Surgical Technique |

New Ab Interno Technique for Removal of Iris-Embedded EX-PRESS Shunt and Chronic Eye Pain Caused by Shunt Malpositioning

Davinder S. Grover, MD, MPH1; Melissa A. Fellman, MD2; Ronald L. Fellman, MD1
[+] Author Affiliations
1Glaucoma Associates of Texas, Dallas
2University of Texas Medical School at Houston
JAMA Ophthalmol. 2013;131(10):1356-1358. doi:10.1001/jamaophthalmol.2013.4274.
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Grover et al describe a clear corneal ab interno technique to remove a nonfunctioning and/or malpositioned EX-PRESS shunt. They also describe a new finding, chronic eye pain from internal malpositioning of the shunt, which was completely relieved by shunt removal.

The EX-PRESS shunt (Alcon Laboratory) is a stainless steel implant designed to shunt aqueous from the anterior chamber to the subconjunctival space. The device is placed under a scleral flap, with the lumen ideally positioned parallel to the iris. A properly positioned EX-PRESS shunt creates a controlled communication between the anterior chamber and the bleb.1 Several shunt-specific complications have been described elsewhere, including blockage, extrusion or exposure, and anterior dislocation.24 In addition to these complications, malpositioning of the shunt can occur but, to our knowledge, has never been reported as a source of debilitating chronic eye pain requiring shunt removal.

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Figure 1.
Preoperative Clinical Photographs in Patient 1

Gonioscopic photographs of the right eye demonstrating the malpositioned EX-PRESS shunt embedded in the iris stroma before (A) and after (B) dilation. C, Preoperative external photograph of the bleb in the affected (right) eye; the bleb appears diffuse and elevated with healthy-appearing conjunctiva. D, Preoperative gonioscopic photograph of the patient’s left eye demonstrating a properly positioned EX-PRESS shunt.

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Figure 2.
Postoperative Clinical Photographs of the Affected (Right) Eye in Patient 1

A, Gonioscopic photograph demonstrating the postoperative appearance of the angle. The sclerostomy is patent and the iris stroma is indented, marking the former location of the shunt. B, Postoperative external photograph of the bleb.

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Figure 3.
Intraoperative Photographs Demonstrating Ab Interno Removal of an EX-PRESS Shunt in Patient 2

A, Scleral tissue adjacent to the shunt is incised with a 25-gauge microvitreoretinal blade. B, The lumen of the shunt is cannulated with the microvitreoretinal blade. C, D, The distal tip of the shunt is directed posteriorly, allowing the anterior lip to be delivered into the anterior chamber. E, F, Microsurgical forceps are used to retrieve the shunt and remove it from the anterior chamber through the corneal incisions.

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