Long-term results of Ahmed glaucoma valve implantation for uveitic glaucoma

Intermediate-Term Outcomes of Ahmed Glaucoma Valve Implantation for Uveitic Glaucoma: A Tertiary Centre Experience

PURPOSE

To present the outcomes of Ahmed glaucoma valve (AGV) implantation in uveitic glaucoma (UG) in a tertiary eye center in Riyadh, Saudi Arabia.

METHODS

A retrospective review of all UG patients who underwent AGV implantation at a single, tertiary care eye center from January 2008 to December 2018. The main outcome measures were change in mean intraocular pressure (IOP), number of antiglaucoma medications, overall success rate in different follow-up periods, complete and qualified success from last follow up, and complications. The success of the treatment was defined as patients achieving intraocular pressure (IOP) levels between 6- and 21-mm Hg with or without additional antiglaucoma medications and/or a minimum of 20% reduction from baseline IOP.

RESULTS

The study included 74 patients (86 eyes), with a mean follow-up of 4.9 ± 2.9 years. The mean IOP was 32.2 ± 8.5 mmHg at baseline and 16.3 ± 6.6 mmHg at the last follow-up (p < 0.001). The mean number of antiglaucoma medications decreased from 3.5 ± 0.7 preoperatively to 1.3 ± 1.4 at the last follow-up (p < 0.001). Overall survival rates at 1, 3, 5, and 10 years were 96.5%, 92.7%, 91%, and 56.9%, respectively. Complete and qualified success rates were 37.9% and 48.3% at the end of follow up, respectively. The rate of postoperative complications was 56%, of which 18 eyes (20%) required surgical revision. Bivariate Cox proportional hazards regression analysis did not reveal any factors significantly associated with failure.

CONCLUSIONS

AGV is safe and effective in providing intermediate-term IOP control in UG patients. Complications reported in our cohort were mostly transient and conservatively treated.

Complications Following XEN45 Gel Stent and Glaucoma Drainage Device Implantation During Glaucoma Fellowship

Purpose XEN45 Gel Stent and glaucoma drainage device (GDD) implantation is safe and effective for glaucoma treatment and should be taught during glaucoma fellowship training. However, complications may still occur, with potentially sight-threatening consequences. The purpose of this study is to describe the management of complications following a series of XEN45 Gel Stent and GDD surgeries performed over the course of glaucoma fellowship training. Methods This is a retrospective case series of XEN45 Gel Stent surgeries performed on 16 eyes and GDD surgeries performed on seven eyes. Patient demographics, disease characteristics, and complications are reviewed. The intra- and postoperative course of five select cases with complications are described in detail. Results The most frequent complications following XEN45 implantation were transient hypotony (10 eyes, 63%), reduced visual acuity (VA) (five eyes, 31%), choroidal effusion (three eyes, 19%), hyphema (two eyes, 13%), and intraocular pressure (IOP) spike (two eyes, 13%). Thirteen eyes (81%) required bleb needling, and three eyes (19%) required XEN45 replacement. Complications following GDD implantation included hypotony (three eyes, 43%), reduced VA (two eyes, 29%), choroidal effusion (two eyes, 29%), IOP spike (two eyes, 29%), implant exposure (two eyes, 29%), and shallow anterior chamber (one eye, 14%). Three eyes (43%) required revision or explantation with a secondary glaucoma surgery. One choroidal effusion following XEN45 surgery and one following GDD surgery were hemorrhagic choroidal effusions requiring surgical drainage. Conclusion Significant and potentially sight-threatening complications may occur following XEN45 Gel Stent and GDD implantation performed over the course of fellowship training. Glaucoma fellows should be ably equipped to recognize, diagnose, and manage these complications both intra- and postoperatively.

Effectiveness of Angle-Based Minimally Invasive Glaucoma Surgery after Laser Trabeculoplasty: An Analysis of the IRIS® Registry (Intelligent Research in Sight)

OBJECTIVE

Angle-based minimally invasive glaucoma surgery (ab-MIGS) has grown substantially, although long-term efficacy is poorly understood. We analyze ab-MIGS effectiveness with and without preceding laser trabeculoplasty (LTP).

DESIGN

Retrospective cohort study.

SUBJECTS

Eyes undergoing ab-MIGS (Canaloplasty, Goniotomy, Trabectome, and iStent) with and without prior laser trabeculoplasty (< 2 years preceding MIGS) were identified in the IRIS® Registry (Intelligent Research in Sight) 2013 to 2018.

METHODS

Propensity score matching (PSM) was undertaken to define the following 4 cohorts: (1) standalone ab-MIGS, no prior LTP vs. (2) standalone ab-MIGS, with prior LTP; and (3) ab-MIGS + phacoemulsification, no prior LTP vs. (4) ab-MIGS + phacoemulsification, with prior LTP.

MAIN OUTCOME MEASURES

Failure was defined as subsequent glaucoma reoperation after ab-MIGS (either MIGS or traditional glaucoma surgery). Time-to-event outcome and incidence rates were calculated using survival analysis, and adjusted hazard ratios (aHRs) were generated using multivariate Cox proportional hazards models. Medication data were not available for analysis.

RESULTS

A total of 164 965 unique MIGS procedures were performed, from 2013 to 2018. After PSM, we identified 954 eyes undergoing standalone ab-MIGS and 7522 undergoing ab-MIGS + phacoemulsification. For eyes undergoing standalone ab-MIGS, those with prior LTP (n = 477) were more likely to undergo reoperation vs. those without LTP (n = 477) at 6 and 12 months. In multivariable models, those with prior LTP were more likely to undergo reoperation over the 36-month period vs. those without prior LTP (aHR, 1.53; CI, 1.15-2.04; P = 0.004). For eyes undergoing ab-MIGS + phacoemulsification, those with prior LTP (n = 3761) were more likely to undergo reoperation vs. those without LTP (n = 3761) at 12, 24, and 36 months. In multivariable models, those with prior LTP were more likely to undergo reoperation over the 36-month period vs. those without prior LTP (aHR, 1.53 CI, 1.15-2.04; P = 0.004).

CONCLUSIONS

Prior LTP may be associated with a higher chance of subsequent glaucoma surgery following ab-MIGS, either with or without concurrent phacoemulsification. These findings have important implications for understanding who may benefit most from ab-MIGS, and for guiding patient and surgeon treatment expectations.

FINANCIAL DISCLOSURES

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Gonioscopy-Assisted Transluminal Trabeculotomy in Uveitis-Related Ocular Hypertension and Glaucoma

PRCIS

Gonioscopy-assisted transluminal trabeculotomy (GATT) may be an effective first-line surgery for decreasing intraocular pressure (IOP) and medication burden in patients with uveitis-related ocular hypertension (OHT) or glaucoma.

OBJECTIVE

The purpose of the study is to determine the efficacy of GATT in lowering IOP in uveitis-related OHT or glaucoma.

METHODS

Retrospective case series that included patients with uveitis-related OHT or glaucoma who underwent GATT with or without concomitant cataract extraction and intraocular lens implantation at 2 Canadian academic centres from July 2018 to May 2022. Primary outcomes were: complete (no medications) and qualified success (with medication), and failure defined as (1) IOP >21 mm Hg with maximal medical therapy, (2) the need for additional glaucoma procedure, (3) loss of light perception secondary to glaucoma, and (4) IOP <6 mm Hg for 3 months.

RESULTS

Twenty-one eyes from 18 patients were included with a mean preoperative IOP of 26.2 ± 7.3 mm Hg on 4.3 ± 0.7 classes of glaucoma drops. The average follow-up was 29.2 ± 17.6 months and 76% of eyes (n = 16) had reached at least 12 months of follow-up. At the 12-month follow-up visit, there was a significant decrease in average IOP by 9.9 ± 7.9 mm Hg (38%, P = 0.005) and a decrease of 1.9 in glaucoma medication classes ( P = 0.002). Of eyes, 14% achieved complete success, whereas 80% of eyes achieved qualified success. Six eyes failed (29%) and 5 patients (24%) required additional glaucoma surgery. The most common postoperative complication was hyphema (n = 9; 43%).

CONCLUSION

This small case series suggests that GATT may be an effective first-line surgery for decreasing IOP and medication burden in patients with uveitis-related OHT or glaucoma. Further studies with longer follow-ups should be conducted to assess its long-term outcomes.

