Glyxambi
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 822
  • Home
  • Print this page
  • Email this page


 
   Table of Contents      
CASE REPORT
Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 861-862

A microinvasive technique for management of corneal edema secondary to glaucoma drainage device tube-corneal touch


1 Centre for Sight, B5/24 Safdarjung Encl, New Delhi, India
2 Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission16-Oct-2017
Date of Acceptance06-Feb-2018
Date of Web Publication22-May-2018

Correspondence Address:
Prof. Viney Gupta
Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar - 110 029, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_987_17

Rights and Permissions
  Abstract 


We present a case of tube endothelial touch where a suture technique for repositioning of the Ahmed glaucoma valve was performed. Advantage of this technique is that it is minimally invasive and anterior chamber stability is maintained during the procedure.

Keywords: Ahmed glaucoma valve, glaucoma drainage device, tube-corneal touch


How to cite this article:
Kumar H, Gupta A, Gupta V. A microinvasive technique for management of corneal edema secondary to glaucoma drainage device tube-corneal touch. Indian J Ophthalmol 2018;66:861-2

How to cite this URL:
Kumar H, Gupta A, Gupta V. A microinvasive technique for management of corneal edema secondary to glaucoma drainage device tube-corneal touch. Indian J Ophthalmol [serial online] 2018 [cited 2019 Oct 18];66:861-2. Available from: http://www.ijo.in/text.asp?2018/66/6/861/232859



When a glaucoma drainage device (GDD) is not positioned properly, it can cause more complications other than tube occlusion. An anteriorly malpositioned tube can cause corneal-endothelial damage and posteriorly placed tube can cause chronic iritis and cataract formation.[1] In these cases, removal and reinsertion of the tube through a new pathway is usually the treatment of choice,[2] but if the conjunctiva is fibrosed it can be difficult to reopen the conjunctiva for the reinsertion of the tube. In this report, we describe the use of an innovative approach of suturing back the tube away from the cornea in a case of tube endothelial touch.


  Case Report Top


A 57-year-old male with diabetes, hypertension, and renal impairment came for glaucoma opinion. He gave a history of using antiglaucoma medication (timolol brimonidine combination, latanoprost, and dorzolamide) in his left eye (LE) for 3 years. He had a family history of glaucoma. On examination, his right eye (RE) was absolute stage of neovascular glaucoma (NVG). His LE best-corrected visual acuity was 6/12 and intraocular pressure (IOP) was 29 mmHg with pseudophakia and NVG. His fundus in LE showed near total cupping. The LE had undergone laser for the proliferative diabetic retinopathy.

Since his IOP was not controlled with maximum tolerable medication, he underwent LE, Ahmed glaucoma valve (AGV) implantation which was performed in 2015. He came 1 year later after surgery with a complaint of progressive diminution of vision in his LE. His visual acuity in LE was 6/36 and IOP in LE was 12 mmHg on timolol eye drops.

On slit-lamp examination, it was seen that the AGV tube was touching the endothelium causing localized corneal edema in LE [Figure 1].
Figure 1: Tube-corneal touch. Localized central corneal edema is shown by the black arrow

Click here to view


Repositioning of the tube was performed using the following technique:

First, the position of the tube was determined. Since it was placed in superotemporal quadrant, then rough position of the suture was planned over the cornea, and accordingly, insertion and removal of a 9-0 prolene (Ethicon; Johnson and Johnson, USA) straight transchamber needle was planned so that the suture lies over the body of the AGV tube. On both sides, fornix-based conjunctival peritomies were done and partial-thickness scleral flaps created. Then, the straight needle of the prolene suture was inserted into the eye from 10 o'clock limbus under the scleral flap and exited from 2 o'clock limbus.

Care was taken that the needle is above the AGV tube and the second end of the needle is then passed 2 mm posterior to the first suture. Then, the suture was cut and tightened with a 3-2-1 knot. Tightening of the suture displaces the tube away from the cornea. The scleral flaps and conjunctival peritomies on both sides were closed such that the suture knot is not exposed.

