Combined trabeculectomy with non-valved drainage implant under a single shared scleral flap: A novel approach to refractory glaucoma.

BackgroundTo describe a new technique and present its long-term outcome for prevention of Ahmed glaucoma valve (AGV) tube exposure in patients with refractory glaucoma.MethodsTwenty-seven eyes of 24 patients (mean age, 50 years; age range, 16–78 years; 8 females, 16 males) with refractory glaucoma who had the AGV implant were retrospectively reviewed. For AGV implantation, a long scleral flap combined with Tenon advancement and duplication was used. In this technique, a long scleral flap is created to completely cover the extraocular part of valve’s tube, and the flap surface is covered with duplicated Tenon’s tissue. The average follow-up after AGV implantation was 21.7 months (range, 12–36 months).ResultsThe mean intraocular pressure before the operation, which was 44.1 mmHg (range, 26–62 mmHg), decreased to 14.2 mmHg (range, 8–20 mmHg) at the last follow-up visit, showing 67% reduction with AGV implantation. The mean number of antiglaucomatous medications was 4.1 before the AGV implantation and decreased to 0.9 after the operation, showing 88% reduction. In 14 eyes (51.9%), there was no change in the best corrected visual acuity (BCVA), and in 11 eyes (40.7%), the BCVA increased by 2 lines on the Snellen chart postoperatively. No patient developed postoperative hypotony, flat anterior chamber, diplopia, strabismus, erosion or exposure of the tube, or tube/plate migration.ConclusionsThe long scleral flap augmented with Tenon advancement and duplication is an effective and safe surgical technique for the implantation of AGV and preventing tube exposure in cases of refractory glaucoma.

To report the safety and efficacy of combined trabeculotomy and trabeculectomy (CTT) in advanced primary developmental glaucoma with corneal diameter 14 mm or more. A total of 74 (121 eyes) consecutive patients aged 3 days-100 months (median, 10 months) with advanced developmental glaucoma were included. Primary CTT was performed by a single surgeon at a tertiary eye care centre in India over a 13-year period. The main outcome measures were changes in and final levels of intraocular pressure (IOP), corneal clarity, visual acuity, and refractive status. Mean preoperative IOP was 29.4+/-7.6 mmHg (range, 10-56 mmHg) and mean postoperative IOP was 15.5+/-6.6 mmHg (range, 6-38 mmHg) (P<0.0001) with percentage reduction of 44.5+/-27.1. Kaplan-Meier survival analysis revealed 3-, 6-, 9-, 12-, 24-, 48-, and 72-month success rates of 86.5, 80.5, 78.1, 75.5, 71.1, and 60.5%, respectively. Majority (80.5%) of the patients were myopes with mean spherical equivalent of 5.8+/-4.5D (range, 0.75-22.0D). Using various age-appropriate testing procedures, at the final follow-up visit, 14 patients (41.2%) had age-appropriate normal visual acuity and 20 patients (58.8%) had subnormal visual acuity. Best-spectacle-corrected visual acuity of > or =20/60 was achieved in seven patients (26.9%). There were no sight-threatening intraoperative and postoperative complications. CTT is safe and effective in patients with advanced primary developmental glaucoma. It offers good IOP control with a low complication rate, with about one-third of patients achieving a visual acuity of 20/60 or better.

