Glaucoma Drainage Device Surgery Research Articles

Intraluminal Suture Placement for Management of Hypotony After Glaucoma Drainage Device Surgery.

Intraluminal 3-0 Supramid stent placement can be an effective long-term solution for hypotony after glaucoma drainage device surgery. This procedure may obviate the need for conjunctival dissection. In some cases, additional procedures are required. To describe the utility of implantation of a multifilament polyamide suture (Supramid) in the tube lumen to reverse hypotony after glaucoma drainage device (GDD) surgery. Patients who underwent tube revision with intraluminal placement of a 3-0 Supramid stent, with or without external ligature, to manage hypotony following GDD surgery between January 2010-October 2020. Resolution of hypotony was defined as IOP >5mmHg and the absence of hypotony-related structural abnormalities. Overall success was the absence of failure criteria (IOP ≤5mmHg, >21mmHg, or <20% reduction below baseline IOP after 3 months for 2 consecutive study visits; additional glaucoma surgery; or loss of light perception), with or without adjunctive ocular hypotensive therapy. Nine eyes of 9 patients underwent placement of a 3-0 Supramid stent with resolution of hypotony in all eyes with mean follow-up duration of 33.3 ±24.0 months. Overall success was achieved in 7 of 9 eyes. Four eyes required intervention after stent placement: 1 eye required selective laser trabeculoplasty followed by replacement of the original stent with a shorter 3-0 Supramid suture and external ligature; 1 eye underwent revision for tube exposure; and 2 eyes underwent laser suture lysis to release an external suture ligature. In cases of hypotony after GDD, particularly when it is desirable to reduce the extent of additional conjunctival dissection, intraluminal placement of a 3-0 Supramid stent via an intracameral approach can be an effective long-term solution. Post-operative adjustments were required in many cases.

A comparative study of cystoid macula edema following glaucoma drainage device surgery versus trabeculectomy

PurposeTo assess and compare the risk for development of cystoid macula edema (CME) after glaucoma drainage device (GDD) implantation versus conventional trabeculectomy with mitomycin (trab) for glaucoma.MethodsRetrospective review of consecutive patients receiving trab or GDD implantation between 2016 and 2018. Inclusion criteria were availability of pre- and postoperative spectral domain optical coherence tomography (SD-OCT) of the macula. SD-OCT images were evaluated for presence of CME qualitatively, central subfield thickness (CST) and macular volume (MV).Results73 eyes could be included, 42 received trab and 31 GDD surgery. Eyes receiving trab on average had 0.8 ± 0.8 previous intraocular operations, while eyes with GDD implantation had 3.1 ± 1.9 (p < 0.001). Occurrence of postoperative CME was significantly more frequent after GDD implantation (6 out of 31 (19.4%)) than after trab (2 out of 42 eyes = 4.8%), (p = 0.049). Mean preoperative CST as well as MV was comparable in both groups (CST before trab: 282.7 ± 23.0 µm, CST before GDD 284.2 ± 27.3 µm, p = 0.287; MV before trab: 7.8 ± 1.1 mm3, MV before GDD: 8.0 ± 0.8mm3, p = 0.305). Mean postoperative CST and MV were significantly higher after GDD (CST 338.5 ± 129.3 µm, MV 8.8 ± 2.6 mm3) than after trabeculectomy (CST 290.6 ± 60.2 µm, p = 0.038; MV 7.8 ± 1.2mm3, p = 0.039).ConclusionsIn real-life conditions, GDD surgery seems to be associated with a higher risk to develop CME when compared to conventional trabeculectomy. This information may be helpful for glaucoma surgeons to advise the patients on postoperative risks of surgery.

Incidence and Outcomes of Hypertensive Phase After Glaucoma Drainage Device Surgery

