Letters to the Editor

Transcameral suture for tubecornea touchceo_2409 178..188

Glaucoma drainage devices have been used for over threedecades in refractory glaucoma, and recent trials recom-mend their use earlier in the disease process.1,2 Cornealdecompensation because of tube–cornea touch appears tobe one of the main late postoperative complications.1,2 Theendothelial failure begins with local corneal oedema thatsubsequently becomes generalized.

Interventions to rectify this complication include tuberepositioning that involves major surgery or the rela-tively easier trimming of the tube through two paracentesisincisions.1,3–5 Occasionally explantation of the deviceis necessary.1,2 Recently Bochmann and Azuara-Blancodescribed a simple and novel technique of tube reposition-ing using transcameral sutures that we used and docu-mented with pre- and postoperative photographs.2

A 68-year-old man with known history of glaucomawas referred for a decompensated right cornea secondaryto tube–cornea touch. He had undergone right cataractsurgery and implantation of Molteno glaucoma drainagedevice (Molteno Ophthalmic Ltd., Dunedin, New Zealand)3 years earlier. He complained of photophobia and foreignbody sensation in the right eye, especially the supero-temporal quadrant. Ocular history included childhoodsquint surgery and glaucoma, which was managed medi-cally for 5 years followed by left eye phacotrabeculectomy5 years ago. The right eye cataract and Molteno glaucomadrainage device surgery was complicated with postopera-tive cystoid macular oedema that responded to topical fluo-romethalone and diclofenac. Visual acuity was logMAR0.4 right eye and 0.0 left eye (Snellen acuity 6/15 right 6/6left eye). Examination revealed supero-temporal cornealoedema in the right eye (Fig. 1a); on gonioscopy the tubewas seen touching the cornea in this area (Fig. 2). Intraocu-lar pressures were 10 mmHg right eye and 12 mmHg lefteye. The right pupil was small, did not dilate, andalthough there was a red reflex, the fundus details couldnot be made out.

As the tube was short, we felt that trimming of the tubewould not relieve the corneal touch. A transcameral sutureadjustment of tube positioning, described by Bochmannand Azuara-Blanco, was considered to be the safest andeasiest initial approach. Informed consent was obtained,and the procedure was performed as detailed by Bochmann:a 10-0 polypropylene suture on double-armed 3-inchstraight needles was placed transcamerally from limbus tolimbus running over and depressing the tube away from thecornea.2 The technique was modified by burying suturesunder a conjunctival flap as suggested by one of the authors(A Azuara-Blanco, pers. comm., 2010). From a practicalpoint of view, he also advised that in order to be effective,only one of the sutures needed to be above the tube. Post-operatively, topical Prednefrin forte (Allergan Inc., Gordon,

NSW, Australia) and chloromycetin drops were prescribedfor 2 weeks; fluoromethalone and diclofenac were contin-ued after that.

Five weeks postoperatively the visual acuity waslogMAR 0.2 (Snellen acuity 6/9), the photophobia wasbetter, and he had no foreign body sensation. The smallpupil and corneal haze did not permit a refraction or fundusexamination. The intraocular pressures remained con-trolled at 11 mmHg and 12 mmHg in the right and left eyes,respectively. The tube remained away from the cornea(Fig. 3) and the corneal haze demonstrated improvement.(Fig. 1b)

Tube malposition may result from shallow scleral angu-lation, incorrect tube length, migration and can be aggra-vated by eyelid rubbing and blinking.1–5 Decompensationhas been reported in up to a third of cases; corneal touch isa common cause with a reported frequency up to 20%.1

a

b

Figure 1. Comparison of corneas demonstrating the haze (a)and reduction after procedure (b). The transcameral suture canbe seen in the anterior chamber (arrow).

