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Editors Selection IGR 12-3

Surgery: Tube implantation through ciliary sulcus

Comment by Jeffrey Freedman on:

26650 Glaucoma tube shunt implantation through the ciliary sulcus in pseudophakic eyes with high risk of corneal decompensation, Weiner A; Cohn AD; Balasubramaniam M et al., Journal of Glaucoma, 2010; 19: 405-411

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Corneal decompensation associated with glaucoma implant use, has been an ongoing problem that has been discussed for many years, without any finite solution as to the actual cause. Weiner et al. (1421) present their clini cal experience with the implantation of a Baerveldt 350 tube shunt, through the ciliary sulcus, with the additional factor of eyes regarded as high risk for corneal decompensation, due to the presence of a posterior chamber lens (PCIOL), corneal transplant, or corneal edema. Thirty-six pseudophakic eyes are presented are presented, consisting of 23 clear corneas, six edematous corneas, and seven clear corneal transplants. The tube was placed between the iris and the PCIOL, by way of the ciliary sulcus. The main outcome measures were postoperative corneal status, postoperative intraoperative pressure (IOP), and complications.

Ciliary sulcus placement of a glaucoma tube shunt in high risk eyes reduces the risk for corneal decompensation

At final visit, all 23 preoperative clear native corneas and six of seven corneal transplants remained clear. Thus only one of 30 preoperative clear corneas failed. Postoperative IOP success was defined as a pressure between 5 and 21 mmHg. Mean follow up was 21.8 months. Mean preoperative IOP was 27.9 mmHg, which reduced to a mean postoperative IOP of 10.1 mm Hg., being lowered by 30% or more in 34 of 36 eyes (91.7%). Five eyes met the criteria of failure because of postoperative IOP control. Postoperative hyphema appeared to be a more frequent complication than seen with angle placement of tubes.

The findings of the study indicated that ciliary sulcus placement of the tube in eyes with a PCIOL, and at risk for corneal decompensation, lowers this risk, as well as that of posterior segment complications, when compared to reported results utilizing angle and pars plana insertion of tubes in similar cases.

A prospective randomized study, comparing angle placement to ciliary sulcus placement, in corneas of eyes with PCIOLS, and other factors likely to increase corneal decompensation, would be useful.

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