Glaucoma drainage devices are designed to divert aqueous humor from the anterior chamber to an external reservoir, where a fibrous capsule forms about weeks after surgery and regulates flow. They also have demonstrated success in complicated glaucomas, such as uveitic glaucoma, neovascular glaucoma, and pediatric and developmental glaucomas, among others. Since the introduction of the first glaucoma drainage device, Molteno implant , various modifications of the original design and improvements in surgical techniques over the past 40 years have led to greater success and lower complication rates. In addition, other glaucoma drainage devices have been introduced and offer unique features designed to facilitate implantation, improve IOP control, and reduce acute postoperative hypotony. Currently, the glaucoma drainage devices are available in different sizes, materials, and design with the presence or absence of an IOP regulating valve.
Associated choroidal Gloryhole ations are generally treated with corticosteroid and cycloplegic agents. However, subsequent studies have not shown these agents to be effective. Patient had a failed trabeculectomy. The tube may be placed in the sulcus in a pseudophakic eye or pars plana in an aphakic, vitrectomized eye. The entire surgery will take about two hours. Imlant access to premium Baerveldt implant Subscribe today.
Free gay oneline dating. How to insert Baerveldt Glaucoma Implant 350
There are also device related complications, which will require Baerveldt implant revision. A similar surgical Doctor spanks Baerveldt implant used in all patients for placement of a mm 2 Baerveldt implant. The tube is covered with a piece of graft tissue, which is a piece of donated eye tissue used for transplantation purposes. Wear the plastic shield provided over your Baerveldt implant at night for the first 2 weeks. Rarely, if it was causing infection or shifting position, it would be removed. Also known as "aqueous shunts" or "glaucoma drainage devices," we'll refer to them simply as "implants. In addition, variables such as preoperative IOP and the magnitude of change in IOP between preoperative and postoperative levels have been found to be related to the development of SCH. When combined with cataract surgery, it can take just over an hour to an hour and a half. Suprachoroidal hemorrhage after Molteno implantation. Transparent tissue at the front of the eye in front of the iris and lens.
Its content should not be considered medical advice, diagnosis or treatment recommendations.
- A glaucoma valve is a medical shunt used in the treatment of glaucoma to reduce the eye 's intraocular pressure IOP.
- Complications of Baerveldt Glaucoma Drainage Implants.
- Sometimes, a trabulectomy is not effective, or the eyes may exhibit extensive scarring from previous surgeries.
Its content should not be considered medical advice, diagnosis or treatment recommendations. Submit to journal Education Zone. Subscribe User Login. Filter Specialty Register Login. Filter specialty. Submit To The Journals. How to insert Baerveldt Glaucoma Implant Baerveldt glaucoma tube implant with scleral patch graft.
Patient had a failed trabeculectomy. Tube covered with scleral patch graft. Tied off with Get access to premium content Subscribe today. Previous Video Next Video. Related Videos Glaucoma. Gel Stent Implantation — Repositioning. Gel Stent Implantation — Primary Needling. In Partnership. Submit to the Journals.
Baerveldt drainage devices have proven to be extremely effective 70 to 80 percent in controlling IOP and have a lower risk of surgical failure than other GDDs. In comparison to the glaucoma drainage devices that use an ab externo procedure, ab interno implants, such as the Xen Gel Stent, are transscleral implants to channel aqueous humor into the non-dissected Tenon's space, creating a subconjunctival drainage area similar to a bleb. Double vision right after the surgery is common, but also can sometimes persist after the wounds have healed. This may happen because the optic nerve in a person with advanced glaucoma may be too weak to tolerate the surgical trauma. Website Sponsors We appreciate support from corporations who believe in our mission to educate glaucoma patients and speed a cure. Sign in to download free article PDFs Sign in to access your subscriptions Sign in to your personal account.
Baerveldt implant. Also By The Authors
Glaucoma Drainage Devices - EyeWiki
Glaucoma drainage devices are designed to divert aqueous humor from the anterior chamber to an external reservoir, where a fibrous capsule forms about weeks after surgery and regulates flow.
They also have demonstrated success in complicated glaucomas, such as uveitic glaucoma, neovascular glaucoma, and pediatric and developmental glaucomas, among others. Since the introduction of the first glaucoma drainage device, Molteno implant , various modifications of the original design and improvements in surgical techniques over the past 40 years have led to greater success and lower complication rates.
In addition, other glaucoma drainage devices have been introduced and offer unique features designed to facilitate implantation, improve IOP control, and reduce acute postoperative hypotony. Currently, the glaucoma drainage devices are available in different sizes, materials, and design with the presence or absence of an IOP regulating valve.
