Advanced glaucoma can often be refractory to medical/laser treatments and surgical intervention is essential to preserve vision. In cases with unsuccessful primary trabeculectomies, the next common surgical option is to incorporate a Baerveldt 250 Glaucoma Drainage Device (GDD) in the anterior chamber via a corneal incision for additional outflow of aqueous humour to the subconjunctival space [1, 2]. This can be particularly challenging in patients who have pre-existing inflammatory conditions and have damaged sclera [1]. This short article describes a novel use of Tutoplast (Innovative Ophthalmic Products, Costa Mesa, California, USA) for scleral reinforcement before implantation of GDD over two operations.

Patient 1 is a 56-year-old lady with uncontrolled advanced open-angle glaucoma and chronic scleritis. She previously lost vision in the left eye after unsuccessful trabeculectomies, diode laser, Molteno tube surgery, and a failed penetrating keratoplasty. Her only seeing right eye had scleromalacia from recurrent scleritis and sustained high pressure, despite a previous trabeculectomy and endocyclophotocoagulation (to spare the sclera). In light of this, a two-staged tube surgery was planned; the first stage consisted of a superior peritomy, and then reinforcing the existing thin sclera from the limbus with Tutoplast. The Tutoplast was trimmed to fit the scleral bed for the Baerveldt plate and tube. Two layers of the pericardial graft were attached onto the sclera with Tisseel glue (Baxter AG, Vienna, Austria). The conjunctiva was repositioned, glued and sutured to the limbus. After 2 weeks, the patient underwent the second stage, where the GDD was placed over the Tutoplast, and the plate was sutured. A 7/0 Supramid suture was placed to occlude the GDD lumen. The GDD was inserted into the anterior chamber through a superotemporal limbal tunnelled incision. A thinned double layer of Tutoplast was glued on the tube and the conjunctiva was placed over the graft (Figs. 1 and 2).

Fig. 1
figure 1

Patient 1′s left eye with marked scleromalacia, especially superotemporally post removal of a failed Molteno tube

Full size image
Fig. 2
figure 2

Patient 1′s right eye post insertion of the pericardium graft superotemporally for reinforcement of sclera prior to Baerveldt (Advanced Medical Optics, Santa Ana, California, USA) tube implantation (black arrow)

Full size image

Patient 2 is a 67-year-old lady with rheumatoid arthritis and secondary chronic uveitic glaucoma. She too had uncontrolled progressive glaucoma with visual deterioration despite treatment. She also had severe scleromalacia secondary to recurring scleritis. Since previous interventions included a failed trabeculectomy and endocyclophotocoagulation, she was listed to have a GDD. Once again, this was approached in a two-step manner, where the pericardial graft was glued in the right eye prior to the implantation of GDD.

In the two resistant glaucoma patients with scleromalacia, reinforcing the existing scleral tissue before implantation of GDD was their only option to prevent blindness. The concept of a two-step procedure allows the eye to incorporate the Tutoplast and ensure that subsequent manipulation would be safe and effective for plate fixation [3]. Alternatively, in a thinned scleral the site of implantation could be changed; however, evidence suggests that inferior tubes increase the risk of exposure, which may risk endophthalmitis [4]. This is explained by gravitational transit of the tear film to the lower lid, which increases pooling of commensal organisms near the inferior tube.

Despite a recent survey highlighting glaucoma surgeons preferring trabeculectomies over GDD in advanced glaucoma, they remain contraindicated in scleromalacia patients due to the risk of perforation [5]. The concept of a two-step GDD procedure allowed a safe and effective outcome for recalcitrant glaucoma patients with scleral thinning.