We read with great interest the recent article by Bitrian and associates in which they retrospectively reviewed 33 eyes with hypotony maculopathy before and after surgical bleb revision. Using different surgical techniques for bleb repair (compressive sutures, scleral flap suturing, or scleral patch grafting), they obtained a significant improvement in visual acuity (VA) (from logMAR VA 0.78 to logMAR 0.45 at 12 months), good intraocular pressure (IOP) control (from 3.51 to 12.06 mm Hg) with glaucoma drops in 48% of the patients, and a 15% re-revision rate to correct persistent hypotony.

Their successful results show how important it is to correct macular hypotony, even in cases of late onset, in which treatment is more difficult owing to tissue degradation over time. In this regard, after reviewing our late hypotony cases (n = 6; 9.33 ± 7.75 years after the primary procedure; mean duration of hypotony of 7.5 ± 7.45 months), we would like to share some points to complement their findings. First, based on our clinical experience, we performed the same surgical technique in all of our patients, with excision of the old avascular tissues and donor scleral patch reinforcement. In our series, this approach reduced the re-revision rate, and in fact, none of our patients needed a second procedure. Second, revision techniques may lead to bleb failure and subsequent hypertension, incrementing the risk for progression in patients with previous glaucomatous optic nerve damage. As suggested by Harizman, we sutured the scleral patch tightly anteriorly and laterally but left it free posteriorly in all our cases to ensure posterior aqueous outflow. In our limited case series, IOP was 2.33 ± 2.34 mm Hg preoperatively, at 6 months was 13 ± 0.52 mm Hg, and at 1 year was 12.5 ± 1.5 mm Hg with no anti-glaucoma drops in 67% of patients. Third, similarly to Bitrian and associates’ results, all patients experienced VA improvement from logMAR VA 0.71 ± 0.31 at baseline to 0.37 ± 0.09 at 6 months and 0.33 ± 0.1 at 1 year.

In summary, our results further support the authors’ conclusions that surgical bleb revision successfully treats hypotony maculopathy even months after onset, improving VA and maintaining good IOP control. We propose that tight adaptation of a scleral patch over the anterolateral flap area, but with loose suturing of the posterior edge, may reduce persistent hypotony but still preserve bleb function.