Case Report: Successful needle revision of an encapsulated bleb following PAUL glaucoma Implant surgery in a pediatric patient

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.