Long-term Efficacy of the Baerveldt 250 mm2 Compared with the Baerveldt 350 mm2 Implant

Systematic Literature Reviews Comparing the Long-Term Safety Outcomes for the Port Delivery System with Ranibizumab (PDS) Versus Other Ocular Implants

OBJECTIVES

To determine whether the types and rates of post-surgical complications associated with the Port Delivery System with ranibizumab (PDS) are comparable with those reported for other ocular implants that cross the sclera.

METHODS

Systematic literature reviews were conducted to determine the long-term (≥ 18-month) safety of ocular implants that cross the sclera in clinical trials and real-world studies. Complication types and rates were compared with those reported for the PDS in phase III clinical trials (Archway, Pagoda, and Pavilion).

RESULTS

Sixteen clinical trials (24 publications) and 43 real-world studies were identified reporting 30 complications in eyes with 15 implant types and 8 ocular diseases. Implants were associated with an acceptable, well-characterized safety profile, with most complications resolving spontaneously or with treatment. Device-related complications were reported in 0.7% (0.0-5.0%) of study eyes in clinical trials and 1.3% (0.0-14.5%) of eyes in real-world studies. Rates of conjunctival complications were 2.1% (0.0-22.8%) and 2.2% (0.9-4.6%), respectively. The overall types and rates of adverse events of special interest reported for the PDS in phase III trials (cataract, conjunctival bleb, vitreous hemorrhage, conjunctival erosion, conjunctival retraction, endophthalmitis, implant dislocation, retinal detachment, and hyphema) were within the ranges reported for other ocular implants.

CONCLUSIONS

The rates of complications reported in phase III clinical trials for the PDS were within the ranges reported for other ocular implants that cross the sclera. This suggests that the long-term safety of the PDS is consistent with other ocular devices established in ophthalmology clinical practice.

TRIAL REGISTRATION

PROSPERO international prospective register of systematic reviews: CRD5202234129, CRD42022343129.

Ahmed ClearPath vs. Baerveldt Glaucoma Implant: A Retrospective Noninferiority Comparative Study

PURPOSE

To compare the efficacy and safety of 2 nonvalved glaucoma drainage devices (GDDs): Ahmed ClearPath (ACP) vs. Baerveldt glaucoma implant (BGI).

DESIGN

Single-center, retrospective, comparative study.

PARTICIPANTS

Consecutive patients who underwent ACP or BGI surgery for glaucoma (250 mm2 or 350 mm2 models), had ≥ 6 months of follow-up, and no prior GDD implantation.

METHODS

Chart review of ACP or BGI surgery in patients with glaucoma at Wills Eye Hospital (2020-2023).

MAIN OUTCOME MEASURES

The primary outcome measure was surgical failure at the end of follow-up, defined as intraocular pressure (IOP) > 21 or < 6 mmHg at 2 consecutive visits, progression to no light perception (NLP) vision, glaucoma reoperation, or implant removal. Secondary outcome measures included the rate of postoperative complications and changes in best corrected visual acuity (BCVA), IOP, and glaucoma medications.

RESULTS

A total of 128 eyes of 113 patients (63 ACP, 65 BGI) with similar baseline characteristics and a mean follow-up duration of 19.6 ± 10.8 (median 20.5) months were included. Surgical failure occurred in 12 eyes (9.4%) with no significant difference between ACP and BGI eyes (9.5% vs. 9.2%, respectively; P = 0.810). Reasons for failure included IOP > 21 mmHg (3/12, 25.0%), glaucoma reoperation (5/12, 41.7%), and tube removal (4/12, 33.3%). No eyes progressed to NLP vision. Kaplan-Meier survival analysis showed similar cumulative rate of surgical failure in both groups (P = 0.871). Both groups achieved significant IOP and medication reduction compared to their baseline. Final IOP, BCVA, and complication rates were similar in both groups, but medication number was significantly lower in the ACP group (P = 0.012). Both the 250 mm2 and 350 mm2 models had similar outcomes, but diplopia was significantly associated with the 350 mm2 model of either implant (P = 0.012). Univariate logistic regression analysis did not identify either tube type or plate size as predictors of surgical failure.

CONCLUSIONS

This study compares the recently approved ACP vs. BGI. Both implants had similar surgical failures and complication rates. Final IOP was similar in both groups, but ACP achieved lower medication number. Diplopia was significantly associated with the use of 350 mm2 model of either implant. Neither tube type nor plate size were significant predictors of surgical failure.

FINANCIAL DISCLOSURE(S)

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

Same-quadrant Baerveldt Glaucoma Implant-250 to Baerveldt Glaucoma Implant-350 exchange

Purpose

In eyes with a prior failed aqueous shunt (or "tube") requiring additional intraocular pressure (IOP) control, options include angle surgery, cyclodestruction, second tube, tube revision, or tube exchange. We present a case of a same-quadrant tube exchange of a Baerveldt-250 (BGI-250) to BGI-350.

Observations

The patient is a 71-year-old African American female with severe-stage primary open angle glaucoma of both eyes, and this case focuses on the right eye. This eye had prior cataract surgery with iStent, prior BGI-250 in the anterior chamber (AC), and prior iStent removal with gonioscopy assisted transluminal trabeculotomy (GATT). The visual acuity (VA) was 20/150, and the IOP was 26 mmHg on 3 IOP-lowering medications. The prior superotemporal BGI-250 had its "wings" on top of the superior and lateral rectus muscles and its tube tip in the AC. The implant was removed in its entirety including the superficial and deep layers of its capsule. The new BGI-350 was stented with a 3-0 polypropylene ripcord, ligated with a 7-0 polyglactin suture, and implanted with its wings under the rectus muscles and the tube tip in the sulcus. For early IOP-lowering prior to ligature dissolution, 2 needle stab fenestrations and an additional 7-0 polyglactin wick was used. The capsule from the prior BGI-250 was used as a patch graft for the new BGI-350. The ligature dissolved at postoperative week (POW) 6. By POW8, the IOP was 18 mmHg on 3 IOP-lowering medications and frequent topical steroid, the AC was quiet, and the ripcord was removed. A slow steroid taper finished at postoperative month (POM) 6. By POM 12, the VA was still at baseline 20/150, and the IOP was 14 mmHg on 3 IOP-lowering medications.

