Giant papillary conjunctivitis after Ahmed glaucoma valve implantation with double-layer pericardial patch graft tube coverage: A case report

Abstract

BACKGROUND

Giant papillary conjunctivitis (GPC) is an inflammatory disorder of the superior tarsal conjunctiva characterized by enlarged papillae, hyperemia, itching, foreign-body sensation, and mucous discharge. It is most commonly associated with contact lens wear, but may also occur in non-contact-lens wear because of chronic mechanical irritation, such as exposed sutures, ocular prostheses, scleral buckles, and elevated filtering blebs after glaucoma surgery. In postoperative patients, GPC may mimic infection or glaucoma drainage device-related complications, which can delay diagnosis and lead to unnecessary concern regarding tube exposure or device failure. Recognition of this entity is clinically important because prompt diagnosis may allow effective medical treatment and preservation of the implant.

CASE SUMMARY

A 57-year-old man with advanced primary angle-closure glaucoma underwent Ahmed glaucoma valve implantation in the left eye after failed trabeculectomy and inadequate intraocular pressure control. The tube was covered with double-layer processed human pericardial patch graft. Five months after surgery, he developed progressive itching, redness, foreign-body sensation, and mucous discharge from the operated eye. Upper eyelid eversion revealed marked superior tarsal conjunctival hyperemia with multiple giant papillae. The cornea was clear, the anterior chamber was deep and quiet, and the tube and patch graft were intact and well positioned, without exposure. No exposed sutures, retained foreign body, tube exposure, or graft exposure was identified; therefore, the exact trigger could not be confirmed. A possible explanation is that the tube-patch complex created a higher conjunctival profile, thereby increasing friction between the superior tarsal conjunctiva and the graft area during blinking, which may have provoked a papillary response. He was treated with topical fluorometholone 0.1% and olopatadine 0.1% twice daily. Symptoms improved within two weeks. At the final follow-up, 1 month after treatment, there was complete resolution without recurrence, best-corrected visual acuity had improved to 20/40, and intraocular pressure remained stable.

CONCLUSION

GPC may occur after Ahmed glaucoma valve implantation even when the tube and double-layer pericardial patch graft remain fully covered and unexposed. In postoperative patients presenting with itching, redness, or mucous discharge, routine upper eyelid eversion is essential for establishing the diagnosis and preventing misdiagnosis. Early recognition and prompt medical treatment may relieve symptoms and preserve implant function.

Key Words: Ahmed glaucoma valve; Glaucoma drainage device; Giant papillary conjunctivitis; Pericardial patch graft; Case report

Core Tip: Giant papillary conjunctivitis may develop after Ahmed glaucoma valve implantation even when the tube and pericardial patch graft remain fully covered and unexposed. In this patient, postoperative itching, redness, and mucous discharge were caused by superior tarsal giant papillae rather than infection or device failure. Routine upper lid eversion is essential in symptomatic patients, because early recognition allows successful medical treatment and preservation of implant function.

INTRODUCTION

Giant papillary conjunctivitis (GPC) is an inflammatory disorder of the superior tarsal conjunctiva characterized by enlarged papillae, itching, foreignbody sensation, and mucous discharge[1]. GPC most commonly occurs in contact lens wearers but may also develop in noncontactlens wearers due to chronic mechanical irritation from ocular prostheses, extruded scleral buckles, or filtering blebs after glaucoma surgery[2-4]. In postoperative eyes, these symptoms may overlap with those infection or glaucoma drainage device–related complications, making careful examination, including upper eyelid eversion, clinically important[1]. Medical treatment with topical antiallergic and antiinflammatory therapies can be effective in appropriate cases[5]. We report a case of GPC after Ahmed glaucoma valve implantation with a doublelayer processed human pericardial patch graft for tube coverage, despite intact graft and the absence of graft exposure.

CASE PRESENTATION

Chief complaints

Five months after Ahmed glaucoma valve implantation, the patient presented with progressive itching, redness, foreign-body sensation, and mucous discharge in the left eye, associated with decreased visual acuity.

