OBJECTIVE: To evaluate the results of Ahmed Glaucoma Valve implantation in African American and white patients.
METHODS: In this retrospective, comparative case-control study, we reviewed 86 eyes of 86 patients, comparing the surgical outcomes in white patients (n = 43) with matched African American patients (n = 43). Success was defined as an intraocular pressure (IOP) between 6 mm Hg and 21 mm Hg with or without glaucoma medicines, without further glaucoma surgery, and without loss of light perception (definition 1) and an IOP between 6 mm Hg and 21 mm Hg and achievement of a 20% reduction in IOP from the preoperative level (definition 2).
RESULTS: The mean follow-up was 2.3 years for white patients and 2.5 years for African American patients (P = .50). At the last follow-up, the mean +/- SD IOP was 15.3 +/- 3.3 mm Hg and 15.3 +/- 3.5 mm Hg (P = .77) in white and African American patients, respectively. Life table analysis showed a significantly lower success rate for African American patients compared with white patients by both definition 1 (P = .03) and definition 2 (P = .006). Cox proportional hazards regression analysis detected African American race as a risk factor for surgical failure by both definitions. Visual outcomes and complications were comparable between the 2 groups.
CONCLUSION: African American patients have a greater risk of surgical failure after Ahmed Glaucoma Valve implantation compared with white patients.
BACKGROUND: Glaucoma drainage devices are more commonly inserted into the anterior chamber because of the relative ease of this method of insertion. However, in certain cases, posterior placement of the tube may be necessary or may be more desirable. The outcome of a series of patients with glaucoma drainage devices inserted into the pars plana was examined.
METHODS: Retrospective chart review of patients who underwent pars plana implantation of Molteno and Baerveldt glaucoma drainage devices at the Sydney Eye Hospital.
RESULTS: There were 33 cases reviewed. The mean follow-up period was 30.2 months. The mean final postoperative intraocular pressure was reduced to 13.4 +/- 4.4 mmHg (SD) from 33.06 +/- 8.47 mmHg preoperatively. The mean number of intraocular pressure-lowering medications in use postoperatively was 0.6 +/- 0.8, reduced from 3.6 +/- 1.27 medications in use preoperatively. Sixteen (48.5%) eyes were classified as complete successes, 14 (42.4%) eyes as qualified successes and three eyes (9%) as failures. Kaplan-Meier survival analysis for cumulative success (absence of failure) predicted 61.1% survival at 60 months. Complications included five cases of decompensation of corneas or corneal grafts, one case each of conjunctival wound dehiscence, large choroidal effusion, epiretinal membrane, Molteno plate extrusion and intraocular pressure unresponsive to medical therapy, and three cases of tube blockage.
CONCLUSIONS: In this series of patients, pars plana insertion of glaucoma drainage devices has been shown to be an effective alternative for selected cases where anterior chamber tube insertion is not possible or is not ideal.
OBJECTIVE: To analyze the longer-term surgical outcomes of Ahmed and Baerveldt shunt implants in the treatment of refractory glaucoma.
DESIGN: Retrospective, nonrandomized, comparative trial.
PARTICIPANTS: Consecutive patients who underwent glaucoma shunt implantation (70 Baerveldt, 48 Ahmed) by a single surgeon.
METHODS: Follow-up retrospective analysis of 118 consecutive cases of refractory glaucoma that required placement of either Ahmed or Baerveldt shunt implants for intraocular pressure (IOP) control. The longer term clinical course (survival curve analysis up to 48 months) was reviewed.
MAIN OUTCOME MEASURES: The primary outcome measure was surgical success (6 mmHg < or = IOP < or = 21 mmHg without additional glaucoma surgery or devastating complication). Secondary outcome measures included mean IOP and number of medications used at the following postoperative visits: day 1, 1 week, 1 month, 3 months, 6 months, and every 6 months thereafter (up to 48 months). In unsuccessful cases, the median time to failure was determined.
RESULTS: No significant differences in success rates were noted at 1, 2, 3, or 4 years after surgery, with 4-year success rates of 62% for the Ahmed group and 64% for the Baerveldt group (P = 0.843). Mean IOPs were comparable from 1 to 48 months (P>0.05). However, patients in the Ahmed group required more glaucoma medications at 18, 24, 30, and 36 months (P<0.05). The median times to failure were 3.2 months in the Baerveldt group, compared with 15.0 months in the Ahmed group (P = 0.009).
