Clinical experience with urgent tube shunt implantation through the ciliary sulcus in phakic eyes

  • Adam J. Weiner
  • Yotam Weiner
  • Melissa L. Severson
  • Asher Weiner
Original Paper



To review the clinical course and outcomes of 3 phakic, ischemic, and inflamed eyes in which we performed urgent tube shunt implantation through the ciliary sulcus without lensectomy.


This is a retrospective interventional case series. Three eyes of 3 diabetic patients with uncontrolled severe neovascular glaucoma, shallow anterior chambers with closed angles and poor view to the posterior segment, where concomitant lensectomy was not recommended due to uncontrolled uveitis and ischemia, underwent tube shunt implantation through the ciliary sulcus. Main outcome measures were surgical complications, especially injury to the crystalline lens, and postoperative intraocular pressure (IOP).


No surgical complications, including injury to the crystalline lens, have occurred. We used surgical modifications to allow sufficient visualization of the sulcus area to avoid injury to the crystalline lens during scleral tunneling and tube insertion through the ciliary sulcus. Postoperatively, the uveitis, ischemia, and vision have improved and IOP was controlled throughout follow-up. Cataract surgery with pupilloplasty was performed in one eye a year later with no complications and no interruption to IOP control.


Based on our small and limited retrospective study, and under unusual circumstances, urgent tube shunt implantation through the ciliary sulcus may be considered in phakic eyes with severely uncontrolled IOP, shallow anterior chambers and poor view to the posterior segment, and when concomitant lensectomy is not recommended. We advise the use of appropriate surgical modifications by experienced glaucoma surgeons to prevent intraoperative complications. Further and larger studies are needed to evaluate the safety of this surgical option.


Tube shunt implantation Ciliary sulcus Glaucoma surgery Intraocular pressure Phakic Crystalline lens Cataract 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB), St. Peter’s Hospital, Albany, New York, approved this study.

Human and animal rights

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Since this study is retrospective and does not reveal any identifiable information on any of the patients studied, no informed consent was required or obtained.


  1. 1.
    Weiner A, Cohn AD, Balasubramaniam M, Weiner AJ (2010) Glaucoma tube shunt implantation through the ciliary sulcus in pseudophakic eyes with high risk of corneal decompensation. J Glaucoma 19:405–411CrossRefPubMedGoogle Scholar
  2. 2.
    Weiner Y, Faridi O, Weiner A (2013) Clinical experience with sulcus-implanted Baerveldt glaucoma tube shunts fully concealed behind the iris in undilated pseudophakic eyes. J Glaucoma 22:667–671CrossRefPubMedGoogle Scholar
  3. 3.
    Rumelt S, Rehany U (1998) Implantation of glaucoma drainage implant tube into the ciliary sulcus in patients with corneal transplants. Arch Ophthalmol 116:685–687CrossRefPubMedGoogle Scholar
  4. 4.
    Tello C, Espana EM, Mora R, Dorairaj S, Liebmann JM, Ritch R (2007) Baerveldt glaucoma implant insertion in the posterior chamber sulcus. Br J Ophthalmol 91:739–742CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Moon K, Kim YC, Kim KS (2007) Ciliary sulcus Ahmed valve implantation. Korean J Ophthalmol 21:127–130CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Prata TS, Mehta A, De Moraes CG, Tello C, Liebmann JM, Ritch R (2010) Baerveldt glaucoma implant in the ciliary sulcus: midterm follow-up. J Glaucoma 19:15–18CrossRefPubMedGoogle Scholar
  7. 7.
    Koo EB, Hou J, Han Y, Keenan JD, Stamper RL, Jeng BH (2015) Effect of glaucoma tube shunt parameters on cornea endothelial cells in patients with Ahmed valve implants. Cornea 34:37–41CrossRefPubMedGoogle Scholar
  8. 8.
    Lee Eun-Kyoung, Yun Yong-Jun, Lee Jong-Eun, Yim Jin-Ho, Kim Chang-Sik (2009) Changes in corneal endothelial cells after ahmed glaucoma valve implantation: 2-year follow-up. Am J Ophthalmol 148:361–367CrossRefPubMedGoogle Scholar
  9. 9.
    Tan AN, Webers CAB, Berendschot TTJM, de Brabander J, de Witte PM, Nuijts RMMA, Schouten JSAG, Beckers HJM (2017) Corneal endothelial cell loss after Baerveldt glaucoma drainage device implantation in the anterior chamber. Acta Ophthalmol 95:91–96CrossRefPubMedGoogle Scholar
  10. 10.
    Seo JW, Lee JY, Nam DH, Lee DY (2015) Comparison of the changes in corneal endothelial cells after pars plana and anterior chamber Ahmed valve implant. J Ophthalmol. PubMedPubMedCentralGoogle Scholar
  11. 11.
    Alvarenga LS, Mannis MJ, Brandt JD, Lee WB, Schwab IR, Lim MC (2004) The long-term results of keratoplasty in eyes with a glaucoma drainage device. Am J Ophthalmol 138:200–205CrossRefPubMedGoogle Scholar
  12. 12.
    Kwon YH, Taylor JM, Hong S, Honkanen RA, Zimmerman MB, Alward WLM, Sutphin JE (2001) Long-term results of eyes with penetrating keratoplasty and glaucoma drainage tube implant. Ophthalmology 108:272–278CrossRefPubMedGoogle Scholar
  13. 13.
    Knape RM, Szymarek TN, Tuli SS, Driebe WT, Sherwood MB, Smith MF (2012) Five-year outcomes of eyes with glaucoma drainage device and penetrating keratoplasty. J Glaucoma 21:608–614CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Anshu A, Price MO, Price FW (2012) Descemet’s stripping endothelial keratoplasty: long-term graft survival and risk factors for failure in eyes with preexisting glaucoma. Ophthalmology 119:1982–1987CrossRefPubMedGoogle Scholar
  15. 15.
    Topouzis F, Coleman AL, Choplin N, Bethlem MM, Hill R, Yu F, Panek WC, Wilson MR (1999) Follow-up of the original cohort with the Ahmed glaucoma valve implant. Am J Ophthalmol 128:198–204CrossRefPubMedGoogle Scholar
  16. 16.
    Iwao K, Inatani M, Seto T, Takihara Y, Ogata-Iwao M, Okinami S, Tanihara H (2014) Long-term outcomes and prognostic factors for trabeculectomy with mitomycin c in eyes with uveitic glaucoma: a retrospective cohort study. J Glaucoma 23:88–94CrossRefPubMedGoogle Scholar
  17. 17.
    Kiuchi Y, Sugimoto R, Nakae K, Saito Y, Ito S (2006) Trabeculectomy with mitomycin c for treatment of neovascular glaucoma in diabetic patients. Ophthalmologica 220:383–388CrossRefPubMedGoogle Scholar
  18. 18.