Unlike the nonvalved devices, the valved or flow-restrictive devices allow only unidirectional flow from the anterior chamber to the subconjunctival space with a minimum opening pressure. Table 1 provides a summary of commercially available devices with their respective characteristics. This review article will discuss the currently available glaucoma drainage devices, preoperative considerations and surgical technique, description and management of various complications, surgical outcomes in refractory glaucomas, comparative studies of various glaucoma drainage devices, and comparative studies of glaucoma drainage devices and trabeculectomy.
Patient Selection Glaucoma drainage devices have traditionally been reserved for patients with severe uncontrolled glaucoma who have failed previous glaucoma surgery. They are commonly used in the management of congenital and developmental glaucomas.
Clinical Examination Careful preoperative examination and planning are essential for successful surgical outcomes. Clinicians should assess mobility of the conjunctiva to determine the best quadrant for drainage implant insertion.
The iris should be inspected under high magnification to detect neovascularization to consider preoperative use of anti-vascular endothelial growth factor VEGF agents to minimize intraoperative and postoperative bleeding.
Anterior chamber depth should be assessed to determine if tube insertion in the anterior chamber would be safe without touching the iris or cornea. Gonioscopy should be performed preoperatively to determine the locations of peripheral anterior synechiae which may interfere with the tube insertion into the anterior chamber intraoperatively.
The lenticular status of the eye should be noted. The tube may be placed in the sulcus in a pseudophakic eye or pars plana in an aphakic, vitrectomized eye. In an eye with a cataract, a combined surgery may be considered. Selection of Glaucoma Drainage Device For a beginning surgeon, valved devices may be preferred as the surgical technique is simpler with localization to one quadrant without manipulation of the adjacent rectus muscles. In patients with poor compliance with postoperative medication use and follow-up visits, valved implants may be preferred because they usually require less postoperative follow-up and care.
The amount of conjunctival scarring may determine the size of the implant and available area for a single-plate versus double-plate device. Early IOP control is determined by the presence or absence of a valve in an implant, as the tube offers no resistance to aqueous flow.
Because nonvalved devices are often occluded with a stent or ligature suture, the postoperative IOP is unchanged and requires continuation of all preoperative medications until the fibrous capsule forms. With all devices, long-term IOP control depends on the surface area of the implant , which determines bleb size, tissue response to the implant, and thickness of the fibrous capsule controlling percolation of aqueous humor through the bleb wall.
Plate material has been studied in various studies to determine its influence on final IOP, as it may affect tissue reaction and the degree of bleb encapsulation. Ayyala et al. The AGV silicone and polypropylene material has also been investigated in a prospective, multicenter, comparative series, which reported improved final IOP control with the silicone model compared with the polypropylene model .
Plate size of various implants has been investigated to determine its influence on the final IOP. Heuer et al. In another prospective study comparing mm 2 and mm 2 Baerveldt implants, Britt et al. These studies indicate that size of the implant does matter, but to a limited extent. Anesthetic Considerations The choice of anesthesia for inserting a glaucoma drainage device depends on the presence of other medical co-morbidities, the cooperation level of the patient, and the comfort of the surgeon.
A sub-Tenon injection is also a good alternative. Topical or intracameral anesthesia is usually not sufficient because of manipulation of extraocular muscles with some implants. General anesthesia may be reserved for patients with special circumstances, such as claustrophobia or altered mental status. Initially, a fornix-based or limbus-based conjunctival incision is created to allow adequate exposure for insertion of the plate.
A corneal or scleral suture can be placed to improve exposure in the working quadrant. The implant is anchored between two rectus muscles with the anterior edge approximately 8 to 10 m m posterior to the limbus. If a two plate implant is used, one plate is positioned in each of two quadrants.
The tube connecting the two plates may be passed under or over the intervening rectus muscle. With all valved implants, prior to the plate anchorage, the tube should be primed with balanced salt solution with a gauge cannula to ensure that the valve leaflets are not fused after sterilization techniques. The tube of the nonvalved implant should be irrigated as well to ensure its patency. Once the implant has been appropriately positioned, the plate is secured to the globe with two non-absorbable sutures or nylon sutures on a spatulated needle.
The suture knots should be rotated into the fixation eyelets to prevent erosion through the conjunctiva. Secure attachment to the underlying sclera is essential to prevent anterior, posterior, or lateral migration of the implant during the postoperative period. After the plate is attached to the globe, the tube is laid across the cornea and cut with a sharp scissors to create a beveled edge with the opening toward the cornea.
The tube should extend approximately 2. A gauge needle is used to create a track through which the tube is inserted into the anterior chamber just anterior and parallel to the iris. The tube may be secured to the sclera a few millimeters anterior to the plate with 7- 0 or Vicryl suture. This suture helps to stabilize the tube and should not be tight; otherwise, it will restrict flow in valved devices.
