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Comparison of Surgical Outcomes of Trabeculectomy, Ahmed Shunt, and Baerveldt Shunt in Uveitic Glaucoma Audrey Chow1, Bruce Burkemper1, Rohit Varma1, Damien C

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Comparison of Surgical Outcomes of Trabeculectomy, Ahmed Shunt, and Baerveldt Shunt in Uveitic Glaucoma Audrey Chow1, Bruce Burkemper1, Rohit Varma1, Damien C Chow et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:9 Journal of Ophthalmic https://doi.org/10.1186/s12348-018-0150-y Inflammation and Infection ORIGINALRESEARCH Open Access Comparison of surgical outcomes of trabeculectomy, Ahmed shunt, and Baerveldt shunt in uveitic glaucoma Audrey Chow1, Bruce Burkemper1, Rohit Varma1, Damien C. Rodger2, Narsing Rao1 and Grace M. Richter1* Abstract Background: Uveitis is defined as a collection of syndromes involving intraocular inflammation which can lead to pain, tissue damage, and vision loss. Ophthalmic surgery in uveitis patients can be challenging due to inflammation-induced fibrosis and scarring. Trabeculectomy and implantation of glaucoma drainage devices (aqueous shunts) have been used in surgical management of uveitic glaucoma, however there is a paucity of literature examining the comparative results of these entities in this unique setting. The purpose of this retrospective comparative study is to compare clinical outcomes of trabeculectomy with MMC, Ahmed shunt, and Baerveldt shunt surgery specifically in uveitic glaucoma. Results: Median IOP, IOP reduction, glaucoma medication use, and visual acuity at 6- and 12-month follow-up were similar across groups. Postoperative hypotony rate was significantly different across trabeculectomy (53%), Baerveldt (24%), and Ahmed (18%) groups (p = 0.027); other complication rates were similar. Baerveldt eyes had a lower failure rate compared to trabeculectomy (p = 0.0054) and Ahmed (p = 0.0008) eyes. Conclusions: While there was no difference in IOP reduction between trabeculectomy, Ahmed, and Baerveldt, Baerveldt eyes had the lowest failure rate. Keywords: Glaucoma, Uveitis, Trabeculectomy, Ahmed, Baerveldt, Aqueous shunt Background However, surgical intervention may be indicated if intra- Uveitis is defined as a collection of syndromes involving ocular pressure (IOP) cannot be adequately controlled intraocular inflammation which can lead to pain, tissue by medications alone. These procedures include trabecu- damage, and vision loss [1, 2]. With an estimated lectomy and implantation of glaucoma drainage devices 109,000 cases of uveitis in the USA and 43,000 new (aqueous shunts). Two types of aqueous shunts are the cases a year, it is the third leading cause of preventable valved Ahmed shunt and the non-valved Baerveldt shunt blindness in the developed world [3]. Twenty percent of [5]. Previous studies have separately demonstrated that patients with uveitis develop glaucoma due to inflamma- trabeculectomy, Ahmed shunt, and Baerveldt shunt are tion or secondary to corticosteroid treatment of uveitis all reasonably effective in controlling uveitic glaucoma [2–4]. In uveitic glaucoma, elevated intraocular pressure [6–9]. Prior literature suggests that while trabeculectomy results from increased resistance to aqueous outflow and has good outcomes in uveitic glaucoma in the short can lead to irreversible optic nerve damage and eventual term, the risk of failure is relatively high in the long term blindness [3]. [6, 10–12]. Bettis et al. compared the outcomes of trabe- Ophthalmic surgery in uveitis patients can be challen- culectomy with mitomycin C (MMC) and Ahmed valve ging due to inflammation-induced fibrosis and scarring. implantation and found that the Ahmed device was more effective than the trabeculectomy in uveitic eyes * Correspondence: [email protected] [13]. Iverson et al. showed that the non-valved Baerveldt 1Department of Ophthalmology, USC Roski Eye Institute, Keck Medicine of device was also likely better than the trabeculectomy University of Southern California, 1450 San Pablo Street, Suite 4700, Los Angeles, CA 90033, USA with MMC in controlling uveitic glaucoma [14]. Be- Full list of author information is available at the end of the article tween the Ahmed and Baerveldt shunts, both the © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Chow et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:9 Page 2 of 10 Ahmed Baerveldt Comparison Study (ABC) and the topical anti-inflammatory medications. Forty-eight per- Ahmed Versus Baerveldt Study (AVB) found that Baer- cent of patients were on systemic glaucoma medications, veldt patients had lower failure rates and lower median and 14% were on immunosuppressive medications. The postoperative IOP but experienced more early postoper- median visual acuity was 0.7 (0–3) logMAR units. 