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The Ahmed Glaucoma Valve in Refractory Glaucoma

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The Ahmed Glaucoma Valve in Refractory Glaucoma Eye (2005) 19, 183–190 & 2005 Nature Publishing Group All rights reserved 0950-222X/05 $30.00 www.nature.com/eye The Ahmed JC Das, Z Chaudhuri, P Sharma and S Bhomaj CLINICAL STUDY Glaucoma Valve in Refractory Glaucoma: experiences in Indian Eyes Abstract Eye (2005) 19, 183–190. doi:10.1038/sj.eye.6701447 Published online 16 July 2004 Purpose To evaluate the efficacy of the Ahmed Glaucoma Valve implant in refractory Keywords: Ahmed Glaucoma Valve; refractory glaucomas in Indian eyes. glaucoma; intraocular pressure; aqueous Materials and methods A retrospective drainage devices review was conducted on the charts of 122 eyes of 122 patients with refractory glaucoma treated with Ahmed Glaucoma Valve implant placement at Guru Nanak Eye Centre, New Introduction Delhi between January 1996 and December 1999. The main outcome measure was success Aqueous drainage devices (ADD) have now at the last follow-up. Success was defined as assumed an important place in our surgical Guru Nanak Eye Centre an intraocular pressure (IOP) of 22 mmHg or armamentarium for the treatment of New Delhi 110 002, India less and 5 mmHg or more and at least a 30% complicated and refractory glaucomas both as a reduction in IOP without visually devastating primary surgical modality1–3 and as a secondary Correspondence: complications or additional glaucoma surgery. procedure where trabeculectomy with or Z Chaudhuri, E-310, Purvasha, Anand Lok The mean postoperative IOP Results without adjunctive antimetabolite therapy has Society Mayur Vihar Phase-1 7 (17.29 3.79 mmHg) was significantly either failed or is reported to have a very low New Delhi 110091, India (Po0.001) lower than the mean preoperative chance of success. 1,4–10 The latter group consists Tel: þ 91 011 22759613 IOP (31.4777.86 mmHg) at last follow up of paediatric glaucomas,11–18 neovascular Fax: þ 91 011 22792342 (mean 12.5178.37 months; range 3–24 months). glaucomas,19 and a variety of glaucomas Email: drzia@ bol.net.in, The cumulative probability of success by associated with low success after filtration ziachaudhuri@ 20–22 Kaplan – Meier analysis was 85.95% at 12 surgery in conditions such as uveitis, hotmail.com months and 82.83% at 24 months. The mean aphakia,23 pseudophakia,23 post-vitreoretinal number of postoperative antiglaucoma surgery,23–24 and postpenetrating Received: October 2003 medications (0.7570.80) was also significantly keratoplasty25–28 surgery. Accepted: 29 December lower (Po0.001) than the mean preoperative Glaucoma drainage implants that have been 2003 Published online: 16 July number of antiglaucoma medications used extensively include the nonrestrictive 2004 (2.83 þ 0.72). The most common complication glaucoma drainage devices like Molteno was corneal-tube contact, which occurred in implant, the Baerveldt implant and the Schocket The above study was five (4.10%) eyes. Retinal detachment occurred tube shunt, and the valved, restrictive drainage conducted in Guru Nanak postoperatively in one eye with the clinical devices like the Krupin Denver Valve and the Eye Centre, Maulana Azad Medical College, University diagnosis of neovascular glaucoma secondary 1 Ahmed Glaucoma Valve implants. A glaucoma of Delhi, New Delhi, India. to Eale’s disease. Two patients had tube drainage device with a valve is designed to No grants or sponsorships extrusion requiring repositioning and reduce the incidence of postoperative hypotony have been requisitioned for reinforcement with scleral patch graft. although the final outcome in terms of long this study. The authors do Conclusions Ahmed Glaucoma Valve term reduction in the intraocular pressures not have any proprietary or financial interest in any implantation is an effective and relatively safe (IOPs) has been found to be better with the product or procedure 7 therapy for the treatment of refractory nonvalved devices in some studies. This study mentioned in this glaucoma in Indians. describes our clinical experiences with the manuscript AGV in refractory glaucoma JC Das et al 184 Ahmed Glaucoma Valve implant in Indian eyes with Merseline posterior to the insertions of the rectus muscles glaucoma that was refractory to conventional medical/ with the anterior edge of the explant at least 8 mm laser and surgical treatment. posterior to the limbus. These sutures were applied to prevent the migration of the plate and therefore of the tube. The tube was trimmed to extend from 1 to 3 mm Materials and methods beyond the posterior surgical limbus. Before inserting the A retrospective analysis of 122 eyes of 122 patients with tube into the anterior chamber a 6 Â 8mm2 rectangular glaucoma uncontrolled by medications and previous partial thickness, limbus-based scleral flap was dissected. glaucoma laser/surgical interventions, undergoing A paracentesis opening was made at the limbus in the glaucoma surgery with the Ahmed Glaucoma Valve inferotemporal quadrant with a sharp tapered blade, and implant (model S-2 with surface