Surgical management of raised intra-ocular tension in the hostile ocular surface - recurrent tube erosion in a patient with systemic sclerosis: a case report

BACKGROUND: The surgical management of patients with uncontrolled glaucoma and scleroderma is challenging, as the hostile ocular surface poses a challenge to surgery. A serious complication is tube erosion, with the risk of subsequent endophthalmitis. Here, we present a novel technique of harvesting autologous tissue to successfully manage recurrent tube extrusion. CASE PRESENTATION: MG is a 60-year-old Arabic lady diagnosed with scleroderma, that was previously managed with systemic corticosteroids. She has chronic open angle glaucoma, with a failed left eye trabeculectomy, which was then managed by a Baerveldt tube (BVT) insertion. Eight months after this primary surgery, she developed an anterior uveitis. This was further complicated by conjunctival erosion, tube exposure, leak around the sclerostomy site and hypotony. The erosion was likely secondary to her tight eyelids as a result of her scleroderma. She was taken back to theatre for tube revision, with single layer amniotic membrane transplant (AMT) over the exposed area, but the tube was eroding again after 2 months. She eventually underwent tube extraction, pars plana tube plate stabilisation, pars plana vitrectomy (PPV), pars plana tube insertion, phacoemulsification and intra-ocular lens insertion, jointly with the vitreo-retinal surgeons and with high dose prednisolone cover both pre- and post-operatively. We harvested the capsule which had grown over the end plate of the original tube. We sutured this over the new tube, specifically over a single layer of tutoplast prior to conjunctival closure. Almost a year on, the pars plana tube remains in place with no complications. CONCLUSIONS: This case highlights the role of a pars plana tube in cases of cicatricial disease, with the use autologous tissue instead of grafts wherever possible. In patients with systemic disease such as scleroderma, pre-operative immunosuppression helps to reduce the of erosion in difficult cases.