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Patient PortalAqueous Shunt Surgery
Apressure-reducing option foror severe, complex, or refractory glaucoma where all other approaches have been exhausted, scarring prevents standard surgeries or bleeding issues in the eye would lead otherwise to failure
What is an Aqueous Shunt?
An Aqueous Shunt (also called a glaucoma implant or “valve”) is a tiny silicone tube that surgically redirects fluid from inside your eye to a small reservoir that is created in the eye's tissue surface. Instead of trying to restore your eye's natural drainage or creating a simple external pathway, a tube shunt is a more complex bypass system designed to manage very high pressures and refractory disease. Molteno Shunts are most commonly used at EPSAZ because of their proven durability and sustained pressure control but the surgeons at EPSA have had over 50 years of combined experience with every shunt device and have been involved with several studies comparing them. We have also been selected to participate in an FDA trial for a new device that may offer better results
The surgeon places one end of the tube inside your eye (in the anterior chamber) and the other end consists of the plate or reservoir which is placed the eye muscles under the eye's surface tissue under the superior eyelid. Fluid flows through the tube into the reservoir capsule that forms, where it is absorbed. This achieves the most dramatic pressure reduction of any glaucoma procedure — an average of 10.1 mmHg, or 29% reduction at 12 months in our database.
When is Aqueous Shunt appropriate? This device is is chosen for the most severe and refractory glaucomas: patients who have failed multiple surgeries (SLT, ABiC, XEN, trabeculectomy), patients with very advanced optic nerve damage s, patients with complex anatomy that makes other surgeries inadvisable, or patients with glaucoma secondary to trauma, inflammation, bleeding or other systemic disease.
What to Expect — Before, During, and After
Before your procedure: You will be given IV sedation after which you will receive local anesthesia . Your eye will be prepped and draped for surgery. The surgical team will position you, and you will be asleep throughout.
During the procedure: The surgeon creates a small incision in the conjunctiva (the clear membrane over the white of your eye). The tube is inserted into the anterior chamber of your eye, and the external plate is positioned under the external tissues and eyelid. Small sutures anchor the tube and plate. The surgery is complex and precise. Total time is 45–60 minutes.
After the procedure: Your eye will be considerably more sensitive than after earlier procedures. Expect significant soreness, swelling, and blurred vision. You will use antibiotics and anti-inflammatory drops for 4–8 weeks. A hypertensive phase (temporarily elevated pressure) occurs in all shunt patients and requires close monitoring. Tube shunt recovery is longer and requires meticulous surgical management.
Recovery timeline:
- Day 1: Significant discomfort and swelling. Vision very blurry. Continue antibiotics and anti-inflammatory drops. Limit activities for 1–2 weeks.
- Week 1: First postop visit. Monitor tube position, plate location, and pressure. Hypertensive phase may develop; medication adjustments are common.
- Weeks 2, 4, 6, 8: Regular follow-up visits at these intervals. Continue close monitoring for hypertensive phase, hypotony, and tube function. Medications adjusted as needed.
- Week 12: Final postop assessment. Plate encapsulation (normal process) is expected. Pressure response and tube function confirmed. Continue drops 4–8 weeks. Return to routine glaucoma schedule.
Tube shunt has significant risk potential. This is a complex glaucoma surgery. Possible complications include: tube malposition, hypotony (pressure too low, damaging vision), hypertony (pressure remaining too high), tube-corneal touch, hyphema (bleeding), infection, double vision and plate erosion with the latter two being quite rare. Most complications are manageable with experienced surgical care, but awareness is essential. Only do this surgery if recommended by an experienced glaucoma specialist.
Your Follow-up Schedule
Tube shunt requires intensive follow-up similar to trabeculectomy, but with even greater attention to pressure dynamics. The tube can create pressure that is too low (hypotony) or too high (hypertony), and these must be managed carefully.
What we monitor: Tube position and function, external plate appearance, aqueous humor flow, pressure dynamics (hypotony risk is highest early), inflammation, and any signs of malfunction. Some tubes have valves that activate at certain pressures — these require careful assessment of how the valve is functioning.
Long-term management: Like trabeculectomy, tube shunt requires lifelong monitoring. The tube is permanent and designed to last a lifetime, but it can fail or require revision after many years. Commitment to follow-up appointments is essential to catch problems early.
Our Outcomes — What EPSAZ Patients Experience
Here is what we see in our database of 986 patients who had tube shunt, followed for 12 months:
What these numbers mean: Tube shunt achieves the highest absolute pressure reduction of any procedure — 29% at 12 months. The 10.1 mmHg average drop is exceptional and appropriate for very severe, refractory glaucomas. The safety rating of 1/5 reflects the complexity and the need for intensive postoperative management. This is not a "light" surgery — it is the most aggressive option reserved for the most difficult cases. This is the go to procedure in pediatric glaucoma even in infants when other procedures have failed. We still see adults who had this procedure by Dr. Reiss when they were babies many years ago. So it is usually well tolerated.
Who does well with tube shunt? Patients with advanced, refractory glaucoma who understand the need for complex surgical intervention. Patients who have failed other surgeries and need aggressive pressure control. Patients committed to frequent follow-up visits and lifelong monitoring. Patients whose vision is at serious risk without maximum pressure control.
Why is it the last resort? Tube shunt is not performed lightly. It is typically reserved for patients in whom all other procedures (SLT, ABiC, iStent, GATT/KDB, AlloFlo, XEN, trabeculectomy) have been exhausted. The procedure is complex, recovery may be longer, and complications are more likely than with gentler Minimally Invasive Options (MIGS) options. But for sever refractory glaucoma, it offers the best chance of achieving significant pressure reductions in high pressure cases where lower pressure targets are necessary to preserve vision.