Polypropylene suture–guided valve tube for posterior chamber implantation in patients with pseudophakic glaucoma

TECHNIQUE

Polypropylene suture–guided valve tube for posterior chamber implantation in patients with pseudophakic glaucoma Javier Moreno-Montan˜e´s, MD, PhD, Francisco Fantes, MD, Pio Garcı´a-Go´mez, MD

We describe a new surgical procedure for implanting a glaucoma drainage tube in the posterior chamber. A needle with a 10-0 polypropylene suture is introduced into the posterior chamber, and a 23-gauge needle is also introduced as the barrel on the polypropylene needle tip. After the 23-gauge needle is withdrawn from the posterior chamber, the polypropylene needle tip is pulled and the suture crosses the anterior and posterior chambers. A sliding knot is made around the drainage tube. The tube is pushed into the scleral tunnel and posterior chamber as the suture is pulled to position the tube. The knot is loosened and the suture removed from the eye by pulling from either side. This procedure is easy and effective for implanting a tube in the posterior chamber in pseudophakic eyes and is indicated after penetrating keratoplasty or in eyes with compromised endothelial function. J Cataract Refract Surg 2008; 34:1828–1831 Q 2008 ASCRS and ESCRS

Implantation of a glaucoma drainage device (GDD) successfully controls surgical intraocular pressure (IOP) and optic nerve damage. A study comparing GDD implantation in the anterior chamber and trabeculectomy showed similar IOP reductions with both procedures after 1 year.1 The incidence of postoperative complications was higher after trabeculectomy with mitomycin-C than with a GDD during the first year of follow-up.2 However, in some eyes, implanting a GDD in the anterior chamber may result in endothelial decompensation and corneal edema. These eyes include those with low endothelial cell density, Fuchs endothelial dystrophy, a shallow anterior

chamber, extensive synechial angle closure, or need for posterior keratoplasty. Some reports have suggested that in these high-risk cases, it is advisable to insert the GDD into the posterior chamber if the patient is pseudophakic.3,4 However, in some eyes, it is difficult to implant a flexible silicone tube in the posterior chamber because the tube is pushed into the posterior chamber in restricted space under the iris without a clear microscopic view. In some cases, the iris or an intraocular lens (IOL) may complicate adequate implantation of the tube. We describe an easy and effective technique to facilitate implantation of the tube in the posterior chamber using a 10-0 polypropylene (Prolene) suture.

Accepted for publication May 13, 2008.

SURGICAL TECHNIQUE

From the Department of Ophthalmology (Moreno-Montan˜e´s, Garcı´a-Go´mez), Clinica Universitaria de Navarra, Facultad de Medicina, Universidad de Navarra, Pamplona, Spain; Bascom Palmer Eye Institute (Fantes), University of Miami, Miller School of Medicine, Miami, Florida, USA.

After a limbal peritomy is performed in the selected area and the scleral bed is exposed, the plate of a glaucoma valve is secured to the sclera 8 to 10 mm posterior to the limbus. A straight needle with a 10-0 Prolene suture is then introduced into the peripheral cornea 180 degrees from the tube position, advanced into the posterior chamber, and passed through the sclera near the tube (Figure 1, A). If placement of the suture needle is inadequate, the needle is pulled out and passed through the sclera at another site; no stitches are needed to suture the first scleral hole. If placement of the suture needle is adequate, a 23-gauge needle is introduced into the posterior chamber as a barrel over the polypropylene needle tip (Figure 1, B). The

No author has a financial or proprietary interest in any material or method mentioned. Dr. Jose´ I. Belda provided comments about the surgical procedure. Roman Ferrero supplied the Figure 1 drawings. Corresponding author: Javier Moreno-Montan˜e´s, MD, PhD, Department of Ophthalmology, Clı´nica Universitaria, Universidad de Navarra, Apartado 4209, 31080 Pamplona, Spain. E-mail: jmoreno@ unav.es.

