Sutureless Valve Implants for Glaucoma Safe, Quick

Fran Lowry

March 17, 2016

FORT LAUDERDALE, Florida — For patients with refractory glaucoma who undergo tube shunt surgery, sutureless drainage valve implantation is safe, effective, and faster than standard techniques that involve suturing, according to a new study.

"The traditional way — standard tube shunt surgery, which is how I was taught — is to make incisions around the eye, place the valve, in this case the Ahmed valve, and then use about a dozen stitches to close things up," said Nathan Radcliffe, MD, from Weill Cornell Medical Center in New York City.

"As I did more and more of these, I came to feel not just that some of the sewing we were doing was unnecessary, but that it is actually harmful," Dr Radcliffe told Medscape Medical News.

When you use stitches, you first have to "puncture tissue. Then the stitches stay in the eye and dissolve, in some cases causing inflammation as they do. If they don't dissolve over time, you have a foreign body in the eye, which can end up being a nidus for inflammation, infection, and other problems," he explained.

Dr Nathan Radcliffe

"I've seen people who had great surgeries but the stitches left behind a year or 2 later ended up causing infection," he added.

Over time, Dr Radcliffe found areas of the surgery where stitches weren't required, and after a "7-year evolution of technique," he finished with no sutures at all.

Dr Radcliffe and his colleagues conducted a retrospective review of 127 eyes from 103 patients who underwent sutureless implantation of a glaucoma valve (Ahmed, New World Medical) over a 1-year period.

A fibrin sealant (Tisseel, Baxter Healthcare Corp.) was used in place of sutures.

Dr Radcliffe presented the results of the study during a poster session here at the American Glaucoma Society 2016 Annual Meeting.

Of the 127 eyes, 26 underwent valve implantation only, 45 underwent valve implantation plus cataract extraction with intraocular lens placement, 34 underwent valve implantation plus endoscopic cyclophotocoagulation (Endo Optiks), and 22 underwent valve implantation plus cataract extraction with intraocular lens placement plus endoscopic cyclophotocoagulation.

Outcomes in the four treatment groups were essentially the same. "It didn't make too much of a difference what else you did, as long as you put the valve in," he said. And the reductions in pressure were "consistent" with what has been reported in the literature, he added.

There was a significant reduction in intraocular pressure in the study cohort at 6 months (P < .0001).

Table 1. Reduction in Intraocular Pressure After Sutureless Implantation

Time From Procedure Mean Reduction From Baseline, mm Hg
Baseline 26.22
1 day 13.55
1 week 12.32
1 month 16.25
3 months 15.89
6 months 15.89

 

There was also a significant reduction in the number of medications needed at 6 months (P < .0001).

Table 2. Reduction in Glaucoma Drops Used After Sutureless Procedure

Time From Procedure Mean Reduction From Baseline, Drops
Baseline 2.49
3 months 1.58
6 months 1.69

 

Seven patients underwent reoperation, two for uncontrolled intraocular pressure, two for tubes clogged with iris tissue, one for hypotony, one for encapsulation or dysesthesia, and one for cornea-tube touch.

"This number of reoperations is standard, if not even a little better than the average result," Dr Radcliffe reported. "The cornea-tube touch could potentially be attributed to not having sewn as many things in, but it happens at a higher rate in most series in which stitches are used, so I don't think we see anything here that suggests there was a price paid for cutting down on the number of stitches."

However, he pointed out that there is a learning curve with this technique.

"You are using the eye's anatomy to hold everything in place. That is why, for me, the sutureless technique evolved over 7 years," he explained. "If you are a new surgeon and you want to try this technique, you should not just switch over; you should cut down on your sutures, and as you get more comfortable with the technique, cut down more and more. When you see how comfortable patients are afterward, and the good results, you tend to want to do more sutureless procedures."

Caveats

Dr Eiyass Albeiruti

The biggest advantage of sutureless drainage valve implantation is the time it saves, said Eiyass Albeiruti, MD, from the Eye Center of Grand Rapids in Michigan.

"Typically, compared with the standard surgical technique using sutures, this procedure can be performed in half the time. It's really quick. You're literally positioning the implant on the eye, putting the glue down, and pulling the conjunctiva over everything," Dr Albeiruti told Medscape Medical News.

He expressed concern, however, that with this technique, tubes could migrate postoperatively. "It's the reason I haven't stopped using sutures yet," he said. "I like to make sure a shunt remains in exactly the same position after surgery, which is best achieved by using nonabsorbable sutures to secure it to the sclera."

Another potential problem is when the fibrin starts to break down. "The fibrin glue doesn't last forever, and it is not as strong as sutures are," said Dr Albeiruti. The fibrin sealant is supposed to be a relatively temporary adhesive that lasts long enough for the natural healing mechanisms of the eye to take over. "But if the glue resorbs before this happens, there may be potential for some leakage," he explained.

"Also, there are forces that pull against the conjunctiva — whether due to contraction, eye movements, or eye rubbing. Without anterior sutures holding down the conjunctiva, it can retract and lead to exposure of the anterior patch or tube. Because of this, some surgeons who like to close using glue will advance the conjunctival edge well past the limbus, and might even put in a couple of stitches to anchor it down," he said.

"If you are trying to improve efficiency, it's a technique you can use, but if your goal is to minimize any chance of tube migration or anterior exposure or leakage postoperatively, you will want to stick with the suture technique," he said.

Dr Radcliffe reports that he is a consultant for New World Medicine. Dr Albeiruti has disclosed no relevant financial relationships.

American Glaucoma Society (AGS) 2016 Annual Meeting: Abstract 36. Presented March 3, 2016.

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