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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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  Table of Contents 
Year : 2020  |  Volume : 27  |  Issue : 4  |  Page : 241-243  

Overfiltering Bleb en Route to Annular Ciliochoroidal Effusion

1 Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
2 Department of Urgent and Emergency Care Centre, Rotherham General Hospital, Rotherham, UK

Date of Submission26-Jul-2020
Date of Acceptance14-Dec-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Essam A Osman
Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, P. O. Box: 245
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/meajo.MEAJO_340_20

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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.

Keywords: Annular ciliochoroidal effusion, aqueous misdirection mimicker, overfiltering bleb, shallow anterior chamber, trabeculectomy

How to cite this article:
Jamjoom H, Osman M, Osman EA. Overfiltering Bleb en Route to Annular Ciliochoroidal Effusion. Middle East Afr J Ophthalmol 2020;27:241-3

How to cite this URL:
Jamjoom H, Osman M, Osman EA. Overfiltering Bleb en Route to Annular Ciliochoroidal Effusion. Middle East Afr J Ophthalmol [serial online] 2020 [cited 2021 Sep 22];27:241-3. Available from: http://www.meajo.org/text.asp?2020/27/4/241/307403

   Introduction Top

Ciliochoroidal effusion is an abnormal accumulation of fluid in the suprachoroidal space, a well-known complication of glaucoma surgery.[1] However, this may result from other intraocular surgeries and a number of conditions, including inflammatory, infectious diseases, trauma, neoplasms, drug reactions, and venous congestion.[2] Idiopathic causes fall under the umbrella of uveal effusion syndrome, a rare condition that is usually considered a diagnosis of exclusion.

Ciliochoroidal effusion must be integrated in the differential diagnosis of shallow or flat anterior chamber with low intraocular pressure (IOP) after trabeculectomy with mitomycin C, however, overfiltration, wound leak, cyclodialysis cleft, and serous choroidal detachment should be ruled out.[3]

   Case Report Top

A 75-year-old diabetic male, complaining of poor vision in both eyes for a long duration had a history of central retinal vein occlusion in the right eye with multiple anti-VEGF injections in both eyes and vitrectomy in the left eye for vitreous hemorrhage. On examination, visual acuity (VA) in the right eye was counting finger at 5 meters, with IOP) of 17 mmHg on full topical anti-glaucoma medications, immature cataract with pseudoexfoliation, advanced optic disc cupping, severe nonproliferative diabetic retinopathy, and open-angle with narrow approach on gonioscopy. The left eye was pseudophakic with hand motion VA, IOP of 14 mmHg on full anti-glaucoma medications, 280° closed-angle on gonioscopy, pale optic disc, and ischemic retina.

In view of advanced pseudoexfoliative glaucoma with immature cataract in the right eye on full antiglaucoma medications, decision was made after consent for combined trabeculectomy with MMC (0.2mg/ml for 2 minutes) and phacoemulsification as well as intraocular lens (IOL) implantation. Operation went uneventful without complications. The first post-operative visit showed that VA was 20/400, IOP was 5 mmHg with formed diffuse conjunctival bleb without leak with moderate AC depth, patent iridectomy, and the IOL in place with good red reflex and flat retina. The patient was given ofloxacin and prednisolone acetate 1% 4 times a day. He was seen after one week with counting finger VA, IOP 4 mmHg, well-formed huge bleb, and shallow AC with iridocorneal touch in which pressure patch to bleb was applied in the clinic to decrease the overfiltering bleb, but the trial failed. The patient was admitted to the hospital for the reformation of the AC under topical anesthesia; the situation improved on table but relapsed on the 2nd day as the AC got shallow again. At that time, a decision was made to revise the bleb under local anesthesia and more sutures were applied to the scleral flap of trabeculectomy with closure of conjunctiva. Postoperative review showed unrecordable IOP, moderate AC depth, and minimal bleb leak that was treated with mega contact lens applied to the cornea. Within 2 days, leak stopped and AC got shallow again. Ultrasound biomicroscopy (UBM) was done and revealed ciliochoroidal effusion [Figure 1]. A diagnosis of ciliochoroidal effusion mimicking aqueous misdirection was settled. Atropine and frequent topical steroid drops were advised. After 5 days, the AC became well-formed and the cornea was clear. The VA was 20/400 and IOP 14 mmHg [Figure 2]. The patient was followed for one month with the same last picture and controlled IOP [Figure 3] and [Figure 4].
Figure 1: Ultrasound biomicroscopy showed flat AC and ciliochoroidal effusion

