Experience with the Baerveldt glaucoma implant in treating neovascular glaucoma

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.

Surgical outcomes including visual improvement after glaucoma surgery in patients with neovascular glaucoma

Purpose

This study aimed to evaluate the prognostic factors affecting surgical outcomes, including visual acuity (VA) improvement, after glaucoma surgery in patients with neovascular glaucoma (NVG).

Methods

The medical records of 116 patients (116 eyes) with NVG who had undergone trabeculectomy or Ahmed glaucoma valve implantation were reviewed retrospectively. The primary outcome measure was surgical success at 6 postoperative months, defined as sufficient intraocular pressure (IOP) reduction (IOP ≤21 mmHg, ≥20% reduction, regardless of topical medication use) without additional glaucoma surgery, hypotony, or progression to no light perception. Success was categorized as complete or qualified based on whether an improvement in VA was observed in addition to the abovementioned definition.

Results

The complete and qualified success rates at 6 months were 44.6% and 92.2%, respectively. Age (p = 0.001), preoperative best-corrected VA (p = 0.031), duration of decreased VA (p = 0.001), closed-angle status (p = 0.013), and etiology (p = 0.007) differed significantly between the groups with and without complete success. Multivariate analysis revealed that age (odds ratio [OR] 1.05; p = 0.026), duration of decreased VA (OR 1.05; p = 0.016), and 360° closed-angle status (OR 3.27; p = 0.031) were risk factors for surgical failure according to the complete success criteria, but not the qualified success criteria.

Conclusions

Patients with NVG showed improved visual prognosis and successful IOP reduction after glaucoma surgery at a relatively younger age if the duration of visual loss was not prolonged and the angle status was not completely closed.

Long-term outcomes of Baerveldt glaucoma implant surgery in Japanese patients

This study evaluated the long-term surgical outcomes of Baerveldt glaucoma implant (BGI) surgery in patients with refractory glaucoma (204 eyes/204 patients). Surgical failure was defined by: < 20% reduction in preoperative intraocular pressure (IOP), or criterion A (IOP > 21 mmHg), criterion B (IOP > 17 mmHg), or criterion C (IOP > 14 mmHg). Reoperation, loss of light perception vision, or hypotony also denoted failure. The probability of success at 5 years postoperatively using criteria A, B, and C was 72.4%, 49.7%, and 24.4%, respectively. The mean IOP decreased significantly from 32.7 ± 9.7 mmHg preoperatively to 13.1 ± 3.9 mmHg at 5 years; the mean number of glaucoma medications also decreased from 3.7 ± 1.2 to 1.8 ± 1.9 (both P < 0.01). The number of previous intraocular surgeries was significantly associated with failure in the multivariable analysis for criterion B (hazard ratio 1.30; P < 0.01) and criterion C (hazard ratio 1.19; P = 0.031). Early and late postoperative complications occurred in 82 (40.2%) and 28 (13.7%) eyes, respectively. Postoperative interventions were performed in 44 eyes (21.6%). BGI surgery resulted in significant long-term decreases in IOP and the number of glaucoma medications. BGI surgery is effective for refractory glaucoma. However, postoperative interventions due to complications are required in numerous cases.

Diabetes more than retinopathy, it’s effect on the anterior segment of eye

Diabetes mellitus (DM) is one of the chronic metabolic noncommunicable diseases that has attained worldwide epidemics. It threatens healthy life around the globe, with mild-to-severe secondary complications and leads to significant illness including nephropathy, neuropathy, retinopathy, and macrovascular abnormalities including peripheral vasculopathy, and ischaemic heart disease. Research into diabetic retinopathy (DR), which affects one-third of persons with diabetes, has made considerable strides in recent years. In addition, it can lead to several anterior segment complications such as glaucoma, cataract, cornea, conjunctiva, lacrimal glands and other ocular surface diseases. Uncontrolled DM also caused gradual damage to corneal nerves and epithelial cells, which raises the likelihood of anterior segment diseases including corneal ulcers, dry eye disease, and chronic epithelial abnormalities. Although DR and other associated ocular complications are well-known, the complexity of its aetiology and diagnosis makes therapeutic intervention challenging. Strict glycaemic control, early detection and regular screening, and meticulous management is the key to halting the progression of the disease. In this review manuscript, we aim to provide an in-depth understanding of the broad spectrum of diabetic complications in the anterior segment of the ocular tissues and illustrate the progression of diabetes and its pathophysiology, epidemiology, and prospective therapeutic targets. This first such review article will highlight the role of diagnosing and treating patients with a plethora of anterior segment diseases associated with diabetes, which are often neglected.

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.

Short-Term Postoperative Outcome of Baerveldt Glaucoma Implant with Two Tubes Inserted into the Vitreous Cavity

Here, we report a new surgical technique designed to increase filtration volume and reduce intraocular pressure (IOP) in glaucoma and its one-year outcome. Two tubes were created from a single Baerveldt glaucoma implant (BI) by folding the tube in a U-shape and incising only the outer edge of the stretched loop tip. The tubes were placed into the vitreous cavity via the pars plana through a long scleral tunnel, without a scleral valve or graft patch. Twenty eyes of 18 patients with neovascular glaucoma were included. This technique was performed in 10 eyes of 10 patients (double group), and outcomes were compared to 10 eyes of eight patients in which a single tube BI was inserted (single group). The primary outcome measures included IOP, supplemental medical therapy score (SMTS), and intraoperative and postoperative complications before and after surgery at 12 months. The mean IOP (SMTS) were 32.0 ± 11.33 mmHg (4.1) in the double group and 29.7 ± 6.31 mmHg (5.7) in the single group, preoperatively reduced to 11.8 ± 2.70 mmHg (0.2) (63% reduction, p < 0.004) and 14.2 ± 4.05 mmHg (1.1) (52% reduction, p < 0.002) after 12 months, respectively. SMTS showed 95% (p = 0.005) and 89% (p = 0.005) reductions, respectively. Although there was no significant difference in IOP between the two groups at 12 months (p = 0.16), there were significant differences in the SMTS between the two groups before, and 6 and 12 months after, surgery (p = 0.01, 0.04 and 0.04, respectively). A reduction in the SMTS suggests that increasing filtration volume by placing two tubes has the potential to further reduce IOP as compared with a single tube.

Three-Year Outcomes of Pars Plana Ahmed and Baerveldt Glaucoma Implantations for Neovascular Glaucoma in Japanese Eyes

PRCIS

Tube shunt implantation through the pars plana was effective for neovascular glaucoma (NVG) for at least 3 years, with few serious postoperative complications observed.

PURPOSE

The aim was to report 3-year outcomes of pars plana Ahmed and Baerveldt glaucoma implantation for NVG in Japanese eyes.

PATIENTS AND METHODS

This study examined 41 eyes of 39 patients who underwent tube shunt implantation through the pars plana with the Baerveldt glaucoma implant (BGI group, 26 eyes) or Ahmed glaucoma valve (AGV group, 15 eyes) for NVG and who were followed up for over 3 years at Osaka Medical College between January 2009 and April 2016. Outcome measures were intraocular pressure (IOP, mm Hg) at presurgery and at 6 months and 1, 2, and 3 years postoperative. Postoperative failure was defined as an IOP of >21 mm Hg or <5 mm Hg, further glaucoma surgery, or no light perception.

RESULTS

Mean IOPs at presurgery and at 3 years postoperative were 34.8±9.1 and 15.6±4.6 in the AGV group, and 36.9±9.2 and 12.8±5.5 in the BGI group. Mean antiglaucoma medication scores at 3 years postoperative were 1.3±1.4 in the AGV group and 0.4±0.8 in the BGI group (P=0.05). The number of eyes with a probability of failure at 6 months and at 2 and 3 years postoperative was 2, 3, and 4, respectively, in the BGI group, and 0, 1, and 2, respectively, in the AGV group.

