JOCGP

10.5005/jp-journals-10008-1121
Tube Exposure Repair
SURGICAL TECHNIQUE

Tube Exposure Repair

Stirbu Oana, Jorge Vila

ABSTRACT Tube Exposure

All across the world, glaucomatologists are adopting broader The causes of the conjunctival erosion are not well-defined.
use of glaucoma drainage implants even as a primary surgical
Early tube exteriorization is usually related to a dehiscence
modality. To avoid tube exposure, which may predispose the
eye to endophthalmitis, the implanted tube must be covered by of the suture, while late onset tube extrusion is produced by
a patch graft. However, these patch grafts also carry a high erosion of the scleral/graft patch and of the overlying
rate of progressive thinning and erosion, which is believed to conjunctiva in the context of a quiet eye. One mechanical
result from the lack of cellular infiltration from the surrounding
host conjunctival stroma and poor integration of these patch
factor that might influence is the micromotion of the tube
grafts to the host tissue. An ideal patch graft should offer good with ocular movements and blinking, in a pathologic ocular
tensile strength, be suitable for tectonic support, and have tissue or in elder patients, in which thinning and micro-
biological activities to promote cellular infiltration by the filtration lead to hypotonia with its entire syndromic picture.
surrounding host conjunctival stroma, thus reducing progressive
allogeneic patch graft thinning/erosion. This review talks about The tube of a glaucoma drainage implant must not be
various materials and modalities used for an exposed tube left in direct contact with the overlying conjunctiva. The
repair. use of patches or grafts of different materials has improved
Keywords: Conjunctival erosion, Patch graft, Tube shunt. the development of this technique to reduce the frequency
of endophthalmitis. 3 Various authors have proposed
How to cite this article: Oana S, Vila J. Tube Exposure Repair.
J Current Glau Prac 2012;6(3):139-142. different tissues for the graft with successful results:
Autologous or human donor sclera,4 pericardium,5 dura
Source of support: Nil
mater,6 cornea or human cadaveric fascia lata,7 amniotic
Conflict of interest: None declared membrane,8 autologous Tenon9 and expanded polytetra-
fluoroethylene.10
INTRODUCTION In the late 90s, various case reports have drawn the
More than three decades after the addition of tubes in the attention on the possibility of patch melting, involving
glaucoma surgical armamentarium, tube implantation different tissues, such as pericardium patch graft11 or dura
technique (known under several names, such as tube shunt, mater.6 A comparative study of the tube coverage on 62
aqueous shunt, aqueous tube shunt, seton, glaucoma eyes with donor sclera, dura mater or pericardium patch
drainage device, glaucoma drainage implant, glaucoma grafts in the initial surgery showed that no material was
drainage shunt, etc.) has gained numerous adepts worldwide more prone to melting than the other.12
and various designs have been invented in order to improve The frequency of tube extrusion when Ahmed device is
its efficacy and lower the complications. implanted varies from 5 to 7% to 14.3%13-15 and in a recently
The growing confidence in glaucoma drainage device published study on 12 patients, the authors report a 30.8%
implants is accredited by the recent results of the tube vs of tube exposure.16 Nevertheless, these high frequencies are
trabeculectomy study. After 5 years of follow-up, shunt not present in multicenter or meta-analysis studies.
surgery proved a higher success rate compared to In a multicenter study on 276 patients which determined
trabeculectomy with mitomycin C (MMC). Both procedures the relative efficacy and complications of the Ahmed FP7
were associated with similar reduction of the intraocular glaucoma valve and the Baerveldt 101 to 350 glaucoma
pressure (IOP) and use of supplemental medical therapy, implant in refractory glaucoma, the authors present a
while additional glaucoma surgery was needed more frequency of tube erosion of 2% in Ahmed device and 3%
frequently after trabeculectomy with MMC than tube shunt in Baerveldt implant at 1 year follow-up. Interestingly, no
placement.1 tube erosion was depicted as early postoperative
The complications described after tube surgery include: complication, defined as occurring in the first 3 months after
Immediate hypotony after surgery, excessive capsule tube implantation.17
fibrosis with decreased permeability of the capsule formed A meta-analysis of 38 studies including 3,255 eyes with
around the plate, erosion of the tube or plate edge, strabismus an average follow-up of 26.1 ± 3.3 months evaluated
and infection. The most common shunt-specific delayed conjunctival erosion and tube exposure in Ahmed, Baerveldt
complication is exposure of the tube through overlying and Molteno implants. The overall incidence of exposure
eroded conjunctiva.2 was 2.0 ± 2.6% (n = 64) of eyes with an average exposure/
Journal of Current Glaucoma Practice, September-December 2012;6(3):139-142 139
Stirbu Oana, Jorge Vila

