Glaucoma drainage device surgery in children and adults: a comparative study of outcomes and complications

The PAUL® glaucoma implant: 1-year results of a novel glaucoma drainage device in a paediatric cohort

PURPOSE

The PAUL® glaucoma implant (PGI) is a novel glaucoma drainage device, which has not been previously reported in paediatric glaucoma management. This study aims to evaluate the safety and effectiveness of the PGI in a paediatric cohort.

METHODS

A retrospective evaluation of 25 cases of paediatric PGI surgery (age 8 months to 16 years) was performed at Manchester Royal Eye Hospital between September 2019 and July 2020. Primary outcome measures included failure (intraocular pressure (IOP) > 21 mmHg or < 20% reduction of IOP, removal of the implant, further glaucoma intervention or visual loss. Secondary outcomes included mean IOP, mean number of medications, logMAR visual acuity and complications.

RESULTS

Eleven eyes (48%) had a complete success and achieved an unmedicated IOP < 21 mmHg, and 21 eyes (84%) had a qualified success (with or without medications). Four failures were observed, 2 due to hypotony and 2 underwent further surgery (gonioscopy-assisted transluminal trabeculotomy). The mean preop IOP was 30.9 ± 5.9 mmHg (n = 25), falling to 13.5 ± 6.8 mmHg at 1 month, 17.9 ± 7.2 mmHg at 3 months, 13.4 ± 5.1 mmHg at 6 months, 13.2 ± 4.9 mmHg at 12 months and 11.8 ± 4.6 mmHg at 24 months. The mean change in IOP from the preoperative visit to the last visit was a reduction of 19.1 ± 7.7 mmHg. A significant reduction in the number of medications and IOP was demonstrated after PGI (p < 0.0001). Nine patients required removal of the intraluminal Prolene stent from the PGI for further pressure lowering.

CONCLUSION

The one- to two-year results demonstrate paediatric PGI has high qualified success rates and effectively reduces IOP and the need for glaucoma medical therapy.

Effect of guided Ahmed glaucoma valve implantation on corneal endothelial cells: A 2-year comparative study

PURPOSE

To compare the effects of guided and non-guided Ahmed glaucoma valve (AGV) implantation on the corneal endothelium.

METHODS

Medical records of patients who underwent AGV implantation in the anterior chamber (AC) were reviewed retrospectively. The eyes were divided into two groups depending on the use of a guidance technique with spatula and a 4-0 nylon intraluminal stent. Specular microscopy was performed to measure corneal endothelial cell density (ECD) loss after surgery, and the rate of ECD change was calculated. Tube parameters were measured using anterior segment optical coherence tomography (AS-OCT).

RESULTS

The ECD loss during 2 years of follow-up was significantly lower in the guided AGV implantation (gAGV) group than in the non-guided implantation (ngAGV) group, and the rate of ECD change was -0.62 ± 1.23 and -1.42 ± 1.57%/month in the gAGV and ngAGV groups, respectively (p = 0.003). The mean tube-cornea distance (TCD) and mean tube-cornea angle (TCA) were significantly greater in the gAGV group than in the ngAGV group. The frequency of tube repositioning within 2 years after surgery was 0% in the gAGV group and 12.66% in the ngAGV group (p = 0.005).

CONCLUSIONS

The use of a guidance technique can reduce corneal endothelial loss during the first 2 years after AGV implantation in the AC. The tube was positioned at a more distant and wider angle from the cornea in the eyes of the gAGV group, which may have contributed to the reduced need for tube repositioning to prevent corneal decompensation.

A Novel Tube Insertion Technique for Glaucoma Drainage Device Implantation

PURPOSE

Early hypotony after non-valved glaucoma drainage device (GDD) implantation for complex glaucomatous eyes with labile aqueous production can lead to significant visual morbidity. We therefore sought to report the early postoperative outcomes of a novel surgical technique that allows atraumatic insertion of non-valved GDDs through a much smaller 25-gauge scleral track, to minimize entry site leakage and improve safety.

METHODS

Retrospective case series of 15 consecutive cases undergoing non-valved GDD insertion into the anterior chamber using a previously unreported technique.

RESULTS

All eyes underwent successful GDD insertion using our novel technique, with no intraoperative complications. The mean preoperative intraocular pressures (IOP), at day 1, week 1 and week 3 were 31.4, 22.4, 23.7, and 25.6 mm Hg, respectively. A statistically significant IOP reduction was achieved at day 1, week 1 and week 3 postoperatively ( P <0.05) without any observed leakage at the scleral entry site. One eye (6.7%) with complex panuveitic glaucoma developed early hypotony (5 mm Hg) with shallow choroidal detachments on day 1. This was successfully managed with 1 intracameral ophthalmic viscoelastic device injection given at the slit-lamp and no further intervention.

