A Cost-Cutting Option

A technique to eliminate the scleral patch graft from a tube shunt procedure.

By Michael Patterson, DO

In this video, Dr. Patterson introduces his technique of fixing a tube in place without the use of a patch graft or a scleral flap. This is an ingenious idea, as it avoids many of the complications that can be associated with a patch graft and holds the tube firmly in place using the patient’s own tissues.

-Section Editor Soosan Jacob, MS, FRCS, DNB

The ever-changing landscaping of coding and reimbursement has made it imperative to find ways to perform surgery in a more cost-efficient manner. Obviously, patients’ safety is paramount and should always be the first consideration, but what if we ophthalmologists could perform a procedure more cost-effectively without decreasing safety? Microinvasive glaucoma surgery (MIGS) is the hottest topic in glaucoma, and most of the procedures are very safe. Not all patients are suitable candidates for MIGS, however; some need more aggressive IOP lowering.


For some of those patients, the Ahmed Glaucoma Valve (New World Medical) provides the level of IOP lowering needed to prevent continual optic nerve damage and vision loss. Using an Ahmed Glaucoma Valve is a far more invasive surgery than the newer MIGS procedures. The risks are greater, but the reduction in IOP is typically considerably more dramatic.

Watch it Now

Although this approach cannot be used in all patients, it is a cost-efficient option for the ASC setting.

We can no longer be reimbursed for tissue or graft placement to help cover the tube of the Ahmed Glaucoma Valve in an ambulatory surgery center (ASC), although hospitals can bill insurers for the same procedure. As a result, the overall reimbursement for the procedure in an ASC is dropping. For this reason, I developed a technique for use in my ASC that omits the patch graft (see Watch It Now).


My technique is based on two main concepts.

Less Is More

Adding a step to a procedure increases the risk that something will go wrong. My technique eliminates the time needed for cutting and placing a patch graft and decreases intraoperative manipulation of the globe. I do not need an antibiotic to soak the graft. Nor must I worry about a secondary infection down the road from the graft tissue. The technique represents an off-label use of the Ahmed Glaucoma Valve. The manufacturer recommends the use of donor sclera, pericardium, or a corneal allograft.

A Penny Saved Is a Penny Earned

Saving $200 to $300 per surgery might not mean much to all of us, but performing 200 of these cases per year will save an ASC a considerable amount of money.


My technique allows me to avoid the unnecessary grafting of donor tissue and instead use only the host tissue for the procedure. This method is cost-effective without sacrificing patients’ care.

Section Editor Soosan Jacob, MS, FRCS, DNB
• senior consultant ophthalmologist at Dr. Agarwal’s Eye Hospital, Chennai, India

Section Editor Jonathan S. Myers, MD
• associate attending surgeon on the Glaucoma Service and director of the Glaucoma Fellowship at Wills Eye Hospital, Philadelphia

Michael Patterson, DO
• Eye Centers of Tennessee in Crossville, Cookeville, Jamestown, and McMinnville, Tennessee
• captain, United States Army Reserves
• (931) 260-8069; michaelp@ecotn.com; Twitter @MP_EyeCentersTN
• financial disclosure: consultant to New World Medical and Glaukos


Contact Info

Bryn Mawr Communications LLC
1008 Upper Gulph Road, Suite 200
Wayne, PA 19087

Phone: 484-581-1800
Fax: 484-581-1818

About Glaucoma Today

Glaucoma Today is mailed bimonthly (six times a year) to 11,519 glaucoma specialists, general ophthalmologists, and clinical optometrists who treat patients with glaucoma. Glaucoma Today delivers important information on recent research, surgical techniques, clinical strategies, and technology.