Ab Interno Ahmed Glaucoma Valve Plugs In An Eye With Persistent Hypotony.

PURPOSE: This case report aims to describe a new method for increasing intraocular pressure (IOP) in patients with acute hypotony resulting from uveitis flare-ups and preexisting glaucoma drainage devices. The temporary glaucoma tube plug method described is effective and safe. METHODS: This case report presents a 47-year-old female patient with a history of chronic panuveitis and secondary glaucoma, who had 2 previously implanted Ahmed glaucoma valves. The patient developed panuveitis flare-up and persistent hypotony. A novel method of ab interno plugging of the glaucoma tubes using 2-0 prolene suture plugs was performed. Following treatment, the IOP increased successfully and remained within the normal range. CONCLUSION: The temporary ab interno glaucoma tube plug method effectively increased IOP in a patient with 2 preimplanted Ahmed glaucoma valves with persistent low IOP due to uveitis.

Hypotony in uveitis: an overview of medical and surgical management.

Hypotony is a well-recognised, sight-threatening complication of uveitis. It can also be the final common endpoint for a multitude of disease entities. Multiple mechanisms underlie hypotony, and meticulous clinical history alongside ocular phenotyping is necessary for choosing the best intervention and therapeutic management. In this narrative review, a comprehensive overview of medical and surgical treatment options for the management of non-surgically induced hypotony is provided. Management of ocular hypotony relies on the knowledge of the aetiology and mechanisms involved. An understanding of disease trajectory is vital to properly educate patients. Both anatomical and functional outcomes depend on the underlying pathophysiology and choice of treatment.

Risk factors for ocular hypotony after XEN Gel Stent implantation.

PURPOSE: To investigate the incidence of postoperative hypotony, and risk factors for the development of hypotony in eyes who had undergone XEN Gel Stent implantation. METHODS: In this retrospective, single-centre case series, medical records of 170 consecutive eyes who had undergone XEN Gel Stent implantation with or without simultaneous phacoemulsification for primary or secondary open angle glaucoma were analysed. Primary outcome parameters were the incidence of postoperative hypotony and potential risk factors for its development, and secondary parameters were pre- and postoperative visual acuity, intraocular pressure (IOP), and number of IOP-lowering eye drops. RESULTS: Postoperative hypotony ≤ 6 mmHg occurred in 57% of eyes. Hypotony was without complications in 70.1%, 13.4% had transient complications with spontaneous resolution, and 16.5% had complications requiring treatment. Mean visual acuity logMAR before surgery accounted for 0.47 ± 0.46 in all eyes and 0.47 ± 0.48 at the 4-week visit. There was no significant difference of BCVA in the group of eyes with and without postoperative hypotony before and after surgery. The mean IOP before surgery was 24.6 ± 8.4 mmHg and decreased significantly to 18.4 ± 10.2 after 4 weeks. Eyes with an axial length over 24.3 mm had a threefold increased risk for postoperative hypotony (OR 3.226, 95% confidence interval 1.121-9.279). This risk was decreased in eyes with simultaneous cataract surgery (OR 0.483, 95% confidence interval 0.258-0.903). CONCLUSION: In our sample, postoperative hypotony was a common complication after XEN Gel Stent implantation, but serious, persistent complications were rare. A longer axial length predisposes the eye for the development of hypotony.

Insertion of a Preserflo microshunt inside a non-valved glaucoma shunt to treat late-onset hypotony.

We present a case of advanced glaucoma with previously failed trabeculectomy who underwent a Baerveldt tube (BVT) insertion, with initial success. However, 9 months post BVT insertion he developed profound clinically significant hypotony. Two attempts at controlling this with suture exchange led to episodes of significant ocular hypertension, followed by hypotony each time. We describe a technique of using a cut segment of the novel, polystyrene-block-isobutylene-block- styrene (SIBs) based Preserflo Microshunt (Santen Inc., Miami, FL) inserted into the tip of a BVT to control late onset hypotony with success. IOP at 6 weeks was 12mmHg on two drops with complete resolution of the choroidal maculopathy.

Ultrasound biomicroscopy as a tool in the evaluation and management of ocular hypotony in uveitis.

