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    Securing grafts without sutures

    Technique maintains static glaucoma drainage device placement, reduces risk of surgery complications


    Posterior device placement

    Perhaps most significant, suturing the conjunctiva can be tedious and difficult depending on the plate position. Placing the plate farther forward reduces the difficulty with suturing as it provides easier access and visibility.

    However, it is always better, from both a cosmetic as well as a fibrosis-scarring perspective, to place the device as posterior as possible, about 10 to 12 mm behind the limbus.

    A proximity too close to the limbus can cause patient discomfort and may cause other issues, such as a larger cystic bleb and fibrosis. The main drawback to this placement is that when the plate is placed farther back it becomes extremely difficult to suture as both accessibility and visibility are reduced.

    As a result, it is more common to place the plate farther forward, only 8 to 9 mm behind the limbus.

    A more posterior placement aids in reducing or eliminating the need for sutures. Due to the natural curvature of the plate, placing it farther back toward the equator allows it to suction to the sclera, fitting snugly and reducing the chances of migration. Additionally, once the conjunctiva is closed, there is enough pressure on the plate to keep it in place.

    Using an ocular sealant (ReSure, Ocular Therapeutix) in place of the sutures further ensures the plate will remain static. We have not seen any migration since implementing the use of the sealant.

    In terms of safety, it has been shown to be safe to use on corneal wounds.9 It is likewise as safe for use on the sclera and with the patch graft. It is very rare for patch grafts to shift. Therefore, adding another suture to secure them not only adds time, but also increases the chance of fibrosis, which can occur quickly.

    A small amount of sealant in place of a suture is more than adequate to ensure the graft remains in place. Overall, the use of a sealant results in less time in the operating room, less equipment in terms of sutures and all the accompanying paraphernalia, greatly increased efficiency for the procedure as a whole, and greater comfort for patients.

    Applying the sealant

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