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TUBE SHUNT PROCEDURE STEPS

(described for a left eye, ST approach , Biggerstaff style)

PHASE STEP MATERIALS INSTRUCTIONS NOTES/PEARLS


Scleral Traction Suture 7-0 vicryl Partial superior limbal suture superiorly to bring ST conj into view
Exposure 0.12/Needle
driver
Topical block Lido Use 0.12 to pick up conj and inject, then use BSS bottle needle to (whole portion is a
1%/Marcaine smooth it out Biggerstaff special)
on a 30g
Conj dissection 0.12/blunt Start cutting conj at 12 o clock towards fornix about 7mm? back, Grab tenons (and
wescott scissors then widen in subconj space by blunt dissection. not conj) when you
Then do a close limbal peritomy for 3-4 clock hrs. can!
Another cut towards fornix.
Switch to stevens and do a WIDE blunt dissection posteriorly,
WIDE
Inject more lido/Marcaine into posterior subtenons space
BGI Isolate SR/LR Stevens muscle First hook to isolate muscle Doesn’t really
implantation muscles hooks/stevens Second hook to ensure no check ligaments not isolated matter which wing
muscle hooks of the implant you
place in first, but it
seems most place
under the SR first
BGI insertion Nugent forceps Slide under SR, pull out muscle hook, isolate LR, then insert wing
(with underneath LR
implant)/muscle
hook
Securing BGI to 7-0 vicryl (open Measure 9mm to check where sutures should go.
sclera new suture) Pass needle through sclera (drive posteriorly), then mid-pass,
0.12/needle place plate over the needle to protect needle from back-tracking
driver and potentially going towards globe (2-1-1)
Do it for the other suture

Tube ligation 7-0 vicryl place 1st knot (3 wraps), and then flip over to bottom, about
tier/needle ~5mm from plate, then tighten REALLY tight.
driver check for water-tightness with 30g canula with BSS, grabbing end
of tube
switch to needle driver/needle driver or hand.
place 2 more knots (ultimately will be 3-1-1).
Tube Scleral 0.12/cautery Power settings?
insertion cauterization probe/BSS Cautery with BSS flow
bottle to
assistant

Trimming tube 0.12/Stevens Trim tube to about 2mm from the limbus, beveled up/anteriorly
scissors

Scleral tunnel 30g needle/0.12 About 2mm posterior to limbus


Track to ?ciliary body to have needle just above the iris
Insertion of tube Tissue Insert tube Guide it in by
into anterior forceps/tissue grabbing limbal
chamber forceps conj for counter
traction

Securing tube 8-0 vicryl Mattress suture: Ensure there are


flat to sclera 0.12/needle 1 bite towards posteriorly, cross to other side of the tube, then 1 no kinks in tube
driver bite towards anteriorly before placing
Knot should end up on anterior, it should be snug but not suture
ligating/buckling the tube (2-1-1)

Fenestrations 8-0 vicryl Go thru both sides of tube Note, per PTC
needle Place both fenestrations between the two mattress sutures about 20 IOP= x2
0.12/needle fene, 30 IOP = x3
driver
Closing up Halo patch graft Tissue Place some BSS on halo graft to hydrate it Try and have knots
forceps/tissue Place graft on , with the curved edge facing the limbus lying adjacent/on
forceps Switch to needle driver with the 8-0 vicryl edge of graft
Pass vicryl posteriorly thru limbus, then thru patch graft, then 2-1-
1 (very similar to passing suture to secure implant to sclera)
Do the same with other side of graft

Covering Tissue Approximate conj and see where it lies


graft/implant forceps/tissue Switch to needle driver with 8-0 vicryl
with conj forceps Partial thickness, running limbal suture
First thru sclera then grabbing conj, 2-1-1
Leave one end loose and tuck underneath conj
Go towards fornix and do a running suture
Finish the running suture and end somewhat short (2-1-1?)
Do the same with the other side of the peritomy
Inferior subconj 30g needle 1cc?
dex/ancef