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| CASE REPORT |
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| Year : 2018 | Volume
: 56
| Issue : 4 | Page : 261-262 |
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A case of hypotony maculopathy after aqueous drainage implant
A Sudarvizhi, V Sharmila Devi, M Ananda Babu
Department of Ophthalmology, Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Chennai, Tamil Nadu, India
| Date of Web Publication | 19-Feb-2019 |
Correspondence Address:
Dr. V Sharmila Devi
No. 2 A, 4th Block, Ramaniyam Apartments, 8th Main Road, Shanthi Colony, Anna Nagar, Chennai - 600 040, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjosr.tjosr_101_18
A 60-year-old male presented with defective vision and low intraocular pressure (IOP) in the left eye (LE) following cataract surgery combined with aqueous drainage implant which was done elsewhere 2 months ago. In the right eye (RE), he presented with primary angle closure glaucoma and Grade 2 nuclear sclerosis. In LE, scleral patch graft with loose sutures with shallow anterior chamber and nonvalved aqueous drainage implant with fundus features suggestive of hypotony maculopathy were noted. The patient underwent tight compression suturing of scleral patch graft with intracameral sodium hyaluronate injection for LE and clear corneal phacoemulsification with trabeculectomy with releasable sutures with Mitomycin-C 0.02% for RE. Postoperatively, visual acuity and IOP in LE were improved and in RE postoperative outcome was successful with no complications.
Keywords: Aqueous drainage implant, hypotony maculopathy, releasable sutures
How to cite this article:
Sudarvizhi A, Devi V S, Babu M A. A case of hypotony maculopathy after aqueous drainage implant. TNOA J Ophthalmic Sci Res 2018;56:261-2 |
| Introduction | |  |
Hypotony maculopathy is a significant complication that has been associated with loss of visual acuity following filtering surgery.[1] It requires timely intervention as intraocular pressure (IOP) correction in long-standing maculopathy may not improve vision.[1],[2] Herein, we report a case of hypotony maculopathy following filtration surgery which was timely intervened with a good outcome.
| Case Report | | |
A 60-year-old male presented with a complaints of defective vision in the left eye (LE) for the past 1 month. He had cataract surgery combined with aqueous drainage implant done in his LE elsewhere 2 months ago. On examination, best-corrected visual acuity in the right eye (RE) was 6/60 and hand movements in LE. IOP by applanation tonometry was recorded as 40 mmHg in RE and 6 mmHg in LE. Slit lamp examination showed Van Herrick's Grade 2 anterior chamber depth and Grade 2 nuclear sclerosis in RE. LE showed scleral patch graft with loose sutures with shallow anterior chamber and nonvalved aqueous drainage implant in anterior chamber and posterior chamber intraocular lens [Figure 1]a. All angles were closed on gonioscopy of RE, and it was not done in LE as there was hypotony. Fundus examination of RE was within normal limits, and LE fundus examination showed disc edema and radiating internal limiting membrane folds away from fovea suggestive of hypotony maculopathy [Figure 1]b. Automated perimetry of RE showed inferior arcuate scotoma and could not be done in LE as the visual acuity is low. | Figure 1: (a) Anterior segment image of the left eye with scleral patch graft and aqueous drainage implant in the anterior chamber. (b) Fundus of left eye showing hypotony maculopathy. (c) Posttreatment fundus of left eye showing resolved maculopathy
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For LE, tight compression suturing of scleral patch graft with intracameral sodium hyaluronate injection was done. For RE, clear corneal phacoemulsification with trabeculectomy with releasable sutures with Mitomycin-C (MMC) 0.02% was done [Figure 2]. Postoperatively, visual acuity and IOP in LE were 6/60 on the 5th postoperative day, and 14 mmHg and in RE were 6/6 P and 14 mmHg. Posttreatment fundus of LE showed resolved maculopathy [Figure 1]c.
| Discussion | | |
Hypotony maculopathy is ocular hypotony complicated by papilledema and/or folding of the retina and choroid in the posterior pole.[2] Male sex, young age, myopia, and primary filtering surgery with an antifibrotic agent are all risk factors associated with hypotony maculopathy.[2] The incidence of hypotony maculopathy has been on the increase after the introduction of antimetabolites in glaucoma filtering surgery.[1],[2]
Treatment options include conservative methods such as pressure patching or bandage contact lenses to prevent excess filtration, conjunctival compression sutures, scleral flap revisions, anterior chamber gas, intravitreal gas, and vitrectomy with perfluorocarbon gas.[2] Patients with a shallow anterior chamber and overfiltrating blebs following a recent trabeculectomy can be treated successfully with a combination of a long-acting gas and a viscoelastic material.[3] Herein our case, hypotony with a shallow anterior chamber in LE was successfully managed with intracameral viscoelastics injection and tight compression suturing of the scleral patch graft. Postoperatively, IOP was improved from 6 to 14 mmHg and visual acuity regained from hand movements to 6/60.
Hypotony and its related sequelae, choroidal effusions, or suprachoroidal hemorrhage, are more common with the nonvalved drainage devices.[2],[4] Intraoperative prompt scleral tunnel dissection and in open nonvalved tube models, ligature of the tube prevents hypotony.[2],[4] The releasable suture technique for trabeculectomy has the advantage of technical ease and of not requiring a laser and further no incidence of shallow anterior chamber in the postoperative period.[5],[6] Here, in our case, the other eye with primary angle closure glaucoma with immature cataract was managed with phacoemulsification with trabeculectomy with releasable suture with MMC 0.02%. Postoperatively, IOP was brought to 14 mmHg with no incidence of flat anterior chamber.
| Conclusion | | |
Hypotony after a filtering surgery requires timed intervention and it restores visual acuity in these patients. Releasable sutures for trabeculectomy and ligatures around the nonvalved tube in the implant can prevent hypotony.
Declaration of the patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Costa VP, Arcieri ES. Hypotony maculopathy. Acta Ophthalmol Scand 2007;85:586-97.  |
| 2. | Thomas M, Vajaranant TS, Aref AA. Hypotony maculopathy: Clinical presentation and therapeutic methods. Ophthalmol Ther 2015;4:79-88. |
| 3. | Kurtz S, Leibovitch I. Combined perfluoropropane gas and viscoelastic material injection for anterior chamber reformation following trabeculectomy. Br J Ophthalmol 2002;86:1225-7. |
| 4. | Rathi Shweta G, Seth Natasha G, Kaur Savleen. A prospective randomized controlled study of Aurolab aqueous drainage implant versus Ahmed glaucoma valve in refractory glaucoma: A pilot study. IJO 2018;66:1580-5. |
| 5. | Zhou M, Wang W, Huang W, Zhang X. Trabeculectomy with versus without releasable sutures for glaucoma: A meta-analysis of randomized controlled trials. BMC Ophthalmol 2014;14:41. |
| 6. | Thomas R, Jacob P, Braganza A, Mermoud A, Muliyil J. Releasable suture technique for trabeculectomy. Indian J Ophthalmol 1997;45:37-41. [ PUBMED] [Full text] |
[Figure 1], [Figure 2]
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