PMC5077236_01
The upper eyelid is trapped behind an engorged and very large superotemporal filtering bleb.. Note: The lower eyelid is in normal position.
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A 56-year-old African-American female presented to the emergency department with right eye pain and inability to close her eye following the instillation of her glaucoma drops (Figure 1). The bleb was injected but seidel negative and extended from the limbus posteriorly for approximately 16 mm and circumferentially from 8:30 to 1:00 (Figure 1).
Computed tomography image of the orbit demonstrates the superiorly subluxed globe with a superotemporal Ahmed valve (arrow).. Notes: Both globes are normal in size and shape. The orbits are shallow with no evidence of intraorbital tumor, rectus muscle enlargement, or inflammatory process. The right globe appears to be 2 mm proptotic compared to the left.
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Computed tomography scan of the orbits (Figure 2) showed shallow orbits with no intraorbital masses, rectus muscle enlargement, or inflammatory changes.
Bleb needling was performed with a 30 guage needle under topical anesthesia.. Notes: The needle is introduced 1-2 mm from the bleb surface and advanced subconjunctivally until the internal fibrous capsule is perforated (black arrow). The needle is retracted without removing it from the subconjunctival space (blue arrow) and advanced again to perforate the capsule a second time (red arrow). The needed is then withdrawn from the eye (yellow arrow). Both nasal and temporal needling were performed.
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Under topical anesthesia at the slit lamp, a 30-guage needle was passed transconjunctivally in the superonasal quadrant perforating the internal fibrous capsular wall of the bleb (Figure 3).
Postoperative appearance of the patient after needling and repositioning of the upper eyelid in front of the globe.. Note: The bleb can be seen to be diffuse for 360 .
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At this point, the globe was successfully reposited by pinching and pulling the upper eyelid anteriorly and up while placing gentle posterior pressure on the globe while the patient looked down (Figure 4).