Treatments · Glaucoma · Tube Shunt Surgery · Updated May 2026
Private PAUL glaucoma tube implant surgery, London 2026
The PAUL Glaucoma Implant (PGI, Advanced Ophthalmic Innovation) is a small-lumen silicone tube shunt that a consultant glaucoma surgeon inserts to drain aqueous humour from the anterior chamber to a posterior scleral plate. By bypassing the trabecular meshwork it lowers intraocular pressure in refractory, neovascular, uveitic and post-failed-trabeculectomy glaucoma where drops, SLT and minimally invasive surgery have not delivered enough pressure control.
Our London consultant glaucoma team offers same-week PAUL assessment, transparent UK 2026 self-pay pricing, full preoperative imaging, theatre with surgeon and dedicated glaucoma nurse, and structured one-year follow-up. This page sets out costs, candidacy, evidence, recovery and how PAUL compares with Baerveldt, Ahmed, Preserflo MicroShunt, Xen gel stent and trabeculectomy.
Fast answer: private PAUL glaucoma tube implant in the UK in 2026
Typical cost per eye
GBP 5,500-9,000 self-pay all-inclusive. Bilateral surgery is staged at separate sittings.
What it does
Implants a silicone tube and posterior plate to drain aqueous, lowering intraocular pressure into the low teens.
Procedure time
Approximately 60-90 minutes in theatre under local with sedation or general anaesthesia.
Reversibility
The implant is intended to be permanent but can be revised, ligated or explanted if complications occur.
What is the PAUL Glaucoma Implant?
The PAUL Glaucoma Implant (PGI), developed by Professor Paul Chew and manufactured by Advanced Ophthalmic Innovation, is a non-valved, small-lumen silicone tube shunt. Its 0.127 mm internal lumen is markedly smaller than legacy Baerveldt and Molteno tubes, which limits early postoperative aqueous flow and reduces the rate of hypotony while still providing durable long-term pressure control. The flexible silicone end-plate (342 mm sq) is fixated 8-10 mm posterior to the limbus in a quadrant chosen to avoid prior surgical scarring.
In theatre the consultant glaucoma surgeon opens a conjunctival peritomy, sutures the plate to the sclera, tunnels the tube into the anterior chamber (or pars plana when combined with vitrectomy), occludes the lumen with an absorbable Vicryl ligature to allow the fibrous bleb to mature over 4-6 weeks, and patches the limbal entry site with a partial-thickness corneal or scleral graft. The result is a low, stable intraocular pressure that protects the optic nerve from further glaucomatous damage.
PAUL is now widely used across UK glaucoma units for refractory glaucoma after failed trabeculectomy, for neovascular, uveitic and ICE-syndrome glaucoma, and for paediatric and aphakic glaucoma where a smaller, lower-profile plate is preferable.
UK 2026 private PAUL glaucoma implant cost per eye
Our published self-pay package is fully inclusive of consultant fee, anaesthetist fee, theatre, the PAUL implant device, intra- and postoperative medication and structured follow-up to 12 months. There are no hidden top-ups for suture lysis, anterior segment imaging or routine bleb needling.
| Component | UK 2026 self-pay (per eye) |
|---|---|
| PAUL implant, standard primary case | GBP 5,500 - 7,500 |
| PAUL implant, complex case (neovascular, uveitic, post-failed-trabeculectomy, pars plana tube) | GBP 7,000 - 9,000 |
| Combined PAUL plus phacoemulsification cataract surgery | GBP 7,500 - 10,500 |
| Combined PAUL plus pars plana vitrectomy | GBP 8,500 - 11,500 |
| Theatre top-up for bleb needling under direct vision (if required after month 3) | Included in package |
Full glaucoma-surgery pricing across all techniques is set out on our private glaucoma surgery cost UK page. For glaucoma laser pricing see private SLT laser glaucoma treatment cost UK. Spread payments are available through finance.
