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Outcomes of Ahmed Glaucoma Valve Implantation in Children with Primary Congenital Glaucoma

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Outcomes of Ahmed Glaucoma Valve Implantation in Children with Primary Congenital Glaucoma CLINICAL SCIENCES Outcomes of Ahmed Glaucoma Valve Implantation in Children With Primary Congenital Glaucoma Yvonne Ou, MD; Fei Yu, PhD; Simon K. Law, MD, PharmD; Anne L. Coleman, MD, PhD; Joseph Caprioli, MD Objectives: To evaluate the long-term efficacy of in- children had a mean (SD) age of 1.8 (2.6) years, a mean traocular pressure reduction and complications of Ahmed (SD) preoperative intraocular pressure of 28.4 (6.7) glaucoma valve (AGV) implantation in children with pri- mm Hg, and a mean (SD) follow-up time of 57.6 (48.0) mary congenital glaucoma. months. The cumulative probability of success was 63% in 1 year and 33% in 5 years. After a second AGV im- Methods: The medical records of patients with pri- plantation, the cumulative probability of success was 86% mary congenital glaucoma who underwent AGV implan- in 1 and 2 years and 69% in 5 years. Hispanic ethnicity tation with a minimum follow-up of 6 months were re- (P=.02) and being female (P=.005) were associated with viewed. The primary outcome measure was cumulative increased risk of failure. probability of success, defined as intraocular pressure greater than 5 mm Hg and less than 23 mm Hg and at Conclusions: Thirty-three percent of AGV implanta- least a 15% reduction from the preoperative intraocular tions in children with primary congenital glaucoma were pressure, without serious complications, additional glau- successful after 5 years of follow-up. With the implan- coma surgery, or loss of light perception. tation of a second AGV, the 5-year success rate in- creased to 69%. Results: Thirty eyes of 19 children with primary con- genital glaucoma who underwent AGV implantation with a minimum follow-up of 6 months were reviewed. The Arch Ophthalmol. 2009;127(11):1436-1441 RIMARY CONGENITAL GLAU- The Ahmed glaucoma valve (AGV) coma (PCG) is present at (New World Medical, Inc, Rancho birth but often goes unrec- Cucamonga, California) is a tube shunt ognized until increased in- device with a unidirectional flow-restric- traocular pressure (IOP) tive mechanism designed to prevent post- Pdamages ocular structures and produces operative hypotony. The success rates re- vision loss. Primary congenital glaucoma ported for this device in the pediatric is a potentially blinding disease that usu- population range from 58% to 93% in ally does not respond adequately to medi- achieving IOP of less than 21 mm Hg, but cal treatment. Although goniotomy and these rates have been in mixed popula- trabeculotomy are associated with good tions of children with a variety of pediat- early success rates, eventually 20% of these ric glaucoma diagnoses and with short- procedures fail and many children with term follow-up.8,9,19,20 These reports include PCG require additional surgery to con- children with congenital glaucoma as well trol IOP in the long-term.1-3 Various sur- as children with secondary diagnoses in- gical approaches have been proposed, in- cluding aphakia or pseudophakia, Sturge- cluding trabeculectomy with or without Weber syndrome, uveitic glaucoma, an- adjunctive antimetabolites,4,5 nonpenetrat- iridia, and anterior segment dysgenesis. ing external trabeculectomy,6 combined Because of the heterogeneity in the mecha- trabeculotomy and trabeculectomy,7 glau- nisms of glaucoma secondary to these vari- coma drainage devices,8-11 and cyclode- ous disorders, we evaluated the long-term structive procedures.12,13 Trabeculec- surgical efficacy of AGV implantation in tomy with mitomycin C has shown children with PCG. promise, with studies reporting 52% to 95% success rates.14-16 However, the in- METHODS Author Affiliations: Glaucoma creased success with the addition of anti- Division, Jules Stein Eye metabolites has also resulted in well- Institute, David Geffen School recognized long-term complications such This was a retrospective study of patients of Medicine, University of as bleb failure, bleb leak, and bleb- with PCG who underwent AGV implantation California, Los Angeles. related endophthalmitis.16-18 from January 1, 1995, to December 31, 2007, (REPRINTED) ARCH OPHTHALMOL / VOL 127 (NO. 11), NOV 2009 WWW.ARCHOPHTHALMOL.COM 1436 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 at the Glaucoma Division, Jules Stein Eye Institute, University The eye was the unit of analysis. However, repeat analysis of California, Los Angeles, with a minimum of 6 months of was performed with 1 eye per patient (n=19 patients), using follow-up. Children with secondary diagnoses including the first eye that underwent AGV implantation. In cases where aphakia or pseudophakia, Sturge-Weber syndrome, uveitic both eyes received AGV implantation