Conclusions & importance

Patients with a prior failed tube requiring additional IOP-lowering can undergo a same-quadrant tube exchange. BGI-350s may offer more IOP-lowering than BGI-250s, but the IOP-lowering achieved in this patient's case could be attributable to differences in postoperative management in addition to endplate size; longer follow-up is needed. A tube exchange offers the opportunity to reposition the tube tip from the AC to the sulcus and to use the prior tube's capsule as a patch graft for the new tube.

Choroidal Effusions after Glaucoma Drainage Implant Surgery: Risk Factors and Surgical Management

OBJECTIVE

To report the incidence of patients who developed choroidal effusions after glaucoma drainage implant (GDI) surgery and determine risk factors for and outcomes of surgical intervention.

DESIGN

Retrospective case series.

SUBJECTS

Medical records of 605 patients who underwent GDI surgery from January 1, 2017 to June 7, 2021 at New York University Langone Health and New York Eye and Ear Infirmary of Mount Sinai were reviewed.

METHODS

Preoperative, intraoperative, and postoperative clinical data were obtained. Multivariate logistic regression evaluated the factors associated with the need for surgical intervention. Patient records were analyzed for effusion resolution, intraocular pressure (IOP), visual acuity (VA), and complications across treatment modalities.

MAIN OUTCOME MEASURES

Incidence of choroidal effusion development and need for surgical intervention.

RESULTS

Choroidal effusions developed in 110 (18%) patients (110 eyes). Surgical intervention to drain the effusion or ligate the implant tube was performed in 19 (17%) patients. The average time to surgical intervention was 47.6 days. Among patients who developed postoperative effusions, risk factors for requiring surgical intervention included history of selective laser trabeculoplasty (SLT) (P = 0.004; odds ratio [OR], 14.4), prior GDI surgery (P = 0.04; OR 8.7), 350-mm2 Baerveldt glaucoma implant placement (P = 0.05; OR, 4.8), and anterior chamber shallowing (AC; P < 0.001; OR, 25.1) in the presence of effusions. The subgroup that required multiple surgeries for effusion resolution had a significantly lower mean IOP at the most recent follow-up compared with those who received medical management only (P < 0.001). A higher percentage of patients who required surgical intervention lost VA at the most recent follow-up compared with patients whose effusions resolved with conservative management (i.e., medical management, AC viscoelastic injection).

CONCLUSIONS

Choroidal effusions after GDI surgery resolved with conservative management in most patients. A history of SLT or GDI placement, implantation of a BGI-350, and the presence of a shallow chamber were risk factors for surgical intervention. Although interventions, such as surgical drainage are at times necessary, a better understanding of their impacts can help guide postoperative decisions. The risks and benefits of these procedures must be carefully considered in these high-risk eyes.

FINANCIAL DISCLOSURE(S)

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

Comparing Ahmed-FP7 to Baerveldt-250 and Baerveldt-350 surgical outcomes: 1-year results from a retrospective cohort study leveraging the electronic health record

OBJECTIVE

To compare outcomes following Ahmed-FP7 (AGI-FP7), Baerveldt-250mm2 (BGI-250), or Baerveldt-350mm2 (BGI-350) implantation.

METHODS AND ANALYSIS

Retrospective cohort study comprising 800 eyes from 800 individuals who underwent surgery 1 January 2016-31 December 2020 at a tertiary-care institution. Data were extracted from standardised fields in the electronic health record. Primary outcome was failure (defined as intraocular pressure (IOP) ≤5 mm Hg or >18 mm Hg or reduction <20% at two consecutive visits from month 3 onwards; or visual acuity (VA) loss ≥3 lines; or return to the operating room (OR)). Secondary outcomes were IOP, VA, number of follow-up visits and return to the OR.

RESULTS

A total of 523 AGI-FP7, 133 BGI-250 and 144 BGI-350 cases were analysed. The AGI-FP7 group was more likely to be younger and diagnosed with secondary glaucoma, with a higher mean baseline IOP (28.5±12.2 vs 22.0±7.7 mm Hg in BGI-250 and 23.4±9.0 in BGI-350, p<0.001). Cumulative failure rate at month 12 was 30% (AGI-FP7) vs 39% (BGI-250) vs 33% (BGI-350, p=0.159). Mean IOP at month 12 was lower in the BGI-350 group compared with AGI-FP7 (12.4±4.4 vs 14.8±5.6 mm Hg, p=0.003) but not BGI-250 (vs 13.1±4.6, p=0.710). Target IOP was achieved in 71% of AGI-FP7, 66% BGI-250, and 76% BGI-350. VA loss and rates of return to the OR did not differ between groups. Both BGI-250 and BGI-350 had more follow-up visits than AGI-FP7 (p<0.001).

CONCLUSION

These three glaucoma drainage devices performed similarly within 1 year, with no difference in failure rates despite differing baseline patient characteristics.

Comparing Surgical and Clinical Success Rates of Ahmed FP7, and Baerveldt 250 and Baerveldt 350 Glaucoma Drainage Devices

PRCIS

Surgical and clinical success rates were similar among Ahmed FP7, and Baerveldt 250 and 350 glaucoma drainage devices at three years.

PURPOSE

To compare rates of surgical and clinical success in patients with Ahmed FP7 (FP7), Baerveldt 250 (B250), or Baerveldt 350 (B350) glaucoma drainage devices (GDDs).

DESIGN

A retrospective cohort study.

