Did you know? Historical facts about glaucoma surgery #1: - 11th Oct 2018

Absorbable suture occluding the tube of a Molteno3 implant

In the 1970s a two-stage surgery was developed to prevent hypotony [1]. In the first surgery the plate of the implant was sutured onto the globe beneath Tenon’s tissue, then, in a second surgery 8 weeks later, the tube of the implant was inserted into the anterior chamber (AC). Between the first and second surgeries a thin layer of collagen was laid down in the wall of the bleb (the tissues around the plate) [2]. When the aqueous started draining from the AC, up the tube and into the bleb, the thin layer of collagen prevented hypotony by acting as a flexible barrier.

Unexpectedly, the two-stage surgery also resulted in much less bleb fibrosis and better IOP control. Keeping aqueous out of the bleb for 8 weeks was very beneficial. This technique became known as ‘delayed drainage’.

When Vicryl™(polyglactin) sutures were developed, the two-stage procedure was replaced by a single surgery [3]. At the time of surgery a 5.0 Vicryl suture was tied around the tube, completely blocking all flow. 5.0 Vicryl dissolves after 4-6 weeks so there was a 4-6 week delay before aqueous started to drain into the bleb. This produced similar results to the 8 week two-stage procedure.

Vicryl is a trade mark of Ethicon Inc.

References:
1) Molteno ACB, Van Biljon G, Ancker E: Two-stage insertion of glaucoma drainage implants . Trans Ophthalmol Soc NZ 1979;31:17-26.
2) Molteno AC, Fucik M, Dempster AG, Bevin TH. Otago Glaucoma Surgery Outcome Study: factors controlling capsule fibrosis around Molteno implants with histopathological correlation. Ophthalmology. 2003 Nov 1;110(11):2198-206.
3) Molteno AC, Polkinghorne PJ, Bowbyes JA. The vicryl tie technique for inserting a draining implant in the treatment of secondary glaucoma. Australian and New Zealand journal of ophthalmology. 1986 Nov;14(4):343-54.

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