Suprachoroidal seton implantation in refractory glaucoma: a novel surgical technique

PURPOSE: To describe a new surgical technique in which aqueous humor is diverted from the anterior chamber to the suprachoroidal space for the augmentation of uveoscleral outflow in the management of refractory glaucoma. METHODS: Four painful-blind eyes of four consecutive patients were included in the study. Mean age of patients was 54.7+/- 9.2 years. Preoperative diagnosis was neovascular glaucoma complicating diabetic retinopathy in three cases and chronic angle-closure glaucoma in one case. Mean preoperative intraocular pressure of the patients receiving two medications was 58.5 +/- 9.2 mm Hg. A modified Krupin eye valve with disk was implanted into the suprachoroidal space. The anterior tube part of the Seton device was placed into the anterior chamber through the long scleral tunnel for draining the aqueous humor from the anterior chamber to the suprachoroidal space. RESULTS: The placement of modified Krupin eye valve with disk to the suprachoroidal space was achieved in all cases. While mean preoperative intraocular pressure was 58.5 +/- 9.2 mm Hg, it was 14.2 +/- 4.7 mm Hg at postoperative one week. It was 13.5 +/- 4.6 mm Hg and 15 +/- 4.9 mm Hg at one and three months respectively. At the last follow-up visit, mean intraocular pressure was 17.25 +/- 5.37 mm Hg ranging from 12 to 24 mm Hg. Choroidal detachment was developed in one case and regressed in six weeks. Rubeosis irides regressed at third month in three cases. None of the eyes developed suprachoroidal hemorrhage, retinal detachment, or phthisis bulbi. CONCLUSION: The drainage of aqueous humor from the anterior chamber to the suprachoroidal space with the implantation of the glaucoma Seton device is effective in lowering intraocular pressure in refractory glaucoma.     

Trabeculectomy with internal tube shunt: a novel glaucoma surgery

PURPOSE: To describe a pilot study that evaluates the efficacy and mechanism of action of a new glaucoma operation, trabeculectomy with internal tube shunt. METHODS: Twenty-three patients underwent the new operation in one eye for open angle glaucoma. Under a scleral flap, a deep sclerectomy was performed, resulting in an intrascleral lake. Laterally, on both sides, a small silicone tube was placed between the intrascleral lake and the suprachoroidal space. A trabeculectomy stoma and a peripheral iridectomy permitted easy access of aqueous to the tube. Postoperative and preoperative results were analyzed and also compared with results of 45 eyes that underwent a conventional trabeculectomy. RESULTS: After a mean follow-up time of 324 days, the mean postoperative IOP was 13.8 mm Hg compared with a preoperative value of 25.4 mm Hg. The mean number of postoperative medications was only 1.1 compared with a preoperative value of 3.0. No significant change in outflow facility was seen. The bleb size was very small. In comparison, in conventional trabeculectomy eyes, the outflow facility and bleb size were significantly larger. CONCLUSION: Trabeculectomy with internal tube shunt is very effective in lowering IOP. It is postulated to work, to a large extent, by allowing access of the aqueous humor to the suprachoroidal space where the protein colloid osmotic pressure of uveal blood causes its absorption. This new procedure offers many advantages over other filter procedures and tube shunts.     

Hydrostatic pressure of the suprachoroidal space

The hydrostatic pressure of the suprachoroidal space was measured in 18 cynomolgus monkey eyes by one of two methods: (1) direct cannulation, or (2) silicone sponge implantation. The intraocular pressure (IOP) and suprachoroidal pressure were monitored simultaneously with the IOP being held at various levels between 5 and 60 mm Hg. In eyes with direct cannulation, at an IOP of 15 mm Hg, the pressure in the anterior suprachoroidal (supraciliary) space was 0.8 +/- 0.2 mm Hg (n = 6, mean +/- SE) below the IOP, but the posterior suprachoroidal pressure was 3.7 +/- 0.4 mm Hg (n = 8) below the IOP. The suprachoroidal pressure in eyes with silicone sponge implant was 4.7 +/- 0.6 (n = 7) mm Hg below the IOP. A change in IOP produced a corresponding change in the supraciliary space pressure. However, the pressure difference between the anterior chamber and the posterior suprachoroidal space increased at higher IOP. This pressure differential is the driving force for uveoscleral outflow.     