110/147 ative complications, namely, hypotony [15–18]. How- (75%) of patients had prior eye surgery, 22 of which had ever, these studies examined patients with glaucoma of a prior glaucoma filtering surgery. Fifty-nine percent eyes broad range of etiologies, not uveitic glaucoma specific- were pseudophakic with no significant difference in the ally. Hypotony is especially relevant to uveitis where proportion of pseudophakia across groups (p =0.96).Fif- there is an increased risk of postoperative hypotony due ty-eight percent of the eyes had idiopathic uveitis. to ciliary body inflammation and shutdown [4]. The The most common uveitis location in all groups was Ahmed valve relies on the Venturi effect to open the anterior uveitis (n = 127), and the most common valve for fluid outflow by facilitating a pressure differen- known etiologies were herpes simplex virus (n = 18), tial when the pressure within the eye reaches an upper uveitis-glaucoma-hyphema syndrome (n =9), and threshold (8–12 mm). The tension on the membranes Vogt-Koyanagi syndrome (n = 6). Other etiologies in- within the valve is responsible for reducing hypotony cluded sarcoidosis, birdshot, ankylosing spondylitis, due to overfiltration [19–21]. In the setting of low aque- juvenile rheumatoid arthritis, rheumatoid arthritis, ous production, theoretically, the Ahmed valve has this syphilis, Posner-Schlossman syndrome, Fuch’s hetero- additional mechanism in place to reduce hypotony, chromic iridocyclitis, parasite, human leukocyte anti- whereas the Baerveldt does not. While the risk of hypot- gen B27, and tuberculosis. ony due to overfiltration would be lower with the As shown in Table 2, at 6-month follow-up, median Ahmed, there would still be hypotony if there were sig- IOP was reduced from 34 (23–50) to 10 (1–25) mmHg nificant aqueous underproduction. in the trabeculectomy group, 40 (26–58) to 16 (8–28) Direct comparison of outcomes of trabeculectomy mmHg in the Ahmed group, and 33 (19–85) to 12 (5–33) with MMC, Ahmed, and Baerveldt surgery in uveitic pa- mmHg in the Baerveldt group (p =0.015). Further, tients is yet to be reported. The purpose of this retro- pairwise comparison showed that Ahmed IOP at spective comparative study is to compare clinical 6 months was significantly higher than that of trabecu- outcomes of these entities specifically in the setting of lectomy (p = 0.02) and of Baerveldt (p = 0.0086), while uveitic glaucoma. We hypothesized that trabeculec- there was no significant difference between trabeculect- tomies would have poorer outcomes than aqueous omy and Baerveldt (p = 0.32). Both the point and per- shunts due to persistent inflammation and postoperative cent IOP reduction in trabeculectomy (22 (11–47) scarring. Additionally, considering the increased risk hy- mmHg, 69% (41–97)), Ahmed (24 (7–40) mmHg, 65% potony in uveitic patients, we predicted that the valved (21–81)), and Baerveldt (21 (5–75) mmHg, 64% (40–89)) Ahmed shunt would have lower rates of hypotony than groups were similar (p = 0.56). The median number of the non-valved Baerveldt shunts in patients with uveitic postoperative topical glaucoma medications was 0 (1–3) glaucoma. in the trabeculectomy group, 2 (0–4) in the Ahmed group, and 2 (0–4) in the Baerveldt group (p =0.098).Theper- Results and discussion centage of patients on systemic glaucoma medications A total of 147 eyes from 147 patients that met the study postoperatively was 6% in the trabeculectomy group, criteria were identified and reviewed. Seventeen eyes (17 9% in the Ahmed group, and 6.5% in the Baerveldt patients) underwent trabeculectomy with MMC, 22 eyes group (p = 0.86). Topical glaucoma, anti-inflammatory, (22 patients) underwent Ahmed implantation, and 108 systemic glaucoma, immunosuppressive medication eyes (108 patients) underwent Baerveldt implantation. use, change in visual acuity, and rate of follow-up One trabeculectomy, 11 Baerveldt, and 2 Ahmed eyes cataract surgery were similar in all groups. also underwent combined procedures with cataract ex- Outcome measures at 12-month follow-up are shown traction with intraocular lens implant at the time of in Table 3. At that time point, there was no significant glaucoma surgery. A total of 15 eyes underwent cataract difference in absolute IOP (p = 0.19), point IOP reduc- surgery during the follow-up period. tion (p = 0.62), or percent IOP reduction (p = 0.76) Patient baseline demographics and ocular characteristics across groups. Median IOP, point IOP reduction, and are summarized in Table 1. There were no significant dif- percent IOP were 10 (5–38) mmHg, 22 (10–39) ferences in these entities across groups. The median age mmHg, and 69 (36–82)%, respectively, in the trabecu- of the study population was 62 years (19–96); 57% of the lectomy group; 14 (6–27) mmHg, 24 (11–46) mmHg, study population were female, and 14% were diabetic. The 67 (29–86)%, respectively, in the Ahmed group; and 12 median IOP before surgery was 35 mmHg (19–85) on (4–38) mmHg, 21 (8–76) mmHg, and 65 (38–89)%,re- four (0–5) topical glaucoma medications and one (0–3) spectively, in the Baerveldt group. The median number of Chow et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:9 Page 3 of 10 postoperative topical glaucoma medications was 0 (0–4) overall. The odds ratio for Ahmed versus trabeculectomy in the trabeculectomy group, 2 (0–4) in the Ahmed group, failure was 1.22 (95% CI 0.28–5.26).
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