Clinical outcomes of Ahmed glaucoma valve implantation in pediatric glaucoma

Outcome of Ahmed glaucoma valve implant in congenital fibrovascular pupillary membrane with secondary glaucoma

BACKGROUND

Congenital fibrovascular pupillary membranes in secondary glaucoma (CFPMSG) is kind of refractory childhood glaucoma. The aim of the study is to evaluate the efficacy and safety of Ahmed glaucoma valve (AGV) implants in CFPMSG.

METHODS

Twelve patients with CFPMSG who underwent anterior chamber reconstruction (ASR) with a stable anterior chamber but uncontrolled intraocular pressure (IOP) underwent AGV implantation. Patients with a follow-up period of > 12 months were enrolled. Demographic data were collected. All patients underwent comprehensive ophthalmic examinations before and after surgeries, including IOP measurement, A- and B-scan ultrasonography, and ultrasound biomicroscopy (UBM), etc. Success was defined as postoperative intraocular pressure (IOP) ≤ 21 mmHg with (qualified success) or without (complete success) the use of glaucoma drugs.

RESULTS

The median age of enrolled patients was 15.1 ± 12.5 months old (range 4.5-46) and 58.3% of them were female. At last follow-up (32.0 ± 16.0 months), the average IOP was declined (postoperative: 18.7 ± 4.5 mmHg vs. preoperative: 29.0 ± 4.0 mmHg, p < 0.001). The number of glaucoma drugs decreased from 3 (range 2-3) to 1.5 (range 0-3) (P < 0.001), while the anterior chamber depth (ACD) remained stable (3.21 ± 0.70 mm and 3.40 ± 0.82 mm, respectively) (p = 0.57) after AGV implantation. The complete success rate was 25% (3/12) and the qualified success rate was 58.3% (7/12). The total success rate was 83.8%. No severe complications were noted.

CONCLUSIONS

This study demonstrated that AGV implants could be safe and effective for CFPMSG with uncontrolled IOP. AGV implantation is a feasible option for the treatment of CFPMSG.

Outcomes of a Second Ahmed Glaucoma Implant With Mitomycin-C in Pediatric Glaucoma After Initial Valve Failure

PRCIS

After the failure of a glaucoma drainage device in children, implantation of a second Ahmed glaucoma valve with mitomycin-C allows a significant reduction of intraocular pressure and number of medications with good medium-term and long-term survival.

INTRODUCTION

The effectiveness of glaucoma drainage devices (GDD) is limited in time. There is little literature regarding the optimal management strategy after failure of a GDD in pediatric glaucoma.

PURPOSE

To report the outcomes of Ahmed glaucoma valve implantation (AGV) with mitomycin-C (MMC) after failure of a GDD in children.

METHODS

Retrospective chart review of patients with a history of at least 1 GDD receiving an AGV implantation with MMC between 2000 and 2019. We defined complete success as an IOP of 5-21 mm Hg without glaucoma medication and qualified success as a final IOP of 5-21 mm Hg with one or more glaucoma medication, without loss of vision.

RESULTS

Twenty-one patients (22 eyes) met the inclusion criteria. The intraocular pressure and number of medications were significantly reduced. The probability of complete success was 47% [95% CI: 29%-75%] at 2 years and 34% [95% CI: 18%-65%] at 4 years. The probability of qualified success was 74% [95% CI: 56%-97%] at 2 years, and 54% [95% CI: 34%-84%] at 5 years. Failure happened in 10 eyes after a mean time of 4.3 years ±3.6 (6 mo to 15 y), 5 of which (23%) for severe complications or loss of vision.

DISCUSSION

This study of implantation of a second valve with MMC reports a significant decrease in IOP and medications with medium-term and long-term success rates close to those reported for first valve implantation, although with a high risk of complications.

Initial Clinical Experience with Ahmed Valve in Romania: Five-Year Patient Follow-Up and Outcomes

BACKGROUND

Glaucoma is a leading cause of irreversible blindness worldwide and is particularly challenging to treat in its refractory forms. The Ahmed valve offers a potential solution for these difficult cases. This research aims to assess the initial clinical experience with Ahmed valve implantation in Romania, evaluating its effectiveness, associated complications, and overall patient outcomes over a five-year period.

METHODS

We conducted a prospective study on 50 patients who underwent Ahmed valve implantation due to various types of glaucoma. Patients were monitored at several intervals, up to five years post-surgery. Intraocular pressure and visual acuity were the primary measures of success.

RESULTS

On average, patients maintained the intraocular pressure within the targeted range, with the mean intraocular pressure being 17 mmHg 5 years post-surgery. Success, defined as maintaining target intraocular pressure without additional surgery, was achieved in 82% at 1 year, 68% at 3 years, and 60% after 5 years postoperative.

CONCLUSION

Ahmed valve implantation is a viable treatment option for refractory glaucoma, demonstrating significant intraocular pressure reduction and manageable complication rates over a five-year follow-up period. Future research should focus on long-term outcomes and optimization of surgical techniques to further reduce complication rates and improve patient quality of life.

New approach to AGV implantation with scleral tunnel method by prolene suture: Şimşek Technique

PURPOSE

To present the short-term outcomes of our novel technique, the suture-assisted method, in long scleral tunnel Ahmed Glaucoma Valve (AGV) implantation.

METHODS

This retrospective study included glaucoma patients who underwent AGV implantation using the suture-assisted long scleral tunnel method and were fellowed for at least 6 months between January 2022 and November 2022. Preoperative and postoperative assessments included best-corrected visual acuity (BCVA), intraocular pressure (IOP), anterior and posterior segment examinations, anti-glaucomatous medications, and intraoperative and postoperative complications were also evaluated.

RESULTS

Eight eyes of seven patients were included in the study. The mean age was 52.25 ± 29.38 years (r:8-76 years), and there were 5 female and 2 male patients. The mean follow-up duration period was 8.62 ± 2.50 months (r:6-12 months). The mean IOP was 27.12 ± 3.48 mmHg preoperatively and 11.62 ± 3.48 mmHg on postoperative on 1st day, 11.62 ± 3.20 mmHg at 1st week, 18.75 ± 8.94 mmHg at 1st month, 16.62 ± 2.72 mmHg at 3rd month, 16.12 ± 3.75 mmHg at 6th month. Postoperative hyphema was observed in one eye, and tenon cyst excision was performed in two eyes. No tube exposure was observed in any eye during the follow-up period. No hypotony-related complications were observed during follow-up.

