The Ahmed drainage implant in the treatment of pediatric glaucoma

doi:10.1016/S0002-9394(02)02274-2

American Journal of Ophthalmology

Volume 135, Issue 6, June 2003, Pages 821-829

https://doi.org/10.1016/S0002-9394(02)02274-2 Get rights and content

Abstract

Purpose

To report the safety and efficacy of Ahmed Glaucoma Valve (New World Medical, Inc., Rancho Cucamonga, California, USA) implantation for the management of pediatric glaucoma in the early and intermediate follow-up period.

Design

Consecutive interventional case series.

Methods

A retrospective chart review was conducted on 60 eyes (44 patients, age range at surgery 1.5 months to 16 years, average 6 ± 4.9 years), with pediatric glaucoma that underwent Ahmed Glaucoma Valve implantation for medically uncontrolled intraocular pressure (IOP) between the years 1995 and 2000. Outcome measures were control of IOP below 21 mm Hg, the need for antiglaucoma medications after surgery, and loss of 2 or more lines of Snellen acuity. Complications were monitored.

Results

The postoperative follow-up period for each eye averaged 24.3 ± 16 months (range, 3 to 60 months). At last follow-up, IOP was controlled in 44 eyes (73%), 11 of which did not need antiglaucoma therapy. Kaplan-Meier life-table analysis showed probability of success with or without medications of 93% (95% confidence interval [CI], 86%–100%), 86% (95% CI, 77%–96%), 71% (95% CI, 59%–87%), and 45% (95% CI, 28%–80%) after 12, 24, 36, and 48 months of follow-up. Average IOP decreased from 32.8 ± 6.2 before surgery to 16.6 ± 8.0 postoperatively (P < .0001). The average number of medications used decreased from 4.4 ± 1.97 to 2.0 ± 2.0 (P < .0001). Kaplan-Meier survival analysis did not reveal any difference in survival profiles related to specific diagnosis of glaucoma, age (above or below 18 months), or prior surgery. Complications occurred in 30 eyes (50%). Although most resolved or were treated successfully, four patients had severe visual loss during the follow-up. Uveitis was a significant risk factor for tube exposure (Fisher exact test, P = .006).

Conclusions

Ahmed Glaucoma Valve implantation is an effective treatment for pediatric glaucoma, although patients frequently require antiglaucoma medications. However, a high rate of potentially sight-threatening postoperative complications warrants ongoing close follow-up.

Section snippets

Design

Study design was a consecutive, interventional case series.

Methods

We conducted a retrospective chart review of all patients who underwent Ahmed Glaucoma Valve implantation at The Hospital for Sick Children, Toronto, Canada, from April 1, 1995, through April 30, 2000. The retrospective review of patient charts for this study was approved by the hospital’s research ethics board. All surgeries were done by the senior author (A.V.L.), who was also present at almost all follow-up examinations. In all cases, the indication for surgery was glaucoma not sufficiently

Results

The study group included 44 consecutive patients who underwent Ahmed Glaucoma Valve Implant insertion in 60 eyes. In four eyes, a second Ahmed valve was implanted after failure of the first device, bringing the total number of implanted valves to 64. However, to avoid confusion, these four valves were not included in the statistical analysis, and the eyes were counted as failures. Table 1 summarizes the demographics of our study population. In 46 eyes of 32 patients (46 of 60, 77%, and 32 of

Discussion

Management of pediatric glaucoma that does not respond satisfactorily to medical treatment or is not considered suitable for angle or filtering surgery is difficult. The higher failure rate of trabeculectomy in children and long-term complications of intraoperative antimetabolites warrant consideration of alternative interventions.23, 24 Because of associated complications, including chronic hypotony, phthisis, and cataract, cyclodestruction is often reserved for eyes that have poor visual

References (38)

D.R. Anderson
Trabeculotomy compared to goniotomy for glaucoma in children
Ophthalmology
(1983)
R.H. Taylor et al.
The epidemiology of pediatric glaucomathe Toronto experience
J AAPOS
(1999)
A.K. Mandal et al.
Mitomycin C-augmented trabeculectomy for refractory congenital glaucoma
Ophthalmology
(1997)
J.A. Englert et al.
The Ahmed valve in refractory pediatric glaucoma
Am J Ophthalmol
(1999)
N.G. Hamush et al.
Ahmed glaucoma valve implants for management of glaucoma in Sturge-Weber syndrome
Am J Ophthalmol
(1999)
D.S. Minckler et al.
Clinical experience with the single-plate Molteno implant in complicated glaucomas
Ophthalmology
(1988)
R. Hill et al.
Molteno implantation for glaucoma in young patients
Ophthalmology
(1991)
S.P. Donahue et al.
Baerveldt implant surgery in the treatment of advanced childhood glaucoma
J AAPOS
(1997)
T.E. Eid et al.
Long-term effects of tube-shunt procedures on management of refractory childhood glaucoma
Ophthalmology
(1997)
M.R. Djodeyre et al.
Clinical evaluation and risk factors of time to failure of Ahmed glaucoma valve implant in pediatric patients
Ophthalmology
(2001)

B.A. Francis et al.