What is included in your PAUL package
Consultant glaucoma assessment
Full slit-lamp examination, gonioscopy, Goldmann applanation, dilated fundus examination, visual-field testing (24-2 and 10-2) and a same-day decision on candidacy and timing.
Optic-nerve and anterior-segment imaging
Optic-nerve OCT (RNFL and ganglion-cell), anterior-segment OCT to plan the tube quadrant, and corneal endothelial cell count to assess long-term endothelial risk.
Implant and theatre
PAUL implant device, consultant glaucoma surgeon, dedicated glaucoma scrub team, microscope and Vicryl ligation suture, corneal or scleral patch graft, anaesthetist fee.
Postoperative medication
Topical antibiotic, intense topical steroid taper, cycloplegic, and a written drop schedule with named pharmacy supply for the first 12 weeks.
Structured follow-up
Reviews on day 1, week 1, weeks 4-6 for suture lysis or ligature release, then months 3, 6 and 12. Suture lysis and routine bleb needling included.
Direct surgeon access
A named consultant surgeon, direct mobile contact for the first 6 weeks, and rapid same-day review for any pressure spike, hypotony or anterior-chamber concern.
What does the evidence say about PAUL?
Multi-centre peer-reviewed series of the PAUL implant from Singapore, the UK, India and Switzerland consistently report mean intraocular pressure in the 12-14 mmHg range at 12 and 24 months, with a 60-75 percent reduction in medication burden and complete success rates (IOP under 18 mmHg without drops) of 50-65 percent at two years. Published comparative work in Ophthalmology, the British Journal of Ophthalmology and Eye reports comparable or superior pressure control to the Baerveldt 350 mm sq tube, with significantly fewer early hypotony and tube-related corneal touch events thanks to the smaller 0.127 mm internal lumen and lower-profile plate.
The current Royal College of Ophthalmologists glaucoma surgical guidance and the European Glaucoma Society 5th edition treatment guidelines recognise non-valved tube shunts including PAUL as a primary option for refractory glaucoma, neovascular glaucoma and glaucoma after failed trabeculectomy. National Institute for Health and Care Excellence (NICE) interventional procedure guidance supports tube shunt surgery on standard arrangements.
PAUL vs other glaucoma surgery options
| Option | Mechanism | Typical target IOP | Best suited to |
|---|---|---|---|
| PAUL implant | Small-lumen non-valved tube to posterior scleral plate | 12-14 mmHg | Refractory, neovascular, uveitic, post-failed trabeculectomy |
| Trabeculectomy with MMC | Subconjunctival bleb under a scleral flap | 10-13 mmHg | Primary open-angle glaucoma, healthy conjunctiva |
| Preserflo MicroShunt | Bleb-forming subconjunctival SIBS microtube | 13-15 mmHg | Moderate-to-advanced open-angle glaucoma |
| Xen gel stent | Ab-interno gelatin microstent forming a low bleb | 14-16 mmHg | Mild-to-moderate primary open-angle glaucoma |
| Hydrus Microstent · iStent · OMNI canaloplasty | Trabecular bypass MIGS at cataract surgery | 15-18 mmHg | Mild-moderate open-angle glaucoma combined with cataract |
| iDose TR | Intracameral travoprost-eluting titanium implant | 17-19 mmHg | Open-angle glaucoma needing drop alternative |
For a wider plain-English comparison see our drops vs SLT vs MIGS vs surgery guide.
Are you a candidate for PAUL?
Good candidates
- Open-angle glaucoma with progression despite maximum tolerated topical therapy and prior SLT.
- Failed trabeculectomy, failed Preserflo MicroShunt or failed Xen gel stent.
- Neovascular glaucoma, uveitic glaucoma, ICE syndrome and traumatic glaucoma.
- Aphakic and pseudophakic glaucoma, paediatric and juvenile-onset glaucoma where the smaller plate is helpful.
- Conjunctival scarring from prior surgery, where a tube avoids the need for a healthy filtration bed.
Better suited to other options
- Mild open-angle glaucoma controlled on one or two drops — consider iStent MIGS at cataract surgery.