month of 0.09 ± 0.14%. Among individual drainage devices, Table 1: Materials used for tube coverage and/or tube
exposure repair
the authors did not find significant differences in the
Ocular tissues
incidence of exposure or percent exposure per month.18
Autologous Conjuntiva, tenon, cornea,
As for the early onset of the leak, between postoperative sclera, collagen fibrous tissue
months 1 and 3, few studies approached the topic. One of Heterologous Sclera, cornea
them includes three patients with iridocorneal endothelial Extraocular tissues
syndrome and one patient with chronic panuveitis, on which Autologous Fascia lata, buccal mucosa
uneventful implantation of Molteno (1), Ahmed (2), and Heterologous Dura mater, pericardium, acellular
dermis, amniotic membrane
Baerveldt (1) aqueous shunts was performed. The use of
aqueous suppressants, bandage contact lens, conjunctival Synthetic tissues
Ologen®, polytetrafluoroethylene
photocoagulation, sutures, tissue adhesives, conjunctival
autografts and scleral patch grafts were unsuccessful in the
described cases. The authors described resolution of the leak The graft tissues reported to have been used in the tube
after removal of the aqueous shunt.19 exposure repair include autologous and donor eye tissues
Notably, good results were reported with a modified (full thickness sclera,11 split-thickness hinged scleral flap31
implant technique in which the need for tube coverage patch cornea,32 autologous scar tissue,33 conjunctival pedicle
is obviated. In a retrospective study on 35 consecutive flaps34), extraocular tissues (amniotic membrane,35 donor
patients who underwent Molteno implant with a partial acellular dermis,36 buccal mucosa37) and synthetic materials
thickness scleral tunnel to cover the tube, conjunctival such as biodegradable scaffold collagen matrix Ologen®.38
dehiscence and tube exposure was not observed in the In a case series of two patients presenting tube erosion
4-year follow-up period. The authors suggest that outcome after Ahmed and Baerveldt implant respectively, with
may be related to an absence of the immune-mediated original pericardial patch graft, a full thickness donor scleral
processes proposed for thinning and melting of patch graft was used to cover the tube.11 A conjunctival pedicle
grafts.20 flap attached to its original vascular supply was used to
cover tube exposure in 4 eyes with Baervaldt implant, in
Tube Exposure Repair addition to a new human pericardium graft.34 Erosion of
The externalization or extrusion of the tube through an the drainage tube was reported to be successfully managed
eroded conjunctiva represents one of the most serious using a double layer of amniotic membrane in a consecutive
complications of the glaucoma drainage device, as it seems series of three patients with exposure of the tube secondary
to represent a major risk factor for endophthalmitis.21 When to necrosis of the overlying bovine pericardial patch and
tube exposure occurs, prompt surgical revision is highly conjunctiva. The repair of the defect was carried out with a
recommended to prevent this potentially devastating double layer of amniotic membrane, the inner one acting as
complication. Endophthalmitis after aqueous drainage a graft and the outer as a patch. The authors also used
device may occur in the first 2 to 30 days postoperatively22,23 autologous serum postoperatively to promote epithelial
or in the late postoperative period, related to the tube growth.35 A retrospective review of 8 eyes that underwent
externalization24-26and its frequency varies from 0.9 to corneal patch graft repair of exposed tubes showed stable
6.3%.27,28 Interestingly, a report of a case of late onset conjunctival coverage with no epithelial breakdown over
H. influenzae endophthalmitis in an immunized child after the corneal patch graft and with no tube reexposure, scleral
bilateral glaucoma drainage implants without evidence of thinning or ocular infection in 7 eyes.32 The use of oral
conjunctival erosion or wound dehiscence was found in the buccal mucous membrane in combination with a lamellar
literature.29 In a study on late endophthalmitis associated corneal patch graft for repair of 3 exposed tubes was
with Baerveldt glaucoma implants, exposure of the described in cases with limited supply of local conjunctiva.37
glaucoma drainage implant tube was present in all cases A recent and highly recommended study details a new
and the authors recommended prophylactic surgical revision surgical technique of repairing tube erosion using donor
with a patch graft in all cases in which there is an exposed acellular dermis graft, as also the complications of the repair
tube.30 surgery. The author used the dermis graft in 30 cases, leaving
No author cited below advocates simple conjunctival a 2 to 3 mm intentional gap between the conjunctival edges
closure without a graft; the graft materials used to repair over the dermis graft, with complete epithelization within
the tube extrusion are mainly the same used to initially cover weeks.36 Also, a split-thickness hinged scleral flap technique
the drainage implant tube (Table 1). resulted in the successful recovery of the tube without