After tube repositioning, corneal edema resolved and his visual acuity improved to 6/18. A panretinal photocoagulation was augmented for the persistent iris neovascularization. This modified McCannel suture prevented further tube endothelial touch. The patient's cornea remains clear even after 12 months of the procedure [Figure 2].
Figure 2: After tube repositioning using 9–0 Prolene suture

Click here to view



  Discussion Top


Glaucoma drainage devices (GDDs) are the treatment of choice for refractory glaucomas. Even after successful implantation of a GDD, many complications can occur over the course of follow-up. Tube-corneal touch leading to corneal decompensation is one of the complications after AGV implantation.[3] Patients who have a shallow anterior chamber, corneal guttata, corneal edema, or eyes with corneal transplant may be at greater risk. Apart from mechanical touch which may be constant or intermittent,[4] endothelial loss may also be due to the jet stream of aqueous humor through the silicon tube during heartbeat.[5]

Many different approaches to address the problem of corneal touch have been advocated.[6],[7] Conventional treatment of corneal touch after AGV implantation through the anterior chamber involves cutting the long tube or repositioning the tube through a new scleral pathway, ciliary sulcus, or pars plana.[2]

Repositioning a GDD tube requires one to redissect the scarred conjunctiva and the patch graft and then remove and reinsert the tube. This dissection carries a significant risk of inadvertent tube damage during the surgery and wound healing problems postoperatively which may lead to tube or patch graft exposure. Moreover the chances of intra operative bleeding could be more in eyes with iris neovascualrisation such as ours. Hence, an alternative minimal approach was planned by placing a transcameral double armed 9-0 prolene suture from limbus to limbus. It did not require any incision; hence, we did not have any wound-related complications such as wound leakage, infection, and scarring.[8],[9] This technique also avoids intraoperative hypotony which in eyes with advanced glaucomatous optic neuropathy could lead to wipe-out phenomenon causing complete loss of vision which was avoidable with this approach.


  Conclusion Top


The closed chamber technique to depress the tube away from endothelium with double-armed suture is quick, safe, minimally invasive procedure to correct the tube endothelial touch.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hong CH, Arosemena A, Zurakowski D, Ayyala RS. Glaucoma drainage devices: A systematic literature review and current controversies. Surv Ophthalmol 2005;50:48-60.  Back to cited text no. 1
[PUBMED]    
2.
Weiner A, Cohn AD, Balasubramaniam M, Weiner AJ. Glaucoma tube shunt implantation through the ciliary sulcus in pseudophakic eyes with high risk of corneal decompensation. J Glaucoma 2010;19:405-11.  Back to cited text no. 2
[PUBMED]    
3.
Sarkisian SR Jr. Tube shunt complications and their prevention. Curr Opin Ophthalmol 2009;20:126-30.  Back to cited text no. 3
[PUBMED]    
4.
Law SK, Coleman AL, Caprioli J. Dynamic tube movement of Ahmed glaucoma valve. J Glaucoma 2009;18:628-31.  Back to cited text no. 4
[PUBMED]    
5.
McDermott ML, Swendris RP, Shin DH, Juzych MS, Cowden JW. Corneal endothelial cell counts after Molteno implantation. Am J Ophthalmol 1993;115:93-6.  Back to cited text no. 5
[PUBMED]    
6.
Tello C, Espana EM, Mora R, Dorairaj S, Liebmann JM, Ritch R, et al. Baerveldt glaucoma implant insertion in the posterior chamber sulcus. Br J Ophthalmol 2007;91:739-42.  Back to cited text no. 6
    
7.
Kumar H, Gupta A, Gupta V. Achieving an ideal position of the tube in anterior chamber: A new approach. Ophthalmol Point Care 2017;1:e56-7.  Back to cited text no. 7
    
8.
Kataria P, Kaushik S, Singh SR, Pandav SS. A novel technique of a transcorneal suture to manage an iris tuck into the tube of a glaucoma drainage device. J Glaucoma 2016;25:e731-3.  Back to cited text no. 8
[PUBMED]    
9.
Dada T, Gupta R, Tinwala SI, Sobti A, Panda A. Repositioning of Ahmed glaucoma valve tube in the anterior chamber with prolene sutures to manage tube-endothelial touch. Nepal J Ophthalmol 2012;4:309-11.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed641    
    Printed0    
    Emailed0    
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal