LAUSR

We introduce a new technique for the management of encapsulated non filtering blebs which are unresponsive to needling procedure. A 21 year-old man with a visual acuity of 20/30 presented with encapsulated bleb in the left eye 4 weeks after a successful trabeculectomy operation with adjunctive mitomycin C for medically uncontrolled glaucoma. The internal ostium was patent on gonioscopic examination. Intraocular pressure was 35 mmHg despite multiple therapies with bimatoprost, brimonidine, and dorzalomide-timolol fixed combination. He underwent two consecutive bleb needling procedures with adjunctive subconjunctival 5-fluorouracil (5-FU) injections which were successful initially but encapsulated bleb recurred. The 5-FU augmented bleb needling was performed at the slit lamp after cleaning the patient’s eyelid and periorbital skin with 10% providone iodine followed by instillation of a drop of 5% providone iodine. Needling of the bleb was performed using a 27-gauge needle. The aim was to remove episcleral scarring which was obstructing the intrascleral pathway. This was followed by an injection of 0.1 mL of 5-FU solution (50 mg/mL) along the far posterior margins of the bleb area. Anterior segment OCT analysis demonstrated that there was a thick walled Tenon cyst without any filtration (Fig. 1). Finally he was scheduled for vitrector assisted cystectomy. After explaining the benefits of the procedure informed consent was obtained and he was scheduled for vitrector assisted cystectomy. It was explained to the patient that conventional surgical cystectomy may still be necessary despite the procedure. The surgical technique for vitrector assisted cystectomy was as follows. Under retrobulbar anesthesia with lidocaine 2%, a lid speculum was inserted. An 8/0 vicryl traction suture was placed at 12 o’clock position in the cornea. A 28 gauge needle attached to 1 mL syringe filled with lidocaine was used to make an incision on the conjunctiva temporal to the bleb and lidocaine was injected aiming to create a dissection