Inferior extension of a filtering bleb following laser goniopuncture in a patient with conjunctivochalasis

Purpose: Inferior extension of filtering blebs after glaucoma surgery is rare. Conjunctivochalasis, an age-related redundancy of the conjunctiva, may influence bleb morphology but is often overlooked. This report describes an inferiorly extended filtering bleb following deep sclerectomy and subsequent Nd:YAG laser goniopuncture in a patient with pre-existing conjunctivochalasis. Methods: A 66-year-old man with advanced primary open-angle glaucoma underwent combined phacoemulsification, deep sclerectomy, and intraoperative mitomycin C in the right eye. Initial recovery was uneventful, with IOP at 15 mmHg and a mildly elevated bleb. Results: At six weeks, bleb flattening and an IOP rise to 19 mmHg prompted Nd:YAG laser goniopuncture. Two weeks later, a diffuse, hypovascular bleb extended inferiorly into the fornix, corresponding to an area of conjunctivochalasis. IOP was 9 mmHg, with no hypotony, leak, or symptoms. The bleb regressed spontaneously over one month, stabilizing superiorly with IOP at 13 mmHg without medications. Conclusions: This case suggests that conjunctivochalasis may act as a low-resistance pathway for aqueous diffusion after increased outflow from goniopuncture, leading to atypical bleb spread. While self-limiting here, such morphology could have implications for comfort, contact lens use, or hypotony risk. Pre-existing conjunctival redundancy may influence postoperative bleb morphology and should be considered in surgical planning and follow-up after bleb-forming glaucoma surgeries.