Prevention of Ocular Tenon Adhesion to Sclera by a PDMAA Polymer to Improve Results after Glaucoma Surgery.

The authors describe a process that may eventually reduce the risk of scar formation after glaucoma surgery. For this, a thin hydrogel coating is photochemically generated and linked to the sclera surface at the surgical site. This coating is generated from a photoreactive prepolymer containing anthraquinone groups, which is administered as a thin pad to the sclera surface. Short UV irradiation leads to a reaction of the photogroups with neighboring chains via C-H insertion crosslinking, thus transforming the precursor polymer into a hydrogel. Simultaneously, a reaction between the photogroups and the underlying sclera tissue occurs, so that the hydrogel patch becomes covalently linked to the tissue. The authors show that the resulting thin coating is strongly cell repellent and hinders tenon fibroblasts to form tenon tissue at the site of the coating and is suitable for inclusion into a surgical procedure.

A novel surgical technique for prevention of Ahmed glaucoma valve tube exposure: long scleral flap augmented with Tenon advancement and duplication.

BACKGROUND: To describe a new technique and present its long-term outcome for prevention of Ahmed glaucoma valve (AGV) tube exposure in patients with refractory glaucoma. METHODS: Twenty-seven eyes of 24 patients (mean age, 50 years; age range, 16-78 years; 8 females, 16 males) with refractory glaucoma who had the AGV implant were retrospectively reviewed. For AGV implantation, a long scleral flap combined with Tenon advancement and duplication was used. In this technique, a long scleral flap is created to completely cover the extraocular part of valve's tube, and the flap surface is covered with duplicated Tenon's tissue. The average follow-up after AGV implantation was 21.7 months (range, 12-36 months). RESULTS: The mean intraocular pressure before the operation, which was 44.1 mmHg (range, 26-62 mmHg), decreased to 14.2 mmHg (range, 8-20 mmHg) at the last follow-up visit, showing 67% reduction with AGV implantation. The mean number of antiglaucomatous medications was 4.1 before the AGV implantation and decreased to 0.9 after the operation, showing 88% reduction. In 14 eyes (51.9%), there was no change in the best corrected visual acuity (BCVA), and in 11 eyes (40.7%), the BCVA increased by 2 lines on the Snellen chart postoperatively. No patient developed postoperative hypotony, flat anterior chamber, diplopia, strabismus, erosion or exposure of the tube, or tube/plate migration. CONCLUSIONS: The long scleral flap augmented with Tenon advancement and duplication is an effective and safe surgical technique for the implantation of AGV and preventing tube exposure in cases of refractory glaucoma.

Improvement in Both Primary and Eccentric Ocular Alignment After Thyroid Eye Disease-Strabismus Surgery With Tenon's Recession.

PURPOSE: To evaluate the improvement in primary and eccentric gaze ocular alignment in thyroid eye disease (TED) patients undergoing horizontal strabismus surgery with Tenon's recession. METHODS: This is an Institutional Review Board-approved retrospective analysis of TED patients undergoing horizontal strabismus surgery for esotropia. The study included all patients from 2007 to 2016 operated on by a single surgeon at Columbia University Medical Center. Surgical success was defined as the ability to fuse at both near and distance either without prismatic correction or with less than 10 prism diopters (PD) of correction. Measurements of ocular alignment were also made in eccentric fields of gaze. This study was Health Insurance Portability and Accountability Act compliant with protection of individually identifiable information. RESULTS: Thirty-eight patients with TED and restrictive horizontal strabismus underwent unilateral or bilateral medial rectus recession to relieve diplopia. All patients underwent Tenon's recession with dissection of Tenon's from the overlying conjunctiva permitting it to retract into the orbit. Overall the success rate was 87% with a reoperation rate of 7.9%. The improvement in horizontal deviation in both primary and eccentric gaze was statistically significant (p < 0.001). The change in vertical deviation in the 5 cardinal positions of gaze was not statistically significant. The postoperative change in vertical deviation was not proportional to the preoperative horizontal deviation or the amount of horizontal recession. CONCLUSIONS: Due to the preoperative incomitance of ocular deviations in TED patients, persistent postoperative eccentric misalignment is expected. The addition of Tenon's recession to TED-horizontal strabismus surgery led to statistically significant improvement in ocular alignment in both primary and eccentric gaze. This is the first study of TED-strabismus surgery to analyze the postoperative results in positions outside of primary and reading gaze. The authors postulate that the release of scar tissue by the addition of Tenon's recession contributes to these improvements.

