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Long-Term Outcomes of Uveitic Glaucoma Treated with Ahmed Valve Implant in a Series of Chinese Patients

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Long-Term Outcomes of Uveitic Glaucoma Treated with Ahmed Valve Implant in a Series of Chinese Patients Int J Ophthalmol, Vol. 11, No. 4, Apr.18, 2018 www.ijo.cn Tel:8629-82245172 8629-82210956 Email:[email protected] ·Clinical Research· Long-term outcomes of uveitic glaucoma treated with Ahmed valve implant in a series of Chinese patients Ning Bao1, Zheng-Xuan Jiang1 , Paul Coh2, Li-Ming Tao1 1 Department of Ophthalmology, the Second Affiliated Hospital ● KEYWORDS: uveitic glaucoma; Ahmed glaucoma valve; of Anhui Medical University, Hefei 230601, Anhui Province, follow-up; Chinese population China DOI:10.18240/ijo.2018.04.15 2Department of Ophthalmology, University of California, San Francisco 94143-0730, California, USA Citation: Bao N, Jiang ZX, Coh P, Tao LM. Long-term outcomes Correspondence to: Zheng-Xuan Jiang; Li-Ming Tao. Department of uveitic glaucoma treated with Ahmed valve implant in a series of of Ophthalmology, the Second Affiliated Hospital of Anhui Chinese patients. Int J Ophthalmol 2018;11(4):629-634 Medical University, 678 Furong Road, Hefei 230601, Anhui Province, China. [email protected]; [email protected] INTRODUCTION Received: 2017-11-27 Accepted: 2018-01-29 laucoma is a leading cause of blindness disease and is G characterized by elevated intraocular pressure (IOP), Abstract optic nerve damage and visual defects[1]. Some types of ● AIM: To report long-term outcomes of secondary glaucoma glaucoma include neovascular glaucoma, secondary glaucoma due to uveitis treated with Ahmed glaucoma valve (AGV) associated with uveitis, and angle recession, which usually are implantation in a series of Chinese patients. bad responsive to conventional medical therapies and surgical ● METHODS: The retrospective study included 67 eyes procedures[2-3]. Uveitis is swelling and irritation of the uvea from 56 patients with uveitic glaucoma who underwent which is the middle layer of the eye. It accounts for 5%-20% AGV implantation. Success of the treatment was defined of blindness cases in the United States and Europe[4]. One of as patients achieving intraocular pressure (IOP) levels the major complications is glaucoma which arises secondary to between 6 and 21 mm Hg with or without additional anti- [1,5-6] uveitis or the corticosteroids used to treat uveitis . Uveitic glaucoma medications and/or a minimum of 20% reduction glaucoma is difficult to manage because it may be difficult to from baseline IOP. The main outcome measurements obtain a desirable IOP through medical treatments and surgeries. included IOP, the number of glaucoma medications at There are many therapies used to treat of uveitic glaucoma. 1, 3, 6, 12, 24, 36, 48 and 60mo after surgery, surgical One of the most common procedures used is trabeculectomy. complications, final best-corrected vision acuity (BCVA), The major complication of this procedure is bleb fibrosis[7-8]. visual field (VF) and retinal nerve fiber layer (RNFL). Although the application of anti-fibrotic agents such as ● RESULTS: The mean follow-up was 53.3±8.5 (range mitomycin C, have been used in surgery, the success rate of 48 to 60)mo. The cumulative probability of success rate filtration surgery remains unsatisfactory[9]. Furthermore, as the was 98.5%, 95.5%, 89.6%, 83.6%, 76.1%, 70.1%, 65.7% and recurrent inflammatory response of uveitis transpires in these 61.2% at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively. IOP patients, filtration surgery in uveitic glaucoma yields lower was reduced from a baseline of 30.8±6.8 to 9.9±4.1, 10.1±4.2, success rates than other refractory glaucoma[10]. 10.9±3.7, 12.9±4.6, 13.8±3.9, 13.2±4.6, 12.3±3.5 and 13.1±3.7 mm Hg In recent years, aqueous drainage devices have been widely at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively (P<0.01). The number of postoperative glaucoma medications used to treat uveitic glaucoma. The Ahmed glaucoma valve was significantly decreased compared with baseline at (AGV) is a shunt device used to restrict flow in uveitic [11-12] all time points during the study period (P<0.05). There glaucoma . It has shown better surgical results with fewer was no significant difference between preoperative and postoperative complications compared with traditional surgical [12] postoperative BCVA. Remarkable surgical complications procedures in uveitic glaucoma . The success rates of were not found after surgery. The VF and RNFL of the AGV implantation are higher in some studies compared with [12-14] patients were stable after the surgery. trabeculectomy . However, success rates are inconsistent ● CONCLUSION: AGV implantation is safe and effect in among different studies. Moreover, there is little report of terms of reducing IOP, decreasing the number of glaucoma success rates of AGV in Chinese uveitic glaucoma. Herein, we medications, and preserving vision for patients with present the outcomes of patients with uveitic glaucoma who uveitic glaucoma. were treated with AGV implantation. 