Double-plate Molteno Research Articles

The efficacy of adjunctive mitomycin C and/or anti-VEGF agents on glaucoma tube shunt drainage device surgeries: a systematic review

PurposeThe effectiveness of mitomycin C (MMC) in trabeculectomy has long been established. The aim of this review is to evaluate the efficacy and safety of adjunctive agents in tube shunt drainage device surgery for glaucoma or ocular hypertension, since controversy still exists regarding their benefit.MethodsWe searched CENTRAL, PubMed, Embase, Web of Science, Scopus, and BASE for RCTs, which have used adjuvant antimetabolites—either MMC or 5-Fluorouracil (5-FU)—and/or anti-vascular endothelial growth factors (anti-VEGF) agents. The main outcome was IOP reduction at 12 months.ResultsTen studies met our inclusion criteria. Nine used the Ahmed Glaucoma Valve (AGV) implant, while the double-plate Molteno implant was used in one study. Four studies used MMC. The remaining six studies used an anti-VEGF drug – either bevacizumab, ranibizumab or conbercept.Only one MMC-study reported a significant difference in the IOP reduction between groups at 12 months, favouring the MMC group (55% and 51%; p < 0.01). A significant difference was also reported by two out of five bevacizumab-studies, both favouring the bevacizumab group (55% and 51%, p < 0.05; 58% and 27%, p < 0.05), with the highest benefit seen in neovascular glaucoma cases, especially when panretinal photocoagulation (PRP) was also used. Neither ranibizumab nor conbercept were found to produce significant differences between groups regarding IOP reduction.ConclusionThere is no high-quality evidence to support the use of MMC in tube shunt surgery. As for anti-VEGF agents, specifically bevacizumab, significant benefit seems to exist in neovascular glaucoma patients, especially if combined with PRP.

Aqueous shunts for glaucoma.

Aqueous shunts for glaucoma.

Long-term results of non-valved glaucoma drainage implant surgery and glaucoma drainage implant combined with trabeculectomy.

Purpose:The purpose was to investigate the efficacy and complications of nonvalved glaucoma drainage implant (GDI) surgery and GDI combined with trabeculectomy.Subjects and Methods:Serial Japanese patients who received GDI were retrospectively investigated. The survival rate of eyes was analyzed using the Kaplan-Meier method, defining death as: (1) Intraocular pressure (IOP) <6 mmHg, or ≥22 mmHg, and <20% reduction of preoperative IOP, (2) additional glaucoma surgery, (3) loss of light perception. Prognostic factors of age, sex, previous surgery, type of glaucoma, synechial closure, preoperative IOP, type of GDI (single-, double-plate Molteno, Baerveldt 350) and GDI combined with trabeculectomy were investigated employing proportional hazards analysis.Results:One hundred and twenty-four eyes of 109 patients aged 53.3 ± 7.8 years old were analyzed. Types of GDI were single-plate (15.3%), double-plate Molteno (71.8%), and Baerveldt 350 (12.9%). The results of survival rate analysis were 86.1, 71.1, 71.1, and 64.6% for 1, 3, 5, and 10 years respectively. Thirty-four eyes (27.4%) died because of uncontrolled IOP (19.4%), loss of light perception (5.6%), and additional glaucoma surgery (2.4%). Single-plate Molteno was the only risk factor for failure. Persistent unphysiological hypotony (0.8%) and bullous keratopathy (5.6%) were observed.Conclusion:Nonvalved GDI surgery and GDI combined with trabeculectomy using nonabsorbable tube ligature proved to be an excellent device for any type of glaucoma in Japanese patients. Hypotony and corneal endothelial loss are the most serious complication in the long-term results of our patients.