CONCLUSIONS: No differences were observed in longer term survival rates and IOP profiles between Ahmed and Baerveldt shunt implants up to 48 months following surgery. Patients in the Baerveldt group were more likely to develop early postoperative hypotony-related complications and failure, whereas patients undergoing Ahmed implants were more likely to be on additional glaucoma medications (starting at 18 months postsurgery) and develop later onset failure.
PURPOSE: To report the intermediate-term results of the Baerveldt 250-mm2 Glaucoma Implant for treatment of adult glaucoma.
DESIGN: Retrospective, noncomparative, interventional case series.
PARTICIPANTS: One hundred eight adult patients (108 eyes) with glaucoma who received a Baerveldt 250-mm2 Glaucoma Implant.
INTERVENTION: Implantation of the Baerveldt 250-mm2 Glaucoma Implant.
MAIN OUTCOME MEASURES: Intraocular pressure (IOP), visual acuity, number of glaucoma medications, and surgical complications. Success was defined as IOP > or = 6 mmHg and < or = 21 mmHg (with or without antiglaucoma medications), without further glaucoma surgery, devastating complication, or loss of light perception attributable to drainage implantation.
RESULTS: Mean age was 63.8+/-16.5 years. Mean postoperative follow-up was 22.8 months (range, 0.2-84.9; interquartile range, 3.9-36.3). Mean preoperative IOP was 36.3+/-13.0 mmHg, on 2.9+/-1.1 antiglaucoma medications. The mean postoperative IOP at final visit was 15.8+/-7.6 mmHg (P<0.0001, paired t test), on 0.8+/-1.0 antiglaucoma medications (P<0.0001, Wilcoxon test). Kaplan-Meier success rates were 0.92 (6 months, n = 81), 0.88 (12 months, n = 75), 0.84 (18 months, n = 68), and 0.79 (24 months, n = 61).
CONCLUSIONS: The Baerveldt 250-mm2 Glaucoma Implant provides good intermediate-term success for the treatment of adult refractory glaucoma.
AIM: To evaluate the Baerveldt glaucoma implant (BGI) in paediatric glaucoma treatment.
METHODS: In a retrospective non-comparative case series 55 eyes of 40 consecutive paediatric patients (< or =16 years) with primary or secondary glaucoma underwent Baerveldt (350 mm2) implantation. Surgical outcome was evaluated by Kaplan-Meier table analysis.
RESULTS: The overall success rate was 80% at last follow up, with a mean follow up of 32 (range 2-78) months. Cumulative success was 94% at 12 months and 24 months, 85% at 36 months, 78% at 48 months, and 44% at 60 months. 11 eyes (20%) failed postoperatively because of an IOP >21 mm Hg (eight eyes), persistent hypotony (two eyes), and choroidal haemorrhage following cataract surgery (one eye). The most frequent complication needing surgery was tube related (20%). A new observation was mild to moderate dyscoria in 22% of the eyes, all buphthalmic, caused by entrapment of a tuft of peripheral iris in the tube track.
CONCLUSIONS: The BGI is effective and safe in the management of primary and secondary glaucoma. When angle surgery has proved to be unsuccessful or inappropriate in paediatric patients, a BGI is a good treatment option. One must be prepared to deal with the tube related problems.
OBJECTIVE: To describe the long-term outcomes of cases of neovascular glaucoma drained by Molteno implants.
METHODS: A prospective study of 145 eyes (130 patients) followed up for a mean of 3.3 years (range, 0.02 year [5 days] to 18.1 years) in the province of Otago, New Zealand, from 1979 to 2002.
RESULTS: Insertion of a Molteno implant controlled the intraocular pressure at 21 mm Hg or less with a probability (95% confidence interval) of 0.72 (0.64-0.80), 0.60 (0.51-0.69), and 0.40 (0.29-0.50) at 1, 2, and 5 years, respectively. Failure to control intraocular pressure at 1, 2, and 5 years was significantly correlated with persistent iris neovascularization (P<.001, P<.001, and P = .01, respectively). Visual acuity at final follow-up in nonenucleated eyes was maintained or improved in 56 eyes (39%) and deteriorated to light perception or better in 25 (17%) or no light perception in 47 (32%). Seventeen eyes (12%) were enucleated.
