Aqueous shunt to the ocular surface for severe dry eye

Abstract

Objective
In very dry eyes from any etiology, there is a need for near-continuous fluid supply to
the ocular surface. Here is presented a patient with severe dry eyes who had a double-
tubed valve shunt implanted to divert the aqueous humor to the lower lid fornix,
thereby wetting the eye. Such arrangement has previously been used in eyes with
keratoprosthesis and glaucoma.

Methods
A 67 year old woman had been severely incapacitated with pain and photophobia for
many years. Tear menisci were virtually absent, Schirmer values were repeatedly zero,
and vision was reduced in one eye. Etiology seemed to be scarring of lacrimal gland
ductules caused by vernal catarrh. 

Results
The shunt was implanted without complications, immediately resulting in wetting. After
6 months the eye is totally quiet and comfortable, with 20/25 vision and mild epiphora
due to obstructed canaliculi. The tube in the lower fornix is rarely felt. Antibiotic drops
are given twice daily and no infection has occurred.

Conclusion
So far the patient has done well with a totally quiet and wet eye. The only complication
has been epiphora. If the long-term risks are low, this principle may be of value in end-
stage dry eyes such as in autoimmune diseases, chemical burns, and trachoma.

Keywords
dry eye, aqueous shunt

Introduction

Very severe dry eyes without any visible tear secretion are common in chronic, end-
stage inflammatory and scarring conditions of the ocular surface. Autoimmune
diseases, such as ocular cicatricial pemphigoid (OCP), Stevens - Johnson syndrome
(SJS), graft-versus-host disease (GVHD), as well as severe chemical burns, can end up
with totally dry keratinized corneas. In addition, longstanding trachoma, vernal catarrh
and other chronic inflammatory ocular surface conditions – common worldwide – can
likewise lead to severe dryness. The cause of the surface dryness would be expected to
be scar formation around the lacrimal ductules from the lacrimal gland and accessory
glands, obstructing the flow from otherwise normal lacrimal gland tissue. This is in
contrast to the much more common situation in e.g. Sjögren’s syndrome where the
gland itself becomes inflamed and dysfunctional but where the tear secretion rarely
ceases completely. 
Therapeutic options to wet the ocular surface in the most severely dry eyes are few.
The canaliculi have usually already scarred close, obstructing outflow. Tarsorrhaphy has
limited value and scleral lenses are difficult to fit, expensive, and only rarely successful
in the long run. This leaves artificial tear solutions as drops as the only practical
alternative but with limited retention time and effectiveness. Treatment of the
inflammatory component of the underlying disease has usually at this stage failed to
prevent the final dryness. Therefore the possibility of providing a continuous flow of
fluid over the ocular surface in dry eyes has intrigued ophthalmologists for decades.
Thus spray pumps, attached to spectacle frames, have been developed with increasing
sophistication(1,2). Also, pump systems leading fluid to the fornices via subcutaneously
placed tubings have been tested (3-5). Transposition of salivary gland ducts to the
lower lid fornix is surgically possible but the unevenness of the salivary secretion during
the day has been a problem (6). Autotransplantation of submandibular gland is a more
recent and promising approach (7). 

Another principle for establishing continuous fluid delivery to the ocular surface could
be the diversion of aqueous humor to the lid formices. Some recent developments in
glaucoma shunt technology might accomplish such arrangement. Standard glaucoma
shunt plates can become enclosed by a dense capsule, causing the intraocular pressure
to rise to unacceptable levels. Diverting the aqueous humor to nearby epithelialized
cavities where a fibrous capsule is less likely to form, has been shown to bypass the
problem. Past research on this principle has included experiments in monkeys(8) and a
patented device (9). More recently this concept has been tested in humans with severe
glaucoma after keratoprosthesis surgery (10-12). Thus valved tube shunts have been
implanted in patients, diverting the aqueous humor to a nasal sinus or to the lower lid
fornix. Only one very recent infection has occurred in 32 such patients (8 with tubes to
the fornix), with a follow-up time of up to 3 ½ years (cumulatively 54 shunt years).
This development opens the possibility of using such valve shunts to the lid fornix in
severe dry eyes as well. Here we describe the initial outcome of such a procedure in a
patient who for many years has suffered from debilitating keratoconjunctivitis sicca.