To describe the incidence, risk factors, clinical characteristics, and long-term outcomes of a hypertensive phase (HP) after glaucoma drainage device (GDD) implantation. Retrospective cohort study SUBJECTS: Eyes that underwent implantation of their first GDD from January 2010 to October 2020 at a tertiary care center. HP was defined as intraocular pressure (IOP) >21 mmHg occurring at 2 consecutive visits in the first 90 days after the date of surgery for Ahmed Glaucoma Valve (AGV) or in the first 90 days after tube opening for Baerveldt Glaucoma Implant (BGI). Generalized estimating equations and Fisher's exact tests were used to evaluate risk factors for HP and risk factors for failure of GDD surgery after occurrence of a HP. Incidence and risk factors for HP. Overall surgical success rates, defined as the absence of failure criteria: IOP >21 mmHg, ≤5 mmHg, or <20% reduction below baseline IOP after 3 months for 2 consecutive visits, with or without adjunctive ocular hypotensive therapy; additional glaucoma surgery; or loss of light perception. Among 419 eyes of 360 patients that underwent GDD implantation, 42 (10.0%) eyes developed HP. Onset of HP was 20.8±10.5 days after Ahmed Glaucoma Valve and 11.7±20.3 days from the date of tube opening after Baerveldt implantation. Mean IOP during HP was 26.5±3.2 mmHg with peak IOP of 30.0±5.9 mmHg. Median follow-up duration was 21.5 months after onset of HP. Younger age and neovascular glaucoma were significant risk factors for HP occurrence in a multivariable model. Resolution of HP occurred in 32 eyes (76.2%) after a mean duration of 48.0±53.0 days. Additional surgery with a second GDD or cyclophotocoagulation was performed for 12 eyes (28.6%). The overall success rate among eyes with a HP was 52.6% at 2 years, which was significantly lower than that observed among control eyes that did not experience HP (76.3%), P<0.01. The incidence of HP was 10.0%. Younger age and neovascular glaucoma were significant risk factors for HP in the multivariable model. The risk of surgical failure after HP is significantly higher compared to eyes that did not experience HP.

Virna Glaucoma Implant (VGI) as the Management of Secondary Glaucoma following TASS : A Case Report

Introduction : Secondary glaucoma may occur in severe TASS. The inflammatory cell and debris can clog trabecular meshwork causing IOP to rise. In this case, we describe the successful management of secondary glaucoma due to TASS using Virna Glaucoma Implant (VGI).&#x0D; Case Illustration : A 66-year-old woman presented with decreased vision in the left eye one week after anterior vitrectomy and anterior segment lavage due to TASS. She had a history of phacoemulsification and intraocular lens placement with complication of PCR. On ocular examination, the visual acuity was 1/60 in the left eye with intraocular pressure (IOP) 55 mmHg. After maximum glaucoma medication using timolol, latanoprost, brinzolamide eye-drops and oral acetazolamide IOP was 22mmHg. Glaucoma Drainage Device (GDD) surgery using VGI was performed. After 2.5 weeks, IOP in the left eye was reduced to 19 mmHg without anti-glaucoma medication and visual acuity has improved to 6/60, showing a favourable outcome.&#x0D; Discussion : TASS may cause significant damage to the trabecular meshwork, which leads to secondary glaucoma. Although medical therapy is often used to control elevated IOP, surgical therapy may be required to treat refractor IOP elevation. GDD surgery has been reported to have effective outcomein secondary glaucoma and pseudophakic eyes.&#x0D; Conclusion : Secondary glaucoma is considered as one of the characteristics in the late stages of TASS, and required prompt treatment. VGI implantation is a promising choice of treatment in managing secondary glaucoma following TASS when medication is not effective.

Concurrent adjacent strabismus surgery with glaucoma drainage device placement in childhood glaucomas

BackgroundDetermine outcomes of concurrent strabismus surgery with placement of a glaucoma drainage device (GDD) in children.MethodsRetrospective review of pediatric patients who underwent simultaneous lateral rectus (LR) muscle surgery with superotemporal GDD placement. Strabismus and GDD success were defined as residual horizontal misalignment < 10 prism diopter (PD) and intraocular pressure (IOP) < 21 mmHg, no visually devastating complications, and no additional IOP-lowering surgeries.ResultsFifteen eyes of 13 patients (69% male) underwent LR surgery (14 recessions, 1 resection) for exotropia or esotropia simultaneous with GDD placement (13 Baerveldt, 2 Ahmed) at 8.34 ± 5.26 years. Preoperative visual acuity (VA) in operative eye (0.89 ± 0.54) was worse than non-operative eye (0.23 ± 0.44, p = 0.0032). Preoperative horizontal deviation was 38.3 ± 9.4 PD and LR recession was 7.4 ± 1.1 mm. At final follow-up, VA in operative eye (0.87 ± 0.52) was unchanged from preoperative (p = 0.4062). Final IOP was significantly decreased (12.4 ± 4.7 mmHg vs. 31.1 ± 11.4 mmHg, p = 0.0001) as was number of glaucoma medications (2.7 ± 1.7 vs. 1.1 ± 1.3, p = 0.0037). Five (38%) and 9 patients (69%) met criteria for strabismus and GDD success, respectively. Two eyes required tube revision and endoscopic cyclophotocoagulation and 2 eyes had additional strabismus surgery.ConclusionsConcurrent strabismus and GDD surgery decreased horizontal deviation and obtained IOP control. It is important to consider correction of strabismus at time of GDD placement to maximize visual development and improve cosmesis in children with glaucoma.

