Surgical outcomes of combined phacoemulsification and glaucoma drainage implant surgery for Asian patients with refractory glaucoma with cataract

PURPOSE: To examine the safety and efficacy of combined phacoemulsification and glaucoma drainage implant surgery in providing reduction of intraocular pressure (IOP) and visual rehabilitation in eyes with refractory glaucoma and cataract. DESIGN: Interventional case series. METHODS: A retrospective chart review was performed on all subjects who underwent combined phacoemulsification with intraocular lens implantation and glaucoma drainage implant surgery by a single surgeon at the National University Hospital, Singapore. The implants used were the 185 mm2 Ahmed glaucoma valve and the 350 mm2 Baerveldt glaucoma implant. In terms of IOP, a complete success was defined as IOP of between 6 to 21 mm Hg without medication, qualified success as IOP between 6 to 21 mm Hg with one or more medication, and failure as a sustained IOP of >21 mm Hg or <6 mm Hg with or without one or more medication on two or more visits. RESULTS: A total of 32 combined phacoemulsification and glaucoma implant surgeries in 32 patients was performed. All patients were of Asian origin, and the mean age was 58 +/- 16 years (range, 20-78 years). The Baerveldt glaucoma implant and Ahmed glaucoma valve implant were inserted in 16 eyes each. With a mean follow-up of 13 +/- 5 months (range 6 to 22 months), IOP was reduced from a mean of 28.0 +/- 11.5 mm Hg to 15.2 +/- 6.0 mm Hg postoperatively (P <.0001), whereas the number of antiglaucoma medications decreased from a mean of 2.4 +/- 1.4 to.3 +/-.7 (P <.0001) at last follow-up. Overall, there were 24 eyes (75%) that were classified as complete successes, 4 eyes (12.5%) that were qualified successes, and 4 eyes that failed (12.5%). Twenty-three eyes (72%) had improvement of visual acuity, while only one eye had a loss of more than 1 line of Snellen acuity. There was no case that encountered an intraoperative complication, and postoperative complications occurred in 12 eyes (38%), the most common of which was hypotony (in six eyes, 19%). CONCLUSION: For subjects with refractory glaucoma and cataract, combined phacoemulsification and glaucoma drainage implant surgery provide good visual rehabilitation and control of IOP, with low incidence of complications.     

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.     

【In Press】 Long-term results of Ahmed glaucoma valve implantation in Egyptian population

AIM: To evaluate the long-term results and complications of Ahmed glaucoma valve (AGV) implantation in a cohort of Egyptian patients. METHODS: A retrospective study of 124 eyes of 99 patients with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 5y was performed. All patients underwent complete ophthalmic examination and intraocular pressure (IOP) measurement before surgery and at 1d, weekly for the 1, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP was measured by Goldmann applanation tonometry and/or Tono-Pen. Complications and the number of anti-glaucoma medications needed were recorded. Success was defined as IOP less than 21 mm Hg with or without anti-glaucoma medication and without additional glaucoma surgery. RESULTS: Mean age was 23.1±19.9y. All eyes had at least one prior glaucoma surgery. IOP was reduced from a mean of 37.2±6.8 mm Hg to 19.2±5.2 mm Hg after 5y follow-up with a reduced number of medications from 2.64±0.59 to 1.81±0.4. Complete and qualified success rates were 31.5% and 46.0% respectively at the end of follow-up. The most common complications were encapsulated cyst formation in 51 eyes (41.1%), complicated cataract in 9 eyes (7.25%), recessed tube in 8 eyes (6.45%), tube exposure in 6 eyes (4.8%) and corneal touch in 6 eyes (4.8%). Other complications included extruded AGV, endophthalmitis and persistent hypotony. Each of them was recorded in only 2 eyes (1.6%). CONCLUSION: Although refractory glaucoma is a difficult problem to manage, AGV is effective and relatively safe procedure in treating refractory glaucoma in Egyptian patients with long-term follow-up. Encapsulated cyst formation was the most common complication, which limits successful IOP control after AGV implantation. However, effective complications management can improve the rate of success.     