CONCLUSIONS

This novel single needle-docking intraocular insertion manoeuvre is an easily adoptable technique to make GDD insertion through a smaller 25-gauge water-tight scleral track more efficient and less traumatic. The technique reduces scleral distortion and therefore improves surgical safety particularly in eyes with complex secondary glaucoma.

Risk Factors for Glaucoma Drainage Device Exposure in Children: A Case-Control Study

PURPOSE

To identify the risk factors for glaucoma drainage device (GDD) exposure in children.

DESIGN

Retrospective case-control study.

METHODS

The study population comprised children (one eye each) who presented with a history of GDD exposure to a tertiary care eye hospital over the period January 2014 to January 2020. Consecutive children (age <18 years) were included. A control group from the same time period (children without GDD exposure) were included in the ratio of 5 controls to every 1 case of exposure. The main outcome measures included risk factors for exposure (univariate and multivariate analysis).

RESULTS

A total of 21 eyes (of 21 children with implant exposure) and 115 eyes (of 115 children without exposure) were included in this study. During the same study period, a total of 494 eyes had undergone GDD implantation, giving an estimated incidence of exposure of 4.25%). In the bivariate analysis, GDD exposure was associated with multiple previous ocular surgeries (P = .001), longer follow-up duration (P < .001), combined procedure at the time of primary implantation (P = .002), and a younger age at the time of primary implantation (P = .006). The former 3 risk factors continued to prove a statistically significant association on multivariable regression analysis. Postoperative use of eye lubricants was more common among children in the control group (P = .007).

CONCLUSION

In pediatric glaucoma patients, younger age and combined procedure at the time of primary GDD implantation, in addition to multiple previous ocular surgeries, were associated with greater risk of implant exposure. Postoperative use of eye lubricants may be protective.

Outcomes of inferonasal glaucoma drainage device surgery in the management of childhood glaucoma

PURPOSE

To evaluate indications and postoperative outcomes of inferonasal Ahmed and Baerveldt glaucoma drainage devices (GDDs) in pediatric glaucoma.

METHODS

This retrospective study included patients ≤18 years of age at inferonasal GDD placement, from June 2013 to September 2021. Demographic information, indications, and outcomes were recorded. Successful eyes had intraocular pressure (IOP) ≥5 and ≤21 mm Hg or (in severe cases, where entry IOP was ≤21 mm Hg) 20% below preoperative values without additional IOP-lowering surgery or vision-threatening complications.

RESULTS

A total of 68 eyes of 52 patients were included. Mean age was 9.8 ± 5.8 years. Most common diagnoses included primary congenital glaucoma (n = 28 eyes [41%]) and glaucoma following cataract surgery (n = 12 eyes [18%]). Success rates by Kaplan-Meier survival analysis (95% CI) at 1, 2, 3, and 5 years were 62.2% (49.4-72.7), 49.0% (36.3-60.6), 36.8% (24.0-49.8), and 31.9% (18.5-44.5), respectively. Surgical failure was associated with Ahmed (vs Baerveldt) GDD (HR = 3.2; P = 0.002) and inferonasal site as initial (vs subsequent) GDD received (HR = 2.2; P = 0.048). Twenty-five eyes (36.7%) had at least one complication. Although vision-threatening complications were uncommon (n = 2 eyes [3%]), less severe complications were relatively common and included new/worsened strabismus (n = 9 patients [17%]), corneal edema (n = 6 eyes [9%]), lens opacities (n = 4 [6%]), tube or patch graft exposure (n = 3 [4%]), tube blockage (n = 2 eyes [3%]), and other (n = 8 eyes [12%]).

CONCLUSIONS

In this study cohort, inferonasal GDDs for childhood glaucoma had modest success, with frequent though rarely vision-threatening complications.

Insertion of a Preserflo microshunt inside a non-valved glaucoma shunt to treat late-onset hypotony

We present a case of advanced glaucoma with previously failed trabeculectomy who underwent a Baerveldt tube (BVT) insertion, with initial success. However, 9 months post BVT insertion he developed profound clinically significant hypotony. Two attempts at controlling this with suture exchange led to episodes of significant ocular hypertension, followed by hypotony each time. We describe a technique of using a cut segment of the novel, polystyrene-block-isobutylene-block- styrene (SIBs) based Preserflo Microshunt (Santen Inc., Miami, FL) inserted into the tip of a BVT to control late onset hypotony with success. IOP at 6 weeks was 12mmHg on two drops with complete resolution of the choroidal maculopathy.