629 Treatment of uveitis glaucoma with Ahmed valve implant SUBJECTS AND METHODS Management After Surgery Follow-up of the patients after Study Population This was a retrospective and non-comparative surgery included IOP, VF, Ahmed valve area changes and study of AGV implantation. We reviewed the records of complication, uveitis control, additional glaucoma medications, all uveitic glaucoma patients who underwent AGV implant other complications. When the IOP was above 21 mm Hg, the surgery at the Department of Ophthalmology, the Second brinzolamide and carteolol hydrochloride eye drops were used. Affiliated Hospital of Anhui Medical University from Jun. The tropicamide, tobramycin dexamethasone and pranoprofen 2009 to Apr. 2012 due to glaucoma that was uncontrolled eye drops were used in the uveitic glaucoma patients who had by medical treatment or with glaucoma surgery. This study eye red, eye pain and VA decreased. contained 67 eyes of 56 patients with uveitic glaucoma. Statistical Analysis Comparisons between continuous Clinical information including age, gender, race, number of outcomes were assessed using a one-way analysis of variance anti-glaucoma medications, previous glaucoma surgeries were with the Dunnett multiple comparison test. Kaplan-Meier collected. As active uveitis may influence the outcome of life-table analysis was used to assess cumulative probability surgery, the patients in the study were clinically in remission of success. Comparisons between categorical factors were for over 6mo and received oral prednisone 1 mg/kg·d and examined with the Chi-square or Fisher exact test. P values were tapered for 3wk[1,15]. All the patients underwent a full <0.05 were considered statistically significant. ophthalmic examination, including visual acuity (VA), IOP, RESULTS slit-lamp examination of the anterior chamber, gonioscopy, Patient Data Fifty-six patients (67 eyes) underwent AGV implantation for uveitic glaucoma. All the patients underwent central corneal thickness, measurement of IOP, fundus surgery before Apr. 2012. The clinical characteristics including examination with special attention to optic disc parameters, age, sex, follow-up period, diagnosis, laterality, previous retinal nerve fiber layer (RNFL), and visual field (VF). surgeries, preoperative and last postoperative IOP, VA, number The study was approved by the Local Institutional Ethnics of medications used, and surgical history for each patient are Committee of the Second Affiliated Hospital of Anhui Medical summarized in Table 1. The average age at the time of surgery University and met the tenets of the Declaration of Helsinki. was 45.3±12.9 (range 24 to 65)y and mean follow-up time was The participants provided their written consent to participate in 53.3±8.5 (range 48 to 60)mo. Totally 31 (46.3%) eyes were this study. pseudophakic and 11 (16.4%) eyes were aphakic. Surgical Technique All AGV implant surgeries were performed In the present study, anterior uveitis was the common case, under retrobulbar anesthesia by the same surgeon, with the use which affected 52 (77.6%) eyes. The most of patients of a fornix-based conjunctival and Tenon’s capsule flap. The were concomitant with other diseases, 21 (31.3%) patients surgery involved a standard technique which was mentioned had ankylosing spondylitis and 16 (23.9%) patients were in the previous studies. Firstly, in order to expose a surgical HLA-B27 positive. Surgical histories may influence the field, the corneal traction suture was anchored at the peripheral success rate of the AGV implantation. Of 58 (86.6%) of the 67 cornea using 8-0 nylon. An AGV single-plate silicone eyes had previous ocular surgeries and 26 (38.8%) had failed implant (New World Medical Inc., Rancho Cucamonga, trabeculectomies with mitomycin C used in surgeries. CA, USA) was used in all patients. Secondly, a conjunctiva Surgical Success The qualified success rate was 98.5%, and Tenon’s capsule incision of approximately 10 mm were 95.5%, 89.6%, 83.6%, 76.1%, 70.1%, 65.7% and 61.2% at made circumferentially at 5 mm posterior from the limbus in 1, 3, 6, 12, 24, 36, 48 and 60mo by Kaplan-Meier survival the supratemporal quadrant, and the sub-Tenon’s space was analysis (Figure 1). undermined. The implant was primed by the injection of saline Intraocular Pressure Control The mean preoperative and solution through a 25-gauge blunt cannel. The body of the postoperative IOPs are summarized in Table 2. The mean implant was secured onto the sclera at 8 to 10 mm posterior preoperative IOP was 30.8±6.8 mm Hg and postoperative from the limbus with a 10-0 nylon suture. Paracentesis into IOPs were 9.9±4.1, 10.1±4.2, 10.9±3.7, 12.9±4.6, 13.8±3.9, the anterior chamber was made with a 23-gauge needle at 2 13.2±4.6, 12.3±3.5 and 13.1±3.7 mm Hg at 1, 3, 6, 12, 24, 36, mm posterior to the limbus.
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