Hypotony After Trabeculectomy in a Patient With Juvenile Idiopathic Arthritis- Associated Uveitis

CA SE PRE SENTATION An 11-year-old girl presented to our clinic with glaucoma in her left eye secondary to juvenile idiopathic arthritis-associated uveitis. The patient’s right eye was pseudophakic after undergoing a trabeculectomy 4 years earlier and cataract extraction with IOL implantation a few years later. In 2006, an outside ophthalmologist performed a trabeculectomy with mitomycin C on the patient’s left eye to resolve an elevated IOP of 36 mm Hg. Six weeks later, the patient presented with a flat anterior chamber that was subsequently reformed with intracameral Healon (Advanced Medical Optics, Inc., Santa Ana, CA). Three days after this intervention, however, the eye was again hypotonous and had a flat anterior chamber. One week after the second episode of hypotony, the surgeon revised the trabeculectomy in the patient’s left eye. Her postoperative regimen included topical prednisolone, atropine, and Vigamox (moxifloxacin; Alcon Laboratories, Inc., Fort Worth, TX) in her left eye only. The patient was also using systemic prednisone, infliximab, and methotrexate for her juvenile idiopathic arthritis. Two months after the patient’s initial surgery, she presented to our service with a BCVA of 20/40 and an IOP of 5 mm Hg OS. The examination was significant for a shallow anterior chamber, a negative Seidel test, and choroidal folds involving the foveal region (Figure 1). Ultrasound biomicroscopy (UBM) did not show choroidal effusions or abnormalities of the ciliary body (Figure 2). An examination of the patient’s pseudophakic right eye was normal. The IOP measured 7 mm Hg, and a slitlamp examination revealed a low bleb with minimal vascularity. We decided to manage the patient conservatively and taper her oral and topical prednisone. This action was intended to stimulate conjunctival fibrosis and strengthen resistance to aqueous outflow. Over the next several weeks, the patient’s visual acuity and maculopathy slowly improved, and the IOP in her left eye stabilized at 10 mm Hg. In September 2006, she developed herpes simplex virus Hypotony After Trabeculectomy in a Patient With Juvenile Idiopathic ArthritisAssociated Uveitis