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JAMA Ophthalmology Clinical Challenge
February 2018

A 70-Year-Old Man With Pain and a Creamy Elevated Lesion After Transscleral Cyclophotocoagulation

Author Affiliations
  • 1Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
JAMA Ophthalmol. 2018;136(2):209-210. doi:10.1001/jamaophthalmol.2017.3067

A 70-year-old man with diabetes and a history of bilateral ocular trauma from a remote gunpowder explosion with resulting bilateral cicatricial lagophthalmos, corneal and conjunctival scarring, and secondary open-angle glaucoma developed persistently elevated intraocular pressures (approximately 30 mm Hg) in the right eye while receiving maximal medical therapy. His baseline visual acuity was count fingers OD. Transscleral cyclophotocoagulation (TSCPC) was recommended over filtering surgery because of extensive conjunctival scarring and lagophthalmos. Transscleral cyclophotocoagulation was performed with 19 spots (1300-1500 mW) at 3 seconds each, without audible pops, and sparing the superotemporal quadrant. The day after treatment, the patient was comfortable with an intraocular pressure of 23 mm Hg. Two weeks later, he developed pain and redness while receiving a steroid taper, and examination revealed episcleritis and a small scleral depression temporally. Topical prednisolone therapy was increased; however, during subsequent weeks, his pain intensified. Examination on postoperative day 37 revealed stable visual acuity of count fingers, intraocular pressure of 19 mm Hg, no hypopyon, but a diffusely injected conjunctiva with a creamy fluctuant elevated lesion temporally (Figure).

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