CONCLUSIONS: The insertion of Molteno implants for neovascular glaucoma maintained or improved vision in 39% of eyes, whereas 12% were eventually enucleated (all of which initially had visual acuity <20/1200). The outcome depended mainly on progression of the underlying vascular disease.
PURPOSE: The Tube Versus Trabeculectomy (TVT) Study will compare the safety and efficacy of nonvalved tube shunt surgery to trabeculectomy with mitomycin C in patients with previous intraocular surgery.
DESIGN: Multicenter randomized clinical trial.
METHODS: None
SETTING: 17 Clinical Centers.
STUDY POPULATION: Patients 18 to 85 years of age who have undergone previous trabeculectomy, cataract extraction with intraocular lens implantation, or both and have inadequately controlled glaucoma with intraocular pressure (IOP) >or=18 mm Hg and <or=40 mm Hg on tolerated medical therapy.
INTERVENTIONS: Study patients were randomized to undergo placement of a 350-mm(2) Baerveldt glaucoma implant or trabeculectomy with mitomycin C (0.4 mg/ml for 4 minutes).
MAIN OUTCOME MEASURES: IOP, complication rates, visual acuity, visual field, quality of life, reoperations for glaucoma, and need for supplemental medical therapy.
RESULTS: A total of 212 patients were enrolled between October 1999 and April 2004. The age of the study population was 71.0 +/- 10.4 years (mean +/- SD), and 53% were women. The baseline IOP was 25.3 +/- 5.3 mm Hg (mean +/- SD). There were no significant differences in the demographic and ocular characteristics between the 2 treatment groups.
CONCLUSIONS: Practice patterns vary in the surgical management of glaucoma, and there are differing opinions among glaucoma surgeons regarding the preferred surgical approach in patients who have undergone previous cataract extraction and/or failed filtering surgery. Forthcoming data from the TVT Study should provide valuable information comparing two surgical procedures commonly used in this patient population.
OBJETIVO: Evaluar la eficacia y seguridad del intraoperatoria de mitomicina C (MMC) en los ojos sometidos a implante de válvula de Ahmed Glaucoma.
Diseño: ensayo clínico controlado aleatorizado.
PARTICIPANTES: Sesenta pacientes con glaucoma refractario.
INTERVENCIÓN: Sesenta ojos de 60 pacientes con glaucoma refractario fueron aleatorizados para recibir MMC intraoperatoria (0,5 mg / ml durante 5 minutos) (n = 34) o solución salina equilibrada (n = 26) durante el implante de válvula de Ahmed Glaucoma.
Principales medidas de resultado: el éxito quirúrgico se define de acuerdo a dos criterios diferentes: (1) la presión intraocular (PIO) entre 6 y 21 mmHg, con o sin medicamentos contra el glaucoma, y (2) la reducción de la PIO de al menos el 30% con respecto a los valores preoperatorios . Los ojos que requieren cirugía adicional glaucoma, el desarrollo de la tisis, o mostrando la pérdida de la percepción de la luz se clasificaron como fracasos. Las tasas de éxito en ambos grupos se compararon mediante Kaplan-Meier y el test de log rank. Otras medidas de resultado fueron la PIO promedio, el número de medicamentos para el glaucoma y complicaciones.
RESULTADOS: Con un seguimiento medio de 12,3 meses, Kaplan-Meier análisis de supervivencia demostró una probabilidad de éxito del 59% a los 18 meses para el grupo de MMC y un 61% para el grupo control cuando el primer criterio de éxito se utilizó (PIO entre 6 mmHg y 21). Cuando una reducción de la PIO de al menos 30% se utilizó como criterio para definir el éxito, el análisis de supervivencia de Kaplan-Meier demostró una probabilidad de éxito a los 18 meses de 62% para el grupo de MMC y 67% para el grupo control. No hubo diferencias significativas en las tasas de supervivencia entre los 2 grupos con cualquiera de los criterios (P = 0,75 y P = 0,37, respectivamente). Después de 15 días de la operación, la PIO media no difirió significativamente de la MMC y control de los ojos. Los números medios de medicamentos antiglaucoma postoperatorias fueron similares en los ojos tratados con MMC y controles. No hubo diferencia significativa entre la incidencia de complicaciones postoperatorias en ambos grupos.
CONCLUSIÓN: La mitomicina C no aumentó las tasas de éxito a corto o medio plazo de la implantación de válvula de Ahmed.
