Visual improvement following trabeculectomy in a 17-year-old

Glaucoma is a leading cause of blindness globally; however, in terms of the irreversibility of blindness, it is the number one cause. Glaucoma treatment aims at slowing the progression and reducing the risk of further structural and functional damage as much as possible. A rare subset of glaucoma is juvenile open-angle glaucoma (JOAG) diagnosed in individuals between 3 and 40 years of age. The JOAG tends to have rapid progression and it is associated with higher intraocular pressure (IOP) and fluctuations compared to primary open-angle glaucoma. The IOP also tends to be refractory to medical therapy control and often requires surgical intervention. In the treatment of glaucoma, functional improvement is not an expectation. This is a case report of a JOAG patient with visual improvement following trabeculectomy. A 17-year-old female presented with a 4-year history of gradual visual loss in both eyes. Diagnosed elsewhere to have glaucoma with no known baseline IOP value and is already on travoprost. Visual acuity (VA) at presentation was counting finger (close to face right eye, 2 m left eye) and IOP were 22 and 19 mmHg, respectively. The patient subsequently underwent trabeculectomy with mitomycin C in both eyes at a single sitting. She had a marked improvement in vision postoperatively. At 6 weeks postoperative review, VA was 6/36 and 6/18 in the right and left eyes, respectively, and pressures were 9 and 8 mmHg, respectively. There is currently no proven mechanism to explain visual recovery; however, visual improvement may have resulted from some reversal of retinal ganglion cell damage following significant IOP lowering. Improvement in vision is not an expectation following treatment for glaucoma; however, some case reports have reported this occurrence following trabeculectomy. Hence, even in very advanced presentations, especially in young individuals as in this case, there should not be hesitation with surgical intervention following appropriate counseling.