Update on Diagnosis and Treatment of Uveitic Glaucoma

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Preserflo microshunt implant for the treatment of refractory uveitic glaucoma: 36-month outcomes

OBJECTIVES

To determine 36-month efficacy and safety outcomes of the PRESERFLO Microshunt implant in the treatment of refractory uveitic glaucoma.

METHODS

Consecutive patients with uncontrolled uveitic glaucoma despite maximum medical treatment received PRESERFLO Microshunt implant with mitomycin C (MMC) in a tertiary referral glaucoma practice. Efficacy and safety outcomes data were collected at month 6, 12, 24, and 36, postoperatively. The primary outcome was surgical success, defined as intraocular pressure (IOP) between 5 and 21 mmHg or > 20% reduction from baseline, and absence of criteria for surgical failure. Secondary outcomes were IOP, visual acuity (VA), use of glaucoma medical therapy, surgical complications, rate of reoperation for glaucoma.

RESULTS

21 eyes of 21 patients were included. The mean rate of success was 0.74 (95%CI 0.48-0.88), 0.68 (0.43-0.84), 0.47 (0.25-0.67), and 0.47 (0.25-0.67, at 6, 12, 24, and 36 months postoperatively, respectively. The mean IOP decreased by 30.7% (95% CI 13.7-47.7), 26.5% (95% CI 3.2-49.8), 33.5% (95% CI 21.8-45.3), and 30.1% (95% CI 7.2-52.9) from baseline at postoperative month 6, 12, 24, and 36, respectively (p < 0.001). The mean ± SD number of glaucoma medications decreased from 4.1 ± 0.9 to 0.9 ± 1.2 at the final follow up (p = 0.0005). No sight-threatening complications were reported by 36 months.

CONCLUSIONS

Three-year results of the PRESERFLO Microshunt implant demonstrated favourable efficacy and safety profile in the treatment of refractory uveitic glaucoma.

Corneal Endothelial Cell Loss after Ciliary Sulcus Placement of Ahmed Glaucoma Valve in Patients with Noninfectious Uveitic Glaucoma

This study was performed to investigate the corneal endothelial cell density (CECD) reduction and treatment efficacy in patients with uveitic glaucoma treated by the ciliary sulcus placement of the Ahmed glaucoma valve (AGV). This retrospective study included 27 eyes of 27 patients with noninfectious uveitis who underwent the sulcus placement of the AGV. Each patient underwent a clinical assessment including a CECD measurement before surgery and at 3, 6, 9, and 12 months after surgery. The mean CECD was 2431.4 ± 367.5 cells/mm2 at preoperative baseline and 2360.5 ± 391.3 cells/mm2 at 12 months (p = 0.074), with a reduction rate of 2.73 ± 9.29%. The CECD reduction was significantly greater in patients with unilateral uveitis than that with bilateral uveitis. The rate of successful intraocular pressure control was 88% at 12 months, and the number of intraocular pressure-lowering medications was significantly reduced (p < 0.001). The current study showed that the implantation of an Ahmed tube into the ciliary sulcus provided stable intraocular pressure control in patients with glaucoma secondary to noninfectious uveitis, and CECD reduction was moderate in most patients at 12 months.

Sarcoid Uveitis: An Intriguing Challenger

The purpose of our work is to describe the actual knowledge concerning etiopathogenesis, clinical manifestations, diagnostic procedures, complications and therapy of ocular sarcoidosis (OS). The study is based on a recent literature review and on the experience of our tertiary referral center. Data were retrospectively analyzed from the electronic medical records of 235 patients (461 eyes) suffering from a biopsy-proven ocular sarcoidosis. Middle-aged females presenting bilateral ocular involvement are mainly affected; eye involvement at onset is present in one-third of subjects. Uveitis subtype presentation ranges widely among different studies: panuveitis and multiple chorioretinal granulomas, retinal segmental vasculitis, intermediate uveitis and vitreitis, anterior uveitis with granulomatous mutton-fat keratic precipitates, iris nodules, and synechiae are the main ocular features. The most important complications are cataract, glaucoma, cystoid macular edema (CME), and epiretinal membrane. Therapy is based on the disease localization and the severity of systemic or ocular involvement. Local, intravitreal, or systemic steroids are the mainstay of treatment; refractory or partially responsive disease has to be treated with conventional and biologic immunosuppressants. In conclusion, we summarize the current knowledge and assessment of ophthalmological inflammatory manifestations (mainly uveitis) of OS, which permit an early diagnostic assay and a prompt treatment.

Reimplantation of a drainage valve device in refractory glaucoma. A clinical case

Background: Implantation of various drainage devices is one of the treatments for refractory glaucoma, resistant to traditional surgical methods. The most commonly used glaucoma drainage device for refractory glaucoma is the Ahmed glaucoma valve. However, the long-term success rate of the surgery may be limited because of the development of complications during the late postoperative period. The complications do not allow the control of the achieved intraocular pressure (IOP) level. In such cases, a repeated implantation of the Ahmed valve may be one of the options for the surgical treatment. Clinical case description: Second Ahmed valves were implanted to two patients with refractory repeatedly operated glaucoma at the Department of surgical glaucoma treatment of the S. Fyodorov Eye Microsurgery Federal State Institution in Moscow. Previously, both patients had the Ahmed valves installed at their places of residence. During the postoperative period, one patient was found to have an encapsulated cyst around the drainage body, and later the revision of the operation area was performed. As a result of the repeated Ahmed valve implantation, the IOP compensation was achieved 9 months after the surgery. Conclusion: A repeated implantation of the Ahmed valve may be an option for the surgical treatment, if the first implant failed to control the IOP, in order to compensate the IOP and preserve the visual functions in patients with refractory repeatedly operated glaucoma.

Comparison of Surgical Outcomes between Trabeculectomy with Mitomycin C and Ahmed Valve Implantation with Mitomycin C in Eyes with Uveitic Glaucoma

We compared 1-year outcomes of trabeculectomy with mitomycin C (MMC) and Ahmed valve implantation with MMC as a first surgical procedure in patients with uveitic glaucoma. A total 38 eyes of 38 patients undergoing trabeculectomy (n =16) or Ahmed valve implantation (n = 22) were included. Surgical success was defined as intraocular pressure (IOP) ≤21 mmHg, IOP reduction ≥20% from baseline, no secondary glaucoma surgery, and no loss of light perception. The main outcome measurements including success rate, IOP, and the number of antiglaucoma medications and complications were compared. The overall success rates were comparable between the Ahmed and trabeculectomy groups (81.3 vs. 81.8%, p = 0.987). The mean IOPs were similar as well (p = 0.084), though the number of antiglaucoma medications was significantly lower in the trabeculectomy group than in the Ahmed group (1.0 ± 1.2 vs. 2.2 ± 1.1; p = 0.005). A statistically significant reduction in corneal endothelial cell density was noted in the Ahmed group (p = 0.004). Both treatments offered reasonable IOP control and safety for eyes with uveitic glaucoma. However, significantly fewer antiglaucoma medications were used in the trabeculectomy group. Furthermore, our results suggest that cautious postoperative monitoring with regard to corneal endothelial cell density should be additionally performed after Ahmed valve implantation.

Assessing risk factors for postoperative hypotony in Ahmed glaucoma valve implantation surgery

PURPOSE

To assess the risk factors associated with the development of hypotony after Ahmed glaucoma valve (AGV) implantation.

METHODS

One hundred and ninety-three eyes of 177 patients with various types of glaucoma that were treated with AGV implantation were retrospectively evaluated. Intraocular pressure lower than 6 mmHg related to the surgery is defined as postoperative hypotony. Patients' demographic characteristics, type of glaucoma, preoperative and postoperative visual acuity, necessity of antiglaucoma treatments, lens status, previous ocular surgeries, intraocular pressure (IOP) measurements before and after surgeries, the need for additional procedures and postoperative complications were recorded from the patients' charts.

RESULTS

Hypotony was seen in 68 of 193 eyes (35.2%) postoperatively. In 45 eyes (23.3%), it has occurred in first postoperative day and in 23 eyes (11.9%) after the first day within the first week. There was no difference in intraocular pressures between two groups in the first year follow-up. Pre- and postoperative best-corrected visual acuities, age and gender were not statistically different between hypotony and no hypotony groups (p > 0.05). Also, lens status, history of previous ocular surgery, type of glaucoma and number of preoperative glaucoma medication usage were not found to be different between groups (p > 0.05).