Consideration for eliminating conjunctival closure in the enucleation procedure.

To compare post-operative results and complications in patients who undergo enucleation with or without suture closure of the conjunctiva. This was a retrospective chart review study. Review of 50 cases of enucleation surgery at the University of Arkansas for Medical Sciences and Arkansas Children's Hospital between July 2011 and December 2014. Criteria for inclusion in the study were all cases of enucleation that had extraocular muscles attached to a spherical orbital implant with or without conjunctival closure, and at least 2 months of postoperative follow up. Post-operative complications were evaluated. A total of 36 cases fulfilled the criteria for inclusion in the study; 12 cases with direct sutured layered direct closure of Tenon's and then conjunctiva and 24 cases with Tenon's capsule sutured closure but without direct conjunctival sutured closure. No implant complications were identified in either group (p = 1.0). Mean follow-up for all groups was 16.71 months (range 2 to 43 mo., SD 11.94). Mean follow up for the non-closure group was 14.42 months (range 2.25 to 36 mo., SD 10.35). Two cases in the conjunctival closure group developed a conjunctival cyst, affecting prosthesis fit, approximately 3 months postoperatively: no such cysts were identified in the non-conjunctival closure group. Fisher exact test for cyst formation between the two groups was not statistically significant (p = 0.1048). Direct conjunctival closure following enucleation surgery does not appear to increase the risk of extrusion, exposure, or infection. Foregoing direct closure decreases surgical time and reduces cost. It is unclear if this decreases conjunctival cyst formation.

Removal of Tenon fortified by conjunctival-limbal autograft in treatment of pterygium.

PURPOSE: To describe a simple and effective technique for the prevention of pterygium recurrence. METHODS: This is a retrospective consecutive single-center case series with recurrence rate as the main outcome measure. Dissection of the conjunctiva, the Tenon's layer, and the sclera was continued up to the insertion of medial rectus. The exposed Tenon's layer was excised for 2 to 3 mm. The entire free edges of the conjunctiva was tacked firmly to the sclera. The conjunctival-limbal graft was sutured firmly to the sclera, recipient limbus, and to the conjunctiva incorporating the reciprocal edges. RESULTS: We report findings in a total of 36 patients, with 20 (%55.5) males and 16 (%44.4) females. Median age of the patients was 44.5 years (range 16-80). The mean follow-up period was 23.1 ± 6.5 months. The mean size of pterygium in mm length was 3.8 ± 0.7. Recurrence did not occur in any patient. Diplopia was not reported by any patients. CONCLUSIONS: Conjunctival-limbal autograft combining with selective exicison of Tenon's layer but without damage to any essential tissue such as the semilunar fold or Tenon's capsule pulley is a relatively simple and effective procedure.

Conjunctiva and Tenon's Capsule Handling in the Port Delivery System with Ranibizumab Implant Insertion Procedure: Surgical Pearls.

OBJECTIVES: To describe conjunctiva and Tenon's capsule handling during the Port Delivery System with ranibizumab (PDS) implant insertion procedure including up-front assessments, planning, and instrumentation, with emphasis placed on the peritomy, scleral dissection, and closure steps. METHODS: Surgical pearls based on experience accumulated in the PDS clinical trial program in patients with retinal diseases. RESULTS: Preoperative preparation, specific instruments, and meticulous techniques are key to optimizing surgical outcomes. Before surgery, assessment of factors that affect conjunctival integrity and an in-office conjunctiva examination are conducted. Gentle, purposeful conjunctiva and Tenon's capsule handling with nontoothed forceps and suturing with a BV needle are recommended to prevent tissue damage. The peritomy is 6 mm by 6 mm, centered around the planned implant location in the superotemporal quadrant. A complete sub-Tenon's capsule dissection is achieved using a wide, robust lateral and posterior dissection technique to free tissue from the sclera and minimize tension. The globe is stabilized during scleral cutdown by grasping the sclera with fine-toothed forceps away from the incision edge to prevent tissue delamination. When closing the peritomy, both the conjunctiva and Tenon's capsule are completely captured and sutured with scleral anchoring at the apex of the peritomy to help prevent conjunctival retraction and erosion. Mitigation and detection of adverse events is critical to successful surgical outcomes. CONCLUSIONS: The PDS implant insertion procedure is straightforward, but it requires planned preoperative preparation, specific instruments, and meticulous techniques. The surgical pearls described here offer insights for optimizing outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:266-273.].