PURPOSE: Chronic uveitis can lead to hypotony that may result in severe visual impairment. We highlight the use of ultrasound biomicroscopy (UBM) as an imaging tool to decide the modality of therapy and management of uveitic hypotony. METHODS: This was a retrospective hospital-based interventional case-series study that included a total of 36 eyes of 25 patients with uveitic hypotony seen between January 1997 and January 2020. RESULTS: Thirty-six eyes of 25 patients with uveitic ocular hypotony were included. Unilateral involvement was seen in 56%. The median age of presentation was 21 years with a median follow-up of 21.5 months. Anterior uveitis was noted in 13.88%, intermediate uveitis in 52.77%, and panuveitis in 33.33% eyes. UBM findings commonly noted were pars plana membranes, supraciliary effusion, blunted ciliary process, and ciliary body traction. Other findings included ciliochoroidal detachment and ciliary body edema. Moreover, 22.2% eyes were managed with medical therapy alone, whereas 77.8% eyes received both medical and surgical intervention based on UBM findings. Furthermore, 66.7% eyes showed improvement in intraocular pressure, 13.9% eyes maintained the same IOP, whereas 19.4% eyes had worsening of IOP at final follow-up. CONCLUSION: We found UBM as a useful imaging tool in evaluating and judiciously deciding the mode of management of uveitic hypotony.

Winning the battle of refractory hypotony.

BACKGROUND: Trabeculectomy, a mainstay in the management of glaucoma is associated with various complications, the most dreaded being hypotony. PURPOSE: We present a challenging case of late-onset refractory hypotony following trabeculectomy. SYNOPSIS: : A 64-year-old male patient diagnosed with primary open angle glaucoma in the right eye underwent combined surgery. Three weeks later, he presented with hypotony which responded well with medical management and then he was lost to follow-up. Two years later, he presented with severe hypotony with shallow choroidal detachment in the right eye, which failed to respond to medical management. Compression sutures were placed over the bleb which also failed to work. Subsequently bleb repair was done with corneal patch graft, which helped resolve the bleb leak, with an improvement in visual acuity and intraocular pressure. HIGHLIGHTS: This video highlights the importance of prompt and timely intervention of an overfiltering bleb in preventing irreversible visual loss. VIDEO LINK: https://youtu.be/8DrxzqQ4qP4.

Posttraumatic Ocular Hypotony Through Epithelial Downgrowth. / Posttraumatische Bulbushypotonie durch Epithelinvasion.

BACKGROUND: Intraocular epithelial downgrowth is a rare but potentially devastating posttraumatic complication. If left untreated, this may result in corneal decompensation, secondary angle-closure glaucoma, retinal detachment and blindness. PATIENT AND METHOD: A 10-year-old patient with penetrating globe injury and delayed wound management elsewhere presented with corneal melting and decompensation, retinal detachment and ocular hypotony. Following penetrating keratoplasty, cyclopexy and vitrectomy, corneal melting in the interface with renewed retinal detachment was noted within days. The hopeless prognosis required enucleation of the globe. RESULTS: Optical coherence tomography revealed not only corneal melting, but also markedly hyperreflective structures posterior to the cornea. Immunohistology demonstrated diffuse multi-layered nonkeratinised squamous cell epithelium on the posterior corneal surface, iris, ciliary bodies, and retina, as well as below the choroid, with renewed tractional retinal detachment. CONCLUSION: Posttraumatic epithelial downgrowth may result in tractional retinal detachment, cyclodialysis cleft and/or corneal melting. Hyperreflective membrane deposits on OCT may be indicative of diffuse epithelial downgrowth. Especially in children, prompt wound closure in globe injuries is vital to avoid this serious posttraumatic complication.

Management of hypotony-related maculopathy after combined phacoemulsification and trabeculectomy: January consultation #1.