METHODS

A total of 157 eyes of 129 adult patients with FP7, B250, B350 GDDs, and 190 eyes of 99 medically controlled glaucoma patients were enrolled at a tertiary care institution from August 2017 through July 2019. They were followed through April 2020. The main outcome measures included surgical and clinical failure. Surgical failure was defined as intraocular pressure (IOP) outside 5-21 mm Hg, IOP reduced <20% below baseline, additional glaucoma surgery, GDD removal, or no light perception. Eyes that did not meet their goal IOP ranges or required secondary glaucoma interventions were deemed clinical failures.

RESULTS

A total of 43 (12.4%) FP7, 36 (10.4%) B250, 78 (22.5%) B350, and 190 (54.8%) medically treated control eyes were enrolled. By the postoperative year 3 visit, 10 (23.2%) FP7, 11 (30.6%) B250, and 32 (41.0%) B350 eyes had met a surgical failure criterion ( P =0.127). There were no significant differences in the numbers of eyes meeting their IOP target ranges ( P =0.510), and rates of secondary glaucoma surgeries ( P =0.270). Overall clinical success was attained among 83.3% FP7, 81.8% B250, and 68.0% B350 eyes ( P =0.447).

CONCLUSIONS

The GDD groups were similar in their rates of success, based on both the surgical and clinical success definitions.

Comparing Surgical Outcomes in Neovascular Glaucoma between Tube and Trabeculectomy: A Multicenter Study

OBJECTIVE

To compare the surgical outcomes between Baerveldt glaucoma implant (BGI) surgery and trabeculectomy with mitomycin C for patients with neovascular glaucoma (NVG).

DESIGN

Retrospective clinical cohort study at 5 clinical centers in Japan.

PARTICIPANTS

Patients treated with trabeculectomy or BGI for NVG between April 1, 2012, and December 31, 2019, at 5 clinical centers were recruited.

METHODS

The inclusion criteria were age ≥ 20 years and having NVG. The exclusion criteria were eyes with no light perception vision and with previous tube-shunt surgery. If both eyes in the same patient satisfied the inclusion criteria, the eye that was treated first was investigated. We included 100 eyes undergoing BGI surgery and 204 eyes undergoing trabeculectomy.

MAIN OUTCOME MEASURES

The primary outcome was surgical success or failure, with failure being defined according to 3 criteria: < 20% reduction of the preoperative intraocular pressure (IOP) or criterion A (IOP > 21 mmHg), criterion B (IOP > 17 mmHg), or criterion C (IOP > 14 mmHg). Cases of reoperation, a loss of light perception vision, or hypotony were also considered failures.

RESULTS

The probability of success was significantly higher in patients undergoing BGI surgery than in those receiving trabeculectomy for criteria A (P < 0.01) and B (P = 0.01). Trabeculectomy was significantly associated with surgical failure in the multivariable analysis for criterion A (hazard ratio, 1.70) and criterion B (hazard ratio, 1.50). The overall incidence of postoperative complications was similar between the 2 groups. Reoperations for glaucoma were required significantly more frequently in the trabeculectomy group than in the BGI surgery group (20.1 % vs. 5.0%; P < 0.01).

CONCLUSIONS

Baerveldt glaucoma implant surgery had a higher success rate compared with trabeculectomy in patients with NVG for a target IOP < 21 mmHg or < 17 mmHg. The rates of postoperative complications were similar between both surgical procedures. Additional glaucoma surgery was required more frequently after trabeculectomy than after BGI surgery.

Comparison of Outcomes of Glaucoma Drainage Implant Surgery With or Without Prior Failed Trabeculectomy

PRECIS

A comparison of 186 glaucoma patients with mixed diagnoses who underwent nonvalved glaucoma drainage device (GDD) implant surgery showed similar long-term intraocular pressure (IOP), medication, and visual acuity (VA) outcomes between those with prior failed trabeculectomy surgery versus those without.

PURPOSE

The purpose of this study was to evaluate whether prior failed trabeculectomy adversely affects the outcome of glaucoma tube surgery.

PATIENTS AND METHODS

A total of 186 eyes of 186 patients who underwent a nonvalved GDD implant surgery by a single surgeon between 1996 and 2015 at a University practice were included. Patients were of mixed diagnoses and over 18 years old. Before the GDD surgery, 65 had a previous failed glaucoma filtering surgery and 121 had no prior glaucoma surgery. Demographic information, preoperative and postoperative IOP, medication, VA, and complications were collected from chart review.

RESULTS

No significant difference was noted in mean IOP and mean medication use (13.0 and 12.6 mm Hg on 2.0 and 1.7 medication classes at 5 y postoperatively, respectively), mean VA and change in VA from baseline, or numbers of complications (P>0.05), between eyes that had a prior failed filtration surgery and those that had not. Kaplan-Meier plots for failure over 5 years using a lower limit of <5 mm Hg and an upper limit of ≥18, ≥15, or ≥12 mm Hg did not show a significant difference between groups. Subanalyses were performed to examine only primary glaucoma eyes and results were similar. Further group subanalyses comparing those with baseline IOP ≥25 or <25 mm Hg, age 65 and above or below 65 years and those specifically with Baerveldt 350 mm2 implants also did not show significant differences.

CONCLUSION

Prior failed filtration surgery does not appear to affect the outcome of future GDD surgery.

Rates of Diplopia in Ahmed FP7, Baerveldt 250, and 350 Glaucoma Patients Compared With Medical Controls

PRECIS

Diplopia was present in ~20% of patients with Ahmed FP7 (FP7) or Baerveldt 350 (B350), compared with 5% to 6% in those with Baerveldt 250 (B250) or controls, suggesting risk of diplopia should be included in preoperative counseling.

PURPOSE

The purpose of this study was to examine the prevalence of diplopia and strabismus in patients with B250, B350, or FP7 glaucoma drainage devices (GDD).