CONCLUSION

We believe that suture-asissted application of the long scleral tunnel method not only prevents tube exposure but also facilitates the passage of the AGV silicone tube through the scleral tunnel, reducing the surgical time contributing to a decreased the risk of infection.

Challenges of Secondary Glaucoma Management Following Congenital Cataract Surgery, Penetrating Keratoplasty and Vitreoretinal Surgery

Glaucoma is one of the world's leading causes of irreversible vision loss. It is often asymptomatic until it reaches an advanced stage, which can have a significant impact on patients' daily lives. This paper describes the case of a 50-year-old female patient who presented with acute onset of ocular pain, photophobia, and loss of visual acuity in her right eye (RE). The patient's medical history includes congenital cataracts, surgical aphakia, nystagmus, strabismus, amblyopia, and secondary glaucoma. Ophthalmological examination showed BCVA RE-hand movement, left eye (LE)-0.08 with an intraocular pressure (IOP) of 30 mmHg in RE and 16 mmHg in LE. Biomicroscopic examination of RE showed corneal graft, epithelial and endothelial edema, endothelial precipitates, corneal neovascularization, aphakia, and Ahmed valve superotemporally. Despite maximal topical and systemic treatment, Ahmed valve, and trabeculectomy, secondary glaucoma in the right eye remained refractory. Reimplantation of an Ahmed valve was performed. This resulted in a favorable outcome with increased visual acuity and controlled intraocular pressure. The combination of aphakia, penetrating keratoplasty, and secondary glaucoma is a challenge for any surgeon. It is important that both the perioperative risks and the possible complications are carefully assessed in each patient, especially if associated pathology is present.

Clinical outcomes of Ahmed glaucoma valve implantation in primary open-angle glaucoma and pseudoexfoliative glaucoma

PURPOSE

To investigate the clinical outcomes of Ahmed glaucoma valve (AGV) implantation in primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG).

METHODS

The patients who underwent AGV implantation for POAG and PEXG between January 2015 and December 2021 in a single tertiary center eye clinic were reviewed retrospectively. Thirty-one eyes with the diagnosis of POAG constituted Group 1 and 40 eyes with the diagnosis of PEXG constituted Group 2. The primary outcome measures were intraocular pressure (IOP) changes after AGV implantation and surgical success at the last visit. We evaluated complete and qualified surgical success using the following three criteria: (1) IOP ≤ 21mmH g, (2) IOP ≤ 18 mmHg, and (3) IOP ≤ 15 mmHg, as well as the absence of any serious complications, such as light perception loss and phthisis bulbi, and additional de novo glaucoma surgery.

RESULTS

The mean follow-up times were 25.2 (± 21.4) months and 27.6 (± 19.8) months for Groups 1 and 2, respectively (p > 0.05). In Groups 1 and 2, the mean preoperative IOPs were 31.9 ± 9.4 mmHg and 32.3 ± 8.4 mmHg, respectively, which significantly reduced to 14.5 ± 0.7 mmHg and 11.6 ± 0.6 mmHg, respectively at the last postoperative visit (p < 0.001 for both). The mean IOP value at the last visit was statistically significantly lower in Group 2 (p = 0.006). At the last visit, the number of eyes with qualified success according to criteria 1, 2, and 3 was 26 (83.9%), 25 (80.6%), and 18 (58.1%), respectively, in Group 1 and 39 (97.5%), 39 (97.5%), and 32 (80%), respectively, in Group 2. The comparison of the qualified success rates showed statistically significantly higher rates in Group 2 for criterion 2 (p = 0.038).

CONCLUSION

AGV implantation had high success rates in both POAG and PEXG, but at the final visit, lower IOP levels were reached in the latter.

Concurrent adjacent strabismus surgery with glaucoma drainage device placement in childhood glaucomas

BACKGROUND

Determine outcomes of concurrent strabismus surgery with placement of a glaucoma drainage device (GDD) in children.

METHODS

Retrospective review of pediatric patients who underwent simultaneous lateral rectus (LR) muscle surgery with superotemporal GDD placement. Strabismus and GDD success were defined as residual horizontal misalignment < 10 prism diopter (PD) and intraocular pressure (IOP) < 21 mmHg, no visually devastating complications, and no additional IOP-lowering surgeries.

RESULTS

Fifteen eyes of 13 patients (69% male) underwent LR surgery (14 recessions, 1 resection) for exotropia or esotropia simultaneous with GDD placement (13 Baerveldt, 2 Ahmed) at 8.34 ± 5.26 years. Preoperative visual acuity (VA) in operative eye (0.89 ± 0.54) was worse than non-operative eye (0.23 ± 0.44, p = 0.0032). Preoperative horizontal deviation was 38.3 ± 9.4 PD and LR recession was 7.4 ± 1.1 mm. At final follow-up, VA in operative eye (0.87 ± 0.52) was unchanged from preoperative (p = 0.4062). Final IOP was significantly decreased (12.4 ± 4.7 mmHg vs. 31.1 ± 11.4 mmHg, p = 0.0001) as was number of glaucoma medications (2.7 ± 1.7 vs. 1.1 ± 1.3, p = 0.0037). Five (38%) and 9 patients (69%) met criteria for strabismus and GDD success, respectively. Two eyes required tube revision and endoscopic cyclophotocoagulation and 2 eyes had additional strabismus surgery.

CONCLUSIONS

Concurrent strabismus and GDD surgery decreased horizontal deviation and obtained IOP control. It is important to consider correction of strabismus at time of GDD placement to maximize visual development and improve cosmesis in children with glaucoma.

Long-term surgical outcomes of Aurolab aqueous drainage implant in pediatric eyes with primary congenital glaucoma versus aphakic glaucoma

PURPOSE

To compare the outcomes of the Aurolab aqueous drainage implant (AADI) placed in eyes with refractory primary congenital glaucoma (PCG) versus aphakic glaucoma (APG).