Combined Baerveldt glaucoma drainage implant and trabeculectomy with mitomycin C for refractory glaucoma

PURPOSE: To describe the surgical technique and clinical outcomes of a procedure for refractory glaucoma, concurrent Baerveldt glaucoma implant (BGI) and trabeculectomy with mitomycin C. MATERIALS AND METHODS: Medical records of all patients who underwent combined Prolene-ligated BGI and trabeculectomy with mitomycin C were retrospectively reviewed. Main outcome measures were intraocular pressure (IOP), number of glaucoma medications, visual acuity, and complications. Kaplan-Meier survival analysis was used to determine success, defined as IOP < 22 mm Hg, no reoperation for glaucoma, and no loss of light perception vision. RESULTS: The mean +/- SD follow-up period for 38 eyes of 36 patients was 34 +/- 36 months (range, 3-121 months), during which 18 of 38 eyes (47%) required laser suture lysis of the Prolene suture. Intraocular pressure was reduced from a mean (+/- SD) preoperative value of 35.7 +/- 12.8 to 12.7 +/- 4.7 mm Hg at 1-year follow-up and 11.9 +/- 5.5 mm Hg at the last follow-up visit ( < 0.001). Number of medicines used for glaucoma was reduced from a mean +/- SD preoperative value of 2.5 +/- 0.9 to 0.5 +/- 0.6 at 1-year follow-up and 0.6 +/- 0.8 at the last follow-up visit ( < 0.001). LogMar visual acuity remained stable at mean of 1.15 +/- 0.85 preoperatively, compared with 1.14 +/- 1.05 at 1-year follow-up, but declined to 1.61 +/- 1.01 at the last follow-up visit, a loss of an average of four lines of vision ( = 0.004). Cumulative success was 91% at year 1, 86% at year 2, and 81% at year 3. Three eyes (8%) had suprachoroidal hemorrhages, one eye (3%) needed reoperation for an extruded implant, one (3%) eye had poor vision due to chronic hypotony, three eyes (8%) required additional glaucoma surgery during the postoperative period, and one eye (3%) needed revision of the implant for pressure control. CONCLUSIONS: Combined BGI and mitomycin C trabeculectomy provides excellent postoperative IOP control in patients with refractory glaucoma.     

Valve implants of glaucoma pressure regulator for refractory glaucoma: own experience

PURPOSE: To present our experiences in valve implantation for refractory glaucoma. MATERIAL AND METHODS: From October 1993 to December 1996 implantations of Glaucoma Pressure Regulator Optimed were performed in 7 eyes of 7 patients. There were 4 men and 3 women aged from 32 to 65 years. There were 3 eyes with neovascular glaucoma due to diabetes mellitus, 2 eyes with posttraumatic glaucoma, including 1 case after keratoplasty, 1 eye with postkeratoplasty glaucoma and 1 eye with aphakic glaucoma. Preoperative IOPs ranged from 33 to 61 mm Hg (mean 37.6 +/- 7.2 mm Hg). RESULTS: Success was considered an IOP of less than 22 mm Hg without medication (complete success) or with medication (qualified success) without additional filtering surgery. Postoperative success was obtained in 4 out of 7 eyes after follow-up period of 37.4 +/- 17.08 months (range 16-39 months). Early complications were hyphema (1 patient, 14.3%), blockage of intracameral portion of the tube (1 patient, 14.3%), hypertony (1 patient, 14.3%). Late complications were: external conjunctival bleb failure (2 patients, 28.6%), blockage of intracameral portion of tube by fibrovascular tissue (1 patient, 14.3%). CONCLUSION: Our experiences confirm that the valve implant is still today an alternative surgical procedure for controlling IOP in eyes with refractory glaucoma that have visual potential.     