Materials and Methods

The patient is a 67 year old woman with a history of several decades of increasingly
severe irritation in both eyes (Fig. 1). The diagnosis of dry eyes was made over 20
years ago. All puncta had been closed, the lower cauterized, and the upper had plugs.
The patient was at the time of examination so incapacitated that she had to wear dark
glasses and she used more than one bottle of artificial tears per day for instillation
which still gave her only momentary relief. She was otherwise healthy and she had no
symptoms of dry mouth or rheumatoid arthritis. On examination visual acuity was
found to be 20/70 in the right eye and 20/20 in the left. Intraocular pressures were 8
and 10 mm Hg respectively, by applanation tonometry. Schirmer tests were repeatedly
0 mm/5 minutes, with anesthesia, in both eyes. Slit lamp examination revealed virtual
absence of tear menisci (Fig 2). Fluorescein staining showed superficial punctate
keratitis in the right cornea, less in the left. 

Examination of the tarsal conjunctivae suggested the etiology of the condition. There
was a whitish subepithelial sheen, indicating diffuse scarring from healed vernal
conjunctivitis (difficult to photograph). On further questioning, the patient remembered
severe eye problems for several years during her childhood. 

The patient underwent examination by a rheumatologist (JGD). No history of systemic

connective tissue disease could be elicited and the patient appeared healthy.
Sedimentation rate was 15 mm, ANA screen negative, rheumatoid factor was normal,
SS antigens negative. The hematological profile was normal. There was no history of
dry mouth. On the basis of these findings, Sjögren’s syndrome appeared unlikely. 

The possibility of implanting a valve shunt diverting aqueous to the lower lid fornix,
thereby wetting the ocular surface, was discussed in detail with the patient who desired
to have the operation done in her worse, right eye. Extensive informed consent for the
operation was obtained preoperatively and the Institutional Review Board was
consulted. The surgery consisted of implanting a valve shunt which had been
manufactured at our request by New World Medical, Inc. (Rancho Cucamonga, CA). The
shunt, previously described (11,12), consists of a proximal fine tube of silicone to be
inserted to the anterior chamber. It connects to a valve similar to that of a standard
Ahmed S-2 valve shunt, made for an opening pressure of 10 – 12 mmHg. Our shunt did
not have a plate but rather the valve was enclosed by a silicone rubber housing. From
the side of this housing a distal tube emerges to be drawn up to the lower lid fornix
(Fig. 3). 

The proximal tube to the anterior chamber was inserted beneath a half-depth 4 mm
scleral flap, entering into the anterior chamber through a 23 g needle track of the
limbus. The tube extended approximately 3 to 4 mm into the anterior chamber and was
positioned anterior to the iris (Fig. 4). The valve housing was sutured to the sclera in
the lower nasal quadrant with two 9-0 nylon sutures, in a manner similar to the
attachment of a standard S-2 shunt plate. The distal tube was tied to a 4-0 silk suture
and the needle was passed temporally under the conjunctiva to about midpoint of the
fornix where it was exited upwards, and the tube was pulled through. The tube was cut
so that it was allowed to lie flat in the fornix, extending for about one centimeter. Two
10-0 nylon sutures were placed to temporarily keep the tube flat at the bottom of the
fornix. Aqueous could immediately be seen trickling out of the tube opening. A soft
contact lens (Kontur 16.0 mm diameter, 9.8 mm base curve, plano, Kontur Kontact
Lens Co, Inc., Richmond, CA 94801) was finally placed on the eye. It was kept for 2
weeks in order to keep the patient more comfortable.
Figure 1.
67-year old female with many years of marked discomfort from very dry eyes.