A 59-year-old man with mild to moderate pigmentary glaucoma was referred for management of hypotony-related maculopathy 3 years after combined phacoemulsification and trabeculectomy in his right eye. His ocular history is significant for retinal detachment in the right eye that was surgically treated with a pars plana vitrectomy and scleral buckle 5 years prior to the current presentation and 1 year prior to his combined phacoemulsification-trabeculectomy procedure. After trabeculectomy, he reportedly had a wound leak with hypotony and choroidal effusion. The patient was referred to a second surgeon who performed a bleb revision with a pericardial patch graft, but the patient had a severe intraocular pressure (IOP) spike in the immediate postoperative period requiring suture removal. This resulted in recurrent hypotony with maculopathy. A second bleb revision with pericardial patch graft was performed but was not successful in raising the IOP out of the single digits or in resolving the maculopathy. Accordingly, the patient was referred for further assessment. At presentation, the patient's corrected distance visual acuity was 20/100 in the right eye and 20/20 in the left eye. Applanation tonometry IOP was 4 mm Hg and 16 mm Hg for the right and left eyes, respectively. Central corneal thickness was 609 µm in the right eye and 574 µm in the left eye. The right pupil was noted to be slightly irregular with a relative afferent pupillary defect. Slitlamp examination of the right eye was notable for a moderately elevated, Seidel test-negative bleb, and deep anterior chamber. The left eye had a Krukenberg spindle and mild nuclear sclerotic cataract but was otherwise unremarkable. Fundus examination of the right eye was notable for significant macular folds with edematous nerve fiber layer (NFL) and optic nerve. The left optic nerve and fundus examination were unremarkable. Gonioscopy revealed open angles with dense trabecular meshwork pigment in both eyes. There was a nicely patent superior sclerostomy in the right eye. There was no cyclodialysis cleft. Optical coherence tomography (OCT) of the macula showed chorioretinal folds and NFL edema in the right eye and was normal in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202101000-00022/figure1/v/2021-01-04T143903Z/r/image-tiff). The OCT of the optic nerve in the right eye was distorted secondary to the chorioretinal folds, whereas the left eye was notable for mild superior thinning of the NFL (Figure 2JOURNAL/jcrs/04.03/02158034-202101000-00022/figure2/v/2021-01-04T143903Z/r/image-tiff). Humphrey visual field revealed a superior nasal step in the right eye (Figure 3JOURNAL/jcrs/04.03/02158034-202101000-00022/figure3/v/2021-01-04T143903Z/r/image-tiff). Axial lengths were 25.33 mm and 26.53 mm in the right and left eye, respectively; it is notable that the right eye had a shorter axial length despite the scleral buckle, which demonstrates the degree of axial shortening from hypotony (Figure 4JOURNAL/jcrs/04.03/02158034-202101000-00022/figure4/v/2021-01-04T143903Z/r/image-tiff). What would be your approach for managing this patient's hypotony? Does the fact that the referring surgeon had performed 2 failed bleb revision procedures prior to referral influence your approach? Given that a previous attempt at revision resulted in an extreme IOP spike would you also recommend a glaucoma procedure? If so, what procedure would you perform? Would you do it coincident with the revision or in a staged procedure later on an as-needed basis?

Hypotony Without Globe Rupture During Orbital Fracture Repair.

A 29-year-old male presented to the emergency department with an orbital fracture. He denied ocular symptoms and CT showed bilateral fracture of nasal bones, left medial orbital wall, and left orbital floor, with herniation of orbital fat and minimal retrobulbar hematoma. Pre-operative ophthalmic exam was unremarkable. Intra-operatively, intraocular pressure of the left eye was 5 mm Hg, a significant change from 17 mm Hg preoperatively. Globe exploration revealed no injury. Post-operatively, IOP normalized. With these findings it was felt that ocular manipulation related to the orbital fracture repair placed significant and intermittent pressure on the globe, thereby lowering IOP. Laryngoscope, 131:2238-2240, 2021.

Bilateral anterior segment dysgenesis and peripheral avascular retina with tractional retinal detachment in an infant with multiple congenital anomalies-hypotony-seizures syndrome 3.

Background: Multiple congenital anomalies-hypotony-seizures syndrome 3 (MCAHS3) is a rare autosomal recessive disorder caused by mutations in the PIGT gene. PIGT encodes phosphatidylinositol-glycan biosynthesis class T, which plays a crucial role in protein anchoring to cell membranes. The clinical presentation of MCAHS3 is variable in expression and severity, but can be characterized by developmental delay, seizures, hypotonia, facial dysmorphism, and other abnormalities.Materials and Methods: Case report.Results: We report unusual ocular findings including bilateral anterior segment dysgenesis, avascular retinal periphery, and tractional retinal detachment in a 1-month-old male infant with compound heterozygous PIGT mutations consistent with MCAHS3. Whole-exome sequencing did not detect any other genetic abnormalities.Conclusions: This case expands the clinical spectrum of MCAHS3 to include anomalies in ocular anterior segment and retinal vascular development. Given the rarity and the genetic heterogeneity of MCAHS3, giving rise to varied non-ocular phenotypes, it is possible that milder intraocular phenotypes could have gone unrecognized in the past.

[Management of posttraumatic ocular hypotony]. / Management der posttraumatischen Bulbushypotonie.

