Intravitreal HPMC for chronic structural ocular hypotony: a case series summary

A study from the UK reported a promising approach for managing structural hypotony in eyes that have visual potential. The investigators, led by Karla Orsine Murta Dias, MD, from Moorfields Eye Hospital NHS Foundation Trust, London, reported that use of 2% hydroxypropylmethylcellulose (HPMC) dispersive viscoelastic(Eyefill HD, Bausch+Lomb) improved vision and restored ocular anatomy in a pilot study. The results were reported in the British Journal of Ophthalmology.¹

Managing chronic ocular hypotony management remains a significant challenge,² the authors explained. This potentially sight-threatening condition³ is subdivided into numerical hypotony and structural hypotony. Regarding the former, there is disagreement about the intraocular pressure (IOP) level that defines hypotony, with the highest reported value being below 6.5 mmHg.^2-6

Structural hypotony is low IOP combined with with anatomic changes directly caused by the low pressure, the list of which is extensive.¹

If left untreated, the investigators emphasized, the globe eventually becomes deformed, leading to structural changes and phthisis.^7-9 The treatment depends on the cause and can be medical and surgical management; however, the visual outcomes are often poor.^4,7,10

The investigators recounted that while intravitreal viscoelastic agents have been used anecdotally to manage hypotony, no structured protocols or prospective data have been published. They also pointed out that there is no established standard of care for restoring ocular anatomy and function in eyes with structural hypotony and visual potential.

Case series

Orsine Murta Dias and colleagues conducted a prospective interventional case series to assess the visual and anatomic outcomes after intravitreal injections of HPMC to treat chronic structural hypotony. The study included eight patients who had chronic structural hypotony for longer than 3 months. The IOP in all cases was less than 6.5 mmHg (range, 1–5 mm Hg). The initial best-corrected visual acuity (BCVA) levels upon entrance into the study ranged from 0.3 to 1.7 logarithm of the minimum angle of resolution (logMAR). Visual potential was evident in all cases and all patients had a clear cornea and visual axis.

Patients received multiple intravitreal injections of HPMC ranging from 70 to 1,400 µL that were administered every 2 to 4 weeks until one of the following occurred, ie, the pre-morbid axial length was achieved, an IOP of from 10 to 15 mm Hg was sustained for 4 weeks with no signs of hypotony, or the axial length of the contralateral eye was reached. Patients were followed for 12 months after the first intravitreal injection.

What did the evaluation of HPMC show?

The evaluation of the eight patients showed that the corrected logMAR BCVA improved in 87.5% of eyes, while the BCVA in one eye remained stable. The final BCVAs ranged from 0.1 to 1.6 logMAR.

The IOP increased in 87.5% of eyes to 3 to 23 mmHg. The axial length also increased in 75% of eyes, with a median increase of 1 mm (range, 0.6–2.9 mm), the investigators reported.

Two adverse events were reported, ie, uveitis flare-ups leading to loss of HPMC clarity in two eyes that was treated with topical and intravitreal steroids, and two cases of temporary visual loss after injection of HPMC that resolved after paracentesis.

Orsine Murta Dias and colleagues concluded, “This study demonstrates that intravitreal HPMC, delivered via a structured protocol, can improve the VA, IOP, and axial length in selected patients with chronic structural hypotony. These findings suggest a reproducible therapeutic strategy with potential to prevent irreversible ocular damage in eyes with visual potential.”

They also noted that their study “provides a foundation for future clinical trials and may inform the development of standardized treatment pathways for vision preservation in hypotony.”

References
1. Orsine Murta Dias K, Yang E, Calcagni A, et al. Novel therapeutic strategies to restore vision in ocular hypotony (STRETCH): results from a prospective pilot series. Br J Ophthalmol. 2026;110:857-62. doi:10.1136/bjo-2025-327866
2. Stead RE, Juma Z, Turner S, et al. A novel use of reticulated hyaluronic acid (Healaflow) for hypotony eyes in patients with uveitis. Br J Ophthalmol. 2016;100:727–30. doi:10.1136/bjophthalmol-2015-307799

3. Wang Q, Thau A, Levin AV, et al. Ocular hypotony: A comprehensive review. Surv Ophthalmol. 2019;64:619–38. doi:10.1016/j.survophthal.2019.04.006

4. Okonkwo ON, Tripathy K.Ocular hypotony. In: StatPearls. 2022. https://www.ncbi.nlm.nih.gov/books/NBK582144/

5. Scott ML, Netland PA, Salim S, et al. Assessing and managing hypotony maculopathy. EyeNet Magazine. 2019; October 1, 2009. https://www.aao.org/eyenet/article/assessing-managing-hypotony-maculopathy
6. Trubnik V. Managing hypotony after trabeculectomy. Rev Ophthalmol. 2015. https://www.reviewofophthalmology.com/article/managing-hypotony-after-trabeculectomy
7. O’Connell SR, Majji AB, Humayun MS, et al. The surgical management of hypotony. Ophthalmology. 2000;107:318–23. doi:10.1016/S0161-6420(99)00047-0
8. Küçükerdönmez C, Beutel J, Bartz-Schmidt KU, et al. Treatment of chronic ocular hypotony with intraocular application of sodium hyaluronate. Br J Ophthalmol. 2009;93:235–9. doi:10.1136/bjo.2008.143834
9. Tosi GM, Schiff W, Barile G, et al. Management of severe hypotony with intravitreal injection of viscoelastic. Am J Ophthalmol. 2005;140:952–4. doi:10.1016/j.ajo.2005.06.019
10. Schubert HD. Postsurgical hypotony: relationship to fistulization, inflammation, chorioretinal lesions, and the vitreous. Surv Ophthalmol. 1996;41:97–125. doi:10.1016/s0039-6257(96)80001-4