The following transcript has been edited for clarity.
Shivani S. Kamat, MD: Hi everyone. My name is Shivani S. Kamat, MD, and I am here at the American Academy of Ophthalmology in New Orleans. I just moderated a session titled Glaucoma Fellowship Director Survival Guide, and we talked about surgical pearls that we, as fellowship directors, offer our fellows. I have with me Brian Francis, MD. He is the fellowship director at UCLA Doheny Eye Institute. Brian, tell us about your talk.
Brian A. Francis, MD, MS: Thank you for inviting me to the session. Our talk was about glaucoma tube shunt erosions and some surgical pearls for how to repair those. I’ll go over two cases. The first one was a standard tube erosion, where the tube erodes between the limbus and the plate. The key for that is careful dissection, not only to uncover the tube that’s eroded, but really getting a posterior dissection back over the plate area. You’re releasing those adhesions between the capsule and tenons. That allows you then to pull the conjunctiva anteriorly and really get good coverage, prevent re-exposure, and get good healing.
The second case I wanted to briefly mention was a bit of a controversial topic, which is when you have a plate erosion of a tube. The typical teaching is that in a plate erosion, you're going to need to remove the whole tube and the plate and put a tube in a different quadrant or do something else to control the IOP. But what we’ve shown is that with careful surgical technique, you can salvage these tubes and keep them functioning and get good closure and prevent exposure. The key pearls for that scenario include getting a wide dissection underneath the conjunctiva around the area where you have the erosion, number one. Number two, you need to remove any epithelial edges that have grown under the tissue or especially when you have the edge of the plate eroded, the epithelium will grow under that plate and form an epithelial pocket. So you need to get under there and remove that epithelium. You can be aided with alcohol or I prefer cautery to remove that epithelium. And then we use a large pericardial patch graft, which you can cut to size, and we tuck the edges. We do wide edges so they have good overlap underneath the exposed area. So we get that all the way under and tuck those edges under and then do the closure from the conjunctiva to the middle part of the pericardial patch graft and then to the other edge of the conjunctiva. That not only pulls the conjunctiva together, but it anchors that patch graft in the area where you want, underneath the conjunctiva.
Dr. Kamat: I really like that tip because I agree it is quite controversial. And as a glaucoma specialist myself and fellowship director who teaches trainees, I've always remained a little on the fence when it comes to what to do with plate exposure. Many of us tend to favor removal, so I really do think that was fascinating. And what I want to ask you, just as a final question, is: In your talk, you showed us a case and I believe it was month 4 that was the last follow-up that you had listed. So assuming you've done more than some of these, do you have long-term follow-up where they haven't re-exposed fairly quickly?
Dr. Francis, MD: With that technique, we have not had any exposures or re-exposures. I don't do every eroded plate trying to salvage it. If almost the entire plate is eroded, then you have to use your judgment. It also depends on the health of the surrounding tissue. So if the health of the surrounding tissue is pretty good and you think you can mobilize that tissue, then I think it's worth considering.
Dr. Kamat: Awesome. Well, thank you so much and thank you for joining us.
Dr. Francis: Thank you. GP