PMC3617541_01
(a) This pre-operative photograph demonstrates a large avascular bleb superonasally in the patient's left eye, (b) This photograph taken 8 months post-operatively demonstrates a thick-walled diffuse bleb superonasally
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F1
Examination revealed an avascular bleb superonasally [Figure 1a], with a well-controlled intraocular pressure (IOP) in the mid-to upper single digits. Seven months post-operatively, the patient demonstrates a large thick-walled bleb, and IOP measures 10 mmHg [Figure 1b].
(a) This intraoperative photograph demonstrates an 8 mm by 8 mm conjunctival defect superonasally following excision of the avascular bleb, (b) This intraoperative photograph demonstrates subconjunctival and subtenon's dissection in preparation for creation of a rotational flap
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F2
Due to the previous conjunctival incision for a limbus-based trabeculectomy, the remaining conjunctiva retracted, leaving a large conjunctival defect measuring 8 mm by 8 mm [Figure 2a]. An equal-sized limbal peritomy was created (distance between points B and C = distance between points A and B, Figure 3a). Figure 2b demonstrates intraoperative conjunctival peritomy and dissection. A relaxing incision (distance between points C and D) was created to facilitate the extension of the conjunctival flap for the closure.
Diagrammatic representation of rotational conjunctival flap creation. (a) An equal size of peritomy (distance B to C = A to B) and a relaxing incision (point C to D) were made, (b) The conjunctiva at point (B) has been rotated to cover the conjunctival defect (A). The prepared conjunctival flap can be then rotated to cover to defect (from points D   C   B  A), (c) The incisions can be closed with running polyglactin sutures
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F3
Figure 3a). An equal-sized limbal peritomy was created (distance between points B and C = distance between points A and B, Figure 3a). Figure 2b demonstrates intraoperative conjunctival peritomy and dissection. A relaxing incision (distance between points C and D) was created to facilitate the extension of the conjunctival flap for the closure. The prepared conjunctival flap was then rotated to cover the large defect [Figure 3b]. Figure 3c demonstrates the resultant closure.