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Presbyopia is a gradual decrease of accommodation that becomes clinically significant during the fifth decade of life. Its pathophysiological changes remain uncertain and controversial. In recent years, Schachar and associates1 suggested that presbyopia occurs because of growth in the equatorial diameter of the lens, and the ciliary muscle contraction can no longer tense the zonule and expand the lens coronally. Based on this theory, scleral expansion by making radial relaxing incisions in the sclera or implanting plastic bands intrasclerally to expand the scleral ring were postulated to restore the accommodation. Although the clinical efficacy of these surgical techniques remains to be proven, they are being offered widely as a means to correct the inevitable ocular affliction of presbyopia. We report an unusual case of glaucoma care in a patient with previous anterior ciliary sclerotomy and scleral expansion procedure.
Report of a Case
A 59-year-old white man had ocular discomfort and evidence of bleb leakage in the left eye. Two years before consultation, he underwent anterior ciliary sclerotomy for presbyopia in both eyes. Six months later, his left eye required glaucoma medication for increased intraocular pressure (IOP). He subsequently underwent a scleral expansion procedure (SEP) for his left eye in an attempt to restore the accommodation and reduce the IOP. Nonetheless, his IOP remained uncontrolled, and he required a trabeculectomy without antimetabolite.
Examination of his left eye revealed best-corrected visual acuity of 20/100 and IOP of 10 mmHg. A small superior conjunctival bleb was noted to be thin, leaking, and extending 3 mm anteriorly onto the superior cornea. The surrounding conjunctiva was hyperemic, scarred, and retracted. Deep conjunctival scars were associated with the insertion sites of 4 silicone expansion bands. Two bands were exposed, and 1 was extruded (Figure 1).
Left eye with conjunctiva hyperemia and scarring, exposed superior nasal scleral expansion band, and filtration bleb migrated anteriorly onto the cornea.
Bleb revision was performed by excision of the anterior extension onto the cornea and the leaky avascular portion of the bleb, with mobilization of the surrounding conjunctiva to cover the trabeculectomy site. The conjunctiva was secured to the limbus with interrupted 9-0 polyglactin sutures at 2 wings. The conjunctiva overlying the expansion bands was dissected, and the bands were removed. Four weeks after surgery, visual acuity improved to 20/30, with the IOP controlled at 12 mm Hg (Figure 2).
Left eye 1 month after bleb revision.
Anterior ciliary sclerotomy involves radial scleral incisions overlying the ciliary body in the 4 oblique quadrants to restore lost zonular tension, thereby improving accommodation according to the controversial Schachar theory.1,2 In SEP, silicone bands are inserted at the depth of the sclerotomy or tunneled into the sclera to counteract rapid regression of the surgical effect of anterior ciliary sclerotomy.2,3
There are conflicting reports that SEP may have an effect on reducing the IOP.2-5 In a prospective, nonrandomized study4 of patients with glaucoma uncontrolled with medication, a median IOP reduction of 7 mm Hg was reported. However, in another prospective small case series, IOP was not modified after SEP.5 The proposed mechanisms of IOP reduction include creation of a localized ciliochoroidal detachment, expansion of the anterior chamber angle, and facilitation of aqueous outflow.2,3 The decreased scleral rigidity from multiple scleral incisions may also result in an artificially lowered IOP by applanation. However, scarring and hardening of sclera or closure of the proposed ciliochoroidal space may ultimately reverse the initial effect.
In our patient, 3 implanted bands were exposed or extruded. Erosion of a foreign body through the conjunctiva is common when the implant is close to the limbus. Even with additional protection with scleral or pericardial grafts to cover the extraocular portion of glaucoma drainage devices near the limbus, glaucoma specialists frequently observe thinning of the overlying graft and conjunctiva over time.
In this case, the conjunctival retraction and foreign body reaction associated with prior peritomies and implanted expansion bands led to aggressive scarring of tissue surrounding the filtration bleb. This tight scarring limits the aqueous filtration and is frequently associated with progressive thinning and bleb leakage. In patients who have undergone a previous SEP, the expansion bands should be removed to eliminate the continuous foreign body reaction in the limbal quadrants and to improve the chance of success with glaucoma surgery.
The authors have no commercial or proprietary interest in any products or methods mentioned in this article.
Corresponding author: Simon K. Law, MD, 100 Stein Plaza 2-235, Jules Stein Eye Institute, Los Angeles, CA 90095 (e-mail: email@example.com).
Law SK, Syed HM, Caprioli J. Glaucoma Care in a Patient With Previous Anterior Ciliary Sclerotomy and Scleral Expansion Procedure. Arch Ophthalmol. 2003;121(11):1646–1648. doi:10.1001/archopht.121.11.1646
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