Glaucoma surgeons describe strategies they find helpful for optimizing outcomes with glaucoma tube shunt surgery.
Reviewed by Jonathan Eisengart, MD, and Steven J. Gedde, MD
Glaucoma tube shunt surgery may seem somewhat mundane, but a certain amount of finesse can help surgeons ease difficult situations and achieve the best long-term outcomes for patients. Jonathan Eisengart, MD, and Steven J. Gedde, MD, discussed techniques they have refined over time.
Dr. Eisengart, clinical assistant professor of ophthalmology, Cleveland Clinic, Cleveland, began by discussing traction suture placement to improve exposure in challenging situations.
Noting that the typical corneal traction suture may not allow adequate leverage for rotating the globe to achieve the exposure needed for proper tube placement in the inferonasal or superonasal quadrants, Dr. Eisengart suggested passing the traction suture posterior to the cornea transconjunctivally through the sclera.
“The toughness of the sclera allows the surgeon to pull more securely, and the posterior placement allows more globe rotation, enabling good exposure and facilitating identification of the inferior and medial rectus muscles,” he said.
Surgeons can also encounter difficulty gaining adequate exposure in cases requiring revision or removal of a tube shunt. Dr. Eisengart presented a case involving superonasal tube exposure in which he placed the traction suture transconjunctivally about 4 mm behind the limbus.
The technique provided both good exposure of the plate and protected the cornea. Dr. Gedde, professor of ophthalmology and John G. Clarkson Chair in Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, explained that he places the traction suture at the limbus. The suture facilitates exposure throughout the case, and it is also used in the conjunctival closure, he said.
“Pulling the traction suture in a direction away from the quadrant of surgical implantation allows improved surgical exposure throughout the case,” he said.
“Pulling the traction suture in the opposite direction (i.e., toward the quadrant of implantation) at the end of the procedure brings the conjunctiva to the limbus, making closure of a fornix-based flap very easy. I incorporate the traction suture in the conjunctival closure as a horizontal mattress suture.”
Jonathan Eisengart, MD
E: [email protected]
This article was adapted from Dr. Eisengart’s presentation at the 2019 meeting of the American Glaucoma Society. Dr. Eisengart has no relevant financial interests to disclose.
Steven J. Gedde, MD
E: [email protected]
This article was adapted from Dr. Gedde’s presentation at the 2019 meeting of the American Glaucoma Society. Dr. Gedde has no relevant financial interests to disclose.