Enduragen patch grafts for exposed orbital implants.

PURPOSE: To present a new technique using the recently introduced Enduragen(®) material (Tissue Science Laboratories) as a patch graft for exposed ocular implants. METHODS: A retrospective, interventional, non-comparative case series of 3 patients who had Enduragen patch grafts for the closure of Tenon's capsule and conjunctiva over exposed ocular implants. Medical records were reviewed and the following parameters were collected: age, gender, indication for surgery, type of surgery, laterality, type of orbital implant, complications after repair and length of follow-up. RESULTS: Three patients were identified, 2 males and 1 female. One patient had a secondary quad-motility implant with supertemporal exposure. The second patient had a secondary implant with a fistula at the lateral aspect of the socket. The third patient had a centrally exposed primary hydroxyapatite implant. All patients received Enduragen patch grafts to cover the implant. Follow up ranged from 40 to 43 months (mean, 41.3 months; SD, ± 1.5). None of the 3 patients had any signs of implant re-exposure at the time of the last post-operative visit. There were no intra-operative or early complications observed. CONCLUSIONS: This consecutive case series suggests that Enduragen could be used as a safe and effective patch graft for exposed ocular implants. However, a larger prospective study with longer follow-up would be useful in further defining the indications and limitations of the Enduragen patch graft for the treatment of exposed orbital implants.

[Method of implant insertion in anophthalmic socket].

The method of extraocular muscles fixation is presented, it consist in direct fixation to alloplant according to their physiological attachment to ensure stump movement after enucleation. A total of 54 patients aged 26-82 years were treated. Primary enucleation was performed in 46 patients and 8 patients were previously treated with brachytherapy. Surgery was performed under general anesthesia using microsurgical technique. After alloplant was fixed to the anterior surface of tenon's capsule a running suture was put horizontally and conjunctival suture had vertical orientation. A pressure dressing was applied for 2-3 days. Generally there were no technical difficulties, but in patients after brachytherapy separation of muscles and tenon's capsule was complicated because of scarring in the site of previous radiation.

Outcomes of Ipsilateral Simple Limbal Epithelial Transplantation, Tenonectomy, Mitomycin and Amniotic Membrane Transplantation for Treatment of Recurrent Pterygium.

PURPOSE: To report on the outcomes of recurrent pterygium treated by ipsilateral simple limbal epithelial transplantation (SLET), mitomycin, tenonectomy, and amniotic membrane transplantation. METHODS: A retrospective, interventional study was conducted including all patients with recurrent pterygium who underwent SLET surgery under a single surgeon using ipsilateral donor tissue with a minimum 6-month follow-up at Toronto Western Hospital, Canada. Outcome measures included the following: recurrence rates, best spectacle-corrected visual acuity, and postoperative complications. RESULTS: Ten eyes of 10 patients, aged 60.7 ± 18.5 years (range 23-79) with a mean follow-up time of 15.2 ± 10.0 months of which 50% (n = 5) were men, were included. Eight eyes (80%) had a history of 2 or less pterygium operations. Two patients had 3 and 5 previous pterygium operations, respectively. Concurrent limbal stem cell disease was noted in 6 eyes (60%). Average number of pterygium recurrences per eye was 1.9 ± 1.3 (range 1-5). Mean pre-op best-corrected visual acuity was 0.5 LogMAR (Snellen equivalent 20/60, range 20/20 to counting fingers). Best-corrected visual acuity remained the same or improved in 6 eyes (60%). Recurrence was noted in 1 eye (10%) with a history of 5 previous pterygium excisions and remained stable at the last follow-up. No patients required a second operation. CONCLUSIONS: Ipsilateral SLET with mitomycin, tenonectomy, and amniotic membrane transplantation is a novel technique to address recurrent pterygium. Concurrent limbal stem cell diseases are often present. Initial results demonstrate low recurrence. Visual improvement is modest. Stabilization of the ocular surface to improve vision is possible.

Closure of mid-posterior Tenon's capsule in enucleation.