Corneal Edema and Keratoplasty: Risk Factors in Eyes With Previous Glaucoma Drainage Devices

PURPOSE

To assess risk factors contributing to corneal decompensation following glaucoma drainage device (GDD) implantation.

DESIGN

Retrospective case control study.

METHODS

Records of 1610 eyes that underwent GDD implantation between June 1, 2009, and April 1, 2020, at the Johns Hopkins Wilmer Eye Institute were reviewed. Seventy-nine eyes (5%) developed corneal decompensation, of which 46 underwent keratoplasty. These 79 cases were matched with 220 controls. Cox proportional hazard models with robust standard error estimates to account for clustering at the matched-pair level were used to assess risk factors for corneal decompensation. Kaplan-Meier survival analysis analyzed time to corneal decompensation.

RESULTS

The mean (SD) age of cases and controls was 68 (12.3) and 60.5 (15.9) years, respectively. The mean time from GDD implantation to corneal decompensation was 32 months, and the cumulative probability of developing decompensation at 3, 6, and 9 years was 4.7%, 9.2%, and 14.8%, respectively. Final visual outcomes in cases were worse, with a final mean ± SD visual acuity (logMAR) of 1.96±1.25 relative to a mean±SD visual acuity of 1.11±1.36 in controls (P < .001). In the multivariable model, significant risk factors for corneal decompensation were increased age (adjusted hazard ratio [AHR] 1.39, 95% CI 1.18, 1.63; P ≤ .001), history of Fuchs dystrophy or iridocorneal endothelial syndrome (AHR 9.18, 95% CI 5.35, 15.74; P ≤ .001), and postoperative complications such as hypotony (AHR 3.25, 95% CI 1.85, 5.72; P ≤ .001) and tube-cornea touch (AHR 6.37, 95% CI 3.77, 10.75; P ≤ .001).

CONCLUSIONS

The risk of postoperative corneal decompensation is persistent over time. Patients receiving GDDs, particularly those with advanced age, preexisting corneal pathology, and postoperative complications, should be counseled regarding their increased risk for corneal decompensation.

iSTAT (Intraluminal Suture Transfixed and Titratable) technique for ligature-free Reversal of long-term drainage implant hypotony

Purpose

To describe the iSTAT (Intraluminal Suture Transfixed and Titratable) technique, an improvement on prior tube occlusion methods, allowing for variable flow.

Observations

A 76-year-old woman who underwent an uncomplicated glaucoma drainage device (GDD) placement for uncontrolled mixed mechanism glaucoma presented with hypotony 4 years post-operatively. The iSTAT technique was performed to adjust the flow in the GDD tube: a 4-0 polypropylene suture tip was blunted with a low-temperature cautery, creating a bulbed end that would occlude the tube. The suture was introduced into the tube bulb-first intracamerally, extending to the plate. If partial occlusion of the tube is desired, the suture can be secured in place by piercing the side wall of the tube tip with the distal end of the suture. After complete occlusion of the GDD tube with a large bulb, the patient had intraocular pressures (IOPs) > 40 mmHg on post-operative day 1, which remained in the 25-30 mmHg range 2-3 weeks post-operatively on maximally tolerated medications. Patient underwent a second revision with a smaller-bulbed stent (with a 3-0 polypropylene suture), which stabilized her IOP at 8 mmHg.

Conclusion and Importance

The iSTAT technique allows for an ab interno revision, titration of flow, and stabilization of the stent in the wall of the tube. The ab interno approach precludes the need for conjunctival incisions, thus maintaining bleb integrity and permitting surgery under topical anesthesia. The intracameral stabilization of the stent in the tube allows for smaller bulbs to titrate the flow without external ligatures.

Glaucoma control after phacoemulsification in eyes with functioning glaucoma filtration surgeries: trabeculectomies versus glaucoma drainage devices

PURPOSE

Several studies have demonstrated decompensation of intraocular pressure (IOP) control following phacoemulsification in eyes with a functioning trabeculectomy. Limited evidence base suggests that this effect is minimal in eyes with functioning glaucoma drainage devices (GDD). The aim of this study was to report on glaucoma control after phacoemulsification in eyes with a functioning GDD compared to eyes with a functioning trabeculectomy.