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Figure 2: Deep AC with decreased effusion

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Figure 3: Slit-lamp picture showed deep AC

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Figure 4: Slit-lamp picture showed the bleb after stopped leak

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   Discussion Top

Overfiltering or a bleb leak is a common cause of hypotony which can be a risk factor for choroidal effusions after glaucoma surgery especially with the use of mitomycin C, and also a significant risk factor for prolonged hypotony.[4]

Vision-threatening complications, including shallowing of the anterior chamber, PAS formation, cataract, corneal decompensation, choroidal effusion, suprachoroidal hemorrhage, endophthalmitis, and hypotony maculopathy, can be secondary to untreated overfiltration or bleb leaks.[4]

Shallow anterior chamber after glaucoma surgery is not uncommon and may be associated with low, normal, or high IOP. Suprachoroidal hemorrhage and pupillary block should be ruled out in shallow AC with high IOP.

In general, any condition that results in a low IOP can be considered a risk for ciliochoroidal effusion development.[5] In our case, an old age patient with relatively high axial length, 24 mm, with the probability of loosely closing the sclera flap, all these are risk factors to have overfiltration and its sequelae. A trial of pressure patch over the upper lid for 10 minutes while the patient was in sitting position and looking straight ahead and slightly down had been applied before the decision was made to reform the AC, revise the bleb, and add more sutures to the sides of trabeculectomy flap.

Pravin and Dugel et al.[5] reported 18 patients diagnosed initially as aqueous misdirection, but they were found subsequently to have annular peripheral choroidal detachment; ten eyes were treated medically similar to our case and eight eyes were treated by surgical drainage.

Grigera and Moreno.[6] presented 15 patients with flattening of the anterior chamber following filtering surgery, all his patients were hypotensive or normotensive when examined, and all displayed a supraciliary effusion on UBM. These effusions were not detected clinically and they were not apparent on B-scan in a large number.

Liu et al.[7] reported a similar case of choroidal effusion mimicking aqueous misdirection drained twice and diagnosed with transverse B scan. In our case, bleb overfiltration was the major risk factor for ciliochoroidal effusion. Tight closure of sclera flap is essential step to avoid overfiltation then you can titrate the bleb with suture lysis. Bleb compression suture was in mind in our case but because of very thin conjunctiva and high bleb, we preferred to go for revision and apply more suture to sclera flap.

In conclusion, we believe that annular peripheral choroidal detachment should be included in the differential diagnosis of the shallow or flat anterior chamber after glaucoma surgery. Overfiltering bleb can be due to loose sclera flap that needs bleb revision and re-suturing. Ciliochoroidal effusion can be treated medically in a simple way by using frequent topical steroids and atropine eye drops.

Informed consent

An informed consent was obtained from the patient for the anonymous use of the images and to publish the findings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Bellows AR, Chylack LT Jr, Hutchinson BT. Choroidal detachment. Clinical manifestation, therapy and mechanism of formation. Ophthalmology 1981;88:1107-15.  Back to cited text no. 1
Callahan C, Ayyala RS. Hypotony and choroidal effusion induced by topical timolol and dorzolamide in patients with previous glaucoma drainage device implantation. Ophthalmic Surg Lasers Imaging 2003;34:467-9.  Back to cited text no. 2
De Barros DS, Navarro JB, Mantravadi AV, Siam GA, Gheith ME, Tittler EH, et al. The early flat anterior chamber after trabeculectomy: A randomized, prospective study of 3 methods of management. J Glaucoma 2009;18:13-20.  Back to cited text no. 3
Al Habash A, Aljasim LA, Owaidhah O, Edward DP. A review of the efficacy of mitomycin C in glaucoma filtration surgery. Clin Ophthalmol 2015;9:1945-51.  Back to cited text no. 4
Pravin U, Dugel MD. Annular peripheral choroidal detachment simulating aqueous misdirection after glaucoma surgery. Ophthalmology 1997;104:439-44.  Back to cited text no. 5
Grigera D, Moreno C. Ultrasound biomicroscopy in eyes with a nterior chamber flattening after trabeculectomy. Can J Ophthalmol 2002;37:27-33.  Back to cited text no. 6
Liu S, Sun LL, Kavanaugh AS, Langford MP, and Liang C. Recurrent annular peripheral choroidal detachment after trabeculectomy. Case Rep Ophthalmol 2013;4:192-8.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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