Elderly woman with a bleb leak



To describe a unique incidence of inadvertent filtering bleb creation after intravitreal injections.


An 84-year-old woman with a history of wet age-related macular degeneration requiring intravitreal injections presented with a Seidel-positive conjunctival cyst. The cyst was in an area where she had received multiple injections and was suspected to be an inadvertent filtering bleb secondary to a full-thickness scleral hole created by these injections. She underwent surgical closure of the fistula and repair of the bleb.

Conclusions and Importance

This case emphasizes the importance of recognizing this potential complication of intraocular injections and outlines steps that should be taken to prevent poor outcomes and vision loss.


Aqueous leakage from a conjunctival filtering bleb is a known complication of glaucoma filtration surgery. Bleb leaks in patients without prior glaucoma surgery have been reported due to the creation of an inadvertent filtering bleb, occurring particularly after cataract surgery. This has become less common since the introduction of phacoemulsification and clear corneal incisions. Most cases result from superior scleral incisions with internal wound gape, which prevent wound healing and permit aqueous to filter into the subconjunctival space. , We present herein a case of an inadvertent bleb created after intravitreal injection with subsequent complications.

Case report

An 84-year-old woman presented to the Bascom Palmer Eye Institute’s emergency room with one week of left eye pain and blurry vision. She had a diagnosis of wet age-related macular degeneration (AMD) bilaterally and had received an intravitreal ranibizumab injection 4 weeks prior in the same eye. She had cataract surgery 4 years ago in the left eye, no other intraocular surgeries and no history of ocular trauma. She denied a history of glaucoma. Her medical history included hypertension, diabetes mellitus type 2, osteoarthritis and hypothyroidism.

On examination, her best-corrected visual acuity was count fingers in the right eye (secondary to advanced wet AMD) and 20/50 in the left eye. Her intraocular pressures (IOP) were 20 mmHg in the right eye and 8 mmHg in the left eye. Slit lamp exam was unremarkable in the right eye. Slit lamp evaluation of the left eye demonstrated a thin avascular superior conjunctival cyst with no associated mucopurulent infiltrate and a Seidel-positive leak ( Fig. 1 A and B ), measured approximately 1.4mm from the limbus. An underlying round scleral hole was illuminated through the thin leaking bleb. This sclerostomy was noted 3mm superior to the limbus. Her anterior chamber was deep with trace cell and 1+ flare, but there was no vitritis. Fundus exam revealed healthy optic nerves with cup-to-disc ratio of 0.3 and 0.4 in the right and left eyes respectively, and bilateral central macular scars with retinal pigment epithelial mottling. Anterior-segment optical coherence tomography (AS-OCT) confirmed presence of a full-thickness scleral hole.

Fig. 1A

Slit lamp photograph of the superior conjunctival filtering bleb with a scleral fistula (black arrow).

Jan 3, 2022 | Posted by in OPHTHALMOLOGY | Comments Off on Elderly woman with a bleb leak

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