You just finished your surgical training a couple of year ago and now a patient with a failed trabeculectomy is referred to your clinic. What will you do? This can be a daunting challenge for a younger surgeon but we have your answer right here, courtesy of Prof Ramesh Ayyala from USF Tampa in Florida, USA. The conjunctiva is often scarred, the anatomy is distorted, and the intraocular pressure is dangerously high. Your goal is to restore aqueous outflow by combining a bleb revision with the placement of a ClearPath glaucoma drainage device. First, you must carefully dissect the conjunctiva away from the old scleral flap. Once you have addressed the sub-conjunctival fibrosis, you create a new posterior space for the ClearPath seton. This device is excellent for these cases because its flexible, plate-less design fits easily into the scarred orbital tissue, however you must do a ligature suture plus a ripcord suture to ensure success and avoid post-op hypotony. After securing the device to the sclera, you tunnel the tube into the anterior chamber, ensuring it is well away from the corneal endothelium. Next is the revision of the failed bleb. By combining the revision with a seton, you provide a reliable, long-term solution for a patient who has already failed traditional filtration surgery. Focus on meticulous tissue handling; your patient’s vision depends on this new outflow track. Amazing work!