CONCLUSION

Findings for NVG cases showed tube shunt implantation through the pars plana was effective. Equivalent good IOP reductions were noted in both groups, with the BGI group requiring fewer postoperative antiglaucoma medications compared with the AGV group. Furthermore, both groups exhibited few serious postoperative complications.

Risk Factors for Failure of Tube Shunt Surgery: A Pooled Data Analysis

PURPOSE

To identify the risk factors associated with failure of tube shunt surgery.

DESIGN

Pooled analysis of 3 prospective multicenter, randomized clinical trials.

METHODS

A total of 621 patients with medically uncontrolled glaucoma were enrolled, including 276 from the Ahmed Baerveldt Comparison Study, 238 from the Ahmed Versus Baerveldt Study, and 107 from the tube group of the Tube Versus Trabeculectomy Study. Patients were randomized to treatment with an Ahmed glaucoma valve (model FP7) or Baerveldt glaucoma implant (model 101-350). The associations between baseline risk factors and tube shunt failure were assessed using a Cox proportional hazards regression model. The primary outcome measure was the rate of surgical failure defined as intraocular pressure (IOP) > 21 mmHg or reduced < 20% from baseline, IOP ≤ 5 mmHg, loss of light perception vision, reoperation for glaucoma, or removal of implant.

RESULTS

The cumulative probability of failure after tube shunt surgery was 38.3% after 5 years. In multivariable analyses, baseline factors that predicted tube shunt failure included preoperative IOP (≤ 21 mmHg compared to IOP > 21 and ≤ 25 mmHg; HR, 2.34; 95% CI, 1.52-3.61; P < .001), neovascular glaucoma (HR, 1.79; 95% CI, 1.28-2.52; P = .001), randomized treatment (for Ahmed glaucoma valve; HR, 1.36; 95% CI, 1.04-1.78; P = .025), and age (for 10 year decrease in age; HR, 1.19; 95% CI, 1.09-1.31; P < .001).

CONCLUSIONS

Lower preoperative IOP, neovascular glaucoma, Ahmed implantation, and younger age were predictors of tube shunt failure. This Study provides the largest prospectively collected dataset on tube shunt surgery.

Posterior segment complications of Ahmed valve implantation

BACKGROUND

To assess the time, incidence, and outcome of posterior segment complications of Ahmed valve implantation (AVI).

METHODS

248 eyes that underwent AVI were reviewed retrospectively. Visual acuity, preoperative characteristics, and postoperative posterior segment complications were assessed.

RESULTS

The incidence of posterior segment complications of AVI was 31.4% (78/248). The mean follow-up period was 97.4 ± 53.5 months. The mean time to occur posterior segment complication was 1.5 months. The most common posterior segment complication was choroidal detachment (17.7%) and others included ocular decompression retinopathy (3.2%), hypotonic maculopathy (2.8%), vitreous hemorrhage (2.0%), retinal detachment (1.2%), endophthalmitis (1.2%), suprachoroidal hemorrhage (1.2%), epiretinal membrane (0.8%), cystoid macular edema (0.8%), and proliferative vitreoretinopathy (0.4%). Older age, hypertension, and postoperative hypotony had an increased risk of posterior segment complications of AVI.

CONCLUSIONS

The overall incidence of posterior segment complications of AVI was 31.4%. Older age, hypertension, and postoperative hypotony were significantly associated with posterior segment complications of AVI.

Factors associated with the surgical outcomes of Baerveldt glaucoma implant for open-angle glaucoma, an age-related eye disease

To identify the factors associated with the surgical outcomes of Baerveldt glaucoma implant (BGI) for open-angle glaucoma (OAG), the medical records of 51 consecutive OAG patients (age, 43-91 years) who underwent BGI were retrospectively reviewed (median follow-up, 21.7 months). Surgical success was defined as the following postoperative intraocular pressures (IOPs, mmHg): (A) 6 ≤ IOP ≤ 21; (B) 6 ≤ IOP ≤ 18; and (C) 6 ≤ IOP ≤ 15 without loss of light perception or additional glaucoma surgery. Univariate analysis showed that age (all criteria), glaucoma type (criterion C), and preoperative IOP (criteria A and B) were the candidate factors (P < 0.20). When the patients were divided into two groups according to median age (72 years), the success probability was higher in the older group for criteria B (P = 0.047) and C (P = 0.02), and the postoperative IOP was lower in the older group 1-year post-surgery (P = 0.002). Furthermore, the multivariate Cox proportional hazards model revealed that older age was independently associated with surgical success for criteria B (relative risk [RR], 0.94; P = 0.02) and C (RR, 0.94; P = 0.01). In conclusion, older age is a factor associated with the surgical success of BGI for OAG.

The influence of etiology on surgical outcomes in neovascular glaucoma

Background

The authors sought to evaluate visual outcomes in patients with varying etiologies of neovascular glaucoma (NVG), who were treated with glaucoma drainage devices (GDD).

Methods

This was a retrospective case series of patients at a large academic teaching institution who had surgical intervention for neovascular glaucoma between September 2011 and May 2019. Eyes were included if there was documented neovascularization of the iris/angle with an intraocular pressure (IOP) > 21 mmHg at presentation. Eyes must also have been treated with surgical intervention that included a GDD. Primary outcome measure was visual acuity at the 1-year post-operative visit. Secondary outcome measure was qualified success after surgery defined by: pressure criteria (5 mmHg < IOP ≤ 21 mmHg), no re-operation for elevated IOP, and no loss of LP vision.

Results

One hundred twenty eyes met inclusion criteria. 61.7% had an etiology of proliferative diabetic retinopathy (PDR), 23.3% had retinal vein occlusions (RVO), and the remaining 15.0% suffered from other etiologies. Of patients treated with GDD, eyes with PDR had better vision compared to eyes with RVO at final evaluation (p = 0.041). There was a statistically significant difference (p = 0.027) in the mean number of glaucoma medications with Ahmed eyes (n = 70) requiring 1.9 medications and Baerveldt eyes (n = 46) requiring 1.3 medications at final evaluation.

Conclusions

In our study, many patients with NVG achieved meaningful vision, as defined by World Health Organization (WHO) guidelines, and IOP control after GDD. Outcomes differed between patients with PDR and RVO in favor of the PDR group. Different GDD devices had similar performance profiles for VA and IOP outcomes. Direct prospective comparison of Baerveldt, Ahmed, and cyclophotocoagulation represents the next phase of discovery.

Sociodemographic and Economic Factors in Outcomes of Tube Shunts for Neovascular Glaucoma

Importance

Few studies have analyzed associations between sociodemographic factors and neovascular glaucoma (NVG) outcomes.

Aim and background

To determine the potential impact of sociodemographic and economic factors on the NVG tube shunt surgery outcomes.

Design

Retrospective, single-center, comparative case series.

Participants

Consecutive patients who underwent tube shunt surgery for NVG and had ≥6 months of follow-up.

Materials and methods

Regional average adjusted gross income (AGI) was determined by cross-referencing self-reported residential zip codes with average AGI per zip code supplied by the Internal Revenue Service. Two groups were created: (1) lower-income: individuals from neighborhoods with the lowest 10% of AGI (near the United States poverty line), (2) higher-income: the remaining 90% of individuals.

Main outcome measures

Visual acuity (VA), intraocular pressure (IOP), and glaucoma medication number at 6 months and the most recent visit.