PURPOSE: To evaluate the potential advantages of closing mid-posterior Tenon's capsule during enucleation surgery by comparing its thickness and relative tissue strength with anterior Tenon's capsule. To evaluate surgical outcomes of enucleation using mid-posterior Tenon's capsule closure. METHODS: This is an experimental laboratory study and retrospective surgical case series. Histologic examination of Tenon's capsule was performed on permanently fixated human orbital specimens. Suture pull-out testing as a measure of tissue strength was performed on anterior and mid-posterior Tenon's capsule in nonfixated human cadaver orbits. A retrospective review of enucleations with primary orbital implant placement performed by the authors between 1998 and 2008 was conducted to determine the surgical outcomes of enucleation using closure of mid-posterior Tenon's capsule. RESULTS: Histologic analysis showed the average thickness of mid-posterior Tenon's capsule to be 121% greater than that of the anterior portion (518 vs. 234 µ, p < 0.001). Suture pull-out strength was 84% higher in mid-posterior versus anterior Tenon's capsule (741 vs. 1298 g, p = 0.016). Of the 103 enucleations performed by the authors (54 with unwrapped silicone implants and 49 with unwrapped porous polyethylene), there were 2 cases (1.9%) of implant extrusion and 1 case (1%) of implant exposure. CONCLUSION: From a structural and biomechanical standpoint, mid-posterior Tenon's capsule is significantly thicker and stronger than anterior Tenon's capsule, theoretically providing a superior barrier to orbital implant exposure and extrusion after enucleation.

Tenonplasty Combined With Amniotic Membrane Transplantation for Patients With Severe Ocular Burns Induced Anterior Segment Necrosis.

This article describes a novel surgical technique for successful repair of intractable corneoscleral necrosis caused by severe ocular burns. In this prospective case series, 19 eyes of 15 consecutive patients with sectional scleral necrosis and persistent corneal epithelial defects were treated with tenonplasty and amniotic membrane transplantation. The main outcome measure was the stability of the ocular surface after reepithelialization and repair of defects. All patients underwent successful combined surgery involving tenonplasty and amniotic membrane transplantation, in which the conjunctival and corneal surfaces were reconstructed. The interval from injury to surgery was 37.4 ± 24.5 days (3-91 days), and the ocular surfaces became stabilized in 82.2 ± 35.4 days (26-156 days, median 87 days). At the final visit, all cases presented with corneal opacity and neovascularization to various degrees. The best-corrected visual acuity decreased from 2.83 ± 1.02 LogMAR preoperatively to 2.87 ± 1.31 LogMAR postoperatively. The results imply that tenonplasty combined with amniotic membrane transplantation could provide vascular supply to the ischemic sclera, repair defects in the conjunctiva, and promote corneal reepithelialization, thus facilitating ocular surface stabilization after burns.

A Tenon's capsule/bulbar conjunctiva interface biomimetic to model fibrosis and local drug delivery.

Glaucoma filtration surgery is one of the most effective methods for lowering intraocular pressure in glaucoma. The surgery efficiently reduces intra-ocular pressure but the most common cause of failure is scarring at the incision site. This occurs in the conjunctiva/Tenon's capsule layer overlying the scleral coat of the eye. Currently used antimetabolite treatments to prevent post-surgical scarring are non-selective and are associated with potentially blinding side effects. Developing new treatments to target scarring requires both a better understanding of wound healing and scarring in the conjunctiva, and new means of delivering anti-scarring drugs locally and sustainably. By combining plastic compression of collagen gels with a soft collagen-based layer, we have developed a physiologically relevant model of the sub-epithelial bulbar conjunctiva/Tenon's capsule interface, which allows a more holistic approach to the understanding of subconjunctival tissue behaviour and local drug delivery. The biomimetic tissue hosts both primary human conjunctival fibroblasts and an immune component in the form of macrophages, morphologically and structurally mimicking the mechanical proprieties and contraction kinetics of ex vivo porcine conjunctiva. We show that our model is suitable for the screening of drugs targeting scarring and/or inflammation, and amenable to the study of local drug delivery devices that can be inserted in between the two layers of the biomimetic. We propose that this multicellular-bilayer engineered tissue will be useful to study complex biological aspects of scarring and fibrosis, including the role of inflammation, with potentially significant implications for the management of scarring following glaucoma filtration surgery and other anterior ocular segment scarring conditions. Crucially, it uniquely allows the evaluation of new means of local drug delivery within a physiologically relevant tissue mimetic, mimicking intraoperative drug delivery in vivo.