CONCLUSIONS

Potential risk factors such as age, sex, lens status, history of previous ocular surgeries, preoperative glaucoma medication usage or glaucoma type are not found to influence upon postoperative hypotony prevalence for AGV surgery. Surgery type and personal ocular factors, which could not be determined beforehand, could be more important than demographic features.

Evaluating the long-term efficacy and effectiveness of Viscocanalostomy and combined phacoemulsification with Viscocanalostomy in the treatment of patients with uveitic glaucoma: 5-year follow up data

BACKGROUND

Uveitic glaucoma commonly leads to a more intense optic nerve damage than other types of glaucoma, causing glaucomatous optic nerves and visual field defects. Anterior uveitis is the most commonly associated risk factor. Surgical intervention is usually indicated when all medical treatment has failed. We report five-year results for 16 eyes of uveitic glaucoma managed with viscocanalostomy (VC)/Phaco viscocanalostomy (PVC).

METHODS

Retrospective analysis on all uveitic glaucoma cases meeting a five-year follow up was completed. All patients were managed surgically with either viscocanalostomy (VC) or phacoviscocanalostomy (PVC). Outcomes evaluated included intraocular pressures measurement pre-listing, on day 1, year 1 to year 5. Complete success rate was defined as achieving an intraocular pressure (IOP) lower than 21 mmHg or reduced by 30% without medications, and qualified success was achieved when IOP was lower than 21 mmHg or a reduction in IOP of 30% with topical medical therapy ± Laser goniopuncture (LGP). If further surgeries were required to reduce IOP due to glaucoma progression then they were classified as a failure.

RESULTS

A total of 16 patients with uveitic glaucoma were reviewed. Complete success was seen in 75% of patients at year 1, 50% of patients at year 3 and 19% of patients in year 5. Conversely qualified success was achieved in 94% of patients at year 1, 86% of patients at year 3 and 75% of patients at year 5. In the group of patients requiring further surgery, 50% of patients had previous surgeries, including cataract surgery, trabeculectomy and viscocanalostomy. There was a mean number of 4 pre-operative drops before their primary surgery and a mean drop in eye medications of 1.1 at 5 years follow-up. Success rates were prognostically linked to lower mean number of interventions and lower percentage of previous surgeries.

CONCLUSION

There remains a significant paucity of information in the utilization of PVC in uveitic glaucoma. The advantage of nonpenetrating glaucoma surgery (NPGS) includes the lack of entry into the anterior chamber and the avoidance of an iridectomy which may reduce intraocular inflammation and postoperative complications. Our study shows that non-penetrating surgery is successful in treating advanced uveitic glaucoma.

The Effect of Perioperative Uveitis Control on the Success of Glaucoma Surgery in Uveitic Glaucoma

Purpose

To study the effects of perioperative uveitis control (PUC) on postoperative intraocular pressure (IOP) and uveitis activity in uveitic glaucoma (UG) patients who required glaucoma surgeries.

Patients and Methods

A retrospective chart review of 109 patients (120 eyes) which had glaucoma surgery for UG. A total of 66 eyes which had PUC were compared to 54 eyes which did not have. Measurements of IOP and uveitis activity were recorded preoperatively and over 2 years postoperatively. Average number of antiglaucoma medications and frequency of surgical failure were obtained in both groups.

Results

Over 2 years postoperatively, average IOP was lower in eyes which had PUC. Significant differences in IOP were found at 3 months (P = 0.004), 6 months (P = 0.001), 1 year (P < 0.001), and 2 years (P < 0.001). Lower grades of anterior chamber (AC) inflammation were found in eyes which had PUC. Significant differences were found at 1 month (P < 0.001), 3 months (P < 0.001) and 6 months (P = 0.001). Mean number of antiglaucoma medications at last visit was 0.7 ± 1.1 for eyes which had PUC and 2.6 ± 1.5 for eyes which did not have PUC (P < 0.001). Among eyes which had PUC, only two eyes required second glaucoma surgeries, while 16 eyes with no PUC required further glaucoma surgeries after 27.7 ± 12.5 months (P < 0.001).

Conclusion

Proper PUC in patients going for UG surgeries results in lower IOP levels and less AC inflammation over 2 years postoperatively. A comprehensive PUC regimen is needed for uveitic glaucoma patients going for surgeries.

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Monitoring and Treatment of Juvenile Idiopathic Arthritis-associated Uveitis: Brazilian Evidence-based Practice Guidelines

Purpose: To present a national guideline for ophthalmologic care and surveillance of juvenile idiopathic arthritis-associated uveitis (JIA-uveitis).Methods: Review article based on medical literature and the experience of an Expert Committee composed of members of the Brazilian Society of Pediatric Ophthalmology/Brazilian Council of Ophthalmology and the Brazilian Society of Pediatrics/Brazilian Society of Rheumatology. Studies with a high level of evidence were selected by searching the PubMed/Medline database. The final document was approved by the experts.Results: The main recommendations are that children/adolescents with JIA should undergo screening according to their risk factors. Ophthalmological checkups should also consider ocular inflammation and therapy. Topical glucocorticoids should be the first line of therapy, with systemic glucocorticoids acting as bridge treatments in severe uveitis. Methotrexate should be the first-line systemic therapy and anti-tumor necrosis factor (anti-TNF alpha) the second for uncontrolled uveitis.Conclusions: This evidence-based guideline for JIA-uveitis will be useful for both ophthalmology and rheumatology practice.

Detection of glaucoma using retinal fundus images: A comprehensive review

Content-based image analysis and computer vision techniques are used in various health-care systems to detect the diseases. The abnormalities in a human eye are detected through fundus images captured through a fundus camera. Among eye diseases, glaucoma is considered as the second leading case that can result in neurodegeneration illness. The inappropriate intraocular pressure within the human eye is reported as the main cause of this disease. There are no symptoms of glaucoma at earlier stages and if the disease remains unrectified then it can lead to complete blindness. The early diagnosis of glaucoma can prevent permanent loss of vision. Manual examination of human eye is a possible solution however it is dependant on human efforts. The automatic detection of glaucoma by using a combination of image processing, artificial intelligence and computer vision can help to prevent and detect this disease. In this review article, we aim to present a comprehensive review about the various types of glaucoma, causes of glaucoma, the details about the possible treatment, details about the publicly available image benchmarks, performance metrics, and various approaches based on digital image processing, computer vision, and deep learning. The review article presents a detailed study of various published research models that aim to detect glaucoma from low-level feature extraction to recent trends based on deep learning. The pros and cons of each approach are discussed in detail and tabular representations are used to summarize the results of each category. We report our findings and provide possible future research directions to detect glaucoma in conclusion.

Analysis of Efficacy and Safety of Pediatric Ahmed Glaucoma Valve (FP8) in Advanced Age Populations

PRECIS

The FP8 glaucoma valve was demonstrated to be reasonably safe with reliable results in an advanced age patient population.

PURPOSE

As life expectancy increases, a growing number of patients with glaucoma are of an advanced age. There are little to no data looking at glaucoma surgical treatment options in patients over the age of 85. Our study describes the safety and efficacy of the FP8 Ahmed glaucoma valve in this patient population.

MATERIALS AND METHODS

This was a retrospective study of patients over 85 years of age undergoing FP8 Ahmed glaucoma valve implantation. Preoperative age, sex, intraocular pressure (IOP), and number of glaucoma medications were recorded. Primary outcome variables were IOP and number of medications. Secondary outcome variables included any intraoperative or postoperative complications.

RESULTS

Mean IOP preoperatively was 26 mm Hg on an average of 3 glaucoma medications (n=56). IOP was significantly reduced at all time points in follow-up for an overall reduction of 42% at 1 year and 46% at 2 years. Mean IOP at 1 year follow-up was 15 mm Hg and 14 mm Hg at 2 years follow-up. Glaucoma medications were reduced from a mean of 3 preoperatively to 2 postoperatively.

CONCLUSIONS

Implantation of an FP8 Ahmed glaucoma valve is a relatively safe procedure to achieve satisfactory IOP and decreased reliance on glaucoma medications in an advanced age population.

