Main

Sir,

Needle revision is an accepted method of management for failed or poorly functioning trabeculectomy blebs.1, 2, 3 We report a case of chronic ciliochoroidal effusion occurring after needle revision of failed trabeculectomy bleb in an only eye with poor vision due to cataract. The effusion failed to resolve with conservative management and required subsequent surgical intervention.

Case report

An 80-year-old-woman was referred to a glaucoma team for further management of her glaucoma. She was blind in her left eye from uncontrolled glaucoma. She had had an unaugmented fornix-based right trabeculectomy 8 years previously that had failed. The intraocular pressure (IOP) in the right eye was uncontrolled despite maximal tolerated medical therapy (Guttae Timoptol 0.25% b.d., Guttae Xalatan nocte, and Guttae Trusopt 2% bd).

At presentation she had a flat, scarred right trabeculectomy bleb, the IOP was 22 mmHg OD, and the optic disc was cupped with a vertical cup–disc ratio of 0.8. A right nuclear sclerotic cataract (grade 2+) was noted with almost 360° posterior synechiae. Angles were open with a patent sclerostomy. Snellen visual acuities were 6/36 OD and PL OS.

In order to maximise residual vision, a right phacoemulsification of cataract was planned. A target IOP was set at less than 15 mmHg and the option of combined cataract extraction and trabeculectomy was considered. Prior to any final decision with regards surgical procedure, it was decided to carry out a needle revision of the trabeculectomy bleb. If the bleb could be salvaged and satisfactory IOP control achieved, a combined procedure would be unnecessary.

The patient underwent slit-lamp needling of trabeculectomy bleb with injection of 5-fluorouracil (5-FU). A good flow of aqueous was visualised with reformation of a bleb. At 1 week the bleb had once more flattened and the IOP was 26 mmHg. A further needling with 5-FU injection was undertaken. Postprocedure, the IOP was 6 mmHg with an elevated bleb. After 2 days, the IOP had risen to 12 mmHg and the anterior chamber was shallow. The bleb remained formed with no evidence of leak. Biomicroscopy identified the presence of ciliochoroidal effusions, confirmed and delineated by B-scan (Figure 1). Visual acuity was reduced to 6/60.

Figure 1
figure 1

Biomicroscopy identified the presence of ciliochoroidal effusions, confirmed and delineated by B-scan.

Full size image

It was elected to treat the ciliochoroidal effusions conservatively and over the subsequent 3 months the patient was observed closely with no active treatment. During this period, the anterior chamber was deep and the trabeculectomy bleb remained formed with the presence of numerous microcysts. The IOP was maintained at 9 (± 2) mmHg. Visual acuity progressively deteriorated to hand motion. The ciliochoroidal effusions remained unchanged. It was felt that the visual loss was due to the progression of the cataract and the obstruction of the visual axis by the ciliochoroidal effusions.

The patient remained significantly visually disabled and surgical intervention was planned. In order to minimise the number of surgical episodes and maximise visual rehabilitation, it was decided to undertake drainage of the choroidal effusion combined with phacoemulsification of cataract.

Phacoemulsification of cataract was undertaken through a clear corneal superior section under local anaesthesia. The IOP was maintained during the procedure with Healon™ tamponade in the anterior chamber. An intraocular lens was placed in the capsular bag thereby facilitating fundal visualisation of choroidal drainage. The corneal section was temporarily secured with one suture while ciliochoroidal drainage was undertaken. A conjunctival incision was made and two oblique sclerotomies formed 6 mm posterior to the limbus in the superonasal and superotemporal quadrants. Straw-coloured fluid was expressed by gentle pressure on the posterior lip of the sclerotomy with periodic reformation of the anterior chamber with balanced salt solution (BSS). The fundus was examined until the choroidal effusions had completely flattened. The sclerotomies were closed with 6/0 silk sutures and a firm pressure obtained by injection of BSS via the corneal paracentesis.

The following day visual acuity was 6/12 (pin hole) and the IOP was 13 mmHg. There were no choroidal effusions and the bleb was formed.

At 6-month follow-up, the visual acuity was 6/9 unaided and the IOP was 14 mmHg on no treatment. No ciliochoroidal effusions were present and a draining filtration bleb was noted.

Comment

Slit-lamp needling of failed trabeculectomy blebs with adjunctive 5-FU injection has been shown to be a relatively safe and successful method of lowering IOP.1, 2, 3

Development of ciliochoroidal effusion after needling has been reported previously in the literature.1, 4, 5 Generally effusions settle with conservative management. Serious complications of needling have been reported including suprachoroidal haemorrhage.6

The initial management of ciliochoroidal effusion is conservative as once the hypotony is reversed the detachments normally resolve. Surgical management of chronic ciliochoroidal effusions includes reformation of the anterior chamber with viscoelastic or, if this fails, surgical drainage.

During ciliochoroidal drainage, it is important to minimise anterior chamber collapse to prevent the risk of suprachoroidal haemorrhage and further extension of the ciliochoroidal effusions in a hypotonus eye. Anterior chamber maintainers or higher density viscoelastic agents may be utilised to this effect.

It may be argued that removing the cataract alone may have resulted in resolution of the ciliochoroidal effusions, thereby avoiding the additional risks of choroidal drainage. The authors feel, however, that this would have led to a significant delay in visual rehabilitation in view of the absence of useful vision in the fellow eye.