[Revision for hypotension after trabeculectomy-Specific features in a young male patient]

A 34-year-old male patient with primary juvenile open-angle glaucoma presented 3 months after trabeculectomy with mitomycin C in the left eye due to progressive visual deterioration. Ocular hypotension with an intraocular pressure of 2 mmHg was noted along with a prominent filtering bleb and macular folding of the retina and choroid as the cause of reduced visual acuity. The diagnosis of hypotony maculopathy was established. After an initial lack of improvement, revision surgery was performed. Intraoperatively, a very thin and undersized scleral flap with a torn suture as well as a disproportionately large sclerectomy were identified, rendering adequate suture revision impossible. Therefore, the fistulation site was covered with a 5 × 5 mm Lyoplant® implant (Aesculap, Braun, Melsungen, Germany, acellular bovine pericardium) and secured with sutures to achieve controlled reduction of aqueous humor filtration. The postoperative course was uneventful. The intraocular pressure normalized to 12 mmHg 6 weeks after revision surgery, visual acuity improved and optical coherence tomography demonstrated a normal macula. This case highlights the importance of adequate size and thickness of the scleral flap, particularly in young patients with more compliant sclera, to prevent hyperfiltration and hypotony maculopathy. Coverage of the scleral fistula with bovine pericardium proved to be an effective surgical treatment option.