e10 COPYRIGHT © SLACK INCORPORATED Canaloplasty for Pigmentary Glaucoma With Coexisting Conjunctival Lymphoma Parul Ichhpujani, MD Behin Barahimi, MD Carol L. Shields, MD Ralph C. Eagle, Jr., MD L. Jay Katz, MD ABSTRACT This case report presents canaloplasty as a bleb-free sur- gical option for lowering intraocular pressure in cases with postoperative conjunctival scarring. [Ophthalmic Surg Lasers Imaging 2011;42:e10-e11.] INTRODUCTION Non-penetrating surgery has recently emerged as a potential alternative to traditional guarded filtration sur- gery in the surgical treatment of glaucoma. 1,2 We report for the first time that canaloplasty can be considered as a surgical option when a trabeculectomy cannot be per- formed following excision of a conjunctival tumor. CASE REPORT A 72-year-old man with pigmentary glaucoma (pre- viously diagnosed) underwent a trabeculectomy in his right eye in 1994. Visual acuity in both eyes was 20/20. Intraocular pressure (IOP) was 12 and 22 mm Hg in the right and left eyes, respectively. Gonioscopy showed an open angle with 2+ pigmentation in both eyes. Topical therapy included bimatoprost 0.03% at bedtime in both eyes and timolol 0.5% in morning in the left eye. Slit- lamp examination the right eye revealed an avascular bleb (Fig. 1A). The cup–disc ratio was 0.7 in both eyes (average sized disc). Humphrey visual field testing (central 24-2 threshold test) showed a nasal step in the right eye (mean deviation = -2.45 dB; pattern standard deviation = 6.78 dB) and an early superior arcuate defect in the left eye (mean deviation = -3.85 dB; pattern standard deviation = 3.43 dB). Retinal tomography showed a rim area of 0.60 mm 2 in the right eye and 1.95 mm 2 in the left eye. Biomicroscopy revealed a salmon-colored subepithe- lial conjunctival mass measuring 25 3 15 3 3 mm in the superomedial fornix of the left eye (Fig. 1A).The mass was completely excised and treated with adjuvant cryothera- py. 3 Histopathology disclosed an extranodular marginal zone lymphoma of mucosa-associated lymphoid tissue. Following excision, the IOP in the left eye re- mained elevated at 24 to 26 mm Hg. Surgical op- tions included an inferior tube shunt or canaloplasty. Extensive postoperative superior conjunctival scarring precluded trabeculectomy (Fig. 1B). Non-penetrat- ing Schlemm’s canaloplasty using the iScience cannula (iScience Interventional Inc., Menlo Park, CA) was performed (Fig.1B). 4 Conjunctival peritomy was followed by creation of a 4.5 3 4.5 mm superficial partial-thickness scleral flap. A deep scleral flap, 0.5 mm smaller than the superficial one, was created to gain access to Schlemm’s canal by careful anterior dissection. Schlemm’s canal was un- roofed and then both ostia of the canal were dilated with a microcannula and the iTrack microcatheter (iScience Interventional Inc.) was advanced in small steps into the complete circumference of the canal, injecting minuscule amounts of high viscosity viscoelastic every 1 or 2 clock- hours to dilate the canal to a width of approximately 300 From the Glaucoma Service (PI, BB, LJK), the Oncology Service (CLS), and the Department of Pathology (RCE), Wills Eye Institute, Philadelphia, Pennsylvania. Originally submitted January 14, 2010. Accepted for publication December 2, 2010. Posted online February 10, 2011. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to L. Jay Katz, MD, Glaucoma Service, Wills Eye Institute, 840 Walnut Street, Philadelphia, PA 19107. E-mail: ljk22222@aol.com doi: 10.3928/15428877-20110203-01 ■ CASE REPORT ■