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134 Indian Journal of Ophthalmology Volume 66 Issue 1
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1. Kaufman  HE. Adenovirus advances: New diagnostic and
therapeutic options. Curr Opin Ophthalmol 2011;22:290‑3.
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Adenoviral keratoconjunctivitis associated with stromal
Bilateral idiopathic spontaneous
filtering bleb with ectopia lentis:
A case report and review of literature
Premanand Chandran, Anjali S Khairnar,
Nabeed Aboobacker, Ganesh V Raman
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.
Key words: Hypotony, lens dislocation, spontaneous filtering
bleb
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Glaucoma Department, Aravind Eye Hospital, Coimbatore,
Tamil Nadu, India
Correspondence to: Dr. Premanand Chandran, Glaucoma Department,
Aravind Eye Hospital, Avinashi Road, Coimbatore  ‑  641  014,
Tamil Nadu, India. E‑mail: drcgprem@yahoo.co.in
Manuscript received: 22.07.17; Revision accepted: 03.10.17
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Eye (Lond) 2017;31:781‑7.
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and immunological comparisons of therapeutic regimens for
corneal infiltrates secondary to adenoviral keratoconjunctivitis.
Vestn Oftalmol 2015;131:49‑55.
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
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 [Fig. 1a and b] and 8 to 1 o’clock in the LE [Fig. 1d and 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 [Fig. 1c and 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
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Cite this article as: 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.
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January 2018 Case Reports 135

to disc ratio of 0.5:1 with healthy neuroretinal rim, choroidal
folds, and attached retina in BE.
Corneal topography and pachymetry  (Orbscan, Bausch
and Lomb, Orbtek Inc., UT, USA) were suggestive of
oblique astigmatism in BE without evidence of corneal
ectasia [Fig.  2a and b]. Anterior segment optical coherence
tomography  (DRI OCT Triton plus, Topcon, Tokyo, Japan)
showed aqueous pockets in subconjunctival and intrascleral
spaces in BEs [Fig. 3a and b]. There was no communicating
fistula between the anterior chamber and subconjunctival
space.
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
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

a b c

d e f
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)

a b
Figure 2: Corneal topography image of the right (a) and left (b) eye showing oblique astigmatism
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136 Indian Journal of Ophthalmology Volume 66 Issue 1
a The authors certify that they have obtained all appropriate
b
Figure 3: Anterior segment optical coherence tomography of the
right (a) and left eye (b) showing aqueous pockets in subconjunctival
and intrascleral spaces
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
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
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.
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