Double scleral tunnel technique to prevent glaucoma drainage device exposure.

To describe a new surgical technique designed to reduce the risk of tube exposure following glaucoma drainage device (GDD) surgery. A retrospective, single-center study included all patients who underwent GDD surgery by a single surgeon between January 2018 and December 2019, using a double scleral tunnel technique to secure the tube to the sclera. A 23-gauge needle was used to create a 3 mm partial thickness scleral tunnel near to the GDD plate, with a second partial thickness scleral tunnel created 2.5 mm from the surgical limbus into the anterior chamber (AC). The silicone tube was passed through both scleral tunnels and into the AC. 46 GDD surgeries were performed during the time frame. The mean age of patients was 65 ± 13 years. Mean follow up duration was 27.7 ± 8.15 months (range 11 to 44). Significant reductions in intraocular pressure and number of glaucoma medications were achieved. Zero exposures were recorded occurring during follow-up. This double scleral tunnel technique to secure the GDD silicone tubing firmly to the sclera may reduce micro-movements which have been purported to be associated with tissue erosion post GDD surgery. The addition of this simple technique to existing GDD surgery may reduce the risk of post-operative tube exposure.

Defining the role of ab externo Xen gel stent in glaucomatous eyes with prior failed surgical intervention

PurposeTo evaluate the safety and efficacy of Xen45 Gel stent (Xen; Allergan) in eyes that have failed prior surgical intervention, compared to traditional glaucoma drainage device (GDD) or continuous-wave cyclophotocoagulation (CPC). Since this population has low expected success rates with additional surgery, it is vital to compare to standard-of-care surgical options.MethodsRetrospective, single-center, case–control study of ab externo transconjunctival Xen shunt in eyes that have previously undergone trabeculectomy and/or GDD surgery. Postoperative data were collected for 18 months. Failure was defined as no light perception, additional glaucoma surgery required, or intraocular pressure (IOP) of < 6 mmHg after 6 weeks postoperatively.ResultsEighteen Xen eyes and 36 control eyes matched on both glaucoma type and previous glaucoma surgeries were included. Seventy-two percent had primary open angle glaucoma, 11% uveitic, 6% primary angle closure, 6% pseudoexfoliation, and 6% pigmentary glaucoma. Fifty-six percent of eyes in each group had prior trabeculectomy, 28% of Xen and 31% of control eyes had prior GDD, and 17% of Xen and 14% of control eyes had both. Baseline medicated IOP was lower in the Xen group (21.8 ± 7.2) compared to controls (27.5 ± 9.4, P = 0.043). The cumulative failure rate at year 1 was 17% for Xen and 20% for controls (P = 0.57). Mean survival time was 14.1 (± 1.5) months and 11.4 (± 0.6) months for controls. There was no difference in minor complication rates between groups (P = 0.65), but the Xen group had a significantly lower rate of serious complications (P = 0.043) defined as vision threatening or requiring surgical intervention in the operating room. When censored for additional glaucoma procedures, there were no differences at year 1 in IOP, change in IOP, number of IOP-lowering medications, or number of medications reduced from baseline.ConclusionsThe Xen shunt provides a reasonable alternative to current standard of care, with a similar failure rate at year 1, with a noninferior IOP reduction compared to GDD and CPC, and a preferred safety profile.

Combined Corneal Transplant, Glaucoma Drainage Implantation, and Pars Plana Vitrectomy Outcomes in a Pediatric Population.

