Abstract
PurposeTo assess the efficacy and survival rate of the Trabectome-mediated ab interno trabeculectomy combined with non-fenestrated Baerveldt glaucoma implant compared with the Baerveldt glaucoma implant alone.Methods In this retrospective comparative case series, 175 eyes undergoing primary glaucoma surgery (Baerveldt–Trabectome [BT] group: 60 eyes and Baerveldt [B] group: 115 eyes) were included. Participants were identified using the procedural terminology codes. Groups were then matched by Coarsened Exact Matching that resulted in the inclusion of 51 eyes in each group. The primary outcome measure was surgical success defined as 5 mmHg intraocular pressure (IOP) 21 mmHg, and IOP reduction 20% from baseline, and no need to reoperation for glaucoma. Secondary outcome measures were IOP, number of glaucoma medications, and best-corrected visual acuity (BCVA).Results The cumulative probability of success at one year was 61% in the BT group and 50% in the B group. IOP decreased from 23.5 2.4 mmHg at baseline to 14.1 2.7 mmHg at the final follow-up in the BT group (P = 0.001). The corresponding values for the B group were 23.2 2.0 mmHg and 13.9 1.6 mmHg, respectively (P = 0.001). There was no significant difference between the groups in terms of IOP at the final follow-up (P = 0.56). The number of medications at baseline was 2.3 0.3 in both groups. However, the BT group needed fewer drops at all postoperative time intervals and used 1.1 0.3 versus 2.0 0.4 eye drops (group B) at the final follow-up visit (P = 0.004). Eyes in B with phacoemulsification had a significantly higher IOP on day 1 compared to B (23.2 14.3 versus 17.9 11.4, P = 0.041). During the one-year follow-up, 7 (13.7%) patients in BT group and 18 (35.2%) in B group experienced hypotony (P = 0.04). No dangerous hypotony or hypertension occurred in BT group. The mean BCVA at baseline was 0.64 0.85 logMAR and changed to 0.55 0.75 logMAR in BT and B groups, respectively (P = 0.663). The corresponding numbers for the final follow-up visit was 0.72 1.07 and 0.63 0.97 logMAR, respectively (P = 0.668).ConclusionWe observed similar rates of success and IOP reduction using BT and B techniques. BT group needed fewer glaucoma medications. Tube fenestration was unnecessary in BT group resulting in less postoperative ocular hypotony and hypertension. The results of our study indicate that additional trabectome procedure makes Baerveldt glaucoma implant safer, easier to handle, and more predictable in the most vulnerable patients with advanced glaucoma.
Highlights
Trabeculectomy and large glaucoma drainage devices (GDDs) are often chosen as primary surgical interventions for refractory glaucoma with a low target intraocular pressure (IOP)
Coarsened Exact Matching resulted in 51 eyes in the BT group matched to 51 eyes in the B group
There was one case of choroidal detachment in each group that responded to conservative management. Both BT and B techniques were effective in reducing IOP
Summary
Trabeculectomy and large glaucoma drainage devices (GDDs) are often chosen as primary surgical interventions for refractory glaucoma with a low target intraocular pressure (IOP) Both allow to bypass the impaired conventional outflow route and can achieve IOPs below that of the episcleral veins. In contrast to the Ahmed glaucoma implant (New World Medical Inc, Rancho Cucamonga, California, USA), another common device, the Baerveldt implant does not have a flow restrictor and requires a ligature suture that ties off the lumen to prevent hypotony[6] until a capsule has formed around the implant after four to six weeks.[7] The clinical definition of hypotony is IOP low enough to result in vision loss caused, for instance by corneal edema, astigmatism, cystoid macular edema, or maculopathy.[8] Since GDDs are often used in severe glaucoma with advanced optic neuropathy, a high postoperative IOP can be detrimental. Many surgeons use spatulated needles to create slitshaped fenestrations anterior to the ligature that permit limited flow.[9,10,11] titrating this is challenging and the effect can range from no flow to frank hypotony.[10]
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