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

Incidence and Outcomes of Hypertensive Phase After Glaucoma Drainage Device Surgery

PURPOSE

To describe the incidence, risk factors, clinical characteristics, and long-term outcomes of a hypertensive phase (HP) after glaucoma drainage device (GDD) implantation.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Eyes that underwent implantation of their first GDD from January 2010 to October 2020 at a tertiary care center.

METHODS

Hypertensive phase was defined as intraocular pressure (IOP) >21 mmHg occurring at 2 consecutive visits in the first 90 days after the date of surgery for Ahmed Glaucoma Valve (AGV) or in the first 90 days after tube opening for Baerveldt Glaucoma Implant (BGI). Generalized estimating equations and Fisher exact tests were used to evaluate risk factors for HP and risk factors for failure of GDD surgery after occurrence of a HP.

MAIN OUTCOME MEASURES

Incidence and risk factors for HP. Overall surgical success rates, defined as the absence of failure criteria: IOP >21 mmHg, ≤5 mmHg, or <20% reduction below baseline IOP after 3 months for 2 consecutive visits, with or without adjunctive ocular hypotensive therapy; additional glaucoma surgery; or loss of light perception.

RESULTS

Among 419 eyes of 360 patients that underwent GDD implantation, 42 (10.0%) eyes developed HP. Onset of HP was 20.8 ± 10.5 days after AGV and 11.7 ± 20.3 days from the date of tube opening after BGI. Mean IOP during HP was 26.5 ± 3.2 mmHg with peak IOP of 30.0 ± 5.9 mmHg. Median follow-up duration was 21.5 months after onset of HP. Younger age and neovascular glaucoma were significant risk factors for HP occurrence in a multivariable model. Resolution of HP occurred in 32 eyes (76.2%) after a mean duration of 48.0 ± 53.0 days. Additional surgery with a second GDD or cyclophotocoagulation was performed for 12 eyes (28.6%). The overall success rate among eyes with a HP was 52.6% at 2 years, which was significantly lower than that observed among control eyes that did not experience HP (76.3%), P < 0.01.

CONCLUSIONS

The incidence of HP was 10.0%. Younger age and neovascular glaucoma were significant risk factors for HP in the multivariable model. The risk of surgical failure after HP is significantly higher compared to eyes that did not experience HP.

FINANCIAL DISCLOSURE(S)

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

Effect of Early Aqueous Suppression After Valved Tube Shunt Surgery for Uveitic Glaucoma

PURPOSE

To compare outcomes of early aqueous suppression (EAS) and standard therapy (ST) after Ahmed Glaucoma Valve (AGV) implantation for uveitic glaucoma.

DESIGN

Retrospective comparative cohort study.

PARTICIPANTS

All patients with uveitic glaucoma underwent AGV implantation from January 2010 to October 2020 at Northwestern Medicine.

METHODS

Excluding the first postoperative day 1 (POD1), only eyes with IOP 10-15 mmHg at their first visit with IOP ≥ 10 mmHg were included in the main analysis. Early aqueous suppression (EAS) was defined as initiation of ocular hypotensive therapy when IOP was first 10-15 mmHg. Standard therapy was initiation of therapy at any later time. Failure was defined as IOP > 21 mmHg, < 5 mmHg, or < 20% reduction in IOP from baseline after 3 months, for 2 consecutive study visits. Hypotony was defined as IOP ≤ 5 mmHg for ≥ 2 visits. Hypertensive phase was defined as IOP > 21 mmHg for 2 consecutive visits in the first 3 months.

MAIN OUTCOME MEASURES

Proportion achieving overall success; incidence of hypotony and hypertensive phase.

RESULTS

Twenty-eight eyes of 26 patients were in the EAS group and 20 eyes of 19 patients were in the ST group, with a mean follow-up of 17.7 and 28.2 months, respectively. Baseline IOP was similar in the EAS (31.2 ± 10.1 mmHg) and ST (34.6 ± 12.2 mmHg) groups; P = 0.18. Final IOP was lower in the EAS group (12.9 ± 4.6 mmHg) than the ST group (16.4 ± 5.7 mmHg; P = 0.02) on 2.6 ± 0.9 medications in the EAS group and 1.8 ± 1.5 in the ST group (P = 0.07). Overall success was achieved in 87% of EAS eyes and 74% of ST eyes (P = 0.43). There were no statistically significant differences in the occurrence of additional glaucoma surgery (4% for EAS, 20% for ST; P = 0.11), hypotony (7% for EAS, 0% for ST; P = 0.50), or hypertensive phase (4% for EAS, 21% for ST; P = 0.09).

