Kim Inae J, Wang Jessie, Qiu Mary
The University of Chicago Department of Ophthalmology and Visual Sciences, Chicago, IL, USA.
Am J Ophthalmol Case Rep. 2023 Dec 7;33:101975. doi: 10.1016/j.ajoc.2023.101975. eCollection 2024 Mar.
In eyes with a prior failed aqueous shunt (or "tube") requiring additional intraocular pressure (IOP) control, options include angle surgery, cyclodestruction, second tube, tube revision, or tube exchange. We present a case of a same-quadrant tube exchange of a Baerveldt-250 (BGI-250) to BGI-350.
The patient is a 71-year-old African American female with severe-stage primary open angle glaucoma of both eyes, and this case focuses on the right eye. This eye had prior cataract surgery with iStent, prior BGI-250 in the anterior chamber (AC), and prior iStent removal with gonioscopy assisted transluminal trabeculotomy (GATT). The visual acuity (VA) was 20/150, and the IOP was 26 mmHg on 3 IOP-lowering medications. The prior superotemporal BGI-250 had its "wings" on top of the superior and lateral rectus muscles and its tube tip in the AC. The implant was removed in its entirety including the superficial and deep layers of its capsule. The new BGI-350 was stented with a 3-0 polypropylene ripcord, ligated with a 7-0 polyglactin suture, and implanted with its wings under the rectus muscles and the tube tip in the sulcus. For early IOP-lowering prior to ligature dissolution, 2 needle stab fenestrations and an additional 7-0 polyglactin wick was used. The capsule from the prior BGI-250 was used as a patch graft for the new BGI-350. The ligature dissolved at postoperative week (POW) 6. By POW8, the IOP was 18 mmHg on 3 IOP-lowering medications and frequent topical steroid, the AC was quiet, and the ripcord was removed. A slow steroid taper finished at postoperative month (POM) 6. By POM 12, the VA was still at baseline 20/150, and the IOP was 14 mmHg on 3 IOP-lowering medications.
CONCLUSIONS & IMPORTANCE: Patients with a prior failed tube requiring additional IOP-lowering can undergo a same-quadrant tube exchange. BGI-350s may offer more IOP-lowering than BGI-250s, but the IOP-lowering achieved in this patient's case could be attributable to differences in postoperative management in addition to endplate size; longer follow-up is needed. A tube exchange offers the opportunity to reposition the tube tip from the AC to the sulcus and to use the prior tube's capsule as a patch graft for the new tube.
对于先前房水引流装置（或“引流管”）植入失败且需要进一步控制眼压（IOP）的眼睛，可选择的方法包括房角手术、睫状体破坏术、植入第二个引流管、引流管修复或引流管置换。我们报告一例将Baerveldt - 250（BGI - 250）引流管在同一象限置换为BGI - 350引流管的病例。
患者为一名71岁的非裔美国女性，双眼患有重度原发性开角型青光眼，本病例主要关注右眼。该眼此前接受过iStent白内障手术，前房植入过BGI - 250引流管，并且在房角镜辅助下经腔小梁切开术（GATT）时取出过iStent。视力（VA）为20/150，使用3种降眼压药物时眼压为26 mmHg。先前颞上象限的BGI - 250引流管的“翼”位于上直肌和外直肌上方，引流管尖端在前房。将植入物整体取出，包括其囊膜的浅层和深层。新的BGI - 350引流管用3 - 0聚丙烯撕脱线固定，用7 - 0聚乙醇酸缝线结扎，其“翼”植入在直肌下方，引流管尖端置于巩膜沟内。为在结扎线溶解前早期降低眼压，采用了2处针刺造孔并额外放置一根7 - 0聚乙醇酸引流条。先前BGI - 250的囊膜用作新BGI - 350的补片移植。结扎线在术后第6周溶解。至术后第8周，使用3种降眼压药物及频繁局部应用类固醇时眼压为18 mmHg，前房安静，撕脱线拆除。术后第6个月逐渐缓慢停用类固醇。至术后第12个月，视力仍维持在基线水平20/150，使用3种降眼压药物时眼压为14 mmHg。
对于先前引流管植入失败且需要进一步降低眼压的患者，可进行同一象限的引流管置换。BGI - 350可能比BGI - 250能更好地降低眼压，但该患者眼压降低可能除终板大小差异外还归因于术后管理的不同；需要更长时间的随访。引流管置换提供了将引流管尖端从前房重新定位到巩膜沟的机会，并可将先前引流管的囊膜用作新引流管的补片移植。