Results

The mean annual AGI in the higher-income group (130 patients) was $69,596 ± 39,700 and the lower-income group (16 patients) was $27,487 ± 1,600 (p < 0.001). Age, sex, distance to the clinic, language, and all baseline clinical variables (including VA and IOP) were comparable between groups. Lower-income was associated with non-white race (81.3 vs 52.3%; p = 0.024). At month 6, VA in the lower-income group [median: HM (20/70–NLP)] was worse than the higher-income group [median: CF (20/25–NLP)] (log MAR VA: 2.32 ± 0.8 vs 1.77 ± 1.1; p = 0.02); these trends persisted through the most recent visit (p = 0.043). Follow-up IOP and medications were similar between groups.

Conclusions and relevance

Lower-income may be associated with worse VA outcomes following NVG tube shunt surgery.

How to cite this article

Shalaby WS, Arbabi A, Myers JS, et al. Sociodemographic and Economic Factors in Outcomes of Tube Shunts for Neovascular Glaucoma. J Curr Glaucoma Pract 2021;15(2):70–77.

Case Report: Perioperative Kounis Syndrome in an Adolescent With Congenital Glaucoma

A 12-year-old male patient suffering from congenital glaucoma developed bradycardia, left ventricular failure, and hypotension after induction of anesthesia. Electrocardiography and echocardiography revealed a complete normalization of ECG and a complete spontaneous recovery in the cardiac function 72 hours from the beginning of the clinical manifestations, while cardiac Magnetic Resonance Imaging was performed, and coronary Computed Tomography scan revealed a myocardial bridge of a tract of the left anterior descendent coronary artery. Diagnosis of Kounis syndrome (KS) was made, a relatively novel, under-recognized clinical condition, defined as the manifestation of an acute coronary syndrome accompanied by mast cell activation and platelet aggregation involving interrelated and interacting inflammatory cells in the setting of allergic, hypersensitivity, anaphylactic or anaphylactoid insults. We described one of the first pediatric cases of KS related to anesthetic medications. In children, this syndrome has been only described in isolated case reports or small case series. Thus, it appears critical to report new cases of KS in children to increase the awareness of this disease in pediatric healthcare workers so as to enhance its early recognition and optimal therapeutic strategy. Furthermore, it appears of paramount importance the implementation of universal guidelines accepted by allergology and cardiology societies, in order to standardize the management of pediatric and adult patients with KS. Finally, a close collaboration between pediatric allergists and cardiologists seems fundamental for an optimal multidisciplinary patient care.

Effect of Vitamin D3 on Regulating Human Tenon's Fibroblasts Activity

Purpose

To study the in vitro effect of vitamin D3 on the healing response of human Tenon's fibroblasts (HTF) and its possible role in preventing excessive postoperative subconjunctival fibrosis.

Methods

Effect of vitamin D3 on cytotoxicity and cell survival of primary cultured HTF was measured by lactate dehydrogenase and PrestoBlue assays, respectively. Proliferation and migration of vitamin D3-treated HTF (D3-HTF) was determined by CyQUANT proliferation and scratch assay, respectively. The mRNA expression profiles of control-HTF and D3-HTF from six subjects (three with glaucoma and long-term use of topical medications, three with primary pterygium) were assessed by RNA sequencing analyses to identify potential biomarkers for the inhibitory effect on HTF by vitamin D3. Validation of these biomarkers and their potential pathways were performed by quantitative real-time polymerase chain reaction (qRT-PCR) detection.

Results

Pure monolayers of HTF from controls (retinal detachment or squint surgeries), pterygium, and glaucoma subjects were successfully prepared and passaged. Proliferation and migration of pterygium and glaucoma HTF were inhibited by vitamin D3 in a dose-dependent manner, and without cytotoxicity or decrease in cellular viability with concentrations up to 10 µM. The qRT-PCR results were consistent with the transcriptome analyses, vitamin D3 appears to enhance CYP24A1, SHE, KRT16 but suppresses CILP expression in HTF.

Conclusions

Vitamin D3 can inhibit the in vitro activity of HTF without compromising cellular survivability at concentration up to 10 µM. This has potential clinical application for improving the outcome of pterygium and filtering surgeries.

Translational Relevance

Vitamin D3 can suppress the in vitro proliferation, migration, and transdifferentiation of human Tenon's fibroblasts, without the cytotoxicity of mitomycin-C, the current standard antifibrotic agent in clinical use.

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.

Autologous Scleral Pocket Technique for Ahmed Glaucoma Valve Implantation with Pars Plana Tube Insertion for Neovascular Glaucoma

Specific postoperative complications, such as tube exposure and conjunctival erosion, have occurred despite the favorable surgical outcomes of tube shunt surgeries for refractory glaucoma. The new autologous scleral pocket technique is performed by inserting the tube into the vitreous cavity without using a donor scleral patch. The purpose of this study was to evaluate the surgical results of Ahmed glaucoma valve (AGV) implantation using this technique for neovascular glaucoma (NVG), which is one of the representative refractory types of glaucoma. This observational retrospective case series included 15 consecutive eyes of 15 patients with NVG who had undergone AGV implantation at Kobe University between January 2018 and December 2019. The mean preoperative intraocular pressure (IOP) was 37.2 ± 13.8 mmHg and the glaucoma drug score was 4.2 ± 2.2. The mean IOP and glaucoma drug score at 1 year postoperatively decreased to 15.0 ± 4.6 mmHg and 1.3 ± 2.0, respectively (p < 0.001). No significant change in the corneal endothelial cell density following surgery was observed (p = 0.09); however, one patient required an additional trabeculectomy at 7 months postoperatively. No cases of tube exposure or conjunctival erosion were observed at 1 year postoperatively. These results indicated the effectiveness and safety of this technique in patients with NVG.

Efficacy and Safety of the Susanna Glaucoma Drainage Device After 1 Year of Follow-up

PRECIS

This study found a rate of failure of 13.6% of the new Susanna Glaucoma Drainage Device (SGDD) after 1 year of follow-up. Severe complications occurred in 1 patient (4.5%).

PURPOSE

The purpose of this study was to determine the success and complications rates of the SGDD implant in refractory glaucoma.

PATIENTS AND METHODS

This is a retrospective study. Medical records from all consecutive refractory glaucoma patients (failed trabeculectomies with the use of adjunctive mitomycin) followed in a private clinical practice were included in the study. All patients had undergone SGDD implant surgery from September 2016 to July 2019 were included. All surgeries were done by the same surgeon (R.S.). Primary outcome was surgical failure, defined as intraocular pressure (IOP) >18 mm Hg and/or <20% IOP reduction from baseline, IOP<5 mm Hg, reoperation for glaucoma, need of implant removal or loss of light perception vision. Secondary outcomes included mean IOP, use of supplemental medical therapy, and complications.

RESULTS

In all, 22 eyes were analyzed. Mean patient age was 63±15 years (range: 27 to 87 y). Mean IOP decreased from 23±7 to 11±8 mm Hg (P<0.001, paired t test) at an average of 18±9 months after the tube implant. The mean SD number of glaucoma medications was reduced from 3.3±1 to 1.5±1.2 at the last postoperative visit (P<0.01, paired t test). No early postoperative complications occurred. There was 1 case of late persistent hypotony in a patient with previous endocyclophotocoagulation that was solved with tube ligature with silk 8-0. Failure because of high IOP occurred in 2 cases. There was no extrusion or erosion of the tube and the plate.

CONCLUSION

The SGDD presented a 13.6% failure rate (86.4% success rate) with very few complications, being an efficient and safe alternative for refractory glaucoma.