CONCLUSIONS

EAS was associated with a lower final IOP after AGV in uveitic glaucoma eyes; however, more medications were in use at the final visit. No statistically significant differences in overall success or the incidence of adverse events were observed.

FINANCIAL DISCLOSURE(S)

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

Combined Dexamethasone Intravitreal Implant and Glaucoma Drainage Device Placement for Uveitic Glaucoma

PRECIS

At 1-year postoperative follow-up, concurrent placement of a dexamethasone intravitreal implant and glaucoma drainage device effectively controlled intraocular pressure (IOP) and inflammation in eyes with uveitic glaucoma with no changes in systemic immunomodulatory therapy.

PURPOSE

The purpose of this study was to assess 1-year postoperative outcomes in eyes with uncontrolled uveitic glaucoma following concurrent placement of a dexamethasone intravitreal implant and glaucoma drainage device.

MATERIALS AND METHODS

This is a retrospective, observational case series of patients with chronic, noninfectious uveitis and uveitic glaucoma uncontrolled on maximal tolerated medical therapy with at least 1-year postoperative follow-up. The main outcomes were visual acuity, IOP, number of glaucoma medications, recurrent inflammation, frequency of topical steroids, systemic immunomodulatory therapy, and adverse events. Success was defined as IOP <21 mm Hg and IOP reduced by >20% from baseline on at least 2 consecutive visits after 3 months either with or without glaucoma medications (ie, partial or complete success, respectively).

RESULTS

Eight eyes in 6 patients met the inclusion criteria. The average age was 44.1±19.7 years (range: 10 to 68 y) and 50% were female. At 1-year, there was no significant change in visual acuity. No eyes lost ≥3 lines of vision. The majority of eyes (87.5%) achieved complete (n=2) or partial success (n=5) with a decrease in average IOP from 36.5 to 11.8 mm Hg (P=0.002). Glaucoma medication use decreased from 3.0 to 1.3 medications (P=0.04). There was a significant decrease in the number of episodes of recurrent inflammation in the 6 months following surgery compared with the 6 months before surgery (P=0.004).

CONCLUSION

In this small case series, dexamethasone intravitreal implant combined with Ahmed glaucoma drainage device appears to be an effective approach for the management of uncontrolled uveitic glaucoma.

Efficacy of glaucoma drainage devices in uveitic glaucoma and a meta-analysis of the literature

Purpose

To assess the efficacy of glaucoma drainage devices (GDD) in uveitic glaucoma and non-uveitic glaucoma, and to perform a meta-analysis of previously published results to compare with our data.

Methods

Retrospective case-control study, in which all eyes that underwent GDD surgery were included from 2015 onwards. Cases were defined as patients with uveitic glaucoma. Patients with non-uveitic glaucoma served as controls. To compare our results, a review of the literature was performed using PubMed database.

Results

A total of 99 eyes were included (38 with uveitic glaucoma). The preoperative IOP was 25.9 ± 7.7 mmHg and 27.9 ± 9.6 mmHg for patients with and without uveitis (p = 0.277). No significant differences were found between patients with and without uveitis in the final IOP or reduction in IOP (44.9% vs. 42.8%, respectively). Within the first year after surgery, 13.2% of cases developed macular edema (vs. 6.6%; p = 0.267) and 15.8% a transient hypotony (vs. 8.2%; p = 0.242). A meta-analysis of 24 studies showed a postoperative weighted mean difference of − 17.8 mmHg and 2.2 lower number of IOP-lowering medications in uveitic glaucoma (compared to − 13.2 mmHg and 3.5 in the current study, respectively).

Conclusion

GDD surgery in patients with uveitis has a similar effect on IOP as in patients without uveitis. The risks of developing macular edema and hypotony were slightly higher in patients with uveitis, but the results were not statistically significant. These findings are in line with previous reports, though data on the efficacy of GDD surgery and macular edema in uveitic glaucoma is scarce.

Electronic supplementary material

The online version of this article (10.1007/s00417-018-4156-9) contains supplementary material, which is available to authorized users.