青光眼引流器植入联合小梁切除术治疗难治性青光眼的临床观察

目的：观察青光眼引流器植入联合小梁切除术治疗难治性青光眼的疗效。方法对34例（46只眼）难治性青光眼行青光眼引流器植入联合小梁切除术治疗,观察术后视力、眼压、滤过泡及并发症等情况。结果34例难治性青光眼中,新生血管性青光眼12例（17只眼）,无晶状体眼4例（4只眼）,人工晶状体眼1例（1只眼）,外伤性青光眼2例（2只眼）,发育性青光眼9例（12只眼）,色素播散性青光眼2例（2只眼）。术前平均眼压（42．15±2．32）mmHg,术后眼压控制30只眼,眼压部分控制7只眼,眼压失控9只眼,术后平均眼压（18．34±3.55）mmHg,眼压有效控制率为80．43％。功能性滤过泡形成率67．39％,手术并发症较少。结论新型国产青光眼引流器植入联合小梁切除术治疗难治性青光眼疗效好,安全性高,术后并发症少,可以推广使用。     

Deep sclerectomy with a nonabsorbable implant (T-Flux): preliminary results

BACKGROUND: Deep sclerectomy is one of the two main types of nonpenetrating surgical methods of treating open-angle glaucoma. We aimed to determine, in a prospective study, the efficacy, success rate and complications of deep sclerectomy with implantation of a nonabsorbable drain made of highly hydrophilic acrylic (T-Flux). METHODS: Twenty-five patients (25 eyes) with medically uncontrolled open-angle glaucoma were treated by deep sclerectomy with implantation of the T-Flux drain. We determined the rates of intraocular pressure (IOP) reduction, surgical success (four categories) and complications. To evaluate the efficacy of this new implant in detail, we compared the success rates with those in a group of patients matched for age, sex, diagnosis, preoperative IOP, number of preoperative antiglaucoma medications and previous ocular surgery who underwent successful viscocanalostomy. RESULTS: For two eyes in the deep-sclerectomy group, surgery was converted to standard trabeculectomy owing to perforation of the trabeculo-Descemet's membrane during dissection of the corneal stroma. The following results apply to the remaining 23 eyes. After a mean follow-up period of 16.21 (standard deviation [SD] 3.93) months, the mean IOP had fallen from 26.26 (SD 4.3) mm Hg preoperatively to 17.60 (SD 4.35) mm Hg at the last postoperative visit (p = 0.000). The rate of complete success (IOP < 21 mm Hg without medication) was 86.9% at 1 month, 56.5% at 12 months and 39.1% at the last visit. The rates of qualified success (IOP < 21 mm Hg with or without medication) were 95.6%, 91.3% and 82.6%, respectively. No postoperative complications of the type that might occur after trabeculectomy were observed. Three eyes with an insufficient reduction in IOP underwent goniopuncture with a neodymium:YAG laser. Statistical analysis of the success rates revealed that deep sclerectomy with T-Flux implantation was comparable to viscocanalostomy at all postoperative visits (p > 0.05). INTERPRETATION: A statistically significant drop of IOP with few postoperative complications over the short term was achieved with deep sclerectomy and T-Flux implantation. The success rates were comparable to, and not significantly better than, those of viscocanalostomy.     