simultaneously, the right glaucoma, aniridia, and anterior segment dysgenesis were eye was evaluated. excluded. This study was approved by the University of Cali- Kaplan-Meier survival analyses were used to assess the long- fornia, Los Angeles institutional review board. term success rates according to the criteria defined earlier. In addition, Cox proportional hazards regression analysis was used DATA COLLECTION to determine the predictive factors for failure. The following potential predictors were evaluated in a univariate analysis: age, Preoperative data were collected from the records of the pa- sex, ethnicity, baseline IOP, preoperative cup-disc ratio, pres- tients and included age at the time of surgery, sex, race, eye ence of preoperative corneal edema, preoperative medications laterality, mean IOP prior to AGV implantation, prior ocular used, and number of previous glaucoma surgical procedures. surgical procedures, specific glaucoma diagnosis and other ocu- In comparing Hispanic vs non-Hispanic patients, continuous lar history, number of medications used, and type of AGV used variables were compared using the Kruskal-Wallis test, whereas in the surgery. categorical variables were compared using the Fisher exact test. Postoperative data were collected from the records of the The Cochran-Armitage test was used to evaluate the underly- ing trend in postoperative medication use and changes in cup- patients from all consecutive visits. Collected data include IOP Ͻ measurements, number of medications used, axial length, cup- disc ratios. P .05 was considered statistically significant. All disc ratio, presence of corneal edema and Haab striae, surgical statistical analyses were performed using SAS version 9.1 sta- complications, additional surgical procedures performed, and tistical software (SAS Institute, Inc, Cary, North Carolina). follow-up time. Cup-disc ratios were recorded during the evalu- ation under anesthesia or at the time of surgical intervention RESULTS by 1 of the 3 surgeons (J.C., A.L.C., and S.K.L.). Quantitative visual acuity information was limited due to patient age at the time of surgery but was obtained at postoperative visits when- PREOPERATIVE CHARACTERISTICS ever possible. Thirty eyes of 19 patients were included in the study. SURGICAL TECHNIQUE Twelve patients (63%) were male. Eight patients (42%) were white, 8 patients (42%) were Hispanic, and 3 pa- The polypropylene and silicone single-plate AGVs (models S-2 tients (16%) were Asian. The mean (SD) age at the time and FP-7, respectively) were implanted by 3 experienced sur- of AGV implantation for each eye was 1.8 (2.6) years, geons (J.C., A.L.C., and S.K.L.) using similar techniques. A for- with a range of 0.02 to 9.9 years. Twenty-eight eyes (93%) nix-based flap of the conjunctiva and Tenon capsule was cre- underwent prior glaucoma surgery, with 7 (23%) un- ated in the superior temporal or superior nasal quadrant, with dergoing a single angle surgical procedure (goniotomy the anterior edge of the plate secured with nondissolvable su- or trabeculotomy) and 18 (60%) undergoing 2 or more ture 10 mm posterior to the superior temporal corneolimbal junction or 8 mm posterior to the superior nasal corneolimbal angle surgical procedures. Among the 7 patients who had junction. The tube was flushed with balanced salt solution to only a single procedure prior to AGV implantation, 2 were ensure patency before insertion through a scleral track that was of older age (mean age, 8.4 years) at the time of implan- created with a 22- or 23-gauge needle into the anterior cham- tation, suggesting that the single angle surgical proce- ber. Viscoelastic was injected to reform the anterior chamber dure controlled the IOP for a relatively long time before as needed at the discretion of the individual surgeon. A com- further intervention was necessary. The remaining 5 pa- mercially available processed pericardial graft (Tutoplast; IOP, tients had IOP uncontrolled after a single angle surgical Inc, Costa Mesa, California) was used to cover the scleral en- procedure, and a decision was made to proceed to AGV try site and the anterior 8 mm of the tube by securing it to the implantation. Three eyes (10%) also underwent trabecu- episcleral surface with interrupted 8-0 polyglactin sutures (Vic- lectomy in addition to angle surgery prior to drainage de- ryl; Ethicon, Inc, Somerville, New Jersey). The conjunctiva and Tenon capsule were then reapproximated to the limbus with vice implantation. The mean (SD) number of prior glau- 9-0 polyglactin sutures. coma surgical procedures was 1.8 (0.9). The mean (SD) preoperative IOP was 28.4 (6.7) mm Hg, while the mean (SD) IOP at the last follow-up was 17.7 (6.7) mm Hg. STATISTICAL METHODS Data on glaucoma medications used prior to AGV im- The primary outcome measure was surgical success, defined as plantation
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