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Purpose: To evaluate the predictive value of initial intraocular pressure difference of the detached and fellow eyes of patients with complex rhegmatogenous retinal detachment on postoperative persistent ocular hypotony., Methods: This retrospective observational study included 538 eyes of 538 unilateral complex rhegmatogenous retinal detachment patients with a proliferative vitreoretinopathy grade of C-1 or higher, treated with silicone oil endotamponade following pars plana vitrectomy. The patients were divided into Group A (patients having silicone oil removal without ocular hypotony; n=504) and Group B (patients with persistent ocular hypotony following silicone oil removal [n=8, 23.5%] and with retained silicone oil [n=26, 76.5%] due to the risk of persistent ocular hypotony; total n=34). Ocular hypotony was defined as an intraocular pressure of <6 mmHg on two or more occasions. Patients' demographics, including age, sex, and follow-up time, and ocular characteristics, including ocular surgical and trauma history, initial and final best-corrected visual acuity, intraocular pressure and initial intraocular pressure difference of the detached and fellow eyes, and anatomical success rates and postoperative complications, were retrospectively collected from the electronic patient files., Results: The initial intraocular pressure was significantly lower in the detached eyes of Group B than in Group A (8.3 ± 3.5 vs. 12.9 ± 3.3, p<0.001). Also, the initial intraocular pressure difference was significantly higher in Group B than in Group A (8.9 ± 3.2 vs. 2.2 ± 2.7mmHg, p<0.001). The receiver operating characteristic curve analysis showed that the cutoff value of the initial intraocular pressure difference was 7.5mmHg for the risk of persistent ocular hypotony. The most influential factors on postoperative persistent ocular hypotony in the binary logistic regression analysis were the initial intraocular pressure difference and the need for a retinectomy., Conclusion: In eyes with complex rhegmatogenous retinal detachment treated with pars plana vitrectomy and silicone oil tamponade, the initial intraocular pressure difference could be of value in predicting postoperative persistent ocular hypotony and could guide surgeons on the decision of silicone oil removal.

Competing Interests: The authors report no conflicts of interest.

Prcis: Bleb revision procedures for hypotony maculopathy (HM) following glaucoma filtering surgery show promising outcomes, including notable improvements in visual acuity and IOP., Purpose: This study assesses morphologic characteristics using SD-OCT in patients with HM following glaucoma filtering surgery and evaluates the results of its treatment., Materials and Methods: A retrospective analysis of all HM patients between January 2019 and March 2023. Inclusion criteria consisted of both preoperative and postrevision SD-OCT images of the macula and the presence of HM as observed on OCT images preoperatively. HM was graded according to its appearance in OCT both prerevision and postrevision surgery. Changes in visual acuity and IOP were assessed., Results: A total of 45 eyes of 45 patients were included. In all, 21 eyes had HM limited to retinal pigment epithelium (RPE), 18 eyes had involvement of RPE and photoreceptor layers, and 6 eyes had additional intraretinal or subretinal edema. After revision surgery with IOP elevation, 64% of eyes had complete HM regression with no HM signs in OCT imaging. Overall, 80% of patients achieved at least 1 grade improvement in HM. Preoperative visual acuity increased from 0.7±0.4 (logMAR) to 0.4±0.4 at 2 weeks postoperatively, over the course of an increase of IOP from 3.5±1.8 to 17.1±10.6 mm Hg at day 1. Eyes with complete HM regression had higher IOP at day 1 compared with those without improvement ( P =0.04). The median time between HM onset and revision was 10.0 days for those with complete regression and 27 days for those without improvement ( P =0.04)., Conclusions: Bleb revision procedures for HM following glaucoma filtering surgery show promising outcomes, including notable improvements in visual acuity and IOP. The timing of revision surgery appears to influence the outcome. In our study, earlier intervention was associated with better results. Even delayed surgeries can lead to an improvement, although complete morphologic restoration may not be achieved in advanced grades of HM., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Hypotony is a rare postoperative complication of strabismus surgery. Resolution has been reported to occur within 1 month of surgery. Here, we describe the case of a 14-year-old boy with prolonged hypotony maculopathy following uneventful bilateral medial rectus recession. The hypotony resolved without long-term sequela after 7 months of treatment with topical steroids and atropine. Ultrasound biomicroscopy revealed a ciliary body effusion, which we hypothesize was the cause of decreased aqueous humor production and hypotony., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Prcis: Intraluminal 3-0 Supramid stent placement can be an effective long-term solution for hypotony after glaucoma drainage device surgery. This procedure may obviate the need for conjunctival dissection. In some cases, additional procedures are required., Purpose: To describe the utility of implantation of a multifilament polyamide suture (Supramid) in the tube lumen to reverse hypotony after glaucoma drainage device (GDD) surgery., Patients: Patients who underwent tube revision with intraluminal placement of a 3-0 Supramid stent, with or without external ligature, to manage hypotony following GDD surgery between January 2010 and October 2020., Methods: Resolution of hypotony was defined as IOP >5 mm Hg and the absence of hypotony-related structural abnormalities. Overall success was the absence of failure criteria (IOP ≤5 mm Hg, >21 mm Hg, or <20% reduction below baseline IOP after 3 months for 2 consecutive study visits; additional glaucoma surgery; or loss of light perception), with or without adjunctive ocular hypotensive therapy., Results: Nine eyes of 9 patients underwent placement of a 3-0 Supramid stent with a resolution of hypotony in all eyes with a mean follow-up duration of 33.3 ±24.0 months. Overall success was achieved in 7 of 9 eyes. Four eyes required intervention after stent placement: 1 eye required selective laser trabeculoplasty followed by replacement of the original stent with a shorter 3-0 Supramid suture and external ligature; 1 eye underwent revision for tube exposure; and 2 eyes underwent laser suture lysis to release an external suture ligature., Conclusions: In cases of hypotony after GDD, particularly when it is desirable to reduce the extent of additional conjunctival dissection, intraluminal placement of a 3-0 Supramid stent via an intracameral approach can be an effective long-term solution. Postoperative adjustments were required in many cases., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

