- Tube shunt patch grafts are commonly used during glaucoma drainage device implantation surgery but their necessity is questioned.
- Medicare reimbursement for tube shunt surgeries will be bundled starting in 2015, incentivizing reducing costs.
- Alternatives to patch grafts exist like creating a scleral tunnel with a needle or scleral flap alone that may reduce complications like tube erosion or migration.
- Risk factors for tube erosion include younger age, history of inflammation, and thin or damaged sclera. The goal is to minimize force on the tube by securing it well and making the scleral flap or graft wide to reduce risk. A patch graft may only be truly necessary in
1. Tube Shunt Patch Grafts:Tube Shunt Patch Grafts:
Do We Need Them?Do We Need Them?
H. George Tanaka, MDH. George Tanaka, MD
Assistant Clinical ProfessorAssistant Clinical Professor
California Pacific Medical CenterCalifornia Pacific Medical Center
San Francisco, CASan Francisco, CA
3. • Medicare payments for CPT 66180
– 11,111 in 2011
– 12,021 in 2012
– 12,835 in 2013
We’re doing more tubesWe’re doing more tubes
4. As of January 1, 2015:As of January 1, 2015:
reimbursement for CPT 67255reimbursement for CPT 67255
is bundled with CPT 66180is bundled with CPT 66180
5. • Do your tubes at the hospital
• Scleral flap
• Needle track
Alternatives to a patch graftAlternatives to a patch graft
6. • Needle track
– 20 gauge MVR blade
– 5-6 mm posterior to limbus
– no tube erosions
– no tube migrations
Leong JK, et. al. : Outcome of graft free Molteno tube insertion. Br J Ophthalmol. 2006;90(4):501-505.
Albis-Donado O, et. al.: Evaluation of Ahmed glaucoma valve implantation through a needle-generated scleral tunnel in Mexican children with glaucoma.
Indian J Ophthalmol. 2010;58(5):365-373.
Mesa-Gutierrez JC, et. al. : Graft-free Ahmed tube insertion: a modified method at 5 mm from limbus. Clin Ophthalmol. 2010;4:359-363.
Alternatives to a patch graftAlternatives to a patch graft
7. Scleral flaps: Back to the FutureScleral flaps: Back to the Future
Molteno ACB, Van Rooyen MMB, Bartholomew RS. Implants for draining neovascular glaucoma. Br J Ophthalmol. 1977;61:120-125.
8. • Tube insertion under scleral flap caused hypotony and tube-cornea touch
• Scleral graft was used to maintain normal contour of tube against the globe
Scleral patch graft for Molteno setonsScleral patch graft for Molteno setons
Freedman, J. Scleral patch grafts for Molteno setons. Ophthalmic Surgery. 1987;18:532-4.
10. • Patch graft
• Scleral flap
• Needle
PROS CONS
Familiar
Coverage
Suture lysis (cornea)
Cost
Cosmesis (peri, sclera)
Limbal edge
Immunologic?
Infectious?
Cost
Coverage
Cosmesis
Need normal sclera
Need normal sclera
Limited thickness
Cost
Speed
Cosmesis
11. • Younger age and history of inflammation
• Concomitant surgery
• No association with:
– Type of implant
– Implant location
– Type of patch graft
Trubnik V, et. al. Evaluation of risk factors for glaucoma drainage device-related erosions: A retrospective case-control study. J Glaucoma, 2015;24(7):498-502
Chaku M, et.al. Risk factors for tube exposure as a late complication of glaucoma drainage implant surgery. Clin Ophthal 2016;10:547-553.
Risk factors for tube erosionRisk factors for tube erosion
12. • Patch graft
• Scleral flap
• Needle
What is the relative risk of tube erosion?
15. Goal = minimize F
F
flap
tube
Securing tube to sclera with 10-0 nylon suture
sclera
16. Goal = minimize F
F
tube
flap
Don’t sew flap or graft too tightly
sclera
17. Goal = minimize F
F
tube
flap
Place sutures to “tent up” flap
sclera
18. Goal = minimize F
F
tube
flap
Make the flap as wide as possible
sclera
19. • Thin sclera
– High myopia
– Recurrent scleritis
– Other conditions
• Collagen vascular disease
• Autoimmune disease
• Repair tube erosion
When do I really need a patch graft?When do I really need a patch graft?
From The Sclera. C Stephen Foster, Maite Sainz de la Maza,
Springer Science, Chapter 8: Non-Inflammatory
Diseases of the Scleral, pg. 279, 1994.