METHODS

Single-centre retrospective comparative study of patients with a functioning non-valved GDD (Baerveldt 350; Johnson & Johnson Surgical Vision) or trabeculectomy undergoing phacoemulsification. Glaucoma outcomes including IOP, cup:disc ratio (CDR), global retinal nerve fibre layer (RNFL) thickness and visual field mean deviation (MD) are reported. Failure was defined as IOP rise > 20% from baseline.

RESULTS

Fifteen eyes with a functioning trabeculectomy and twenty-three eyes with a functioning GDD with 24-month post-phacoemulsification data were identified. Mean IOPs were significantly lower in the trabeculectomy group at month 24 compared to the GDD group, 9.5 and 15.9 mmHg (p = 0.001) respectively. At month 12, there was significant worsening on MD in GDD group compared to trabeculectomy group, - 20.0 dB and - 11.3 dB respectively (p = 0.03). A greater proportion of eyes failed in the GDD group compared to the trabeculectomy group, N = 15 (65%) and n = 7 (47%), p = 0.26.

CONCLUSION

As with functioning trabeculectomies, phacoemulsification should be approached with similar caution in eyes with functioning GDD. An existing GDD is at least as likely to fail following clear corneal phacoemulsification as an existing trabeculectomy and non-augmented GDDs may be at greater risk.

Management of a recurrent encapsulated bleb with a cost-effective non-valved glaucoma drainage device

Despite the advancements in the surgical management of glaucoma, childhood glaucoma remains a challenging surgical disease worldwide. An early adolescent boy with primary congenital glaucoma, status after glaucoma drainage device (GDD) implantation, on maximum medical therapy, was presented with a swelling in the superotemporal orbital region. The patient had undergone an uneventful GDD implantation 2 years prior to presentation. A similar swelling, which was diagnosed to be a Tenon's cyst, had been excised on three earlier occasions. Given that the repeat capsular excision would also have the same likelihood of failure, and poor intraocular pressure control, a non-valved, cost-effective Aurolab aqueous drainage implant (AADI, Aurolab, Madurai, India) implantation was done inferonasally. In this patient, AADI proved to be a safe and effective alternative for the known GDDs.

Ahmed implant coated with poly(2-methacryloyloxyethyl phosphorylcholine) inhibits foreign body reactions in rabbit eyes

Purpose

Wound healing after Ahmed glaucoma valve (AGV) implantation often entails fibrosis as a foreign body reaction to the silicone plate. Poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) forms an antifouling surface that inhibits fibrosis during wound healing. In this study, we aimed to compare the effects of the implantation of AGV coated with PMPC (wPMPC) versus AGV without PMPC (woPMPC) in rabbits.

Methods

Six New Zealand White rabbit does underwent AGV implantation in both eyes. For each rabbit, one eye was randomly selected for implantation of AGV wPMPC and a conventional AGV (woPMPC) was implanted in the contralateral eye. Gross conjunctival vascularity was compared between the two groups at the first, second, and fourth weeks after surgery. The eyes were enucleated in four weeks and subjected to staining with hematoxylin and eosin and Masson’s trichrome stain. The fibrosis and inflammation status among the eye samples were compared by measuring the thickness of the fibrotic walls and counting the number of chronic inflammatory cells around the AGV. Counting of inflammatory cells and measuring fibrotic wall thickness were done in a blinded method to eliminate observer bias. Statistical analysis was performed using the Mann-Whitney U test.

Results

Gross and histological examinations revealed no toxic effects of PMPC. There were no apparent differences in overall conjunctival vascularity between the two groups at weeks 1, 2, and 4 after surgery. The average inflammatory cell counts were 14.3 ± 5.8 per slide and 27.3 ± 8.6 per slide in the wPMPC and woPMPC groups, respectively (p = 0.037). The average thicknesses of the fibrotic wall were 57.9 ± 11.3 μm and 81.5 ± 21.3 μm in the wPMPC and woPMPC groups, respectively (p = 0.025).

Conclusion

Compared to the woPMPC group, the number of inflammatory cells and fibrosis were significantly decreased in the wPMPC group.

Rate of Corneal Grafting Post-Glaucoma Drainage Device Use in Pediatric and Adult Patients

PRCIS

Kaplan-Meier analysis was used to compare the rate of corneal grafting after glaucoma drainage device (GDD) placement in pediatric and adult patients. Adults were at an increased risk of receiving a corneal graft after device placement.

PURPOSE

The goal of this study was to compare the rate of corneal graft implantation after GDD placement in pediatric and adult patients.

PATIENTS

Patients receiving a GDD between January 1, 1985 and December 31, 2017 were selected from the medical records. Patients receiving their first device while <18 years of age were considered children for the extent of the study.