DESIGN

Retrospective comparative interventional case series.

METHODS

Case files of consecutive eyes with PCG or APG that underwent AADI surgery between January 2013 and December 2016 and had a minimum 4 years follow-up were extracted from a computerised database. Failure was defined as intraocular pressure (IOP)>21 mm Hg or reduced<20% below baseline on two consecutive follow-up visits after 3 months, IOP≤5 mm Hg on two consecutive follow-up visits after 3 months, reoperation for glaucoma or a complication, or loss of light perception.

RESULTS

Eighty-nine eyes underwent AADI placement, including 42 eyes (47%) with PCG and 47 eyes (53%) with APG. Both groups were comparable at baseline. At 1 year, the APG group had lower mean IOP (13.6±8.1 mm Hg vs 17.6±7.5 mm Hg, p=0.02) with use of fewer IOP-lowering medications (0.8±1.0 vs 1.5±1.0, p=0.01) than the PCG group. The cumulative failure rate at 4 years was 57% (95% CI 43% to 72%) in PCG versus 40% (95% CI 28% to 56%) in the APG eyes (p=0.11). Eyes with PCG had greater tube-related complications (48% vs 38%, p=0.07) and number of reoperations (40% vs 32%, p=0.02) compared with eyes with APG.

CONCLUSIONS

Eyes with APG had relatively better outcomes after AADI placement compared with PCG during 4 years of follow-up. Reoperations accounted for more than 70% of the failures.

Comparison of the Ahmed and Baerveldt Glaucoma Drainage Implants in the Treatment of Primary Congenital Glaucoma

PURPOSE

To compare the outcomes of the Ahmed glaucoma valve (AGV) (New World Medical, Inc) with the Baerveldt glaucoma implant (BGI) (Johnson & Johnson Vision) in primary congenital glaucoma (PCG).

METHODS

This was a retrospective review of children with PCG who underwent AGV or BGI implantation with a minimum follow-up of 6 months. Main outcome measures were intraocular pressure (IOP), the number of glaucoma medications, success rate, complications, and surgical revisions.

RESULTS

The study included 153 eyes of 86 patients (120 eyes in the AGV group and 33 eyes in the BGI group), and the mean follow-up period was 58.7 ± 6.9 months in the AGV group and 58.5 ± 5.0 months in the BGI group. At baseline, IOP was lower in the AGV group (33 ± 6.3 vs 36.4 ± 6.1 months; P = .004) and the number of glaucoma medications was comparable between groups (3.4 ± 0.9 vs 3.6 ± 0.5 medication; P = .183). At 5 years, the mean IOP (18.4 ± 5.0 vs 16.3 ± 2.5 mm Hg; P = .004) and number of glaucoma medications (2.1 ± 1.3 vs 1.0 ± 1.0 medication; P = .001) were significantly less in the BGI group. Furthermore, the surgical success was 53.4% in the AGV group and 78.8% in the BGI group (P = .013).

CONCLUSIONS

Both the AGV and BGI were successful in providing adequate IOP control in patients with PCG. Long-term follow-up showed that the BGI was associated with a lower IOP, fewer glaucoma medications, and a higher success rate. [J Pediatr Ophthalmol Strabismus. 2023;60(6):448-454.].

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ahmed and Baerveldt Glaucoma Drainage Devices in Childhood Glaucoma: A Meta-Analysis

PRCIS

The effectiveness of Ahmed glaucoma valve (AGV) and Baerveldt glaucoma implant (BGI) was comparable in the management of childhood glaucoma over the long term despite initial better success rate with BGI. There were higher tube block and retraction rates in the BGI group and higher tube exposure rates in the AGV group.

PURPOSE

To evaluate the outcomes and safety of AGV and BGI in childhood glaucoma.

MATERIALS AND METHODS

We performed a systematic literature review of publications from 1990 to 2022 in PubMed, EMBASE, ClinicalTrials.gov, Ovid MEDLINE, Cochrane CENTRAL, and google scholar for studies evaluating AGV and BGI in childhood glaucoma. Primary outcome measures were intraocular pressure (IOP) reduction and glaucoma medication reduction. The secondary outcome measures were the success rates and incidence of postoperative complications. We conducted a meta-analysis using a random effects model.

RESULTS

Thirty-two studies met the inclusion criteria. A total of 1480 eyes were included. The mean IOP reduction was 15.08 mm Hg ( P < 0.00001) for AGV and 14.62 ( P < 0.00001) for the BGI group. The mean difference between pre and postoperative glaucoma medications was 1 ( P < 0.00001) fewer medications in the AGV group and 0.95 ( P < 0.0001) fewer medications in the BGI group. There was a lower success rate in the AGV versus BGI groups at 2 years [63% vs 83%, respectively ( P < 0.0001) and 3 years (43% vs 79%, respectively ( P < 0.0001)]; however, the success was higher for AGV at 5 years (63% vs 56% in the BGI group, P < 0.001). The incidence of postoperative complications was comparable in the AGV and BGI groups, with rates of 28% and 27%, respectively.

CONCLUSIONS

The IOP and glaucoma medication reduction, success rates, and incidence of postoperative complications were comparable in Ahmed and Baerveldt groups. Most literature comes from retrospective low-quality studies on refractory childhood glaucoma. Further larger cohort studies are needed.

Ahmed to Baerveldt glaucoma drainage device exchange in pediatric patients

BACKGROUND

There is no consensus and few reports as to the surgical management of encapsulated Ahmed glaucoma drainage devices (GDD) which no longer control intraocular pressure (IOP), especially within the pediatric population. The purpose of this study was to report outcomes of exchanging the Ahmed GDD for a Baerveldt GDD in children with refractory glaucoma.

METHODS

Retrospective review of children (< 18yrs) who underwent removal of Ahmed FP7 and placement of Baerveldt 350 (2016-2021) with ≥ 3-month follow-up. Surgical success was defined as IOP 5-20 mmHg without additional IOP-lowering surgeries or visually devastating complications. Outcomes included change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), and number of glaucoma medications.