Otago Glaucoma Surgery Outcome Study

To evaluate the efficacy of the 175-mm2 Molteno3 implant in patients with nonneovascular glaucoma. A hospital-based, retrospective historical control comparative case series comparing results in the first 87 eyes to receive the 175-mm(2) Molteno3 implant with those in a control group of 115 eyes receiving the 274-mm(2) double-plate Molteno implant. Success was defined as an intraocular pressure (IOP) of at least 6 mm Hg but not more than 21 mm Hg with or without hypotensive medication. The mean postoperative follow-up was 3.0 years (range, 13 days to 5.6 years) in the Molteno3 implant group and 6.2 years (range, 1 day to 13.9 years) in the double-plate Molteno implant group. The mean (SD) preoperative IOP was 25.6 (7.1) mm Hg in the Molteno3 implant group in eyes treated with a mean of 2.3 ocular hypotensive medications, and 25.7 (8.0) mm Hg in the double-plate Molteno implant group in eyes treated with a mean of 2.2 medications. The mean (SD) postoperative IOP at 36 months was 13.9 (3.2) mm Hg in the Molteno3 implant group in eyes treated with a mean of 0.9 ocular hypotensive medications, and 14.5 (3.4) mm Hg in the double-plate group in eyes treated with a mean of 0.7 medications. The probability of IOP control at 3 years was 0.79 in both groups. There was significantly more postoperative hypotony in eyes without a polyglactin 910 tie in the Molteno3 implant group (P= .04); however, significantly more eyes with flat anterior chambers in the double-plate group required anterior chamber reformation (P= .03). The 175-mm(2) Molteno3 implant provided intermediate-term successful treatment of nonneovascular glaucoma comparable to that provided by the double-plate Molteno implant.

Vitrectomía vía pars plana e implante simultáneo de dispositivo de drenaje para glaucoma

Purpose To evaluate intraocular pressure (IOP) and visual acuity (VA) results after glaucoma drainage device (GDD) implantation combined with simultaneous pars plana vitrectomy (PPV). Material and methods Retrospective review of 8 eyes (7 patients). The diagnosis was neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy in 4 eyes, in a which a double plate Molteno implant was placed, and glaucoma secondary (GS) to complicated cataract surgery in 3 eyes and penetrating trauma in one eye, in which a glaucoma Ahmed valve was implanted. Results Mean preoperative IOP was 35.77 mmHg (20-50) and 11.5 mmHg (2-20) postoperatively, and mean number hypotensive drugs was decreased from 2.33 (0-3) before surgery to 0.62 (0-3) after it. Preoperative VA in NVG was light perception or counting fingers, and it was lost in three eyes. In GS, VA before surgery was below 0.1 in all eyes, and three months after surgery mean VA was 0.42 (0.1-0.8). Mean follow-up was 10.12 months (5-27). The complications were tube obstruction in two cases, one of these presenting also a suprachoroidal hemorrage and ptisis bulbi, plate exposure in one case, and bullous keratopathy as a late complication in another eye. Conclusions The VA and IOP were well controlled with this procedure in GS. In NVG, IOP was controlled, but visual results were poor due to complications and the underlying pathology.

Simultaneous pars plana vitrectomy and glaucoma drainage device implant

PurposeTo evaluate intraocular pressure (IOP) and visual acuity (VA) results after glaucoma drainage device (GDD) implantation combined with simultaneous pars plana vitrectomy (PPV). Material and methodsRetrospective review of 8 eyes (7 patients). The diagnosis was neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy in 4 eyes, in a which a double plate Molteno implant was placed, and glaucoma secondary (GS) to complicated cataract surgery in 3 eyes and penetrating trauma in one eye, in which a glaucoma Ahmed valve was implanted. ResultsMean preoperative IOP was 35.77mmHg (20–50) and 11.5mmHg (2–20) postoperatively, and mean number hypotensive drugs was decreased from 2.33 (0–3) before surgery to 0.62 (0–3) after it. Preoperative VA in NVG was light perception or counting fingers, and it was lost in three eyes. In GS, VA before surgery was below 0.1 in all eyes, and three months after surgery mean VA was 0.42 (0.1–0.8). Mean follow-up was 10.12 months (5–27). The complications were tube obstruction in two cases, one of these presenting also a suprachoroidal hemorrage and ptisis bulbi, plate exposure in one case, and bullous keratopathy as a late complication in another eye. ConclusionsThe VA and IOP were well controlled with this procedure in GS. In NVG, IOP was controlled, but visual results were poor due to complications and the underlying pathology.

Refractory glaucoma – tube or diode?