MATERIALS AND METHODS

In this cohort study, glaucoma patients 18 years and above who had received, or would be receiving, a B250, B350, or FP7 GDD, and medically treated controls were consecutively enrolled from August 8, 2017, through July 31, 2019. The Diplopia Questionnaire was administered ≥30 days postoperatively, and upon enrollment to the controls. All diplopic patients underwent orthoptic measurements, which were reviewed by a strabismus specialist. Patients with GDDs in quadrants other than superotemporal, multiple GDDs, or scleral buckles were excluded. Bonferroni correction was applied for pairwise comparisons.

RESULTS

Diplopia was reported in 23/129 (17.8%) GDD patients and 5/99 (5.1%) control patients (P=0.003): 8/35 (22.9%) FP7, 2/32 (6.3%) B250, and 13/62 (21.0%) B350, with significant differences between FP7 versus controls (P=0.014) and B350 versus controls (P=0.011). Diplopia was attributable to GDD in 2 FP7 (5.9%, 95% confidence interval: 0.7-19.2), 0 B250, and 4 B350 (6.5%, 95% confidence interval: 1.7-15.2) patients, without significant differences between the GDDs.

CONCLUSIONS

Patients with the larger (B350) or the higher profile plate (FP7) GDDs were more likely to experience diplopia than controls, and diplopia was attributable to the GDD in ~6% of patients with either a FP7 or a B350 GDD. Since diplopia can affect patients' quality of life, preoperative counseling for GDD surgery, particularly B350 and FP7, should include a discussion of the risk of diplopia.

Treatment outcomes in the neovascular glaucoma tube versus trabeculectomy study

PURPOSE

To compare surgical outcomes between patients who underwent Baerveldt glaucoma implantation versus trabeculectomy (TLE) for the treatment of neovascular glaucoma.

METHODS

We performed a prospective, randomized, controlled clinical trial at Hiroshima University and Tsukazaki Hospital, Japan. Patients were randomized to Baerveldt glaucoma implantation (23 patients) or TLE (27 patients). The primary outcome measure was the rate of intraocular-pressure control. Secondary outcome measures included complications and interventions. We defined "failure" as intraocular pressure ≥ 22 mmHg or < 20% reduction from baseline pressure, on two consecutive follow-up visits; need for additional glaucoma surgery; vision-threatening complications; or loss of light perception. Kaplan-Meier analysis was used to determine surgical success rates. Postoperative complications and interventions were compared between the two groups with Pearson Chi-square tests.

RESULTS

There were no significant differences in demographic or ocular characteristics between the treatment groups at baseline. The postoperative follow-up was 26.6 ± 19.4 months in the Baerveldt group and 27.3 ± 20.1 months in the TLE group. There were no statistical differences (Mann-Whitney nonparametric tests with Bonferroni correction) in postoperative intraocular pressure measured at 6-month intervals. Success rates were 59.1 and 61.6% at 1-year after Baerveldt glaucoma implantation and TLE, respectively. Kaplan-Meier analysis showed no significant difference in success between groups (P = 0.71, log-rank test). Medication use, visual acuity, and interventions were similar between groups. Thirteen late postoperative complications developed in the Baerveldt glaucoma implantation group and four complications developed in the TLE group. Tube exposure was the most common late complication.

CONCLUSION

These two procedures produced similar surgical success, intraocular-pressure reductions, visual acuity, and number of medications at the last visit. The TLE group showed smaller numbers of late complications and patients who lost more than two lines of visual acuity. Therefore, TLE might be a safer and better way to treat patients with neovascular glaucoma.

Primary outcomes of Baerveldt glaucoma implants with a modified technique to control intraocular pressure in different cases of glaucoma

INTRODUCTION

To describe the outcomes of Baerveldt glaucoma implants implanted via a modified technique with regard to early intraocular pressure (IOP) reduction in cases of uncontrolled glaucoma.

METHODS

The medical records of patients who had Baerveldt glaucoma implants of 350 or 250 mm² implanted via a modified technique and were followed up for a period of at least 6 months were reviewed. The primary outcome measures were the mean IOP and number of glaucoma medications at each visit. We evaluated complete success rates at 1 day, 1 week and 1 month, defined as IOP values [Formula: see text] 5 mmHg and ≤ 21 mmHg prior to ligature rupture.

RESULTS

A total of 42 eyes had Baerveldt glaucoma implants and met the inclusion criteria. The mean preoperative intraocular pressure (IOP) was 34.2 ± 11.2 mmHg. The postoperative mean IOP values were 15.1 mmHg ± 8.8 (p < 0.05), 17.7 ± 7.1 mmHg (p < 0.05), 12.3 ± 4.0 mm Hg (p < 0.05) at 1 day, 1 month, and 6 months, respectively. The rate of complete success on the first day was 78%, at the first month was 69%, and at 6 months was 95.2%. The number of glaucoma medications used was significantly lower at 6 months (P =  < 0.001).

CONCLUSION

The modified surgical technique using Baerveldt implants enables a safe, effective, and reliable IOP control in early postoperative patients with uncontrolled glaucomas.

Health-related quality of life in Ahmed FP7, and Baerveldt 250 and 350 patients compared with medical controls

PURPOSE

To compare health-related quality of life (HRQoL) in patients with Ahmed FP7 (FP7), Baerveldt 250 (B250) and Baerveldt 350 (B350) glaucoma drainage device (GDDs), and medically treated controls.

METHODS

This was a prospective cohort study from August 2017 to July 2019. The NEI 25-Item Visual Function Questionnaire (VFQ-25), the Adult Strabismus-20 questionnaire (AS-20) and the Diplopia Questionnaire were conducted ≥30 days postoperatively in GDD patients, on enrolment for controls. Age, sex, treatment type, visual acuity, mean deviation and diplopia were evaluated for association with HRQoL RESULTS: Of the 128 GDD patients enrolled, 35 (27.3%) had FP7, 32 (25.0%) had B250 and 61 (47.7%) had B350. In univariate analysis, decreased HRQoL was associated with younger age (r² range 0.042-0.071), diplopia (r² range 0.039-0.119), GDD treatment (r² range 0.023-0.103), lower visual acuity (r² range 0.021-0.215) and worse mean deviation (r² range 0.029-0.131). All GDD groups had lower HRQoL subscores than the controls. HRQoL scores were lower compared with controls among B350 patients for AS-20 Self-perception subscale, B250 and B350 for Reading and General Function subscales, and FP7 and B350 for VFQ-25 Visual Functioning subscale. There were no significant differences among the GDDs.