140
JAYPEE
 JOCGP

Tube Exposure Repair

reexposure or serious complications in 3 cases.31A recent 14. Montañez FJ, Laso E, Suñer M, Amaya C. Ahmed drainage
case report presented Ologen®, a biodegradable collagen device implant. Our experience between 1995 and 2003. Arch
Soc Esp Oftalmol 2005;80:239-44.
matrix implant that induces normalized wound healing, 15. Chen H, Zhang SX, Lui L, Lin D, Tang X, Sun L, et al.
successfully used in one patient with Baerveldt tube Intermediate-term and lon-term clinical evaluation of the Ahmed
exposure.38 glaucoma valve implantation. Zhonghua Yan Ke Za Zhi
2005;41:796-802.
CONCLUSION 16. Kaya M, Ozbek Z, Yaman A, Durak I. Long-term success of
Ahmed glaucoma valve in refractory glaucoma. Int J Ophthalmol
Conjunctiva erosion and tube exposure are infrequent 2012;5:108-12.
complications of glaucoma drainage implant surgery, which 17. Budenz DL, Barton K, Feuer WJ, Schiffman J, Costa VP,
Godfrey DG, et al. Comparison Study Group. Treatment
need prompt repair due to the risk of endophthalmitis.
outcomes in the Ahmed Baerveldt Comparison Study after 1
While many techniques and materials are successfully year of follow-up. Ophthalmology 201;118(3):443-52.
used to address this situation, further comparative 18. Stewart WC, Kristoffersen CJ, Demos CM, Fsadni MG, Stewart
prospective studies are required to determine the best repair JA. Incidence of conjunctival exposure following drainage
method. device implantation in patients with glaucoma. Eur J Ophthalmol
2010 Jan;20:124-30.
19. Robert MC, Hamel P, Blondeau P, Lesk MR. Persistent leak
REFERENCES after glaucoma aqueous shunt implantation. J Glaucoma 2012.
20. Leong JK, McCluskey P, Lightman S, Towler HM. Outcome of
1. Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, graft free Molteno tube insertion. Br J Ophthalmol 2006;90:
Budenz DL. Tube versus trabeculectomy study group treatment 501-05.
outcomes in the tube versus trabeculectomy (TVT) study after 21. Al-Torbak A, Al-Shahwan S, Al-Jadaan I, Al-Hommadi A,
5 years of follow-up. Am J Ophthalmol 2012;15:789-803. Edward DP. Endophthalmitis associated with the Ahmed
2. Minckler DS, Francis BA, Hodapp EA, Jampel HD, Lin SC, glaucoma valve implant. Br J Ophthalmol 2005;89:454-58.
Samples JR, et al. Aqueous shunts in glaucoma: A report by the 22. Perkins TW. Endophthalmitis after placement of a Moteno
American Academy of Ophthalmology. Ophthalmology implant. Ophthalmic Surg 1990;21:733-34.
2008;115:1089-98. 23. Smith MF, Doyle JW, Sherwood MB. Comparison of the
3. Freedman J. Scleral patch grafts with Molteno setons. Baerveldt glaucoma implant with the double-plate Molteno
Ophthalmic Surgery 1987;18:532-34. drainage implant. Arch Ophthalmol 1995;1134:444-47.
4. Heuer DK, Budenz DL, Coleman A. Aqueous shunt tube erosion. 24. Krebs DB, Liebman JM, Ritch R, Speaker M. Late infections
J Glaucoma 2001;10:493-96. endophthalmitis from exposed glaucoma setons (case report).
5. Raviv T, Greenfield DS, Liebmann JM, Sidoti PA, Ishikawa H, Arch Ophthalmol 1992;110:174-75.
Ritch R. Pericardial patch grafts in glaucoma implant surgery. J 25. Hong CH, Arosemena A, Zurakowski D, Ayyala RS. Glaucoma
Glaucoma 1998;7:27-32. drainage devices a systematic literature review and current
6. Brandt JD. Patch grafts of dehydrated cadaveric dura mater for controversies. Surv Ophthalmol 2005;50:48-60.
tube-shunt glaucoma surgery. Arch Ophthalmol 1993;111: 26. Ranganath A, Hashim A. Late-onset endophthalmitis secondary
1436-39. to exposed glaucoma tube implant in a rare case of paediatric
7. Tanji TM, Lundy DC, Minckler DS, Heuer DK, Varma R. Fascia glaucoma. Case Rep Ophthalmol Med 2011;2011:1836-47.
lata patch graft in glaucoma tube surgery. Ophthalmology 27. Francis B, DiLoreto DA, Chong LP, y otros. Late-onset bacteria
1996;103:1309-12. endophthalmitis following glaucoma drainage implantion.
8. Anand A, Sheha H, Teng CC, Liebmann JM, Ritch R, Tello C. Ophthalmic Surg Lasers Imaging 2003;34:128-30.
Use of amniotic membrane graft in glaucoma shunt surgery. 28. Chihara E, Kubota H, Takanashi T, Nao-i N. Outcome White
Ophthalmic Surg Lasers Imaging 2011;42:184-89. pump shunt surgery for neovascular glaucoma in Asian.
9. Tamçelik N, Sarici AM, Yetik H, Ozkök A, Ozkiris A. A novel Ophthalmics Surgery 1992;23:666-71.
surgical technique to prevent posoperative Ahmed valve tube 29. Trzcinka A, Soans FP, Archer SM, Moroi SE. Late-onset
exposure through conjuntiva: Tenon advancement and Haemophilus influenzae endophthalmitis in an immunized child
duplication. Ophthalmic Surg Lasers Imagng 2010;41:370-74. after Baerveldt implant. J AAPOS 2008;12:412-14.
10. Jacob T, LaCour OJ, Burgoyne CF, LaFleur PK, Duzman E. 30. Gedde SJ, Scott IU, Tabandeh H, et al. Late endophthalmitis
Expanded polytetrafluoroethylene reinforcement material in associated with glaucoma drainage implants. Ophthalmology
glaucoma drain surgery. J Glaucoma 2001;10:115-20. 2001;108:1323-27.
11. Lama PJ, Fechtner RD. Tube erosion following insertion of a 31. a Lee ES, Kang SY, Kim NR, Hong S, Ma KT, Seong GJ, Kim
glaucoma drainage device with a pericardial patch graft. Arch CY. Split-thickness hinged scleral flap in the management of
Ophthalmol 1999;117:1243-44. exposed tubing of a glaucoma drainage device. J Glaucoma
12. Smith MF, Doyle JW, Ticrney JW Jr. A comparison of glaucoma 2011;20:319-21.
drainage implant tube coverage. J Glaucoma 2002 32. Singh M, Chew PT, Tan D. Corneal patch graft repair of exposed
Apr;11(2):143-47. glaucoma drainage implants. Cornea 2008Dec;27(10):1171-73.
13. Ayyala RS, Zurakowski D, Smith JA, Monshizadeh R, Netland 33. Puustjärvi T, Rönkkö S, Teräsvirta M. A novel oculoplastic
PA, Richards DW, Layden WE. A clinical study of the Ahmed surgery for exposed glaucoma drainage shunt by using
glaucoma valve implant in advanced glaucoma. Ophthalmology autologous graft. Graefes Arch Clin Exp Ophthalmol
1998;105:1968-76. 2007;245:907-09.