Long-term results of Ahmed glaucoma valve implantation in Egyptian population

AIM: To evaluate the long-term results and complications of Ahmed glaucoma valve (AGV) implantation in a cohort of Egyptian patients. METHODS: A retrospective study of 124 eyes of 99 patients with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 5y was performed. All patients underwent complete ophthalmic examination and intraocular pressure (IOP) measurement before surgery and at 1d, weekly for the 1st month, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP was measured by Goldmann applanation tonometry and/or Tono-Pen. Complications and the number of anti-glaucoma medications needed were recorded. Success was defined as IOP less than 21 mm Hg with or without anti-glaucoma medication and without additional glaucoma surgery. RESULTS: Mean age was 23.1±19.9y. All eyes had at least one prior glaucoma surgery. IOP was reduced from a mean of 37.2±6.8 to 19.2±5.2 mm Hg after 5y follow-up with a reduced number of medications from 2.64±0.59 to 1.81±0.4. Complete and qualified success rates were 31.5% and 46.0% respectively at the end of follow-up. The most common complications were encapsulated cyst formation in 51 eyes (41.1%), complicated cataract in 9 eyes (7.25%), recessed tube in 8 eyes (6.45%), tube exposure in 6 eyes (4.8%) and corneal touch in 6 eyes (4.8%). Other complications included extruded AGV, endophthalmitis and persistent hypotony. Each of them was recorded in only 2 eyes (1.6%). CONCLUSION: Although refractory glaucoma is a difficult problem to manage, AGV is effective and relatively safe procedure in treating refractory glaucoma in Egyptian patients with long-term follow-up. Encapsulated cyst formation was the most common complication, which limits successful IOP control after AGV implantation. However, effective complications management can improve the rate of success.     

非穿透性小梁手术联合双层羊膜植入物治疗青少年型青光眼

目的　探讨非穿透性小梁手术 (NPTS)联合羊膜植入物治疗青少年型青光眼的临床效果。方法　对 2 6例 (32只眼 ) 12～ 2 8岁青少年型青光眼患者进行非穿透性小梁手术联合羊膜植入物治疗。术后观察患者眼压、眼内反应及滤过泡情况 ,并做前房角镜检查。患者术后平均随访时间 (8 3± 4 2 )个月。结果　患者术后视力较术前无明显变化。患者术前平均眼压 (2 8 6± 7 3)mmHg(1mmHg =0 133kPa) ,术后 (15 7± 3 7)mmHg ,差异有显著意义 (t=4 82 ,P <0 0 1)。术前用药2～5种 ,平均 3 2种 ;术后用药 0～ 2种 ,平均 0 8种 ,差异有显著意义 (秩和检验 ,t=12 8,P <0 0 1)。随访期间眼压≤ 2 1mmHg者 30只眼 (93 8% ) ,无需药物治疗而眼压正常者 18只眼 (5 6 3% ) ,用药后眼压保持正常者 12只眼 (37 5 % )。术后 6只眼有轻微前房出血 ;无前房变浅、眼部炎性反应、脉络膜脱离等并发症发生。术后患者经前房角镜检查 ,可见术区后弹力膜及残存小梁网变薄 ,5只眼可见小梁处有微穿孔。结论　NPTS联合羊膜植入术能有效降低眼压 ,减少抗青光眼药物的应用 ,术后并发症少 ,是治疗青少年型青光眼的有效方法之一。     

Ahmed FP-7青光眼引流阀治疗难治性青光眼的18个月效果

目的 评估Ahmed FP-7青光眼阀植入治疗难治性青光眼的效果。设计 回顾性病例系列。研究对象 哈尔滨医科大学附属第二医院难治性青光眼患者45例46眼。方法 对以上患者行Ahmed FP-7青光眼阀植入,术后平均随访（10.7±7.3）个月。不用降眼压药眼压≤21 mm Hg定义为成功。主要指标 眼压、视力、手术后并发症。结果 术后18个月成功率为74.1 %;术前平均眼压（45.8±12.1）mm Hg,术后18个月为（17.6±5.3）mm Hg （P<0 .001）。视力提高 9眼,无改变35眼。手术并发症包括引流盘纤维包裹9眼（19.6%）、脉络膜脱离6眼（13.0%）、前房出血5眼（10.9%）、引流管暴露2眼（4.3%）。结论 18个月的随访显示,Ahmed FP-7青光眼阀植入术可控制3/4的难治性青光眼患者的眼压。（眼科,2013,22：253-256）     

【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.     