The tube is often covered to prevent its erosion through the conjunctiva. Patch graft materials include processed pericardium, sclera, fascia lata, dura, or cornea. The patch graft should be secured to the globe with interrupted sutures at the anterior corners by using either Vicryl or nylon sutures. In lieu of a patch graft, a partial thickness scleral flap can be constructed. The needle track and tube entry are done under this flap. The flap is then sutured with nylon sutures. After the patch graft has been placed, the conjunctiva and Tenon layers are pulled over the plate, tube, and patch graft and secured into place with Vicryl suture.
In some cases, the monofilament Vicryl suture is preferred because of its higher tensile strength and finer vascular needle to prevent buttonholes when handling thin conjunctiva. At the end of the operation, the eye should be inspected to ensure that the implant plate, patch graft, and intraocular portion of the tube are in good position.
Fluorescein drops or strips can be used to inspect the conjunctiva for leaks. Any buttonholes found in the conjunctiva should be closed with Vicryl suture. At the conclusion of the procedure, a subconjunctival injection of antibiotic and steroid is given. Internal Tube Occlusion Stent Aqueous drainage through a nonvalved device can be regulated in the early postoperative period by passing a or Prolene or nylon suture through the lumen of the implant.
Once the fibrous capsule around the plate has formed, the stent suture is removed at the slit lamp under local anesthesia. External Tube Occlusion Ligature The flow of aqueous humor through a nonvalved device can also be restricted by placing a suture ligature around the external aspect of the tube. The external occlusion may be accomplished using a non-absorbable suture with a releasable knot or a or absorbable Vicryl suture tied around the tube.
Alternatively, nylon or Prolene suture may be used to ligate the tube inside the anterior chamber to allow for later suture lysis with the argon laser. Four to 6 weeks later, after a capsule has formed around the implant, the conjunctiva is opened and the tube is inserted into the anterior chamber to complete the procedure. However, the tube may also be placed in the sulcus in a pseudophakic eye or in the pars plana in a vitrectomized eye.
Whenever possible, single-plate implants should be placed in the supero-temporal quadrant. This area provides the easiest access for the surgeon to implant the plate and is least likely to produce motility disturbances. Implantation of a large plate aqueous shunt in the supero-nasal quadrant has been associated with Brown's superior oblique tendon syndrome .
Substantial hypertropias and limitations of down gaze have been reported with inferior implantation of two-plate Molteno and the Krupin valve with disc . In eyes containing silicone oil, the implant is placed in the inferior quadrant to minimize loss of oil, which is lighter than aqueous and floats up.
Using anti-metabolites with improved success in trabeculectomy led to considerable interest in using these agents with glaucoma drainage devices. One early study indicated that patients receiving mitomycin C at the time of glaucoma implant surgery had lower final IOP, required fewer post-operative medications, and had less pronounced hypertensive phases; however, the duration of the post-operative hypotensive phase was prolonged and was associated with an increase in choroidal effusions, flat anterior chambers, and other post-operative complications .
However, subsequent studies have not shown these agents to be effective. Two retrospective studies reported no benefit of intraoperative use of mitomycin C with Baerveldt implants  . Two prospective randomized trials studied the effectiveness of intraoperative use of mitomycin C with Molteno and AGV implantation. Neither trial demonstrated higher success rates with intraoperative mitomycin C in terms of final IOP, visual acuity, and number of antiglaucoma medications required postoperatively  .
As a result of these investigations, antifibrosis agents are not currently used with glaucoma drainage devices. Following glaucoma drainage implant surgery, the patient is seen on postoperative day 1, and attention is paid to the tube position and wound architecture.
A topical antibiotic and steroid are started four times daily and continued for 4 to 6 weeks. Initial follow-up is at 1 week, and the frequency of visits depends on the clinical status of the eye.
For valved implants, preoperative glaucoma medications are discontinued to prevent hypotony. For nonvalved implants, the glaucoma medications are usually continued until a fibrous capsule forms around the plate, at which point the ligature suture may spontaneously open.
If further IOP lowering is required, the stent can also be removed. Glaucoma drainage devices can be associated with various postoperative complications. The early postoperative complications are similar to other filtration procedures including flat chambers, hypotony, and suprachoroidal hemorrhage    . Valved implants usually reduce, but do not eliminate hypotony. Hypotonous eyes are conservatively managed as long as the anterior chamber depth is maintained. If there is lenticular-corneal touch, then a viscoelastic should be injected to reform the anterior chamber.
Associated choroidal effusions are generally treated with corticosteroid and cycloplegic agents. If these measures fail, surgical revision may be required. Valve Malfunction This is a rare complication. All valved devices should be primed at the time of the surgery as sterilization techniques may lead to adhesion of the valve membranes that prevents flow to the plate .
In addition, careful surgical handling during insertion is required to prevent damage to the plastic rivets holding the valve . Hyphema Hyphema may occur following procedures performed on eyes with neovascular glaucoma. It is seen less commonly now with the preoperative use of anti-VEGF agents.