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Surgical Technique | Surgeon's Corner

Forniceal Conjunctival Pedicle Flap for the Treatment of Complex Glaucoma Drainage Device Tube Erosion

Davinder S. Grover, MD, MPH; James Merritt, MD; David G. Godfrey, MD; Ronald L. Fellman, MD
JAMA Ophthalmol. 2013;131(5):662-666. doi:10.1001/jamaophthalmol.2013.2315.
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This retrospective study evaluated the safety and efficacy of the forniceal conjunctival pedicle flap for repair of conjunctival-deficient tube erosions. Additionally, we report the split-lid technique, a procedural improvement if fornix access is difficult. We identified 15 eyes of 14 consecutive patients with complex tube erosions. The mean age was 72.8 years and 33.3% had diabetes mellitus. Most patients were functionally monocular and 80% had undergone 4 or more prior ocular surgical procedures. There was no difference between the following preoperative and postoperative values: visual acuity, intraocular pressure, or number of glaucoma medications. The mean follow-up time after pedicle flap repair was 49 months. There were no recurrent erosions allowing for preservation of the drainage implant with excellent intraocular pressure control. This study demonstrates the relative long-term safety and success of this novel technique.

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Figures

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Figure 1. Medical illustration demonstrating the management and preparation of the eroded tube prior to harvesting the forniceal conjunctival pedicle flap. The illustration is from a surgeon's perspective. A, Initial presentation of an eroded glaucoma drainage tube in the superior-temporal quadrant in a left eye. B, The scar tissue has been gently dissected away from the eroded tube. The tube is secured to the sclera with a single 9.0 nonabsorbable polypropylene suture. C, The eroded tube is covered by a piece of partial-thickness corneal patch graft. Notice the cornea is tucked under a lip of healthy conjunctiva and secured to the sclera with an absorbable suture. Reproduced with permission. Copyright 2012 A. B. Hernandez.

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Figure 2. Medical illustration demonstrating the forniceal conjunctival pedicle flap. A, The conjunctival pedicle flap has been harvested from the fornix and is transferred to the area of erosion. The ratio of the flap is roughly 3:1 when comparing the length and width. B, The flap has been appropriately sutured to the targeted destination using absorbable sutures. Note that the proximal portion is not sutured to avoid disrupting the vascular supply to the flap. This portion of the flap heals by primary intent. Reproduced with permission. Copyright 2012 A. B. Hernandez.

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Figure 3. Medical illustration demonstrating the forniceal pedicle flap technique in the setting of a very tight orbit that necessitated a full-thickness surgical incision through the lid and tarsus to properly access the forniceal conjunctiva. A, Surgical splitting of the lid allows for improved access to the fornix in this case. B, The flap is sutured in a manner similar to cases that did not require splitting of the lid. C, The surgical closure and postoperative appearance after the lid-splitting technique allows for minimal scarring and morbidity. Reproduced with permission. Copyright 2012 A. B. Hernandez.

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Figure 4. External photographs of case 7 demonstrating the postoperative course following a tube erosion repair with a pedicle flap. A, Slit-lamp photograph on postoperative month 1. Healthy and vascularized conjunctiva cover the patch graft and tube. B, Photograph on postoperative month 14 demonstrates a normal external appearance of the eyelids and anterior segment. C, Slit-lamp photograph on postoperative month 14 demonstrates a healthy appearing forniceal conjunctival flap covering a previously exposed tube.

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