    Nakatake S, Yoshida S, Nakao S, Arita R, Yasuda M, Kita T, Enaida H, Ohshima Y, Ishibashi T (2014) Hyphema is a risk factor for failure of trabeculectomy in neovascular glaucoma: a retrospective analysis. BMC Ophthalmol 14:55–61CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Brito PN, Rosas VM, Coentrão LM, Carneiro ÂV, Rocha-Sousa A, Brandão E, Falcão-Reis F, Falcão MA (2015) Evaluation of visual acuity, macular status, and subfoveal choroidal thickness changes after cataract surgery in eyes with diabetic retinopathy. Retina 35:294–302CrossRefPubMedGoogle Scholar
  20. 20.
    Haddad NMN, Sun JK, Abujaber S, Schlossman DK, Silva PS (2014) Cataract surgery and its complications in diabetic patients. Seminars in Ophthalmol 29:329–337CrossRefGoogle Scholar
  21. 21.
    Samanta A, Kumar P, Machhua S, Rao GN, Pal A (2014) Incidence of cystoid macular oedema in diabetic patients after phacoemulsification and free radical link to its pathogenesis. Br J Ophthalmol 98:1266–1272CrossRefPubMedGoogle Scholar
  22. 22.
    Chu CJ, Johnston RL, Buscombe C, Sallam AB, Mohamed Q, Yang YC, for the United Kingdom Pseudophakic Macular Edema Study Group (2016) Risk factors and incidence of macular edema after cataract surgery. A database study of 81984 eyes. Ophthalmology 123:316–323CrossRefPubMedGoogle Scholar
  23. 23.
    Baker CW, Almukhtar T, Bressler NM, Glassman AR, Grover S, Kim SJ, Murtha TJ, Rauser ME, Stockdale C, Diabetic Retinopathy Clinical Research Network Authors/Writing Committee (2013) Macular edema after cataract surgery in eyes without preoperative central-involved diabetic macular edema. JAMA Ophthalmol 131:870–879CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Wang S, Xu Q, Du Y, Wu X (2016) Does phacoemulsification speed the progression of diabetic retinopathy? A meta-analysis. Int J Clin Exp Med 9:8874–8882Google Scholar
  25. 25.
    Brito PN, Rosas VM, Coentrão LM, Carneiro ÂV, Rocha-Sousa A, Brandão E, Falcão-Reis F, Falcão MA (2015) Evaluation of visual acuity, macular status, and subfoveal choroidal thickness changes after cataract surgery in eyes with diabetic retinopathy. Retina 35:294–302CrossRefPubMedGoogle Scholar
  26. 26.
    An TS, Park IW, Kwon SI (2012) The changes in central macular thickness after cataract surgery in patients with diabetic retinopathy. J Korean Ophthalmol Soc 53:1472–1479CrossRefGoogle Scholar
  27. 27.
    Tsilimbaris M, Diakonis VF, Kymionis GD, Eleftheriadou MI, Fragkiskou S, Moschandreas J, Frueh BE, Epstein D, Pallikaris AI (2012) Prospective study of foveal thickness alterations after cataract surgery assessed by optical coherence tomography. Ophthalmologica 228:53–58CrossRefPubMedGoogle Scholar
  28. 28.
    Chu CJ, Dick AD, Johnston RL, Yang YC, Denniston AK, for the UK Pseudophakic Macular Edema Study Group (2017) Cataract surgery in uveitis: a multicentre database study. Br J Ophthalmol. PubMedGoogle Scholar
  29. 29.
    Okhravi N, Lightman SL, Towlera HMA (1999) Assessment of visual outcome after cataract surgery in patients with uveitis. Ophthalmology 106:710–722CrossRefPubMedGoogle Scholar
  30. 30.
    Taravati P, Lam DL, Leveque T, Van Gelder RN (2012) Postcataract surgical inflammation. Curr Opin Ophthalmol 23:12–18CrossRefPubMedGoogle Scholar
  31. 31.
    Nicholson BP, Zhou M, Rostamizadeh M, Mehta P, Elvira Agrón MA, Wong W, Wiley H, Nussenblatt R, Sen HN (2014) Epidemiology of epiretinal membrane in a large cohort of patients with uveitis. Ophthalmology 121:2393–2398CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Kwon HJ, Kong YXG, Tao LW, Lim LL, Martin KR, Green C, Ruddle J, Crowston JG (2017) Surgical outcomes of trabeculectomy and glaucoma drainage implant for uveitic glaucoma and relationship with uveitis activity. Clin Exp Ophthalmol. Google Scholar
  33. 33.
    Almobarak FA, Alharbi AH, Morales J, Aljadaan I (2017) Intermediate and long-term outcomes of mitomycin c—enhanced trabeculectomy as a first glaucoma procedure in uveitic glaucoma. J Glaucoma 26:478–485CrossRefPubMedGoogle Scholar
  34. 34.