The efficacy of a modified ACTSEB (anterior chamber tube shunt to an encircling band) procedure

PURPOSE: To evaluate the efficacy of a modified anterior chamber tube shunt to an encircling band (ACTSEB) procedure for treating intractable glaucoma after scleral buckling procedure. METHODS: A retrospective review of medical records was performed on 7 eyes of 5 patients who underwent a modified ACTSEB procedure to treat intractable glaucoma after an encircling procedure. The modified ACTSEB procedure was performed using a silicone tube with its distal end inserted into the fibrous capsule around a scleral buckle and its proximal end inserted into the anterior chamber. Preoperative and postoperative intraocular pressure (IOP), number of antiglaucoma medications, visual acuity, and complications were recorded. Success was defined as a final IOP of >6 mm Hg and <21 mm Hg with or without medication. Among them qualified success was defined as a final IOP of <22 mm Hg with antiglaucoma medication, and complete success as the same IOP without medication. RESULTS: The overall success rate was 86% (6/7). Qualified success rate was 71% (5/7), and the complete success rate 14% (1/7). No case of hypotony, shallow anterior chamber, fibrous tube occlusion, tube obstruction by lens or iris, conjunctival wound leak, hyphema, or epithelial ingrowth occurred. The only complication was of inferior migration of the silicone tube into the anterior chamber in 2 cases. One of these led to corneal decompensation and subsequent tube removal due to tube migration, and the other underwent tube repositioning at 14 months postoperatively. CONCLUSIONS: The modified ACTSEB procedure provides an efficient means of treating intractable glaucoma after scleral buckling procedure.     

Assessing the role of subconjunctival versus intrascleral application of mitomycin C in high-risk trabeculectomies

PURPOSE: To compare the efficacy and safety of subconjunctival and intrascleral applications of mitomycin C (MMC) in trabeculectomy for high-risk glaucomas. METHODOLOGY: A randomized prospective clinical study was conducted on 41 consecutive eyes with a high risk of glaucoma surgery failure. Patients were randomized to trabeculectomy and application of subconjunctival MMC or to trabeculectomy and application of intrascleral MMC. MMC solution 0.2 mg/ml was applied for 3 minutes under the conjunctival flap overlying the proposed site of trabeculectomy in Group I (n=21), or intrasclerally under the superficial scleral flap in Group II (n=20) RESULTS: After a follow-up of one year, the intraocular pressure (IOP) decreased from a mean basal IOP of 33.0 +/- 8.4 mm Hg to 12.56 +/- 2.54 mm Hg in Group I and from 30.9 +/- 6.6 mm Hg to 11.6 +/- 2.21 mm Hg in Group II. The IOP was 6-21 mmHg, without medication, in 90.5 % of the eyes in Group I and 75 % of the eyes Group II. Ocular hypotony, hypotony maculopathy, choroidal detachment and a shallow anterior chamber were more frequent with the intrascleral application of MMC during trabeculectomy, but the difference was not statistically significant. The overall success of the surgery at one year, i.e., achieving an IOP of 6-21 mmHg and a stable vision, (reduction in visual acuity of < or = 2 lines), was 90.5% in Group I and 75 % in Group II. CONCLUSION: No significant difference was seen in overall success or complication between subconjunctival and intrascleral application of MMC-augmented trabeculectomies in glaucomatous eyes at high risk of surgical failure.     

Scleral tunnel for the implantation of glaucoma seton devices

The technique described in this paper shows how to use a long scleral tunnel for the implantation of anterior tube parts of glaucoma drainage devices. It involves the creation of a scleral tunnel beginning 10 mm behind the limbus and extending to the anterior chamber. Anterior tube parts of Krupin eye valve with disk is inserted through the scleral tunnel to the anterior chamber. The disk part is secured to the episclera as used in the standard technique. We have used this technique in 6 eyes of 6 consecutive patients with refractory glaucoma. The placement of anterior tubes as part of glaucoma seton devices was done in all patients. While mean intraocular pressure (IOP) was 39.3 +/- 4.9 mm Hg (ranged from 29 to 56 mm Hg) preoperatively, it was 16.6 +/- 5.3 mm Hg (ranging from 11 to 25 mm Hg) at the end of follow up. Mean follow-up time was 7.16 +/- 1.16 months (ranging from 6 to 9 months). After surgery, conjunctival erosion or displacement of the anterior tube and dellen formation were not found in any eyes. The use of a long scleral tunnel for the implantation of anterior tube parts of glaucoma seton devices offers some advantages over standard implantation techniques.     