The ahmed versus Baerveldt study at King Khaled Eye Specialist Hospital: Three-year treatment outcomes

PURPOSE:

The purpose of this study was to analyze the outcomes of two frequently used surgical valves in treating refractory glaucoma.

METHODS:

This was a retrospective and nonrandomized study comparing patients aged 18 years or older who underwent implantation using standardized surgical techniques.

RESULTS:

A total of 86 patients were included in the study, 48 in the Ahmed group and 38 in the Baerveldt group. The overall success rate was 63.1% in both the groups. At the 3-year follow-up, the Ahmed group had a mean intraocular pressure (IOP) of 14.0 ± 4.8 mmHg (60% reduction) compared with 15.8 ± 6.2 mmHg (53.3% reduction) in the Baerveldt group (0.536). The Ahmed group required an average of 1.6 ± 1.3 medications (59% reduction) compared with 2.1 ± 1.7 (40% reduction) in the Baerveldt group (P < 0.001).

CONCLUSION:

Despite a high failure rate, both devices were effective in lowering IOP and the need for medications. Lower IOP and medications were needed in the Ahmed group.

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.

Safety and efficacy of paediatric silicone Ahmed glaucoma valve (AGV) in adult eyes with post-VR surgery glaucoma

PURPOSE

To compare the safety and efficacy of the FP8 AGV (paediatric) with the standard FP7 AGV in adult post-vitreoretinal (VR) surgery glaucoma.

METHODS

We included 45 consecutive eyes with post-VR surgery glaucoma implanted with either FP8 (n = 28) or FP7 (n = 17) AGV between 2008 and 2016. The data analysed included visual acuity (VA), intraocular pressure (IOP), complications, interventions, and outcomes.

RESULTS

Mean age (p = 0.24), mean baseline VA (p = 0.77), preoperative IOP (p = 0.41), number of antiglaucoma medications (p = 0.92), and previous surgeries (p = 0.16) were comparable in the two groups. The number of eyes with previous belt buckle was significantly higher (p < 0.001) in the FP8 group (17/28) compared with the FP7 group (2/17), indicating space constraint and scarred conjunctiva. The median follow-up (25th, 75th percentile) was 14.7 (9.1, 25.3) months in the FP7 and 9.8 (6.4, 34.7) months in the FP8 groups (p = 0.62). Postoperatively, the median VA (p = 0.24), the mean IOP at final follow-up (p = 0.15), and median number of AGM (p = 0.99) were comparable in both the groups. The median percentage drop in IOP (95% confidence interval) with the FP7 implant was 55% (43.70%) and with FP8 implant was 53.8% (25, 73), (p = 0.20). None in the FP7 group failed, while three eyes in the FP8 group failed. During the study period, two eyes in the FP8 group had tube exposure that was surgically managed. None of the eyes had implant exposure or loss of light perception.

CONCLUSION

Use of the paediatric FP8 AGV in adult post-VR surgery glaucoma eyes with severe conjunctival scarring and limited subconjunctival space resulted in reasonable IOP control compared with the standard FP7 AGV implant. There were no eyes with implant extrusion.

Efficacy and safety of Ex-PRESS® mini shunt surgery versus trabeculectomy for neovascular glaucoma: a retrospective comparative study

Background

The objective of this study is to evaluate and compare the short-term efficacy and safety of Ex-PRESS® mini shunt surgery and trabeculectomy for neovascular glaucoma (NVG).

Methods

Patients with NVG who underwent Ex-PRESS® mini shunt surgery or trabeculectomy as a primary glaucoma surgery between March 2013 and October 2015 were included in the study, and their medical charts were retrospectively reviewed. The Ex-PRESS® and trabeculectomy groups included 14 eyes and 30 eyes, respectively. Surgical failure was defined by an intraocular pressure (IOP) of ≥21 mmHg (condition A) or ≥ 18 mmHg (condition B); Kaplan–Meier survival analyses and the multivariable Cox proportional hazards model were used to assess efficacies.

Results

Kaplan–Meier survival analyses indicated that the probabilities of success at 1 year for the Ex-PRESS® group were 25.7 and 31.8% based on complete and qualified success under condition A, respectively. The corresponding values for the trabeculectomy group were 47.8 and 69.3%, and there was a significant difference in qualified success with condition A (Fig. 1; P = 0.018), while there were no significant differences in the other criteria. Ex-PRESS® mini shunt surgery and higher intraocular pressure were independent prognostic factors using Cox proportional hazards model analyses in qualified success as in condition A (P = 0.012 and 0.0495, respectively). The occurrences of postsurgical hyphema and bleb leaks were significantly higher in the trabeculectomy group (P = 0.005 and 0.008, respectively).

Conclusion

During a 1 year follow-up, Ex-PRESS® mini shunt surgery was a less effective, but safer treatment for NVG compared with trabeculectomy.

Effect of orbital decompression on dysthyroid optic neuropathy: A retrospective case series

In this study, we try to explore the effect of orbital decompression treatment on severe dysthyroid optic neuropathy.We retrospectively collected demographic and clinical characteristics of thyroid eye disease patients who performed orbital decompression. Then we analyzed the change of best-corrected visual acuity and exophthalmometry after surgery and the correlations among clinical parameters.A total of 22 cases (30 eyes) were included in the study. After orbital decompression, visual acuities improved in 16 eyes, declined in 8 eyes, and had no change in 5 eyes. Best-corrected visual acuity was significantly improved (0.1 vs 0.4, P = .039) and exophthalmometry was significantly declined (22.0 mm vs 16.5 mm, P = .001) after orbital decompression. Better postoperative best-corrected visual acuity was significantly correlated with better preoperative best-corrected visual acuity (r = 0.718, P < .05), and with normal optic disc (r = 0.568, P < .05), but not with age, exophthalmometry, keratopathy, and clinical activity score.These results showed that orbital decompression is a useful approach to manage dysthyroid optic neuropathy. The optimal time for surgery should be chosen based on clinical parameters, such as visual acuity and degree of crowding of orbital apex.

Efficacy of Ahmed Glaucoma Valve Implantation on Neovascular Glaucoma

To evaluate the efficacy of Ahmed glaucoma valve (AGV) implantation in treating neovascular glaucoma (NVG) and analyze the factors influencing the surgical success rate, a retrospective investigation of 59 NVG patients (66 eyes) who underwent AGV implantation was conducted at Jiangsu Province Hospital, China, from January 2014 to June 2018. Intraocular pressure (IOP), visual acuity, surgical success rates, medications, and complications were monitored at post-operative 1 day, 1 week, 1, 3, 6 and 12 months. Surgical success criteria were defined as 6 mm Hg < IOP < 21 mmHg with or without additional medications. Results showed average IOP was statistically significant between pre-operative visit and each follow-up visit (all P<0.05). At 12 months, the success rate was 66.7%. Multiple stepwise regression analysis suggested that age, panretinal photocoagulation (PRP), complications and hyphema were significant factors influencing the surgical success rate (all P<0.05). Thus, we conclude that AGV implantation is effective and safe for treatment of NVG. Surgical success is dependent on age, PRP, complications, and hyphema.

Influence of Vitrectomy-related Factors on the Outcome of Ahmed Glaucoma Valve Implantation

Purpose

To evaluate the outcome of Ahmed glaucoma valve (AGV) implantation in eyes with refractory secondary glaucoma following pars plana vitrectomy (PPV) and the associated prognostic factors.

Methods

A total of 146 eyes in 146 patients who underwent AGV implantation after PPV (followed up for ≥1 year) were included. AGV implantation was considered successful when the intraocular pressure (IOP) was 6 to 21 mmHg regardless of using IOP-lowering medication. The hazard ratios (HRs) associated with surgical failure were determined with Cox proportional analysis.