    Almobarak FA, Alharbi AH, Morales J, Aljadaan I (2017) The influence of phacoemulsification on intraocular pressure control and trabeculectomy survival in uveitic glaucoma. J Glaucoma 26:444–449CrossRefPubMedGoogle Scholar
  35. 35.
    Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL, Tube versus Trabeculectomy Study Group (2012) Treatment outcomes in the tube versus trabeculectomy (TVT) study after five years of follow-up. Am J Ophthalmol 153:789–803CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Aquino MCD, Barton K, Tan AMW, Sng C, Li X, Loon SC, Chew PT (2015) Micropulse versus continuous wave transscleral diode cyclophotocoagulation in refractory glaucoma: a randomized exploratory study. Clin Exp Ophthalmol 43:40–46CrossRefPubMedGoogle Scholar
  37. 37.
    Frezzotti P, Mittica V, Martone G, Motolese I, Lomurno L, Peruzzi S, Motolese E (2010) Longterm follow-up of diode laser transscleral cyclophotocoagulation in the treatment of refractory glaucoma. Acta Ophthalmol 88:150–155CrossRefPubMedGoogle Scholar
  38. 38.
    Bloom PA, Clement CI, King A, Noureddin B, Sharma K, Hitchings RA, Khaw PT (2013) A comparison between tube surgery, Nd:Yag laser and diode laser cyclophotocoagulation in the management of refractory glaucoma. BioMed Res Int. (Article ID 371951) PubMedPubMedCentralGoogle Scholar
  39. 39.
    Lee HM, Kim KN, Kim CS (2015) Change in visual acuity following trans-scleral diode laser cyclophotocoagulation in refractory glaucoma. J Korean Ophthalmol Soc 56:1759–1766CrossRefGoogle Scholar
  40. 40.
    Alzuhairy S, Albahlal A, Aljadaan I, Owaidhah O, Al Shahwan S, Craven ER, Mousa A, Edward DP (2016) Intraocular pressure outcomes following transscleral diode cyclophotocoagulation using long and short duration burns. J Glaucoma 25:782–786CrossRefGoogle Scholar
  41. 41.
    Resende AF, Moster MR, Patel NS, Lee D, Dhami H, Pro MJ, Waisbourd M (2016) Ahmed versus Baerveldt glaucoma drainage implantation in patients with markedly elevated intraocular pressure (30 mm Hg). J Glaucoma 25:738–743CrossRefPubMedGoogle Scholar
  42. 42.
    Kim MS, Kim KN, Kim CS (2016) Changes in corneal endothelial cell after Ahmed glaucoma valve implantation and trabeculectomy: 1-year follow-up. Korean J Ophthalmol 30:416–425CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Mendrinos E, Dosso A, Sommerhalder J, Shaarawy T (2009) Coupling of HRT II and AS-OCT to evaluate corneal endothelial cell loss and in vivo visualization of the Ahmed glaucoma valve implant. Eye 23:1836–1844CrossRefPubMedGoogle Scholar
  44. 44.
    Arroyave CP, Scott IU, Fantes FE, Feuer WJ, Murray TG (2001) Corneal graft survival and intraocular pressure control after penetrating keratoplasty and glaucoma drainage device implantation. Ophthalmology 108:1978–1985CrossRefPubMedGoogle Scholar
  45. 45.
    Sidoti PA, Mosny AY, Ritterband DC, Seedor JA (2001) Pars plana tube insertion of glaucoma drainage implants and penetrating keratoplasty in patients with coexisting glaucoma and corneal disease. Ophthalmology 108:1050–1058CrossRefPubMedGoogle Scholar
  46. 46.
    Kaynak S, Tekin NF, Durak I, Berk AT, Saatci AO, Soylev MF (1998) Pars plana vitrectomy with pars plana tube implantation in eyes with intractable glaucoma. Br J Ophthalmol 82:1377–1382CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Luttrull JK, Avery RL (1995) Pars plana implant and vitrectomy for treatment of neovascular glaucoma. Retina 15:379–387CrossRefPubMedGoogle Scholar
  48. 48.
    Smiddy WE, Rubsamen PE, Grajewski A (1994) Vitrectomy for pars plana placement of a glaucoma seton. Ophthalmic Surg 25:532–535PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Beaumont Eye InstituteOakland University William Beaumont School of MedicineRoyal OakUSA
  2. 2.Oakland University William Beaumont School of MedicineRochester HillsUSA
  3. 3.Department of Ophthalmology and Ira G. Ross Eye Institute, Jacobs School of Medicine and Biomedical SciencesUniversity at Buffalo/State University of New York (SUNY)BuffaloUSA

Personalised recommendations