The posttraumatic ocular hypotony (3% after ocular contusion, 50-74% after open globe injury) can lead to severe secondary damage of the eyeball. In addition to corneal folds, ciliary body and choroidal detachment, papilledema e vacuo and macular folds, the shrinking of the eye can lead to substantial visual impairment. Subsequently, the contralateral eye may react with ocular hypertension. The cause of the hypotony must be identified and causally treated. A preservation of the globe is possible if more than 210 ° of the ciliary body are intact. One of the major causes of posttraumatic hypotony is cyclodialysis. Smaller cyclodialysis clefts respond to a cycloplegic treatment, larger clefts require a surgical approach. The direct cyclopexy can be combined with primary wound repair or pole to pole surgery. An alternative consists of silicone oil endotamponade or occlusion of Schlemm's canal. The posttraumatic ocular hypotony is complex and requires exact diagnostics to be able to differentially and specifically treat the causes of hypotony.

Patient creates filtering bleb: hypotony following traumatic rupture of an old scleral incision for intracapsular cataract surgery.

An 86-year-old woman presented with symptomatic hypotony on the left eye since a few weeks, blurry vision and a very sensitive eye. She had a history of bilateral intracapsular cataract extraction (ICCE) in 1982 and secondary intraocular lens implantation in 1988. The patient mentioned a fall on the left side of the head 6 months earlier. The diagnosis of a superior scleral fistula was made, confirmed by gonioscopy and anterior segment optical coherence tomography. Direct surgical repair of the fistula led to a favourable outcome. This case demonstrates the occurrence of symptomatic hypotony due to the traumatic creation of a scleral fistula with an inadvertent filtering bleb many years after ICCE, and the resolution of signs and symptoms after surgical repair. Conventional as well as contemporary modalities can be valuable in the assessment of such fistulae. Management depends on the clinical course and the mechanism and extent of fistulation.

Severe Hypotony Maculopathy in Anterior Uveitis Associated with Hodgkin Lymphoma.

Purpose: To describe the clinical course and management of anterior uveitis complicated by ocular hypotony associated with Hodgkin lymphoma.Design: Case report.Methods: Chart and multimodal imaging review, including ultrasound biomicroscopy, widefield fundus pictures, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography.Results: A 44-year-old female with progressive visual deterioration and history of low-grade fever developed bilateral granulomatous anterior uveitis complicated by severe hypotony maculopathy, not improving with systemic and topical steroids. After starting ibopamine 2% eye drops, ocular hypotony progressively resolved with visual recovery. Histologic examination of a biopsied enlarged lymph node of the neck revealed the presence of Hodgkin lymphoma, for which the patient underwent systemic chemotherapy.Conclusion: Severe hypotony maculopathy complicating anterior uveitis can be associated with Hodgkin lymphoma. Topical ipobamine 2% was safe and effective in the treatment of ocular hypotony in this case.

Optic Disc Edema and Posterior Globe Flattening Secondary to Ocular Hypotony: Case Report and Discussion Regarding Pathophysiology and Clinical Findings.

ABSTRACT: We describe a case of a young female patient presenting with ocular hypotension (4 mm Hg) secondary to cyclodialysis, and optic disc edema (ODE) after a blunt trauma in the right eye (right eye). MRI showed posterior globe flattening of the right eye, drawing our attention to the pathophysiology behind these findings. The combination of ODE and posterior globe flattening, as observed in the present case of ocular hypotony, is known from other conditions such as intracranial hypertension and space-flight neuro-ocular syndrome, pointing to a common pathophysiological mechanism, possibly resulting from axoplasmic stasis at the level of the lamina cribrosa due to a high translaminar pressure difference.

Pembrolizumab-related Bilateral Ocular Hypotony, Uveitis, Cataracts, Exudative Retinal, and Choroidal Detachments: An Unusual Success Story.

Here, we report the presentation and management of a rare case of sight-threatening bilateral panuveitis with secondary chronic hypotony, subcapsular cataracts, exudative retinal detachments, and choroidal detachments, following initiation of pembrolizumab immunotherapy for metastatic melanoma. An 82-year-old white woman presented with painful, blurry vision 3 days after initiation of pembrolizumab immunotherapy. She had developed a marked panuveitis causing secondary hypotony. The fundal view was entirely limited by acutely dense cataracts and small, uveitic pupils unresponsive to topical dilation. Urgent cataract surgery with intravitreal dexamethasone implant (Ozurdex) was completed successfully and allowed a fundal examination. This revealed bilateral, symmetrical, inferior exudative retinal detachments, and choroidal detachments secondary to chronic hypotony. After 3 months of observation and cessation of oral steroids, the panuveitis remains quiescent, hypotony persists, and the choroidal and retinal detachments are showing progressive self-resolution. The current best-corrected visual acuity is 6/24 OU. She remains under close monitoring. The immune checkpoint inhibitor, pembrolizumab, has been reported to cause sight-threatening adverse effects. We report a rare case of profound bilateral complications treated successfully with oral and intravitreal steroids. To the authors' knowledge, this has not previously been reported in the literature. Ophthalmologists and oncologists should be aware of the ocular effects of pembrolizumab and be able to identify various complications early. Here, cataract surgery with a steroid implant has been an effective sight-saving intervention. The promising visual outcome makes this an unusual success story.