The role of primary needle revision after Ahmed glaucoma valve (AGV) implantation

PURPOSE

To evaluate the efficacy and safety of primary needle revision after Ahmed Glaucoma Valve (AGV) implantation in comparison with glaucoma medication use.

METHODS

In this interventional case series, 23 eyes of 23 patients who underwent AGV implantation were enrolled. Needle revision was performed when the intraocular pressure was higher than the target pressure before glaucoma medications. Using a 30-gauge needle, the Tenon's capsule over the plate was incised and the bleb was reformed. Patients were examined on a postoperative day one, weekly (for four weeks), and every 1-3 months. Two criteria were used to define cumulative success as a minimum 20% reduction in IOP and 5 < IOP ≤ 21 mmHg (Criteria A) or 5 < IOP ≤ 18 mmHg (Criteria B) without (Complete success) or with (Qualified success) glaucoma medication.

RESULTS

In this pilot study, we enrolled 23 patients with a mean age of 53.8 ± 12.4 years (25-78 years) who underwent AGV implantation and a one-year follow-up period. The mean number of primary needle revision was 2.2 ± 1.6 (1-6). One year postoperatively, the cumulative success rate was 91.4% and 86.9% based on Criteria A and B, respectively. The average of preoperative IOP was 28.26 ± 8.86 mmHg (range 15-46 mmHg), reaching 13.78 ± 3.54 mmHg (range 8-20) at the end of the one-year follow-up. (P < 0.001) The mean preoperative medication significantly decreased from a median of 4 (range 3-4) at baseline to 2 (range 1-4) after the one-year follow-up (P < 0.001). One patient experienced leakage over the plate, which was successfully treated via conservative management.

CONCLUSION

This pilot study showed that primary needle revision is a safe and effective method for controlling IOP after AGV implantation with a lower need for medication.

Relationship between Tube Parameters and Corneal Endothelial Cell Damage after Ahmed Glaucoma Valve Implantation: A Comparative Study

PURPOSE

We compared the clinical factors, including anterior chamber tube parameters, in patients with and without corneal endothelial cell damage after Ahmed glaucoma valve (AGV) implantation.

METHODS

In this retrospective and comparative case series, patients who underwent AGV implantation were enrolled consecutively. Serial specular microscopy was performed before and after AGV implantation. Patients were divided into two groups depending on whether there was a significant decrease in corneal endothelial cell density (ECD), which was determined by each patient's rate of ECD change (%/year), calculated using linear regression analyses. Tube parameters such as the tube-cornea distance (TCD) and tube-cornea angle (TCA) were measured with anterior segment optical coherence tomography. Clinical factors related to the rate of ECD change were evaluated with regression analyses and compared between the two groups. The tipping point at which tube parameters became significantly associated with the rate of ECD change was identified with broken stick regression analyses.

RESULTS

There were 30 eyes (32.3%) with ECD damage (group 1) and 63 eyes (67.7%) without damage (group 2). The mean rate of ECD change (%/year) was -18.82 ± 22.97 and 2.14 ± 2.93 in groups 1 and 2, respectively (p < 0.001). The TCA was the only clinical factor associated with the rate of ECD change (regression coefficient, β = 1.254, p < 0.001). The tipping point in the TCA was 26.70° (95% confidence interval, CI: 23.75-29.64°). The mean TCD (mm) was 0.98 ± 0.38 and 1.26 ± 0.39 (p = 0.002), and the mean TCA (degrees) was 28.67 ± 7.79 and 36.35 ± 5.35 (p < 0.001) in groups 1 and 2, respectively.

CONCLUSIONS

A wider TCA was protectively associated with the rate of ECD change, and the TCA was significantly narrower in patients with ECD damage. When inserting a tube into the anterior chamber, surgeons should therefore try to secure a wide TCA of about 30°. In patients with a narrow TCA after AGV implantation, increased attention should be directed toward whether ECD decreases continuously.

Ahmed Versus Baerveldt Glaucoma Drainage Device in Uveitic Glaucoma: A Retrospective Comparative Study

PRECIS

Baerveldt glaucoma drainage device demonstrated a greater reduction in intraocular pressure (IOP) than Ahmed in patients with uveitic glaucoma. The most common cause of failure was uncontrolled IOP in Ahmed and hypotony in the Baerveldt group.

PURPOSE

To compare the efficacy and safety of Ahmed and Baerveldt glaucoma drainage devices in uveitic glaucoma.

MATERIALS AND METHODS

The retrospective comparative study included patients with uveitic glaucoma who underwent Ahmed or Baerveldt glaucoma drainage device implantation with a minimum follow-up of 3 months. Success was defined as IOP ≥6 and ≤21 mm Hg and >20% reduction on 2 consecutive visits after the third month with (qualified success) or without (complete success) medications and no further glaucoma surgery or loss of vision. IOP, number of medications, visual acuity, complications, and interventions were compared between groups.

RESULTS

In total, 137 eyes of 122 patients (67 Ahmed, 70 Baerveldt) were included. The preoperative IOP and number of medications in the Ahmed group (32.7±10.3 mm Hg; 4.1±1.3) were similar to Baerveldt (32.1±10.2 mm Hg; 4.3±1.3; P=0.73, 0.35). These at the last follow-up were (18.1±9.8 mm Hg; 2.1±1) in Ahmed and (12.7±6.9 mm Hg; 1.3±1.3) in Baerveldt groups (P=0.04, 0.01). The Baerveldt had greater IOP reduction (60.3% vs. 44.5%) and complete success rate (30% vs. 9%) with higher complication rate (51.4% vs. 20.9%) (all P≤0.05). The de novo glaucoma reoperation rate was 19% in the Ahmed group and 4% in the Baerveldt group (P=0.006). Hypotony resulted in failure in 7 eyes (10%) in the Baerveldt group and none in the Ahmed group (P=0.013).

CONCLUSIONS

Higher complete success rate and significantly greater reduction in mean IOP and number of medications were observed in the Baerveldt group, but with a higher rate of complications including hypotony.

Surgical Outcomes of a Second Ahmed Glaucoma Valve Implantation in Asian Eyes with Refractory Glaucoma

Results

The cumulative failure rates were 9.5%, 20.0%, 32.5%, and 46.0% at six months, one year, two years, and three years of follow-up. At final follow-up, complete success and qualified success rates were 23.8% and 33.3%, respectively; mean IOP and number of medications decreased by 5.6 mmHg (23.9%) and 1.7 mmHg (54.8%), respectively, from preoperative baseline (P < 0.01). More common postoperative complications included hypertensive phase (38.1%), corneal decompensation (23.8%), and tube exposure (14.3%).

Conclusion

An additional AGV implant had good short and modest long-term effectiveness in reducing IOP following a failed glaucoma tube shunt in Asian eyes, with the mentioned common postoperative complications to be actively monitored and managed.

Canaloplasty in the Treatment of Primary Open-Angle Glaucoma: Patient Selection and Perspectives

Canaloplasty is a surgical procedure that has undergone a number of developments since its introduction in 2005. Many thousands of canaloplasties have been performed around the world since then and is, by definition, a blebless procedure. It does not necessitate the use of any antifibrotic agents and results in safe and effective IOP reductions in patients with open-angle glaucoma (OAG) with minimal complications and no bleb-related adverse events. When considering the surgical management of patients with early and medium stages of the disease, canaloplasty can be considered as a first line option. This paper will overview the theoretical effectiveness of canal surgery, the fundamental aspects of aqueous outflow resistance with particular emphasis on the role of the trabecular meshwork, Schlemm's canal, and the collector channels, and the methods available for the clinical evaluation of the outflow pathways in relation to the ocular anatomy. Further, the paper will detail the surgical technique itself and how this has developed over time together with the clinical aspects that should be accounted for when selecting patients for this surgery.

Efficacy and Safety of the Ab-interno Xen Gel Stent After Failed Trabeculectomy

AIMS

To assess the efficacy and safety of the Xen gel stent in reducing intraocular pressure (IOP) in eyes with prior failed trabeculectomy and to determine the frequency of complications and further intervention.

METHODS

Retrospective case note review of all patients with prior trabeculectomy undergoing Xen surgery across 5 centers from August 2015 to May 2017.