To report the incidence, etiology, and risk factors for tube explantation in patients undergoing patch-free glaucoma drainage device (GDD). Of the total 1303 patients who underwent patch-free GDD (703 non-valved GDD and 600 valved GDD) for refractory glaucoma during January 2020-October 2023, we identified five cases of postoperative complications following GDD that required tube or shunt removal. Median (IQR) age of our study cohorts was 54.5 (8-66) years. The incidence of tube exposure and tube explantation was 0.003% and 0.004%, respectively. The median time interval for tube or plate explantation from the time of GDD surgery was 11.5 (2-16) months. The diagnoses of refractory glaucoma for which GDD was performed were secondary glaucoma following multiple vitreoretinal (VR) surgery (60%), primary open-angle glaucoma (20%), and aphakic glaucoma (20%). Of these, two patients (40%) presented with recurrent tube exposures, two patients (40%) with tube exposure and early endophthalmitis, and one patient (20%) with persistent hypotony. Four patients (80%) had undergone non-valved Aurolab aqueous drainage implant and one underwent (20%) Ahmed glaucoma implant. Three patients (60%) had diabetes mellitus with a history of multiple VR surgical intervention. GDD explantation was done in three patients (60%), and the remaining two patients (40%) required only tube amputation. One patient presented with orbital cellulitis, and there was no culture growth seen in any of our study cohorts. Tube and plate exposures pose a significant risk for potential infections and warrant prompt explantation of GDD to avoid endophthalmitis. Previous history of multiple VR surgeries, diabetes mellitus, and non-valved implants were the common risk associations noted for tube exposures in our retrospective study.

&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Introduction and Objectives: Glaucoma drainage device is widely used in glaucoma surgery. Ahmed Glaucoma Valve (AGV) implant is one of the most used glaucoma drainages with a low incidence of complication. This study aimed to evaluate the outcomes and complication of Ahmed Glaucoma valve implantation in patients with refractory glaucoma at Dr Yap Eye Hospital &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Methods: Medical records of 30 patients (30 eyes) who had AGV implant surgery at Dr Yap Eye Hospital from January 2014 to October 2016 were reviewed. Pre-operative data include age, gender, eye laterality, type of glaucoma, visual acuity, and intraocular pressure and. The IOP, visual acuity (VA), and complications were measured at day 2, day 7, 1 month, 3 months, and 6 months. The postoperative complications were documented. &#x0D; Results: The mean IOP at baseline was 45.78 ± 13.04 mmHg, decreased after the operation to 14.41 ± 9.86 mmHg at day- 2 and 17.6 ± 14.6 mmHg at 6 months follow up. The mean initial VA was 2.47 ± 0.56 and unchanged 2.4 ± 0.74, at last, follow up. Early postoperative complications (0-3mos) were flat anterior chamber (4 eyes, 13%), hyphema (4 eyes, 13%), and tube exposure (4 eyes, 13%). The late postoperative complication (after 3 mos) was tube exposure (1 eye, 3%), bullous keratopathy (1 eye, 3.3%), and dislocation of the implant (1 eye, 3.3%). The rang of tube exposure onset was 49-235 days (mean 99.5 ± 90.54 days) after implantation. Flat anterior chamber and hyphema could be successfully managed conservatively while tube exposure needed surgical repair. Three cases of tube exposure required explantation. Endophthalmitis was detected in one case of tube exposure. &#x0D; Conclusion: AGV implantation appears to be a safe and effective surgical option in patients with refractory glaucoma. &#x0D; &#x0D; &#x0D;

The purpose of this study was to report a rare case of late-onset subconjunctival abscess associated with an unexposed Ahmed glaucoma valve implant secondary to Serratia marcescens, a rare conjunctival pathogen. Case description including clinical imaging and literature review of glaucoma drainage device (GDD)-related infections. A 73-year-old man presented with blurring of vision, redness, and pain on his right eye 2 months after Ahmed glaucoma valve implantation for advanced postpenetrating-keratoplasty glaucoma. The patient was nonsmoker, had fairly controlled type 2 diabetes mellitus on insulin, and had undergone multiple eye surgeries on the right eye. On ocular examination, the conjunctiva was injected with fairly delineated yellowish-white subconjunctival material in the superotemporal quadrant with no associated tube exposure or leak, and the anterior chamber was quiet. The patient was assessed with Ahmed glaucoma valve infection with subconjunctival abscess and was treated by Ahmed glaucoma valve explant with directed systemic and topical antimicrobial therapy. The culture and sensitivity results revealed S. marcescens sensitive to ciprofloxacin, ceftazidime, gentamicin, and amikacin. Despite the virulence of the pathogen, the eye was saved. Ahmed glaucoma valve infection with subconjunctival abscess secondary to S. marcescens is rare. GDD-related infections should be suspected in patients presenting with blurring of vision, pain, and redness even in the absence of tube exposure. Early diagnosis and treatment with culture-guided antimicrobial therapy combined with GDD explant is fundamental in optimizing the visual outcome.