Long-term outcomes of Ahmed glaucoma valve implantation in refractory glaucomas

PURPOSE: To evaluate the long-term efficacy of intraocular pressure (IOP) reduction and complications of Ahmed glaucoma valve (AGV) implantation (New World Medical, Inc, Rancho Cucamonga, California, USA) in refractory glaucoma. DESIGN: Retrospective cohort study. METHODS: Retrospective medical records from 64 patients (78 eyes) with refractory glaucoma who underwent AGV implantation with a minimum of three years of follow-up were reviewed. Data regarding age, gender, race, eye laterality, specific glaucoma diagnosis, best-corrected visual acuity (BCVA), number of medications, IOP, visual fields, surgical complications, and follow-up interval were collected from all visits and were analyzed. The primary outcome measure was cumulative probability of success defined as IOP of less than 21 mm Hg and of 5 mm Hg or more with a minimum of 15% reduction from baseline IOP, without additional glaucoma surgery or loss of light perception. Secondary outcomes included IOP and number of medications at three, six, 12, 24, 36, 48, and 60 months after surgery, surgical complications, and final BCVA. RESULTS: The cumulative probability of success was 80% and 49% at one and five years, respectively. IOP was reduced from a mean of 30.4 +/- 10.7 mm Hg to 17.0 +/- 5.0 mm Hg at 12 months and 15.9 +/- 3.0 mm Hg at 60 months (P < .001). The number of medications decreased from 3.2 +/- 1.0 medications at baseline to 1.6 +/- 0.4 at 12 months and 2.1 +/- 0.2 at 60 months (P < .001). Prior glaucoma surgery and the silicone type of AGV were statistically significant risk factors for failure (P < .001). CONCLUSIONS: Approximately 50% of single-plate AGV implantations in refractory glaucoma were considered successful after five years of follow-up. Prior glaucoma surgery was a statistically significant risk factor for failure.     

Sequential or simultaneous cyclophotocoagulation and glaucoma drainage implant for refractory glaucoma

PURPOSE: To describe the outcomes of combining cyclophotocoagulation and tube-shunt glaucoma drainage implants, either sequentially or simultaneously, for the control of refractory glaucomas. PATIENTS AND METHODS: A retrospective review was conducted of all patients that had been treated at our institute with both cyclophotocoagulation and a tube-shunt glaucoma drainage implant in the same eye between January 1996 and June 2000. Preoperative and postoperative intraocular pressure, number of glaucoma medications, vision, and complications data were collected for each eye. RESULTS: A total of 10 eyes of 9 patients met the study criteria. The minimum follow-up period after the last surgery was 15 months. Intraocular pressures were reduced from 28.5 +/- 7.2 mm Hg preoperatively to 13.9 +/- 5.4 mm Hg postoperatively at 15 months (P < 0.000, n = 9). Medications were reduced from 2.7 +/- 1.2 preoperatively to 0.3 +/- 0.5 postoperatively at 15 months (P < 0.000, n = 9). Of the eight eyes with measurable Snellen acuity, postoperative vision decreased two or more lines in five eyes (63%). Complications included transient hypotony (one eye), transient serous choroidal detachment (two eyes), cystoid macular edema (two eyes), corneal edema (three eyes), and panuveitis with chronic hypotony and traction retinal detachment (one eye). CONCLUSIONS: Combining cyclophotocoagulation with tube-shunt glaucoma drainage implants can effectively reduce intraocular pressure and number of glaucoma medications needed to achieve target intraocular pressure goals. Further study is needed to determine the safety of this combined approach compared with other available options to manage refractory glaucomas.     

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.     

Filtering valve implant surgery for eyes wtih neovascular glaucoma

We performed filtration surgery with a unidirectional, pressure-sensitive valve implant in 40 eyes with neovascular glaucoma. The device consisted of an open Supramid tube (outside diameter 0.58 mm, inside diameter 0.38 mm) sealed to a Silastic tube with a slit valve. The Supramid tube was inserted at the corneoscleral limbus 1 to 4 mm into the anterior chamber and the Silastic portion was located under a lamellar scleral flap. Twenty-seven of 40 eyes (68%) had a postoperative IOP less than or equal to 24 mm Hg with a mean follow-up of 13.8 months. Ten of these 27 eyes required postoperative medical therapy to achieve this level of IOP control. The glaucoma valve implant failed to return IOP to normal in 13 of the 40 eyes (32%), 11 of these as a consequence of scarring of the external bleb.     

