Utility of Operative Glaucoma Tube Shunt Viscoelastic Bolus Flush
Utility of Operative Glaucoma Tube Shunt Viscoelastic Bolus Flush
Utility of Operative Glaucoma Tube Shunt Viscoelastic Bolus Flush
10.5005/jp-journals-10008-1188
Utility of Operative Glaucoma Tube Shunt Viscoelastic Bolus Flush
RESEARCH ARTICLE
ABSTRACT How to cite this article: Groth SL, Greider KL, Sponsel WE.
Utility of Operative Glaucoma Tube Shunt Viscoelastic Bolus
Objective: To assess the utility of viscoelastic injection to Flush. J Curr Glaucoma Pract 2015;9(3):73-76.
induce bleb expansion and decrease intraocular pressure (IOP)
in eyes with encapsulated glaucoma tube shunt blebs. Source of support: Nil
Design: Case series. Conflict of interest: None
Subjects and participants: Forty-three glaucomatous eyes,
including 13 eyes with congenital, 13 uveitic, 5 neovascular, INTRODUCTION
5 open angle, 4 narrow angle and 3 traumatic glaucomas.
Chronic glaucoma can be managed both medically
Methods, interventions or testing: All patients underwent and surgically. When other measures fail to control
viscoelastic flush procedure. A pre-bent 27 or 30-gauge
cannula was passed through a 25-gauge paracentesis, intraocular pressure (IOP), tube shunts are commonly
advanced over the iris across the anterior chamber, and used to facilitate drainage of aqueous humor from the
insinuated into the tube shunt lumen. Once the cannula was anterior chamber. Early complications that may occur
firmly lodged in position, 0.45 to 0.85 ml of viscoelastic was after glaucoma tube shunt surgery include hypotony with
injected to hyperinflate the bleb.
or without hyphema, irideal obstruction, and uveitic, or
Main outcome measures: Paired t-tests were performed conjunctival inflammatory reactions that may contribute
comparing preoperative IOP and number of medications used
preoperatively vs levels measured at 1, 6, 12, 18 and 24 months.
to excessive capsular fibrosis.1-3 Late complications may
include conjunctival erosion with implant or suture
Results: Intraocular pressure was reduced from a mean
exposure, implant migration, valve occlusion, or chronic
preoperative level of 26.0 ± 1.2 (sem) mm Hg to 15.8 ± 1.0 at
1 month, remaining stable thereafter at each 6-month interval encapsulation with increase in IOP. A multicenter clinical
with 15.1 ± 1.1 mm Hg at 24 months (p < 0.0001). Medication trial observed a 29.8% failure rate of tube shunts after
use did not vary significantly from baseline. Pressure remained 5 years.4 This failure was overwhelmingly the consequence
≤ 21 mm Hg after 2 years in 85% of eyes cannulated within
of fibrotic encapsulation of the bleb.5,6 Clinical maneuvers
1 year of primary tube shunt implantation (n = 23), and in 62%
of eyes cannulated more than 1 year after tube shunt placement directed toward restoring function at the slit lamp
(n = 20). include bleb massage combined with anterior chamber
Conclusion: Tube shunt expansion with bolus viscoelastic flush ballottement. Such maneuvers, if carried out in the early
successfully restored encapsulated bleb function, providing a postoperative phase, can frequently successfully breach
substantial (~10 mm Hg) IOP decrease into the mid-normal the lining of a newly encapsulated bleb, but such efforts
pressure range. This persisted in the majority of treated eyes are generally unsuccessful after the fibrin lining has
for the entire study period.
become cross-linked. Transient resumption of medical
Keywords: Bleb fibrosis, Glaucoma surgery, Glaucoma tube therapy to manage the postoperative hypertensive phase
shunt, Intraocular pressure, Modification/revision of glaucoma
that often arises 4 to 6 weeks after primary tube shunt
tube shunt, Ocular hypertension, Viscoelastic.
placement is sometimes successful. However, a substantial
proportion of blebs requiring such mitigation ultimately
1
Resident, 2Resident Physician, 3Director and Professor provide unsatisfactory pressure control. Failure of
1 intractable encapsulation of tube shunts has been
Department of Ophthalmology, University of North Carolina
Chapel Hill, North Carolina, USA managed by internal debulking bleb revision procedures
2
Chicago Medical School, Chicago, Illinois, USA
to attempt to restore pressure control to adequate levels.
