Recurrent Annular Peripheral Choroidal Detachment after Trabeculectomy
A 54-year-old African-American male with a remote history of prednisone treated polymyositis developed bilateral open angle glaucoma. His past ocular history included trabeculectomy in the right eye, bilateral cataract surgery and the maintenance of topical steroid drops to manage his rebound iritis. On the day of surgery, he reported some mild cold symptoms, but he insisted on having the surgery done. He had an uneventful trabeculectomy with mitomycin C performed on his left eye and did well during the first postoperative week with deep anterior chamber and an IOP in the 7–9 mm Hg range. He was on Vigamox 0.5% (Alcon, Fort Worth, Tex., USA) and prednisolone acetate 1% 4 times a day. He returned for a follow-up on postoperative day 11 with a complaint of persistent left eye pain for the last 3 days. On examination, his visual acuity was 20/80, pin holed (PH) to 20/30, and IOP was 10 mm Hg. His anterior chamber was flat with a complete iris-cornea touch except a 1/5 cornea thickness space between the cornea and the intraocular lens (IOL). The superior fornix-based bleb was slightly elevated without leakage and the peripheral iridectomy was patent. There were severe fibrin exudates in the anterior chamber with a 360° posterior synechiae of the pupil. The retina was flat on fundus exam without scleral depression. The initial differential diagnosis included: overfiltration, pupillary block, aqueous misdirection, choroidal effusion or choroidal hemorrhage. Inflammation was considered to play a role because of his history of steroid dependency, eye pain and copious fibrin in the anterior chamber. He was given oral prednisone 60 mg daily, topical Atropine 1% (Falcon Pharmaceuticals, Ltd., Fort Worth, Tex., USA) and phenylephrine 2.5% (Akorn, Inc., Lake Forest, Ill., USA) to dilate the pupil. Prednisolone was discontinued and Durezol (Difluprednate Ophthalmic Emulsion 0.05%; Alcon) was given one drop every hour []. In addition, he was given a 2-mg dexamethasone subconjunctival injection. Following the application of dilating drops in the clinic, the anterior chamber began reforming and posterior synechiae began to break down. He was sent home with Atropine 1% and phenylephrine 2.5% 4 times a day as well as Durezol every hour. The next morning, his visual acuity was 20/200 (PH 20/60), IOP was 7 mm Hg, and his anterior chamber was flat with cornea-IOL touch. His fundus exam revealed no choroidal detachment or hemorrhage. Healon (Abbott Medical Optics Inc., Santa Ana, Calif., USA) was injected to reform the anterior chamber []. His oral prednisone and topical drops were continued.\nDespite this treatment, the patient returned to the clinic 2 days later. He had a totally flat anterior chamber with a normal fundus and an IOP of 10 mm Hg. Aqueous misdirection was suspected, but peripheral choroidal effusion could not be ruled out. Transverse B-scan using a temporal approach identified a shallow annular anterior choroidal effusion (fig. ). He was taken to the operating room the same day and the suprachoroidal effusion was drained from infero-nasal and infero-temporal sclerotomies []. A moderate amount of light yellow clear fluid was retrieved. The anterior chamber was reformed with Healon (Abbott Medical Optics Inc.) at the end of the surgery aiming at a high IOP to prevent choroidal effusion from recurring. He was continued on oral prednisone 60 mg daily and Durezol every 2 h and dilating drops 4 times a day.\nHis anterior chamber remained deep for 2 days with IOP in the mid-teens. However, on the third day after drainage of the choroidal effusion, the anterior chamber was flat with an IOP of 10 mm Hg. Aqueous misdirection was suspected, but repeat transverse B-scans showed recurrent peripheral choroidal effusion. The patient was taken to the operating room. One sclerotomy wound was reopened and a smaller amount of suprachoroidal fluid aspirated. The conjunctival incision for trabeculectomy was opened and additional 10–0 nylon sutures were placed on the sclera flap. Also, a half-thickness 3 × 3 mm donor scleral patch was placed to reinforce a thin area on the scleral flap. Postoperatively, his anterior chamber was deep with an IOP in the 40's. The IOP was lowered to the 30's over the next 2 days with paracentesis and ocular massage. Suture lysis was performed on the third postoperative day and his IOP decreased to the mid 20's. The patient developed a large corneal epithelial defect postoperatively. The oral prednisone was decreased by 20 mg every 2 days from the initial 60 mg/day, and topical Durezol was decreased from one drop every 2 h to 4 times a day to promote corneal healing.\nThe patient presented 7 days later with counting fingers vision due to diffuse corneal stromal edema and Descemet's membrane folds. The epithelial defect was completely healed and the IOP was 18 mm Hg with a deep anterior chamber. The corneal edema was thought to be due to the rapid steroid tapering. Oral prednisone 60 mg/day was resumed. The first dose of prednisone was given in the clinic and topical Durezol was increased to one drop every 2 h. The patient's corneal edema and Descemet's membrane folds cleared with vision improving to 20/50 the next morning. Oral prednisone was slowly tapered by 10 mg/week, while topical Durezol was continued at one drop every 2 h for 5 weeks, followed by a very slow taper. At this point, his anterior chamber depth stabilized and cornea remained clear. Suture lysis was performed cautiously and as needed. Visual acuity in the eye returned to 20/20 and IOP was 15 mm Hg, 8 months after the initial surgery, without glaucoma drops.