Figure 2.
Virtual absence of tear menisci (fluorescein staining). Schirmer values repeatedly 0 mm /5
minutes. Superficial punctate keratitis. Vision 20/70.
Figure 3.
Valved tube shunt. The short tube is inserted into the anterior chamber. The valve is totally
enclosed in silicone rubber and is attached to the sclera in the lower nasal quadrant. The long
tube is drawn temporally through the conjunctiva, shortened and left at the bottom of the lower
lid fornix. Aqueous is then delivered continuously to the fornix and distributed over the surface of
the eye by blinking

Figure 4.
Post-operative appearance. Since puncta and canaliculi had been obliterated earlier, the lower lid
tear meniscus is voluminous and there is mild epiphora. The corneal epithelium has healed and
the vision is restored. The intraocular tube is visible in the 5 o’clock meridian.
Figure 5.
The distal tube is visible at the bottom of the lower lid fornix where it is rarely felt. The eye is
quiet and there is no conjunctival reaction.

Results

Postoperatively the patient did well with a minimum discomfort for a few days. In fact,
she felt instantaneous relief when the lower tear meniscus welled up (Fig. 4). She
reported occasional epiphora (the puncta had been left closed). Schirmer tests
postoperatively varied from 5 mm to 17 mm in 5 minutes, with anesthesia. After one
month visual acuity had increased to 20/25. The intraocular pressure has been
measured at between 5 mm and 9.5 mm by applanation tonometry. There has been no
shallowing of the anterior chamber, hypotony maculopathy, or other complications of
hypotony. 

The patient initially received vancomycin (14 mg/ml), moxifloxacin 0.5 % and
prednisolone acelate 1 %, all topically four times daily. This regimen was over a month
lowered to twice a day. Three weeks postoperatively an attempt was made to open the
right upper punctum to relieve the epiphora. Dissection under local anesthesia by an
ophthalmic plastic surgeon, Dr. Peter Rubin, resulted in removal of the plug stem but
the caniliculus remained scarred and obliterated. A re-canalization procedure is planned
for the future. 

Later in the minor operating room under topical anesthesia, the tube was shortened to
about 5 mm exposed length. An additional 10-0 nylon suture was placed to keep the
tube at the bottom of the fornix (Fig. 5). The patient has during the follow-up period of
6 months felt substantial relief in the operated eye and she is, so far, satisfied with the
outcome. 
Discussion

The encouraging aspect of this patient’s short-term follow-up is not only that the
aqueous humor wets the external eye surface so well but also that the eye rapidly
became very quiet without irritation. The relief was almost instantaneous after the
operation. Also, the exit tube is very rarely felt at the bottom of the lower lid fornix,
only if the eye is rubbed. This was expected from our experience with fluid delivery via
a subcutaneous tube to the lower lid fornix(3,4).

The only, fortunately minor, side effect has been epiphora, due to the obliterated
canaliculi. In severely dry eyes, such as in end-stage autoimmune diseases, the puncti
and canaliculi are usually completely scarred down. Surgical recanalization is very
difficult in these cases and epiphora may be the price to pay for the continuous wetting
of the eye. On the other hand, if the canaliculi are open, it has been our experience that
glaucoma patients with fornix shunt do not report epiphora during the day. Occasionally
they describe “some wetness on the pillow” when they wake up in the morning. This is
probably explained by the fact that aqueous is secreted continuously around the clock
(2 uL/min(13)). Tear production during the day has similar value but the night-time
secretion is markedly reduced (14). Thus the slight epiphora during the night is likely
due to uninterrupted aqueous secretion and absence of blink pump during sleeping
hours.

What are the potential long-term risks in this technique of diverting aqueous to the lid
fornix? First, there must be the usual risks of glaucoma shunts such as tube or valve
erosion and exposure, intraocular tube damage to the corneal endothelium, intraocular
obstruction of the tube, or, rarely, infection. Then the added risk of infection due to the
connection with the conjunctival surface must be considered. However, based on
previous experience with valve shunts ending in the nasal sinuses or lower lid fornix,
the risk of endophthalmitis seems low. In more than 50 cumulative shunt years only
one recent infection has occurred. These valved tube shunts seem to have
unidirectional flow, thus fluid cannot in vitro be forced from the distal end to exit
through the proximal tube opening. It is unlikely that the low dose prophylactic
antibiotics (vancomycin plus a fluoroquinolone once or twice a day) which are given
routinely after keratoprosthesis (with or without shunt), could prevent infection if a
bacterial bolus managed to reach the inside of the eye. This suggests that it is the
unidirectional flow of the aqueous that reduces the risk of infection. 