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Q 2008 ASCRS and ESCRS Published by Elsevier Inc.

0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.05.063

TECHNIQUE: POSTERIOR CHAMBER TUBE IMPLANTATION

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Figure 1. A: A straight needle with a 10-0 Prolene suture is introduced into the peripheral cornea 180 degrees from the tube, advanced into the posterior chamber, and passed through the sclera near the tube. B: A 23-gauge needle, which is the same size as the tube, is introduced into the posterior chamber as a barrel over the suture needle tip. C: After the 23-gauge needle is withdrawn from the posterior chamber, the polypropylene needle tip is pulled and the suture crosses the anterior and posterior chambers. D: A sliding knot is made by wrapping the long suture (the part of the suture inside the eye) twice (2 in the figure) around the tip of the drainage tube to the short suture (the part outside the eye near the needle (1 in the figure). When the long suture is pulled, the knot tightens; when the short suture is pulled, the knot unties. E: The tube is pushed into the scleral tunnel and the posterior chamber simultaneously as the suture that crosses the eye is pulled gently to situate the tube correctly in the posterior chamber until the tip is visible in the pupil. F: The knot is loosened by pulling the short suture (1 in D).

23-gauge needle is withdrawn from the posterior chamber, the polypropylene needle tip is advanced, and the suture crosses the anterior and the posterior chambers (Figure 1, C). The tube is cut to the appropriate length so it can be viewed through the pupil. A sliding knot is made by wrapping the long suture (the suture segment from inside the eye) twice around the tip of the drainage tube to the short suture (the part outside the eye near the needle). When the longer suture is pulled, the knot is tightened; when the shorter suture is pulled, the knot unties (Figure 1, D). The tube is pushed into the scleral tunnel and introduced into the posterior chamber at the same time the suture

that crosses the eye is gently pulled to situate the tube correctly in the posterior chamber until the tip is seen in the pupil (Figure 1, E). This suture traction does not affect the knot because the surgeon pulls from the suture, increasing the tightness of the knot (Figure 1, E). Using this procedure, the tip and middle of the tube can be controlled, ensuring adequate movement of the tube into the eye. It is important to avoid introducing the short suture completely into the posterior chamber. Finally, the knot is loosened by pulling the short suture (Figure 1, F). The Prolene suture is then removed from the eye by pulling it from either side. This surgical procedure is easy to perform and facilitates

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the introduction and movement of the flexible tube into the posterior chamber. Case Report An 80-year-old woman with glaucoma in the left eye was evaluated 1 year after complicated cataract surgery. An IOL had been implanted in the anterior chamber of the left eye; pseudophakodonesis and peripheral anterior synechias between the cornea and the iris in the superior area were seen (Figure 2). Uneventful phacoemulsification had been performed in the right eye 4 years previously. The best corrected visual acuity (BCVA) was 0 (logMAR units) in the right eye and 1 in the left eye; the endothelial cell density was 2508 cells/mm2 and 911 cells/mm2, respectively, and the IOP values were 18 mm Hg and 32 mm Hg, respectively, with administration of latanoprost, timolol, brimonidine, and dorzolamide. Combined surgery was carried out 1 month later in the left eye. Peribulbar anesthesia (2 cc mepivacaine and 2 cc bupivacaine) was administered. No mydriatic drops were used preoperatively. Two partial-thickness triangular scleral flaps, 180 degrees apart, were made 2.5 mm posterior to the surgical limbus on both sides. After a 7.0 mm clear corneal incision was made, the rigid IOL was explanted from the anterior chamber. Another IOL (model CZ70BD, C23 diopters, Alcon) was implanted in the posterior chamber and sutured transsclerally in the sulcus. The IOL was fixated with each IOL eyelet sutured to the sulcus using a double-armed 10-0 Prolene suture. An FP7 Ahmed glaucoma valve (New World Medical, Inc.) was fixated in the sclera with the plate sutured in the superotemporal area using a 9-0 nylon suture. The tube was introduced into the posterior chamber and over the IOL optic using the 10-0 suture-guided procedure. This approach was useful because the eye did not have a capsular bag; implanting the tube into the posterior chamber, which required pushing the tube only, facilitated positioning the tube under the IOL in the vitreous. The external tube was secured to the sclera with a 10-0 nylon suture and covered by scleral tissue. Finally, the conjunctiva was sutured. Prednisolone neomycin sulfate 0.1% eyedrops were administered 8 to 10 times daily during the first postoperative week and prednisolone eyedrops 3 times daily. At 9 months, the BCVA was 0.5 and the IOP was 9 mm Hg with prednisolone eyedrops 3 times daily (Figure 3). The postoperative endothelial cell count was similar to the preoperative value. The suture-guided procedure has been performed in 3 other cases without complications. In 2 cases an Ahmed valve was implanted and in 1 case, a Molteno valve.

