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   Table of Contents      
CASE REPORT
Year : 2018  |  Volume : 66  |  Issue : 1  |  Page : 134-136

Bilateral idiopathic spontaneous filtering bleb with ectopia lentis: A case report and review of literature


Glaucoma Department, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Submission22-Jul-2017
Date of Acceptance03-Oct-2017
Date of Web Publication28-Dec-2017

Correspondence Address:
Dr. Premanand Chandran
Glaucoma Department, Aravind Eye Hospital, Avinashi Road, Coimbatore - 641 014, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_630_17

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  Abstract 


A 26-year-old male presented with superior filtering bleb with scleral thinning, dislocated lens, and hypotony in both the eyes. His cornea was normal without any sign of ectasia, and there was no history of recurrent redness, trauma, or surgery in either eye. Anterior segment optical coherence tomography did not reveal communicating fistula between the anterior chamber and subconjunctival space. Physical examination and blood investigations did not reveal any systemic association. He was diagnosed to have spontaneous filtering bleb, which is a rare condition observed with ocular or systemic abnormalities.

Keywords: Hypotony, lens dislocation, spontaneous filtering bleb


How to cite this article:
Chandran P, Khairnar AS, Aboobacker N, Raman GV. Bilateral idiopathic spontaneous filtering bleb with ectopia lentis: A case report and review of literature. Indian J Ophthalmol 2018;66:134-6

How to cite this URL:
Chandran P, Khairnar AS, Aboobacker N, Raman GV. Bilateral idiopathic spontaneous filtering bleb with ectopia lentis: A case report and review of literature. Indian J Ophthalmol [serial online] 2018 [cited 2019 Sep 23];66:134-6. Available from: http://www.ijo.in/text.asp?2018/66/1/134/221805



Spontaneous subconjunctival filtering bleb is a rare occurrence and has been observed with ocular or systemic abnormalities such as Axenfeld syndrome,[1] Terrien marginal degeneration,[2],[3] familial craniofacial dysmorphism,[4],[5] scleritis,[6] and connective tissue diseases.[7] To the best of our knowledge, only few cases have been reported till date, and we report a 26-year-old patient with bilateral spontaneous filtering bleb.


  Case Report Top


A 26-year-old male presented with defective vision in both eyes (BEs) since childhood. The patient had no history of previous ocular surgery, trauma, or systemic illness. His best-corrected visual acuity was 6/18 with + 11 + 1.5 × 90 in the right eye (RE) and 6/12 with + 11.5 + 2.5 × 90 in the left eye (LE). Slit-lamp examination showed a diffuse conjunctival bleb near the limbus extending from 10 to 4 o'clock in the RE [Figure 1]a and [Figure 1]b and 8 to 1 o'clock in the LE [Figure 1]d and [Figure 1]e with superior scleral thinning in BEs. Seidel's test was negative in BE. RE showed clear cornea with deep anterior chamber and inferonasal dislocated lens. LE showed iridocorneal adhesion in the paracentral zone with corneal scar, iris atrophy, and aphakic lens status. Dilated examination revealed microphakic-dislocated lens in the anterior chamber in the RE and inferonasal dislocated lens in the LE [Figure 1]c and [Figure 1]f. Anteriorly dislocated lens in the RE was reposited into the posterior chamber in the supine posture. His intraocular pressure was 6 and 3 mmHg in the RE and LE, respectively. On gonioscopy, angles were closed in BEs without evidence of ostium or cyclodialysis cleft. Fundus examination showed a cup to disc ratio of 0.5:1 with healthy neuroretinal rim, choroidal folds, and attached retina in BE.
Figure 1: Slit-lamp photograph of the right eye showing inferonasal dislocated lens, superonasal diffuse bleb with scleral thinning (a and b) and anterior dislocated microphakic lens on dilatation (c). Left eye showing iridocorneal adhesion and aphakic lens status, superonasal diffuse bleb with scleral thinning (d and e) and inferonasal dislocated lens on dilatation (f)

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Corneal topography and pachymetry (Orbscan, Bausch and Lomb, Orbtek Inc., UT, USA) were suggestive of oblique astigmatism in BE without evidence of corneal ectasia [Figure 2]a and [Figure 2]b. Anterior segment optical coherence tomography (DRI OCT Triton plus, Topcon, Tokyo, Japan) showed aqueous pockets in subconjunctival and intrascleral spaces in BEs [Figure 3]a and [Figure 3]b. There was no communicating fistula between the anterior chamber and subconjunctival space.
Figure 2: Corneal topography image of the right (a) and left (b) eye showing oblique astigmatism

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Figure 3: Anterior segment optical coherence tomography of the right (a) and left eye (b) showing aqueous pockets in subconjunctival and intrascleral spaces

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Physical examination did not reveal joint or skin hyperextensibility, brachydactyly, facial dysmorphic features, or marfanoid habitus. Blood investigations including rheumatoid factor, homocysteine, and lysine level were within normal limits. Antinuclear antibody test was negative. Electrocardiogram and echocardiogram were normal.