后房植入Ahmed引流管治疗伴浅前房的人工晶状体眼性青光眼

目的 研究后房植入Ahmed引流管对术前伴浅前房人工晶状体眼的难治性青光眼的手术效果及安全性.方法 取5例(6只眼)入工晶状体眼性青光眼患者行Ahmed青光眼瓣膜阀植入,因前房较浅,术中将引流管植入后房,观察术后眼压控制情况及术中术后并发症,随访6～14个月.结果 术后6个月时,患者眼压平均为(17.8±1.8)mmHg,其中1例患者术后3周时眼压升高,经超声生物显微镜检查发现引流管退缩至巩膜内,二次手术后眼压恢复正常.1例患者术后4个月出现玻璃体阻塞引流管.术中及术后未见其他并发症发生.结论 对于术前发现浅前房的人工晶状体眼性青光眼者,术中将引流管植入后房是一种较为安全有效地手术方式.     

青光眼引流阀植入术式的改良和临床应用

目的：评价改良的青光眼引流阀植入术治疗水眼(玻璃体切除术后)难治性青光眼患者的效果及其安全性。

方法：手术术式改良：在角膜缘后5～7mm处以月形刀做宽约2mm、长约3mm的巩膜套袖,在距角膜缘3.5mm处以月形刀做长约1.5mm以角膜缘为基底的巩膜隧道,经该巩膜隧道以一次性矛形刀穿刺入后房,引流管修剪至合适长度后经巩膜套袖巩膜隧道穿入虹膜和人工晶状体之间的后房内,缩小瞳孔后可在瞳孔缘看见引流管口,引流管口斜面朝向瞳孔缘。将2016-03/2017-08入住我院行玻璃体切除和人工晶状体植入术后继发青光眼的患者26例26眼纳入本研究。所有患者均采用改良术式行青光眼引流阀植入术。术后随访时间：1、3d,1wk,1、6mo,此后每6mo随访1次。对手术前后眼压和术中术后并发症及其相关的处理方式进行分析。

结果：术前、术后第1d、末次随访平均眼压分别为42.5±8.1、12.1±11.2、14.3±5.9mmHg。术前与术后第1d眼压和末次随访眼压比较,差异均有统计学意义(P<0.001)。术后第1d与末次随访眼压比较,差异无统计学意义(P=0.89)。术后第1d眼压<6mmHg者有8眼,术后第1d眼压>6mmHg、术后第3d降到6mmHg以下者6眼,术后早期低眼压率54%。予玻璃体腔注气(空气)、注药(曲安奈德)或前房注入黏弹剂等处理后眼压逐渐恢复正常。随访期间无角膜内皮失代偿、引流管暴露、爆发性脉络膜出血、眼内炎等严重并发症。

结论：改良的青光眼引流阀植入术是治疗玻璃体切除术后难治性青光眼的一种安全、有效、并发症少的手术方式。前房注黏弹剂、玻璃体腔注气是治疗青光眼阀植入术后早期低眼压的简单、有效、可重复、操作简便的方法。     

Fibrous capsule surrounding silicone encircling band and Gore-Tex surgical membrane.

Since the anterior chamber tube shunt to an encircling band(ACTSEB) is not a simple procedure, an extended polytetrafluoroethylene (e-PTFE)-silicone tube (anterior chamber tube shunt to a surgical membrane; ACTSSM) was attempted as a new glaucoma drainage implant. To see whether the newly-modified, two-fold e-PTFE-silicone tube implant could prevent early hypotony and to compare the tissue response to each implant, ACTSEB and ACTSSM procedures were done in normal colored rabbit eyes. It was found the ACTSSM kept the depth of the postoperative anterior chamber normal. And in general, foreign body responses were light microscopically similar. The fibrous capsule lining the e-PTFE was composed of thicker, less dense fibroblasts, as well as less collagen than that lining the silicone encircling band. These findings seemed to be related to the difference in the pressure-lowering capacity between ACTSEB and ACTSSM.     