A clinical study of the Ahmed glaucoma valve implant in advanced glaucoma

Purpose:To evaluate the results and extrusion rates of the Ahmed glaucoma valve (AGV) implantation through a needle-generated scleral tunnel, without a tube-covering patch, in children.Materials and Methods:A retrospective review of the charts of 106 Mexican children implanted with 128 AGVs operated between 1994 and 2002, with the needle track technique, at our institution, with at least six months follow up was done. Main outcome measures were intraocular pressure (IOP) control, tube extrusions or exposure and other complications.Results:Kaplan-Meier analysis demonstrated a 96.9% survival rate at six months, 82.4% at one year, 78.7% at two years, 70% at three years and 41.6% at four years. Total success at the last follow-up (IOP between 6 and 21 mm Hg without medications) was achieved in 30 eyes (23.5%), 58 eyes (45.3%) had qualified success (only topical hypotensive drugs) and 40 eyes (31.3%) were failures. The mean pre- and post-operative IOP at the last follow up was 28.4 mmHg (SD 9.3) and 14.5 mmHg (SD 6.3), respectively. No tube extrusions or exposures were observed. Tube-related complications included five retractions, a lens touch and a transitory endothelial touch. The risk of failure increased if the eye had any complication or previous glaucoma surgeries.Conclusion:Medium-term IOP control in Mexican children with glaucoma can be achieved with AGV implantation using a needle-generated tunnel, without constructing a scleral flap or using a patch to cover the tube. There were no tube extrusions, nor any tube exposures with this technique.

Purpose:To report a complication pertaining to subconjunctival bevacizumab injection as an adjunct to Ahmed Glaucoma Valve (AGV) implantation.Case Report:A 54-year-old woman with history of complicated cataract surgery was referred for advanced intractable glaucoma. AGV implantation with adjunctive subconjunctival bevacizumab (1.25 mg) was performed with satisfactory results during the first postoperative week. However, 10 days after surgery, she developed wound dehiscence and tube exposure. The second case was a 33-year-old man with history of congenital glaucoma and uncontrolled IOP who developed AGV exposure and wound dehiscence after surgery. In both cases, for prevention of endophthalmitis and corneal damage by the unstable tube, the shunt was removed and the conjunctiva was re-sutured.Conclusion:The potential adverse effect of subconjunctival bevacizumab injection on wound healing should be considered in AGV surgery.

To report a case of recurrent Ahmed glaucoma valve (AGV) tube exposure dueto scleral patch graft (SPG) melt Background: AGV is a useful modality in the management of medically refractory glaucoma. Human donor SPG has been employed to cover the external portion of the tube to prevent its exposure. A 23 year old male with Anterior chamber intraocular lens (ACIOL)had undergone retinal detachment (RD) surgery with silicone oil insertion (SOI)followed by SO removal (SOR), re- RD and SO re-injection, followed by implantation of Ahmed glaucoma valve (AGV) for uncontrolled glaucoma in the right eye. Three months after the AGV implantation, he presented with exposure of the subconjuctival portion of AGV tube with melted, displaced and shrunk donor sclera graft, which was managed by placing larger sized, full thickness, donor scleral patch graft (SPG) over the exposed tube. Six months later, he presented again with tube exposure and the donor SPG was found to be retracted nasally and shrunk to one fourth of its original size. The AC portion of the tube was blocked by the SO bubble and the emulsified SO could be seen inside the exposed tube. The patient underwent SOR with tube explanation and intraocular pressure was later controlled with transscleral cyclophotocoagulation and medical management. SPG thinning and the overlying conjunctival erosion can occur after the AGV implantation. This can cause AGV tube exposure and hence, long - term patient follow up is essential to ensure timely identification of this possible complication and prompt treatment.