METHODS

We compared the rate of receiving a corneal graft after GDD implantation using Kaplan-Meier analysis. Baseline patient characteristics and surgical characteristics were compared using a generalized estimating equation.

RESULTS

Corneal grafting occurred in 8.6% of adults and 4.7% of children from the original cohort. The rate of receiving a corneal graft at 5, 10, and 15 years was 9.4%, 16.8%, 39.4% and 1.6%, 1.6%, 12.5% for adults and children, respectively. However, certain characteristics were different between the 2 groups.

CONCLUSION

Adult patients were more likely to receive a corneal graft after GDD placement. However, pediatric and adult patients differed in the prevalence of preexisting corneal disease, glaucoma type, GDD type used, and types of previous surgeries. Elucidation of the impact of these factors on corneal graft rate requires a larger cohort size.

Surgical Outcomes of Superotemporal Versus Inferonasal Placement of Aurolab Aqueous Drainage Implant in Refractory Pediatric Glaucoma

PURPOSE

We sought to describe the outcomes of the Aurolab aqueous drainage implant (AADI) placed in the superotemporal (ST) versus the inferonasal (IN) quadrant in pediatric eyes with refractory glaucoma.

DESIGN

Retrospective comparative interventional case series.

METHODS

This was a retrospective study of patients ≤18 years of age who underwent AADI implantation and completed a minimum of 2-year follow-up. The choice of the quadrant depended upon the amount of scarring and conjunctival mobility. Cumulative success at 2 years was defined as intraocular pressure (IOP) ≤21 mm Hg or reduced by ≥20% below baseline on 2 consecutive follow-up visits after 3 months, IOP ≤5 mm Hg on 2 consecutive follow-up visits after 3 months, reoperation for glaucoma or a complication, or loss of light perception vision.

RESULTS

A total of 144 patients (144 eyes) underwent AADI placement, including 48 eyes (33%) in the IN and 96 eyes (67%) in the ST quadrants. The IOP was significantly higher in the IN group (17.5 ± 7.4 mm Hg vs 13.7 ± 6.2 mm Hg, P = .005) with a greater number of medications (1.5 ± 1.0 vs 0.8 ± 0.9, P = .001) after 2 years of follow-up. Cumulative success rates at 2 years were 50.7% (95% confidence interval 35.4%-63.9%) in the IN group and 65.6% (95% confidence interval 56.5%-75.7%) in the ST group (P = .15). Complications occurred more frequently in the IN group, with significantly more tube exposure (12% vs 0%, P = .05).

CONCLUSIONS

Placement of the AADI in the ST quadrant has better IOP-related outcomes and is a safer surgical option in pediatric eyes compared with the IN quadrant. It may be prudent to avoid AADI in the IN quadrant in children unless the ST location is not a viable option.

Management of endophthalmitis related to glaucoma drainage devices: review of the literature and our experience

Glaucoma drainage device (GDD)-related endophthalmitis is a devastating complication of device implantation. There are no guidelines in the literature to assist clinicians in deciding if the GDD should be explanted or if patients require pars plana vitrectomy (PPV). This study compares the outcomes of GDD explantation with device retention and also independently compares the outcomes of PPV versus intravitreal antibiotics alone in patients with GDD-related endophthalmitis. A literature search for studies discussing GDD-related endophthalmitis from 2005 to 2019 was performed; 30 articles were included. The visual acuity/anatomical outcomes were compared between GDD explantation and retention, and between patients that received a PPV and those that did not. These outcomes were combined with a medical records review of 13 patients with GDD-related endophthalmitis from an academic institution. A total of 88 eyes were included. 70.5% underwent GDD explantation, while 37.8% received a PPV. GDD explantation was associated with a lower rate of evisceration/enucleation when compared to GDD retention (4.8% versus 19.2%, OR 0.22, 95% CI 0.05-1.01, p = 0.05), but visual acuity outcomes were similar. No eyes that received an immediate vitrectomy became phthisic or required evisceration/enucleation, compared an evisceration/enucleation rate of 15.2% in eyes treated solely with intravitreal antibiotics (OR 1.18, 95% CI 1.04-1.33, p = 0.04). Explantation of the GDD and immediate vitrectomy are both associated with better anatomical outcomes in GDD-related endophthalmitis. Further research is needed to provide more definitive guidelines in the ideal management of these patients.

Glycerin-preserved Human-donor Corneoscleral Patch Grafts for Glaucoma Drainage Devices

PRECIS

Glycerin-preserved, human-donor, corneoscleral patch grafts are effective and safe for glaucoma drainage device (GDD) implantation, and they are comparable to previously reported materials. It can be preserved with the sterile technique for up to 12 months.