The combination of glaucoma drainage device (GDI), pars plana vitrectomy (PPV), and corneal transplantation is well reported in adults. However, little is known about the outcomes of such combined procedures in pediatric patients. We present a retrospective, single-center study to evaluate the safety and outcomes of concurrent GDI and/or PPV with corneal transplantation in patients 18 years and younger. Retrospective chart review of pediatric patients (aged 0-18 years) who received either corneal transplants or keratoprosthesis in combination with at least 1 additional procedure (either GDI and/or PPV) at the Illinois Eye and Ear Infirmary, Chicago, IL, between 2003 and 2017. Primary outcomes included vision, intraocular pressure, and cup-to-disc ratio (C/D). Secondary outcomes included the number of repeat surgeries and intraoperative and postoperative complications. Thirty-six patients were included with a mean age of 8.4 years and an average follow-up of 49.7 months. Nineteen patients received corneal surgery, GDI, and PPV; 4 received corneal and GDI surgery; and 13 received corneal and PPV surgery. Of the 19 patients with all 3 procedures, 48% experienced an increase in vision with an average improvement of 0.9 lines at the last follow-up. Intraocular pressure decreased by an average of -7.2 mm Hg for all groups. Fifty-three percent of all patients experienced complications. Combined keratoplasty, GDI, and PPV seems to be effective in the management of complex pediatric eye disease. However, owing to the high risk of complications in this vulnerable patient population, careful consideration must be taken when determining a patient's surgical candidacy for combined cornea/glaucoma/retina procedures.

Refractive Outcomes for Combined Phacoemulsification and Glaucoma Drainage Procedure.

IntroductionTo evaluate the refractive outcome of combined cataract extraction and glaucoma drainage device (GDD) surgery.MethodsPatients who had undergone combined phacoemulsification with GDD surgery [Baerveldt, Abbott Medical, Abbott Park (IL) or Ahmed valve, New World Medical, Rancho Cucamonga (CA)] between June 2009 and August 2017 were included in the study. The main outcome measure evaluated was whether or not spherical equivalent (SE) between ± 1D from target refraction was achieved at 3–6 months postoperatively.ResultsThe final analysis included 42 eyes of 38 patients who underwent combined phacoemulsification and GDD surgery. A refractive outcome of spherical equivalent (SE) between ± 1D of the target refraction was achieved in 30 of 42 eyes (71.43%) at 3–6 months after surgery. Mean preoperative axial length (AL) of eyes with postoperative SE outside ± 1D from target (SD = 0.98, p = 0.003) was noted to be 25.37 ± 0.98 mm (longer mean AL) and that of eyes with SE between ± 1D (SD = 0.89, p = 0.000) was found to be 23.34 ± 0.89 mm (average mean AL). Twelve (29%) eyes were noted to have a mean 0.52D (SD = 0.49; range 0.02–1.49) of corneal astigmatism induced by combined surgery. Age, central corneal thickness, preoperative anterior chamber depth, and pre- and postoperative intraocular pressure did not significantly affect refractive outcomes.ConclusionRefractive outcomes within 1.00D of the target refraction were achieved in most patients undergoing a combined surgical approach. Longer AL was a risk factor among patients with refractive change > 1.00D from target.

Comparison of Outcomes Following Glaucoma Drainage Tube Surgery Between Primary and Secondary Glaucomas, and Between Phakic and Pseudophakic eyes.

Purpose:To report outcomes of glaucoma drainage device (GDD) surgery based on primary or secondary glaucoma diagnosis and lens status.Design:Single-center, retrospective, consecutive cohort study.Methods:University of Florida patients aged 18 to 93 years who underwent nonvalved GDD surgery between 1996 and 2015 with a minimum of 1-year follow-up were examined. Of the 186 eyes of 186 patients enrolled, 108 had a primary glaucoma and 78 a secondary glaucoma diagnosis. Excluding 13 aphakic patients, 57 eyes were phakic and 116 pseudophakic. Mean intraocular pressure (IOP), mean number of medications, visual acuity (VA), surgical complications, and failure (IOP ≥18 mm Hg, IOP <6 mm Hg, reoperation for glaucoma, or loss of light perception) were the main outcome measures.Results:No significant difference was noted in mean IOP and mean medication use (12.8 ± 4.5 and 13.0 ± 6.6 mm Hg on 2.0 ± 1.2 and 1.5 ± 1.1 medication classes, respectively), mean VA (1.08 ± 0.98 and 0.94 ± 0.89, respectively), failure, or numbers of complications and reoperations (P > 0.05) between eyes with primary and secondary glaucomas at up to 5 years postoperatively. Comparison of phakic and pseudophakic eyes showed a statistically significant higher success rate for the pseudophakic patient group at the ≥18 mm Hg upper limit and <6 mm Hg lower limit (P = 0.01), and significantly fewer eyes required reoperation to lower IOP (6.9% vs 23%).Conclusions:GDD surgery appears equally effective for secondary glaucomas as for primary glaucomas, and has a better outcome for pseudophakic eyes than phakic eyes.