Purpose:To study the safety and efficacy outcomes of Micropulse Transscleral Cyclophotocoagulation (MP-TSCPC) as a primary versus additional therapy in eyes with uncontrolled glaucoma.Methods:This was a prospective, interventional, comparative study. All patients with advanced and refractory glaucoma treated with MP-TSCPC from April 2020 to December 2020 were recruited in this study.Results:A total of 77 eyes of 77 patients were analyzed. Group A (n = 33), included patients with advanced glaucoma at high risk for invasive surgery, who underwent MP-TSCPC as the primary intervention, and group B (n = 44) included patients who had undergone previous surgical intervention and MP-TSCPC was used additionally to control the intraocular pressure (IOP). Mean IOP and mean number of antiglaucoma medications were 34.06 (13.9) mmHg and 3.64 (0.7), respectively, in group A and 35.61 (11.5) mmHg and 3.73 (0.9), respectively, in Group B. Postoperatively, the mean IOP and percentage of IOP reduction were significantly lower at 1, 3, and 6 months, that is, 20.78 (32%), 22.07 (30%), and 19.09 (37%), respectively, in group A and 23.68 (35%), 19.50 (44%), and 19.61 (42%), respectively, in group B, but there was no difference between the groups at all visits. Postoperative need for ocular hypotensive drugs did not differ in group A (P = 0.231); however, it was significantly lower in group B (P = 0.027). Group A had 87%, 77%, and 74% success rates at 1, 3, and 6 months, respectively, whereas group B had 91%, 86%, and 77% success rates at 1, 3, and 6 months, respectively. Postoperative complications and intervention did not reveal any statistical difference between the two groups.Conclusion:MP-TSCPC may be considered as a temporizing measure both as a primary or as an additional intervention to control the IOP in eyes with refractory and advanced glaucoma that have a high risk of vision-threatening complications with invasive surgery.

To present and compare the long-term results of Dr. Tamcelik's previously described technique of Tenon advancement and duplication with the conventional Ahmed glaucoma valve (AGV) implantation technique in patients with refractory glaucoma. This study was a multicenter, retrospective case series that included 303 eyes of 276 patients with refractory glaucoma who underwent glaucoma valve implantation surgery. The patients were divided into three groups according to the surgical technique applied and the outcomes compared. In group 1, 96 eyes of 86 patients underwent AGV implant surgery without patch graft; in group 2, 78 eyes of 72 patients underwent AGV implant surgery with donor scleral patch; in group 3, 129 eyes of 118 patients underwent Ahmed valve implant surgery with "combined short scleral tunnel with Tenon advancement and duplication technique". The endpoint assessed was tube exposure through the conjunctiva. In group 1, conjunctival tube exposure was seen in 11 eyes (12.9 %) after a mean 9.2 ± 3.7 years of follow-up. In group 2, conjunctival tube exposure was seen in six eyes (2.2 %) after a mean 8.9 ± 3.3 years of follow-up. In group 3, there was no conjunctival exposure after a mean 7.8 ± 2.8 years of follow-up. The difference between the groups was statistically significant. (P = 0.0001, Chi-square test). This novel surgical technique combining a short scleral tunnel with Tenon advancement and duplication was found to be effective and safe to prevent conjunctival tube exposure after AGV implantation surgery in patients with refractory glaucoma.

