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Hyperoleon in filtering bleb
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  1. Anand Naik Bukke,
  2. Tanuj Dada,
  3. Karthikeyan Mahalingam and
  4. Sikshya Moharana
  1. Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institue of Medical Sciences, New Delhi, India
  1. Correspondence to Dr Anand Naik Bukke; naikanand6461{at}gmail.com

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Description

A middle-aged male patient presented to the glaucoma clinic for a routine follow-up examination. He had a history of undergoing vitreoretinal surgery with silicone oil insertion in the right eye, 6 years ago. Eight months following primary surgery, the patient developed intractable secondary glaucoma with silicone oil emulsification (hyperoleon) for which silicone oil removal was performed. Despite silicone oil removal, intraocular pressure (IOP) was not controlled (32 mm Hg on maximum tolerable glaucoma medications) and the patient underwent trabeculectomy augmented with mitomycin C after 2 months of silicone oil removal. The best-corrected visual acuity was 20/40 (−2DS/ −1DC @ 180°) at the present follow-up. Slit-lamp examination showed the presence of hyperoleon in the moderately elevated bleb (figure 1), and anterior segment optical coherence tomography imaging supported the same finding. The IOP was 12 mm Hg (on two topical hypotensive drugs). Fundus evaluation revealed a vertical cup disc diameter ratio of 0.9:1, with a thin inferior neuroretinal rim.

Figure 1

(A) Magnified image of the bleb (red arrow) showing hyperoleon in the bleb, (B) slit illumination showing hyperoleon superiorly and (blue arrow) showing demarcation between hyperoleon and aqueous humour in the bleb.

Hyperoleon can cause silicomacrophagocytic open-angle glaucoma.1 2 Even after silicone oil removal, hyperoleon can persist in the angle of the anterior chamber, which can lead to an elevated IOP. Trabeculectomy has a lower success rate in such eyes, due to pre-existing conjunctival fibrosis and the presence of hyperoleon which can migrate through the trabeculectomy ostium into the filtering bleb causing inflammation and obstruction to the aqueous outflow. Ahmed glaucoma valve surgery has shown to have a better success rate compared with trabeculectomy in these eyes.3 4 Hyperoleon in filtering bleb can mimic blebitis, air bubbles postcataract surgery or an encysted bleb.

Patient’s perspective

I am happy that my disease is treated adequately by my doctor.

Learning points

  • Emulsified silicone oil can cause intractable secondary glaucoma.

  • Its migration into subconjunctival space through ostium can adversely impact the outcomes of trabeculectomy.

  • In such cases, glaucoma drainage devices have a better success rate compared with glaucoma filtration surgery.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors ANB was involved in data acquisition, manuscript drafting, preparation, intellectual input and approved the first manuscript. KM was involved in data acquisition and intellectual input. TD was involved in intellectual input and approved the final manuscript. SM was involved in data acquisition.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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