Outcomes and lessons learned from two decades’ experience with glaucoma drainage device implantation for refractory Sturge Weber–associated childhood glaucoma

To evaluate glaucoma drainage device (GDD) implantation for refractory pediatric glaucoma associated with Sturge-Weber syndrome (SWS). The medical records of consecutive children with SWS-associated glaucoma at a single center who were treated by a single surgeon using GDDs over 20years were reviewed retrospectively. The main outcome measure was GDD treatment success, defined as absence of any of the following indications of treatment failure: (1) intraocular pressure (IOP) of >21mm Hg on two consecutive visits despite maximal medical therapy, (2) additional IOP-lowering surgery, and (3) sight-threatening complications. A total of 22 eyes of 22 children were included. The median age at glaucoma diagnosis was 0.73years (range, 0.06-13.2), and the median age at GDD surgery was 4.8years (range, 0.6-13.3). Most eyes (14 [68%]) had prior glaucoma surgery. Mean follow-up was 2.8±1.5years. Success (95% confidence interval) by Kaplan-Meier analysis for GDD surgery at 1, 3, and 5years was 91% (68-98), 75% (50-89), and 52% (24-73), respectively. Failure occurred in 8 eyes (36%). Complications were common, occurring in 50% of eyes, with 23% of eyes having more than one complication. Severe vision-threatening complications (n=3) included one case each of possible infection requiring GDD removal, persistent hypotony, and cilioretinal artery occlusion. GDDs are an effective treatment for SWS-associated glaucoma but have a high rate of complications. We report several severe complications that prompted surgical modifications for increased safety when implanting GDDs in eyes with SWS-associated glaucoma.

Comparison of Locally Sourced Pericardium and Other Conventional Patch Graft Materials in a Glaucoma Drainage Device Surgery.

PurposeOur study aimed to compare the outcomes and costs of various patch graft materials used in the setting of glaucoma drainage device (GDD) surgeries: conventional Tutoplast® pericardium (TP), locally-obtained Lifenet® pericardium (LP), and tissue-banked corneal (CP) and scleral (SP) patches.DesignRetrospective observational study.SubjectsOne hundred and ninety-five eyes of 185 patients who underwent glaucoma device surgery with patch grafts were included.Materials and methodsPatient records were reviewed for demographics and surgical data including age at the time of GDD surgery, race, sex, eye, history of diabetes or immunologic disease, glaucoma diagnosis, length of follow-up, pre- and postoperative intraocular pressure (IOP), type and location of GDD, patch type, and tube-related complications.Main outcome measuresThe primary outcome measures were rates of patch graft-related complications including conjunctival dehiscence with and without tube exposure. Secondary outcome measures were IOP control achieved and cost of patch graft materials.ResultsMean follow-up for all eyes was 17.1 months. Overall, conjunctival dehiscence without tube exposure occurred in four eyes (2.1%); tube exposure was seen in six eyes (3.1%). The mean time to exposure was 3.3 months (range 1–8 months). The rate of tube exposure was 2.3% of eyes with TP grafts, 10.7% of eyes with CP grafts, 2.8% of eyes with SP grafts, and 0% of eyes with LP grafts. There was no significant difference in rates of tube exposure rates by graft material (p = 0.26). Multivariate logistic regression analysis with adjustment for patch type, age, sex, implant type, and location revealed no significant risk factors for tube exposure. Univariate logistic regression was then performed on the same risk factors as well as diabetes, prior and concurrent ocular surgery, and showed no significance.ConclusionOur preliminary, short-term results show that locally sourced patch graft material can be a cost-effective alternative to traditionally used patch grafts without an increase in tube exposure rates. To further determine the efficacy of the different patch graft materials, longer-term comparative prospective trials are needed. Longer prospective studies are needed to compare the long-term safety and rate of tube exposures in these locally obtained patch graft materials.How to cite this articleAggarwal S, Kremer C, Engelhard S, et al. Comparison of Locally Sourced Pericardium and Other Conventional Patch Graft Materials in a Glaucoma Drainage Device Surgery. J Curr Glaucoma Pract 2021;15(1):14–18.

Rates of Diplopia in Ahmed FP7, Baerveldt 250, and 350 Glaucoma Patients Compared With Medical Controls.