Results

The most common cause for PPV was complications of proliferative diabetic retinopathy (50%). The mean and peak IOPs between PPV and AGV implantation were 26.9 ± 6.6 and 35.9 ± 10.2 mmHg, respectively. AGV implantation was performed on average 18.7 months after PPV, and its overall success rate was 80.1% during a mean follow-up period of 43.6 months. In multivariate analyses, rubeosis observed before AGV implantation (HR, 4.07; 95% confidence interval, 1.57 to 10.6; p = 0.004) and higher peak IOP before AGV (HR, 1.04; 95% confidence interval, 1.00 to 1.07; p = 0.034) were predictive of failure. However, no PPV-related factors were associated with the surgical outcome of AGV implantation.

Conclusions

The outcome of AGV implantation is good in refractory glaucoma following PPV. Rubeosis after PPV and higher peak IOP before AGV are risk factors for poor outcomes. Patients who undergo PPV should be followed for the development of rubeosis and IOP control.

Randomized comparative trial of diode laser transscleral cyclophotocoagulation versus Ahmed glaucoma valve for neovascular glaucoma in Chinese - a pilot study

Purpose

This is a pilot study to compare the effectiveness and safety of diode laser transscleral cyclophotocoagulation (TSCP) with the Ahmed glaucoma valve (AGV) in the management of neovascular glaucoma (NVG).

Methods

Eyes with NVG and an IOP greater than 21 mmHg on maximal medications, without previous glaucoma surgery or cyclodestruction, were randomized for either TSCP or AGV implantation. These eyes were followed for at least 6 months and analyzed with respect to their visual outcome, IOP, number of glaucoma medications required, and related complications.

Results

Twenty eyes (eight TSCP and 12 AGV) of 19 subjects with a follow-up duration of greater than 6 months were recruited. Mean follow-up duration was 28.5±17.9 and 31.0±15.4 months for the TSCP and AGV groups, respectively (P=0.80). IOP was successfully controlled in 86% of the eyes for both interventions. By including preservation or improvement of visual acuity as additional criteria for overall success, success decreased to 63% for TSCP and 42% for AGV, although the difference was not statistically significant (P=0.65). Eyes that had TSCP had fewer complications and required less subsequent procedures, compared to those that underwent AGV implantation.

Conclusion

Both procedures were equally effective in controlling the IOP and reducing glaucoma medications in NVG. However, eyes with AGV implant tended to have higher rates of visual loss and complications, as well as requiring more postoperative procedures, than eyes that were treated with TSCP, although the difference was not statistically significant.

Clinical Efficacy and Safety of the EX-PRESS Filtration Device in Patients with Advanced Neovascular Glaucoma and Proliferative Diabetic Retinopathy

Background

The prognosis of conventional filtration surgery in eyes with neovascular glaucoma (NVG) is limited due to increased fibrovascular proliferation or bleeding. This study aims to evaluate the safety and efficacy of the EX-PRESS filtration device in the management of NVG associated with proliferative diabetic retinopathy (PDR).

Methods

In this retrospective case series, we reviewed the medical records of patients diagnosed as having NVG associated with PDR who underwent EX-PRESS filtration surgery. The main outcome measures were: postoperative intraocular pressure (IOP), the percent of IOP drop, the number of glaucoma medications, visual acuity, and complications of surgery. Successful surgery was defined as an IOP <22 mm Hg and >5 mm Hg with or without additional glaucoma surgery, and no loss of light perception or less than a 2-line decrease on the Snellen chart of the best corrected visual acuity (BCVA).

Results

Five patients (5 eyes) were included in this study. The mean preoperative IOP was 33.4 ± 5.9 mm Hg compared to an IOP of 17.0 ± 3.0 mm Hg at the last follow-up (p = 0.003). The mean number of preoperative anti-glaucoma medications was 3.8 ± 0.4 compared to 2.2 ± 1.5 (p = 0.06) at the last follow-up visit. Final visual acuity improved or stabilized within 1 Snellen line in all 5 patients. Three patients had a "hypertensive phase" (defined as an IOP >21 mm Hg during the first 6 postoperative months) which resolved within 2 months. Two patients developed a hyphema that resolved spontaneously. None of the patients experienced any serious complications.

Conclusion

EX-PRESS filtration device has a good IOP-lowering effect and a low rate of complications in patients with advanced NVG associated with PDR. In addition, there was no loss of light perception or no line decrease of the BCVA.

Combined Phacoemulsification and Ahmed Valve Glaucoma Drainage Implant: A Retrospective Case Series

Purpose

To report on the efficacy and safety of combined phacoemulsification and an Ahmed valve glaucoma drainage implant with respect to visual acuity improvement, intraocular pressure (IOP) control, and requirement for antiglaucoma medication.

Methods

A retrospective chart review was conducted of 41 eyes (31 patients) with coexisting visually significant cataracts and uncontrolled glaucoma who had combined phacoemulsification and Ahmed valve implantation. The outcome measures were: visual acuity, IOP, antiglaucoma medication requirements, and intra- and post-operative complications. Success was categorized as absolute (IOPp<21 mmHg without the need for antiglaucoma medication) and relative (IOPp<21 mmHg with one or more antiglaucoma medications). Failure was considered to be an IOPp<6 mmHg or IOP>21 mmHg on maximally tolerated medications or any devastating complication.

Results

The mean patient age was 67.3±5.9 years old. The mean visual acuity improved from 0.73±0.5 to 0.16±0.16 (p=0.000). The mean IOP decreased from 28.2±3.1 to 16.8±2.1 (p=0.000, 40.4%), while the number of antiglaucoma medication decreased from 2.6±0.66 to 1.2±1.4 (p=0.000). The absolute and relative success rates were 56.1% and 31.7%, respectively; 5 eyes (12.2%) were considered failures. There were no intraoperative complications; postoperative complications occurred in 8 eyes (19.5%). A hypertensive phase was detected in 12 (29.3%) eyes.

Conclusions

Combined phacoemulsification and Ahmed valve glaucoma drainage implantation is a safe and effective alternative to phacotrabeculectomy in patients with coexisting cataract and refractory glaucoma.

Retinal pigment epithelium changes in pediatric patients with glaucoma drainage devices

Purpose

Retinal changes secondary to hypotony are usually described as wrinkling or folding of the inner portion of the choroid, the retinal pigment epithelium (RPE), and the outer retinal layers in the macular area due to scleral wall collapse. We describe a new retinal finding in children with suspected hypotony after implantation of Baerveldt Glaucoma Implant (BGI).

Observations

Four patients in our series developed significant RPE defects after BGI implant. The RPE defects appeared as elongated white lines observed solely in the posterior pole, in no particular pattern, and seemed to be worse in infants with anterior segment dysgenesis and with collagen disorders.

Conclusion and importance

Children have thinner and more elastic scleral walls than adults. This characteristic may cause the inward scleral wall to collapse when the eye is hypotonic. The resulting redundancy of the retina leads to wrinkling and RPE defects characterized by hypopigmented lines predominantly in the macular area. Such findings, to our knowledge, have not been previously reported in pediatric patients.

Short-term outcomes after EX-PRESS implantation versus trabeculectomy alone in patients with neovascular glaucoma

Background

The purpose of this study was to investigate postoperative clinical outcomes in patients with neovascular glaucoma (NVG) who underwent trabeculectomy or EX-PRESS implantation and to identify predictors of successful EX-PRESS implantation.