RESULTS

Twelve eyes of 10 patients underwent superotemporal Ahmed FP7 to Baerveldt 350 GDD exchange at 8.8 ± 3.6 years. Time to Ahmed failure was 2.7 ± 1.9 years with 1-, 3-, and 5-year survival rates of 83% with a 95% CI[48,95], 33% with a 95% CI[10, 59], and 8% with a 95% CI[0, 30]. At final follow-up (2.5 ± 1.8 years), success rate for Baerveldt 350 GDDs was 75% (9 of 12 eyes) with 1 and 3-yr survival rates of 100% and 71% with 95% CI[25,92], respectively. IOP (24.1 ± 2.9 vs. 14.9 ± 3.1 mmHg) and number of glaucoma medications (3.7 ± 0.7 vs. 2.7 ± 1.1) were significantly decreased (p < 0.004). BCVA remained stable. Two eyes required cycloablation and 1 eye developed a retinal detachment.

CONCLUSIONS

Ahmed removal with Baerveldt placement can improve IOP control with fewer medications in cases of refractory pediatric glaucoma. However, more eyes with greater follow-up are required to determine long-term outcomes.

Pediatric Glaucoma-From Screening, Early Detection to Management

Pediatric glaucoma (PG) covers a rare and heterogeneous group of diseases with variable causes and presentations. Delayed diagnosis of PG could lead to blindness, bringing emotional and psychological burdens to patients' caregivers. Recent genetic studies identified novel causative genes, which may provide new insight into the etiology of PG. More effective screening strategies could be beneficial for timely diagnosis and treatment. New findings on clinical characteristics and the latest examination instruments have provided additional evidence for diagnosing PG. In addition to IOP-lowering therapy, managing concomitant amblyopia and other associated ocular pathologies is essential to achieve a better visual outcome. Surgical treatment is usually required although medication is often used before surgery. These include angle surgeries, filtering surgeries, minimally invasive glaucoma surgeries, cyclophotocoagulation, and deep sclerectomy. Several advanced surgical therapies have been developed to increase success rates and decrease postoperative complications. Here, we review the classification and diagnosis, etiology, screening, clinical characteristics, examinations, and management of PG.

A Comprehensive Review of Pediatric Glaucoma Following Cataract Surgery and Progress in Treatment

Glaucoma following cataract surgery (GFCS) remains a serious postoperative complication of pediatric cataract surgery. Various risk factors, including age at lensectomy, intraocular lens implantation, posterior capsule status, associated ocular/systemic anomaly, additional intraocular surgery, and a family history of congenital cataract and GFCS, have been reported. However, the optimal surgical approach remains unclear. This review evaluates the diagnostic criteria, classification, risk factors, mechanism, and surgical management, especially the efficacy of minimally invasive glaucoma surgery, in GFCS, and aims to propose an optimal clinical management strategy for GFCS. The results of our review indicate that ab interno trabeculotomy (goniotomy) may be the most appropriate first-line treatment for GFCS.

Ologen augmentation of Ahmed valves in pediatric glaucomas

BACKGROUND

We previously showed that Ologen increased success and survival rates of Ahmed glaucoma devices in a small number of children. The current study analyzed the same surgical technique in an expanded cohort.

METHODS

Retrospective interventional case series of children who underwent Ologen augmentation of Ahmed glaucoma device (OAGD) from 2018 to 2021 with ≥6 months' postoperative follow-up. Complete success was defined as intraocular pressure (IOP) of 5-20 mm Hg without glaucoma medications or additional IOP-lowering surgeries. Complete or qualified success was defined as above, except that IOP control was maintained with or without glaucoma medications.

RESULTS

A total of 26 eyes of 18 patients underwent OAGD at a median age of 2.0 years. Diagnoses included primary congenital glaucoma (5 eyes) and glaucoma secondary to nonacquired ocular anomalies (9 eyes), nonacquired systemic anomalies (8 eyes), and acquired conditions (4 eyes). Seventeen eyes had ≥1 prior eye surgery (average, 1.6 ± 0.9 surgeries per eye). Preoperative IOP was 29.4 ± 9.9 mm Hg on an average of 2.7 ± 1.0 glaucoma medications. At final follow-up (1.3 ± 1.0 years; median 1.0), IOP (13.4 ± 4.7 mm Hg) and number of glaucoma medications (0.3 ± 0.7, median 0) were significantly decreased (P < 0.0001). Complete success was achieved in 77% of eyes (20/26); Kaplan Meier analysis showed 1- and 3-year survival rates of 82% (95% CI, 59-93) and 60% (95% CI, 25-83), respectively. Complete or qualified success was achieved in 100% of eyes (26/26) at final follow-up. There were no visually devastating complications.

CONCLUSIONS

OAGD showed a high rate of success defined by decreased IOP and medication dependency in our study cohort of pediatric glaucoma patients.

Outcomes of Baerveldt Glaucoma Drainage Devices in Pediatric Eyes

PRCIS

In children, Baerveldt implants showed 84% success at 1 year, but decreased to 32% at 8 years. Age, race, and glaucoma type were not risk factors for failure. Concurrent intraocular surgery was associated with complications.

PURPOSE

Evaluate success and risk factors for failure and complications of Baerveldt glaucoma implants in children.

METHODS

Retrospective case series of children who underwent Baerveldt implant placement (2012-2019 by single surgeon) with ≥1 year follow-up. Ocular examination and surgical details were collected. Failure defined as intraocular pressure (IOP) <5 mm Hg or >21 mm Hg for 2 consecutive visits, need for IOP related surgery, or visually significant complication.

RESULTS

One hundred-six eyes of 76 patients underwent 110 Baerveldt placement at median 6.4 years. Baerveldt placement was combined with additional procedures in 49% with vitrectomy most common (30%). Success of first Baerveldt (per patient) was 64% at final follow-up (median 4.7 y). One-, 5-, and 8-year survival rates were 84%, 60%, and 32%, respectively. There was no difference (P=0.97) in survival between first Baerveldt and all Baerveldt surgeries. Failure of first Baerveldt was not associated with sex, age, ethnicity, prior IOP-lowering surgery, concurrent intraocular surgery, or glaucoma type. Complications occurred in 14% and were associated with concurrent surgery. Twenty-six percent required additional IOP-lowering surgery. At final follow-up, IOP and glaucoma medications were significantly decreased (P<0.0001). Eyes underwent an average of 3.8±2.3 ocular surgeries and 3.0±2.0 glaucoma surgeries.

