We appreciate the interest and comments from Dr Pazos and colleagues about our recent manuscript. We agree that excision of old, avascular conjunctiva is a necessary step toward a successful surgical outcome, although our preference is to use a patch graft, such as pericardium or donor sclera, only when additional reinforcement is needed to restrict aqueous outflow.

In our study, a pericardial patch graft was used as part of the bleb revision procedure in 9 of 33 eyes (27%). Of the 5 eyes (15%) in our series requiring a second bleb revision, a pericardial patch graft was used in 2 eyes at the time of the initial bleb revision. In our clinical experience, failure of the original filtration bleb and subsequent hypertension is less likely if the original trabeculectomy flap can be salvaged and resutured as we described. In a series of 14 patients described by Halkiadakis and associates who underwent bleb revision surgery with a scleral patch graft, 3 (21%) required a second scleral patch graft revision. We agree with Dr Pazos and colleagues that suturing of a patch graft in the manner in which they describe is a helpful technique when necessary and that any subsequent surgery increases the risk of bleb failure. However, the use of a patch graft at the time of bleb revision did not eliminate the risk of subsequent revision surgery in our series or the one described by Halkiadakis and associates.

We thank Dr Pazos and colleagues for the opportunity to further discuss the surgical techniques described in our manuscript. We concur that surgical bleb revision is an effective method to improve visual acuity and intraocular pressure outcomes in cases of hypotony maculopathy, even in some cases when hypotony has been present for many months. Further studies are needed to develop methods that will also reduce the risk of subsequent surgery in these challenging cases.