Clinical and Experimental Ophthalmology 2011; 39: 178–188 doi: 10.1111/j.1442-9071.2010.02409.x

© 2011 The AuthorsClinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists

The use of transcameral sutures to manage tube–cornealtouch resulted in reduction of corneal oedema and haze byrepositioning the tube away from the endothelium. Theprocedure is less complex and safer than the more invasiveoption of tube repositioning via a steeper scleral tunnel orthrough a new insertion site. The photographs clearlyillustrate the improved position of the tube and subse-quent improvement of corneal oedema. This technique oftranscameral suture is simple to use and is likely to be usedmore frequently in managing tube–cornea touch.

Khoi Tran MBBS MMed(OphthSci)1

and Ravi Thomas MD FRANZCO2

1Sydney Eye Hospital, Macquarie St, Sydney, New SouthWales, and 2University of Queensland & Queensland Eye

Institute, South Brisbane, Queensland, AustraliaReceived 21 July 2010; accepted 5 August 2010.

REFERENCES

1. Hong CH, Arosemena A, Zurakowski D et al. Glaucomadrainage devices: a systematic literature review andcurrent controversies. Surv Ophthalmol 2005; 50: 48–60.

2. Bochmann F, Azuara-Blanco A. Transcameral sutureto prevent tube-corneal touch after glaucoma drai-nage device implantation: a new surgical technique.J Glaucoma 2009; 18: 576–7.

3. Asrani S, Herndon L, Allingham RR. A newer tech-nique for glaucoma tube trimming. Arch Ophthalmol2003; 121: 1324–26.

4. Gedde SJ, Schiffman JC, Feuer WJ et al. Three-yearfollow-up of the tubes versus trabeculectomy study. AmJ Ophthalmol 2009; 148: 670–84.

5. Wilson MR, Mendis U, Paliwal A et al. Long-termfollow-up of primary glaucoma surgery with Ahmedglaucoma valve implant versus trabeculectomy. Am JOphthalmol 2003; 136: 464–70.

Verteporfin photodynamic therapyfor retinal hemangioblastomaassociated with Von Hippel-Lindaudisease in a 9-year-old childceo_2428 179..189

Von Hippel-Lindau (VHL) disease is an uncommon,inherited, autosomal dominant, multisystem cancer syn-drome and is classified as one of the phakomatosesleading to the development of benign and malignanttumours. Retinal capillary hemangioblastoma (RCH) isthe most frequent manifestation of the VHL syndrome,appearing in about 37% of patients with VHL. It is theearliest manifestation to appear, with the mean age atdiagnosis being 25 years.1

A 9-year-old white male child affected by VHL diseasepresented with sudden best-corrected visual acuity(BCVA) loss and metamorphopsia in his left eye (LE). TheBCVA was 20/20 in the right eye (RE) and 20/40 in the LE.The LE fundus biomicroscopy examination revealed tem-poral, mid-peripheral RCH associated with macularoedema and neuro-sensory retina detachment (Fig. 1a,b).The ocular coherence tomography (OCT) scan (Stra-tus OCT, Carl Zeiss Meditec, Dublin, CA, USA) con-firmed macular thickening (mean foveal thickness:RE = 166 � 7 mm, LE = 306 � 15 mm) with intra-retinalcysts and subretinal fluid extending into the fovea(Fig. 2a). Fluorescein angiography confirmed a largeperipheral RCH with extensive late leakage into themacular subretinal space associated with hard exudates.B-scan ultrasound examination (I3 System-ABD, Innova-tive Imaging Inc., Sacramento, CA, USA) showed anunevenly shaped, hyperechoic lesion with regular internalstructure and limited internal blood flow. No serous retinaldetachment at the tumour margins and no calcification onthe tumour surface were found. On A-scan RCH exhibited

Figure 2. Gonioscopic view demonstrating site of tube–corneatouch (arrow).

Figure 3. Photo demonstrates transcameral sutures (arrow)and repositioned tube postoperatively.

Letters to the Editor 179

© 2011 The AuthorsClinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists