Eyeworld

DECEMBER 2021 | EYEWORLD | 83 G of the tube. Just being alert to the location of the tube is important, she said. To try to plan for this and prevent it from occurring, Dr. Razeghinejad suggested inserting the tube at least 2 mm posterior to the limbus. He also said to have no tension on the con- junctiva when you close it; you may need to undermine the conjunctiva and have the loose conjunctiva covering the whole area of bare sclera before suturing. If you are pulling the conjunctiva toward the limbus with the aid of suture force, Dr. Razeghinejad said there is a good chance that you may get patch and tube exposure. Dr. Myers said that he has used patch grafts in primary surgery to prevent erosions. Howev- er, these often dissolve over time. "For those of us who switched to long intrascleral tunnels for tube insertions, it seems the erosions are less common with intrascleral tunnels without patch grafts," he added, noting that there is not a lot of data to know for sure. "But I haven't seen a case yet of an erosion in a patient with a long scleral tunnel, 5 mm or for tube exposure and endophthalmitis 4 weeks prior. "She had cells in the anterior chamber and exudates around the intracameral portion of the tube," he said. The retina colleagues recommended tube explantation because they thought the tube was infected. The cause of the tube exposure, he said, was anterior tube insertion, which was not addressed in the first tube revision. In the second revision surgery, Dr. Razeghinejad cut the anterior portion of the tube and used a tube extender and inserted it more posteriorly around 12 o'clock. A cornea patch graft was used. Planning and prevention Dr. Smith noted that tube exposure is generally easy to spot when patients come in for rou- tine visits, and she stressed the importance of actively checking when patients come in. "Being constantly aware that this is possible is one of the important things as you follow patients who have had tube shunts," she said. Dr. Smith also said she is careful to advise patients who get repeated retinal injections to remind the retinal surgeon about the placement A: Tube exposure with exudates inside and around the intraocular portion of the tube; B: Tube filled with exudates and cells; C: Cutting the tube; D: The tube extender inserted into the proximal end of the tube; E: Tube inserted at 12 o'clock and corneal patch graft on the tube; F: Conjunctival advancement over the peripheral cornea; as the conjunctiva tend to retract, it will be at the limbus a few months after surgery Source: Reza Razeghinejad, MD continued on page 84

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