Journal of Current Glaucoma Practice, September-December 2012;6(3):139-142 141

Stirbu Oana, Jorge Vila

34. Godfrey DG, Merritt JH, Fellman RL, Starita RJ. Interpolated 38. Rosentreter A, Schild AM, Dinslage S, Dietlein TS.
conjunctival pedicle flaps for the treatment of exposed glaucoma Biodegradable implant for tissue repair after glaucoma drainage
drainage devices. Arch Ophthalmol 2003;121:1772-75. device surgery. J Glaucoma 2012;21:76-78.
35. Ainsworth G, Rotchford A, Dua HS, King AJ. A novel use of
amniotic membrane in the management of tube exposure ABOUT THE AUTHORS
following glaucoma tube shunt surgery. Br J Ophthalmol Stirbu Oana (Corresponding Author)
2006;90:4 417-19.
36. Kalenak JW. Revision for exposed anterior segment tubes. J Consultant, Barcelona Institute of Ophthalmology, Barcelona, Spain
Glaucoma 2010;19:5-10. e-mail: [email protected]
37. Rootman DB, Trope GF, Rotman DS. Glaucoma aqueous
drainage device erosión repair with buccal mucous membane
Jorge Vila
grafts. J Glaucoma 2009;18:618-22. Consultant, Clinical University Hospital, Valencia, Spain

142
JAYPEE