RESULTS

In total, 17 surgeries were reviewed. IOP reduced from 21.5 (±2.4) mm Hg preoperatively to 13.6 (±3.4) mm Hg at month 12 (P<0.05). Medication usage reduced from 2.8 (±0.6) preoperatively to 1.0 (±1.3) at month 12 (P<0.05). Adverse events included: numerical hypotony (IOP<6 mm Hg) in 4 cases (23.5%) that all resolved spontaneously, IOP spike of ≥30 mm Hg in 2 (11.8%) cases and transient occlusion of the implant by iris in 1 (5.9%) case. Secondary filtration surgery (Baerveldt tube implantation) was required in 2 (11.8%) cases. Postoperative bleb intervention was required in 9 cases (52.9%), usually in the first month after surgery.

CONCLUSIONS

Xen reduces IOP and number of medications in eyes with failed trabeculectomy. Detailed preoperative conjunctival assessment and targeted stent placement is required. Prospective data and follow-up beyond 12 months are required but Xen seems a viable, effective, and safe option after failed trabeculectomy.

Ahmed glaucoma drainage implant surgery in the management of refractory uveitic glaucoma: Long-term follow up

OBJECTIVE

To examine the long-term efficacy, safety and complications of Ahmed glaucoma drainage implant surgery in patients with refractory uveitic glaucoma.

METHODS

Retrospective review of consecutive cases of patients with refractory uveitic glaucoma who underwent Ahmed glaucoma drainage implant surgery between 2004-2014. Demographic characteristics of the study population, visual acuity, intraocular pressure (IOP), number of antiglaucoma medications and operative and postoperative complications were recorded. Complete success was defined as IOP≥5 and ≤18mmHg without any medication, as qualified success if IOP≤18mmHg with one or more medications. Patients with less than 12 months of follow-up were excluded.

RESULTS

21 patients (26 eyes) were included. The mean postoperative follow-up was 53.5±31 months. Eight eyes (30%) had at least one previously failed glaucoma surgery. IOP was reduced from a mean of 30.0mmHg to 14.0mmHg at the last follow-up visit (P<.001). The number of IOP-lowering medications was reduced from a median of 2.9 preoperatively to 1.1 at the last follow-up (P<.001). Overall, 7 eyes (27%) were classified as complete success, 13 eyes (50%) were considered as qualified success, and 6 eyes (23%) met the criteria for failure. The most common postoperative complication was hypertensive phase in 12 eyes (46%). Kaplan-Meier life-table analysis showed a cumulative probability of success after Ahmed glaucoma valve implantation of 65% at 84 months.

CONCLUSIONS

Ahmed glaucoma drainage implant surgery may be considered a long-term effective and safety surgical option for patients with refractory uveitic glaucoma.

A novel surgical technique for prevention of Ahmed glaucoma valve tube exposure: long scleral flap augmented with Tenon advancement and duplication

Background

To describe a new technique and present its long-term outcome for prevention of Ahmed glaucoma valve (AGV) tube exposure in patients with refractory glaucoma.

Methods

Twenty-seven eyes of 24 patients (mean age, 50 years; age range, 16–78 years; 8 females, 16 males) with refractory glaucoma who had the AGV implant were retrospectively reviewed. For AGV implantation, a long scleral flap combined with Tenon advancement and duplication was used. In this technique, a long scleral flap is created to completely cover the extraocular part of valve’s tube, and the flap surface is covered with duplicated Tenon’s tissue. The average follow-up after AGV implantation was 21.7 months (range, 12–36 months).

Results

The mean intraocular pressure before the operation, which was 44.1 mmHg (range, 26–62 mmHg), decreased to 14.2 mmHg (range, 8–20 mmHg) at the last follow-up visit, showing 67% reduction with AGV implantation. The mean number of antiglaucomatous medications was 4.1 before the AGV implantation and decreased to 0.9 after the operation, showing 88% reduction. In 14 eyes (51.9%), there was no change in the best corrected visual acuity (BCVA), and in 11 eyes (40.7%), the BCVA increased by 2 lines on the Snellen chart postoperatively. No patient developed postoperative hypotony, flat anterior chamber, diplopia, strabismus, erosion or exposure of the tube, or tube/plate migration.

Conclusions

The long scleral flap augmented with Tenon advancement and duplication is an effective and safe surgical technique for the implantation of AGV and preventing tube exposure in cases of refractory glaucoma.

Fuchs heterochromic iridocyclitis-associated glaucoma: a retrospective comparison of primary Ahmed glaucoma valve implantation and trabeculectomy with mitomycin C

Background: The aim of this study was to compare the safety and efficacy of primary trabeculectomy with mitomycin C and Ahmed glaucoma valve (AGV) implantation in patients with Fuchs heterochromic iridocyclitis (FHIC)-related glaucoma, a rare complication of an uncommon form of uveitis. Methods : In this retrospective comparative case series, 26 FHIC-associated glaucoma patients received trabeculectomy (n=12) or an AGV (n=14). Primary outcome measures were surgical success, defined as intraocular pressure (IOP) ≤21 mmHg, decreasing ≥20% from baseline, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, best corrected visual acuity (BCVA), and IOP. Results: The follow-up was 34.0±17.7 months in patients that received trabeculectomy and 33.4±18.6 months in AGV (P= 0.837). The cumulative probability of success rate was 41.7% for trabeculectomy and 85.7% for AGV, with no significant difference in complications (P>0.05). The IOP in patients that received trabeculectomy dropped from 23.4±3.3 mmHg to 21.6±5.2 mmHg at the final visit (P= 0.041). In patients that received AGV, the IOP decreased from 24±7.8 to 17.1±2.6 mmHg (P= 0.003). The number of glaucoma medications at baseline were 3.3±0.5 in those that received trabeculectomy and 3±0.6 in those that received AGV (P=0.233), and decreased to 2.4±1.0 (P=0.008) and 1.7±0.6 (P=0.002), respectively. BCVA was equal in both groups and did not change (P>0.05). Conclusion: Primary AGV had a higher success rate than trabeculectomy, with patients also needing fewer medications for the management of FHIC-associated glaucoma.

Fuchs heterochromic iridocyclitis-associated glaucoma: a retrospective comparison of primary Ahmed glaucoma valve implantation and trabeculectomy with mitomycin C

Background: The aim of this study was to compare the safety and efficacy of primary trabeculectomy with mitomycin C and Ahmed glaucoma valve (AGV) implantation in patients with Fuchs heterochromic iridocyclitis (FHIC)-related glaucoma, a rare complication of an uncommon form of uveitis. Methods : In this retrospective comparative case series, 26 FHIC-associated glaucoma patients received trabeculectomy (n=12) or an AGV (n=14). Primary outcome measures were surgical success, defined as intraocular pressure (IOP) ≤21 mmHg, decreasing ≥20% from baseline, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, best corrected visual acuity (BCVA), and IOP. Results: The follow-up was 34.0±17.7 months in patients that received trabeculectomy and 33.4±18.6 months in AGV (P= 0.837). The cumulative probability of success rate was 41.7% for trabeculectomy and 85.7% for AGV, with no significant difference in complications (P>0.05). The IOP in patients that received trabeculectomy dropped from 23.4±3.3 mmHg to 21.6±5.2 mmHg at the final visit (P= 0.041). In patients that received AGV, the IOP decreased from 24±7.8 to 17.1±2.6 mmHg (P= 0.003). The number of glaucoma medications at baseline were 3.3±0.5 in those that received trabeculectomy and 3±0.6 in those that received AGV (P=0.233), and decreased to 2.4±1.0 (P=0.008) and 1.7±0.6 (P=0.002), respectively. BCVA was equal in both groups and did not change (P>0.05). Conclusion: Primary AGV had a higher success rate than trabeculectomy, with patients also needing fewer medications for the management of FHIC-associated glaucoma.

Comparison of surgical outcomes of trabeculectomy, Ahmed shunt, and Baerveldt shunt in uveitic glaucoma

Background

Uveitis is defined as a collection of syndromes involving intraocular inflammation which can lead to pain, tissue damage, and vision loss. Ophthalmic surgery in uveitis patients can be challenging due to inflammation-induced fibrosis and scarring. Trabeculectomy and implantation of glaucoma drainage devices (aqueous shunts) have been used in surgical management of uveitic glaucoma, however there is a paucity of literature examining the comparative results of these entities in this unique setting. The purpose of this retrospective comparative study is to compare clinical outcomes of trabeculectomy with MMC, Ahmed shunt, and Baerveldt shunt surgery specifically in uveitic glaucoma.

