Sir,

Nanophthalmos is characterised by small, hypermetropic eyes and thickened sclera. Patients frequently develop glaucoma and primary uveal effusions (PUEs). Postoperative complications are common.1, 2 We describe the successful treatment of secondary uveal effusions (SUEs) in a nanophthalmic patient with posterior sub-Tenon's triamcinolone (PSTT).

Case report

A 72-year-old Caucasian man was referred with raised IOP (40 mm Hg OD, 30 mm Hg OS). Visual acuity was 6/9 bilaterally (+7.00 DS). Gonioscopy demonstrated open angles (Shaffer grade 1, 90°; grade 2, 270°) with normal anatomy. Central AC depth was 2.0 mm (A-scan measurement inclusive of corneal thickness). Medical treatment failed to control IOP OD, and he underwent uncomplicated trabeculectomy. Postoperatively he developed a large SUE (IOP 20 mm Hg, PI patent, AC shallow, bleb well-formed). Ultrasonography demonstrated thickened sclera with significant SUE (Figures 1 and 2), axial length 20 mm. Aqueous misdirection was excluded and nanophthalmos diagnosed. The SUE resolved initially with topical steroids, atropine, and oral acetazolomide (Figure 3). A recurrence required surgical drainage. A further, later, painful recurrence with dilated episcleral vessels was resolved following administration of oral prednisolone 40 mg. Gastric ulceration necessitated discontinuation with recurrence of SUE. PSTT 40 mg was subsequently successful with sustained effect. Later, cataract surgery was followed by SUE, responding rapidly to repeat PSTT. Final IOP was 20 mm Hg (angle open but pigmented, cup : disc ratio 0.7).

Figure 1
figure 1

Fundus photograph of secondary uveal effusions.

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Figure 2
figure 2

B-scan showing SUVs and thickened sclera.

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Figure 3
figure 3

B-scan showing resolved uveal effusions and thickened sclera.

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Comment

Nanophthalmic patients frequently develop SUE following surgery,3 and it is therefore helpful to be aware of the diagnosis preoperatively. Various strategies have been proposed, from conservative management to surgical drainage.4 Oral steroids can be effective. Deep sclerectomy, sclerotomy, intravitreal triamcinolone, and bevacizumab have been described.4, 5

Here, trabeculectomy alone was appropriate, owing to the absence of cataract and open angle. In combined procedures, the higher cataract complication rate may compromise trabeculectomy success.

Differences may exist in pathophysiology of PUE and SUE. PUE is thought to result from increased resistance to uveoscleral outflow in thickened sclera through impedance of episcleral venous drainage. Surgical drainage is frequently indicated for PUE. SUE may have an inflammatory component. Perhaps, nanophthalmic eyes cannot compensate for increased circulation and exudation accompanying surgical inflammation, explaining an apparent role for steroids.

We have described repeatable SUE resolution following PSTT. Potential secondary IOP elevation should be considered. We propose that this novel approach offers a safe, effective management alternative and also a simple mode of surgical prophylaxis.