There could still be the risk of infection around the stoma in the conjunctiva where the
distal tube exits into the fornix. After all, the normal conjunctiva is the host of a
number of bacteria such as Staphylococcus epidermidis and Corynebacteria species, as
well as Haemophilus, Moraxella, Proprionobacterium acnes, etc (15). Again no infection
has occurred in the tissues around the tube exit in altogether 9 cases of valve shunt to
the lower fornix, followed for up to 20 months. Here it is quite possible that the
routinely given topical antibiotics do manage to suppress bacterial colonization and
infection. Clearly a future step in the development of this shunt-to-fornix method will
have to be trying to minimize use of antibiotics. 

The described principle of wetting the ocular surface with aqueous is technically
feasible. It may find some application in the end-stage autoimmune diseases where
epithelial inflammation may be the basis for the disease process but where lack of fluid
may also play a large role.

Acknowledgements

Presented at the International Symposium on Lacrimal Gland, Tear Film, and Dry Eyes
4, held in Puerto Rico November 2004.

Supported by a grant from Alcon Research Institute.

Corresponding author:
Claes H. Dohlman, M.D., Ph.D
Massachusetts Eye and Ear Infirmary
243 Charles Street
Boston, MA 02114
Tel: (617)573-3240
Fax: (617)573-4369
Email: Claes_Dohlman@meei.harvard.edu

References

1. Flynn F, Schulmeister A: Keratoconjunctivitis Sicca and new techniques in its

management, Med J Austral 1967; 1:33-41 

2. Bertera JH, Dohlman CH, Ma JK Programmable microdroplet dispenser functions as

an artificial lacrimal gland. (ARVO abstract). Invest Ophthalmol Vis Sci 2003;2451.

3. Dohlman CH, Doane MG, Reshmi CS: Mobile infusion pumps for continuous delivery
of fluid and therapeutic agents to the eye. Ann Ophthalmol 1971;3:126-128

4. Ralph RA, Doane MG, Dohlman CH. Clinical experience with a mobile ocular perfusion
pump. Arch Ophthalmol 1975;93:1039-43.

5. Murube J, Murube E, Chen Zhou L, Rivas L: Subcutaneous abdominal artificial tears

pump -reservoir for severe dry eye. Orbit 2003;22:29-40

6. Bennett JE, Bailey AL. A surgical approach to total xerophthalmia. Transplantation of

the parotid duct to the inferior cul-de-sac. Arch Ophthalmol 1957;58:367-71.
7. Geerling G, Sieg P, Bastian GO, Laqua H. Transplantation of the autologous
submandibular gland for most severe cases of keratoconjunctivitis sicca. Ophthalmology
1998;105:327-35. 

8. Camras CB, Wang RF, Siegel MJ, et al. Valved tube shunt from the anterior chamber
to the external ocular surface for use in refractory glaucoma. Invest Ophthalmol Vis Sci
1992;33:3949. (ARVO abstract). 

9. White TC. US Patent 082837, 1989.

10. Dohlman CH, Grosskreutz CL, Dudenhoefer EJ, Rubin PAD: Can a glaucoma shunt
be safely extended to the lacrimal sac or ethmoid sinuses in keratoprosthesis patients?
Preliminary findings. Dig J Ophthalmol 2002;7:3

11. Dohlman CH, Barnes SD, Ma JJK, et al : Diverting aqueous humor to distant sites in
severe glaucoma: an update. Invest Ophthalmol Vis Sci 2004 (ARVO)

12. Dohlman CH, Barnes SD, Ma JJK, et al. Diverting aqueous humor to epithelialized
cavities in severe glaucoma. Submitted. 

13. Sears ML: The Aqueous. In: Adler’s Physiology of the Eye (Moses RA, ed) St Louis,
CV Mosby Company 1981;p.204

14. Baum JF: Clinical implications of basal tear flow. In: The Preocular Tear Film in
Health, Disease and Contact Lens Wear (Holly FJ, ed); Dry Eye Institute, Lubbock TX
1986; p.646

15. Perkins R, Kundsin RB, Pratt M, et al: Bacteriology of normal and infected
conjunctiva. J Clin Microbiol 1975; 1:147