Baerveldt glaucoma implant insertion in the posterior chamber sulcus

AIM: To report the clinical outcome of a surgical technique for insertion of the silicone tube of a Baerveldt glaucoma implant (BGI) in the posterior chamber sulcus. METHODS: Non-comparative, interventional case series. Eight eyes of eight patients, with a follow-up of at least 18 months, who underwent insertion of a BGI with the silicone tube placed in the posterior chamber sulcus between 1998 and 2005 were included. Control of intraocular pressure (IOP), number of pressure-lowering medications, visual acuity and surgical complications were recorded. RESULTS: Eight eyes of eight patients (mean (range) age 76.4 (62-94) years) were included in the study. The IOP was reduced from a preoperative mean (SD) of 28.2 (14.4) to 12.6 (5.8) mm Hg at 18 months. The mean (SD) number of preoperative medications for IOP control was reduced from 2.8 (1.5) to 1.3 (1.5) medications in the same period. No complications were observed during surgery or follow-up. CONCLUSION: Placement of the silicone tube in the posterior chamber sulcus is a safe and effective alternative technique for IOP control in patients with pseudophakia. Sulcus placement may reduce the likelihood of corneal endothelial loss and avoid the need for pars-plana vitrectomy and posterior segment tube insertion in complicated eyes.     

Outcomes of sequential tube shunts in complicated glaucoma

OBJECTIVE: To evaluate intraocular pressure (IOP) control, change in visual acuity, and complications in eyes that have undergone a second glaucoma tube shunt procedure. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two eyes of 22 patients that have undergone sequential tube implants for management of glaucoma. METHODS: Parameters analyzed included IOP, visual acuity, and number of hypotensive agent before each shunt procedure and at last follow-up visit. The overall IOP lowering effect attributable to each tube shunt was calculated. Any ocular complications after the second tube shunt were recorded. Success was defined as an IOP between 6 and 21 mm Hg and a 20% reduction in IOP from the second tube shunt procedure. Qualified successes met one of these two requirements at the last follow-up visit. Total failures did not meet any of the above criteria, required additional surgical intervention to lower IOP, or both. MAIN OUTCOME MEASURES: Intraocular pressure control, visual acuity preservation, and complications. RESULTS: At the last follow-up visit, the average percent reduction in IOP from both tube shunt procedures was 42+/-21%. The average percent IOP reduction from the second tube shunt was 33+/-17%. Eleven (50%) patients met the criteria for success, 8 (36.4%) patients were qualified successes, and 3 (13.6%) were failures. The median number of hypotensive agents decreased from two to one. Ten patients experienced new or worse pseudophakic bullous keratopathy after the second tube shunt, six of whom underwent penetrating keratoplasty. Thirteen (59%) patients maintained visual acuity within one line of their second tube shunt pre-operative Snellen visual acuity. Seven (32%) patients lost more than 2 lines, and one patient lost light perception. CONCLUSIONS: Although corneal morbidity is a common complication, a second tube shunt does not cause higher-than-expected rates of other complications associated with tube shunt surgery. Eyes that undergo a second tube shunt procedure can achieve pressure control, require fewer hypotensive agents, and may maintain stable visual acuity.     

