Friday, August 11, 2017

The BOSs (….or the hostile takeover of the filtering bleb)

A few years back it was suggested that cystic blebs often failed due to development of scar (fibrous) tissue occurring posteriorly (Figure 1). 

Figure 1. The Ring of Steel in cystic blebs

This was called the “RING OF STEEL” (Figure 2).

Figure 2

However, what happens in flat blebs? These failing blebs do not show any significant bleb formation but start to develop a progressive increase in intraocular pressure (IOP), usually after a period of initial good IOP control.

Fibrous tissue overlying the bleb, causing failure

I did surgical revision of such failing blebs and found a band of tissue overlying the bleb area. This had effectively sealed the scleral flap, preventing aqueous from going out from under the flap. I have named this tissue, found in the subconjunctival area, as theBAND OF STEEL (BOS). This BOS is responsible for bleb failure in these cases.

As seen in the following figures, this tissue appears as a band and has to be completely excised in order to free the scleral flap. After excision of the BOS, I usually place Mitomycin-C 0.04% for about 3 minutes over the affected area. This is a higher concentration than the MMC 0.02% which I had been using previously. This higher concentration might be more conducive to prevent fibrosis and prevent formation of the “band of steel”.

BOS is being cut

The cut piece of BOS

Monday, August 7, 2017


On 6th of August, 2017  we started our journey to visit Pitas Hospital. 

Located 169 kilometers from Kota Kinabalu, the small town is situated on the far boundary of the state. Due to its location and other factors, it is often difficult to have patients coming down to our hospital for treatment. 

The trip took more than 3 hours by a fast 4-wheel drive for us. The same trip can stretch to more than a day and cost a couple of hundred dollars for the patients who are dependent on infrequent public transports. Thus, our visits to such hospitals are a big boost for the healthcare of these impoverished populations. 

Since, the place is so far off, we had started in the afternoon of the 6th of August. We reached the Orkid Lodge by evening (Orkid is the spelling of orchid in the Malaysian language). The small lodge had minimal comforts. A TV with a single channel greeted us. There was no mineral water or coffee making facility. So we rushed down to the restaurant situated near the lodge. I ordered "roti canai". The accompanying curry was very oily and put me off. I quickly went back to my room, where I watched a movie on my laptop. By 10pm I had fallen asleep.

The next day, 7th August 2017, the hospital hilux took us to the OPD clinic. We were expecting 4o patients. After a quick breakfast of noodles and coffee we started work. Ultimately about 30 patients turned up for the clinic. We diagnosed a few cataract and glaucoma patients among others. Just after 12 noon we started our journey back. On the way back we stopped to buy some roasted corns. These are the sweet corns which are roasted within the leaves giving a peculiar smell and taste to them. We encountered heavy rains on the way and reached our hospital by 4 o'clock in the afternoon.

Tuesday, August 1, 2017


August is the month of independence from colonial rule in India. For this month our guest author is one of the most influential ophthalmologists from India: DR DALJIT SINGH. Born on 11th October 1934, he obtained his MBBS from the Government Medical College, Amritsar in 1956. He served as a member of faculty of the Government Medical colleges in Amritsar and Patiala for 23 years and became an Emeritus professor of these institutions. The Government of India awarded him the fourth highest civilian award of Padma Shri in 1987. Seven years later, he received the Dr. B. C. Roy Award, the highest Indian medical award from the Medical Council of India. At 82 years of age he remains as passionate as ever in writing and clinical work. This article traces his long journey in glaucoma surgery. "The Glog" is honored to have him here as a guest author. Our deepest thanks to him for sharing his thoughts.