Transconjunctival bleb needling with mitomycin C reduces intraocular pressure in pediatric congenital glaucomaNew surgical technique helps manage severe glaucoma in children

Frontiers in Medicine Published October 11, 2026 DOI ↗ Editorial oversight: Dr. Lars van Dijk, PhD · Surgical, Procedural & Diagnostic

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Key Takeaway

Consider transconjunctival bleb needling with mitomycin C as a conservative option for managing hypertensive blebs in children.

This case report details the management of a 9-year-old female with complex surgical history and refractory primary congenital glaucoma. The patient presented with an encapsulated, hypertensive drainage bleb. The intervention consisted of minimally invasive, stepwise transconjunctival bleb needling using a 27-gauge needle and a subconjunctival injection of 0.3 mL of a mixture containing 0.4 mg/mL mitomycin C and 2% lidocaine.

Clinical outcomes showed a progressive reduction in intraocular pressure (IOP) from a baseline of 27 mmHg to 24 mmHg on day 1, 14-17 mmHg on day 9, 10 mmHg at 1.5 months, and 13 mmHg at the final follow-up. Best-corrected visual acuity was maintained at 20/40. A secondary adverse event of superficial punctate keratitis was noted, resulting in poor ocular surface health.

The authors suggest that transconjunctival bleb needling augmented with mitomycin C serves as an effective, conservative alternative to full surgical revision or implant replacement for managing encapsulated, hypertensive drainage blebs in pediatric patients. However, the evidence is limited by the small sample size of 1, and the results should be interpreted with caution regarding generalizability.

How this fits prior evidence

This case report addresses a gap in managing refractory primary congenital glaucoma in pediatric patients. While the report utilizes lidocaine, it does not relate to the prior coverage regarding lidocaine for chronic postsurgical pain, lidocaine-esketamine for hepatic resection, or lidocaine for IUD insertion. It provides a specific surgical alternative for managing encapsulated blebs in children.

Managing eye pressure in children with congenital glaucoma can be incredibly difficult, especially when previous surgeries do not work as expected. For one 9-year-old girl, the pressure remained dangerously high despite her history of complex surgeries. Doctors needed a way to lower her eye pressure without performing a full, invasive surgery to replace her implants.

Doctors tried a less invasive method called transconjunctival bleb needling. They used a tiny 27-gauge needle to create a new drainage path and injected a small amount of mitomycin C and lidocaine. This procedure aimed to open up a blocked drainage area. Over the course of about two months, the girl's eye pressure dropped significantly from 27 mmHg to 13 mmHg.

While the procedure successfully lowered her pressure and maintained her vision, it did cause some surface irritation to the eye. Because this was a single case report, we cannot know if this will work for every child with this condition. It serves as a promising, conservative option for doctors looking to avoid more invasive surgeries.

What this means for you:

A minimally invasive needle technique successfully lowered high eye pressure in a child with complex glaucoma.

Common questions

How did the procedure affect the child's eye pressure?

The procedure successfully lowered the child's eye pressure. It started at 27 mmHg and dropped to 24 mmHg on day one, then to 14-17 mmHg by day nine. By 1.5 months, it reached 10 mmHg, and it remained at 13 mmHg at the final follow-up.

Was the procedure safe for the patient?

The procedure was completed without serious adverse events. However, it did cause some surface issues, specifically a condition called superficial punctate keratitis, which is a type of irritation on the surface of the eye.

How did the child's vision change after the procedure?

The child's vision remained stable throughout the process. Her vision was maintained at 20/40, with some specific targets reaching 20/30. You should talk to a specialist to see if this approach is right for a specific patient.

Study Details

Study typeSystematic review

EvidenceLevel 1

PublishedOct 2026

View Original Abstract ↓

Claims of priority statementAfter conducting a literature review in July 2026 through PubMed, Google Scholar, Cochrane, and Web of Science databases using the keywords (Bleb needling; Encapsulated bleb; Mitomycin C; PAUL Glaucoma Implant; Primary congenital glaucoma), we did not find any prior similar reports. Therefore, to the best of our knowledge, this is the first report of successful needling of the PAUL Glaucoma Implant in a child with primary congenital glaucoma.PurposeTo report the clinical outcomes of a minimally invasive, stepwise transconjunctival bleb needling with mitomycin C (MMC) to rescue a failing, encapsulated PAUL Glaucoma Implant (PGI) in a pediatric patient with refractory primary congenital glaucoma (PCG).MethodsA case report of a 9-year-old female patient with a complex surgical history, including bilateral deep sclerectomies and PGIs, who presented with uncontrolled left intraocular pressure (IOP) of 27 mmHg despite maximal medical therapy. Baseline B-scan ultrasonography and clinical examination confirmed a +1 encapsulated, loculated fluid collection surrounding the left implant plate. The patient underwent an uneventful, stepwise transconjunctival needle revision using a 27-gauge needle combined with a subconjunctival injection of a 0.3 mL mixture of 0.4 mg/mL MMC and 2% lidocaine to mechanically disrupt the fibrous capsule.ResultsOn postoperative day 1, the left IOP was 24 mmHg with a deep anterior chamber. At the 9-day follow-up, the left IOP dropped to 14–17 mmHg with the formation of a quiet, diffuse bleb. By 1.5 months postoperatively, excellent stabilization was achieved with a left IOP of 10 mmHg and best-corrected visual acuity maintained at 20/40 (isolated optotypes reaching 20/30). At the final follow-up (2 months and 11 days), the left IOP remained well-controlled at 13 mmHg. A secondary poor ocular surface with superficial punctate keratitis was successfully managed with aggressive topical lubrication.ConclusionsTransconjunctival bleb needling augmented with MMC is an effective, conservative alternative to full surgical revision or implant replacement for managing encapsulated, hypertensive drainage blebs following PGI surgery in pediatric patients.

Transconjunctival bleb needling with mitomycin C reduces intraocular pressure in pediatric congenital glaucomaNew surgical technique helps manage severe glaucoma in children

How this fits prior evidence

Common questions

Study Details

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Transconjunctival bleb needling with mitomycin C reduces intraocular pressure in pediatric congenital glaucomaNew surgical technique helps manage severe glaucoma in children

How this fits prior evidence

Common questions

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Study Details

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