PURPOSE

To evaluate the efficacy and safety of glycerin-preserved human donor corneoscleral tissue as the patch graft for GDD implantation.

PATIENTS AND METHODS

This was a retrospective noncomparative study from the medical records of 102 eyes from 102 glaucoma patients who underwent GDD implantation by or under supervision of a single surgeon (N.K.) at the Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand between January 2006 and December 2016. The glycerin-preserved human-donor corneoscleral tissue was used as the patch graft to cover the tube portion of GDD over the sclera. The primary outcome measure was the occurrence of patch graft-related complications.

RESULTS

There were 64 males and 38 females with the mean age of 52.8±18.5 years. The underlying diseases included failed filtration surgery with primary open-angle glaucoma 32 eyes and primary angle-closure glaucoma 15 eyes, congenital glaucoma 3 eyes and secondary glaucoma 52 eyes. The mean of ocular surgeries before GDD implantation was 2.3±1.1. Patch graft-related complications included tube exposure in 4 eyes (3.9%) and wound leakage in 4 eyes (3.9%). Eyes with tube exposure underwent regrafting 3 eyes and tube reposition 1 eye. Eyes with wound leaking resolved spontaneously 2 eyes and underwent conjunctival resuturing 2 eyes. The 5-year survival rate of the corneoscleral graft was 95.7%. There was no recurrence of graft-related complications after surgical procedure to correct the complications. Postoperatively, the mean of intraocular pressure and antiglaucoma medications decreased significantly from 27.4±9.8 mm Hg and 3.8±0.93 to 13.8±6.4 mm Hg (P<0.001) and 1.6±1.5 (P<0.001) at the last visit, respectively. The mean follow-up time was 59.9 months (range, 1 to 144.7 mo).

CONCLUSION

The glycerin-preserved human-donor corneoscleral tissue using as the patch graft was a safe alternative for GDD tube coverage. The patch graft-related complications was comparable to other materials.

Comparison of complications after Ahmed versus Baerveldt implant in glaucoma patients: one year follow-up

AIM

To compare surgical results of the Ahmed and Baerveldt implant procedures in glaucoma patients at 1y follow-up at Jakarta Eye Center (JEC) Eye Hospitals.

METHODS

This cohort retrospective study was conducted on glaucoma patients aged ≥18y who had undergone Ahmed and Baerveldt implant surgery. Intraocular pressure (IOP), visual acuity, glaucoma medication, success rate, early and late postoperative complications, and the number of resurgeries were analyzed.

RESULTS

A total of 351 eyes in the Ahmed group and 94 eyes in the Baerveldt group were included in this study. At 1y follow-up, the mean IOP was found to be significantly lower in the Baerveldt group (13±4.47 mm Hg) compared to the Ahmed group (15.02±5.73 mm Hg; P=0.025). Glaucoma medication was required in both the Ahmed and Baerveldt groups (58.92% vs 71.67%). Comparable success rate was found in both groups. The Ahmed group revealed a complete and qualified success of 86.82%, and failure of 13.17%. Similarly, the Baerveldt group showed complete and qualified success in 87.75% and failure in 12.25% cases. In the Ahmed group, 11.97% early complications, 26.06% late complications and 9.97% resurgeries were observed. In comparison, in the Baerveldt group, 23.40% early complications, 30.95% late complications and 11.70% resurgeries were observed.

CONCLUSION

Both groups of glaucoma implants show significant IOP reduction, however, the Baerveldt implant group demonstrates greater IOP reduction with more failure rates and complications than the Ahmed implant group.

Late-onset Subconjunctival Abscess Secondary to Serratia marcescens Associated With Unexposed Ahmed Glaucoma Valve Implant

PURPOSE

The purpose of this study was to report a rare case of late-onset subconjunctival abscess associated with an unexposed Ahmed glaucoma valve implant secondary to Serratia marcescens, a rare conjunctival pathogen.

METHODS

Case description including clinical imaging and literature review of glaucoma drainage device (GDD)-related infections.

