Salvage of a severed Paul Glaucoma Implant tube via anastomosis with an Ahmed Glaucoma Valve in a child with Sturge–Weber syndrome and complicated glaucoma: a case report

Introduction: Refractory glaucoma in Sturge–Weber syndrome (SWS) is challenging to manage, with a high risk of intraoperative complications. The Paul Glaucoma Implant (PGI) is a novel device with smaller inner and outer tube diameters than the Ahmed Glaucoma Valve (AGV). Importance: To describe a creative intraoperative salvage technique for a transected PGI, using a hybrid tube anastomosis with a segment of AGV tube, in a pediatric patient with SWS. Case presentation: A 5-year-old girl with SWS and uncontrolled glaucoma underwent revision surgery 5 months after PGI implantation. Intraoperatively, the PGI tube was inadvertently transected. Rather than replacing the entire implant, which could lead to unwanted intraoperative and postoperative hypotony as well as promote additional fibrosis of the bleb, a segment of AGV tube (~6 mm) was anastomosed to the remaining PGI tube, creating a hybrid conduit. Postoperatively, the patient remained stable without complications over a 6-month follow-up. Clinical discussion: The AGV tube can be expanded to receive the smaller PGI tube, making a watertight anastomosis. Compared to the commercial tube extender, this method is less bulky and therefore has a lower risk of exposure and erosion. This method may help reduce surgery time, especially in high-risk patients like those with SWS, where implanting another PGI in a different quadrant or explanting the device for another surgery could cause complications related to the syndrome. Conclusion: This hybrid tube approach, combining PGI and AGV components, may represent a feasible method for salvaging damaged glaucoma drainage devices in critical intraoperative settings. However, longer-term observation is needed to better evaluate this technique.