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Editors Selection IGR 18-3

Surgical Therapy: Conjunctiva in Gold Micro Shunt implantation

Comment by Celso Tello & Sung-Chul Park on:

27040 In vivo analysis of conjunctiva in gold micro shunt implantation for glaucoma., Mastropasqua L; Agnifili L; Ciancaglini M et al., British Journal of Ophthalmology, 2010; 94: 1592-1596

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Mastropasqua et al. (1998) investigated the conjunctival intraepithelial microcyst density and size in eyes with gold micro shunt (GMS) implantation and demonstrated that conjunctival microcysts are larger and occur more densely in the eyes with successful postoperative IOP control than those without. They proposed an increased trans-scleral aqueous outflow, which may be attributed to the lamellar scleral dissection, as a possible mechanism of these findings. There was no evidence of filtering bleb on slit-lamp biomicroscopy, bleb photography, and anterior segment OCT. However, the presence of conjunctival microcysts requires aqueous outflow to subconjunctival space, although its amount may not be sufficient to be detected clinically.

In addition to the trans-scleral outflow proposed by the authors, it is possible that an inadvertent gap at the scleral incision made for the GMS implantation acted as an aqueous pathway from the anterior chamber to the subconjunctival space. This concept is supported by the fact that the confocal microscopy demonstrated conjunctival microcysts right above the scleral incision (2 mm from the limbus). Similar effect has also been noticed in other surgical procedures including cataract extraction with scleral tunnel incision and nonpenetrating glaucoma surgeries.

The GMS implantation has been proven to be effective in lowering IOP short-term in patients with or without previous glaucoma surgery (Melamed S, et al. Arch Ophthalmol 2009; 127: 264-269). Proposed mechanisms of IOP reduction by the present study are aqueous outflow to the suprachoroidal space demonstrated using anterior segment OCT as well as aqueous filtration across the sclera. Based on the authors' success rate on the eyes with multiple failed glaucoma surgeries, the GMS implantation may prove to be a viable option for management of refractory glaucoma in addition to being a surgical alternative for eyes without previous glaucoma surgery.

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