Primary Congenital Glaucoma in the Developing World

Purpose: To evaluate the efficacy of long scleral tunnel technique used in Ahmed glaucoma valve (AGV) implantation in preventing tube exposure through conjunctiva. Materials and Methods: Patients of adult age, who were unresponsive to maximum medical treatment and underwent AGV implantation, were divided into two groups and investigated retrospectively. Group 1 consisted of 40 eyes of 38 patients that underwent surgery by long scleral tunnel technique and Group 2 consisted of 38 eyes of 35 patients that underwent implantation by processed pericardium patch graft method. Results: The mean age was 54.8 ± 14.6 years (range 26–68 years) and the mean follow-up duration was 46.7 ± 19.4 months (range 18–76 months) for the patients in Group 1, whereas the mean age was 58.6 ± 16.7 years (range 32–74 years) and mean follow-up period was 43.6 ± 15.7 months (range 20–72 months) for the patients in Group 2 (p > 0.05). In the course of follow-up, tube exposure was detected in one (2.5%) eye in Group 1 and in three (7.9%) eyes in Group 2 (p = 0.042). Conclusion: Long scleral tunnel technique is beneficial in preventing conjunctival tube exposure in AGV implantation surgery.

Objective To compare between the surgical outcomes of Tenon capsule grafting and autologous scleral graft in Ahmed glaucoma valve (AGV) surgery in the management of refractory glaucoma and prevention of tube exposure. Patients and Methods. This prospective randomised study included 30 eyes of 30 patients with refractory glaucoma, who were aged between 46 and 58 years and diagnosed with refractory glaucoma. This study was conducted in Menofia University Hospital between July 2018 and December 2019. Informed patient consent was obtained. The studied eyes were divided into two groups: the first group included 15 eyes for which AGV with Tenon capsule grafting was performed, while the second group included 15 eyes for which AGV with autologous scleral graft was performed. All patients were followed up for one year after the surgery. The outcomes were evaluated according to intraocular pressure (IOP) and the number of postoperative glaucoma medications. Visual acuity, visual field, number of postoperative glaucoma medications, and postoperative complications were followed throughout the 1-year follow-up period. Results There was a significant reduction in IOP in both groups, with more reduction in the Tenon graft group where the mean IOP after one year was 11.66 ± 0.89 mmHg, whereas in the scleral graft group, the mean IOP was 14.20 ± 4.0 mmHg (p value < 0.001). However, the difference between the 2 groups in lowering IOP was insignificant. Regarding postoperative complications, tube exposure was observed in one case in the scleral graft group with associated scleral melting and hypotony, postoperative hypotony was more in the scleral graft group with 3 cases (20%), and in the Tenon graft group, hypotony occurred only in 1 case (6.67%). In addition, less vascular blebs were seen in most cases in the Tenon graft group, while most blebs seen in the scleral graft group were vascular blebs. In addition, both groups showed stability in terms of visual acuity and visual field. Conclusion Tenon capsule grafting and autologous scleral grafting might be effective and safe techniques when applied with AGV in the management of refractory glaucoma. Tenon capsule resection with grafting showed relatively low incidence of tube exposure and hypertensive phase.

This study was conducted to report the safety and efficacy of pars plana-modified Ahmed Glaucoma Valve PS2 in advanced secondary glaucoma. We performed a prospective, interventional case series that included patients with advanced secondary glaucoma and uncontrolled intraocular pressure (IOP). Eleven eyes of nine patients with aphakic, neovascular, traumatic, inflammatory and pseudoexfoliation glaucoma were included. All patients had pars plana vitrectomy before tube insertion. One year after surgery, IOP was controlled (21 mmHg or less) in ten of 11 eyes (91%), seven (64%) did not need medical antiglaucoma therapy. Average IOP decreased from 32.2 +/- 8.3 mmHg before surgery to 15.7 +/- 7.7 mmHg postoperatively (P < 0.0001). The average number of topically used medications used decreased from 2.9 +/- 1.2 to 0.545 +/- 0.78 (P < 0.0001). Complications included transient hypotony (three eyes-two of them without tube ligature), transient choroidal effusion (three eyes) and an intermediate increase in IOP (seven eyes). Tube exchange was performed in one eye and needling/bleb excision in two patients. Pars plana-modified Ahmed Valve implantation is effective and safe in advanced glaucoma. Partial ligature of the tube is necessary to prevent early hypotony. Close follow-up of patients is needed to monitor variations of IOP within the first year.