- Drop intolerance without progression — consider iDose TR.
- Healthy conjunctiva and moderate disease — trabeculectomy with mitomycin C may be first-line.
- Low endothelial cell count or corneal graft — pars plana tube placement should be considered.
NHS vs private PAUL implant in the UK
PAUL implantation is available on the NHS at most tertiary glaucoma units but waiting times for non-urgent refractory cases routinely run 6-12 months from referral to theatre, with variable continuity of consultant. Going private brings the consultant assessment to within a week, allows the consultant of your choice to perform the surgery personally, and brings the whole pathway (theatre, named surgeon, glaucoma nurse, suture lysis, bleb needling) under one transparent fixed price. For pricing across all glaucoma procedures see glaucoma prices.
Insurance and funding
Most UK private medical insurers (Bupa, AXA, Aviva, Vitality, WPA, Cigna and Allianz) recognise PAUL implantation under glaucoma surgical codes, subject to your individual policy benefits and pre-authorisation. We provide a CCSD-coded fee quote, the medical justification letter and operative report your insurer will require. See insured patients for the end-to-end process, or finance for spread payments.
Risks and limitations of PAUL
Tube shunt surgery is a major intraocular procedure with a defined risk profile. Early postoperative complications include transient hypotony with shallow anterior chamber, choroidal effusion, intraocular pressure spike (especially when the ligature opens), tube-corneal touch, conjunctival erosion over the patch graft, intraocular bleeding, infection (endophthalmitis is rare but serious), motility disturbance with diplopia (especially superior plates), and progressive endothelial cell loss with long-term risk of corneal decompensation requiring DMEK or DSAEK. Late complications include plate encapsulation with a hypertensive phase, tube migration, late erosion and very rarely explantation. Your consultant will discuss your individual numerical risk in writing during consent.
Recovery timeline after PAUL
First 24-48 hours
Eye shield overnight, mild ache, expected gritty redness and tearing. Pressure is typically high while the ligature holds. Day-1 review with the consultant.
Week 1
Topical antibiotic for a week and intense steroid taper begins. Most office workers return to work in 7-10 days. Avoid heavy lifting, swimming and contact sports.
Weeks 4-6
Vicryl ligature absorbs and tube flow opens. A pressure drop into the low teens is expected. Suture lysis and gentle bleb-needling are performed in clinic if needed.
Months 3, 6 and 12
Visual-field, OCT and endothelial cell count are repeated. Most patients reduce or stop topical pressure-lowering drops by month 6.
How to choose a UK PAUL implant clinic
- Choose a named CCT-holding consultant glaucoma surgeon with an audited series of at least 30 PAUL or comparable non-valved tube cases.
- Ask for the unit's published mean IOP, complete-success rate and re-operation rate at 12 and 24 months.
- Confirm that suture lysis, bleb needling and theatre return are included in the package rather than billed as extras.
- Confirm the corneal endothelial cell count protocol, since long-term endothelial loss is the chief late safety concern.
- Confirm that the surgeon offers combined PAUL plus phacoemulsification or pars plana vitrectomy in a single sitting where clinically indicated.
- Check the clinic's Care Quality Commission rating and the consultant's General Medical Council specialist registration.
For the wider pathway see what to expect at your consultation and the full glaucoma treatments hub.
PAUL glaucoma implant frequently asked questions
How much does a private PAUL glaucoma implant cost in the UK in 2026?
Self-pay PAUL implantation in the UK in 2026 is typically GBP 5,500-7,500 per eye for a standard primary case and GBP 7,000-9,000 per eye for a complex case such as neovascular, uveitic or post-failed-trabeculectomy glaucoma. Combined PAUL plus cataract surgery is GBP 7,500-10,500 per eye and combined PAUL plus pars plana vitrectomy is GBP 8,500-11,500 per eye.
Will PAUL cure my glaucoma?
No glaucoma operation cures glaucoma. PAUL lowers intraocular pressure into the low teens and reduces or stops your need for topical drops, which slows or halts further damage to the optic nerve. The vision you have lost before surgery does not return.
