Vulnerable Filtering Bleb at 48 Weeks Post-Op

At 48 weeks post-op, the bleb shows active aqueous flow at the phonic edge, along with areas of flattening that raise concern for early encapsulation. In the immediate postoperative period, the IOP demonstrated significant peaks and troughs, dropping so low at one stage that choroidal detachments developed. To manage this, we reduced the frequency of steroid drops intentionally to allow a controlled degree of scarring, helping the IOP recover to a safer range.

Looking back at the course so far, the priority has remained the same: keeping the fistula functioning and maintaining adequate aqueous drainage. The challenge is that aqueous humor contains prostaglandins and inflammatory mediators that can increase vascularity and promote fibrosis, both of which threaten long-term bleb survival and may eventually close the fistula.

To counter this process, the current plan is to reduce bleb vascularity through targeted steroid therapy in and around the bleb lake. Betamethasone is preferred in this setting because of its shorter half-life and better tissue absorption, allowing a strong anti-inflammatory effect while minimizing prolonged tissue exposure. The goal is to suppress excessive healing activity without completely shutting down the delicate balance needed to preserve bleb function.