a 65-year - old female came to our clinic with the chief complaints of foreign body sensation and watering from her left eye ( os ) for the past 2 months . the best - corrected visual acuity of the patient was 6/6 in right eye ( od ) and 6/9 os . the intraocular pressure ( iop ) was 14 mmhg od and 4 mmhg os . on slit - lamp examination , there was a circumferential elevated and avascular bleb extending nasally and inferiorly along the limbus os [ fig . the anterior chamber was shallow but formed , and cornea was clear enough to allow the view of posterior segment . optic disc od revealed a vertical cup - to - disc ratio of 0.5 while the same was 0.9 os with greater inferior neuroretinal rim loss . the patient was instilling timolol maleate 0.5% eye drops bid od and 2 hourly lubricating eye drops os . ( a ) top row  slit - lamp photograph of left eye ( at presentation ) showing a diffuse high bleb spreading nasally and inferiorly along the limbus . ( b and c ) middle row  preparation of eye for laser photocoagulation , by staining with gentian violet . ( d and e ) bottom row  slit - lamp photograph of left eye ( 6-week postintervention ) showing limitation of spread of bleb nasally as well as inferiorly bleb revision with a photocoagulative frequency - doubled nd : yag ( 532 nm ) pea - green laser was planned the same day , in accordance to the technique previously described by the authors . a few drops of topical anesthetic and antibiotic were instilled in the involved eye , and the nasal part of the bleb was painted with gentian violet ( gv ) to enhance the effect of the laser . a few shots were given ( 0.3 w for 0.15 s with a spot size of 300500  ) on the conjunctiva in a barrage fashion on the nasal aspect between the cornea and the canthus . however , no reduction in the bleb was seen immediately due to the excessively accumulated fluid [ fig . 1b and c ] . a photodisruptive nd : yag ( 1064 nm ) laser shot of 5 mj energy in a single - burst mode was then given to puncture the inferior dependent portion of the bleb . the photocoagulative frequency - doubled nd : yag ( 532 nm ) laser was then again attempted on the previous site , i.e. , nasally , with success this time around . antibiotic eye drops along with topical lubricants were used in qid dosage for the next 4 days . at 1-week follow - up , bleb was found to have flattened both on the nasal as well as the inferior aspects [ fig . , visual acuity was noted 6/6 and the iop had stabilized at 8 mm os without any antiglaucoma medication . bleb dysesthesia is a commonly encountered problem in good filtering blebs due to the widespread use of antifibrotic agents , which at times may be severe enough to warrant a definitive intervention . nonsurgical and surgical techniques for the management of these symptomatic blebs include the use of lasers ( nd : yag , and argon in the past ) , compression sutures , bleb window cryopexy , and bleb reduction . overhanging blebs can also be surgically trimmed from the cornea with successful relief of symptoms and improvement in visual acuity . a procedure termed as bleb - limiting conjunctivoplasty for the treatment of circumferential the authors have also previously described successfully a technique to reduce overhanging as well as nasally spreading blebs in a small series of patients . the same technique was attempted in a similar way in this patient . however , due to height of the bleb , the effect of scarring did not get registered . an attempt to decrease height of the bleb on the nasal side was then made by draining the fluid out through a yag puncture at the inferior dependent site , using photodisruptive nd : yag laser ( 1064 nm ) . this proved to be helpful , and as soon as the inferior bleb was drained , frequency - doubled nd : yag ( 532 nm ) laser , i.e. , photocoagulative laser along with the dye was again given on the nasal aspect , with success . it is important to watch for a scleral melt , in which case the anterior chamber is in direct communication with the bleb . the scleral melt is invariably seen in eyes with old trabeculectomy , and the area of scleral absence can usually be visualized subconjunctivally . in such a situation or where conjunctival bogginess precludes a proper view of scleral bed , inspite of attempting conjunctival blanching by applying pressure , this procedure should be avoided . since this was not seen , rest of the procedure could be carried out in the described manner and required flattening achieved . in addition , the clinician should be prepared to deal with a loss of iop control . furthermore , a risk of infection and endophthalmitis exists due to creation of an iatrogenic leak . though the surgical techniques have been well described to correct the condition , there is an inherent risk of bleb failure , need for iop - lowering medications , bleb leaks , suture infection , and endophthalmitis . in addition , laser treatment , being a quick outpatient procedure , is preferable for both the surgeon and patient . however , it is not uncommon to encounter high blebs precluding laser penetration leading to need for multiple treatment sessions and also occasional failures . use of photodisruptive nd : yag laser ( 1064 nm ) can be considered in such cases .
this case report aims to highlight the role of photodisruptive neodymium - doped yttrium - aluminum - garnet ( nd : yag ) ( 1064 nm ) laser in the treatment of bleb dysesthesia , which occurs in overhanging blebs or with perilimbal spread . 
 although treatment of such dysesthetic blebs with laser photocoagulation has been previously described , cases where the height of bleb precludes laser penetration , desired effect might not be seen . 
 we herein describe a technique using a combination of photocoagulative ( 532 nm ) and photodisruptive ( 1064 nm ) nd : yag laser for a high bleb migrating nasally and inferiorly along the limbus in a 64-year - old female , causing hypotony and consequent macular edema . 
 successful reduction could be achieved within a week of treatment . by 6 weeks 
 , intraocular pressure improved to 8 mmhg , macular edema subsided , and visual acuity improved to 6/6 . 
 although surgical procedures to correct bleb dysesthesia are available , laser procedures being quick outpatient modalities are more comfortable for the patients .