Mitomycin
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Bleb encapsulation and ’ring of steel’ formation: case report An adult man [exact age at reaction onset not stated] experienced bleb encapsulation and ’ring of steel’ formation following administration of mitomycin during trabeculectomy. The man, who had juvenile-onset primary open-angle glaucoma, presented to hospital at the age of 33 years. He had no family history of glaucoma and no known systemic illness. Records showed that he presented in 2008 with elevated intraocular pressures (IOPs), and that he underwent trabeculectomy of both his eyes in the same year, which was augmented with a 0.04% subconjunctival mitomycin [mitomycin-C] soaked sponge for 2 minutes, and adjuvant subscleral and subconjunctival collagen implant [Ologen] placement in his left eye followed by his right eye. His postoperative course had been uneventful; he was subsequently lost to follow-up. However, in 2018, he presented with increased IOPs in both eyes (current presentation). The glaucomatous optic neuropathy had progressed since his initial surgery; slit-lamp examination revealed bilateral, solid-appearing superior blebs, which were distinctly demarcated and well elevated, barely containing any cystic component, confirmed on ultrasound biomicroscopy. Since this was unusual and correlated with his past records, persistence of the collagen implant was suspected. Further investigations revealed a fibrillar matrix-like structure protruding from the patent ostium in both eyes, possibly the remnant subscleral collagen implant. Therefore, he was treated with topical glaucoma medications. However, because of the structural progression and the desired target IOP not being achieved, repeat trabeculectomy augmented with mitomycin for his right eye was decided. During the procedure, the superior conjunctiva was incised posterior to the pre-existing bleb. Peritomy was performed, exposing the discrete, solid, non-degraded collagen implant. It was dissected and separated from the scleral bed. The sample was sent for histopathological assessment. The subconjunctival application of 0.02% mitomycin-soaked sponge for 2 minutes followed, post which a partial thickness scleral flap was raised. The scleral bed was scarred, and the remnants of the subscleral collagen implant were removed. The sclera flap was then sutured, and the conjunctiva was closed. On postoperative day 1, the bleb appeared diffuse and well-formed. Four weeks postoperatively, the bleb remained diffuse (IOP 10mm Hg). Histopathology demonstrated invasion of few fibroblasts amidst the fibres of the collagen implant peripherally. Hence, bleb encapsulation and formation of ’ring of steel’ was thought to have been due to the prolonged localised effect of mitomycin, which had resulted in excessive fibroblast proliferation in the surrounding. Selvan H, et al. The immortal Ologen: persisting 10 years after trabeculectomy. Canadian Journal of Ophthalmology 54: e305-e308, No. 6, Dec 2019. Available from: URL: 803445257 http://doi.org/10.1016/j.jcjo.2019.03.004
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