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Intraocular Pressure Control After Implantation of an Ahmed JOCGP Ahmed10.5005/jp-journals-10008-1209 valve post failed trabeculectomy ORIGINAL ARTICLE Intraocular Pressure Control after Implantation of an Ahmed Glaucoma Valve in Eyes with a Failed Trabeculectomy 1Rui B Schimiti, 2Ricardo Y Abe, 3Carla M Tavares, 4Jose PC Vasconcellos, 5Vital P Costa ABSTRACT INTRODUCTION Aim: To evaluate the results of Ahmed glaucoma valve (AGV) The need to perform multiple and sequenced surgical in eyes with a failed trabeculectomy. procedures is a relatively common situation in refractory Materials and methods: This retrospective study evaluated glaucoma. Although trabeculectomy with mitomycin C 61 eyes with a failed trabeculectomy that underwent implanta- tion of an AGV due to uncontrolled intraocular pressure (IOP) is still the most popular surgical procedure, the number on maximal medical therapy. Success was defined as IOP of glaucoma implant surgeries has increased in recent ≤ 21 mm Hg (criterion 1) or 20% reduction in IOP (criterion 2) years, possibly because they provide filtering blebs closer with or without antiglaucoma medications. Persistent hypotony, to the equator, with benefits, such as lower risk of late loss of light perception, and reoperation for IOP control were endophthalmitis and good long-term intraocular pres- defined as failure. sure (IOP) control.1-3 The Baerveldt Glaucoma Implant Results: Mean preoperative IOP and mean IOPs at 6, 12, and 24 months were 21.93 ± 6.32 mm Hg (n = 61), 14.15 ± (AMO Inc, Irvine, CA, USA) (BGI) and the Ahmed 4.33 mm Hg (n = 59), 13.21 ± 4.44 mm Hg (n = 56), and glaucoma valve (AGV; New World Medical, Inc., Rancho 13.60 ± 3.27 mm Hg (n = 25) respectively. Mean number of Cucamonga, CA, USA) are the most common types of antiglaucoma medications preoperatively and at 6, 12, and devices used worldwide, and comparative studies have 24 months was 3.95 ± 0.85, 2.19 ± 1.38, 2.48 ± 1.44, and 2.40 ± 1.32 respectively. The reductions in the number of medi- demonstrated a lower incidence of severe complications, cations and IOP measurements were statistically significant but greater dependence on antiglaucomatous medication at all time intervals (p < 0.001, Wilcoxon signed rank test). for adequate IOP control with the latter.4-6 According to criterion 1, the Kaplan–Meier survival curve dis- Previous studies evaluating the performance of AGV closed success rates of 75% at 12 and 24 months. According to criterion 2, the success rates were 57% at 12 months and 55% included a very heterogeneous population of patients at 24 months. The most frequent complications were hyper- or groups with various types of secondary glaucomas, tensive phase (18%) and shallow anterior chamber (16.4%). such as neovascular, inflammatory, postkeratoplasty, or 7-16 Conclusion: The AGV may effectively reduce IOP in eyes that pediatric glaucoma. Studies that specifically measured had a failed trabeculectomy. the performance of this procedure in adults with primary Clinical significance: The AGV is an alternative in eyes with open angle glaucoma (POAG) and primary angle closure a failed trabeculectomy. glaucoma (PACG) that had a failed trabeculectomy were Keywords: Ahmed glaucoma valve, Glaucoma surgery, not found in the literature. The efficacy and safety of the Intraocular pressure, Retrospective study. AGV in this situation are not well established, and this How to cite this article: Schimiti RB, Abe RY, Tavares CM, information would be valuable when making surgical Vasconcellos JPC, Costa VP. Intraocular Pressure Control after decisions. Therefore, we conducted a study to evaluate Implantation of an Ahmed Glaucoma Valve in Eyes with a Failed Trabeculectomy. J Curr Glaucoma Pract 2016;10(3):97-103. the IOP control, the most common complications, and the risk factors related to surgical failure in eyes that Source of support: Nil had one or more failed trabeculectomies and required Conflict of interest: None an AGV implantation. 1Professor and Assistant, 2Postgraduate Student, 3Resident MATERIALS AND METHODS 4,5Professor Patient Selection 1Department of Ophthalmology, Pontifical University; Eye Hospital of Londrina (HOFTALON), Londrina, PR, Brazil This was a retrospective study evaluating patients with University of Campinas, São Paulo, Brazil one or more failed trabeculectomies who underwent 2-5Department of Ophthalmology, University of Campinas, São Paulo, Brazil implantation of an AGV (models S2 and FP7) due to uncontrolled IOP under maximal tolerated medical Corresponding Author: Rui Barroso Schimiti, Rua Jorge Velho 389, Londrina, PR, Brazil. CEP: 86010-160, Phone/Fax: therapy. Only patients with at least 1 year of follow-up 55(43)33223074, Mobile: 55(43)99953587, e-mail: ruioft@ were included in the study, unless failure occurred before