Combined Baerveldt glaucoma drainage implant surgery and surgical bleb revision for preventing a postoperative hypertensive phase
Patient 1, a 62-year-old man with open-angle glaucoma had undergone repeated trabeculectomies in the superior quadrants and had an IOP of 42 mmHg in his left eye. The best-corrected visual acuity (BCVA) was 20/40. BGI surgery was performed in the inferior quadrant where the conjunctiva was intact. Because the optic nerve damage was severe due to the prolonged duration (>2 years) of uncontrolled glaucoma, we performed BGI surgery in combination with surgical bleb revision for early IOP control.\nAfter anesthesia was induced with a peribulbar injection of 2% lidocaine, a clear corneal 6-0 polyglycolic acid (PGA) absorbable violet braided suture (Mani Inc, Tochigi, Japan) was placed in the peripheral cornea, and the area of the failed bleb in the superonasal quadrant was exposed (). The scarred conjunctiva was dissected posteriorly using blunt-tip scissors. A bare scleral flap was dissected using an ophthalmic knife until the aqueous humor egressed (). The fornix-based conjunctival flap was re-approximated to the limbus and closed with 10-0 nylon sutures at each end of the periotomy ().\nA subconjunctival space in the inferotemporal quadrant was then created, and a 350 mm2 Baerveldt implant (Abbott Medical Optics Inc., Santa Ana, CA, USA) was positioned under the inferior and temporal rectus muscles (). To minimize postoperative hypotony, the tube was tightly occluded by ligation with 8-0 PGA absorbable violet braided suture (Mani Inc) before insertion into the anterior chamber. Balanced salt solution was injected into the tube using a 27 gauge cannula to confirm that the tube was totally occluded. The plate was sutured to the sclera with 9-0 nylon sutures. The tube was then cut bevel up, and inserted into the anterior chamber via a needle track created with a 23 gauge needle (). To achieve early IOP control, a needle was used to penetrate both sides of the tube (ie, tube fenestrations were created) in three places (). A scleral graft was used to cover the outer portion of the tube (). The conjunctiva was sutured back in its original position using 8-0 silk sutures. Bleb formation was observed after irrigation with balanced salt solution through the paracentesis (). Subconjunctival injection of betamethasone and tobramycin was administered at the end of the surgery.\nAlthough a small amount of hyphema developed, probably in relation to the surgical bleb revision, it resolved within 7 days postoperatively and did not affect bleb formation.