CASE PRESENTATION

A 73-year-old man presented with blurring of vision, redness, and pain on his right eye 2 months after Ahmed glaucoma valve implantation for advanced postpenetrating-keratoplasty glaucoma. The patient was nonsmoker, had fairly controlled type 2 diabetes mellitus on insulin, and had undergone multiple eye surgeries on the right eye. On ocular examination, the conjunctiva was injected with fairly delineated yellowish-white subconjunctival material in the superotemporal quadrant with no associated tube exposure or leak, and the anterior chamber was quiet. The patient was assessed with Ahmed glaucoma valve infection with subconjunctival abscess and was treated by Ahmed glaucoma valve explant with directed systemic and topical antimicrobial therapy. The culture and sensitivity results revealed S. marcescens sensitive to ciprofloxacin, ceftazidime, gentamicin, and amikacin. Despite the virulence of the pathogen, the eye was saved.

CONCLUSIONS

Ahmed glaucoma valve infection with subconjunctival abscess secondary to S. marcescens is rare. GDD-related infections should be suspected in patients presenting with blurring of vision, pain, and redness even in the absence of tube exposure. Early diagnosis and treatment with culture-guided antimicrobial therapy combined with GDD explant is fundamental in optimizing the visual outcome.

Aurolab Aqueous Drainage Implant With and Without Scleral Patch Graft in Refractory Adult and Pediatric Glaucomas: A Comparative Study

PURPOSE

To compare the 2-year outcomes of eyes that received the Aurolab aqueous drainage implant (AADI) with and without a scleral patch graft.

DESIGN

Retrospective comparative interventional case series.

METHODS

Eyes with AADI and a minimum of a 2-year follow-up were included. Eyes that underwent implantation before January 2016 had surgery with a scleral patch graft covering the distal end of the tube, whereas those that were implanted after this period underwent surgery using a needle-generated scleral tunnel without the patch graft. The cumulative failure of the AADI was defined as intraocular pressure (IOP) >18 mm Hg or not reduced by 30% below baseline on 2 consecutive follow-up visits after 3 months.

RESULTS

We included 215 adult eyes (n = 147 with patch graft, n = 68 without patch graft) and 111 pediatric eyes (n = 73 with patch graft, n = 38 without a patch graft). The mean IOP in eyes without the patch graft was higher at 1 month in adult eyes (before, 27.5 ± 14.1 vs after, 22.3 ± 11.1; P = .01) but not in pediatric eyes (14.3 ± before, 5.8 vs after, 17.8 ± 11.0; P = .39); there were no differences in IOP, vision, number of antiglaucoma medications, and complications between groups at all other time points. None of the eyes without the patch graft experienced tube exposure. Cumulative success rates at 2 years in adults (66.2% vs 63.9%, respectively; P = .85) were similar to those in children (77.2% vs 71.9%, respectively; P = .83) with both techniques.

CONCLUSIONS

AADI placed without a scleral patch graft is as safe and effective as AADI placed with a patch graft in pediatric and adult refractory glaucomas.

A preliminary comparison of the Aravind aurolab drainage implant with the Baerveldt glaucoma implant: A matched case-control study

PURPOSE

The Aurolab^® aqueous drainage implant is a low-cost alternative to the Baerveldt glaucoma implant. The aim of this study was to test the hypothesis that the two implants are comparable in terms of surgical success and safety.

METHODS

We conducted a retrospective case-control study of Aurolab aqueous drainage implant done at our institution from May 2015 and May 2017. Twenty-five consecutive patients who received an Aurolab aqueous drainage implant were matched by age and diagnosis to patients who received a Baerveldt glaucoma implant. Data were collected pre-operative and post-operative visits, including visual acuity and intraocular pressure, number of medications, and complications. Surgical success was defined as intraocular pressure between 5 and 21 mmHg with a minimum 20% reduction from baseline, without loss of light perception or the need for further glaucoma surgery. Cox regression analysis was used to predict factors associated with surgical success.

RESULTS

The median (interquartile range, IQR) intraocular pressure at 1 year was 16.0 (8.0) mmHg for the Baerveldt glaucoma implant and 13.0 (8.0) mmHg for the Aurolab aqueous drainage implant, p = 0.38. Success (mean ± SE) at 1 year for the intraocular pressure >21-mmHg failure criterion was 65% ± 15% for the Baerveldt glaucoma implant and 79% ± 11% for the Aurolab aqueous drainage implant (p = 0.80). The frequency of complications listed was similar for the two groups (Fisher's exact p = 0.71). In the Cox regression, the type of implant was not found to be associated with surgical success.

CONCLUSIONS

Our preliminary results suggest that the Aurolab aqueous drainage implant is comparable to the Baerveldt glaucoma implant. Further long-term data in a larger population are needed to confirm these findings.