With the recent advancement in technologies, real-time integrated intraoperative optical coherence tomography (iOCT) microscopes are available, which facilitates surgical precision and also reduces the risk of complications. Two glaucoma patients with advanced glaucomatous optic neuropathy, who underwent uneventful trabeculectomy with 0.02% mitomycin C, developed persistent hypotony postoperatively till 4-6 weeks. On clinical examination, visual acuity was 1/60 with low intraocular pressure (IOP) of 4 mmHg. Elevated, overfiltering bleb was seen on slit-lamp examination, along with hypotonous maculopathy. Anterior segment optical coherence tomography (AS-OCT) showed multiple large hyporeflective fluid spaces suggestive of overfiltering bleb. Considering the risk of choroidal detachment and further deterioration of vision, iOCT-guided transconjunctival bleb suturing was planned. iOCT helped to identify the exact location of scleral flap, and transconjunctival suturing was done with successful outcomes in terms of improved IOP and visual acuity., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Background: To investigate the outcome of non-valved glaucoma drainage implant surgery (GDIS) in primary open-angle glaucoma (POAG) patients divided in the first GDI group (patients who underwent the first GDIS) and the second GDI group (patients who underwent the second GDIS because of the failed first GDIS)., Methods: Intraocular pressure (IOP), visual acuity (VA), visual field defect (VFD), medication score (MS), survival rate of GDIS, complications, and patient background was retrospectively analyzed. Two success criteria were set: Criteria (1) IOP reduction ≥ 20% and 5 < IOP ≤ 21, Criteria (2) IOP reduction ≥ 20% and 5 < IOP ≤ 14., Results: There were 136 eyes of 109 patients in the first GDI group and 32 eyes of 27 patients in the second GDI group. In the first GDI group and II, mean preoperative IOP was 26.7 ± 6.7 mmHg and 23.7 ± 3.5 mmHg, respectively (P = 0.09). No statistically significant difference in postoperative IOP reduction was found between the two groups (P = 0.39). At 5-years postoperative, the Criteria 1 (Criteria 2) survival rate in the first GDI group and the second GDI group was 60.4% (31.7%) and 61.2% (25.6%), respectively (Criteria 1: hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.30-1.35 [P = 0.24]; Criteria 2: HR: 0.81, 95% CI: 0.46-1.44, P = 0.48). No significant difference in VA, VFD change, MS, or complications was observed. Young patient age was the only significant factor for failure in the first GDI group (odds ratio: 0.95, 95% confidence interval: 0.91-1.00, P = 0.03)., Conclusion: The second GDIS may be as effective as the first GDIS for IOP reduction in POAG patients, however, there is a high risk of failure in young-age patients and the surgery may be ineffective in eyes requiring Criteria 2., (© 2023. The Author(s).)

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., Competing Interests: Competing interests: The authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To describe a case of prolonged hypotony and choroidal detachment following insertion of a Preserflo™ MicroShunt in a patient with primary open-angle glaucoma (POAG)., Case Report: An 84-year-old Caucasian man with medically uncontrolled POAG developed refractory hypotony and choroidal detachment following a mitomycin C augmented Preserflo MicroShunt (PMS) insertion. Initial medical treatment with Dexamethasone 2 mg/mL and Atropine 1% for the hypotony (4 mmHg) and choroidal detachment was unsuccessful, BCVA decreased from the preoperative 20/28 to 20/60. After 90 days, surgery revision was carried out by inserting a 10-0 nylon monofilament suture through the distal end of the PMS reaching the opposite end of the tube. The free end of the nylon suture was exposed from the conjunctiva in the inferotemporal quadrant close to the fornix to ensure access to the occlusive stent. After one month intraocular pressure (IOP) was 7 mmHg, the choroidal detachment was completely regressed, and best corrected visual acuity (BCVA) increased to 20/28, at that time the exposed part of the stent was trimmed. 6 months after the revision surgery IOP was 14 mmHg, BCVA was 20/25, and the nylon stent was retained side to side inside the PMS lumen., Conclusion: The management of hypotony and choroidal detachment after a glaucoma drainage device (GDD) implantation is still unstandardized. The ab externo insertion of a nylon suture grants multiple advantages over the other techniques when performed on a PMS tube.

Background: To report one-year outcomes from a single-centre cohort undergoing PAUL® Glaucoma Implant (PGI) surgery., Methods: Retrospective review of patients undergoing PGI surgery at the University Eye Hospital Bonn, Germany, from April 2021 to September 2021., Results: Forty-five eyes of 41 patients were included. Qualified and complete success rates (95% CI) were 95.6% (88.9%-100%) and 73.3% (60%-86.7%) for Criterion A (IOP ≤ 21 mmHg), 84.4% (73.3%-93.3%) and 74.4% (51.1%-80.0%) for Criterion B (IOP ≤ 18 mmHg), 62.2% (48.9%-75.6%) and 46.7% (31.2%-62.2%) for Criterion C (IOP ≤ 15 mmHg) and 26.7% (13.3%-40.0%) and 22.2% (11.1%-33.3%) for Criterion D (IOP ≤ 12 mmHg), respectively. Mean IOP decreased from 26.1 mmHg (7-48 mmHg) to 12.0 mmHg (3-24 mmHg) (reduction of 48.83%) after 12 months with a reduction of IOP-lowering agents from 0.5 (0-3). One eye (2.2%) needed an injection of viscoelastic due to significant hypotony with AC shallowing, and four eyes (8.9%) developed choroidal detachments due to hypotony which resolved without further interventions after 6 weeks. Three patients (6.7%) developed tube exposure which required conjunctival revision with an additional pericardial patch graft. An intraluminal prolene stent was removed in 19 eyes (42.2%) after a mean time period of 8.4 months (2-12 m). Mean IOP before the removal was 21.9 mmHg (12-38 mmHg) and decreased to 11.3 mmHg (6-16 mmHg)., Conclusions: PGI surgery is an effective procedure for reducing IOP and pressure-lowering therapy. An intraluminal prolene stent impedes hypotony in the early postoperative phase and enables further IOP lowering without additional interventions during the postoperative course., (© 2023 The Authors. Clinical & Experimental Ophthalmology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Ophthalmologists.)

During extraocular muscle surgery, an uneventful scleral suture pass is very essential. In presence of normal intraocular tension, the surgery is quite predictable and safe. However, in the presence of significant hypotony, it becomes challenging. Therefore, to mitigate complication rate in these cases, we have adopted a simple technique, that is, the "pinch and stretch" technique. The surgical steps of this technique are as follows: In eyes with significant ocular hypotony, the surgery is initiated with a routine forniceal/limbal peritomy, following which the muscle is sutured and dis-inserted. Using three tissue fixation forceps, the scleral surface is stabilized. Using first forceps, the surgeon rotates the globe toward themself from the muscle stump, and with the remaining two forceps, the assistant pinches and stretches the episcleral tissue in an outward and upward direction just beneath the intended marks. This creates a flat scleral surface with significant firmness. Sutures are passed over this rigid sclera and the surgery is completed without any complications., Competing Interests: None

Objectives: To describe the efficacy and safety of goniotomy with trabecular meshwork excision using the Kahook Dual Blade (KDB, New World Medical Inc., Rancho Cucamonga, CA) in patients with severe or refractory glaucoma., Methods: This retrospective multicentre case series reports on 40 eyes with severe or refractory open-angle glaucoma that underwent standalone or combined KDB goniotomy and were followed for 12 months post-operatively in the United-States, Mexico and Switzerland. Surgical success was defined as an intraocular pressure (IOP) reduction ≥20% from baseline at 12 months, with fewer medications than preoperatively. Mean IOP and antiglaucoma medication reduction, probabilities of achieving an IOP ≤16 or 18 mmHg, and adverse events were also analysed., Results: Mean IOP decreased from 18.1 ± 5.0 mmHg at baseline to 14.8 ± 3.7 mmHg at 12 months (18.2% reduction, P < 0.001). Concomitantly, the mean number of glaucoma medications decreased from 2.5 ± 1.4 to 1.7 ± 1.2 (32% reduction, P = 0.002). The proportion of eyes achieving an IOP reduction of more than 20% from baseline was 37.5% (n = 15) at 12 months. At 12 months, 67.5% and 82.5% achieved a medicated IOP ≤ 16 and ≤18 mmHg, respectively. No severe complications were reported., Conclusion: Excisional goniotomy with KDB achieves a statistically significant IOP and antiglaucoma medication reduction in severe or refractory glaucoma over a period of 12 months. While its efficacy decreases with time, its favourable safety profile makes it a potentially useful primary or adjunctive procedure in high-risk eyes., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

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., (© 2022. The Author(s).)

