Surprise beneath the scleral patch graft

Background: Success of glaucoma surgery depends on the bleb status. It is determined by the extensive process of healing and wound remodeling that occurs after surgery. [1] Blebs fail either due to scarring or due to overfiltration and leaking. Hypotony secondary to overfiltration following trabeculectomy has reported incidences of 1–18%. [2] Mild overfiltration in the early postoperative period with no associated complications is managed conservatively, whereas persistent hypotony needs intensive management. [3] We present an interesting case which shows management of challenging overfiltering bleb. A 40-year-old male presented with bilateral blurring of vision. He had undergone bilateral cataract extraction with trabeculectomy at the age of 8, followed by multiple scleral patch grafts 5 years ago. Examination revealed intraocular pressures (IOP) of 4 mmHg in the right eye and 6 mmHg in the left eye, along with bilateral overhanging, diffuse blebs. He was planned for compression sutures with possible bleb exploration in the left eye. One week postoperatively, IOP improved to 18.9 mmHg with resolution of choroidal detachment. Purpose: The case report presents an interesting and rare presentation of late-onset scleral necrosis manifesting as ocular hypotony, which adds valuable insight to the clinical literature on post-trabeculectomy complications. Synopsis: Intraoperative bleb exploration revealed multiple necrotic scleral areas underlying the previous graft, responsible for chronic hypotony. After excision of the previous patch grafts, a crescentic banana scleral patch graft was placed over the defect and sutured to provide tectonic support and restore ocular stability. Highlights: This case illustrates the critical role of surgical intervention in managing late-onset scleral necrosis. Banana scleral patch grafting serves as an effective technique for structural reinforcement. Video Link: https://youtu.be/BMzpr-jGBgY