CONCLUSIONS

Glaucoma patients with a younger age, diplopia, lower visual acuity, worse mean deviation or a GDD had lower HRQoL. Those with B350 had lower self-perception scores, consistent with previous reports in the literature. This subscale was not diminished in FP7 or B250, so the decreased self-perception scores may be due to greater visibility or awareness of the B350.

The Baerveldt Glaucoma Drainage Device: Efficacy, Safety, and Place in Therapy

Objective

This review summarizes published findings concerning the Baerveldt-350 glaucoma drainage device (GDD). Most studies focus on the comparison between different treatments; in this review, the primary focus is efficacy, safety, and place in therapy for the Baerveldt implant.

Methods

A systematic review was performed using the PubMed database for literature on March 13th, 2020. Efficacy was estimated by performing multiple meta-analyses to calculate the weighted mean difference in intraocular pressure (IOP) and IOP-lowering medication after surgery. In order to get an indication of the safety of the Baerveldt implant, all recorded peri- and postoperative complication were summarized.

Results

A total of 21 studies, including 12 randomized controlled trials, were included with a follow-up up to 5 years, covering a mix of glaucoma types. At the last follow-up point, at 5 years postoperative, the mean (95% confidence interval) reduction in IOP was 15.57 mmHg (14.43-16.71) and the mean (95% confidence interval) reduction in IOP-lowering medication after surgery was 1.81 (1.61-2.01). Most frequently observed postoperative complications were corneal edema (2-34%) and tube complications (4-33%). Rates of required re-intervention ranged from 0% to 51% across all included studies.

Conclusion

The efficacy of the Baerveldt implant is a significant reduction in IOP in the long term. The safety profile of the Baerveldt implant in terms of complication incidence is similar to those reported for other GDD's. For treatment of secondary glaucoma, we suggest the Baerveldt (or any other similar GDD) as the choice of treatment in patients where highest IOP reduction is desired.

Outcomes of Valved and Nonvalved Tube Shunts in Neovascular Glaucoma

PURPOSE

To determine the outcomes of Ahmed glaucoma valve (AGV; New World Medical Inc) and Baerveldt glaucoma implant (BGI; Advanced Medical Optics) surgery in the setting of neovascular glaucoma (NVG).

DESIGN

Single-center, retrospective study.

PARTICIPANTS

Consecutive patients who underwent AGV or BGI surgery for the treatment of NVG and had ≥6 months of follow-up.

METHODS

Chart review of AGV and BGI surgical outcomes in patients with NVG.

MAIN OUTCOME MEASURES

Progression to no light perception (NLP) vision and 6-month surgical failure, which was defined as intraocular pressure (IOP) >21 mmHg with medications or <5 mmHg at 2 consecutive visits, or glaucoma reoperation.

RESULTS

A total of 152 eyes (91 AGV, 61 BGI) were included with an average follow-up of 29.6 ± 25.8 months. Baseline demographics and clinical characteristics were comparable between groups. At month 6, failure was similar between AGV and BGI eyes (21.6% vs. 25.9%; P = 0.552), but glaucoma medication use was lower in BGI eyes (P < 0.001). At the final visit, 18.7% of AGV and 14.8% of BGI eyes progressed to NLP vision (P = 0.530), and medication use was lower in BGI eyes (P < 0.0001). Multivariate analysis identified lower preoperative visual acuity (VA) (P = 0.001), failure to receive panretinal photocoagulation within 2 weeks of surgery (P = 0.003), and bilaterality of the underlying ischemic retinal pathology (P = 0.026) as the strongest predictors of NLP outcome. Age, sex, race, NVG etiology, tube type, preoperative IOP, extent of synechial angle closure preoperatively, preoperative hyphema, IOP at the first NLP visit, and final IOP were not significant predictors of NLP vision.

CONCLUSIONS

Eyes with AGV and BGI had comparable outcomes in NVG, although fewer medications were required in BGI eyes to control IOP. Progression to NLP vision was associated with poor baseline VA, delayed retinal treatment, and bilaterality of the underlying ischemic retinal pathology.

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.

Initial Clinical Results of the eyeWatch: a New Adjustable Glaucoma Drainage Device Used in Refractory Glaucoma Surgery

PRéCIS:: In this study, we report clinical results after implantation of an adjustable glaucoma drainage device. The intraocular pressure (IOP) profile was efficiently controlled postoperatively as the resistance to aqueous humor outflow was finely adjusted.

PURPOSE

The main purpose of this study was to evaluate the safety and efficacy of the new adjustable glaucoma drainage device eyeWatch used in conjunction with a Baerveldt glaucoma implant in refractory glaucoma.

PATIENTS AND METHODS

This was a multicentric, prospective, noncomparative clinical trial. Patients older than 18 years of age suffering from refractory glaucoma after failed surgeries, with IOP of ≥20 mm Hg, in whom a further glaucoma procedure using an aqueous shunt was planned, were enrolled in this study. The primary outcome was the success rate, defined as an IOP≤18 mm Hg and reduction of >20% from baseline, IOP≥6 mm Hg. Secondary outcomes were mean IOP, visual acuity, number of antiglaucoma medications, number, and type of complications.

