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COMMENTARY |
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Year : 2020 | Volume
: 68
| Issue : 6 | Page : 1153-1154 |
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Commentary: Intraluminal stenting of non-flow restrictive glaucoma drainage devices
Sirisha Senthil
VST Center for Glaucoma Care, L V Prasad Eye Institute, Hyderabad, Telangana, India
Date of Web Publication | 25-May-2020 |
Correspondence Address: Dr. Sirisha Senthil L.V Prasad Eye Institute, Kallam Anji Reddy Campus, L V Prasad Marg, Road No: 2, Banjara Hills, Hyderabad - 500 034, Telangana India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/ijo.IJO_30_20
How to cite this article: Senthil S. Commentary: Intraluminal stenting of non-flow restrictive glaucoma drainage devices. Indian J Ophthalmol 2020;68:1153-4 |
Non-flow restrictive/non-valved glaucoma drainage devices are associated with higher incidence of post-operative hypotony compared to flow restrictive/valved devices.[1],[2] The hypotony in non-flow restrictive devices occurs due to excess aqueous outflow after dissolution of tube ligature. This complication could be transient due to inflammation, which resolves with enhanced topical steroids therapy and the hypotony eventually resolves when the bleb capsule thickens and resists outflow. However, the hypotony could be persistent with serious consequences like choroidal detachment, hypotony maculopathy, cataract formation.[1] Persistent hypotony would need surgical intervention; several methods that have been tried include religature to the tube, stenting of the tube with 3-0 Nylon, Prolene, or Supramid sutures.[3],[4],[5],[6]
A modified technique for flow restriction also includes a combination of intraluminal tube stenting with 3-0 Supramid and external tube ligature with 6-0 vicryl.[2] This dual mode of tube occlusion provides gradual drop in IOP even after the dissolution of external ligature. Conventionally, this intraluminal tube is inserted by an external approach at the tube outlet present at the tube plate junction and the free end of the suture is placed in a subconjunctival pocket reaching the inferior fornix. This intraluminal stent is removed at a later time through a conjunctival nick.[2]
The current article describes a modification of this dual technique, wherein the intraluminal occlusion is achieved by stenting the tube with a short Supramid suture at the tube inlet with a portion of the stent protruding into the anterior chamber.[7] When indicated, the intraluminal stent is removed by an anterior chamber approach through a paracentesis. The advantages of this modification are, no exteriorization of the suture into the subconjunctival space and hence avoiding conjunctival incision for suture removal, and possible leak. The disadvantage being needing a paracentesis and an intraocular intervention for stent removal though a short procedure. Even with this technique stent removal may result in hypotony which may require repeat stenting. Repeat stenting can also be performed through the anterior chamber approach rather than the conjunctival route.
Other techniques described to occlude the tube are tube ligatures (with or without stenting) by an anterior chamber approach with Prolene sutures to decrease the size of the lumen thereby decreasing the outflow rather than causing complete occlusion.[4],[6]
While preventing hypotony is a major advantage of dual tube occlusion, intraluminal stent at the inlet of the tube may also be associated with complications like anterior migration of the suture into the AC, corneal touch with progressive endothelial loss, and infection.[8]
References | | |
1. | Senthil S, Gollakota S, Ali MH, Turaga K, Badakere S, Krishnamurthy R, et al. Comparison of the new low-cost nonvalved glaucoma drainage device with Ahmed glaucoma valve in refractory pediatric glaucoma in Indian eyes. Ophthalmology Glaucoma 2018;1:167-74. |
2. | Barton K, Heuer DK. Modern aqueous shunt implantation: Future challenges. Prog Brain Res 2008;173:263-76. |
3. | Sharkawi E, Artes PH, Oleszczuk JD, Bela C, Achache F, Barton K, et al. Systematic occlusion of shunts: Control of early postoperative IOP and hypotony-related complications following glaucoma shunt surgery. J Glaucoma 2016;25:54-61. |
4. | Vergados A, Mohite A, Sung VC. Ab interno tube ligation for refractory hypotony following non-valved glaucoma drainage device implantation. Graefes Arch Clin Exp Ophthalmol 2019;257:2271-8. |
5. | Kuruvilla S, Landers J, Craig JE. Secondary stenting of glaucoma drainage implant: A novel technique for treatment of late hypotony. Clin Exp Ophthalmol 2016;44:860-1. |
6. | Iyer JV, Pitha I, Jampel H, Boland MV. Management of tube-related hypotony using Ab Interno placement of multifilament nylon suture to reduce flow. Ophthalmol Glaucoma 2019;2:275-6. |
7. | Andrew NH, Huang SG, Craig JE. A modified technique for intraluminal stenting of glaucoma drainage devices: The guide-wire technique. Indian J Ophthalmol 2020;68:1151-3. [Full text] |
8. | Kwon HJ, Kerr NM, Ruddle JB, Ang GS. Endophthalmitis associated with glaucoma shunt intraluminal stent exposure. J Curr Glaucoma Pract 2016;10:36-7. |
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