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Editors Selection IGR 9-4

Surgery: Tube shunt in ciliary sulcus

Comment by Robert Feldman on:

22129 Ab interno sulcus placement of glaucoma tube implants, Camejo L; Noecker R, Ophthalmic Surgery Lasers and Imaging, 2008; 39: 434-435

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Camejo and Noecker (1702) present an eloquent new technique to accurately place a tube shunt in the ciliary sulcus. The theoretical advantage of less ongoing corneal damage is the reason why many surgeons prefer pars plana tube placement as opposed to the anterior chamber. This new technique, a third alternative, presented by Camejo and Noeker basically involves making the entry track via an ab-interno approach and may be useful in pseudophakes when there is no concomitant reason to perform a vitrectomy. By entering 180 degrees away via paracentesis, the 23-gauge needle normally used to enter the anterior chamber can be passed internal to external from the sulcus out through the sclera. The tube can then be inserted by the surgeon's usual technique, with accurate placement. Although this new technique seems technically simple, the real question of whether or not it provides an advantage remains. If the authors are correct and the anterior position of a tube is the direct cause of corneal endothelial cell loss, then the technique may become common. If the cause of corneal endothelial cell loss is changes in aqueous dynamics with resulting changes in corneal endothelial nutrition, the sulcus positioning may have little or no advantage over older techniques. Only time will tell.

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