RESULTS

Fifteen patients were included. The mean follow-up time was 15.6±3.5 months. The mean baseline IOP decreased from 26.2±6.8 mm Hg before surgery to 11.9±2.8 mm Hg at 12 months (P<0.001). The mean number of glaucoma medications decreased from 3.0±0.7 before surgery to 0.8±0.9 at last visit (P<0.001). The success rate was 40% for complete success and 93% for overall success at last follow-up. Complication rate was 7%.

CONCLUSIONS

The novel glaucoma device allows for perioperative and postoperative noninvasive adjustments of the resistance to aqueous humor outflow. This leads to better management of IOP during the early postoperative period, preventing ocular hypotony and eliminating the need for obstructive elements and reinterventions. The rate of complications was low, IOP was adequately controlled and lowered, with a substantial reduction in the number of antiglaucoma medication.

Attaining Intraocular Pressure of ≤10 mm Hg: Comparison of Tube and Trabeculectomy Surgery in Pseudophakic Primary Glaucoma Eyes

PURPOSE

The aim of this study is to evaluate whether trabeculectomy with antimetabolites or glaucoma drainage device (GDD) surgery is more likely to achieve an intraocular pressure (IOP) ≤10 mm Hg.

DESIGN

Retrospective, nonrandomized, cohort study of pseudophakic, primary glaucoma patients.

METHODS

53 pseudophakic patients underwent trabeculectomy and 65 received GDD at the University of Florida by one surgeon between 1993 and 2015. The main outcome measures were mean IOP and percentage of patients obtaining an IOP ≤10 mm Hg for up to 5 years postoperatively. A subgroup undergoing a first time glaucoma surgery was also analyzed because there were more redo glaucoma procedures in the GDD group.

RESULTS

Over 5 years, the mean annual IOP for the trabeculectomy eyes was between 6.9 and 7.8 mm Hg on an average of 0.2 medications, and that for GDD eyes was between 11.4 and 12.1 mm Hg on a mean of 1.6 to 1.9 medications (P < 0.002). A significantly higher percentage of trabeculectomy eyes than GDD eyes achieved a pressure of ≤10 mm Hg, for years 1 to 4 (P < 0.05). Visual acuity (VA) change was not statistically different between the groups, both for mean logMAR acuity and percentage of patients that lost ≥2 Snellen lines. Complication rates were similar between the groups. Postoperative VA change was similar for eyes achieving low IOP ≤5 mm Hg and those eyes with an IOP ≥10 mm Hg.

CONCLUSIONS

Trabeculectomy provided significantly lower IOP for 5 years postoperatively in pseudophakic primary glaucoma patients, and was more likely to achieve an IOP ≤10 mm Hg.

Plate size reduction surgery for the Baerveldt 350-mm2 glaucoma implant for postoperative motor disturbance: A case report

RATIONALE

Diplopia due to ocular motility disturbance is a common complication after glaucoma drainage device (GDD) surgery. The treatment options include prescription prism glasses, strabismus surgery or GDD removal. However, to the best of our knowledge, GDD size reduction surgery has not been reported.

PATIENT CONCERNS AND DIAGNOSES

An 83-year-old woman diagnosed with primary open angle glaucoma was referred to Tsukazaki Hospital due to uncontrolled intraocular pressure (IOP) in December 2015. We performed an EXPRESS shunt surgery on both eyes in January 2016 and a needling procedure on the left eye in May 2017. Thereafter, because IOP in her left eye remained high, we performed Baerveldt 350-mm implantation in her inferotemporal area by placing the tube at the sulcus on December 3, 2017. The next day, 4Δ hypertropia (HT) was detected in the left eye in alternate cover testing in primary gaze, and diplopia in the inferotemporal direction was demonstrated. Although IOP was controlled well between 15 and 20 mmHg in her left eye, diplopia did not improve.

INTERVENTIONS

Three weeks later, we performed a plate size reduction surgery for the Baerveldt 350-mm implant. In this procedure, we cut and removed the plates placed beneath the lateral rectus muscle and inferior rectus muscle, which were thought to be responsible for diplopia.

OUTCOMES

Diplopia improved subjectively, but there was no drastic objective change. We prescribed prism glasses (3Δ base down for the left eye) for remaining mild diplopia. On January 21, 2019, significant objective improvement (2Δ HT with less ocular motor dysfunction demonstrated in the Hess chart) was finally observed.

LESSONS

Early plate size reduction surgery, which was not immediately but ultimately effective in improving motor disturbance in our case, could be a potential option to relieve operation-induced motor disturbance. However, notably, tube shunt surgery has the risk of motility disturbances, which might require additional treatment.

Impact of same-session trabectome surgery on Ahmed glaucoma valve outcomes

PURPOSE

To evaluate the efficacy and survival rates of same session ab interno trabeculectomy with the trabectome and Ahmed glaucoma valve implant (AT) in comparison to the Ahmed glaucoma valve alone (A).

METHOD

A total of 107 eyes undergoing primary glaucoma surgery were enrolled in this retrospective comparative case series, including 48 eyes which underwent AT and 59 eyes which received A alone. Participants were identified using the procedural terminology codes, and their medical records were reviewed. The primary outcome measure was success defined as IOP > 5 mmHg, ≤ 21 mmHg and ≥ 20% reduction of IOP from baseline at two consecutive visits after 3 months, and no need for glaucoma reoperation. Secondary outcome measures were IOP, the number of glaucoma medications, incidence of a hypertensive phase, and best corrected visual acuity (BCVA).

RESULTS

The cumulative probability of success at 1 year was 70% in AT, and 65% in A (p = 0.85). IOP decreased significantly from 26.6 ± 10.1 mmHg at baseline to 14.7 ± 3.3 mmHg at the final follow-up in AT (p = 0.001). The corresponding numbers for A were 27.8 ± 10.2 and 16.7 ± 4.9, respectively (p = 0.001). The final IOP was significantly lower in AT (p = 0.022). The number of medications at baseline was comparable in both groups (2.6 ± 1.2 in AT and 2.5 ± 1.3 in A, p = 0.851). Corresponding number at 1 year visit was 1.2 ± 2 in AT and 2.8 ± 1.8 in A (p = 0.001). The incidence of a hypertensive phase was 18.7% in AT and 35.5% in A (p = 0.05). HP resolved in only 30% of eyes. The criteria for HP resolution were fulfilled in 9 eyes (30%). There was no difference in the rate of resolution of the hypertensive phase between AT and A (33.3 and 28.5%, respectively, p = 0.67).