Purpose: To report a case of bilateral uveitis and hypotony associated with topical cidofovir treatment., Methods: Case report., Results: A 59-year-old diabetic man with HIV/AIDS presented with photophobia, ocular pain, and decreased vision. He was found to have bilateral hypotony, anterior uveitis, and serous choroidal detachments. Infectious disease workup, patient-reported history, and review of the patient's electronic medication list did not identify the etiology. Treatment with intensive topical corticosteroids led to resolution of uveitis and choroidal effusions within 3 months and resolution of hypotony within 9 months. Two years after his initial presentation, the patient developed acute recurrence of bilateral hypotony, anterior uveitis, and serous choroidal detachments shortly after intravenous cidofovir treatment. Careful reevaluation of the patient's outside medical records revealed that he had initiated treatment for rectal herpes simplex virus with compounded topical cidofovir one month before his initial presentation., Conclusion: To our knowledge, this is the first reported case of topical cidofovir causing ocular toxicity. Compounded and topical medications, like cidofovir in this case, may not appear on a patient's electronic medication list, so a focused review of outside medical records may be beneficial when a particular medication toxicity is suspected.

Competing Interests: Competing interests: None declared.

Purpose: To analyze the risk factors and ocular hypotony characteristics of choroidal detachment (CD) after penetrating glaucoma surgery and to compare between eyes with and without CD., Methods: This retrospective study enrolled 173 eyes of 168 patients. Patients who underwent trabeculectomy or Ahmed glaucoma valve implantation due to medically uncontrolled glaucoma and who had intraocular pressure (IOP) < 9 mmHg at any time during the first postoperative week were included., Results: The study population consisted of 61 (36.3%) females and 107 (63.7%) males with a mean age of 60.7 ± 14.2 years. The postoperative median follow-up time was 24 months (range, 12-40 months). Postoperatively, CD developed in 47 (27.1%) eyes. Multivariate analyses demonstrated that eyes with high preoperative IOP (> 40 mmHg) were 12.1 times more likely to develop CD (p = 0.000) and that presence of IOP < 9 mmHg on the first day of surgery increased the CD risk 3.8 times (p = 0.002); male gender raised the risk 2.7 times (p = 0.028). The mean preoperative IOP in CD eyes was significantly higher than in non-CD eyes (p = 0.000). The mean IOP change between preoperative and lowest IOP was significantly greater in those with CD than in those without CD (p = 0.000). The mean lowest IOP in the CD eyes was significantly lower than in the non-CD eyes (p = 0.037). For the surgical failure rate, no significant difference was found between the CD and the non-CD groups (p = 0.14)., Conclusions: The present study demonstrated that high preoperative IOP, presence of IOP < 9 mmHg on the first postoperative day, and male gender were significantly associated with CD after penetrating glaucoma surgery. Choroidal detachment accompanied by hypotony did not affect the final outcome negatively., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To identify the risk factors for a recurrence of a bleb-related infection (BRI)., Study Design: Retrospective cohort study., Methods: The medical records of all patients diagnosed with BRI at Gifu University Hospital between January 1989 and December 2020 were reviewed. The time when conjunctival hyperemia could not be detected and when the anterior chamber was quiet were defined as the resolution time of the BRI. The primary endpoint was a recurrence of a BRI. Kaplan-Meier estimation and the Cox proportional hazards model were used to determine the risk of a recurrence from the initial onset data of each eye. Bacteriological studies were performed to determine the pathogen causing the BRI., Results: There were 108 eyes of 103 patients followed for at least 3 months after the initial BRI. A recurrent bleb infection developed in 21 (19.4%) eyes of 21 patients (13 men, 8 women). Log-rank test at the 10-year follow-up examination revealed that hypotony at the onset of the BRI (P=0.004), the prophylactic use of topical antibiotics at the onset of the BRI (P=0.046), and bleb leakage after the resolution of the BRI (P=0.021) were significantly associated with a BRI recurrence. Cox proportional hazards model showed that ocular hypotony at the onset of the BRI (unadjusted, P=0.007; adjusted for bleb leakage, P=0.015) and bleb leakage after the resolution of the BRI (unadjusted, P=0.027; adjusted for hypotony, P=0.024) were significantly associated with a BRI recurrence. Other factors were not significantly associated with the recurrence of a BRI., Conclusion: We recommend close observations when a bleb leakage is detected after the BRI has resolved., (© 2022. Japanese Ophthalmological Society.)