A novel approach to suprachoroidal drainage for the surgical treatment of intractable glaucoma

PURPOSE: In glaucoma surgery, scarring of the artificial fistula is the limiting factor for long-term control of intraocular pressure (IOP). Several devices and surgical techniques have been developed for artificial aqueous humor drainage in intractable glaucoma. The authors describe a novel surgical technique that uses a silicone tube as a shunt for aqueous flow from the anterior chamber to the suprachoroidal space. PATIENTS AND METHODS: Thirty-one eyes of 31 patients with uncontrollable refractory glaucoma were included in this prospective consecutive case-control study. Each eye had undergone an average of 3.5+/-1.9 previous interventions for glaucoma. The baseline IOP was 44.25+/-8.7 mm Hg despite maximum therapy. As in trabeculectomy, a limbus-based scleral flap was prepared. The suprachoroidal space was accessed via a deep posterior scleral flap. The silicone tube was inserted as an intrascleral connection from the anterior chamber to the suprachoroidal space. Cyclodialysis was avoided by this surgical approach. Success was defined as a lowering of IOP to below 21 mm Hg without the need for further medication or intervention. RESULTS: The mean functional shunt survival was 55.9+/-45.6 weeks. IOP was reduced to 12.9+/-5.2 mm Hg in 70% of all eyes after 30 weeks postoperatively. After 52 weeks, 60% of the eyes could be classified as representing success, and 76 weeks after surgery, 40% of the eyes still showed controlled IOP. In none of the eyes were severe postoperative hypotony or suprachoroidal bleeding observed. No localized or general inflammation or infection was seen in connection with the silicon tube. Two patients needed anterior chamber lavage because of bleeding. In 2 patients the tube had to be removed because of corneal endothelial contact. Shunt failure of the tube was caused in some cases by connective tissue formation at the posterior lumen of the tube. CONCLUSION: This novel surgical approach and the placement of the silicone tube described here have several advantages. Its intrascleral course minimizes the risk of conjunctival erosion and associated infections. No cyclodialysis is performed. Connection to the suprachoroidal space exploits the resorptive capability of the choroid. It guarantees drainage but also provides a natural counterpressure, avoiding severe postoperative hypotony. The suprachoroidal shunt presented here achieves good follow-up results in terms of IOP control. No serious complications have been observed. This new method promises to be an effective surgical technique and presents a new therapeutic option in intractable glaucoma. Fibroblast reaction obstructing the posterior lumen, seemed to be the only factor limiting drainage. Further studies and experiments will be needed to elucidate the exact physiologic mechanisms underlying the draining, the capacity and duration of the draining effect, and the histologic background of suprachoroidal scarring.     

Experience with the baerveldt glaucoma implant in the management of pediatric glaucoma

PURPOSE: To report the clinical outcome in 48 eyes of 48 children who received a Baerveldt glaucoma implant (BGI) for the management of pediatric glaucoma. DESIGN: Retrospective, noncomparative case series. METHODS: The medical records of all patients with pediatric glaucoma who underwent a BGI at two tertiary care referral centers in Los Angeles between 1990 and 1999 were reviewed. Intraocular pressure (IOP), intraoperative and postoperative complications, number of glaucoma medications, visual acuity, and pre- and postoperative corneal diameter and axial length were collected from patient records. Criteria for success were IOP between 6 and 21 mm Hg with or without glaucoma medications, no need for further glaucoma surgery, the absence of visually threatening complications, and some residual vision (minimum visual acuity of light perception). RESULTS: The study included 48 eyes from 48 patients aged 16 years and younger (mean age 4.1 years). Mean preoperative IOP was 31.2 +/- 25.7 mm Hg, and mean postoperative IOP was 16.4 +/- 4.9 mm Hg. Cumulative probability of success (based on the Kaplan-Meier survival curve) was 95% at 6 months, 90% at 1 year, 84% at 2 years, 74% at 36 months, and 58% at 48 months. On average, the BGIs were successful for a mean period of 5.6 years (67.7 months). Overall, 11 eyes failed, with the causes being uncontrolled IOP (eight eyes), retinal detachment (two eyes), and no light perception (one eye). CONCLUSIONS: Baerveldt glaucoma implants can be a safe and effective treatment modality for the management of pediatric glaucoma refractive to medical therapy.     

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.