Tenon's capsule pseudo-tendon repair of a lost medial rectus muscle.

BACKGROUND AND PURPOSE: The loss of an extraocular muscle is an infrequent but serious complication of strabismus surgery. The purpose is to show that a tailored tongue of Tenon's capsule, 7.0 mm to 9.0 mm wide and 12.0 mm to 14.0 mm long, fashioned in the direction of a lost medial rectus muscle and attached at the site of its original insertion can restore full ocular movement in the direction of action of the muscle. CASE REPORT: Thisis a report of a patient who underwent re-shaping and attachment of Tenon's capsule to the original insertion of the medial rectus muscle that ruptured during attempted medial rectus recession for longstanding esotropia with medial rectus restriction. The procedure was done immediately following the loss and failure to retrieve the lost muscle. RESULTS: Residual large angle esotropia and good adduction were obtained postoperatively despite a severed and consecutively lost medial rectus muscle. CONCLUSION: A tongue of Tenon's capsule, attached at the original site of a lost extraocular rectus muscle in a young adult, works as a pseudo-tendon successfully restoring function in the direction of action of that muscle.

Scleral Ischemia in Acute Ocular Chemical Injury: Long-Term Impact on Rehabilitation With Limbal Stem Cell Therapy.

PURPOSE: This study describes the impact of scleral ischemia on globe survival in cases of acute chemical injury and the outcome of limbal stem cell transplant in these eyes. METHODS: This is a single-center, retrospective case study that reviews outcomes in all patients with acute chemical injury of grades IV and above who presented within 6 weeks from injury. The period of the study is between May 2012 and May 2017. Eyes presenting without scleral ischemia underwent amniotic membrane transplantation (group A), whereas eyes presenting with scleral ischemia underwent tenonplasty with amniotic membrane transplantation (group B). Simple limbal epithelial transplantation (SLET) was performed at 6 months in all consenting patients from both these groups. The primary outcome was defined as globe preservation at 3 months, whereas the secondary outcome was defined as SLET success at 1 year. RESULTS: Twenty-three eyes of the 23 patients were included in our study. Of the 13 eyes in group B, 2 eyes developed phthisis and 2 eyes developed hypotony. None of the 10 eyes in group A developed hypotony or phthisis. The eyes that developed into hypotony and phthisis had presented with more extensive scleral ischemia (>180 degrees). In group B, 5 of 7 patients failed SLET. This was high compared with group A in which 2 of 8 patients failed SLET. CONCLUSIONS: The presence and extent of scleral ischemia are important prognostic factors when assessing recovery in eyes with acute chemical injury. The authors recommend that it be added as a poor prognostic indicator in the existing classifications of acute chemical injury.

Tube Shunt Revision With Excision of Fibrotic Capsule Using Mitomycin C With and Without Ologen-a Collagen Matrix Implant: A 3-Year Follow-up Study.

PRECIS: Tube revision with capsule excision in failed glaucoma drainage devices (GDDs) has good medium-term success effectively reducing the intraocular pressure (IOP) and medication burden. Implantation of Ologen may limit the complications, particularly erosion. PURPOSE: To evaluate the 36-month outcomes of tube shunt revision with capsule excision using Mitomycin C (MMC) versus MMC with Ologen-a collagen matrix implant. MATERIALS AND METHODS: Twenty-three eyes with failed GDD underwent tube revision with fibrotic capsule excision. 12 of them received a MMC application whereas the other 11 also received an Ologen implant. Qualified success, changes in IOP, medication burden, and complication rates were evaluated and compared. RESULTS: Three years post-revision, qualified success for the whole cohort was 58% with no significant difference between the MMC group (52%) and MMC+Ologen group (67%; P=0.606). Mean survival time for each group was 27.4 and 29.8 months, respectively. With no intergroup differences through 3 years, capsule excision leads to a significant decrease in IOP from 28.6±6.5 to 15.1±4.3 mm Hg (47% reduction) and in antiglaucoma medications, from 3.6±1.2 to 2.5±1.3 mm Hg (30% reduction; P<0.001). Complication rates were significantly lower in the MMC+Ologen group (27%) compared with the MMC group (75%; P=0.022). Plate erosion happened in 25% of the eyes in the MMC group which required excision of the tube and plate, but no such complication was observed in the MMC+Ologen group. CONCLUSIONS: Revision of a failed tube shunt by excision of the encapsulated bleb offers good medium-term outcomes by reducing the IOP and glaucoma medications. Although the addition of Ologen did not affect the medium-term success, IOP, or medication burden, its implantation yielded significantly lower complication rates.

