Three techniques for guidewire-assisted sulcus glaucoma tube shunt placement

Purpose

Tube shunts can be inserted into the anterior chamber, ciliary sulcus, or pars plana. Sulcus tube placement can be challenging. This report demonstrates three techniques for guidewire-assisted sulcus tube insertion.

Observations

The first technique uses a needle inserted through a paracentesis 180-degrees across from the tube entry site and creates an ab-interno sclerotomy through which the guidewire is inserted by docking it into the needle bevel. The second technique involves inserting the guidewire into the eye via a paracentesis and using microforceps to retrieve it through a sclerotomy. The third technique uses forceps to insert the guidewire into a paracentesis 180° across from the planned tube entry site and dock it into a needle bevel that has been inserted into the sulcus. Each of these techniques provides a reliable and reproducible way to insert a tube into the sulcus.

Conclusions and importance

Guidewire-assisted tube entry offers a promising solution in cases of difficult sulcus tube placement without substantial additional cost.

Baerveldt-350 with adjunctive goniotomy: Pilot results

Purpose

To describe a previously unreported method for optimizing early intraocular pressure-lowering in non-valved aqueous shunt surgery, and to report pilot results from a case series.

Observations

We report pilot results of 30 eyes that underwent Baerveldt-350 implantation with adjunctive goniotomy, in addition to 3 needle-puncture fenestrations, to enhance intraocular pressure lowering and facilitate higher steroid dosing before spontaneous ligature dissolution.

Conclusions and Importance

In patients with open-angle glaucoma, goniotomy is a safe and effective procedure when performed in conjunction with non-valved glaucoma tube shunt implantation.

Gonioscopy-assisted transluminal trabeculotomy in neovascular glaucoma: Salvaging the conventional outflow pathway

Purpose

To report a case of acute neovascular glaucoma with partial synechial angle closure secondary to central retinal vein occlusion that underwent gonioscopy-assisted transluminal trabeculotomy as well as near-monthly anti-vascular endothelial growth factor (VEGF) injections and panretinal photocoagulation (PRP) treatments.

Observations

Nine months after GATT, the patient had achieved intraocular pressure control on no medications. However, she was lost to follow up for 4 months and received no anti-VEGF or PRP during that time; she re-presented with acute NVG and complete synechial closure, and ultimately underwent aqueous shunt implantation.

Conclusions and Importance

To our knowledge, this is the first reported attempt of an ab interno angle surgery to successfully restore aqueous outflow through the conventional outflow pathway in an eye with acute NVG and partial synechial angle closure. We posit that this can be an effective approach to achieve IOP control in NVG with at least partially open angles, as long as sufficient anti-neovascular treatments are administered until the underlying neovascular drive achieves quiescence.

High CO2 Levels Impair Lung Wound Healing

Delayed lung repair leads to alveolopleural fistulae, which are a major cause of morbidity after lung resections. We have reported that intrapleural hypercapnia is associated with delayed lung repair after lung resection. Here, we provide new evidence that hypercapnia delays wound closure of both large airway and alveolar epithelial cell monolayers because of inhibition of epithelial cell migration. Cell migration and airway epithelial wound closure were dependent on Rac1-GTPase activation, which was suppressed by hypercapnia directly through the upregulation of AMP kinase and indirectly through inhibition of injury-induced NF-κB-mediated CXCL12 (pleural CXC motif chemokine 12) release, respectively. Both these pathways were independently suppressed, because dominant negative AMP kinase rescued the effects of hypercapnia on Rac1-GTPase in uninjured resting cells, whereas proteasomal inhibition reversed the NF-κB-mediated CXCL12 release during injury. Constitutive overexpression of Rac1-GTPase rescued the effects of hypercapnia on both pathways as well as on wound healing. Similarly, exogenous recombinant CXCL12 reversed the effects of hypercapnia through Rac1-GTPase activation by its receptor, CXCR4. Moreover, CXCL12 transgenic murine recipients of orthotopic tracheal transplantation were protected from hypercapnia-induced inhibition of tracheal epithelial cell migration and wound repair. In patients undergoing lobectomy, we found inverse correlation between intrapleural carbon dioxide and pleural CXCL12 levels as well as between CXCL12 levels and alveolopleural leak. Accordingly, we provide first evidence that high carbon dioxide levels impair lung repair by inhibiting epithelial cell migration through two distinct pathways, which can be restored by recombinant CXCL12.