Ahmed青光眼阀植入治疗难治性青光眼的体会

目的探讨Ahmed青光眼阀植入治疗难治性青光眼的效果及临床体会。方法回顾性研究2004年1月至2008年12月施行Ahmed青光眼阀植入术联合黏弹剂及异体巩膜瓣等治疗难治性青光眼23例（24眼）。结果术后1周、1月、3月及6月的平均眼压为（10.61±1.57）mmHg,（15.53±1.89）mmHg,（20.11±2.79）mmHg及（20.33±3.73）mmHg,均较术前平均眼压（44.59±3.20）mmHg为低,差异有统计学意义（P〈0.001）。术后1周,手术成功率为95.83%。手术后6月,手术成功率为63.64%。术后常见并发症包括短暂性前房积血、早期低眼压、浅前房、脉络膜脱离及引流管管口阻塞。结论 Ahmed青光眼阀植入的同时,联合应用丝裂霉素C,前房内黏弹剂注入,异体巩膜瓣覆盖引流管以及引流管可吸收缝线的应用,减少了手术后的早期并发症,提高了手术的成功率。     

Management of cornea-lens touch after filtering surgery for glaucoma

The success of filtering surgery for glaucoma may be compromised by a postoperative flat anterior chamber associated with cornea-lens touch, hypotony, and absence of wound leakage. The clinical course of eight patients with this complication was reviewed. Six patients had chronic angle-closure glaucoma. Only one patient responded to medical therapy which included frequent topical application of atropine sulfate 3.0% for 1 hour. Reformation of the anterior chamber with air and drainage of any suprachoroidal fluid was immediately performed in the remaining seven. At the time of follow-up (mean, 16 months), the glaucoma was controlled in all eyes except one. The mean intraocular pressure (IOP) was 14 mmHg in those eyes not requiring reoperation. Six (75%) of eight eyes had diffuse, succulent filter blebs. Five eyes (63%) required no antiglaucoma medications, one eye (12%) required one, one eye (12%) required two, and one eye (12%) underwent repeat filtering surgery. The results suggest that, once medical therapy is not immediately successful, prompt surgical reformation of the anterior chamber along with drainage of any suprachoroidal fluid may preserve the filter blebs in these eyes.     

Surgical revision of failed filtration surgery with mitomycin C augmentation

AIM: The aim of the study was to assess the outcomes of surgical revision with reopening of the scleral flap in eyes with failed glaucoma surgery and adjunctive mitomycin C (MMC). METHODS: Retrospective, noncomparative, interventional case series. Fifty-four eyes of 54 consecutive patients with previously failed trabeculectomy or deep sclerectomy who underwent formal surgical revision (23 with concurrent phacoemulsification) were included. MMC, 0.2 mg/mL for 2 to 3 minutes, was applied under a fornix-based conjunctival flap. The preexisting scleral flap was dissected open to reestablish filtration. RESULTS: Mean follow-up was 39.5+/-10 months. Kaplan-Meier survival analysis showed that the probability (with 95% confidence intervals) of maintaining an intraocular pressure (IOP) between 5 and 18 mm Hg and 20% decrease from preoperative IOP was 64% (47% to 76%) with medications and/or needle revision and 38% (26% to 53%) without, 3 years after surgery. Mean IOP before surgery was 23.6+/-7.2 mm Hg and 14.4+/-6.0 three years after surgery (last IOP before further glaucoma procedure carried forward). Needle revision for bleb failure or high IOP was carried out in 23 eyes (42.5%) and further glaucoma surgery in 5 eyes (9.3%). Patients were on an average of 2+/-1.1 glaucoma medications before surgery. At last follow-up, the number of medications had decreased to 0.8+/-1.2 (P<0.000), with 23 eyes (42.5%) requiring medications to control IOP. Significant complications included delayed suprachoroidal hemorrhage (3 eyes, 5.6%), delayed bleb leaks (5 eyes, 9.3%), hypotony (2 eyes, 3.7%), and blebitis (2 eyes, 3.7%). CONCLUSIONS: There is a progressive increase in IOP with time after surgical revision of failed glaucoma surgery with adjunctive MMC. A significant proportion of eyes will eventually require a needle revision procedure and/or glaucoma medications to further lower IOP. Also, there is a significant incidence of complications associated with this procedure.     