The aim of the present study was to assess the relative effectiveness of tube surgery and cyclodiode laser in terms of achieving intraocular pressure control. A retrospective study was undertaken to compare patients undergoing double plate Molteno tube implantation with patients undergoing diode cyclophotocoagulation. Intraocular pressure (IOP) was documented at 7 days prior to surgery and postoperatively at various time points. Surgical success was defined as a final IOP between 6 (inclusive) and 21 mmHg (inclusive), without the use of topical medication, while 'qualified' success was defined as IOP within the same range with the use of topical medication. Twenty-eight diode patients and 26 tube patients were included for the study. An average follow up of 150 weeks (range = 21-322 weeks) was available. Mean preoperative IOP was 37 +/- 12 mmHg for the tube group and 39 +/- 16 mmHg for the diode group (t = 0.51, P = 0.61). The final IOP was 17 +/- 12 mmHg for the tube group and 21 +/- 13 mmHg for the diode group (t = 0.35, P = 0.73). Surgical success was achieved in 46% of tube eyes and 11% of diode eyes, while qualified success was achieved in 81% of tube eyes compared with 64% of eyes in the diode group. Two eyes which underwent diode became phthisical. IOP control may be achieved in a greater number of patients with tube surgery. The possible benefits of IOP control in diode patients need to be weighed against the risks of long-term visual loss and the need for multiple re-treatments in this group.

Mitomycin C eliminates the short-term intraocular pressure rise found following Molteno tube implantation.

Molteno implants remain popular for treating recalcitrant glaucomas. This study aimed to assess the effect of mitomycin C (MMC) use with Molteno tube implantation upon intraocular pressure (IOP) control and complication rates. In particular, the study aimed to assess any change that MMC might have upon the postoperative hypertensive phase. A retrospective case record study was conducted of all patients undergoing double plate Molteno implant surgery by one surgeon over 5 years. Eyes with recalcitrant glaucoma unresponsive to previous surgery, or deemed unlikely to succeed with trabeculectomy, underwent double plate Molteno tube implantation. Eyes that had MMC (0.3 mg/mL, 3 min) applied to Tenon's capsule over the secondary plate were compared with eyes that underwent surgery without adjunctive MMC application. Twenty-seven eyes received MMC and were similar to 26 eyes not receiving MMC in terms of glaucoma subtype, age, sex, previous surgery, preoperative IOP and postoperative IOP lowering agents. Those not receiving MMC had raised IOP 31-90 days post implantation compared with MMC treated eyes (P < 0.01) and more often received oral antifibrosis medication (P < 0.05). Complications were no more common with MMC except for initial overdrainage. Significant systemic complications from the use of oral antifibrosis medication were common. The findings suggest a useful role for MMC. Caution is advised in case selection for MMC use. Mitomycin C treatment over the secondary plate alone permits removal of this plate if MMC-related complications occur without requiring removal of the whole implant.

Comparison of Double-Plate Molteno and Ahmed Glaucoma Valve in Patients With Advanced Uncontrolled Glaucoma

To compare double-plate Molteno (DPM) with the Ahmed glaucoma valve (AGV) in the treatment of eyes with complicated glaucoma. This matched, retrospective, case-control study was based on diagnosis, number of previous operations, and age. There were 30 patients in each group and only patients with a minimum of 6 months follow up were included. Double-plate Molteno or Ahmed glaucoma valve insertion was performed on each patient to control intractable glaucoma. Success was defined as IOP <22 mm Hg and >4 mm Hg on the last two visits, a decrease of no more than 2 lines in the visual acuity, and no additional surgical intervention to control IOP. The Kaplan-Meier estimated probability of success at 12 and 24 months was 73% and 56% with DPM and 60% and 50% for AGV (P = 0.72). Mean IOP measured 13.36 +/- 5.2 mm Hg following DPM and 16.7 +/- 5.6 mm Hg following AGV at 12 months (P = 0.026) and 13.3 +/- 5.1 mm Hg with DPM and 19 +/- 5.8 mm Hg with AGV at 24 months (P = 0.009). Of the patients involved in the study, 83.5% exhibited hypertensive phase (HP) of AGV vs 43.5% of DPM (P = 0.04). AGV had a tendency to fail earlier (5 months +/- 7 following AGV vs 13 months +/- 13 following DPM, P = 0.07, t-test). Patients with either a second valve insertion or valve removal were 7/30 of AGV vs 1/30 in DPM (P = 0.05). Stent removal was needed by 10/30 DPM and 8/30 AGV had needling/5-FU. The percentage of patients free from failure was similar between the two groups at 36 months. DPM is associated with lower mean IOP in the long term compared to AGV.