Methods

The study designed as a retrospective observational analysis and was set in a single tertiary center. Eighty-nine patients (89 eyes) with NVG, were treated using trabeculectomy alone (Trab group; n=39) or EX-PRESS implantation (EX group; n=50). All patients with a history of glaucoma surgery were excluded. The main outcome measures were postoperative intraocular pressure (IOP), visual acuity (VA), number of medications, complications, additional therapy, and success rate.

Results

The mean follow-up duration was 4.6 months in the Trab group and 4.2 months in the EX group. There was no significant difference in IOP between the groups except at 1-month follow-up (P=0.045). The number of patients with early postoperative hypotony, a shallow anterior chamber, hyphema, or anterior chamber irrigation was significantly lower in the EX group than in the Trab group (P=0.016, 0.008, 0.019, and 0.014, respectively). The other outcomes, ie, VA, number of medications, and success rate, were similar between the two groups. In the EX group, the success rate was significantly lower in 15 patients with a history of vitrectomy compared to that in 35 patients without a history of vitrectomy (P=0.047).

Conclusion

Implantation of an EX-PRESS device may be more effective and safer than trabeculectomy alone in patients with NVG. However, a history of vitrectomy may affect the surgical success rate when using EX-PRESS.

Comparison of Outcomes between Endoscopic and Transcleral Cyclophotocoagulation

Importance: Traditionally cyclophotocoagulation has been reserved as a treatment of last resort for eyes with advanced stage glaucoma, but increasingly it is offered to eyes with less severe disease. Endoscopic approaches in particular are utilized in increasing numbers of patients despite only a small number of publications on its results. Objective: The purpose of this study was to compare the efficacy and safety of endoscopic and transcleral cyclophotocoagulation (ECP and TCP) procedures in eyes with refractory glaucomas. Design, Setting, and Participants: A chart review was performed on consecutive patients who underwent ECP and TCP at a tertiary ophthalmology care center between January 2000 and December 2010. Cases with fewer than 3 months of follow-up or that had concurrent pressure reducing procedures were excluded. The main outcome measures examined were intraocular pressure (IOP), number of glaucoma medications, best corrected visual acuity (BCVA), additional glaucoma procedure required, and complications. Main Outcomes and Measures: Forty-two eyes (42 patients) that underwent ECP and forty-four eyes (44 patients) that underwent TCP were identified. The TCP group had a statistically higher mean age (71.2 ± 16.7 vs. 58.1 ± 22.9 years, respectively), larger proportion of neovascular glaucoma (40.9% vs. 16.7%), worse initial BCVA (logMAR 2.86 vs. 1.81), and higher preoperative IOP (45.3 vs. 26.6 mmHg) than the ECP group. At 12 months follow-up, the mean IOP difference between groups was not statistically significant, although the change in IOP from baseline to 12 months was greater for the TCP group (p = 0.006). The rates of progression to no light perception (NLP) and phthisis bulbi were significantly higher amongst TCP eyes than ECP eyes (27.2% vs. 4.8%, p = 0.017, and 20.5% vs. 0%, p = 0.003, respectively). Of these eyes that progressed, a majority had neovascular glaucoma (NVG). Corneal decompensation was the most frequent complication following ECP (11.9%). Conclusions and Relevance: In patients with preoperative BCVA of 20/400 or better, overall complication rates (cystoid macular edema, exudative retinal detachment, inflammation, cornea decompensation) were higher after ECP than with TCP. In refractory glaucomas in a real world setting (not a trial), TCP was more frequently used in ischemic eyes. TCP was associated with a higher rate of progression to phthisis bulbi and loss of light perception than ECP. However, ECP was associated with a clinically significant rate of corneal decompensation. These outcomes likely were related to the severity of underlying ocular diseases found in these eyes.

Long-Term Outcome of Intravitreal Bevacizumab Followed by Ahmed Valve Implantation in the Management of Neovascular Glaucoma

BACKGROUND

To report the outcome of intravitreal Bevacizumab followed by Ahmed valve implantation in the management of neovascular glaucoma in a patient group with extended follow-up.

METHODS

The records of 16 patients (18 eyes) with neovascular glaucoma refractory to medical therapy who presented to a single surgeon between 2006-2008 were reviewed. Patients received pan-retinal photocoagulation and then intravitreal Bevacizumab followed by Ahmed valve implantation. The main outcome measures were: control of IOP (with or without additional medication), visual acuity (VA) and failure (IOP >21 mmHg or <6 mmHg, reoperation for glaucoma, or loss of light perception).

RESULTS

Pre-operatively, all patients received pan-retinal photocoagulation followed by IVB at a mean of 15.9 (range 4-60) days prior to AGV. The mean pre-operative IOP was 37.1 mmHg (±13.4) on 3.2 (±0.87) medications. Of the 18 eyes, 14 eyes (78%) were treated with AGV alone and 4 eyes (22%) with AGV combined with cataract extraction. Sixteen eyes (89%) received mitomycin C treatment intraoperatively. Post-operatively, the mean follow-up period was 63 months (24-84). At final follow-up, the success rate was 50% (33.3% complete, 16.7% qualified) with a mean IOP of 18.1 mmHg (±9.5) on a mean number of 1.5 (±1.6) medications. The failure rate was 50%, with five eyes (27.8%) not meeting the IOP criteria for success (of these, three eyes required additional surgery to lower the IOP) and five eyes (22.2%) lost light perception.

CONCLUSION

Intravitreal Bevacizumab followed by AGV offers long-term control of IOP without additional surgical intervention in the majority of cases.

Clinical Outcomes of Ahmed Glaucoma Valve Implantation With or Without Intravitreal Bevacizumab Pretreatment for Neovascular Glaucoma: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy and tolerability of Ahmed glaucoma valve (AGV) implantation with intravitreal bevacizumab injection (IVB) pretreatment in the treatment of neovascular glaucoma (NVG).

METHODS

A comprehensive literature search was performed according to the Cochrane collaboration methodology to identify controlled clinical trials comparing AGV implantation with (IVB group) or without IVB (control group) pretreatment for NVG. The main outcome measures were the weighted mean differences (WMDs) for intraocular pressure reduction, a reduction in glaucoma medications, odds ratio (OR) for complete success rates, and qualified success rates. Tolerability estimates were measured by OR for adverse events.

RESULTS

The WMD of the intraocular pressure reduction when comparing the IVB group with the control group was 3.30 (-1.21 to 7.80). The IVB group was associated with numerically greater but nonsignificant IOP lowering efficacy compared with the control group (P=0.152). Both groups were comparable in the reduction of glaucoma medication, with a WMD of 0.28 (-0.03 to 0.59) at the follow-up endpoint (P=0.077). The IVB group was associated with significant greater complete success rates compared with the control group, with a pooled OR of 3.18 (1.41 to 7.19). However, it did not show a significant difference for the qualified success rate between them, with a pooled OR of 2.00 (0.95 to 4.21). The IVB group was associated with a significantly lower frequency of hyphema than the control group, with a pooled OR of 0.15 (0.07 to 0.32).

CONCLUSION

The use of IVB pretreatment for NVG is a safe and effective additional step during AGV implantation surgery.