A female patient in her late 70s underwent uncomplicated non-penetrating deep sclerectomy surgery. Three years after surgery, she presented with a sudden decrease in visual acuity, intraocular pressure (IOP) of 2 mmHg, macular folding and significant macular subretinal fluid. Assuming hypotony as the cause, topical dexamethasone was started, with complete functional and imagological improvement. Two months after withdrawal, she returned with the same symptoms and imagological findings. The same topical treatment was re-established, with progressive and complete improvement. After 14 months of follow-up and a maintenance dose of topical dexamethasone (1id), the patient remained stable with an IOP of 16 mm Hg. Hypotony maculopathy can, in rare cases, lead to subretinal fluid and neurosensory detachment. Topical corticosteroids can reverse and prevent hypotony in patients who are corticosteroid responsive. In advanced glaucoma, extremely low IOP may be as dangerous as high IOP. Timely normalisation of IOP may restore normal retinal architecture with associated functional improvement., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

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., Competing Interests: None

Introduction: To investigate the incidence and causes of intraoperative choroidal detachment (CD) during small-gauge vitrectomy, as well as the anatomic and visual outcomes., Methods: We retrospectively reviewed the medical records of 1026 consecutive patients who underwent small-gauge vitrectomy from June 2017 to December 2018 at Zhongshan Ophthalmic Centre, Guangzhou, China. Data on the presence, location, and extent of intraoperative CD and its relationship to the infusion cannula were collected. Patient demographic characteristics and postoperative anatomic and visual outcomes were also assessed., Results: A total of six cases were found to have intraoperative CD, including two with serous CD, three with limited haemorrhagic CD, and one with CD caused by inadvertent perfusion of gas during air/fluid exchange. Retraction of the infusion cannula and acute ocular hypotony were found to be the main causes of intraoperative CD in five out of the six cases. The best-corrected visual acuity of all cases significantly improved after the surgery., Conclusion: The incidence of intraoperative CD during small-gauge vitrectomy is low; the predominant causes are retraction of the infusion cannula and acute ocular hypotony. Immediate awareness and timely closure of the incision may contribute to a better surgical prognosis., (© 2021. The Author(s).)

Purpose: Late hypotony is an undesirable and challenging complication of glaucoma surgery. We describe our use of the Ologen Collagen Matrix to treat late hypotony developing after trabeculectomy., Study Design: A retrospective study performed at three eye surgery centers in Brazil., Participants: Eighteen patients who underwent 19 eye surgeries., Intervention: Subconjunctival Ologen was implanted at the trabeculectomy sites to treat over-filtering or leaking blebs in patients experiencing late hypotony after trabeculectomy (obtained 6 months after glaucoma surgery). The primary outcome was the intraocular pressure (IOP); we gathered preoperative data records from 19 Ologen treated eyes and days 1, 7, 30, 60, and 180 postoperatively. The secondary outcomes included visual acuity and macular thickness measured via optical coherence tomography; we compared preoperative data to subsequent ones up to sixth-month-evolution., Results: Over the 6-month period, the IOP rose from 2.89 ± 1.59 mmHg preoperatively to 8.21 ± 3.46 mmHg ( p  = 0.0001). Visual acuity improved from 0.33 ± 0.29 to 0.21 ± 0.31 LogMar ( p  = 0.0013). Macular thickness fell from 325.62 ± 58.7 to 283.08 ± 47.35 µm ( p  = 0.0097). We encountered two complications: one related to suture dehiscence following an ocular trauma and one instance of transitory choroidal detachment., Conclusion: Subconjunctival Ologen implants preserved bleb function and successfully treated post-trabeculectomy hypotony as revealed by data collected at the 6-month follow-up. Longer follow-up is necessary to confirm long-term efficacy and safety. There are no financial conflicts of interest to disclose.

Purpose: To evaluate the 2-year surgical treatment outcome in glaucoma patients., Methods: A retrospective, single-center, interventional study was performed on 160 eyes of 125 patients suffering glaucoma, including POAG (82 eyes), pseudoexfoliation (PEX) (59 eyes), pigment dispersion (8 eyes), and secondary glaucoma (2 eyes). Eyes with uncontrolled intraocular pressure (IOP) or signs of glaucoma progression despite medical treatment were included to undergo either trabeculectomy (TE), XEN implantation, combined TE with phacoemulsification (TE + IOL), or XEN implantation with phacoemulsification surgery (XEN + IOL). Primary efficacy outcome was the mean IOP reduction. Secondary outcome was the mean reduction in the number of medications. The data were compared at baseline vs.1 day, 1 week, and 1, 3, 6, 12, and 24 months following surgery. For statistical evaluation, ANOVA-based linear mixed-effects models were performed with SPSS., Results: The mean IOP reduction in a 2-year follow-up was 30.31% (22.17 vs. 15.45 mmHg, p < 0.001). The mean number of antiglaucoma medications was reduced from 2.87 to 0.58 (p = 0.001), where TE alone or combined surgeries seemed to be more effective than isolated XEN surgery. Transient IOP hypotony on the first postoperative day occurred in PEX patients following TE surgery (p = 0.024). At 6 months, PEX patients with isolated XEN surgery showed a transient IOP increase, whereas those after combined TE + IOL surgery showed the lowest IOP within the PEX group compared to other glaucoma patients (p < 0.026)., Conclusions: After 2 years, all performed glaucoma surgeries achieved a significant reduction in IOP and the number of antiglaucoma medications., Competing Interests: All authors share same contribution and declare no conflict of interest., (Thieme. All rights reserved.)

