaucoma that developed a large, filtering bleb following trabeculectomy with intraoperative antimetabolite treatment. The hypotony and the bleb were managed using argon laser photocoagulation. A 26-year-old female patient underwent penetrating keratoplasty in the left eye for keratoconus. Postoperatively, her elevated intraocular pressure could not be controlled medically, and the patient underwent a trabeculectomy with intraoperative antimetabolite application. Two months later, hypotony maculopathy, optic disc edema, and choroidal folds developed, and her vision dropped. Steroid treatment and soft contact lenses did not help. Photocoagulation was applied twice to the surface of the bleb and the surrounding area. After the photocoagulation therapy, the patient's vision improved, intraocular pressure increased, and the optic disc edema and macular folds had resolved. Argon laser photocoagulation applied to a large filtering bleb associated with hypotony maculopathy is a useful treatment for bleb remodeling and elevating intraocular pressure.