CONCLUSIONS

Baerveldt implants showed good success initially, but survival rates declined over time. No risk factors for failure of first implanted Baerveldt were identified. Concurrent surgery was associated with complications. Majority of eyes required multiple surgeries to achieve IOP control and preserve vision.

Trabeculotomy Versus Combined Trabeculotomy-Trabeculectomy for Management of Primary Congenital Glaucoma

PRCIS

Trabeculotomy (T) alone is as safe and effective as combined trabeculotomy-trabeculectomy (TT) in patients with primary congenital glaucoma (PCG) and requires significantly fewer examinations under anesthesia in the postoperative period.

PURPOSE

The purpose of this study was to compare the outcomes of T and combined TT as the initial surgical procedure for patients with PCG.

METHODS

In this retrospective study, medical records of patients who had undergone T or TT as the initial procedure for PCG were reviewed. The primary outcome measure was a surgical success, defined as 5≤ intraocular pressure (IOP) ≤21 mm Hg, IOP reduction of at least 20% with no need for further glaucoma surgery. Secondary outcome measures were the number of glaucoma medications and complications.

RESULTS

A total of 134 eyes from 134 patients with a mean follow-up of 8±6.6 years were included consisting of 106 and 28 eyes, which had undergone T and TT, respectively. Success rates were comparable with both surgical procedures at 1, 2, 3, 4, and 5 years with no statistically significant difference. IOP was significantly decreased from 27.5±4.2 mm Hg preoperatively to 15.62±3.4 mm Hg at the 5-year follow-up visit in the T group and from 25.3±6.5 to 17.1±3.2 mm Hg in the TT group (P=0.1) there was no significant difference between the 2 groups in the number of glaucoma medications (P=0.2). Patients in the T group required significantly fewer examinations under anesthesia than the TT group (7.3±4.4 vs. 10.1±3.9, P=0.04).

CONCLUSION

Trabeculotomy alone seems as effective as combined trabeculotomy-trabeculectomy and may significantly reduce exposure to anesthesia in primary congenital glaucoma patients.

Management of Childhood Glaucoma Following Cataract Surgery

Glaucoma remains a frequent serious complication following cataract surgery in children. The optimal approach to management for 'glaucoma following cataract surgery' (GFCS), one of the paediatric glaucoma subtypes, is an ongoing debate. This review evaluates the various management options available and aims to propose a clinical management strategy for GFCS cases. A literature search was conducted in four large databases (Cochrane, PubMed, Embase, and Web of Science), from 1995 up to December 2021. Thirty-nine studies-presenting (1) eyes with GFCS; a disease entity as defined by the Childhood Glaucoma Research Network Classification, (2) data on treatment outcomes, and (3) follow-up data of at least 6 months-were included. Included papers report on GFCS treated with angle surgery, trabeculectomy, glaucoma drainage device implantation (GDD), and cyclodestructive procedures. Medical therapy is the first-line treatment in GFCS, possibly to bridge time to surgery. Multiple surgical procedures are often required to adequately control GFCS. Angle surgery (360 degree) may be considered before proceeding to GDD implantation, since this technique offers good results and is less invasive. Literature suggests that GDD implantation gives the best chance for long-term IOP control in childhood GFCS and some studies put this technique forward as a good choice for primary surgery. Cyclodestruction seems to be effective in some cases with uncontrolled IOP. Trabeculectomy should be avoided, especially in children under the age of one year and children that are left aphakic. The authors provide a flowchart to guide the management of individual GFCS cases.

Outcomes of Ahmed glaucoma valve implantation in pediatric glaucoma

BACKGROUND: In many types of pediatric glaucoma, there is no clear algorithm for surgical management. In these situations, the procedure of choice can be the implantation of various types of drainage devices. AIM: To evaluate the outcomes of Ahmed Glaucoma Valve implantation in refractory pediatric glaucoma. MATERIALS AND METHODS: The treatment results of 52 children (67 eyes) aged 1 month 17 years (6.6 0.6 years) with unsuccessfully operated primary congenital glaucoma, with glaucoma associated with congenital anomalies of the eyeball, with secondary glaucoma were analyzed. The surgery was considered to be effective when stable intraocular pressure (IOP) was achieved, there were no complications, and no need for repeated interventions. RESULTS: The effect of surgery was maintained for 6 months in 97% of patients, but after 1, 2 and 3 years it decreased to 91.8%, 82%, and 73.9%, respectively, and to 42.8% after 7 years. Postoperative complications included filtering bleb encapsulation (25.3%), iris retraction to the tube with pupil dislocation (4.5%); ciliochoroidal detachment (4.5%); cataract (3.0%), conjunctival erosion with tube eruption (4.5%), endophthalmitis (1.5%), retinal detachment (6.0%), tube retraction (1.5%), hyphema (3.0%). The risk factors for an unfavorable outcome of the procedure were: an increase in the anteroposterior axis of the eyeball length by 20% or more compared to the age norm, IOP at the time of the surgery higher than 32 mm Hg, as well as previous antiglaucoma filtering procedures. CONCLUSIONS: The implantation of the drainage device Ahmed Glaucoma Valve is indicated for refractory pediatric glaucoma in case of ineffectiveness of previous surgeries. However, it is necessary to take into account the decrease in the effectiveness of the device over time, which, combined with the possibility of complications, requires long-term follow-up of patients.

Long-term comparison of the outcomes of Ahmed Glaucoma Valve surgery between glaucoma surgeons and cornea trained surgeons

PURPOSE

To compare the long-term outcomes obtained by glaucoma surgeons versus cornea trained surgeons performing Ahmed glaucoma valve (AGV) surgery.

