This is a Baerveldt Implant surgery in a 19-year-old patient with steroid induced glaucoma and with a failed trabeculectomy. The Baerveldt implant was placed inferonasally and tutoplast was used to cover the tube on the sclera.
Surgery location: on-board the Orbis Flying Eye Hospital in Hanoi, Vietnam
Surgeon: Dr. Jody Piltz-Seymour, Wills Eye Hospital, USA
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Today we are operating on a 19 year old gentleman with steroid glaucoma, he’s had a failed Trebeculectomy superiorly and we’re going to do a Baerveldt implant inferonasally and then we will make a conjunctival peritomy. Can we have the muscle hook please? We hook the muscle.
So wanted to see nice white sclera there. And then I’m going to open, to sort of rub my muscle hook back and forth under the muscle just to make room for the Baerveldt implant. And now we’re going to do the same thing on the other side.
So we can see nice sclera, back there. I just need to ensure that there’s enough freedom of all the conjunctiva here now. I just make sure that it’s nice and open all the way back.
Now let’s take a peek at the baerveldt. So when you put in a Baerveldt implant you have to tie it off.
And this is a non-valved implant, you take the vicryl suture and we don’t need the actual needle, We just want to cut a little loop off. We need to get this very very tight, I recommend using two needle holders. So this suture is going to keep the tube closed for about four to six weeks. But you have to check and make sure that no fluid can get through it at all. Because even though it looks completely close sometimes you can be fooled. And let’s see if we can put some fluid through it. You see how the fluid bounces back and it comes back, so that tube is completely occluded. And this suture is just securing it to the container it came in, so that can all come off. Just trying to make sure there’s enough for him back here for this.
You don’t want there to be forward pressure, you want that to fall nicely back into the orbit. Wanted to sit back by the insertions of the muscles right about there. We’re going to make a superficial pass through the sclera. So normally you have a lot more room to work, so usually there’s not as much scarring and you can get to the tissues more easily.
So in the superior fornix, when you do tube superiorly they need to go back 8 to 10 millimeters. Inferiorly its less because you just want it near the the muscle insertions.
This one is a teeny bit more anterior than is typical but it should be fine.
So now we’re going to take a look at the length of the tube.
And we wanted the tube to extend just a couple millimeters into the anterior chamber.
And we wanted to go in parallel to the iris. So we’re going to try to go in so that we’re parallel to the iris, and away from the cornea.
So the 23 gauge needle makes a very snug fit around the tube,
so we don’t have any leakage around the tube. Good and the tube looks in good position, it doesn’t look near the cornea and it doesn’t look near the iris. I try not to cover the vicryl because sometimes they don’t release right if they’re covered with sclera, that they need to be in contact with the conjunctiva. So that’s a nice fit. So at home I don’t generally suture these, I glue them with fibrin glue. And then We’re going to make a few venting slits.
So because the tube is tied off and he has a bit of a high pressure we don’t want him to continue to have a high pressure, until the tube opens. So we have a couple little slits.
So we’re going to actually pull this tenon’s over to give us some nice support.
He’s got a bit of tension on his issues. We’re just trying to get him anchored in as sturdy as possible, the tube is well covered with the tutoplast. So the tube is in the anterior chamber between the cornea and the iris, the tutoplast is over the tube. The tube is tied off near the plate.
August 14, 2017