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      Late-onset Hypotony Maculopathy After Trabeculectomy in a Highly Myopic Patient With Juvenile Open-angle Glaucoma

      research-article
      , MD, , MD, , MD
      Journal of Glaucoma
      Wolters Kluwer Health, Inc
      hypotony maculopathy, trabeculectomy, high myopia, sclera

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          Abstract

          Hypotony maculopathy is a sight-threatening complication after trabeculectomy. We report on a 34-year-old man with juvenile open-angle glaucoma and high myopia, who developed hypotony maculopathy 14 years after trabeculectomy without bleb leak. This represents the longest known period from trabeculectomy to the development of hypotony maculopathy without bleb leak. The possible mechanisms for the development of late-onset hypotony maculopathy in the highly myopic patient are progressive scleral thinning, reduced scleral rigidity, and scleral morphologic change with aging. These changes might weaken the biomechanical properties of sclera and then contribute to the collapse of the scleral wall during hypotony. This case serves as a reminder that hypotony maculopathy can happen up to 14 years after tabeculectomy even without bleb leak and hypotony should be avoided after trabeculectomy in highly myopic patients with juvenile open-angle glaucoma.

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          Most cited references29

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          The sclera and myopia.

          Myopia is a very common ocular problem, affecting perhaps one billion people worldwide. Most myopia is produced by lengthening of the vitreous chamber of the ocular globe. High myopia is characterized by scleral thinning and localized ectasia of the posterior sclera. The sclera is a dense, fibrous, viscoelastic connective tissue that forms the outer coat of the eye and consists of irregularly arranged lamellae of collagen fibrils interspersed with proteoglycans and non-collagenous glycoproteins. Scleral fibroblasts are located between scleral lamellae, and are responsible for synthesizing the extracellular matrix in which they reside. Research highlighted in this review clearly demonstrates that the sclera is not a static container of the eye, but rather is a dynamic tissue, capable of altering extracellular matrix composition and its biomechanical properties in response to changes in the visual environment to regulate ocular size and refraction. Based on these studies, a strategy directed at reversing myopia-associated scleral extracellular matrix remodeling events would be warranted, particularly in cases of high myopia in humans.
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            Biomechanics of the human posterior sclera: age- and glaucoma-related changes measured using inflation testing.

            The objective of this study was to measure the biomechanical response of the human posterior sclera in vitro and to estimate the effects of age and glaucoma. Scleral specimens from 22 donors with no history of glaucoma and 11 donors with a history of glaucoma were excised 3 mm posterior to the equator and affixed to an inflation chamber. Optic nerve cross-sections were graded to determine the presence of axon loss. The time-dependent inflation response was measured in a series of pressure-controlled load-unload tests to 30 mm Hg and creep tests to 15 and 30 mm Hg. Circumferential and meridional strains were computed from the digital image correlation displacements, and midposterior stresses were determined from pressure and deformed geometry. Among normal specimens, older age was predictive of a stiffer response and a thinner sclera. In the age group 75 to 93, diagnosed glaucoma eyes with axon damage were thicker than normal eyes. Both damaged and undamaged glaucoma eyes had a different strain response in the peripapillary sclera characterized by a stiffer meridional response. Undamaged glaucoma eyes had slower circumferential creep rates in the peripapillary sclera than normal eyes. Glaucoma eyes were not different from normal eyes in stresses and strains in the midposterior sclera. The observed differences in the biomechanical response of normal and glaucoma sclera may represent baseline properties that contribute to axon damage, or may be characteristics that result from glaucomatous disease.
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              Structural and ultrastructural changes to the sclera in a mammalian model of high myopia.

              The development of high myopia is associated with scleral thinning and changes in the diameter of scleral collagen fibrils in humans. In the present study, the association between these scleral changes and the losses in scleral tissue that have previously been reported in animal models were investigated to determine the relationship between changes in collagen fibril architecture and thinning of the sclera in high myopia. Myopia was induced in young tree shrews by monocular deprivation of pattern vision for short-term (12 days) or long-term (3-20 months) periods. Scleral tissue from normal animals over a wide age range (birth to 21 months) was also collected to provide data on the normal development of the sclera. Light and electron microscopy were used to measure scleral thickness and to determine the frequency distribution of collagen fibril diameters in the sclera. Tissue loss was monitored through measures of scleral dry weight. Significant scleral thinning and tissue loss, particularly at the posterior pole of the eye, were associated with ocular enlargement and myopia development after both short- and long-term treatments. However, collagen fibril diameter distribution was not significantly altered after short-term myopia treatment, whereas, from 3 months of monocular deprivation onward, significant reductions in the median collagen fibril diameter were noted, particularly at the posterior pole. The results of this study demonstrated that loss of scleral tissue and subsequent scleral thinning occurred rapidly during development of axial myopia. However, this initial tissue loss progressed in a way that did not result in significant alterations to the collagen fibril diameter distribution. In the longer term, there was an increased number of small diameter collagen fibrils in the sclera of highly myopic eyes, which is consistent with findings in humans and is likely to contribute to the weakened biomechanical properties of the sclera that have previously been reported.
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                Author and article information

                Journal
                J Glaucoma
                J. Glaucoma
                IJG
                Journal of Glaucoma
                Wolters Kluwer Health, Inc
                1057-0829
                1536-481X
                April 2017
                22 July 2016
                : 26
                : 4
                : e137-e141
                Affiliations
                Department of Ophthalmology, Cathay General Hospital, Taipei, Taiwan
                Author notes
                Reprints: Yi-Chun Chen, MD, Department of Ophthalmology, Cathay General Hospital, Taipei, Taiwan, No.280, Sec. 4, Ren’ai Rd., Da’an Dist., Taipei City 106, Taiwan (R.O.C.) (e-mail: rebe254cca@ 123456gmail.com ).
                Article
                00016
                10.1097/IJG.0000000000000485
                5380017
                27404776
                3b2cf9d9-1426-4962-8b19-21eafcf209a6
                Copyright © 2016 The Author(s). Published by Wolters Kluwer Health, Inc

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

                History
                : 16 February 2016
                : 8 June 2016
                Categories
                Online Articles: Case Reports
                Custom metadata
                TRUE
                ONLINE-ONLY

                hypotony maculopathy,trabeculectomy,high myopia,sclera
                hypotony maculopathy, trabeculectomy, high myopia, sclera

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