Small incision glaucoma surgery

This video is amazing — when I first saw this technique, I was in awe because I learned so much. The most surprising thing was that the expert guest surgeon Dr Mohamed Sayed from Miami, Florida, USA was able to roll up the glaucoma seton device (Clearpath from New World Medical) and place it through a small 4-mm conjunctival opening. Truly brilliant and much better than the large incision technique that I showed months ago.

Here is a concise description from Dr Sayed:

This is a case of a patient with severe combined mechanism glaucoma (pseudoexfoliation and secondary angle closure) that is uncontrolled on maximally tolerated medical therapy, including acetazolamide orally.

So ClearPath, the new non-valved glaucoma drainage implant, is very malleable, therefore can be folded or “rolled” to fit through a 4 mm incision in the conjunctiva. We also see that the implant has anteriorly placed islets, therefore allowing the implant to be sutured to the sclera relatively more anteriorly (5-7 mm from the limbus) compared with other types of implants. The implant comes with a pre-placed 4-0 prolene suture, which I typically do not use (personal preference), and therefore took out in the video. I use a 7-0 Vicryl ligature to tie the tube between the islets, and make absolutely sure it is taut. I create an air column in the tube and inject BSS with a cannula in the tube to ensure water tightness, and we can see the air bubble moving in the tube with no leakage. I then make a needle track in the sclera into the anterior chamber using a bent 23-guage needle and I use the traction suture as a lever to change direction of the needle track to ensure I enter the AC parallel to the iris so that the tube is away from corneal endothelium. After the tube is tucked in, I use the spatula needle of the 7-0 Vicryl to make 2 fenestrations in the tube proximal to the ligature, which can help reduce IOP in the first few weeks postoperatively before the ligature dissolves and the tube opens. In this video, I place a Tutoplast processed sclera patch graft, which comes pre-cut and perfectly sized, and therefore does not necessarily need to be sutured to the sclera, I close the conjunctival incision with 4 interrupted 7-0 Vicryl sutures.

I have no financial disclosures.

Thank you so much for everything you do for all ophthalmologists around the globe.

Best,

Mohamed Sayed
Miami, FL

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