The Management of Uveitic Glaucoma in Children

Children comprise a unique population of patients in regard to the diagnostic and therapeutic approach of uveitic glaucoma. The management of glaucoma secondary to uveitis in children is extremely challenging and presents various difficulties, which are associated both with the underlying uveitis and the young age of the patients. The treatment of uveitic glaucoma calls for a thorough and individualized approach, involving both pharmacotherapeutic and surgical modalities. It appears that the efficient control of inflammatory activity plays a significant role in the final visual outcome of these patients. This study aims to review the current literature about the management of uveitic glaucoma in pediatric patients.

Intermediate-term outcomes of Aurolab aqueous drainage implant in refractory paediatric glaucoma

Aim

To report the intermediate-term outcomes of Aurolab aqueous drainage implant (AADI) surgery in paediatric eyes with refractory glaucoma.

Methods

Case records of patients below 18 years, who underwent AADI surgery between 2012 and 2015 with >2 years follow-up, were analysed. The intraocular pressure (IOP), visual acuity, number of antiglaucoma medications, complications and resurgery if any were recorded at baseline, day 1and then at months 1, 3, 6, 9, 12, 18, 24 and at the last visit. Failure was defined as IOP >18 mm Hg or not reduced by at least 30% below baseline, IOP ≤5 mm Hg on two consecutive follow-up visits after 3 months, reoperation for a complication or loss of light perception vision.

Results

101 eyes of 101 patients were included with a mean age of 10.4±4.7 years at the time of surgery and a mean follow-up of 40.9±15.1 months. Glaucoma following cataract surgery was the most common type of glaucoma (n=31, 30%), followed by primary congenital glaucoma (n=29, 29%). The cumulative probability of failure was 15.8% (95% CI 10.1% to 24.5%) at 1 year, 22.7% (95% CI 15.7% to 32.2%) at 2 years, 42.5% (95% CI 32.6% to 53.9%) at 3 years and 62.1% (95% CI 49.5% to 74.8%) at the 4 years time point.

Conclusion

The AADI showed excellent success until 2 years after surgery in paediatric eyes after which failure rates increased. Further prospective studies with longer follow-up are required to evaluate the long-term success of the AADI for paediatric glaucomas.

Ocular hypotony: A comprehensive review

Ocular hypotony is an infrequent, yet potentially vision-threatening, entity. The list of differential causes is extensive, involving any condition that may compromise aqueous humor dynamics or the integrity of the globe and sometimes following medical treatments or procedures. Depending on the cause and the clinical impact, treatment options aim to correct the underlying pathology and to reestablish anatomical integrity, as well as visual function. We review the pathophysiology, clinical presentation, different causes, and associated therapeutic options of ocular hypotony.

Bilateral Deep Sclerectomy with Microperforations as a Successful Secondary Procedure in Aniridia-Associated Glaucoma

Aniridia-associated glaucoma is often refractory to medical treatment. Glaucoma drainage device surgery is often considered after failed angle surgery. However, the potential complications of tube surgery in young children are not negligible. The failure rate of conventional trabeculectomy may be high and can require close and multiple postoperative follow-up visits. Here, we describe a child with aniridia who achieved good short-term results with deep sclerectomy. A 14-month-old girl was referred to our unit following bilateral trabeculotomies for aniridia-associated glaucoma and persistent uncontrolled intraocular pressure (IOP) in both eyes. She underwent sequential bilateral deep sclerectomies with microperforations. The patient achieved normalized IOP in both eyes after 6-month follow-up without any complications. Deep sclerectomy, with microperforations, may be a reasonable surgical procedure to perform in children with aniridia with failed angle surgery before contemplating tube shunt surgery.

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye

BACKGROUND:

One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies.

METHODS:

Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature.

RESULTS:

We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery.

DISCUSSION AND CONCLUSION:

Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.

Baerveldt Scleral Patch Graft Abscess Secondary to Coagulase-Negative Staphylococcus

We report the case of a 69-year-old female who underwent a Baerveldt implant placement for severe-stage primary open-angle glaucoma and developed a bacterial infection of the conjunctiva and abscess of the scleral patch graft with subsequent tube exposure. The infection was identified 3 weeks postoperatively and a topical antibiotic was immediately initiated. A concurrent systemic staphylococcal infection was discovered by an outside physician and oral cephalexin was initiated. Despite antibiotic treatment, the conjunctival erosion progressed, and tube revision was required. Culture of the abscess revealed coagulase-negative Staphylococcus. As alluded to above, the patient also had multiple abscesses on the skin that cultured positive for Staphylococcus aureus. To our knowledge, this is the first case in the literature of coagulase-negative Staphylococcus causing an early postoperative abscess of the scleral patch graft following glaucoma drainage device placement.