Characteristics of glaucoma drainage implants during dynamic and steady-state flow conditions

Ophthalmology

(1998)

A.D. Beck et al.

Trabeculectomy with adjunctive mitomycin C in pediatric glaucoma

Am J Ophthalmol

(1998)

S.F. Freedman et al.

Mitomycin C–augmented trabeculectomy with postoperative wound modulation in pediatric glaucoma

J AAPOS

(1999)

S. Melamed et al.

Post-operative complications after Molteno implant surgery

Am J Ophthalmol

(1991)

A. Da Mata et al.

Management of uveitic glaucoma with Ahmed valve implantation

Ophthalmology

(1999)

T.K. Tanji et al.

Fascia lata patch graft in glaucoma tube shunt surgery

Ophthalmology

(1996)

A. Coleman et al.

Initial experience with the Ahmed glaucoma valve implant

Am J Ophthalmol

(1995)

S.L. Smith et al.

Early clinical experience with the Baerveldt 350 mm glaucoma implant and associated extraocular muscle imbalance

Ophthalmology

(1993)

R.J. Susanna et al.

Mitomycin as adjunct chemotherapy with trabeculectomy in congenital and developmental glaucoma

J Glaucoma

(1995)

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Efficacy of Ahmed and Baerveldt glaucoma drainage device implantation in the pediatric population: A systematic review and meta-analysis
2023, Survey of Ophthalmology
Glaucoma drainage devices (GDD) are increasingly utilized in the management of childhood glaucoma. This systematic review and meta-analysis assesses the efficacy of first-time Ahmed or Baerveldt implantation in children. PubMed, Embase, and Cochrane Library were searched for relevant English-language, peer-reviewed literature. Postoperative outcomes were pooled using random effects regression models with restricted maximum likelihood estimation. Thirty-two studies (1,221 eyes, 885 children) were included. Mean ± standard deviation preoperative IOP was 31.8 ± 3.4 mm Hg. Pooled mean IOP at 12 and 24 months postoperatively were 16.5 mm Hg (95% CI, 15.5–17.6) and 17.6 mm Hg (95% CI, 16.4–18.7), respectively. Pooled proportions of success were 0.87 (95% CI, 0.83–0.91) at 12 months, 0.77 (95% CI, 0.71–0.83) at 24 months, 0.54 (95% CI, 0.44–0.65) at 48 months, 0.60 (95% CI, 0.48–0.71) at 60 months, and 0.37 (95% CI, 0.32–0.42) at 120 months. There were no differences in proportion of success at 12 and 24 months among eyes that received Ahmed and Baerveldt tube shunts, nor between eyes with primary glaucoma, glaucoma following cataract surgery, or other secondary glaucoma. Our findings show that Ahmed and Baerveldt shunts substantially reduced IOP for at least 24 months in childhood glaucoma, with similar findings among device types and glaucoma etiologies.
Risk Factors for Glaucoma Drainage Device Exposure in Children: A Case-Control Study
2023, American Journal of Ophthalmology
To identify the risk factors for glaucoma drainage device (GDD) exposure in children.
Retrospective case-control study.
The study population comprised children (one eye each) who presented with a history of GDD exposure to a tertiary care eye hospital over the period January 2014 to January 2020. Consecutive children (age <18 years) were included. A control group from the same time period (children without GDD exposure) were included in the ratio of 5 controls to every 1 case of exposure. The main outcome measures included risk factors for exposure (univariate and multivariate analysis).
A total of 21 eyes (of 21 children with implant exposure) and 115 eyes (of 115 children without exposure) were included in this study. During the same study period, a total of 494 eyes had undergone GDD implantation, giving an estimated incidence of exposure of 4.25%). In the bivariate analysis, GDD exposure was associated with multiple previous ocular surgeries (P = .001), longer follow-up duration (P < .001), combined procedure at the time of primary implantation (P = .002), and a younger age at the time of primary implantation (P = .006). The former 3 risk factors continued to prove a statistically significant association on multivariable regression analysis. Postoperative use of eye lubricants was more common among children in the control group (P = .007).
In pediatric glaucoma patients, younger age and combined procedure at the time of primary GDD implantation, in addition to multiple previous ocular surgeries, were associated with greater risk of implant exposure. Postoperative use of eye lubricants may be protective.
Infectious and Sterile Endophthalmitis in Eyes with Glaucoma Drainage Device from Two Large Ophthalmic Institutions
2021, Ophthalmology Glaucoma
To describe the predisposing factors, presentation, management, and outcome of glaucoma drainage implant (GDI)-associated endophthalmitis.
