title: Late bleb leak management with trabeculectomy shutdown, Baerveldt glaucoma device implantation, and titratable tube lumen size.
abstract: OBJECTIVE
  To report a case of late subconjunctival bleb leak, and its management to preserve vision and achieve optimal pressure control in a patient with advanced glaucoma, a 3+ Seidel positive bleb leak, and hypotony maculopathy in the better-seeing eye.
  
  
  METHODS
  Case Report.
  
  
  METHODS
  Shutdown of the earlier trabeculectomy site with a scleral graft was achieved before insertion of a 250-mm Baerveldt glaucoma device. An absorbable ligature was used around the tube to prevent early postoperative hypotony. Additional pressure control was obtained by using a permanent polypropylene ligature to decrease the effective lumen size after the resorbence of the vicryl ligature. This suture was left in a location that would be accessible to laser suture-lysis, or manual removal if necessary.
  
  
  RESULTS
  Intraocular pressure at 1 year postoperatively was 13 mm Hg on no medications with resolution of the macular folds and 3 lines of improvement of Snellen corrected distance visual acuity. The leak was completely resolved.
  
  
  CONCLUSIONS
  Excellent pressure control was achieved in the surgical management of a late onset bleb leak by shutting down the old trabeculectomy, and inserting a new Baerveldt tube shunt with an adjustable lumen size.
authors.affiliation: Department of Ophthalmology and Vision Sciences Toronto, University of Toronto, Ontario, Canada.
authors.forename: Garfield
authors.initials: G
authors.lastname: Miller
authors.forename: Diamond Y
authors.initials: DY
authors.lastname: Tam
authors.forename: Iqbal Ike K
authors.initials: II
authors.lastname: Ahmed
mesh_terms: D000368:Aged; D003229:Conjunctival Diseases / Q000601:surgery*; D020327:Glaucoma Drainage Implants; D005902:Glaucoma, Open-Angle / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007429:Intraocular Pressure / Q000502:physiology; D007440:Intubation / Q000295:instrumentation; D008297:Male; D015814:Ocular Hypotension / Q000503:physiopathology / Q000601:surgery*; D019919:Prosthesis Implantation; D019738:Surgically-Created Structures; D013536:Suture Techniques; D014065:Tonometry, Ocular; D014130:Trabeculectomy; D014792:Visual Acuity / Q000502:physiology; D014794:Visual Fields / Q000502:physiology