Prospective evaluation of extraocular motility following double-plate molteno implantation.

To determine the incidence and type of extraocular motility disturbance after double-plate Molteno implantation. In a prospective clinical series, we evaluated preoperative and postoperative ocular motility at 3 and 6 months in 24 eyes of 24 patients undergoing double-plate Molteno implantation. Visual acuity, motility testing, and subjective and objective diplopia were evaluated at each examination. Within the first 6 months postoperatively, new or worse strabismus developed in 11 (46%) of the 24 study patients. Three of the 11 patients had a generalized restriction of the superior rectus and the superior oblique muscles, all of which persisted 6 months after surgery. Four patients had clinical features consistent with an acquired Brown syndrome, and 6 months after surgery, 3 of the 4 patients had a residual deviation, although the deviation in 1 patient resolved. A superior oblique palsy developed in 3 patients, and a lateral rectus palsy developed in 1 patient. All 4 of the muscle palsies resolved or were resolving during the follow-up period, which ranged from 6 to 12 months. Extraocular motility disturbances are not rare after double-plate Molteno surgery. Muscle palsies, acquired Brown syndromes, and generalized restrictions occurred in similar proportions. Patients should be counseled before Molteno surgery concerning the risk of strabismus and diplopia.

The Effect of Mitomycin C on Molteno Implant Surgery

The authors assess whether adjunctive mitomycin C improves Molteno tube shunt surgery in terms of intraocular pressure (IOP), visual acuity, and complication rates. Twenty-five eyes of twenty-five consecutive patients undergoing double-plate Molteno implant surgery were randomized to receive either mitomycin C (MMC) 0.4 mg/mL for 2 minutes or a control balanced salt solution in a masked, prospective study. Intraocular pressure, visual acuity, and complications were recorded 1 week and 1, 3, 6, and 12 months after surgery. A repeated measures analysis of variance (ANOVA) model was used to test the overall effect of the drug on IOP and percent change from preoperative IOP. Thirteen eyes received balanced salt solution and 12 eyes received MMC. There was no difference between the groups with respect to age, preoperative IOP, log mean angle of resolution (LogMar) visual acuity, or number of preoperative medications. Except for week 1, there were no differences between the groups at any of the clinic visits with respect to IOP and percent change from baseline IOP. Analysis of the visual acuity (LogMar) showed reduction in vision for both groups. Complications were similar in each group, as were number of postoperative hypotensive agents required. Adjunct MMC does not demonstrate a significant difference in outcomes compared with placebo in pressure-ridged Molteno implant surgery. Results of this study are limited by a small number of patients in each group and a fixed dose of MMC.

Molteno Implant With Mitomycin C

The authors examine the intermediate-term effects of adjunctive intraoperative mitomycin C (MMC) in a cohort of patients who received double-plate Molteno implants for complicated glaucomas. A consecutive series of 21 patients who received MMC 0.5 mg/ml for 5 minutes as an adjunct to a double-plate Molteno implant was compared by life-table analysis to a historical control group of 18 patients who received either no adjunct or 5-fluorouracil (5-FU) but no MMC. At three years follow-up, 35% (95% confidence interval (CI), 15-57%) of patients who received MMC avoided failure criteria of intraocular pressure (IOP) less than 6 mm Hg or more than 21 mm Hg, addition of glaucoma medication, reoperation for glaucoma, or tube removal. Seventeen percent (95% CI, 4-37%) of patients in the control group at three years follow-up met similar criteria (p = 0.039). No late complications of tube erosion were seen in the MMC group. Intraoperative MMC offers an increased likelihood of a two- to three-year period of medication-free IOP control in patients undergoing double-plate Molteno implants, compared to similar patients receiving 5-FU or no adjunctive antimetabolite therapy.

