Aqueous Shunt Revision with Autologous Capsular Patch Graft: Surgical Technique Description and Preliminary Results

Same-quadrant tube exchange and multiple-layer closure for recurrent tube erosion: Surgical technique description and preliminary results

Purpose

This report describes a surgical approach involving a 5-layer closure performed for a patient with uveitic glaucoma who had an Ahmed Glaucoma Valve placed 12 years prior to presentation, then erosions which were revised 2 and 4 years ago. Additionally, the patient had a Descemet Stripping Endothelial Keratoplasty (DSEK) completed 4 years prior to presentation. The patient presented with a tube that was eroded and a DSEK that had failed.

Observations

We describe the process of same-quadrant tube exchange for a new Baerveldt Glaucoma Implant-350 with repositioning of the tube tip from the anterior chamber to the ciliary sulcus with a 5-layer closure with Tutoplast pericardial patch graft, capsule autograft harvested from the Ahmed capsule, Tenon's transposition from a different quadrant, Tenon's advancement from the same quadrant, and conjunctival advancement. By post-operative month 16, the patient had undergone a repeat DSEK and had an improved visual acuity and well-controlled intraocular pressure on one IOP-lowering medication.

Conclusions

In complex tube revision surgeries with melted sclera, difficult closure under tension, and/or presence of significant tissue defect, pericardial patch graft, capsule autograft, tenon's transposition, tenon's advancement, or conjunctival advancement should be considered, as needed.

Same-quadrant Baerveldt Glaucoma Implant-250 to Baerveldt Glaucoma Implant-350 exchange

Purpose

In eyes with a prior failed aqueous shunt (or "tube") requiring additional intraocular pressure (IOP) control, options include angle surgery, cyclodestruction, second tube, tube revision, or tube exchange. We present a case of a same-quadrant tube exchange of a Baerveldt-250 (BGI-250) to BGI-350.

Observations

The patient is a 71-year-old African American female with severe-stage primary open angle glaucoma of both eyes, and this case focuses on the right eye. This eye had prior cataract surgery with iStent, prior BGI-250 in the anterior chamber (AC), and prior iStent removal with gonioscopy assisted transluminal trabeculotomy (GATT). The visual acuity (VA) was 20/150, and the IOP was 26 mmHg on 3 IOP-lowering medications. The prior superotemporal BGI-250 had its "wings" on top of the superior and lateral rectus muscles and its tube tip in the AC. The implant was removed in its entirety including the superficial and deep layers of its capsule. The new BGI-350 was stented with a 3-0 polypropylene ripcord, ligated with a 7-0 polyglactin suture, and implanted with its wings under the rectus muscles and the tube tip in the sulcus. For early IOP-lowering prior to ligature dissolution, 2 needle stab fenestrations and an additional 7-0 polyglactin wick was used. The capsule from the prior BGI-250 was used as a patch graft for the new BGI-350. The ligature dissolved at postoperative week (POW) 6. By POW8, the IOP was 18 mmHg on 3 IOP-lowering medications and frequent topical steroid, the AC was quiet, and the ripcord was removed. A slow steroid taper finished at postoperative month (POM) 6. By POM 12, the VA was still at baseline 20/150, and the IOP was 14 mmHg on 3 IOP-lowering medications.

Conclusions & importance

Patients with a prior failed tube requiring additional IOP-lowering can undergo a same-quadrant tube exchange. BGI-350s may offer more IOP-lowering than BGI-250s, but the IOP-lowering achieved in this patient's case could be attributable to differences in postoperative management in addition to endplate size; longer follow-up is needed. A tube exchange offers the opportunity to reposition the tube tip from the AC to the sulcus and to use the prior tube's capsule as a patch graft for the new tube.

Surgical techniques for Baerveldt glaucoma implant removal

Purpose

To describe two surgical techniques for removing Baerveldt-350 Glaucoma Implants (BGI-350).

Observations and plan

A 91-year-old female with history of bilateral BGI-350s and prior history of tube associated endophthalmitis in the left eye requiring tube removal and resultant phthisis was referred for tube erosion and hypopyon in the right only-seeing eye, and we recommended tube removal. On exam, the left phthisical eye still had a BGI-350 plate attached under the lateral rectus muscle by one anchoring stalk, as it had not been fully removed previously, and the patient recalled severe pain during attempted tube removal in the left eye. We performed concurrent removal of both BGI-350s under general anesthesia. We describe a surgical technique for removing a BGI-350 when the conjunctiva does not need to be spared for future surgery. We also present a second case of BGI-350 removal with a different technique that aims to spare the conjunctiva for future surgery.

Conclusions and importance

BGI-350s can develop complications requiring repositioning, revision, or removal. Improper removal of BGI-350s can lead to patient discomfort and future complications. We highlight two different techniques to remove a BGI-350, depending on whether the conjunctiva is intended to be spared for future surgery or not. With either technique, we advocate for general anesthesia and a posterior scleral traction suture to provide patient comfort and optimal exposure of the surgical field.