History of present illness

A 57-year-old man with bilateral advanced primary angle-closure glaucoma underwent superotemporal Ahmed glaucoma valve implantation in the left eye after failed trabeculectomy. The tube was covered with a double-layer processed human pericardial patch graft, and postoperative recovery was unremarkable, with intraocular pressure maintained between 7 and 10 mmHg. Approximately five months after surgery, he began experiencing intermittent itching and mild foreign-body sensation, which progressed over several weeks to marked redness, itching, and mucous discharge. There was no history of contact lens wear or ocular prosthesis use.

History of past illness

His ocular history included laser peripheral iridotomy and uncomplicated cataract extraction with posterior chamber intraocular lens implantation in both eyes. A previous trabeculectomy in the left eye failed, leaving a flat, non-functioning bleb. The patient had no history of ocular trauma or, systemic disease.

Personal and family history

The patient had no significant personal or family history of allergies, atopy, or autoimmune diseases.

Physical examination

Five months after surgery, the best-corrected visual acuity was 20/60, and intraocular pressure was 9 mmHg in the left eye. Upper eyelid eversion revealed marked superior tarsal conjunctival hyperemia with multiple giant papillae (≥ 1 mm) and stringy mucous discharge (Figure 1). The cornea was clear; the anterior chamber was deep and quiet without cells, flare, or hypopyon; and the Ahmed tube and double-layer pericardial patch graft were intact and well positioned, without exposure (Figure 2). Careful examination of the bulbar conjunctiva revealed no exposed Vicryl suture remnants, rendering suture-induced GPC unlikely. The previously failed trabeculectomy site was flat and non-functioning. Examination of the fellow eye revealed a normal superior palpebral conjunctiva without papillae, hyperemia, or tarsal conjunctival inflammation, confirming that the process was unilateral and confined to the operated eye.

Figure 1  Slit-lamp photograph showing upper lid eversion with multiple giant papillae of the superior tarsal conjunctiva, and mucous discharge in the left eye.

Figure 2  Slit-lamp photograph showing the Ahmed tube in the anterior chamber (blue arrow) and intact double-layer processed pericardial patch graft coverage (orange arrow) with no evidence of exposure.

Laboratory examinations

No laboratory examinations were performed because the discharge was non-purulent and the intraocular examination was quiet.

Imaging examinations

No imaging examination were required to establish the diagnosis in this case.

MULTIDISCIPLINARY EXPERT CONSULTATION

Multidisciplinary expert consultation was not required. The diagnosis was clinically established by ophthalmic examination, including slit-lamp assessment and upper eyelid eversion, and treatment was provided by the ophthalmology team.

FINAL DIAGNOSIS

GPC of the left eye after Ahmed glaucoma valve implantation with an intact double-layer pericardial patch graft covering the tube.

TREATMENT

The patient was treated with topical fluorometholone 0.1% and olopatadine 0.1%, administered twice daily. Antiglaucoma drops were discontinued postoperatively, and no additional medications were required.

OUTCOME AND FOLLOW-UP

Symptoms and papillary size improved within two weeks of treatment initiation (Figure 3). The decline in visual acuity to 20/60 at the time of GPC diagnosis was likely related to ocular surface disturbances, including mucous discharge, tear-film instability, and conjunctival inflammation, rather than to intraocular inflammation or implant failure, as the cornea was clear, the anterior chamber was quiet, and the tube and patch graft were intact. The improvement in visual acuity after treatment may be explained by reduced papillary inflammation, decreased mucous discharge, improved tear-film quality, and improved ocular comfort. The absence of recurrence despite retention of the pericardial patch graft may indicate that the inflammatory process was transient and medically suppressible rather than being caused by a persistently exposed foreign-body. At the final follow-up 1 month after treatment, there was complete resolution of signs and symptoms, best-corrected visual acuity had improved to 20/40, intraocular pressure remained stable, and the implant remained functional.

Figure 3  Slit-lamp photograph of the same eye two weeks after initiation of treatment, demonstrating decrease of conjunctival papillae size.