Results

Median IOP, IOP reduction, glaucoma medication use, and visual acuity at 6- and 12-month follow-up were similar across groups. Postoperative hypotony rate was significantly different across trabeculectomy (53%), Baerveldt (24%), and Ahmed (18%) groups (p = 0.027); other complication rates were similar. Baerveldt eyes had a lower failure rate compared to trabeculectomy (p = 0.0054) and Ahmed (p = 0.0008) eyes.

Conclusions

While there was no difference in IOP reduction between trabeculectomy, Ahmed, and Baerveldt, Baerveldt eyes had the lowest failure rate.

Ahmed glaucoma valve in uveitic patients with fluocinolone acetonide implant-induced glaucoma: 3-year follow-up

Purpose

To evaluate the efficacy and safety of Ahmed glaucoma valve (AGV) in eyes with noninfectious uveitis that had fluocinolone acetonide intravitreal implant (Retisert™)-induced glaucoma.

Methods

This retrospective study reviewed the safety and efficacy of AGV implantation in patients with persistently elevated intraocular pressure (IOP) after implantation of a fluocinolone acetonide intravitreal implant at the Massachusetts Eye Research and Surgery Institution between August 2006 and November 2015.

Results

Nine patients with 10 uveitic eyes were included in this study, none of which had preexisting glaucoma in the study eye. Mean patient age was 42 years; 6 patients were female and 3 were male. Baseline mean IOP was 30.6 mmHg prior to AGV placement while mean IOP-lowering medications were 2.9. In the treatment groups, there was a statistically significant reduction in post-AGV IOP. IOP was lowest at 1-week after AGV implantation (9.0 mmHg). Nine out of 10 eyes achieved an IOP below target value of 22 mmHg and/or a 20% reduction in IOP from baseline 1 month and 1 year following AGV placement. All other postoperative time points showed all 10 eyes reaching this goal. A statistically significant decrease in IOP-lowering medication was seen at the 1-week, 1-month, and 3-year time points compared to baseline, while a statistically significant increase was seen at the 3-month, 6-month, and 2-year post-AGV time points. No significant change in retinal nerve thickness or visual field analysis was found.

Conclusion

AGV is an effective and safe method of treatment in fluocinolone acetonide intravitreal implant-induced glaucoma. High survival rate is expected for at least 3 years.

Long-term outcomes of uveitic glaucoma treated with Ahmed valve implant in a series of Chinese patients

AIM

To report long-term outcomes of secondary glaucoma due to uveitis treated with Ahmed glaucoma valve (AGV) implantation in a series of Chinese patients.

METHODS

The retrospective study included 67 eyes from 56 patients with uveitic glaucoma who underwent AGV implantation. Success of the treatment was defined as patients achieving intraocular pressure (IOP) levels between 6 and 21 mm Hg with or without additional anti-glaucoma medications and/or a minimum of 20% reduction from baseline IOP. The main outcome measurements included IOP, the number of glaucoma medications at 1, 3, 6, 12, 24, 36, 48 and 60mo after surgery, surgical complications, final best-corrected vision acuity (BCVA), visual field (VF) and retinal nerve fiber layer (RNFL).

RESULTS

The mean follow-up was 53.3±8.5 (range 48 to 60)mo. The cumulative probability of success rate was 98.5%, 95.5%, 89.6%, 83.6%, 76.1%, 70.1%, 65.7% and 61.2% at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively. IOP was reduced from a baseline of 30.8±6.8 to 9.9±4.1, 10.1±4.2, 10.9±3.7, 12.9±4.6, 13.8±3.9, 13.2±4.6, 12.3±3.5 and 13.1±3.7 mm Hg at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively (P<0.01). The number of postoperative glaucoma medications was significantly decreased compared with baseline at all time points during the study period (P<0.05). There was no significant difference between preoperative and postoperative BCVA. Remarkable surgical complications were not found after surgery. The VF and RNFL of the patients were stable after the surgery.

CONCLUSION

AGV implantation is safe and effect in terms of reducing IOP, decreasing the number of glaucoma medications, and preserving vision for patients with uveitic glaucoma.

Managing high risk glaucoma with the Ahmed valve implant: 20 years of experience

AIM

To estimate the efficacy and safety of the Ahmed implant in patients with high risk for failure after glaucoma surgery.

METHODS

In 342 eyes of 342 patients with refractory glaucoma, even with application of medical treatment, the Ahmed valve was introduced for intraocular pressure (IOP) control, in the period of the last 20y. The nature of glaucoma was neovascular in 162 eyes, pseudophakic or aphakic in 49 eyes, inflammatory in 29 eyes and non working previous antiglaucomatic surgical interventions in 102 eyes.

RESULTS

Follow-up ranged from 18 to 120mo with a mean follow-up of 63.2mo. IOP before the operation decreased from 31.6±10.4 mm Hg to 18.3±5.4 mm Hg (no systemic treatment) at the end of follow up period. When we compared the IOP values before the operation using ANOVA showed statistically significant difference (P<0.001). The success rate was 85.2% during the first semester, 76.8% at 12mo and 50.3% at the end of follow up period (18 to 120mo after implantation). Success rate was 25.7% in neovascular glaucoma, 63.2% in aphakic glaucoma and 73.8% in non working previous antiglaucomatic surgical interventions. Complications due to the implant were: serous choroidal detachment in 14.8%, blockage of the tube in 2.8%, malposition of the tube in 4.9%, suprachoroidal hemorrhage in 2.1%, cataract progression in 39.6% (phakic eyes), shallow anterior chamber in 9.2%, hyphaema in 28.9%, exposure of valve in 2.6%, exposure of tube in 9.3%, hypotony in 4.9% and conjunctival fibrosis in 41.5%.

CONCLUSION

Despite the fact that Ahmed valve implant had suchlike results as other implants concerning the IOP control, complications rate due to hypotony or over filtration in the first days after the intervention are not that frequent as with other valve implants.

Outcomes of severe uveitic glaucoma treated with Baerveldt implant: can blindness be prevented?

PURPOSE

To evaluate long-term outcomes on efficacy and safety of severe uveitic glaucoma treated with a Baerveldt glaucoma implant (BGI).

METHODS

A retrospective study of 47 eyes of 47 patients with uveitic glaucoma treated by a BGI between September 2002 and September 2015. Main outcome measures were intraocular pressure (IOP), number of glaucoma medications, course of the uveitis, visual acuity (VA) and complications.

RESULTS

Mean IOP dropped from 30.6 ± 8.1 mmHg with 3.6 ± 1.1 glaucoma medications at baseline to 10.6 ± 4.3 mmHg with 1.0 ± 1.3 glaucoma medications after a mean follow-up of 63.6 ± 43.1 months. In the majority of cases, IOP remained stable during follow-up. However, especially in several patients with viral uveitis, episodes with IOP peaks were observed during a flare-up despite a functioning implant. These peaks remained below preoperative levels. During follow-up, 16 patients (34%) experienced a clinically significant VA loss, mainly because of late-stage glaucoma or hypotony maculopathy. Early postoperative complications were transient choroidal effusion (n = 5), shallow/flat anterior chamber (n = 4), hyphaema (n = 2) and suprachoroidal haemorrhage (n = 1). The most important late postoperative complication was hypotony maculopathy (n = 5), three of these in juvenile idiopathic arthritis (JIA) patients.

CONCLUSION

The BGI is an effective and safe treatment for patients with refractive secondary glaucoma due to uveitis. In a majority of patients, VA remains stable and a low and stable IOP is maintained over time with an acceptable number of complications. In particular, patients with viral uveitis and glaucoma should be closely monitored for IOP peaks that may occur during episodes of a flare-up of uveitis, whereas at the other end of the spectrum, patients with JIA seem much more prone to hypotony maculopathy.

Argon-Laser Iridoplasty in the Management of Uveitis-Induced Acute Angle-Closure Glaucoma

Purpose

To report the use of argon laser iridoplasty in the management of uveitic acute angle-closure glaucoma.

Methods

Interventional case report.

Results

A 46-year-old man developed uveitic acute angle-closure glaucoma with an intraocular pressure (IOP) of 65 mmHg. After unsuccessful attempts with medical treatment and two laser peripheral iridotomies, iridoplasty allowed to break posterior synechiae, open the angle, and reduce the IOP within a few hours.