Figure 2. Anterior chamber IOL and peripheral anterior synechias between the cornea and iris in the superior area.

DISCUSSION Many patients who receive a GDD have had multiple surgeries and have severe underlying ophthalmic diseases. As a result, the endothelial cellular density is low. Other eyes that have had penetrating keratoplasty (PKP) also have uncontrolled glaucoma despite maximum medical treatment. Some studies report the incidence of glaucoma after PKP ranges from 2% to 80%.5,6 The presence of a GDD after PKP has been associated with a poorer long-term prognosis for corneal grafts; graft failure has been reported in 43% to 60% of eyes with a tube in the anterior chamber.7–12 This high risk for graft failure in patients with a GDD implanted in the anterior chamber may be associated with different factors, including endothelial touch by the tube secondary to intraoperative manipulations. Postoperative cornea–tube contact may be secondary to ocular movements, blinking, and eye rubbing.7,10,13

Figure 3. The IOL is sutured transsclerally in the sulcus. The tube position is situated in the posterior chamber and over the IOL optic.

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Maximizing the distance between the tube and the corneal endothelium theoretically decreases the risk for postoperative cornea–tube touch with mechanical endothelial damage. Pars plana tube insertion offers several advantages over limbal insertion that may enhance corneal graft survival. Arroyave et al.7 reported clear grafts in 48% of cases with the GDD in the anterior chamber compared with 83% of cases with the GDD in the vitreous cavity 1 year after GDD implantation. However, insertion of the tube in the pars plana required a vitrectomy, and a vitrectomy with insertion of the tube into the posterior segment carries other surgical risks, including retinal detachment, greater postoperative inflammation, endophthalmitis, vitreous hemorrhage, or incarceration of residual vitreous in the tube lumen.7,13 Implanting the GDD in the posterior chamber may decrease the probability of the tube touching the cornea and prevents complications associated with surgical vitrectomy if the tube is implanted in the vitreous.3 Recently, Tello et al.3 described a surgical procedure to implant the tube in the posterior chamber sulcus. They suggest injecting sodium hyaluronate into the posterior chamber to enlarge the chamber to facilitate entrance of the 23-gauge needle and avoid trauma to the iris, zonula, or capsular bag–IOL complex. However, there are anatomic variations of the anterior segment and the size of the sulcus. Our surgical procedure has some advantages over the technique of Tello et al. in that the position of the site used to introduce the tube through the sclera is determined by the entrance of the suture needle into the internal sulcus (Figure 1, A), avoiding problems caused by anatomic variations. In addition, because the movement of the tube tip is controlled by the suture traction, the flexible tube is prevented from coming into contact with the iris or capsular bag–IOL complex. Our approach has other potential advantages in that it eliminates the need for pars plana vitrectomy with potential postoperative vitreoretinal complications in cases of corneal endothelial complications, and the procedure is simple and can be repeated if the knot loosens during tube implantation in the posterior chamber. Tube placement using this method avoids continuous touch between the tube and the iris and could reduce intraocular inflammation or iris depigmentation. Finally, the procedure can be performed in cases of corneal decompensation after tube implantation in the anterior chamber. It is possible to perform PKP during the same surgery and change the tube position from the anterior chamber to the posterior chamber using the 10-0 suture-guided procedure or to perform this technique in combination with other surgery. In summary, this surgical procedure is easy to perform by a surgeon experienced in glaucoma or anterior segment surgery, facilitates correct implantation of the tube in the posterior chamber, and decreases the risk