Clinical efficacy analysis of Ahmed glaucoma valve implantation in neovascular glaucoma and influencing factors: A STROBE-compliant article

This study aimed to evaluate the efficacy of Ahmed glaucoma valve (AGV) implantation in treating neovascular glaucoma (NVG) and to analyze the factors influencing the surgical success rate.This is a retrospective review of 40 eyes of 40 NVG patients who underwent AGV implantation at Xiangya Hospital of Central South University, China, between January 2014 and December 2016. Pre- and postoperative intraocular pressure (IOP), visual acuity, surgical success rate, medications, and complications were observed. Surgical success criteria were defined as IOP ≤21 and >6 mm Hg with or without additional medications. Kaplan-Meier survival curves and Multivariate cox regression analysis were used to examine success rates and risk factors for surgical outcomes.The mean follow-up period was 8.88 ± 3.12 months (range: 3-17). IOP declined at each visit postoperatively and it was statistically significant (P < .001). An average of 3.55 ± 0.86 drugs was applied preoperatively, while an average of 0.64 ± 0.90 drugs was used postoperatively, with the difference being of statistical significance (P < .05). The complete surgical success rate of 3, 6, and 12 months after the operation was 85%, 75%, and 65%, respectively. Meanwhile, the qualified success rate of 3, 6, and 12 months after the operation was 85%, 80%, and 77.5%, respectively. The multivariate cox regression analysis showed that age (hazard ratio: 3.717, 7.246; 95% confidence interval: 1.149-12.048, 1.349-38.461; P = .028, .021) was influencing factors for complete success rate and qualified success rate among all NVG patients. Gender, previous operation history, primary disease, and preoperative IOP were found to be not significant.AGV implantation is an effective and safe surgical method to treat NVG. Age is an important factor influencing the surgical success rate.

Intermediate-term and long-term outcome of piggyback drainage: connecting glaucoma drainage device to a device in-situ for improved intraocular pressure control

IMPORTANCE

This study provides results of a treatment option for patients with failed primary glaucoma drainage device.

BACKGROUND

The study aimed to describe and evaluate the long-term intraocular pressure control and complications of a new technique joining a second glaucoma drainage device directly to an existing glaucoma drainage device termed 'piggyback drainage'.

DESIGN

This is a retrospective, interventional cohort study.

PARTICIPANTS

Eighteen eyes of 17 patients who underwent piggyback drainage between 2004 and 2013 inclusive have been studied. All patients had prior glaucoma drainage device with uncontrolled intraocular pressure.

METHODS

The piggyback technique involved suturing a Baerveldt (250 or 350 mm) or Molteno3 glaucoma drainage device to an unused scleral quadrant and connecting the silicone tube to the primary plate bleb.

MAIN OUTCOME MEASURES

Failure of intraocular pressure control defined as an intraocular pressure greater than 21 mmHg on maximal therapy on two separate occasions or further intervention to control intraocular pressure.

RESULTS

The intraocular pressure was controlled in seven eyes (39%) at last follow-up with a mean follow-up time of 74.2 months. The mean preoperative intraocular pressure was 27.1 mmHg (95% confidence interval 23.8-30.3) compared with 18.4 mmHg (95% confidence interval 13.9-22.8) at last follow-up. The mean time to failure was 57.1 months (95% confidence interval 32.2-82), and the mean time to further surgery was 72.3 months (95% confidence interval 49.9-94.7). Lower preoperative intraocular pressure was associated with longer duration of intraocular pressure control (P = 0.048). If the intraocular pressure was controlled over 2 years, it continued to be controlled over the long term. Two eyes (11%) experienced corneal decompensation.

CONCLUSIONS

Piggyback drainage represents a viable surgical alternative for the treatment of patients with severe glaucoma with failing primary glaucoma drainage device, particularly in those at high risk of corneal decompensation.

Neovascular glaucoma: a review

Neovascular glaucoma (NVG) is a secondary glaucoma generally associated with poor visual prognosis. The development of new vessels over the iris and the iridocorneal angle can obstruct aqueous humor outflow and lead to increased intraocular pressure. The underlying pathogenesis in most cases is posterior segment ischemia, which is most commonly secondary to proliferative diabetic retinopathy or central vein retinal occlusion. The neovascularization process in the eye is driven by the events that alter the homeostatic balance between pro-angiogenic factors, such as the vascular endothelial growth factor and anti-angiogenic factors, such as the pigment-epithelium-derived factor. Early diagnosis of this condition through slit lamp examination of the iris, iridocorneal angle and retina can help to avoid the development of goniosynechia and obstruction of aqueous humor outflow, with consequent intraocular pressure elevation. Historically, NVG treatment was focused on reducing the posterior segment ischemic process that caused the formation of new vessels, through panretinal photocoagulation. Recently, several studies have investigated the application of intravitreal anti-VEGF therapies in NVG. If clinical treatment with the use of hypotensive topical drops is not sufficient, laser and/or surgical procedures are required for intraocular pressure control.

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.

Neovascular glaucoma: a retrospective review from a tertiary center in China

Background

The purpose of this study is to report the prevalence, etiology, treatment and outcomes of neovascular glaucoma (NVG) in a tertiary care ophthalmic center in China.

Methods

Medical records of patients diagnosed as NVG at the Wenzhou Medical University between 2003 and 2014 were reviewed. Success was defined as IOP between 6 and 21 mmHg without topical or systemic glaucoma medications with retention of presenting visual acuity (VA).

Results

NVG was diagnosed in 483 of 8306 (5.8 %) of all glaucoma patients. Etiology is reported for all 310 eyes of 284 patients managed in the department. Interventions depended on insurance as well as personal finances; outcomes are reported for the 149 eyes of 138 patients with complete data that met follow up requirements. Diabetic retinopathy (DR,39.7 %) was the major cause of NVG. Kaplan Meier survival analysis showed a success rate of 84.8 % at 1 year, 47.5 % at 3 years and 21.9 % at 5 years. Major interventions included glaucoma drainage device (GDD) in 103 eyes and trans-scleral cyclophotocoagulation (TSCPC) in 22 eyes. Complications were more common in the GDD group.

Conclusions

NVG comprised 5.8 % of glaucoma patients seen in a tertiary Chinese hospital. DR was identified as the commonest cause and probably reflects the increasing prevalence of diabetes in China. Surgical interventions were partly determined by insurance status and personal finances. GDD was the commonest surgical intervention used and also had the most complications.

Retrospective review of pars plana versus anterior chamber placement of Baerveldt glaucoma drainage device

PURPOSE

To evaluate outcomes of pars plana (PP) versus anterior chamber (AC) placement of Baerveldt glaucoma drainage device (GDD).

METHODS

This study is a nonrandomized, retrospective case series evaluating 63 eyes that underwent GDD insertion with Baerveldt 350 device under the supervision of 2 surgeons at 5 centers. The drainage tube was either inserted into the AC or through the PP into the vitreous cavity where eyes had been vitrectomized. Surgery was conducted between 2003 and 2010 with minimum patient follow-up of 6 months. Data on postoperative intraocular pressure (IOP), visual acuity, number of hypotensive medications, and surgical complications were recorded.

RESULTS

Of the 63 drainage device surgeries, 34 tubes were placed in the AC and 29 were placed into the posterior segment through the PP. Preoperative mean IOP was 32.3±20.3 mm Hg in the AC group and 32.8±18.4 mm Hg in the PP group. Postoperative mean IOP was reduced at all follow-up time points in both the groups. Postoperative mean IOP in the anterior tube group was 14.0, 12.9, and 14.0 mm Hg and in the PP group was 14.2, 14.2, and 14.0 mm Hg, at the 1-, 2-, and 3-year follow-up, respectively. The qualified success rate at 2 years was 94% for the PP group and 91% for the AC group, whereas absolute success was 35% for the PP group and 27% for the AC group at 2-year follow-up.

CONCLUSIONS

Insertion of the tube of the Baerveldt GDD into the PP is a safe and effective method for IOP control in aphakic, pseudophakic, and vitrectomized eyes where there is a need to avoid anterior tube placement such as coexisting corneal pathology. IOP control results appear comparable to conventional AC placement.