Conclusions

Argon laser iridoplasty allowed rapid reduction of IOP and prevented the need for emergency surgery. Therefore, the authors stipulate that it is a viable management option in active uveitic acute angle-closure glaucoma.

[Ahmed valve in glaucoma surgery]

This is a review on Ahmed valve application in glaucoma surgery. It contains, in particular, data on the Ahmed valve efficiency, results of experimental and histological studies of filtering bleb encapsulation, examines the use of antimetabolites and anti-VEGF agents, and discusses implantation techniques. The current appraisal of antimetabolites delivery systems integrated into the Ahmed valve is presented. Various complications encountered in practice and preventive measures are also covered.

A retrospective study on the outcomes of Ahmed valve versus Ahmed valve combined with fluocinolone implant in uveitic glaucoma

Purpose

To compare the intraocular pressure (IOP) outcomes of Ahmed glaucoma valve (AGV) surgery alone versus AGV with fluocinolone implant in uveitic glaucoma patients.

Methods

We identified uveitic glaucoma patients with AGV surgery alone and AGV surgery combined with fluocinolone implant from the Massachusetts Eye and Ear Ocular Inflammation Database. Demographic information, visual acuity, and IOP were recorded at preoperative visits and 1, 6, and 12 months after surgery. Incidence of hypertensive phase, defined as an IOP of >21 mm Hg or use of additional treatment to lower IOP occurring any time between 7 days to 6 months postoperatively, was investigated. Multilevel mixed effects models were performed to compare the outcomes between groups.

Results

Eighteen eyes of 13 uveitic glaucoma patients with 1-year follow-up data were included. There were 11 eyes of 9 patients (mean age, 56.5 years; 63.6% male) in the AGV group and 7 eyes of 4 patients (mean age, 61.3 years; 71.4% male) in the AGV + fluocinolone group. There was no significant difference in visual acuity change at 1 year after surgery between groups (P = 0.25), although visual acuity improvement was significant in the AGV group (P = 0.01). The hypertensive phase occurred in 91% of AGV patients and 43% of AGV + fluocinolone patients (P = 0.30), with onset of 8-40 days (mean, 18 days) after surgery. IOP and number of glaucoma medications decreased at the 1-year postoperative visits in both the AGV group (P < 0.0001, P < 0.0001) and the AGV + fluocinolone group (P = 0.001, P < 0.0001). Compared to the AGV group, the AGV + fluocinolone group used fewer glaucoma medications (0.28 vs 1.30 [P = 0.01]) and had better inflammation control (P = 0.02). The surgical complication rates were similar between groups.

Conclusions

In uveitic glaucoma, AGV with fluocinolone achieves a similar, desired IOP control but with fewer glaucoma medications than AGV alone.

Long-term outcomes of Ahmed tube implantation in pediatric glaucoma after multiple surgeries

PURPOSE

To report success of Ahmed glaucoma valve (AGV) implantation in eyes with pediatric glaucoma and subconjunctival scarring from previous surgeries.

METHODS

A retrospective review of pediatric glaucoma patients who underwent AGV implantation after ≥ 2 previous surgeries with conjunctival scarring. Preoperative and postoperative parameters were recorded to study success, defined as intraocular pressure (IOP) < 22 mmHg with or without medications and without serious complications.

RESULTS

Eleven eyes of 10 patients were included, and the mean age was 12.7 years. Diagnoses included primary childhood glaucoma, aphakic glaucoma, and anterior segment anomalies. Mean number of prior ocular surgeries was 3.3 (± 1.3). Final mean IOP was 17.5 (± 4.3) mmHg, significantly different from the preoperative mean of 24.8 (± 6.8) mmHg, p = 0.01. Mean number of anti-glaucoma medications also decreased significantly from 2.8 (± 1.5) to 1.4 (± 1.5), p = 0.02. The success rate was 82% at a mean follow-up of 51.6 (± 10.8) months. Complications were minor and transient.

CONCLUSION

Subconjunctival scarring did not increase the risk of failure of tube shunt surgery.

Combined Ahmed valve and phacoemulsification with intraocular lens implantation under infliximab in refractory uveitic glaucoma

PURPOSE

To evaluate the outcome of combined Ahmed glaucoma valve (AGV) and phacoemulsification with posterior chamber intraocular lens implantation under infliximab in refractory uveitic glaucoma (UG).

METHODS

In this prospective interventional case series, 26 eyes of 26 patients with refractory UG underwent surgery under intravenous infliximab. The success rate was defined as intraocular pressure (IOP) 5 to 21 mm Hg with or without antiglaucoma medications (AGM), without additional glaucoma surgical intervention.

RESULTS

The mean IOP (37.8 ± 11.86 to 12.2 ± 2.8 mm Hg; p<0.0001) and mean number of AGM (3.4 ± 1.2 to 0.4 ± 0.1; p<0.001) were significantly reduced after surgery at 2 years. Kaplan-Meier survival analysis showed a cumulative probability of success for IOP control of 92% at 2 years of follow-up.

CONCLUSIONS

Combined AGV and phacoemulsification is an effective treatment for controlling refractory UG with complicated cataract under infliximab.

Risk of Ocular Hypertension in Adults with Noninfectious Uveitis

PURPOSE

To describe the risk and risk factors for ocular hypertension (OHT) in adults with noninfectious uveitis.

DESIGN

Retrospective, multicenter, cohort study.

PARTICIPANTS

Patients aged ≥18 years with noninfectious uveitis seen between 1979 and 2007 at 5 tertiary uveitis clinics.

METHODS

Demographic, ocular, and treatment data were extracted from medical records of uveitis cases.

MAIN OUTCOME MEASURES

Prevalent and incident OHT with intraocular pressures (IOPs) of ≥21 mmHg, ≥30 mmHg, and increase of ≥10 mmHg from documented IOP recordings (or use of treatment for OHT).

RESULTS

Among 5270 uveitic eyes of 3308 patients followed for OHT, the mean annual incidence rates for OHT ≥21 mmHg and OHT ≥30 mmHg are 14.4% (95% confidence interval [CI], 13.4-15.5) and 5.1% (95% CI, 4.7-5.6) per year, respectively. Statistically significant risk factors for incident OHT ≥30 mmHg included systemic hypertension (adjusted hazard ratio [aHR], 1.29); worse presenting visual acuity (≤20/200 vs. ≥20/40, aHR, 1.47); pars plana vitrectomy (aHR, 1.87); history of OHT in the other eye: IOP ≥21 mmHg (aHR, 2.68), ≥30 mmHg (aHR, 4.86) and prior/current use of IOP-lowering drops or surgery in the other eye (aHR, 4.17); anterior chamber cells: 1+ (aHR, 1.43) and ≥2+ (aHR, 1.59) vs. none; epiretinal membrane (aHR, 1.25); peripheral anterior synechiae (aHR, 1.81); current use of prednisone >7.5 mg/day (aHR, 1.86); periocular corticosteroids in the last 3 months (aHR, 2.23); current topical corticosteroid use [≥8×/day vs. none] (aHR, 2.58); and prior use of fluocinolone acetonide implants (aHR, 9.75). Bilateral uveitis (aHR, 0.69) and previous hypotony (aHR, 0.43) were associated with statistically significantly lower risk of OHT.

CONCLUSIONS

Ocular hypertension is sufficiently common in eyes treated for uveitis that surveillance for OHT is essential at all visits for all cases. Patients with 1 or more of the several risk factors identified are at particularly high risk and must be carefully managed. Modifiable risk factors, such as use of corticosteroids, suggest opportunities to reduce OHT risk within the constraints of the overriding need to control the primary ocular inflammatory disease.

Modified Descemet's stripping automated endothelial keratoplasty for eyes with glaucoma drainage devices and shallow anterior chambers

PURPOSE

To present a modified Descemet's stripping automated endothelial keratoplasty (DSAEK) technique to avoid risks of endothelial cell loss related to the presence of a glaucoma tube in cases with shallow anterior chamber.

METHOD

A 72-year-old patient with an only eye and corneal decompensation secondary to a Baerveldt tube was referred for keratoplasty. He was pseudophakic and had shallow anterior chamber. His best-corrected visual acuity was counting fingers close to face. He underwent a combined procedure with withdrawal and shortening of tube followed by a modified DSAEK employing a 7.5-mm donor graft in which a peripheral notch was performed to overlay the silicon tube.