A Comparison of Postoperative Complications From Pressure-Ridge Molteno Implants Versus Molteno Implants With Suture Ligation

The pressure-ridge Molteno implant incorporates a ridge on the proximal episcleral plate to limit aqueous outflow during the immediate postoperative period. This modification is intended to decrease the high incidence of postoperative hypotony and flat anterior chambers following Molteno tube implantation, while avoiding the pressure spikes that can occur with suture ligation of the Molteno tube. This study was devised to compare postoperative intraocular pressure control and complications associated with pressure-ridge Molteno implantation versus a standard Molteno implantation with suture ligation of the tube. Thirty eyes were prospectively randomized to receive either a pressure-ridge, double-plate Molteno implant or a standard, double-plate Molteno Molteno implant with suture ligation of the tube. Postoperative intraocular pressure was significantly higher at day 1 and week 2 in the suture-ligation implant group, although the final pressure at 12 weeks was not different between the two groups. Six of 15 eyes from the pressure-ridge implant group experienced shallow or flat anterior chambers with hypotony, whereas 5 of 15 eyes from the suture-ligation implant group had significant postoperative pressure spikes. Because the ridge effect is unpredictable, further modifications are necessary to prevent postoperative hypotony.

Comparison of the Baerveldt Implant With the Double-Plate Molteno Implant-Reply

In reply We appreciate the interest of Drs Fitzgerald-Shelton and Higginbotham in our article. Obviously, in this era of managed care and cost containment, physicians need to be cognizant of operating costs. However, their comments regarding differential implant cost do not address the topic of total operating costs when implanting either of these glaucoma drainage setons. Usually, the extra dissection to implant a double-plate Molteno takes about 20 additional minutes. Many operating rooms charge more than $20 per minute for each additional half hour of operating time after an initial base time (personal communication with Department of Cost, Price, and Reimbursement, Shands Hospital, Gainesville, Fla, February 1996). Thus, the total cost of a double-plate Molteno implant might be $136 more ($335 for the Molteno double-plate implant plus $400, assuming an additional 20 minutes of operating time) than the cost of a Baerveldt implant ($599). Last, we rarely implant single-plate Molteno

Suprachoroidal Hemorrhage after Molteno Implantation

The objective of this study is to identify the rate and the associated risk factors for suprachoroidal hemorrhage (SCH) after Molteno drain implantation. Data from the Molteno pilot study and single versus double-plate Molteno study were reviewed retrospectively for the occurrence of SCH. Follow-up intervals, demographic variables, ocular data, and medical history were collected. SCH occurred in 6% of the patients enrolled in the Molteno studies; all cases were delayed and none were intraoperative. Significantly associated factors in a multiple logistic regression for SCH were the extent of intraocular pressure (IOP) drop after surgery, the post-operative IOP, a diagnosis of angleclosure glaucoma, and possibly the number of prior surgeries as well. Eyes with SCH did significantly less well in terms of visual acuity outcomes and were more likely to have inadequately controlled IOP. This study suggests that SCH occurs at the same frequency after Molteno implantation as after filtering surgery with antimetabolite use and that eyes with SCH do less well.

Adjunctive Mitomycin C in Molteno Implant Surgery

Purpose: The authors assessed the efficacy of adjunctive intraoperative mitomycin C to produce lower intraocular pressures (IOPs) in patients with complicated glaucoma who underwent double-plate Molteno implantation.Methods: A pilot series of 21 consecutive patients who underwent double-plate Molteno implantation with adjunctive intraoperative mitomycin C (0.5 mg/ml) for 5 minutes was compared with a historical control group who received Molteno implants without mitomycin C (n = 18). With failure defined as an IOP greater than 21 or less than 6 mmHg at two observations 1 month apart, the addition of medication, re-operation for glaucoma, or tube removal, a life-table analysis of IOP was performed on patients with at least 3 months' follow-up.Results: Success in the mitomycin C group was higher (68% at 1 year) than the control group (17% at 1 year; P = 0.006). Loss of more than one line of vision (33%) and re-operation for complications (including flat anterior chamber, choroidal detachment, and tube blockage) (38%) were slightly but not significantly more frequent in the mitomycin C group than in the control group.Conclusion: This study suggests that intraoperative mitomycin C in conjunction with Molteno implant may offer a better chance of achieving target IOPs in the low teens in patients with complicated glaucoma than Molteno implantation alone.