We present a previously undescribed case of a persistent hypotony maculopathy secondary to an iatrogenic cyclodialysis cleft created during XEN-45 gel stent insertion. We present this case as a further analysis of the Karimi et al case of cyclopexy by the corresponding surgeon. Following right XEN-45 implantation, our patient developed immediate and persistent postoperative hypotony for 4 weeks. Gonioscopy revealed a small cyclodialysis cleft at the 1-2 o'clock position. The cyclodialysis cleft was sealed with direct gonioscopic argon laser cyclopexy. Two months after laser treatment and total of 6 months post XEN-45 insertion, right eye visual acuity returned to 6/4 with intraocular pressure 11 mm Hg without any glaucoma medication. Here, we present details of the non-invasive safe and successful management of hypotony maculopathy secondary to the cleft using Argon laser gonio cyclopexy, with no requirement of return to theatre., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hypotony secondary to overfiltration is a recognized complication following trabeculectomy. Persistent hypotony requires intervention ., Purpose: We describe a modified version of placing conjunctival compression sutures directly over the scleral flap., Synopsis: A 70-year-old male patient diagnosed with primary open angle glaucoma in both eyes underwent combined surgery in the right eye. On the tenth post-operative day, the patient presented with severe hypotony with 360ª choroidal detachment. He was treated with corticosteroids and cycloplegics but developed hypotony maculopathy on the subsequent follow-up. Hence, he was further managed surgically by trans-conjunctival flap sutures to which he responded favorably with resolution of choroidal detachment and improvement in intraocular pressure and visual acuity., Highlights: Transconjunctival suturing of the scleral flap is an effective and minimally invasive treatment to prevent visual loss from hypotony maculopathy for an overfiltering bleb following trabeculectomy., Online Video Link: https://youtu.be/BJtUZcyQZ-w., Competing Interests: None

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., Competing Interests: None

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., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

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., Competing Interests: None

To evaluate the effects of the discontinuation of antithrombotic drugs on intraocular pressure (IOP) reduction and complications from ab interno trabeculotomy for patients with glaucoma. We performed a retrospective chart review on the data of patients treated with antithrombotic agents who have undergone ab interno trabeculotomy through Tanito microhook combined with cataract surgery at the Asahi General Hospital and the Tokyo University Hospital, with 6 months of follow-up. The patients were classified into two groups depending on whether they discontinued (AT-) or continued (AT+) antithrombotic therapy during the perioperative phase. The demographics, pre- and postoperative IOP, medication score, best-corrected visual acuity (BCVA), and postoperative complications were analyzed preoperatively and postoperatively at 1 week and 1-6 months. The series included 44 eyes from 44 Japanese patients. The AT- and AT+ groups included 21 eyes from 21 patients and 23 eyes from 23 patients, respectively. The decrease in IOP from the baseline at 1 week postoperative was significantly different between the two groups (p = 0.009), but there were no significant differences observed in the other visits. Hyphema and IOP spikes exceeding 30 mmHg occurred in 10% and 10% of AT- participants, and in 43% and 26% of AT+ participants, respectively. Hyphema and spikes with hyphema occurred more frequently in the AT+ than in the AT- group (p = 0.02 and p = 0.05). The number of patients who had spikes was not significantly different (p = 0.27). In trabeculotomy using the Tanito microhook®, discontinuing antithrombotic therapy had better IOP-lowering effects and less postoperative complications., Competing Interests: The authors have declared that no competing interests exist.

The main aim of glaucoma treatment is to reduce the intraocular pressure (IOP). One of the most common surgical treatments of glaucoma is the implantation of a glaucoma drainage device to drain the aqueous humor from the anterior chamber to a filtration bleb, where the aqueous humor is absorbed. In some cases, the excess of drainage causes ocular hypotony, which constitutes a sight-threatening complication. To prevent hypotony after this intervention, surgeons frequently introduce a suture into the device tube, which increases the hydraulic resistance of the tube and, therefore, the IOP. This study aims to provide an analytical model to correct hypotony following implantation surgery of a glaucoma drainage device, which may help glaucoma surgeons decide on hypotony treatment. The results indicate that the IOP after implanting a cylindrical tube around 300 μm in diameter is essentially the same as that built up in the filtering bleb and can hardly be controlled by introducing a straight suture unless the suture diameter is slightly lower than that of the tube. On the contrary, when the tube diameter is smaller than, for example, 100 μm, significant reductions of the IOP can be obtained by introducing a thin suture into the tube., (© 2021. The Author(s).)

Competing Interests: The authors have no conflicts of interest to declare.