Diplopia was present in ~20% of patients with Ahmed FP7 (FP7) or Baerveldt 350 (B350), compared with 5% to 6% in those with Baerveldt 250 (B250) or controls, suggesting risk of diplopia should be included in preoperative counseling. The purpose of this study was to examine the prevalence of diplopia and strabismus in patients with B250, B350, or FP7 glaucoma drainage devices (GDD). In this cohort study, glaucoma patients 18 years and above who had received, or would be receiving, a B250, B350, or FP7 GDD, and medically treated controls were consecutively enrolled from August 8, 2017, through July 31, 2019. The Diplopia Questionnaire was administered ≥30 days postoperatively, and upon enrollment to the controls. All diplopic patients underwent orthoptic measurements, which were reviewed by a strabismus specialist. Patients with GDDs in quadrants other than superotemporal, multiple GDDs, or scleral buckles were excluded. Bonferroni correction was applied for pairwise comparisons. Diplopia was reported in 23/129 (17.8%) GDD patients and 5/99 (5.1%) control patients (P=0.003): 8/35 (22.9%) FP7, 2/32 (6.3%) B250, and 13/62 (21.0%) B350, with significant differences between FP7 versus controls (P=0.014) and B350 versus controls (P=0.011). Diplopia was attributable to GDD in 2 FP7 (5.9%, 95% confidence interval: 0.7-19.2), 0 B250, and 4 B350 (6.5%, 95% confidence interval: 1.7-15.2) patients, without significant differences between the GDDs. Patients with the larger (B350) or the higher profile plate (FP7) GDDs were more likely to experience diplopia than controls, and diplopia was attributable to the GDD in ~6% of patients with either a FP7 or a B350 GDD. Since diplopia can affect patients' quality of life, preoperative counseling for GDD surgery, particularly B350 and FP7, should include a discussion of the risk of diplopia.

Comparison of Outcomes of Glaucoma Drainage Implant Surgery With or Without Prior Failed Trabeculectomy.

A comparison of 186 glaucoma patients with mixed diagnoses who underwent nonvalved glaucoma drainage device (GDD) implant surgery showed similar long-term intraocular pressure (IOP), medication, and visual acuity (VA) outcomes between those with prior failed trabeculectomy surgery versus those without. The purpose of this study was to evaluate whether prior failed trabeculectomy adversely affects the outcome of glaucoma tube surgery. A total of 186 eyes of 186 patients who underwent a nonvalved GDD implant surgery by a single surgeon between 1996 and 2015 at a University practice were included. Patients were of mixed diagnoses and over 18 years old. Before the GDD surgery, 65 had a previous failed glaucoma filtering surgery and 121 had no prior glaucoma surgery. Demographic information, preoperative and postoperative IOP, medication, VA, and complications were collected from chart review. No significant difference was noted in mean IOP and mean medication use (13.0 and 12.6 mm Hg on 2.0 and 1.7 medication classes at 5 y postoperatively, respectively), mean VA and change in VA from baseline, or numbers of complications (P>0.05), between eyes that had a prior failed filtration surgery and those that had not. Kaplan-Meier plots for failure over 5 years using a lower limit of <5 mm Hg and an upper limit of ≥18, ≥15, or ≥12 mm Hg did not show a significant difference between groups. Subanalyses were performed to examine only primary glaucoma eyes and results were similar. Further group subanalyses comparing those with baseline IOP ≥25 or <25 mm Hg, age 65 and above or below 65 years and those specifically with Baerveldt 350 mm2 implants also did not show significant differences. Prior failed filtration surgery does not appear to affect the outcome of future GDD surgery.

Need for Additional Glaucoma Surgery and Complications Following Glaucoma Drainage Device Surgery.