Surgical Outcome of Ahmed Valve Implantation in Mexican Patients with Neovascular Glaucoma

Purpose: To describe clinical results of Ahmed glaucoma valve implantation in Mexican patients with neovascular glaucoma (NVG).

Materials and methods: We reviewed records of 60 eyes of 60 patients with NVG who underwent Ahmed valve implantation, with a follow-up period of 1 year. We identified successful and failed cases and compared baseline and follow-up characteristics to identify possible differences between both groups.

Results: We classified 36 eyes (60%) as successful and 24 (40%) as failed cases. We found a significant difference in success rate in patients who had a hypertensive phase at any time during the follow-up period (OR = 5.15, CI = 1.49-20.15, p = 0.004). Patients in the success group showed a statistically significant decrease in the number of glaucoma medications 1 year after surgery (p <0.0001). We found a statistically significant difference in success rate in patients who had preoperative best corrected visual acuity (BCVA) better than logmar 0.70 (odds ratio 4.31, CI = 1.1-19.3, p = 0.03086).

Conclusion: A hypertensive postoperative phase and a preoperative BCVA worse or equal to 20/100 seem to be risk factors for Ahmed valve surgical failure in patients with NVG.

How to cite this article: Hernandez-Oteyza A, Lazcano-Gomez G, Jimenez-Roman J, Hernandez-Garciadiego C. Surgical Outcome of Ahmed Valve Implantation in Mexican Patients with Neovascular Glaucoma. J Curr Glaucoma Pract 2014;8(3):86-90.

Management of Secondary Angle Closure Glaucoma

Secondary angle closure glaucomas are a distinct entity from primary angle closure glaucoma (PACG). Unlike PACG, secondary angle closure glaucoma's have an identifable contributory factor/s for angle closure and obstruction of aqueous fow which is usually unrelieved by iridotomy. The treatment of each type of secondary angle closure glaucoma is varied, so identification of the primary cause aids in its effective management. How to cite this article: Annadurai P, Vijaya L. Management of Secondary Angle Closure Glaucoma. J Current Glau Prac 2014;8(1):25-32.

Vision-related quality of life tends to be more severely impaired in patients with dysthyroid optic neuropathy

PURPOSE

Dysthyroid optic neuropathy (DON) is the most severe condition in thyroid eye disease (TED); however, no study has been conducted to assess quality of life in these patients to date. The aim of this study was to evaluate vision-related quality of life in TED patients with DON using a Chinese version of the 25-item National Eye Institute Visual Function Questionnaire (CHI-VFQ-25).

METHODS

The CHI-VFQ-25 scores were compared for 23 TED patients with DON and 13 TED patients without DON. The correlations between the clinical characteristics and subscale scores on the CHI-VFQ-25 and the floor and ceiling effects of the CHI-VFQ-25 were also assessed.

RESULTS

Patients with DON scored significantly lower than patients without DON on the CHI-VFQ-25 (composite score: 54 versus 77, respectively, p = 0.001). Many subscales were significantly correlated with the severity and activity of the disease (p < 0.05). In patients with DON, no floor effects were found, and ceiling effects were only observed for Color vision, Peripheral vision and Social function. Role limitations and Mental health were the lowest scores in all the subscales.

CONCLUSIONS

The current study showed that vision-related quality of life tended to be more severely impaired in TED patients with DON than in patients without DON. The CHI-VFQ-25 may be a promising tool to estimate the benefits of interventions in patients with DON.

The effect of intravitreal bevacizumab injection before Ahmed valve implantation in patients with neovascular glaucoma

To evaluate the effect of intravitreal bevacizumab (IVB) before Ahmed valve implantation for treatment of neovascular glaucoma (NVG). This study is a retrospective, comparative, consecutive case series. The study group consisted of 27 eyes of 26 patients with NVG who underwent an Ahmed valve implantation. Thirteen eyes were treated with Ahmed valve implantation alone (control group), and 14 eyes were treated with a combination of preoperative IVB injection and Ahmed valve implantation (IVB group). Visual acuity, intraocular pressure (IOP), number of anti-glaucoma medications, surgical complications, and success rate were compared between the two groups. There were no significant differences in preoperative characteristics between the two groups. Visual acuity at 1, 2 weeks, and 1 month after surgery were significantly better in the IVB group (p = 0.038, 0.034, and 0.032, respectively). Hyphema associated with Ahmed valve implantation occurred significantly less in the IVB group (p = 0.016). On the other hand, the mean IOP and number of anti-glaucoma medications at all follow-up periods were similar between the two groups. Kaplan-Meier survival analysis showed the probability of success 6 months after surgery as 71.4 % in the IVB group and 84.6 % in the control group. No significant difference in success rate was found between the groups (p = 0.422). IVB before Ahmed valve implantation for treatment of NVG reduced the incidence of hyphema. In this retrospective study, IVB provided better visual outcome in the early postoperative periods but did not significantly improve mean IOP, number of anti-glaucoma medications, or success rate.

The Ahmed versus Baerveldt study: three-year treatment outcomes

OBJECTIVE

To compare 2 commonly used aqueous drainage devices for the treatment of refractory glaucoma.

DESIGN

International, multicenter, randomized trial.

PARTICIPANTS

Patients aged 18 years or older with uncontrolled or high-risk glaucoma refractory to maximum medical therapy, many of whom had failed trabeculoplasty and trabeculectomy.

METHODS

Eligible patients were randomized to an Ahmed-FP7 valve implant (New World Medical, Inc., Rancho Cucamonga, CA) or a Baerveldt-350 implant (Abbott Medical Optics, Inc., Santa Ana, CA) using a standardized surgical technique.

MAIN OUTCOME MEASURES

The primary outcome was failure, defined as intraocular pressure (IOP) outside of the target range (5-18 mmHg, with ≥20% reduction from baseline) for 2 consecutive visits after 3 months, vision-threatening complications, de novo glaucoma procedures, or loss of light perception. Secondary outcome measures include IOP, medication use, visual acuity, complications, and interventions.

RESULTS

A total of 238 patients were enrolled and randomized; 124 received the Ahmed implant and 114 received the Baerveldt implant. Baseline characteristics were similar in both groups. Half the study group had secondary glaucoma, and 37% had previously failed trabeculectomy. The mean preoperative IOP was 31.4±10.8 mmHg on 3.1±1.0 glaucoma medications. Median baseline Snellen visual acuity was 20/100. At 3 years, the cumulative probability of failure was 51% in the Ahmed group and 34% in the Baerveldt group (P = 0.03). Mean IOP was 15.7±4.8 mmHg in the Ahmed group (49% reduction) and 14.4±5.1 mmHg in the Baerveldt group (55% reduction; P = 0.09). Mean number of glaucoma medications was 1.8±1.4 in the Ahmed group (42% reduction) and 1.1±1.3 in the Baerveldt group (65% reduction; P = 0.002). There was a moderate but similar decrease in visual acuity in both groups (P< 0.001). The 2 groups had similar complication rates (52% Ahmed, 62% Baerveldt; P = 0.12); however, the Baerveldt group had a higher rate of hypotony-related vision-threatening complications (0% Ahmed, 6% Baerveldt; P = 0.005). More interventions were required in the Baerveldt group, although the difference did not reach statistical significance (38% Ahmed, 50% Baerveldt; P = 0.07). Most complications were transient, and most interventions were slit-lamp procedures.

CONCLUSIONS

Both devices were effective in reducing IOP and glaucoma medications. The Baerveldt group had a lower failure rate and required fewer medications than the Ahmed group after 3 years, but it experienced more hypotony-related vision-threatening complications.