Cyclodialysis clefts are often associated with ocular hypotony and attendant maculopathy. However, these clefts create an alternative aqueous outflow pathway that can be useful to maintain intraocular pressure (IOP) at physiologic levels under some conditions. At normal levels of IOP, they might prevent glaucoma damage and avoid maculopathy of hypotony. Indeed, historically, cyclodialysis was a planned surgical method for managing glaucoma, and more recently, a minimally invasive glaucoma surgery device that created a small-stented cyclodialysis was in use until removed from the market for unrelated concerns. Cataract surgery in the presence of a cleft, however, might be complicated by extensive fluid misdirection through the cleft with resultant large suprachoroidal effusion. A technique of ab interno temporary suture cyclopexy was devised for a patient needing cataract surgery with an existing traumatic cyclodialysis cleft that was vital for long-term management of IOP. The suture was used to close the cleft transiently during surgery and was removed at the close of the procedure to reestablish patency and preserve the cleft., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

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., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To asses the course of intraocular pressure (IOP) restoration and visual acuity (VA) recovery in eyes with hypotony after trabeculectomy., Methods: Medical charts of patients undergoing trabeculectomy between January 2017 and June 2019 were reviewed. Cases with hypotony (IOP < 5 mmHg) due to over-filtration in the early postoperative period were assessed retrospectively. Primary outcome measures included change in IOP and VA in the postoperative period and percentage of eyes with hypotony on each follow-up., Results: Thirty-five eyes of 31 patients (23 male, 8 female) were included. The mean follow-up was 18.3 ± 6.9 months. The mean IOP was 3.0 ± 3.2, 9.2 ± 6.2, 9.4 ± 5.6, 9.4 ± 4.0, 10.9 ± 3.6 and 10.2 ± 3.3 mmHg at week 1, months 1, 3, 6, 12 and last follow-up, respectively. Out of 35 hypotonic eyes, 8 (22.8%) had prolonged hypotony at month 1, 4 (11.4%) at month 3, 1 (2.9%) at month 6. The decrease in VA continued to be significant at months 1 and 3 (p = 0.015, p = 0.036, respectively) and returned to baseline after the sixth month (p > 0.524)., Conclusions: In eyes with early hypotony after trabeculectomy while low IOP recovers at first month, it takes longer for the visual restoration. The postoperative month 1 appears to be decisive for recovery of hypotony., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Precis: Postsurgical hypotension at 1 week and the presence of an epiretinal membrane (ERM) were significant risk factors for the deterioration of postsurgical visual acuity (VA) at 3 and 12 months, respectively., Purpose: The purpose of this study was to assess the effects of an ERM and postsurgical hypotension <6 mm Hg at 1 week on postsurgical VA loss., Patients and Methods: A total of 69 patients (69 eyes) who underwent trabeculectomy with adjunctive mitomycin C between 2017 and 2019 (mean follow-up period: 22.8 mo) were enrolled, and 14 parameters that could be associated with the deterioration of VA at 3 and 12 months were studied., Results: There was a significant association between VA loss at 3 months and postsurgical intraocular pressure at 1 week (P=0.006 by multiple regression) and hypotony maculopathy (P=0.024 by Fisher exact test). However, this association was lost at 12 months. Instead of postsurgical hypotension, the presence of an ERM was significantly associated with VA loss at 12 months (P=0.035 by Fisher exact test, and P=0.023 by logistic regression)., Conclusions: Postsurgical hypotension at 1 week was significantly associated with mid-term, but not long-term, postsurgical VA loss. The presence of an ERM, which was not a risk factor for mid-term acuity loss, was a significant risk factor for VA loss at 12 months., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Hypotony maculopathy has been classically reported as a complication of glaucoma surgery or ocular trauma. There have been only a few reports of hypotony maculopathy following pars plana vitrectomy (PPV). Here, we report two cases of hypotony maculopathy occurring after PPV for epiretinal membrane (ERM) removal and characteristic photoreceptor folds observed on optical coherence tomography (OCT)., Case Presentation: A 53-year-old Korean woman (case 1) underwent phacoemulsification and posterior chamber lens implantation combined with 25-gauge PPV for ERM removal in the right eye. On the following day, she had severe ocular hypotony, with an intraocular pressure (IOP) that was unmeasurable using a pneumatic tonometer. Despite normalization of IOP, macular retinal and photoreceptor folds with photoreceptor disruptions developed, and Henle's fiber layer hyperreflectivity was identified. Thereafter, retinal and photoreceptor folds gradually disappeared but photoreceptor disruption and Henle's fiber layer hyperreflectivity did not improve until 1 year postoperatively, with persistent central visual field distortion and visual acuity worse than that at the preoperative state. A 20-year-old Korean man (case 2) underwent an additional 25-gauge PPV for ERM removal in the left eye. Examination on the following day showed ocular hypotony and retinal folds with peripheral choroidal detachment. Although IOP was normalized, further OCT revealed photoreceptor folds and photoreceptor disruptions. Since then, the photoreceptor folds resolved; however, the photoreceptor disruption remained in the macula at the 1-year follow up, with persistent distorted vision and visual acuity worse than that at the preoperative state., Conclusions: Early hypotony after vitrectomy for ERM could result in maculopathy leading to irreversible visual decline and metamorphopsia. Photoreceptor folds on OCT are characteristic features and the predominant mechanism of central visual loss in cases of hypotony maculopathy.