In this longitudinal study of patients with open-angle (OAG), pseudoexfoliative (PXE), or neovascular glaucoma (NVG) receiving glaucoma drainage devices (GDD), posttube cumulative rates of reoperation, corneal graft, and visually threatening complications (VT-complications) increased beyond 5 years and were not significantly affected by glaucoma type. To study the need for additional glaucoma surgery and development of complications after first GDD surgery in eyes with primary OAG, PXE, or NVG glaucoma. There were 306 eyes with OAG (n=185), PXE (n=60), or NVG (n=61) glaucoma who received a first GDD between 1996 and 2017. Outcomes including glaucoma reoperation, corneal graft procedure, and VT-complications after GDD were measured. Kaplan-Meier analysis was used to compare cumulative rate of reaching outcomes over time after GDD placement among the 3 glaucoma groups. When comparing the OAG, PXE, and NVG groups, there were no significant differences in post-GDD cumulative rates of reoperation (P=0.33), corneal graft (P=0.26), or VT-complications (P=0.65) over time. For all eyes, the overall cumulative rates for each outcome measure increased beyond 5 years, and specific Kaplan-Meier rates (5-y, 10-y) included: reoperation (16%, 25%), corneal graft (6%, 12%), VT-complications (9%, 14%). When comparing specific GDDs, the Ahmed FP7 had a higher cumulative reoperation rate over time compared with the Baerveldt 350 (P=0.019). Glaucoma type did not significantly affect post-GDD cumulative rates of reoperation, corneal graft, and VT-complication among the OAG, PXE, and NVG groups. For all eyes, cumulative rates of reoperation, corneal graft, and VT-complications increased beyond 5 years. The Ahmed FP7 had a significantly higher cumulative reoperation rate compared with the Baerveldt 350 over time.

Assessing patient cosmetic satisfaction after glaucoma drainage device surgery for different patch grafts

BackgroundThe use of a tissue patch graft is common practice with a glaucoma drainage device (GDD). Patch grafts can be visible in the palpebral fissure and may be cosmetically displeasing for some patients. The aim of this study was to report the cosmetic satisfaction of pericardial, scleral, and corneal patch grafts related to superior GDD surgery.MethodsBaseline clinical data were collected for consecutive patients with glaucoma operated between 2014 and 2019 at two tertiary eye care institutions (for superiorly-placed) Ahmad glaucoma valve implant using sclera, cornea and pericardium patch graft. A patient questionnaire that contained 4 concise questions, with a Likert-scale grading relating to cosmetic satisfaction was administered by a telephone-based interview. Responses and scores for each question were compared across patients who received the three different types of graft. A binominal logistic regression analysis was used to assess the effects of age, gender, type of graft, number of previous ocular surgeries, and final visual acuity to explain differences.ResultsWe included 92 patients who met our inclusion criteria (24 patients received a corneal patch graft, 30 who received sclera and 38 who received pericardium). The mean (±SD) age was 50 (±17.5) years, and the average follow up was 20.7 (± 18.6) months. Regardless of the type of patch graft, most (67–84%) of patients were satisfied with the appearance of their eyes. Patients who received cornea or sclera were more likely to report that their eye looked ‘abnormal’ by others. Younger age was significantly associated with the response to this question.ConclusionPatients are generally satisfied with the appearance of their eye following GDD surgery with each of the patch grafts for superiorly-placed GDDs. Younger patients with cornea or sclera were more likely to report that their eyes looked abnormal.

Glaucoma Drainage Device Technique in a Cohort of Experienced Glaucoma Surgeons in Australia and New Zealand.

To evaluate current practice patterns of surgical techniques for GDD among Australia and New Zealand Glaucoma Society members routinely performing GDD surgery. Survey of surgeons who performed more than 20 GDD in past 5 years. Surgeon participation rate was 31/32 (96.8%). The most common surgical techniques were Baerveldt GDD (24/32, 77.4%), superotemporal placement (31/31, 100%), and peribulbar anesthesia (21/31, 67.7%). Mitomycin C antimetabolite was used routinely by 9/31 surgeons (29.0%). Most surgeons employed intraluminal stents (23/31, 74.2%) with tube fenestrations (19/31, 61.3%). GDD was placed behind the recti muscles (27/31, 87.1%) and secured with nylon (8/0, 9/0 or 10/0) by 29/31 (93.6%). Most common sclerostomy techniques for tube insertion was a 23-G needle passed ab externo (18/31, 58.1%). Tube placement was in the sulcus (11/31, 35.5%) for pseudophakic patients. The external portion of the tube was most commonly covered with a full-thickness scleral patch graft (21/31, 67.7%). Majority of surgeons (21/31, 67.7%) reviewed patients 3 to 4 times in the first month. Although a wide range of practice patterns for GDD implantation exists among Australia and New Zealand Glaucoma Society surgeons, there are consistent techniques currently in use to optimize patient outcomes. This report can help surgeons seeking to improve outcomes and minimize complications when trialing the different surgical options.