area of 185 mm2, New viscoelastic agent (sodium hyaluronate 1.4%) was used to World Medical Inc. , Rancho Cucamonga, CA, USA) at deepen the anterior chamber. A 23-gauge needle was the Glaucoma Services Centre, Guru Nanak Eye Centre, used to enter the posterior surgical limbus parallel to the New Delhi between January 1996 and December 1999 iris plane and the anterior chamber in the was performed. Only one surgeon (JCD) performed all superotemporal quadrant. If a peripheral iridectomy was the surgeries. In the present study group, there were no present from a previous surgery, the needle tract was patients in whom the Ahmed Valve was implanted as a placed slightly to one side of the iridectomy. This primary procedure irrespective of the clinical diagnosis. modification in technique, with reference to the method Documentation of the following information was described in the literature,4,5 was made due to the lack of carried out for each patient regarding: age, gender, easy availability of donor corneoscleral grafts in our detailed clinical history along with general physical, and hospital set-up. In patients with aphakic and systemic examination; a comprehensive ocular pseudophakic glaucoma who had vitreous in the anterior examination including quantitative recording of best chamber, an anterior vitrectomy was performed prior to corrected visual acuity (BCVA) wherever possible using tube placement. The tube was inserted with a smooth Snellens charts (in paediatric patients in the age group of forceps through the needle tract ensuring that no iris or 3–5 years who were unable to read the Snellens chart, corneal touch was present. The tube was then secured standard HOTV optotypes at 3 m were used to record the against the sclera using a figure of eight suture of 9-0 visual acuity), a thorough anterior and posterior segment nylon. The scleral flap was approximated at the two examination, IOP measurement with Goldmann posterior corners with a 10-0 nylon suture. Two running applanation tonometer or Perkins tonometer (for sutures of 8-0 polyglactin (vicryl) were used to secure the paediatric patients); and gonioscopy with a Goldmann conjunctiva and Tenon layers to peripheral cornea and to single mirror gonioprism, measurement of anterior close the two wing incisions, respectively. The anterior chamber depth by ultrasound ‘A’ scan technique using chamber was then deepened with balanced salt solution the Humphrey biometer (model 820 REV.G), and and the viscoelastic was reaspirated as much as possible recording of visual fields using automated perimetry by via the paracentesis opening. Subconjunctival injections Humphrey field analyser (model HFA II 750-5751-A10.1) of antibiotics and corticosteroids were given at the wherever possible. conclusion of surgery. We used viscoelastics to deepen the chamber as a corollary to the modification in our surgical technique. Surgical method Owing to the frequent nonavailability of donor The Ahmed Glaucoma Valve implantation procedure corneoscleral grafts in our hospital set-ups, we inserted was performed under peribulbar anaesthesia in adults the Ahmed valve tube after dissecting out a partial and under general anaesthesia in paediatric patients. The thickness scleral flap (like a trabeculectomy flap). Under conjunctiva was undermined posteriorly by blunt the assumption that the partially dissected scleral bed dissection in the superotemporal quadrant, in all cases to would also act as a sieve for the egression of the aqueous create a winged fornix-based conjunctival flap. A traction resulting in greater hypotony, we deepened the anterior suture was passed under the belly of superior rectus and chamber with viscoelastics while performing the lateral rectus and the globe was rotated as convenient to procedure and with BSS subsequently as mentioned the surgeon. The Ahmed Glaucoma Valve implant was above. irrigated with 2 ml of balanced saline solution (BSS, Postoperatively, all patients were put on topical Alcon, Fort Worth, USA) through the tubing to open the antibiotic-steroid drops, which was tapered slowly over valve mechanism. the course of 4–8 weeks. Antiglaucoma medications were The plate was then secured to the superficial sclera removed or added as per the IOP and the clinical status using two interrupted nonabsorbable sutures of 5-0 of the operated eye. All eyes were examined at 1 day, 1 Eye AGV in refractory glaucoma JC Das et al 185 week, 2 weeks, 1 month, 3 months, 6 months (or more Table 1 Demographics of patient population studied often if clinically indicated), and then periodically at No approximately 1–3 month intervals, depending on the patient’s IOP and clinical status up to at least 1 year after Age in years, mean7SD (n ¼ 122 patients) 44.40724.02 surgery. All the parameters studied for the preoperative No. of paediatric patients (o12 years) 30 Gender (n ¼ 122 patients) evaluation were documented on each follow-up Male 60 wherever possible and decisions to start postoperative Female 62 antiglaucoma medications or to perform other surgeries Glaucoma diagnosis (n ¼ 122 eyes) were taken accordingly.
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