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for corneal decompensation because it eliminates the potential for intraoperative or postoperative cornea– tube touch and mechanical endothelial damage. Although the technique did not cause complications in our cases, a larger series of patients and a longer follow-up are required to establish the safety of this innovative surgical approach. REFERENCES 1. Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL. Treatment outcomes in the Tube Versus Trabeculectomy Study after one year of follow-up; the Tube Versus Trabeculectomy Study Group. Am J Ophthalmol 2007; 143:9–22 2. Gedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC. Surgical complications in the Tube Versus Trabeculectomy Study during the first year of follow-up; the Tube Versus Trabeculectomy Study Group. Am J Ophthalmol 2007; 143:23–31 3. Tello C, Espana EM, Mora R, Dorairaj S, Liebmann JM, Ritch R. Baerveldt glaucoma implant insertion in the posterior chamber sulcus. Br J Ophthalmol 2007; 91:739–742 4. Rumelt S, Rehany U. Implantation of glaucoma drainage implant tube into the ciliary sulcus in patients with corneal transplants. Arch Ophthalmol 1998; 116:685–687 5. Foulks GN. Glaucoma associated with penetrating keratoplasty. Ophthalmology 1987; 94:871–874 6. Lee RK, Fantes F. Surgical management of patients with combined glaucoma and corneal transplant surgery. Curr Opin Ophthalmol 2003; 14:95–99 7. Arroyave CP, Scott IU, Fantes FE, Feuer WJ, Murray TG. Corneal graft survival and intraocular pressure control after penetrating keratoplasty and glaucoma drainage device implantation. Ophthalmology 2001; 108:1978–1985 8. Hodkin MJ, Goldblatt WS, Burgoyne CF, Bell SF, Insler MS. Early clinical experience with the Baerveldt implant in complicated glaucomas. Am J Ophthalmol 1995; 120:32–40 9. Coleman AL, Mondino BJ, Wilson MR, Casey R. Clinical experience with the Ahmed Glaucoma Valve implant in eyes with prior or concurrent penetrating keratoplasties. Am J Ophthalmol 1997; 123:54–61 10. Rapuano CJ, Schmidt CM, Cohen EJ, Rajpal RK, Raber IM, Katz LJ, Wilson RP, Laibson PR, Kremer I. Results of alloplastic tube shunt procedures before, during, or after penetrating keratoplasty. Cornea 1995; 14:26–32 11. Alvarenga LS, Mannis MJ, Brandt JD, Lee WB, Schwab IR, Lim MC. The long-term results of keratoplasty in eyes with a glaucoma drainage device. Am J Ophthalmol 2004; 138:200–205 12. Kwon YH, Taylor JM, Hong S, Honkanen RA, Zimmerman MB, Alward WLM, Sutphin JE. Long-term results of eyes with penetrating keratoplasty and glaucoma drainage tube implant. Ophthalmology 2001; 108:272–278 13. Sidoti PA, Mosny AY, Ritterband DC, Seedor JA. Pars plana tube insertion of glaucoma drainage implants and penetrating keratoplasty in patients with coexisting glaucoma and corneal disease. Ophthalmology 2001; 108:1050–1058

First author: Javier Moreno-Montan˜e´s, MD, PhD Universidad de Navarra, Ophthalmology Dept. Clinica Universitaria de Navarra, Pio XII, 36, 31008 Pamplona, Navarra, Spain

J CATARACT REFRACT SURG - VOL 34, NOVEMBER 2008