3
Debulking bleb revisions have been performed with
WESMD Professional Association, Baptist Medical Center
Biomedical Engineering, University of Texas, Texas and Vision YAG laser membranectomy,7-9 cyclophotocoagulation,10,11
Sciences, University of the Incarnate Word, San Antonio, Texas 5-fluorouracil,12 tissue plasminogen activator,13 and by
USA cannulation of tube with balanced salt solution flush.14
Corresponding Author: William Eric Sponsel, Suite 306, Tube shunt failure has also been managed by sequential
Madison Square Building, 311 Camden Street, San Antonio additional tube placement.15 Performing additional
Texas 78215, USA, Phone: +12102758663, e-mail: sponsel@
earthlink.net
incisional surgery in an eye already demonstrably prone
to a fibrotic healing response may ultimately be the only
option in certain instances, but less invasive surgical 13 patients with congenital, 13 uveitic, 5 neovascular,
approaches to restoring the function of a failed tube shunt 5 open-angle, 4 narrow angle, and 3 with traumatic
would be far preferable whenever possible. Prior research glaucoma. Of the 43 eyes that were treated, 23 eyes
has shown that surgical revision of tube shunt implants underwent the viscoelastic bleb re-expansion within
provides limited long-term benefit when the failure is 12 months of primary tube shunt implant surgery,
due to tube occlusion from fibrosis.16 and 20 eyes were cannulated > 12 months later. Mean
Transcameral injection of viscoelastic into the reservoir preoperative IOP among the 43 eyes was 26.0 ± 1.2 (sem)
via the tube can breach obstructed tubes, protein-sealed mm Hg, improving to 15.8 ± 1.0 mm Hg at 1 month
bileaflet valves, and mild to moderate bleb encapsulation (p < 0.0001), sustained within the normal range at 16.4 ±
with minimal inflammatory impact, potentially obviating 0.9 mm Hg, 17.0 ± 1.0, 14.4 ± 0.9 and 15.1 ± 1.1 mm Hg at 6, 12, 18
the need for more aggressive surgery. This study and 24 months, respectively. Preoperative meds were 0.84
analyzes the efficacy of rapid injection of viscoelastic via ± 0.2 and remained relatively stable at 0.57 ± 0.2, 0.78 ± 0.2,
transcameral cannulation of the tube shunt orifice within 0.84 ± 0.2, 1.14 ± 0.2 and 0.93 ± 0.2 at 1, 6, 12, 18 and 24 months,
the anterior chamber to clear the seton, inducing bleb respectively. Pressure remained ≤ 21mm Hg at 24 months
expansion in an effort to decrease IOP. in 85% of eyes cannulated within 1 year of the primary
implant procedure, and in 62% of eyes cannulated more
METHODS than 1 year after the primary implant. At 2 years, 100% of
This quality assurance analysis case series study was those with angle closure or neovascular glaucoma, 75%
performed on all glaucomatous eyes undergoing a with uveitic or open-angle glaucoma, 67% with congenital
viscoelastic flush procedure to lower IOP over a 4-year or traumatic glaucoma had pressures remaining
period. Informed consent was obtained from each patient, ≤ 21 mm Hg. Table 1 displays the demographics of the
and risks, benefits and alternatives to treatment were 43 subjects in order of the magnitude of their mean level
discussed. All information was stored in accordance with of postcannulation IOP reduction from baseline at the
HIPAA, and IRB approval for this analysis was obtained 12-month interval.
through the Baptist Health Care System Institutional
Review Board. The research was conducted in accordance DISCUSSION
with Declaration of Helsinki. Tube shunt placement offers reduction in IOP for many
All procedures were performed in the operating patients that fail medical, laser and surgical management
room under the stereomicroscope. A 27 or 25-gauge of glaucoma. Unfortunately, tube shunt failure is a
paracentesis was created opposite the proximal tube in well-recognized sequel that may lead to a clinically
the anterior chamber and a straightened 30 or 27-gauge unsatisfactory increase in IOP with time. The results of
cannula was passed through the paracentesis, avoiding this study show that operative flushing of tube shunts is
the lens, insinuated into the tube shunt lumen, and an effective technique that can be used to decrease IOP
an entire vial (0.45 to 0.85 ml) of standard viscoelastic in patients that have previously undergone tube shunt
[Healon (Abbott Medical Optics, Abbott Park, IL), Viscoat placement when IOP remains unsatisfactory despite
(Alcon, Fort Worth, TX), Provisc (Alcon, Fort Worth, TX)] medical management. This straightforward surgical
was injected to hyperinflate the bleb. The viscoelastic maneuver offers a valuable alternative to sequential
was left in situ in both the reservoir and anterior tube shunt placement which requires more extensive
chamber without balanced salt solution rinse-out. The surgical intervention and associated risks. We, therefore,
corneal entry site was then hydrated via cannula, and recommend attempting transcameral flushing of tube
the eyes were treated with topical Maxitrol ointment shunts as a prospective solution to tube shunt failure
(Alcon, Fort Worth, TX), a patch and fox shield, and before resorting to more invasive surgical options.
subsequently received a 1 month tapered regimen of In the present study, patients with neovascular
topical antibiotic [Vigamox (Alcon, Fort Worth, TX)] and glaucoma, chronic uveitis and open angle glaucoma
topical prednisolone acetate [(Omnipred (Alcon, Fort showed the most significant improvement for a sustained
Worth, TX)]. Paired t-test assessments of preoperative IOP duration. There was a weak inverse association between
and medications used were performed against baseline the time elapsed between the initial implant procedure
IOP values at 1, 6, 12, 18 and 24 months. and performance of the viscoelastic flush; 85% of eyes
cannulated within 12 months of the initial procedure
RESULTS
maintained normal IOP for the ensuing 2 years, compared
Forty-three eyes of 43 patients underwent viscoelastic with 62% of those cannulated more than 1 year after their
tube shunt flush procedures. Included were eyes of primary implant procedure.