METHODS

Of the total 376 patients (3 month to 83 year) conducted in this retrospective study, 130 patients with refractory glaucoma were evaluated who had been followed up for at least six months during ten years period. The primary outcome measure was the surgical success of AGV surgery that was categorized in two groups: (A5 ≤ IOP ≤ 21 mmHg and at least 20% reduction in IOP without any glaucoma medications (complete success) and reduction by using one or more glaucoma medications (qualified success) (B) similar to previous criteria but the cutoff for higher IOP at 16 mmHg without vision loss and the need for medication or re-surgery.

RESULTS

Mean age of the patients was 32.99 ± 24.20 years in the glaucoma surgeon group and 25.18 ± 24.33 years in the cornea trained surgeons group (P = 0.07). The overall success of both methods at the end of four years were 66.7% and 41.7% for the group of glaucoma surgeons and cornea trained surgeons, respectively (p = 0.661). The cumulative success according to criterion A and B was 66.7% in the glaucoma surgeon group and 47.1% in the others surgeon group (P = 0.661). Repeated glaucoma surgery was required in 33.3% and 52.9% of the patients in the glaucoma surgeon and cornea trained surgeons groups, respectively (P = 0.661). Although there was a significant difference for IOP among various follow-up periods (p = 0.004), this difference was not significant between the two groups (p = 0.374).Visual Acuity did not have a signifiant difference between various follow-up periods and surgeons groups (p = 0.419 and P = 0. 690, respectively).

CONCLUSION

There were comparable outcomes with regard to complications and success rates between glaucoma surgeons and cornea trained surgeons performing AGV surgery.

Clinical Outcomes After Ahmed Glaucoma Valve Implantation for Pediatric Glaucoma After Congenital Cataract Surgery

PRCIS

Ahmed valve success for glaucoma following congenital cataract surgery lasts at least 5 years in most eyes, and >10 years in some cases. The procedure is a valuable option for these patients.

PURPOSE

The aim of the study was to report on the results of Ahmed valve implantation in children with glaucoma following congenital cataract surgery.

PATIENTS AND METHODS

Medical records were reviewed for 41 pediatric eyes (27 patients) with glaucoma after congenital cataract surgery with Ahmed glaucoma valve (AGV) implantation between 2007 and 2018. The primary outcome measure was surgical success, defined as intraocular pressure (IOP) ≤22 mm Hg (with or without glaucoma medications) on 2 consecutive follow-up visits, without glaucoma reoperation, and without significant visual complications during the follow-up period.

RESULTS

Median age at the time of AGV implantation was 80 months (range: 14 to 146 mo) and the mean follow-up period was 61.1±46.5 months. The cumulative probability of surgical success was 95.1%, 89.8%, 83.1%, and 72.6% at 12, 24, 60, and 84 months, respectively. IOP significantly decreased from 35.8±7.4 mm Hg before valve implantation to 18.7±6.5 mm Hg at the last recorded visit (51.4% decrease; P<0.0001). Most eyes (79%) required medications for pressure control. Complications occurred in 14 eyes (34%), with 12 of these remaining successful. Early hypotony was the most common complication (19.5%). Retinal detachment occurred in 1 eye.

CONCLUSIONS

Despite a decrease in surgical success over time, AGV implantation was successfully used for IOP control in the majority of our pediatric eyes with glaucoma after congenital cataract surgery. Most complications were managed effectively and surgical success was maintained.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma

PURPOSE

Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion.

METHODS

A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures.

RESULTS

Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term.

CONCLUSION

Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

Long-term Results of Ahmed Valve Implantation With Mitomycin-C in Pediatric Glaucoma

PRECIS

Mitomycin was used with Ahmed valve implantation in 81 eyes of 63 children. After 5 years, probability of intraocular pressure (IOP) control without glaucoma medication was 35±6%; 57% achieved IOP control with topical medications after 10 years.

PURPOSE

The purpose of this study was to determine the long-term outcomes of Ahmed glaucoma valve (AGV) implantation with intraoperative application of mitomycin-C (MMC) for the treatment of childhood glaucoma.

METHODS

Retrospective review of children undergoing AGV implantation with subtenon application of MMC between 2000 and 2019. We defined surgical success as a final IOP of 5 to 21 mm Hg with no glaucoma medication, no subsequent glaucoma surgery, and no severe complication. Qualified success was defined if the above criteria were met with topical antiglaucoma medication.

RESULTS

Eighty-one eyes of 63 patients were included. The probability of complete success was 72±5% (63% to 83%) at 1 year, 58±6% (48% to 70%) at 2 years, and 35±6% (25% to 48%) at 5 years. The probability of qualified success was 92±3% (87% to 98%) at 1 year, 79±5% (70% to 89%) at 5 years, 57±7% (44% to 73%) at 10 years, and 39±9% (24% to 62%) at 14 years. The IOP was reduced by an average of 10.7±9 mm Hg from preoperative visit to the last follow-up, and the number of medications decreased from 3.0±1.4 to 1.5±1.4 after implantation.

CONCLUSIONS

A significant proportion of patients achieved long-term IOP control without glaucoma medication. The majority achieved IOP control with additional topical antiglaucoma medications. When compared with existing AGV implantation in childhood literature, the use of MMC appears to lengthen the drop-free (complete success) duration, as well as the long-term IOP control with topical medications.

Angle Surgery in Pediatric Glaucoma Following Cataract Surgery

Glaucoma is a common and sight-threatening complication of pediatric cataract surgery Reported incidence varies due to variability in study designs and length of follow-up. Consistent and replicable risk factors for developing glaucoma following cataract surgery (GFCS) are early age at the time of surgery, microcornea, and additional surgical interventions. The exact mechanism for GFCS has yet to be completely elucidated. While medical therapy is the first line for treatment of GFCS, many eyes require surgical intervention, with various surgical modalities each posing a unique host of risks and benefits. Angle surgical techniques include goniotomy and trabeculotomy, with trabeculotomy demonstrating increased success over goniotomy as an initial procedure in pediatric eyes with GFCS given the success demonstrated throughout the literature in reducing IOP and number of IOP-lowering medications required post-operatively. The advent of microcatheter facilitated circumferential trabeculotomies lead to increased success compared to traditional <180° rigid probe trabeculotomy in GFCS. The advent of two-site rigid-probe trabeculotomy indicated that similar results could be attained without the use of the more expensive microcatheter system. Further studies of larger scale, with increased follow-up, and utilizing randomization would be beneficial in determining optimum surgical management of pediatric GFCS.