Loss of Pressure Control Resulting from Tube Bending during Glaucoma Drainage Tube Perforations.

PURPOSE: Tube perforations are a common method of achieving early intraocular pressure control with ligated glaucoma drainage devices (GDDs). Our purpose was to investigate how bending GDD tubes affects the performance of needle perforations. DESIGN: Experimental report. PARTICIPANTS: Twenty silicone GDD tubes attached to 27 G Rycroft cannulae tied with 7-0 Vicryl 10 mm from the cannulae tips. METHODS: Silicone GDD tubing was fitted over a 27 G Rycroft cannula and tied with a 7-0 suture 10 mm from the cannula tip. The tube was perforated 4 mm from the cannula tip with a 25 G needle (tube was kept straight). The tube was secured in a 50-mm water bath. Aqueous food dye was infused through the cannula from an adjustable height. The tube was observed under magnification while the height of the fluid column was adjusted to establish the pressure gradient at which the tube leaked dye (opening pressure) and ceased to leak (closing pressure), while the tube was held straight and bent 90 degrees. Measurements were repeated after a second perforation and a third perforation. Ten tubes were tested this way with 3 sequential slits. The entire experiment was repeated with another 10 tubes, but this time the tube was allowed to bend within the 3.5-mm open prongs of a needle holder during needle perforation. MAIN OUTCOME MEASURES: Opening and closing pressures. RESULTS: For each tube, the opening and closing pressures were similar and highly reproducible, but there was wide variation between tubes. In the tubes kept straight when perforated, the opening/closing pressure ranged from 5 to 25 cmH2O. The opening and closing pressures of slits made in the bent tube were significantly lower, frequently leaking at <1 cmH2O. Bending the tube after perforation could close a slit and prevent leakage at high perfusion pressure. The second and third successive perforations caused lower opening and closing pressures. CONCLUSIONS: Tube perforations behave like pressure-sensitive valves, opening whenever intraluminal pressure increases above a specific value. However, we found a large variation in the performance of fenestrations made with a 25-G hypodermic needle. Allowing the GDD tube to bend during needle perforation increases the risk of very low opening and closing pressures.

Intraocular endoscopy for the evaluation and treatment of hypotony due to a traumatic cyclodialysis: a case report.

BACKGROUND: A cyclodialysis cleft often leads to direct communication between the anterior chamber and the suprachoroidal space. It is a rare condition that is encountered with blunt trauma, and less commonly, after surgery. Hypotony is the major sequelae that may lead to hypotonous maculopathy, optic disc edema, corneal folds, and astigmatism. These may cumulatively lead to visual loss. We describe how endoscopy in a cyclodialysis repair allowed us to accurately locate the cleft and guided its appropriate management avoiding unnecessary cryopexy. CASE PRESENTATION: A 41-year-old male experienced a traumatic cyclodialysis cleft, which resulted in persistent hypotony. Pars plana vitrectomy was performed to treat vitreous hemorrhage. Scleral indentation was attempted to visualize the cyclodialysis cleft. However, the depression distorted the visualization. Intraocular endoscopy was therefore used to evaluate the cleft. Guided by this assessment, only intraocular gas tamponade was used to reposition the ciliary body. The patient's intraocular pressure was restored to 13 mmHg 3 days after the operation, and OCT confirmed cleft closure 1 month after the operation. CONCLUSION: Endoscopy-assisted repair of cyclodialysis is an approach that enhances visualization and can guard against common causes of persistent cleft and hypotony, as well as reveal the causes of recurrent failure. Hence, it can eliminate unnecessary cryopexy that might worsen the hypotonous state. In our case, intraocular endoscopy was effective for the evaluation of a cyclodialysis cleft and the subsequent selection of an appropriate management technique, gas tamponade, that was more conservative than other approaches initially considered.