RESULTS

No intraoperative or postoperative complications were noted. The endothelial cell count was 2000/mm² after 15 months of the surgery. His best-corrected visual acuity remains 6/18 with a stable glaucoma.

CONCLUSION

This modified technique of DSAEK offers the benefits of endothelial transplant, and it could represent an option to reduce risks of corneal decompensation due to the presence of tubes in cases with shallow anterior chambers.

Deep sclerectomy for uveitic glaucoma: long-term outcomes

PurposeTo report long-term outcomes of deep sclerectomy (DS) in eyes with raised intraocular pressure (IOP) and glaucoma secondary to uveitis.Patients and methodsRetrospective consecutive case series of 43 eyes of 43 patients with uveitic glaucoma. Mitomycin C (MMC) 0.2-0.4 mg/ml was applied sub-conjunctivally prior to scleral flap dissection for 2-3 min in 35 eyes (81%). Combined phacoemulsification and DS was done in 4 cases (9%).ResultsMean follow-up was 68.5±33.5 months. In total, 23 eyes (53.5%) had previous intraocular surgery. Pre-operative IOP was 33.6±12.0 mm Hg. Mean IOP at one, three and five years after surgery was 15.5±5.0 mm Hg, 16.9±6.7 mm Hg and 16.4±5.2 mm Hg, respectively.The probability of IOP <22 and <19 mm Hg was 69 and 62% at 3 years and 60 and 51% at 5 years, respectively. This included eyes that had undergone needle revision and/or laser goniopuncture within that period but had not needed glaucoma medication or further glaucoma procedures. The overall number of glaucoma medications decreased from 3.0±1.2 to 0.8±1.2 by last follow-up (P<0.001). Serious complications included hypotony with macular folds in two eyes and occlusion of the trabeculo-Descemet's membrane (TDM) by iris in two eyes. Recurrence of uveitis was observed in 16 eyes. Seven eyes (16.3%) had subsequent procedures including trabeculectomy with MMC in one eye, DS with MMC in two eyes and Baerveldt tube implantation in five eyes.ConclusionsDS is a safe and effective procedure to lower IOP in uveitic glaucoma. However, as with other glaucoma procedures, a significant proportion of patients will require another IOP-lowering procedure in the long-term.

Short- to long-term results of Ahmed glaucoma valve in the management of elevated intraocular pressure in patients with pediatric uveitis

OBJECTIVE

The aim of this study was to evaluate the long-term outcome of Ahmed glaucoma valve (AGV) implant for elevated intraocular pressure (IOP) in pediatric patients with uveitis.

DESIGN

This was a retrospective chart review.

PARTICIPANTS

The study included 16 eyes (11 children) with uveitis.

METHODS

Success was defined as having IOP between 6 and 21 mm Hg with (qualified success) or without (complete success) antiglaucoma medications and without the need for further glaucoma or tube extraction surgery.

RESULTS

Mean age of patients at the time of AGV implantation was 14.19 ± 3.25 years. AGV implantation was the first glaucoma surgical procedure in 12 eyes (75%). Average postoperative follow-up period was 64.46 ± 33.56 months. Mean preoperative IOP was 33.50 ± 7.30 mm Hg versus 12.69 ± 3.20 mm Hg at the last follow-up visit (p < 0.001). Three eyes (18.7%) were determined as cases of "failure" because of tube removal in 2 eyes and a second AGV implantation in 1 eye. The cumulative probability of complete success was 68.8% at 6 months, 56.3% at 12 months, 49.2% at 36 months, 42.2% at 48 months, and 35.2% at 84 months, and the cumulative probability of eyes without complication was 75.0% at 6 months, 66.7% at 24 months, 58.3% at 36 months, 48.6% at 48 months and 24.3% at 108 months based on Kaplan-Meier survival analysis.

CONCLUSIONS

Although AGV implant is an effective choice in the management of elevated IOP in pediatric uveitis, antiglaucoma medications are frequently needed for control of IOP. Tube exposure is an important complication in the long term. Differential diagnosis between relapse of uveitis and endophthalmitis is important in patients who received AGV implantation.

Assessment of conditions affecting surgical success of Ahmed glaucoma valve implants in glaucoma secondary to different uveitis etiologies in adults

PurposeThere is little known about the long-term efficacy and safety of Ahmed glaucoma valve (AGV) implant and about the conditions affecting surgical success in uveitic glaucoma (UG).Patients and methodsThe charts of adult patients with UG who underwent AGV implantation from 2006 to 2015 were reviewed retrospectively.ResultsData of 46 eyes of 39 patients were evaluated. Mean follow-up was 51.93±23.08 months. Mean preoperative IOP was 37.05±9.62 mm Hg and mean number of preoperative topical anti-glaucomatous medications was 2.98±0.27. One eye (2%) was defined as failure because of implant extraction surgery. In the rest of the eyes, intraocular pressure (IOP) was under control with or without anti-glaucomatous medications during follow-up. The cumulative probability of complete success (IOP control without medications) was 78% at 6 months, 76% at 1 year, 71% at 2 years, 66% at 3 years, and 63% at 4 years (95% confidence interval, 61.24-87.81). The cumulative probability of eyes without complication was 64% at 6 months, 48% at 12 months, 44% at 24 months, 41% at 36 months, and 38% at 48 months (95% confidence interval, 34.64-62.85). Complete success was lower in eyes with previous ocular surgery than the eyes without (P=0.061) and it was lower in eyes with active inflammation at the time of surgery than the eyes without (P=0.011).ConclusionAGV implantation is an effective and safe alternative method in the management of UG, especially when it is performed as a primary surgical option and when no inflammation is present preoperatively.

A Review of the Ahmed Glaucoma Valve Implant and Comparison with Other Surgical Operations

The Ahmed glaucoma valve (AGV) is a popular glaucoma drainage implant used for the control of intraocular pressure in patients with glaucoma. While in the past AGV implantation was reserved for glaucoma patients poorly controlled after one or more filtration procedures, mounting evidence has recently encouraged its use as a primary surgery in selected cases. AGV has been demonstrated to be safe and effective in reducing intraocular pressure in patients with primary or secondary refractory glaucoma. Compared to other glaucoma surgeries, AGV implantation has shown favorable efficacy and safety. The aim of this article is to review the results of studies directly comparing AGV with other surgical procedures in patients with glaucoma.

Combined Ahmed Glaucoma Valve Placement, Intravitreal Fluocinolone Acetonide Implantation and Cataract Extraction for Chronic Uveitis

PURPOSE

To report the outcomes of combined Ahmed glaucoma valve (AGV) placement, intravitreal fluocinolone acetonide implant, and cataract extraction procedure in the treatment of chronic noninfectious uveitis.

PATIENTS AND METHODS

Retrospective case series of patients with chronic noninfectious uveitis who underwent AGV placement, intravitreal fluocinolone acetonide implantation, and cataract extraction in a single surgical session performed at 1 institution from January 2009 to November 2014. Outcome measures included intraocular pressure (IOP) and glaucoma medication use. Secondary outcome measures included visual acuity, systemic anti-inflammatory medications, number of uveitis flares, and complications.

RESULTS

Fifteen eyes of 10 patients were studied, with a mean age of 40.3±15.7 and mean follow-up duration of 26 months (range, 13 to 39 mo). Before surgery, the IOP was 18.5±7.3 mm Hg and patients were using 1.5±1.5 topical glaucoma medications. At the 12-month follow-up, IOP was 12.8±3.2 mm Hg (P=0.01) and patients were using 0.5±0.8 (P=0.03) topical glaucoma medications. At 36 months of follow-up, late, nonsustained hypotony had occurred in 3 eyes (20%), and 1 eye (6%) had received a second AGV for IOP control. Before treatment, patients had 2.7±1.5 uveitis flares in the year before surgery while on an average of 2.1±0.6 systemic anti-inflammatory medications, which decreased to an average of 0.1±0.3 (P<0.01) flares the year after surgery while on an average of 0.4±1.1 (P<0.01) systemic medications.

CONCLUSION

Combined AGV, intravitreal fluocinolone acetonide implant, and cataract extraction is effective in controlling IOP and reducing the number of glaucoma medications at 12 months after treatment in patients with chronic uveitis.