Ologen augmentation of Ahmed glaucoma drainage devices in pediatric glaucomas

Background

Limited data exists on the effectiveness of the collagen matrix, Ologen, on increasing Ahmed glaucoma valve (AGV) success in childhood glaucomas.

Methods

Ocular examination and surgical details of pediatric patients who underwent AGV placement ± Ologen augmentation between 2012 and 2020. Complete success was defined as intraocular pressure (IOP) between 5 and 20 mmHg without glaucoma medications and additional IOP-lowering surgeries. Qualified success was defined as above, except IOP control maintained with or without glaucoma medications.

Results

Twenty-two eyes of 16 patients underwent AGV placement of which 6 eyes had Ologen-augmentation (OAGV) and 16 eyes had conventional surgery (CAGV). Average age was 6.4 ± 5.1 years with 4.2 ± 2.5 follow-up years. There was no difference in age, number of previous surgeries, and preoperative IOP and glaucoma medications. At final follow-up, success rate was 100% (5 eyes complete, 6 eyes qualified) in the OAGV group compared to 31% (0 eyes complete, 5 eyes qualified) in the CAGV group. One and two-year survival rates were 100% for OAGV compared to 62 and 38% for CAGV. Postoperative IOP was significantly lower at 1-month and final follow-up (p = 0.02) as was the number of glaucoma medications at 3, 6, 12-months and final follow-up (p < 0.05) in the OAGV group.

Conclusions

Ologen-augmentation increased the success and survival rates of AGVs in childhood glaucomas. Further, Ologen mitigated the hypertensive phase and decreased medication dependency. Longer follow-up with a greater number of eyes is required to fully evaluate the effectiveness of OAGV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01827-4.

Long-term outcomes of the Ahmed glaucoma valve surgery in childhood glaucoma

PURPOSE

To report the rates of success of Ahmed glaucoma valve (AGV) surgery in early childhood glaucoma and factors associated with success.

METHODS

Children with primary congenital or early childhood secondary glaucoma who underwent AGV surgery over a 10-year period (one eye per child) at a single institution were identified. Surgical failure was defined as having one or more of the following: intraocular pressure of >21 mm Hg 3 months postoperatively, reoperation for glaucoma, and vision loss to no light perception.

RESULTS

A total of 178 patients were identified (median age, 5.8 ± 5.5 years): 125 with primary congenital and 53 with secondary childhood glaucoma. The success rate at 1 year was 92% (95% CI, 88%-96%); at 5 years, 64% (95% CI, 55%-73%); and at 10 years, 36% (95% CI, 25%-52%). Younger age at baseline (P = 0.003) and secondary childhood glaucoma (P = 0.045) were associated with lower success.

CONCLUSIONS

The AGV is associated with high short-term success in children with primary congenital glaucoma, but the 10-year success rates are poor. Younger age and secondary childhood glaucoma may be associated with a more refractory outcome.

Safety and Efficacy of Ahmed Valve on Intractable Glaucoma in Saudi Population

PURPOSE

The study aims to assess the efficacy and safety of Ahmed glaucoma valve implant in eyes with intractable glaucoma and to evaluate the risk factors for failure.

METHODS

A retrospective evaluation of 83 patients (117 eyes) with intractable glaucoma who underwent silicone Ahmed glaucoma valve implant was done in a tertiary care center in Riyadh, Saudi Arabia, between January 2014 and December 2016. Complete success was defined as intraocular pressure (IOP) ≤21 mmHg without medication after a minimum follow-up of 6 months.

RESULTS

Eighty-three patients (117 eyes) with intractable glaucoma were evaluated. After a mean follow-up duration of 20.8 ± 3.1 (12-24) months, the overall success rate was achieved in 104 eyes (88.9%). Thirty-six eyes (30.8%) had a complete success rate, whereas 68 eyes (58.1%) had a qualified success rate. Thirteen eyes (11.1%) failed to achieve controlled IOP. The postoperative probability to fail was found to be increasing with time from 0.9% (0.9) in the 1^st month to 11.1% (9.9) after 1 year. Complications included a hypertensive phase in 25 eyes (21.4%), encapsulation in 10 eyes (8.5%), hyphema in 7 eyes (6%), hypotony in 2 eyes (1.7%), and blood clots in the implanted tube in 2 eyes (1.7%). The presence of hyphema, scleral patch, and coronary heart diseases was found to increase the risk of failure after Ahmed valve implantation (P = 0.006, 0.040, and 0.014, respectively).

CONCLUSIONS

Ahmed glaucoma valve implant was safe and effective in treating cases of intractable glaucoma.

Outcomes of Ahmed glaucoma valve in paediatric glaucoma following congenital cataract surgery in persistent foetal vasculature

PURPOSE

To evaluate the outcomes of primary Ahmed glaucoma valve in refractory secondary glaucoma following congenital cataract surgery, particularly in persistent foetal vasculature.

METHOD

Retrospective review of paediatric patients after Ahmed glaucoma valve implantation for refractory post-lensectomy glaucoma in a tertiary referral centre in Spain. Surgical complications, additional and/or replacements of Ahmed glaucoma valve, intraocular pressure, cup-to-disc ratio, glaucoma medications and final visual acuity were studied.

RESULTS

A total of 29 eyes, 41% with persistent foetal vasculature and 59% with non-persistent foetal vasculature were included with mean follow-up of 105 ± 67 and 74 ± 45 months, respectively, after first Ahmed glaucoma valve implant. Median survival time for the first Ahmed glaucoma valve was significantly lower in persistent foetal vasculature (7.0 ± 3.2 months) compared to non-persistent foetal vasculature (over 129 months), p = 0.001. The cumulative probability of success in persistent foetal vasculature and non-persistent foetal vasculature eyes with Ahmed glaucoma valve were, respectively, 37.5% and 88.2% at year 1 and 28.1% and 71.9% at year 5. Cox regression model suggested persistent foetal vasculature as predictive risk factor of time to Ahmed glaucoma valve failure (hazard ratio: 5.77, p = 0.004). Four eyes developed phthisis bulbi. Mean intraocular pressure prior glaucoma surgery was 32.66 ± 6.73 mmHg and decreased to 16.54 ± 2.75 mmHg (p < 0.001) at final visit. The most frequent early postoperative complication was severe hypotony (32.6%) which tended to be self-limiting. Vitreous haemorrhage was associated with persistent foetal vasculature (p = 0.024). Ahmed glaucoma valve replacements after complications and additional Ahmed glaucoma valve implantations due to unsatisfactory intraocular pressure were more common in the persistent foetal vasculature group.

