Trauma-Related Filtering Bleb in Exfoliation Syndrome

This case involves a 76-year-old male, a retired veterinary academic, under regular follow-up in our clinic for exfoliation syndrome. Despite significant risk factors for glaucoma progression, including advanced age and dense exfoliation material (especially in the right eye), his intraocular pressure (IOP) has remained stable for decades without anti-glaucoma medications or surgical intervention. The patient underwent uncomplicated bilateral cataract surgery approximately two months ago. Preoperative IOP was 14 mmHg (right eye) and 17 mmHg (left eye), decreasing postoperatively to 11 mmHg and 14 mmHg, respectively. Best-corrected visual acuity was 20/20 in both eyes. Retinal nerve fiber layer (RNFL) thickness measured 81 µm in the right eye and 92 µm in the left eye. History revealed a penetrating ocular injury at age 16, when a shard of window glass entered the right eye. No surgical intervention was performed at that time; only patching was applied. On slit-lamp examination, a 3 × 2.5 mm cystic, elevated lesion was noted ~2 mm inferonasally from the limbus. Swept-source anterior segment optical coherence tomography (OCT) demonstrated a dome-shaped subconjunctival cavity with hyporeflective microcystic structures, resembling a filtration bleb typically seen after trabeculectomy. We hypothesize that this filtration route, possibly secondary to old scleral trauma with uveal prolapse, has served as an alternative aqueous outflow pathway, contributing to long-term IOP stability in this high-risk patient.