74
JOCGP
Table 1: Demographics of the 43 subjects showing intraocular pressures and number of ocular hypotensive medications in use
immediately prior to and at the 12-month interval after undergoing viscoelastic tube shunt flush. Subjects are listed in order of the
magnitude of intraocular pressure reduction attained
Age Gender Post- Glaucoma Eye Preop 12-month IOP Preop 12-month
shunt etiology IOP IOP change meds meds
54 M 1 Traumatic L 56 9 –47 0 0
47 M 4 Neovascular R 40 16 –24 5 0
81 F 8 Uveitic R 38 15 –23 3 3
41 F 16 Uveitic R 28 7 –21 1 0
41 F 2 Uveitic R 34 13 –21 0 0
71 F 8 Uveitic R 33 14 –19 0 0
50 F 3 Congenital L 39 10 –19 0 0
62 M 54 Neovascular L 27 9 –18 0 0
87 M 1 POAG R 36 19 –17 0 0
57 M 3 Neovascular L 32 15 –17 0 0
78 F 15 Uveitic L 32 15 –17 0 0
78 F 2 CACG R 34 18 –16 0 0
75 M 8 Uveitic L 30 14 –16 0 0
80 F 55 CACG R 27 12 –15 1 0
1 M 7 Congenital R 24 12 –12 0 0
49 F 1 POAG L 34 22 –12 0 0
75 M 8 Uveitic L 25 14 –11 0 0
14 M 9 Congenital L 23 14 –9 1 0
54 F 19 POAG L 24 15 –9 0 0
43 M 111 Congenital L 21 12 –9 0 0
62 F 154 Neovascular R 24 15 –9 1 1
1 M 1 Congenital R 23 15 –8 0 0
53 M 1 Uveitic L 30 22 –8 0 0
79 F 4 Uveitic L 29 22 –7 0 0
83 F 21 POAG L 28 21 –7 3 2
22 F 3 Congenital L 26 20 –6 2 2
10 F 11 Congenital L 24 18 –6 1 1
4 M 60 Traumatic L 19 15 –4 0 0
56 F 31 POAG L 19 16 –3 0 0
76 M 5 NAG R 16 13 –3 0 0
4 M 21 Congenital R 23 20 –3 0 0
72 F 4 Uveitic R 21 18 –3 0 0
5 M 42 Congenital R 18 16 –2 2 2
6 M 38 Congenital L 19 17 –2 2 0
42 F 2 Neovascular L 28 26 –2 0 0
9 M 95 Congenital L 23 21 –2 3 4
77 F 136 ACG L 16 15 –1 0 0
7 M 7 Congenital R 20 22 2 0 0
54 F 51 Uveitic L 19 21 2 1 2
76 M 9 Uveitic L 28 33 5 0 0
87 F 38 Uveitic L 28 33 5 0 0
3 M 31 Congenital R 25 33 8 0 0
97 R 2 Traumatic L 21 29 8 3 3
M: Male; F: Female
Bleb encapsulation will likely continue to be a consis more successful the management of difficult glaucoma
tent challenge for clinicians and glaucoma patients. cases will become. Innovations directed toward over
The more effective tools made available to combat this coming bleb encapsulation that does not respond to conser
perennial source of intransigent ocular hypertension, the vative measures like massage, medication, or cannulation
remain a priority. Among our patient population, individuals 7. Singh K, Eid TE, Katz LJ, et al. Evaluation of Nd: YAG laser
who failed to respond adequately to tube shunt flush membranectomy in blocked tubes after glaucoma tube-shunt
surgery. Am J Ophthalmol 1997;124(6):781-786.
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8. Tessler Z, Jluchoded S, Rosenthal G. Nd: YAG laser for Ahmed
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This approach and others may ultimately help facilitate
10. Francis BA, Kawji AS, Vo NT, et al. Endoscopic cyclophoto-
long-term pressure control in patients with intractable coagulation in the management of uncontrolled glaucoma
ocular hypertension after tube shunt surgery, but we with prior aqueous tube shunt. J Glaucoma 2011;20(8):523-527.
believe the less invasive tube shunt flush maneuver 11. Sood S, Becker AD. Cyclophotocoagulation versus sequential
should always be attempted before placing another tube shunt as a secondary intervention following primary
tube shunt failure in pediatric glaucoma. J AAPOS 2009;
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functioning filtering blebs with 5-fluorouracil to regain
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