Combined cataract-glaucoma surgery using the intracanalicular Eyepass glaucoma implant: first clinical results of a prospective pilot study

PURPOSE: To study prospectively the safety and pressure-reducing efficacy of the Y-shaped Eyepass glaucoma implant (GMP Vision Solutions, Inc.). SETTING: Departments of Ophthalmology, University of Cologne, Cologne, and University of Erlangen, Erlangen, Germany. METHODS: This study comprised 12 patients with primary open-angle or exfoliative glaucoma and cataract who had phacoemulsification with endocapsular implantation of a foldable intraocular lens and intracanalicular implantation of an Eyepass glaucoma implant. The implant is a silicone microtube shunt that bypasses the trabecular meshwork and connects the lumina of Schlemm canal with the anterior chamber in combined cataract-glaucoma surgery. Perioperative complications, intraocular pressure (IOP), and pressure-reducing topical medications were monitored over a preliminary follow-up. RESULTS: Perforation of the trabecular meshwork during Eyepass implantation occurred in 2 eyes; the antiglaucoma procedure was converted to trabeculotomy after the shunt was explanted, and both eyes were excluded from further follow-up. In the remaining 10 eyes, the mean maximum IOP was 30.4 mm Hg +/- 7.5 (SD) (range 21 to 46 mm Hg) preoperatively, 12.0 +/- 6.1 mm Hg (range 2 to 20 mm Hg) 1 day postoperatively, 17.2 +/- 4.1 mm Hg (range 12 to 27 mm Hg) at 4 weeks, and 18.3 +/- 4.5 mm Hg (range 12 to 25 mm Hg) at the end of the preliminary follow-up. The mean number of topical medications was 3.2 +/- 0.8 preoperatively and 0.9 +/- 0.7 at the end of follow-up (mean 7.1 months). Although there were no major complications requiring surgical revision, 4 eyes had an IOP of 18 or higher at the end of follow-up. CONCLUSION: Combined cataract surgery with Eyepass shunt implantation was safe and appeared to be beneficial in glaucomatous eyes with cataract not requiring a low target IOP.     

Anterior chamber tube shunt to an encircling band in the treatment of neovascular glaucoma

A new procedure for neovascular glaucoma that has reduced intraocular pressure (IOP) significantly and has caused relatively few postoperative complications is introduced. Aqueous is shunted to the reservoir of an encircling no. 20 silicone band from which fluid is postulated to diffuse into the orbit. The anterior chamber tube shunt to an encircling band (ACTSEB) procedure was conducted in 19 eyes with neovascular glaucoma. After surgery 18 of the 19 eyes (95%) followed for periods ranging between five and 26 months (mean: 59 weeks) had controlled IOP using less than or equal to 20 mm Hg as normal, and one eye had partial control (eye 9) at 26 mm Hg. Despite the preoperative use of atropine sulfate, timolol maleate, acetazolamide, and 20% mannitol, the patients' average preoperative IOP was 54.1 mm Hg. After surgery the average IOP fell, dramatically, to 16.2 mm Hg. The mean change in IOP was 37.9 +/- 9.8 (SD). This change is statistically significant by the paired t-test, P less than 0.01. Minimal postoperative medications were required for pressure control. Postoperative complications included hyphema (21%), prolonged flat chamber (74%), localized peripheral lens opacity (5%), localized corneal opacity (5%), and possible acceleration of progressive cataract formation (25%). Results of current surgical procedures used to manage neovascular glaucoma are compared to the ACTSEB results.     

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

AIM: To estimate the efficacy and safety of the Ahmed implant in patients with high risk for failure after glaucoma surgery. METHODS: In 342 eyes of 342 patients with refractory glaucoma, even with application of medical treatment, the Ahmed valve was introduced for intraocular pressure (IOP) control, in the period of the last 20y. The nature of glaucoma was neovascular in 162 eyes, pseudophakic or aphakic in 49 eyes, inflammatory in 29 eyes and non working previous antiglaucomatic surgical interventions in 102 eyes. RESULTS: Follow-up ranged from 18 to 120mo with a mean follow-up of 63.2mo. IOP before the operation decreased from 31.6±10.4 mm Hg to 18.3±5.4 mm Hg (no systemic treatment) at the end of follow up period. When we compared the IOP values before the operation using ANOVA showed statistically significant difference (P<0.001). The success rate was 85.2% during the first semester, 76.8% at 12mo and 50.3% at the end of follow up period (18 to 120mo after implantation). Success rate was 25.7% in neovascular glaucoma, 63.2% in aphakic glaucoma and 73.8% in non working previous antiglaucomatic surgical interventions. Complications due to the implant were: serous choroidal detachment in 14.8%, blockage of the tube in 2.8%, malposition of the tube in 4.9%, suprachoroidal hemorrhage in 2.1%, cataract progression in 39.6% (phakic eyes), shallow anterior chamber in 9.2%, hyphaema in 28.9%, exposure of valve in 2.6%, exposure of tube in 9.3%, hypotony in 4.9% and conjunctival fibrosis in 41.5%. CONCLUSION: Despite the fact that Ahmed valve implant had suchlike results as other implants concerning the IOP control, complications rate due to hypotony or over filtration in the first days after the intervention are not that frequent as with other valve implants.     