Opening an Occluded Molteno Tube With the Picosecond Neodymium-Yttrium Lithium Fluoride Laser

The Molteno tube shunt is the most widely used aqueous drainage device. Obstruction of the tube in the anterior chamber by fibrin, iris tissue, vitreous, or blood is a common reason for failure, with reported incidences up to 14.6%. 1 Use of the neodymium (Nd)-YAG laser to open occluded tubes can be attempted before surgery is performed to restore patency in these complicated cases. 2 The picosecond Nd—yttrium lithium fluoride (Nd-YLF) laser (1053 nm) (Intelligent Surgical Lasers Inc, San Diego, Calif), which uses low-energy-per-pulse levels with high repetition rates, can create optical break-down of target tissues with minimal thermal damage to adjacent structures. We report herein a case in which the picosecond Nd-YLF laser was used safely and controllably to open an occluded Molteno tube and restore aqueous drainage. Report of a Case. A 32-year-old man with bilateral advanced developmental glaucoma and subluxed lenses underwent uneventful doubleplate Molteno implant surgery

Glaucoma after penetrating keratoplasty.

Glaucoma after penetrating keratoplasty remains a management problem. The incidence is significant because of the status of those eyes undergoing PKP. Many have had multiple previous surgeries, and aqueous outflow may be compromised before the PKP. The surgery itself causes additional damage to the angle, often inducing peripheral anterior synechiae formation, with further impediment to aqueous outflow. Control of postkeratoplasty glaucoma is complicated by the need to preserve graft clarity for visual function. Medical treatment with aqueous suppressants is the first line of care. Since the introduction of apraclonidine 0.5%, and with topical carbonic anhydrase inhibitors soon to be introduced, perhaps medical management will become easier. When medical management fails, if the angle is open and viable, argon laser trabeculoplasty may be an option. If further intervention is indicated, the authors recommend a drainage seton (double-plate Molteno, or Baerveldt tube) in those eyes with good visual potential. For those eyes with poor visual potential (or those patients who cannot undergo surgery), we recommend contact Nd: YAG CPC.

Echographic Evaluation of Glaucoma Shunts

It is frequently impossible to determine by clinical examination alone if a filtering bleb is present over the equatorial plate(s) of a glaucoma shunt. This uncertainty can result in management dilemmas when patients with these devices have elevated intraocular pressures (IOPs). The authors describe how standardized echography can be used to determine if fluid is present around the plates and to characterize the blebs. Four hundred twenty-seven plates in 269 patients who had undergone single- or double-plate Molteno implantation underwent standardized echography (both A- and B-scan examinations) to determine if blebs were present around the plates, primarily when results of slit-lamp examinations had been inconclusive. Bleb sizes, locations, and characteristics also were evaluated. Sixty-five percent of the plates had associated blebs, which were graded according to their sizes (small, medium, and large, in 29%, 44%, and 27% of plates with blebs, respectively). Fluid (which appeared as an echolucent area) could be seen underlying and/or overlying the plates (which appeared as echodense lines). Larger blebs were often associated with scleral flattening. Although bleb sizes did not necessarily correlate with the levels of IOP control, the presence of a bleb on ultrasound was indicative of tube patency. Standardized echography was invaluable in the postoperative management of patients who had undergone Molteno implantation because it demonstrated the presence or absence of blebs and characterized them when results of slit-lamp examinations had been inconclusive. This technique also can be used to evaluate similarly designed aqueous shunting devices.

Glaucoma Associated With Epithelial Downgrowth Controlled With Molteno Tube Shunts

We report two histopathologically proven cases of epithelial downgrowth in which the secondary glaucoma was controlled by a double-plate Molteno tube shunt and useful vision restored with a penetrating keratoplasty. The combination of a tube shunt and penetrating keratoplasty may be indicated to maintain useful vision in advanced cases of epithelial downgrowth associated with secondary glaucoma.