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GAVIN W. RODDY: Today we're going to be taking care of a 62-year-old male who has advanced glaucoma. We've offered him a tube, a Baerveldt 350 glaucoma drainage device, in order to lower his intraocular pressure. So we're going to be placing a Baerveldt tube.

In order to place the tube, we're going to obtain exposure by opening 4 millimeters back from the limbus. And because we place the wings of the Baerveldt tube under the muscles, we're going to isolate the superior and lateral rectus. And then we isolate the muscle using a 4-0 silk suture.

Now we turn our attention to the lateral rectus, and using a 4-0 silk, we tie off the muscle. So even though this is a nonvalved tube, I still flush the tube just to confirm that the tube is functioning properly. Take the 6-0 Vicryl to tie off the tube. And then by flushing the tube with BSS, we ensure that the tube is, in fact, tied off.

So now we're ready to place the plate, and we tuck the wings under the muscles that have already been isolated on a 4-0 silk suture. So then we rotate the eye inferonasally to expose the superotemporal quadrant where we're going to be securing the plate to the globe. So the plate's going to be secured 10 millimeters back from the limbus. So we make our marks, pass a suture to secure the plate to the globe.

So with the plate secure to the globe, we're ready to assess the position of the tube as it enters the eye. We put a bevel, an anterior bevel, on the tube. And the tube will be placed under Healon to allow posterior placement of the tube just over the iris plane.

So in addition to a patch graft, I do a scleral tunnel to protect the tube from erosion. So we make a scleral tunnel before diving posterior so we have nice posterior placement of the tube, and we enter the AC far away from the cornea. So with Healon out of the eye, we can confirm proper placement of the tube just over the iris and parallel with the iris. So we're going to secure the tube to the sclera using a 9-0 Vicryl suture.

So because this tube is tied off with a Vicryl suture, we actually need to provide a little pressure reduction in the early postoperative period. So we're going to perform a fenestration that will provide some flow until that Vicryl suture naturally breaks at about six weeks postop. And to reduce the risk of tube exposure through the conjunctiva over time, we use a cornea patch graft to cover the length of the tube.

So with the tube in position in the AC iris plane, and the tube covered by the cornea patch graft, and the fenestration suture in place, we're now ready to close. OK, so the conjunctiva is closed. And the tube is in great position in the superotemporal quadrant just over the iris.

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