Safety and efficacy of tacrolimus-coated silicone plates as an alternative to mitomycin C in a rabbit model of conjunctival fibrosis.

PURPOSE: To find safer and more effective drugs than mitomycin C to prevent conjunctival fibrosis in a rabbit model. METHODS: Twenty-four rabbits were involved and randomly divided into four groups. Limbus-based peritomy was performed at the superior cornea, and normal saline (NS group), mitomycin C (MMC group), SR (SR group), or TC (TC group)-coated silicone plate was inserted at the sub-Tenon's space in each group. Conjunctival congestion was evaluated at 1 and 4 weeks postoperatively. At 4 weeks, the numbers of inflammatory cells, fibroblasts, myofibroblasts, blood vessels, and goblet cells were counted in the conjunctiva and Tenon's capsule around the silicone plate. RESULTS: At 4 weeks, conjunctival congestion was significantly less than that observed at 1 week in the SR and TC groups (p < 0.05), whereas the number of myofibroblasts was significantly lower in the MMC and TC groups (p < 0.05). The conjunctiva was significantly less congested in the TC group versus the other groups at 1 week and 4 weeks (p < 0.05). The TC group had the lowest number of inflammatory cells and MMC group had the lowest number of goblet cells among all groups (p < 0.05). CONCLUSIONS: The TC-coated silicone plate was more effective in inhibiting inflammation and fibrosis versus the MMC-coated silicone plate and was associated with fewer adverse effects in the rabbit model.

One-Year Outcome Predictors of Strabismus Surgery from Anterior Segment Optical Coherence Tomography with Multiple B-Scan Averaging.

Strabismologists are eager to identify preoperative or intraoperative strabismus surgery outcome predictors because of the variable effects in each patient. Conjunctival closure position recession after rectus muscle recession is effective for correcting large angle strabismus. The elasticity of the conjunctiva and Tenon's capsule is important for strabismus surgery management. In this longitudinal study, we evaluated the prognosis of conjunctiva and Tenon's capsule thickness (CTT) near the limbus 1 year after strabismus surgery with a limbal conjunctival incision using swept-source anterior segment optical coherence tomography with multiple B-scan averaging. Also, we identified preoperative and/or intraoperative parameters associated with corrective effects 1 year after surgery in 15 consecutive treatment-naïve patients with exotropia or esotropia who underwent recession and resection. The 1-year CTT was greater than the preoperative CTT on the resection side (269 ± 111 vs 183 ± 53 µm, P < 0.001) but was smaller on the recession side (137 ± 54 vs 183 ± 71 µm, P = 0.02). The corrective effect of surgery (1.6 ± 0.3°/mm) was most strongly correlated with preoperative CTT on the recession side (P = 0.005, ß = -0.73). Hence, CTT on the recession side may provide adjunctive information for strabismus treatment.

A Conjunctival Retractor during Strabismus Surgery.

The use of a conjunctival retractor that expands a small incision in the conjunctiva/Tenon's capsule facilitated the performance of strabismus surgery through a fornix incision. A wide field of exposure revealed the entire area of the muscle insertion. While there is a risk of conjunctival tearing in elderly patients, the use of the retractor is valuable.

Hyaluronidase injection for improved tissue dissection in Baerveldt tube surgery.

PURPOSE: To describe a novel technique for tissue dissection during Baerveldt tube surgery. METHODS: We present a technique for posterior dissection of conjunctiva and Tenon tissue for the placement of a glaucoma drainage device. Hyaluronidase is used in the early stages of surgery in order to minimize tissue trauma and facilitate easy dissection even through existing adhesions and conjunctival scarring. RESULTS: The technique facilitates convenient dissection through tissues. We did not experience any intraoperative or postoperative complications. CONCLUSIONS: The described technique has substantial advantages for Baerveldt tube surgery, specifically in cases of previous ocular surgery and subsequent conjunctival scarring. It is safe and easy to perform, and should be considered in cases of glaucoma drainage device implantation surgeries.