A Simplified Technique for Glaucoma Drainage Device Ciliary Sulcus Implantation

Purpose The study aimed to describe a simplified technique for ciliary sulcus (CS) placement of glaucoma drainage devices (GDD) and to report long-term clinical outcomes in phakic and pseudophakic eyes. Methods This retrospective case series included 10 eyes of 10 patients who underwent CS placement of a PAUL Glaucoma Implant (Advanced Ophthalmic Innovations, Singapore) or Baerveldt 350 mm² implant (Advanced Medical Optics, Santa Ana, USA) at a large tertiary referral eye unit in London in 2021. Indications included uncontrolled intraocular pressure (IOP) despite maximal medical therapy and prior unsuccessful glaucoma surgery, or a low likelihood of trabeculectomy success. Pre- and postoperative data collected by case note review included IOP, visual acuity, visual field indices, number of IOP-lowering medications, and complications. A standardised technique using a 90-degree bent needle to create a controlled scleral tunnel directing the tube into the CS was employed in all cases. Results Mean follow-up was 47.7 months (range 36-57 months). Mean IOP decreased significantly from 28.7 ± 6.9 mmHg preoperatively to 14.4 ± 2.9 mmHg at final follow-up (p = 0.002). The median number of IOP-lowering medications decreased from three preoperatively to 1.5 at final follow-up (p = 0.014). Visual acuity (logMAR) and visual field mean deviation remained stable over follow-up. Six eyes required stent suture removal, and one eye underwent early paracentesis for suspected tube obstruction. Additional glaucoma surgery was required in three pseudophakic eyes with prior glaucoma surgery. One eye developed corneal decompensation requiring a graft; this eye had chronic uveitis and extensive anterior synechiae, and neither the anterior chamber nor sulcus tube was in contact with the corneal endothelium on serial examination. Eyes without prior glaucoma surgery experienced fewer postoperative events. Conclusions Ciliary sulcus placement of GDD tubes using a simplified entry technique achieved durable IOP reduction with preservation of visual function and an acceptable safety profile over long-term follow-up. The technique appears particularly useful in eyes at increased risk of corneal complications or without a suitable anterior chamber and provides a reproducible alternative to anterior chamber tube placement in both phakic and pseudophakic patients.