  Discussion Top


First case of spontaneous filtering bleb was reported in a patient with Axenfeld syndrome by Nemet et al.[1] The patient had prominent Schwalbe line and iridocorneal adhesion in both the eyes. Authors have postulated that increased IOP leads to rupture of the corneoscleral junction resulting in the formation of filtering bleb. Our patient had iridocorneal adhesion only in the LE and did not have anterior embryotoxon in both the eyes. Spontaneous filtering bleb formation due to corneal pathologies such as Terrien and pellucid marginal degeneration have been reported by Soong et al.,[2] Munro et al.,[3] and Toriyama et al.[8] Mechanism proposed was the extreme distortion and stretching of the peripheral cornea resulting in rupture of the Descemet's membrane and bleb formation. Our patient had normal cornea without signs of thinning or degeneration.

Shawaf et al.[4] and Haddad et al.[5] have reported two unrelated families of Lebanese Druze community with syndrome of ectopia lentis, spontaneous filtering bleb, and craniofacial dysmorphism. Dysmorphic features were dental crowding, large beaked nose, and antimongoloid slanting of the palpebral fissures. Authors concluded that the syndrome is due to abnormality in the connective tissue development and it is inherited in an autosomal recessive manner. Pasquale et al.[9] have reported spontaneous filtering bleb in a patient with microspherophakia and dysmorphic features in the form of malar hypoplasia, frontal bossing, and septal deviation. Our patient had filtering bleb and microphakic-dislocated lens, but there was no facial dysmorphic features.

Mantravadi and Stock [6] have reported spontaneous filtering bleb with scleral thinning as a consequence of scleritis in a female with systemic lupus erythematosus. Gerke et al.[7] have reported spontaneous filtering bleb, ocular hypotension, inferior oblique and superior rectus paralysis, and madarosis in a patient with scleroderma. There were no signs of systemic connective tissue abnormality in our patient. Two patients with spontaneous filtering bleb without any other ocular or systemic abnormalities have been reported by Munro et al.[3] and Tatham et al.[10]


  Conclusion Top


Our patient had bilateral superior filtering bleb with scleral thinning, dislocated lens, and hypotony for which the cause could not be elucidated and the probable mechanism of bleb formation would be seeping of aqueous through the area of scleral thinning.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nemet P, Bracha R, Lazar M. Spontaneous filtering blebs in axenfeld syndrome. Am J Ophthalmol 1973;76:590-1.  Back to cited text no. 1
[PUBMED]    
2.
Soong HK, Fitzgerald J, Boruchoff SA, Sugar A, Meyer RF, Gabel MG, et al. Corneal hydrops in Terrien's marginal degeneration. Ophthalmology 1986;93:340-3.  Back to cited text no. 2
    
3.
Munro M, McWhae J, Romanchuk K, Crichton A, Carter G, Ball A, et al. Two cases of spontaneous filtering blebs, one idiopathic and one associated with Terrien marginal degeneration. Cornea 2014;33:752-4.  Back to cited text no. 3
    
4.
Shawaf S, Noureddin B, Khouri A, Traboulsi EI. A family with a syndrome of ectopia lentis, spontaneous filtering blebs, and craniofacial dysmorphism. Ophthalmic Genet 1995;16:163-9.  Back to cited text no. 4
[PUBMED]    
5.
Haddad R, Uwaydat S, Dakroub R, Traboulsi EI. Confirmation of the autosomal recessive syndrome of ectopia lentis and distinctive craniofacial appearance. Am J Med Genet 2001;99:185-9.  Back to cited text no. 5
[PUBMED]    
6.
Mantravadi AV, Stock EL. Spontaneous filtration bleb as a consequence of scleritis. Arch Ophthalmol 2007;125:1578-9.  Back to cited text no. 6
[PUBMED]    
7.
Gerke E, Meyer-Schwickerath G, Joussen F. [Sclerodermie en coup de sabre with spontaneous filtering bleb (author's transl)]. Klin Monbl Augenheilkd 1976;168:426-8.  Back to cited text no. 7
[PUBMED]    
8.
Toriyama K, Inoue T, Suzuki T, Higashiura R, Maeda N, Ohashi Y, et al. Spontaneous bleb formation in a presumed pellucid marginal corneal degeneration with acute hydrops. Cornea 2013;32:839-41.  Back to cited text no. 8
    
9.
Pasquale LR, Smith SG, Traboulsi E, Jampel H. Spontaneous filtration blebs in a patient with microspherophakia. Am J Ophthalmol 1991;112:350-2.  Back to cited text no. 9
[PUBMED]    
10.
Tatham A, Karwatowski W, Kumar P. Spontaneous bleb formation. Clin Exp Ophthalmol 2011;39:712.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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