CONCLUSION

Ahmed glaucoma valve implant with same session trabectome surgery significantly decreased the rate of the hypertensive phase and postoperative IOP as well as the number of glaucoma medications.

Evaluation of Bleb Fluid After Baerveldt Glaucoma Implantation Using Magnetic Resonance Imaging

We evaluated bleb fluid images taken after Baerveldt glaucoma implantation. T2-weighted images of bleb fluid were scanned with 3 Tesla magnetic resonance imaging in 52 patients who had undergone tube-shunt surgery using the 350-mm² endplate Baerveldt glaucoma implant; three-dimensional images were constructed from these images. Bleb fluid images were classified into either a layer of bleb fluid on either side of the endplate (double bleb layer group; n = 24) or one layer outside the endplate (single bleb layer group; n = 28). Despite there being no correlation between the bleb volume and the postoperative IOP (r = −0.080; P = 0.57), the double bleb layer group had significantly lower postoperative IOPs than the single bleb layer group (12.3 ± 3.8 mmHg vs. 14.7 ± 4.1 mmHg, respectively; P = 0.033). The single bleb layer was significantly related to higher numbers of prior intraocular surgeries (relative risk = 2.85; P = 0.0014). Formation of a layer of bleb fluid on either side of the endplate may have resulted in the lower postoperative IOPs after Baerveldt glaucoma implantation. Repeated intraocular surgery adversely affects formation of the double bleb layer.

Five-Year Pooled Data Analysis of the Ahmed Baerveldt Comparison Study and the Ahmed Versus Baerveldt Study

PURPOSE

To determine the relative efficacy of the Ahmed-FP7 and Baerveldt BG101-350 implants.

DESIGN

Pooled analysis of 2 multicenter, randomized clinical trials.

METHODS

A total of 514 patients aged 18 or older with uncontrolled glaucoma that had failed or were at high risk of failing trabeculectomy were randomized to receive an Ahmed implant (n = 267) or Baerveldt implant (n = 247). Cumulative failure rates (using an intraocular pressure [IOP] target of 6-18 mm Hg inclusive), de novo glaucoma surgery rates, mean IOP, mean glaucoma medication use, and visual acuity were compared.

RESULTS

Baseline characteristics were similar between groups. Mean preoperative IOP of the study population was 31.5 ± 11.3 mm Hg on an average of 3.3 ± 1.1 glaucoma medications. At 5 years, mean IOP was 15.8 ± 5.2 mm Hg in the Ahmed group and 13.2 ± 4.7 mm Hg in the Baerveldt group (P < .001). Mean glaucoma medication use was 1.9 ± 1.5 in the Ahmed group and 1.5 ± 1.4 in the Baerveldt group (P = .007). The cumulative failure rate at 5 years was 49% in the Ahmed group and 37% in the Baerveldt group (P = .007). High IOP was the most common reason for failure in both groups, and de novo glaucoma surgery was required in 16% of the Ahmed group and 8% of the Baerveldt group (P = .006). Failure owing to hypotony occurred in 0.4% of the Ahmed group and 4.5% of the Baerveldt group (P = .002). Visual outcomes were similar between groups (P = .90).

CONCLUSIONS

The Baerveldt group had a lower failure rate, lower rate of de novo glaucoma surgery, and lower mean IOP on fewer medications than the Ahmed group. Baerveldt implantation carried a higher risk of hypotony.

Retrospective Comparison of Intermediate-term Efficacy of 350 mm2 Glaucoma Drainage Implants and Medium-sized 230-250 mm2 Implants

Aim

To compare the intermediate-term efficacy of a large surface area Baerveldt 350 mm² glaucoma drainage device (GDD) with medium surface area implants (Baerveldt 250 mm² and Molteno 3, 230, or 245 mm²).

Design

This is a retrospective, nonrandomized comparative trial.

Materials and methods

A total of 94 eyes of 94 patients of mixed glaucoma diagnoses without any prior glaucoma surgical procedures and who had undergone a glaucoma drainage implant surgery with either a large Baerveldt 350 mm² GDD or a medium-sized GDD (Baerveldt 250 mm² or Molteno 230 or 245 mm²) were reviewed for intraocular pressure (IOP), number of glaucoma medications, and visual acuity (VA) preoperatively, and at 1, 2, and 3 years postprocedure.

Results

No significant differences were found in mean IOP, number of glaucoma medications used, and VA at 1, 2, and 3 years postoperatively. The rate of additional glaucoma procedures was similar between the two groups.

Conclusion

There is no clear evidence that a larger implant surface area beyond 230 to 250 mm² is advantageous in providing intermediate-term IOP control.

Clinical significance

It may be technically easier to surgically place a GDD that does not need to have its wings placed underneath the recti muscles, and the IOP results are similar.

How to cite this article

Meyer AM, Rodgers CD, Zou B, Rosenberg NC, Webel AD, Sherwood MB. Retrospective Comparison of Intermediate-term Efficacy of 350 mm² Glaucoma Drainage Implants and Medium-sized 230-250 mm² Implants. J Curr Glaucoma Pract 2017;11(1):8-15.

Relationship between Glaucoma Drainage Device Size and Intraocular Pressure Control: Does Size Matter?

There is ambiguity in the literature regarding whether a larger glaucoma drainage device (GDD) achieves a lower long-term intraocular pressure (IOP). There is some evidence on both sides, but overall there seems to be an optimal surface area of approximately 200-250 mm² beyond which there may be little advantage to increasing the plate size for most patients.