改良黏小管切开术后眼前段相干光断层成像的观察及其眼压下降机制的临床研究

目的应用眼前段相干光断层成像（AS-OCT）检测改良黏小管切开术（VCO）术后手术区域组织结构及滤道,以讨论改良黏小管切开术降眼压的机制。方法横断面研究。研究对象为术后从3~72个月的38例（55只眼）开角型青光眼,均为术前药物控制不良的开角型青光眼。11只眼（20%）因眼压高行Nd：YAG激光房角穿孔术。同时进行视力、眼压、裂隙灯、眼底和AS-OCT检查。AS-OCT的检测指标为：1滤过泡形态,2巩膜池的长、宽、高,3脉络膜上腔,4泪河高度。结果患者术后眼压（15.4±4.9）mm Hg较术前（31.0±10.9）mm Hg明显下降,42只眼有弥散的滤泡。AS-OCT证明了结膜瓣下腔隙的存在,39只眼（70.9%）检测到巩膜池,巩膜池的平均体积为1.09 mm^3（0.04~0.203 mm^3）。结论 AS-OCT检查证明了改良VCO房水引流的可能机制。扁平弥散的结膜下腔隙证明了持续的滤过,为眼外引流;39只眼（70.9%）存在巩膜池。巩膜池的体积与眼压无关,提示脉络膜上腔可能是主要的房水眼内引流途径。     

Long-term results of anterior chamber tube shunt to an encircling band in the treatment of refractory glaucomas.

We performed the anterior chamber tube shunt to an encircling band procedure in 34 patients (36 eyes) with refractory glaucoma, and evaluated the long-term outcome. The preoperative mean intraocular pressure (IOP) was 36.8 +/- 9.6 mmHg, the postoperative mean IOP was 21.6 +/- 13.6 mmHg, a statistically significant (p < 0.01) reduction of IOP following this procedure. The final postoperative IOP was under 21 mmHg in 23 (63.9%) of the 36 eyes. The success rate of IOP control 36 months after the operation without any elevation of post-operative IOP was 30.3% (life-table method). Complications of this procedure included flattening of the anterior chamber (61.1%), damage to the corneal endothelium (25%), hyphema (25%), and a transient IOP elevation (25%). As filtering surgery with 5-fluorouracil is more effective and simple to perform, we conclude that the anterior chamber tube shunt to an encircling band procedure should be reserved for those with refractory glaucoma who have had multiple surgical interventions.     

Surgical management of secondary glaucoma after pars plana vitrectomy and silicone oil injection for complex retinal detachment

OBJECTIVE: To evaluate the outcomes of surgical intervention for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Forty-three eyes of 43 patients who underwent incisional surgery for secondary glaucoma after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment over a 9-year period. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), intraoperative and postoperative complications, visual acuity, and the need for further surgical intervention for glaucoma. Success was defined as IOP < or =21 mmHg and > or =5 mmHg with or without medication but without surgical reoperation for glaucoma. RESULTS: Findings associated with elevated IOP included emulsified oil in the anterior chamber (n = 14), pupillary block from silicone oil (n = 13), open-angle glaucoma without silicone oil in the anterior chamber (n = 9), and angle-closure glaucoma without pupillary block (n = 7). The mean (+/- standard deviation) IOP was 41.4 +/- 15.1 mmHg before surgery for glaucoma and 17.2 +/- 10.2 mmHg after an average follow-up of 19.6 months (P < 0.001). Cumulative success was 69%, 60%, 56%, and 48% at 6, 12, 24, and 36-months respectively. In patients who underwent silicone oil removal alone for surgical management of glaucoma (n = 32), 11 of 12 IOP failures (92%) were due to uncontrolled IOP, whereas most IOP failures in the group who underwent silicone oil removal plus glaucoma surgery (n = 8) failed because of hypotony (3 of 4, 75%, P = 0.027). Of three patients who underwent glaucoma surgery alone to control IOP, one failed because of hypotony. There was no significant change in visual function at last follow-up (logarithm of the minimum angle of resolution [logMAR] 2.01) compared with preoperative visual function (logMAR 2.07, P = 0.74). CONCLUSION: Surgical management of secondary glaucoma after silicone oil injection for complex retinal detachment may achieve good IOP control and stabilization of visual function in most patients. Patients who undergo silicone oil removal alone to control IOP are more likely to have persistent elevation of IOP and possibly undergo reoperation for glaucoma, whereas patients who undergo concurrent silicone oil removal and glaucoma surgery are more likely to have hypotony.     