CONCLUSION

Eyes with persistent foetal vasculature and secondary glaucoma after congenital cataract surgery followed by AGV implantation had a higher number of complications and a decreased probability of success compared to the non-persistent foetal vasculature group. Both groups achieved a significant decrease in intraocular pressure; thus, Ahmed glaucoma valve may be considered as first-line treatment in refractory glaucoma following congenital cataract surgery.

Contemporary management of refractory pediatric glaucoma

PURPOSE OF REVIEW

The management of pediatric glaucoma poses a unique challenge in terms of maintaining lifelong vision and combating an aggressive scarring response from surgery. Contemporary literature regarding the surgical management of children with pediatric glaucoma who fail, or are at a high risk of failure, from conventional surgery is limited. The aim of this review is to highlight recent developments in relation to the current opinion regarding the management of children with refractory pediatric glaucoma.

RECENT FINDINGS

Some studies have reported impressive success rates with circumferential trabeculotomy, even in eyes with previous failed surgery. Early results of deep sclerectomy in populations which may not respond well to conventional angle surgery are encouraging but data is limited for the pediatric age group. In compliant patients in whom multiple postoperative examinations under anesthesia are possible, trabeculectomy remains an effective procedure. Multiple recent studies have demonstrated that glaucoma drainage device (GDD) surgery is associated with 5-year success rates of over 70% in primary childhood glaucomas.

SUMMARY

Glaucoma drainage device surgery is likely to remain a mainstay of surgical management for refractory glaucoma in older children. More prospective data are needed on the success of circumferential trabeculotomy, deep sclerectomy and micropulse laser in pediatric eyes with previous failed surgery. VIDEO ABSTRACT: http://links.lww.com/COOP/A34.

Ahmed Valve Tube Extension in Pediatric Glaucoma

PRéCIS:: Ahmed valve tube extender showed good long-term outcomes for retracted tubes in pediatric glaucoma. The procedure is safe with limited complications.

PURPOSE

To analyze the long-term outcomes of Ahmed valve tube extension in pediatric glaucoma patients.

PATIENTS AND METHODS

This study analyzed the records of all children who underwent surgery involving extension of a pediatric Ahmed valve tube, treated at a tertiary medical center between 2007 and 2018. Surgical success was defined as intraocular pressure between 6 and 22 mm Hg and reduced by at least 20% from its preoperative value, with or without intraocular pressure lowering medications, without additional surgical procedures and without vision loss.

RESULTS

Fourteen eyes of 11 children were treated with the Ahmed tube extender during the study period. Mean age of all children was 5.7±4.7 years (range, 3 mo to 16 y). The most common type of glaucoma was congenital glaucoma (n=6, 42.9%). The mean age at the time of initial valve implant was 2.39±3.89 years and the mean duration from initial insertion to the extension was 3.39±2.95 years. The mean follow-up was 72.8±43.3 months (range, 12 to 140 mo), with 85.7% followed for >2 years. The mean survival was 34.1±37.2 months after the extension. Three surgeries (21.4%) were primary failures, 8 patients (57.1%) failed during follow-up (mean, 40.6±44.4 mo after the extension; range, 1 to 125 mo), whereas 3 patients (21.4%) maintained the successful outcome until their last follow-up visit (mean, 37.7±24.1 mo; range, 12 to 70 mo).

CONCLUSIONS

The Ahmed valve extender can often save a retracted or obstructed tube. The procedure has limited complications and long-term efficacy in one third of the patients.

Ahmed Glaucoma Valve Implantation: Graft-Free Short Tunnel Small Flap versus Scleral Patch Graft after 1-Year Follow-up: A Randomized Clinical Trial

PURPOSE

To compare the efficacy and safety of the graft-free short tunnel small flap (STSF) technique with that of the scleral patch graft (SPG) in Ahmed glaucoma valve (AGV) (New World Medical Inc, Rancho Cucamonga, CA) implantation.

DESIGN

Randomized clinical trial.

PARTICIPANTS

A total of 203 eyes of 203 patients with medically uncontrolled glaucoma, including 102 in the STSF group and 101 in the SPG group.

METHODS

Patients were enrolled and assigned randomly to STSF or SPG.

MAIN OUTCOME MEASURES

Tube exposure, intraocular pressure (IOP), number of glaucoma medications, best-corrected visual acuity, surgical complications, and success rate (defined as IOP >5 mmHg, ≤21 mmHg, and IOP reduction ≥20% from baseline at 2 consecutive visits after 3 months, no reoperation for glaucoma).

RESULTS

Only 1 patient in the SPG group developed tube exposure at 1-year follow-up. The cumulative probability of success during the first year of follow-up was 70% in the STSF group and 65% in the SPG group (P = 0.36). The IOP decreased significantly from 29.6±8.6 mmHg at baseline to 16.4±3.6 mmHg at the final follow-up in the STSF group (P = 0.001). The corresponding numbers for the SPG group were 30.9±11.2 and 15.8±4.7, respectively (P = 0.001). The final IOP was comparable between both groups (P = 0.65). Mean ± standard deviation of the number of glaucoma medications was 1.8±0.9 in the STSF group and 1.6±0.9 in the SPG group at final follow-up (P = 0.32). Postoperative complications developed in 8 patients (19%) in the STSF group and 9 patients (23%) in the SPG group (P = 0.81).

CONCLUSIONS

The STSF and SPG techniques had a comparable complication rate at the 1-year follow-up. Both techniques were comparable in terms of success rate, postoperative IOP, and glaucoma medications.