Evaluation of Long-Term Visual Field Function in Patients Undergoing Glaucoma Drainage Device Implantation

To determine the change in global and regional Humphrey visual fields (VF) after glaucoma drainage device (GDD) implantation over a 3-year follow-up period. Retrospective interventional case series. Patients undergoing GDD placement from between 2010 and 2015 with reliable preoperative and yearly postoperative VF measurements were included. Clinical parameters were compared between preoperative and follow-up visits, including visual acuity, intraocular pressure (IOP), number of glaucoma medications, global VF metrics (mean deviation [MD]), pattern standard deviation (PSD), CIGTS (Collaborative Initial Glaucoma Treatment Study) score of total deviation probability (CIGTS_TDP) and pattern deviation probability (CIGTS_PDP), and regional metrics (regional total deviation (TD), regional pattern deviation (PD), and regional CIGTS_TDP and CIGTS_PDP). Multivariate regression analyses were performed to determine risk factors for VF worsening after GDD surgery. A total of 106 eyes from 95 patients were included. Mean IOP ± SD was reduced from 23.1 ± 8.5mm Hg to 12.7 ± 3.1mm Hg at 3-year follow-up (P < .001). MD, PSD, and global CIGTS_PDP showed no significant changes in follow-up, whereas global CIGTS_TDP showed mild progression from 10.7 to 12.8 at 3-year follow-up (P= .01). No regional metrics showed worsening at follow-up examinations. Defects in the superior hemifield were more common than in the inferior hemifield at baseline and follow-up examinations for all regional metrics. Pre-operative number of glaucoma medications was associated with worsening on CIGTS_TDP. Overall, GDD surgery is effective at stabilizing VF function over 3 years of follow-up. The superior hemifield is affected more than other regions. The number of pre-operative glaucoma medications is associated with mild VF progression, measured by CIGTS_TDP.

Contemporary management of refractory pediatric glaucoma

The management of pediatric glaucoma poses a unique challenge in terms of maintaining lifelong vision and combating an aggressive scarring response from surgery. Contemporary literature regarding the surgical management of children with pediatric glaucoma who fail, or are at a high risk of failure, from conventional surgery is limited. The aim of this review is to highlight recent developments in relation to the current opinion regarding the management of children with refractory pediatric glaucoma. Some studies have reported impressive success rates with circumferential trabeculotomy, even in eyes with previous failed surgery. Early results of deep sclerectomy in populations which may not respond well to conventional angle surgery are encouraging but data is limited for the pediatric age group. In compliant patients in whom multiple postoperative examinations under anesthesia are possible, trabeculectomy remains an effective procedure. Multiple recent studies have demonstrated that glaucoma drainage device (GDD) surgery is associated with 5-year success rates of over 70% in primary childhood glaucomas. Glaucoma drainage device surgery is likely to remain a mainstay of surgical management for refractory glaucoma in older children. More prospective data are needed on the success of circumferential trabeculotomy, deep sclerectomy and micropulse laser in pediatric eyes with previous failed surgery. VIDEO ABSTRACT: http://links.lww.com/COOP/A34.

Electron Beam Irradiated Corneal Versus Gamma-Irradiated Scleral Patch Graft Erosion Rates in Glaucoma Drainage Device Surgery.

IntroductionPatch graft erosion and implant exposure is a known complication of glaucoma drainage device (GDD) surgery. Recently, electron beam (e-beam) irradiated corneal tissue ha s become available; however, limited data exist on the rates of erosion for e-beam irradiated corneal grafts compared to traditional scleral grafts after GDD surgery.MethodsThis retrospective study examines the records of 253 eyes from 225 adult subjects who underwent GDD surgery with either e-beam irradiated corneal or scleral grafts at the Casey Eye Institute by five surgeons between April 22, 2014 and October 11, 2017. Surgical procedures and the occurrence of graft erosion were determined using billing codes and verified by manual review of electronic health records.ResultsThe average age at the time of surgery was 61.3 ± 17.5 years (n = 200) and 60.8 ± 16.8 years (n = 53) for the e-beam irradiated cornea and sclera groups, respectively. The average follow-up time post-surgery was 416 ± 345 days and 495 ± 343 days for the e-beam irradiated cornea and sclera groups, respectively. There were no statistically significant differences in sex, age, follow-up time, and glaucoma diagnosis between the groups; however, the e-beam irradiated cornea group was statistically more likely to have an Ahmed implant as compared to the sclera group. No erosion events were noted in either group.Conclusione-Beam irradiated corneal grafts were used 3.8 times more frequently relative to scleral grafts, yet there were no cases of graft erosion in either group during the follow-up period.