A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma

PURPOSE: To compare endoscopic cyclophotocoagulation (ECP) and the Ahmed drainage implant in the treatment of refractory glaucoma. METHODS: Sixty-eight eyes of 68 patients with refractory glaucoma were prospectively assigned to either ECP or Ahmed tube shunt implantation. All procedures were performed by a single surgeon. Eyes that were included were pseudophakic with a history of at least one trabeculectomy with antimetabolite, an intraocular pressure (IOP) equal to or above 35 mm Hg on maximum tolerated medical therapy, and a visual acuity better than light perception. Exclusion criteria included eyes that had had previous glaucoma drainage device implantation or a cyclodestructive procedure. Success was defined as an IOP more than 6 mm Hg and less than 21 mm Hg, with or without topical anti-hypertensive therapy. RESULTS: The mean follow-up was 19.82 +/- 8.35 months and 21.29 +/- 6.42 months, for the Ahmed and ECP groups, respectively (P = 0.4). The preoperative IOP, 41.32 +/- 3.03 mm Hg (Ahmed) and 41.61 +/- 3.42 mm Hg (ECP) (P = 0.5), and the mean postoperative IOP, at 24 months follow-up, 14.73 +/- 6.44 mm Hg (Ahmed) and 14.07 +/- 7.21 mm Hg (ECP) (P = 0.7), were significantly different from baseline in both groups (P < 0.001). Kaplan-Meier survival curve analysis showed a probability of success at 24 months of 70.59% and 73.53% for the Ahmed and ECP groups, respectively (P = 0.7). Complications included choroidal detachment (Ahmed 17.64%, ECP 2.94%), shallow anterior chamber (Ahmed 17.64%, ECP 0.0%), and hyphema (Ahmed 14.7%, ECP 17.64%). CONCLUSION: There was no difference in the success rate between the Ahmed Glaucoma Valve and ECP in refractory glaucoma. The eyes that underwent Ahmed tube shunt implantation had more complications than those treated with ECP.     

【In Press】 Managing high risk glaucomas with the Ahmed valve implant: 20 years of experience

AIM: To evaluate the efficacy and safety of the Ahmed glaucoma valve in patients with refractory glaucoma. METHODS: In 342 eyes of 342 patients with uncontrolled glaucoma despite topical and/or systemic medical treatment, the Ahmed valve implant was placed for intraocular pressure (IOP) control, during the last 20 years. The type of glaucoma was neovascular in 162 eyes, pseudophakic or aphakic in 49 eyes, inflammatory in 29 eyes and failure of previous antiglaucomatic operations (two or more) in 102 eyes. RESULTS: Follow-up time ranged from 18 to 120mo with a mean follow-up of 63.2mo. Preoperative IOP decreased from 31.6±10.4 mm Hg to 18.3±5.4 mm Hg (only topical treatment) at the last examination. Comparison of preoperative IOP values using ANOVA demonstrated statistically significant difference (P<0.001). Total success rate was 85.2% the first 6mo, 76.76% at 12mo and 50.3% at the last examination (18 to 120mo after implantation). Success rate was 25.7% in neovascular glaucoma, 63.2% in aphakic glaucoma and 73.8% in previous failed trabeculectomies. Complications associated with the use of the valve were: serous choroidal detachment in 14.8%, blockage of the tube in 2.8%, malposition of the tube in 4.9%, suprachoroidal hemorrhage in 2.1%, cataract progression in 39.6% (phakic eyes), shallow anterior chamber in 9.2%, hyphaema in 28.9%, exposure of valve in 2.6%, exposure of tube in 9.3%, hypotony in 4.9% and conjunctival fibrosis in 41.5%. CONCLUSIONS: Although the success of the Ahmed valve implant is similar to that reported for other drainage devices, the complications associated with overfiltration in the immediate postoperative period appear to be less frequent than with other glaucoma valve drainage devices.