sercomtel.com.br that period. All procedures were performed between Journal of Current Glaucoma Practice, September-December 2016;10(3):97-103 97 Rui B Schimiti et al January 2000 and November 2012. This study was at least 8 mm from the limbus. A 23-gauge needle was approved by the Ethics Committee of the University of used to enter the anterior chamber 1 mm posterior to the Campinas and adhered to the tenets of the Declaration of limbus, and viscoelastic (methylcellulose 2%) was injected Helsinki. Medical records were retrospectively reviewed before tube insertion. A rectangular donor scleral patch for preoperative and postoperative follow-up informa- graft (4 × 6 mm) was fashioned and sutured over the tion. At each visit during follow-up, subjects underwent tube using 10-0 nylon sutures. The conjunctiva was also a comprehensive ophthalmic examination, including secured with 10-0 nylon sutures. No antimetabolites were Snellen best corrected visual acuity, slit-lamp biomicros- used in the procedure. Follow-up visits were scheduled copy, Goldmann applanation tonometry, gonioscopy, and after 1 day; 3 days; 1 week; 2 weeks; 1, 3, 6, 12, 18, and dilated fundoscopy examination using a 78-diopter lens. 24 months. All patients received a standard regimen of topical antibiotic drops (moxifloxacin hydrochloride) qid, Outcome Measures discontinued after 2 weeks. Topical corticosteroids drops Outcome measures included IOP, visual acuity, number (prednisolone acetate ophthalmic suspension 1%) were of antiglaucoma medications, surgical success, and com- used initially six times daily and tapered gradually over plications. Surgical success was defined as (a) criterion 1: 8 to 10 weeks depending on the degree of inflammation. IOP ≤ 21 mm Hg with or without antiglaucoma medica- Glaucoma medications were prescribed according to IOP tions; and (b) criterion 2: 20% reduction of preoperative measurements and the severity of the disease. IOP with or without antiglaucoma medications. Statistical Analysis Persistent hypotony (IOP ≤ 5 mm Hg in at least two consecutive visits after 3 months of follow-up), loss Preoperative and postoperative IOP measurements of light perception, and reoperation for IOP control and number of medications were compared using the were also defined as failure. Flat anterior chambers Wilcoxon signed rank test. Cumulative survival rates were graded according to the classification proposed were calculated using Kaplan–Meier survival analysis. by Spaeth.17 An early hypertensive phase (EHP) was Cox proportional Hazards regression analysis with defined as an IOP greater than 21 mm Hg within the first forward stepwise elimination was used to assess poten- 2 months after surgery and after a reduction of IOP to tial predictors for surgical failure. We included variables less than 21 mm Hg had been achieved during the first previously listed as risk factors according to the litera- postoperative week. ture.5,6 The following variables were studied: Race, eye Early postoperative complications were defined as (right or left), glaucoma diagnosis, gender, preoperative those developing within 30 days after the procedure, IOP, previous glaucoma surgeries, preoperative glaucoma and late postoperative complications were defined as medications, preoperative use of oral acetazolamide, those that occurred after this period. Reoperation was interval between last surgery and implant, type of defined as any additional surgery requiring a return to implant, quadrant of valve implantation, and occurrence the operating room and was subdivided in reoperation of hypertensive phase in the postoperative period. Data for complication and reoperation for IOP control. analyses were performed using Statistical Package for We also evaluated the number of eyes that showed the Social Sciences (SPSS) version 19.0 (Inc., Chicago, IL). a significant visual acuity loss, defined as a reduction All reported probability values are two-tailed, and of two or more Snellen lines or category change from p < 0.05 was considered statistically significant. baseline (i.e., counting fingers to hand motion). RESULTS Surgical Technique A total of 61 eyes from 61 patients with one or more failed Surgeries were performed by one of three experienced trabeculectomies who underwent implantation of an attending glaucoma surgeons (JPV, RBC, VPC) or glau- AGV were enrolled in the study. Table 1 shows the clinical coma fellows under their direct surgical supervision. The and demographic characteristics of the subjects. Among AGV models used were the S2 (184 mm2 surface area) and the patients, 43 (70.5%) were Caucasian and 18 (29.5%) FP7 (184 mm2 surface area). All surgeries were performed were African-American; 55 patients (90.2%) had POAG, with peribulbar anesthesia. A fornix-based conjunctival and 6
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