Retrospective chart review.
Eyes that developed GDI-associated endophthalmitis between December 1, 2011, and December 23, 2019, at the Duke Eye Center and Cole Eye Institute.
Patient data search was performed on the basis of diagnostic codes for GDI and endophthalmitis. Endophthalmitis was defined clinically according to each physician’s discretion. Eyes with infection source other than GDI were excluded. Worse vision was defined as a decrease of more than 2 Snellen lines. Data were collected on baseline demographics, systemic and ocular comorbidities, ocular surgical history, best-corrected visual acuity (BCVA), intraocular pressure (IOP), clinical presentation, eye culture results, and treatments performed. Statistical analysis included the paired t test and odds radio calculations.
Visual acuity and IOP at final follow-up.
Thirty cases (0.7%) of GDI endophthalmitis were identified among 4073 GDIs performed at the 2 institutions with active follow-up. Device exposure was identified in 20 eyes (67%) on presentation. The average follow-up after presentation was 22.4 ± 25 months. The most frequently identified organism on culture was Streptococcus pneumoniae. Same-day injection of intravitreal antibiotics was the universal first-line therapy. From baseline to final follow-up, the mean BCVA decreased from −0.84 ± 0.77 to −1.30 ± 0.93 (logarithm of the minimum angle of resolution, P = 0.02). Mean IOP did not change from baseline to final visit in the overall cohort (16.2 ± 8.2 mmHg to 14.6 ± 9.4 mmHg, P = 0.30) and in the subgroup that underwent tube explant (15.9 ± 5.5 mmHg to 15.2 ± 10.4 mmHg, P = 0.97). Eighteen of 20 tube exposure cases (90%) underwent tube explant, 1 underwent tube revision, and 1 re-epithelialized.
Glaucoma drainage implant–associated endophthalmitis was correlated with poor visual outcome. Immediate intravitreal antibiotic delivery was a universal first-line therapy. Tube exposure was a necessary risk factor for late-onset endophthalmitis and required surgical removal or repair.
Long-term outcomes of the Ahmed glaucoma valve surgery in childhood glaucoma
2020, Journal of AAPOS
To report the rates of success of Ahmed glaucoma valve (AGV) surgery in early childhood glaucoma and factors associated with success.
Children with primary congenital or early childhood secondary glaucoma who underwent AGV surgery over a 10-year period (one eye per child) at a single institution were identified. Surgical failure was defined as having one or more of the following: intraocular pressure of >21 mm Hg 3 months postoperatively, reoperation for glaucoma, and vision loss to no light perception.
A total of 178 patients were identified (median age, 5.8 ± 5.5 years): 125 with primary congenital and 53 with secondary childhood glaucoma. The success rate at 1 year was 92% (95% CI, 88%-96%); at 5 years, 64% (95% CI, 55%-73%); and at 10 years, 36% (95% CI, 25%-52%). Younger age at baseline (P = 0.003) and secondary childhood glaucoma (P = 0.045) were associated with lower success.
The AGV is associated with high short-term success in children with primary congenital glaucoma, but the 10-year success rates are poor. Younger age and secondary childhood glaucoma may be associated with a more refractory outcome.
Ocular hypotony: A comprehensive review
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Ocular hypotony is an infrequent, yet potentially vision-threatening, entity. The list of differential causes is extensive, involving any condition that may compromise aqueous humor dynamics or the integrity of the globe and sometimes following medical treatments or procedures. Depending on the cause and the clinical impact, treatment options aim to correct the underlying pathology and to reestablish anatomical integrity, as well as visual function. We review the pathophysiology, clinical presentation, different causes, and associated therapeutic options of ocular hypotony.
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^☆: Internet Advance publication at ajo.com Feb 26, 2003.

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The Ahmed drainage implant in the treatment of pediatric glaucoma☆

Abstract

Purpose

Design

Methods

Results

Conclusions

Section snippets

Design

Methods

Results

Discussion

Ophthalmology

J AAPOS

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

J AAPOS

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

J AAPOS

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Mitomycin as adjunct chemotherapy with trabeculectomy in congenital and developmental glaucoma

J Glaucoma