HOW TO CITE THIS ARTICLE

Rodgers CD, Meyer AM, Sherwood MB. Relationship between Glaucoma Drainage Device Size and Intraocular Pressure Control: Does Size Matter? J Curr Glaucoma Pract 2017;11(1):1-2.

Ahmed Versus Baerveldt Glaucoma Drainage Implantation in Patients With Markedly Elevated Intraocular Pressure (≥30 mm Hg)

PURPOSE

Glaucoma patients with markedly elevated intraocular pressure (IOP) are at risk for developing severe hypotony-related complications. The goal of this study was to compare the surgical outcomes of the Ahmed Glaucoma Valve (AGV) and the Baerveldt Glaucoma Implant (BGI) in this patient population.

METHODS

Patients with preoperative IOP≥30 mm Hg were included. Outcome measures were: (1) surgical failure (IOP>21 mm Hg or <30% reduction from baseline or IOP≤5 mm Hg on 2 consecutive follow-up visits after 3 mo, or additional glaucoma surgery, or loss of light perception) and (2) surgical complications.

RESULTS

A total of 75 patients were included: 37 in the AGV group and 38 in the BGI group. The mean±SD follow-up was 2.3±1.6 years for the AGV group and 2.4±1.7 years for the BGI group (P=0.643). Mean preoperative IOP was 38.7±6.5 mm Hg for the AGV group and 40.8±7.6 mm Hg for the BGI group. At the last follow-up, 10 (27.0%) patients failed in the AGV group compared with 6 (15.8%) patients in the BGI group (P=0.379). The BGI group had higher rate of flat or shallow anterior chamber (n=4, 10%) compared with the AGV group (n=0, 0%) (P=0.043).

CONCLUSIONS

Failure rates of AGV and BGI in patients with IOP≥30 mm Hg were comparable. There were more early hypotony-related complications in the BGI group; however, none were vision threatening. Both glaucoma drainage implants were effective in treating patients with uncontrolled glaucoma in an emergency setting.

Comparison of the Ahmed glaucoma valve with the Baerveldt glaucoma implant: a meta-analysis

BACKGROUND

This study aims to compare the efficacy and safety of the Ahmed glaucoma valve (AGV) with the Baerveldt glaucoma implant (BGI) in glaucoma patients.

METHODS

Databases were searched to identify studies that met pre-stated inclusion criteria, involving randomized controlled clinical trials (RCTs) and non-randomized controlled clinical trials. Treatment effect was analyzed using a random-effect model.

RESULTS

Ten controlled clinical trials (1048 eyes) were analyzed, involving two RCTs and eight retrospective comparative studies. Short-term results (6-18 months) and long-term results (>18 months) were analyzed separately. There was no significant difference in the success rate for short-term follow-up between the AGV and BGI groups (5 studies, 714 eyes, odds ratio [OR]: 0.97; 95 % confidence interval [CI]: 0.56, 1.66; P = 0.90). For long-term pooled results (7 studies, 835 eyes), the success rate of AGVs was lower than that of BGIs (OR: 0.73; 95 % CI: 0.54, 0.99, P = 0.04), However, subgroup and sensitivity analyses did not show a significant difference in the success rate between the two groups (P ≥0.05). The AGV group had a higher mean intraocular pressure than the BGI group in short-term (6 studies, 685 eyes, weighted mean difference [WMD]: 2.12 mmHg; 95 % CI: 0.72-3.52; P <0.05) and long-term pooled results (7 studies, 659 eyes, WMD: 1.85 mmHg; 95 % CI: 0.43, 3.28; P = 0.01). The BGI group required fewer glaucoma medications after implantation than the AGV group in two follow-up periods (all P <0.05). The AGV was found to be associated with a significantly lower frequency of total complications (8 studies, 971 eyes, OR: 0.67; 95 % CI: 0.50-0.90; P = 0.007) and severe complications (8 studies, 971 eyes, OR: 0.57; 95 % CI: 0.36-0.91; P = 0.02) than the BGI.

CONCLUSIONS

The study showed no significant difference in success rate between the two groups. The BGI was more effective for control of intraocular pressure and required fewer medications than the AGV, but the AGV had lower incidence of total and severe complications than the BGI.

The Early Postoperative Complications of Two Different Tube Ligation Methods in Baerveldt Implant Surgery

Objective: To investigate the early postoperative complications in two different tube ligation methods during the first 3 months in Baerveldt implant surgery.

Participants: This study involved 157 eyes from 144 patients who underwent Baerveldt Implant Surgery at the Japanese Red Cross Medical Center, Tokyo, Japan.

Methods: Pre- and postoperative intraocular pressure (IOP), combined surgery, postoperative time-point of tube ligation release, and postoperative complications in two different tube ligation methods [absorbable ligation method using 8-0 polyglactin suture (group A) and nonabsorbable ligation method using 7-0 nylon suture (group B)] were retrospectively reviewed.

Results: After excluding eyes that had undergone combined trabeculectomy (26 eyes) and vitrectomy (2 eyes), eyes with previous tube surgery (22 eyes), and eyes that had undergone the stent method (1 eye), 30 of 28 patients in group A and 71 eyes of 71 patients in group B were found to fit the criteria of this study. The rate of successful surgical outcome was 80% in group A and 74.6% in group B (p = 0.705). During the 3 months postoperative, high IOP tended to occur more often in group B (67.6%) than in group A (46.7%) (p = 0.073), and ciliochoroidal detachment tended to occur more often in group A (10.0%) than group B (2.8%) (p = 0.154).

Conclusion: The results of this study show that both ligation methods are effective, however, the selection of tube ligation method should be done in accordance with the different method-specific risks to which may occur.

How to cite this article: Kawamorita S, Hamanaka T, Sakurai T. The Early Postoperative Complications of Two Different Tube Ligation Methods in Baerveldt Implant Surgery. J Curr Glaucoma Pract 2014;8(3):96-100.