BLOG: How to place a Baerveldt glaucoma implant

ByAhmad A. Aref, MD

Despite monumental achievements in the field of MIGS, glaucoma filtering surgery is still often required for patients with advanced and/or refractory disease states.

Ahmed Aref

In these cases, intervention with the Baerveldt glaucoma implant (Johnson & Johnson Vision) has a proven track record of success. This procedure requires attention to detail to minimize risk for postoperative complications and maximize success. The video accompanying this post provides narrated step-by-step instruction for performance of the procedure as outlined below.

1.Place a corneal traction suture to gain adequate exposure of the quadrant of interest.
2.Create a 5 clock-hour conjunctival peritomy after injecting sub-Tenon lidocaine with epinephrine. Non-toothed forceps should be used to handle conjunctiva and Tenon tissue. Carry out blunt dissection posterior to the insertion of Tenon capsule. Create a relaxing incision on both sides of the peritomy.
3.Apply wet-field cautery as needed.
4.Hook the extraocular muscles of interest (superior and lateral recti for superotemporal implant placement) and bluntly break away any adhesions.
5.Prepare the Baerveldt glaucoma implant for insertion and grasp broadly using non-toothed forceps, and then slide it under each of the respective extraocular muscles.
6.Suture the implant plate to the globe using 9-0 nylon suture passed through sclera and through each of the implant eyelets. Fixate the implant approximately 0.5 mm to 1 mm posterior to each of the extraocular muscle insertions. Bury the suture knots into the internal aspect of each of the eyelets.
7.Irrigate the Baerveldt glaucoma implant tubing with balanced salt solution using a 30-gauge cannula.
8.Ligate the tubing using 7-0 Vicryl suture while grasping one end of the suture with a heavy locking needle holder and the other end between one’s thumb and forefinger.
9.Verify complete ligation by reinjecting balanced salt solution into the tube lumen, aiming to see fluid egress.
10.Use sharp Westcott scissors to trim the tube proximally to create an anterior bevel and aim for 2 mm to 3 mm of tube in the anterior chamber.
11.Bend a 23-gauge needle at a 90° angle.
12.Grasp the globe firmly adjacent to intended area of tube entry using 0.12 mm or 0.22 mm forceps.
13.Use the 23-gauge needle to create a scleral tunnel along the plane of the globe.
14.Once the needle has approached the gray line, rotate the globe into primary position and enter the anterior chamber.
15.Use non-toothed forceps to grasp the tube and place within the scleral tunnel and into the anterior chamber, making sure that the needle enters parallel to the iris plane and maximizing distance away from the corneal endothelium.
16.Suture the scleral portion of the tubing to the globe using 9-0 nylon suture tied in a horizontal mattress fashion.
17.Place tissue patch graft over the proximal portion of the tube and suture in place using 7-0 Vicryl sutures.
18.Place tube fenestrations as needed using monofilament 9-0 Vicryl sutures to act as stents.
19.Reapproximate conjunctiva and Tenon tissue to the limbus and suture each corner with 7-0 Vicryl sutures anchored into the sclera in a horizontal mattress fashion. The remainder of each conjunctival relaxing incision may be closed in a running fashion.
20.Consider placing at least one vertical mattress suture at the limbus using 7-0 Vicryl suture.
21.Verify adequate conjunctival closure with no leaks or buttonholes.
22.Inject subconjunctival antibiotic and steroid.

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Sources/Disclosures

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Disclosures: Aref reports serving as a speaker for Aerie and receiving research support from Allergan.

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BLOG: How to place a Baerveldt glaucoma implant

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