DISCUSSION

Ahmed glaucoma valve implantation is an established treatment option for refractory and complicated glaucoma[6]. Tube exposure remains one of the most clinically important complications of glaucoma drainage device surgery because it increases the risk of infection, including endophthalmitis[6]. To reduce the risk of erosion, the extraocular tube is typically covered with materials such as donor sclera or cornea, amniotic membrane, autologous Tenon’s tissue, or processed pericardium[6]. Processed human pericardium has been used for tube coverage in glaucoma implant surgery, and doublelayer techniques have been proposed to enhance longterm coverage[7,8].

GPC presents with superior tarsal papillae, itching, redness, foreignbody sensation, and stringy mucous discharge[1]. Although classically associated with contact lens wear[2], GPC has also been reported in noncontactlens wearer because of chronic mechanical irritation from ocular prostheses, extruded scleral buckles, and filtering blebs[1,3,4]. This case is notable because GPC developed after Ahmed glaucoma valve implantation, despite intact double-layer processed human pericardial patch graft coverage and the absence of tube or graft exposure.

The delayed onset, approximately five months after surgery, may reflect gradual postoperative conjunctival remodeling, subtle changes in the contour over the tube-patch complex, or delayed ocularsurface inflammation after discontinuation of postoperative corticosteroids. Repetitive blinkrelated interaction between the superior tarsal conjunctiva and operated superotemporal conjunctiva may have triggered a papillary response. However, because no exposed sutures, retained foreign bodies, tube exposure, or graft exposure was identified, the exact trigger could not be confirmed. The absence of visible Vicryl suture remnants is clinically relevant because postoperative conjunctival inflammation may be influenced by sutures used during glaucoma drainage device surgery.

The transient decline in bestcorrected visual acuity from 20/30 to 20/60 is likely attributable to ocularsurface disturbances rather than structural intraocular pathology[1]. Giant papillae and mucous discharge may destabilize the tear film and degrade optical quality during blinking, leading to transient visual impairment. The incomplete recovery to 20/40, rather than return to the preGPC baseline of 20/30, may reflect residual tearfilm instability after resolution of inflammation and/or the effects of preexisting advanced glaucomatous optic neuropathy.

The absence of recurrence suggests that the inflammatory component was transient and medically responsive rather than due to a persistent exposed foreign-body. Intact conjunctival coverage, absence of visible suture remnants, a quiet anterior chamber, and stable intraocular pressure supported this interpretation. Nevertheless, continued observation is warranted because recurrence cannot be excluded from a single case. Because the pericardial patch graft remains in place, followup should include careful assessment for recurrent symptoms and repeat upper eyelid eversion if itching, redness, foreignbody sensation, or mucous discharge recurs. The initial management of recurrence may include topical antiallergic and antiinflammatory therapies, whereas surgical revision should be reserved for cases with confirmed tube or graft exposure, progressive erosion, or recurrence refractory to medical treatment[6].

Correct recognition of GPC in this setting is clinically important because its symptoms may mimic infection, tube exposure, or devicerelated failure[1]. Prompt diagnosis may prevent unnecessary antimicrobial therapy, surgical exploration, or premature concern regarding implant failure, while allowing successful topical antiinflammatory and antiallergic treatment[5]. This case demonstrates that GPC should be considered even without tube or patch graft exposure, and that careful eyelid eversion can prevent misdiagnosis and unnecessary intervention.

However, the underlying mechanisms remains unclear. One possible explanation is that the tube–patch complex creates an elevated conjunctival profile, thereby increasing friction between the superior tarsal conjunctiva and the graft area during blinking, which may provoke a papillary response[1]. Alternatively, localized postoperative ocularsurface inflammation may have been sufficient to trigger GPC, even without overt exposure. These mechanisms remain speculative, and further case reports and comparative studies are needed to clarify whether graft configuration influences postoperative GPC risk.

CONCLUSION

GPC may occur after Ahmed glaucoma valve implantation even when the tube and double-layer pericardial patch graft remain fully covered and unexposed. In patients presenting with postoperative itching, redness, or mucous discharge, upper eyelid eversion is essential for establishing the diagnosis and preventing misdiagnosis. Early recognition and prompt medical treatment may relieve symptoms, preserve patient comfort, and help maintain implant function. Long-term follow-up with periodic upper eyelid eversion at postoperative visits may be considerable, given the permanent presence of the pericardial patch graft, and patients should be counseled about the potential for late-onset recurrence.