Is the implant permanent?
PAUL is intended to remain in the eye for life. It can be ligated, partially occluded, revised or explanted if there is hypotony, tube migration, conjunctival erosion or persistent diplopia, but explantation is uncommon in published series.
Is the surgery painful?
Surgery is performed under local anaesthesia with sedation, or under general anaesthesia by preference. You should feel pressure and movement but no sharp pain. Mild ache for 24-48 hours afterwards is normal and is well controlled by paracetamol.
How long is recovery?
Most office workers return to work within 7-10 days. Heavy lifting, swimming, contact sports and eye rubbing should be avoided for 4 weeks. Vision is often blurred for 2-6 weeks while the ligature releases and the bleb matures.
Will I still need drops after PAUL?
Across published series 60-75 percent of patients reduce or stop their pressure-lowering drops by 6-12 months after PAUL. Some patients with very high baseline pressure, neovascular glaucoma or after combined surgery will still need 1-2 topical agents long term.
Can PAUL be combined with cataract surgery?
Yes. Combined phacoemulsification with intraocular lens and PAUL implantation is offered in a single sitting for patients with co-existing visually significant cataract, and is priced as a combined package.
How does PAUL compare with Baerveldt or Ahmed tubes?
PAUL has a smaller 0.127 mm internal lumen than the Baerveldt 350 and a lower-profile silicone plate, which UK and international comparative series associate with comparable long-term pressure control and fewer early hypotony, tube-touch and corneal endothelial events.
How does PAUL compare with Preserflo or Xen?
Preserflo MicroShunt and Xen gel stent are bleb-forming subconjunctival devices best suited to moderate primary open-angle glaucoma with healthy conjunctiva. PAUL is preferred for refractory disease, conjunctival scarring, neovascular and uveitic glaucoma where a posterior plate is needed.
Can both eyes be done at once?
No. Tube shunt surgery is performed one eye at a time, with at least 4-6 weeks between operations so that pressure stability and the early bleb response can be assessed in the first eye.
What if pressure climbs again later?
A late hypertensive phase or plate encapsulation is treated with topical drops, in-clinic bleb needling with 5-fluorouracil, plate revision or in selected cases a second tube in a different quadrant. The package includes routine in-clinic needling for the first 12 months.
Is PAUL covered by private medical insurance?
Most UK private medical insurers cover PAUL implantation under glaucoma surgical codes subject to pre-authorisation. Our team prepares the CCSD-coded quote, medical justification letter and operative note your insurer will require.
PAUL vs trabeculectomy — which is better?
Trabeculectomy with mitomycin C remains a strong first-line filtration option for primary open-angle glaucoma with healthy conjunctiva. PAUL is preferred when conjunctiva is scarred from previous surgery, in neovascular and uveitic glaucoma, and after failed trabeculectomy. Many UK units now offer PAUL as a primary alternative in moderately advanced disease.
Methodology and sources
Pricing is taken from the eyesurgeryclinic.co.uk 2026 published self-pay tariff for glaucoma surgery as audited in May 2026. Clinical statements draw on peer-reviewed series of the PAUL Glaucoma Implant in Ophthalmology, the British Journal of Ophthalmology, Eye, JCRS, Journal of Glaucoma and Clinical and Experimental Ophthalmology between 2018 and 2026, on European Glaucoma Society 5th edition guidance, Royal College of Ophthalmologists glaucoma surgical guidance, NICE interventional procedure guidance for non-valved glaucoma drainage devices, and on UK and Singapore National Eye Centre audit data presented at UKEGS, EGS and the World Glaucoma Congress. Page last reviewed 25 May 2026 against the live URL set on eyesurgeryclinic.co.uk.
Book a consultant glaucoma assessment
Find out whether the PAUL Glaucoma Implant is right for your refractory or post-trabeculectomy glaucoma with a same-week consultant appointment, full optic-nerve and anterior-segment imaging, and a transparent UK 2026 quote.
Or call 0800 852 7782.
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