Purpose: Bleb dysfunction may occur as a late complication following glaucoma filtration surgery. Over-filtering, thinning and cystic blebs can lead to hypotony, leak and corneal dellen. We report our surgical management and outcomes of this specific entity using donor scleral patch grafts., Methods: This is a 10-year non-comparative, retrospective interventional case series. Bleb reconstruction involved excision of encysted conjunctiva and sclera to identify the original fistula. A functioning donor scleral patch graft was sited over this with fixed and releasable sutures and the conjunctiva advanced. Intraocular pressure, visual acuity and post-operative issues were assessed., Results: A total of 18 eyes of 17 patients with mean age 65 years (standard deviation 13.5) were included. Trabeculectomy was the primary procedure in 72% ( n  = 13) and deep sclerectomy in 28% ( n  = 5). Bleb leak accounted for 61% ( n  = 11), hypotony 33% ( n  = 6) and corneal dellen 6% ( n  = 1). Mean pre-operative intraocular pressure was 7 mm Hg (standard deviation 4.6) which increased to 18.5 mm Hg (standard deviation 12) at day 1 ( p  < 0.001), 11.8 mm Hg (standard deviation 4.6) at 3 months ( p  < 0.05), 12.1 mm Hg (standard deviation 4.2) at 1 year ( p  < 0.01) which was maintained at 12.1 mm Hg (standard deviation 5.3) at last follow-up ( p  < 0.001). Post-operative interventions included bleb needling, re-suturing, suture removal, further glaucoma management, bleb leak and cataract surgery. Visual acuity also improved post-operatively and was maintained., Conclusion: Reconstruction of the filtering bleb architecture with donor sclera results in improved intraocular pressure while maintaining visual acuity. Post-operative care is required to support the restored bleb function. Our findings support the use of scleral patch graft as an effective and safe method for the long-term management of hypotony and bleb leak as a late complication of glaucoma filtration surgery.

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.

Prcis: Treatment of leakage with ocular hypotony after trabeculectomy with mitomycin C (MMC) can be safely achieved through conjunctival patch alone or combined with donor scleral graft in cases of melted underlying sclera., Purpose: To report outcomes of 2 surgical approaches for treating ocular hypotony in eyes with blebs with late-onset leakage after standard trabeculectomy with MMC., Methods: Thirty consecutive cases with bleb leakage and hypotony underwent bleb revision surgery between 2009 and 2014 by the same surgeon (J.W.) at the Department of Ophthalmology of the Mainz University Medical Center, Germany. In 18 patients, an autologous conjunctival patch graft was applied. In 12 patients, the underlying sclera was found melted and an additional scleral donor graft was sutured in place. The authors analyzed intraocular pressure, visual acuity, and optical coherence tomography of the macula preoperatively at 1 day, 1 week, 4 weeks, and 6 months after surgery., Results: The mean IOP was 6.2±3.5 mm Hg preoperatively and 21.7±16.4 mm Hg at 1 day, 13.7±6.7 at 1 week, 13.1±5.1 mm Hg at 4 weeks, and 12.1±4.7 mm Hg at 6 months after surgery. Visual acuity (logMar) increased from 0.57±0.49 preoperatively to 0.49±0.40 at 6 months. Optical coherence tomography showed flattening of macular folds that were present before treatment. No serious adverse event was reported., Conclusions: This revision technique with conjunctival patch and/or additional donor scleral graft is an effective and safe method for treating late bleb leakage and hypotony maculopathy after trabeculectomy with MMC., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Annular ciliochoroidal effusion is a rare condition that can complicate trabeculectomy. We report a case of ciliochoroidal effusion mimicking aqueous misdirection after combined glaucoma and cataract surgery. A 75-year-old male with pseudoexfoliation, chronic angle-closure glaucoma, and advanced optic disc damage developed ciliochoroidal effusion after a combined trabeculectomy and phacoemulsification with intraocular lens implantation. The patient presented with overfiltering bleb, hypotony, and a uniformly shallow anterior chamber that mimicked aqueous misdirection in the clinical picture. Reformation of anterior chamber followed by revision of the bleb was performed. Ultrasound biomicroscopy confirmed the diagnosis. Atropine and steroid eye drops improved the condition. Ciliochoroidal effusion should be ruled out in hypotony with shallow anterior chamber post glaucoma surgery., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Middle East African Journal of Ophthalmology.)

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., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)