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  • 2020–2021 BCSC Basic and Clinical Science Course™

    Go to Academy Store Learn more and Purchase.

    10 Glaucoma

    Chapter 13: Surgical Therapy for Glaucoma

    Trabeculectomy

    Postoperative Management

    Plate-based tube implants tend to require fewer interventions in the postoperative period compared with trabeculectomy. However, complications can occur (Table 13-5).

    Elevated IOP in the early postoperative period can have various causes. The hypertensive phase is marked by a sudden elevation of IOP after previously well-functioning surgery. Usually occurring between 3 weeks and 3 months after surgery, it is caused by decreased permeability of the capsule that forms around the end plate. Over time, the hypertensive phase may resolve as the capsule reorganizes and becomes more permeable to aqueous. Thus, management involves medical treatment to keep the pressure reasonably low while the capsule reorganizes. The incidence of this complication is higher with the Ahmed implant than with the Baerveldt implant, perhaps because the capsule is exposed to aqueous in the early postoperative period with the Ahmed device. Conversely, with Baerveldt implants, exposure of the capsule to aqueous is delayed by the ligature. The use of aqueous suppression early in postoperative management (when the IOP reaches approximately 10–12 mm Hg) is associated with a reduction in the incidence of the hypertensive phase and improved long-term outcomes. Evidence is mixed regarding the value of intraoperative or postoperative adjunctive MMC or 5-FU with tube shunt surgery; however, clinical trials are in progress.

    Other causes of elevated IOP in the postoperative period include a defective valve mechanism and occlusion. Tubes can become occluded with fibrin, blood, vitreous, or iris tissue. A peripheral iridotomy can remedy iris occlusion, while fibrin and heme will usually clear over time without intervention. Elevated IOP in Baerveldt shunts that have been ligated can be managed by applying a green or diode laser to the ligature with settings similar to those used for nylon suture lysis. If a rip cord has been placed, it can be pulled. However, if these procedures are performed too early, hypotony may ensue. Fenestrations can also be created at the slit lamp to provide temporary IOP relief while waiting for the ligature to dissolve.

    Shallow anterior chamber in the postoperative period occurs for reasons similar to those seen after trabeculectomy. Choroidal effusions and malignant glaucoma are managed in a similar fashion. Overfiltration may require a return to the operating room to either ligate the tube or place a suture in the lumen of the tube to restrict aqueous outflow.

    Tube erosion occurs in 1%–8% of plate-based tube implant surgeries (Fig 18-13). The causes include mechanical factors, immune response, and fragile conjunctiva overlying the tube. Tube erosion requires surgical correction, as patients with this complication are at high risk for infection. Repair may involve placing a new allograft, moving the tube to a different location, or removing the tube (Video 13-12). The risk of endophthalmitis after tube shunt surgery is about 0.5% in 5 years. Management of endophthalmitis often requires tube removal.

    Table 13-5 Complications of Tube Shunt Surgery and Options for Their Prevention and Management

    VIDEO 13-12 Tube revision.

    Courtesy of Chandrasekharan Krishnan, MD.

    Figure 13-18 Tube exposures increase the risk of developing endophthalmitis and should be repaired urgently.

    (Courtesy of Chandrasekharan Krishnan, MD.)

    Diplopia occurs in about 5% of patients. It is often due to displacement of the globe by a large bleb or injury or impingement of an extraocular muscle. Management with prisms is usually successful. If the deviation precludes prism use, strabismus surgery or tube removal may be indicated.

    • Bains U, Hoguet A. Aqueous drainage device erosion: a review of rates, risks, prevention, and repair. Semin Ophthalmol. 2018;33(1):1–10.

    • Cui QN, Hsia YC, Lin SC, et al. Effect of mitomycin C and 5-fluorouracil adjuvant therapy on the outcomes of Ahmed Glaucoma Valve implantation. Clin Exp Ophthalmol. 2017;45(2):128–134.

    • Pakravan M, Rad SS, Yazdani S, Ghahari E, Yaseri M. Effect of early treatment with aqueous suppressants on Ahmed Glaucoma Valve implantation outcomes. Ophthalmology. 2014;121(9):1693–1698.

    • Yazdini S, Doozandeh A, Pakravan M, Ownagh V, Yaseri M. Adjunctive triamcinolone acetonide for Ahmed Glaucoma Valve implantation: a randomized clinical trial. Eur J Ophthalmol. 2017;27(4):411–416.

    • Zheng CX, Moster MR, Khan MA, et al. Infectious endophthalmitis after glaucoma drainage implant surgery: clinical features, microbial spectrum, and outcomes. Retina. 2017;37(6):1160–1167.

    TREATMENT DECISIONS AND DATA

    Trabeculectomy or Tube Shunt Surgery?

    In the Tube Versus Trabeculectomy (TVT) Study, 212 eyes with uncontrolled glaucoma that had previously under gone trabeculectomy or cataract surgery were randomized into 2 treatment groups. One group had trabeculectomy with MMC (0.4 mg/mL for 4 minutes), while the other underwent Baerveldt tube shunt surgery (350 mm2).

    At 5 years, mean IOP and number of glaucoma medications were similar between the groups. However, there was a significantly higher failure rate (defined as IOP >21, <20% reduction of IOP, persistent IOP <5, or loss of light perception) in the trabeculectomy group, and that group also required more reoperations. The “complete success” rate (achieving successful IOP control without medication) and quality-of-life measures were similar between the 2 groups. The most common postoperative complications were shallow/flat anterior chamber, wound leak, and choroidal effusions in the trabeculectomy group. The most common postoperative complications in the tube group were shallow/flat anterior chamber, per sis tent corneal edema, and choroidal effusions. The trabeculectomy group required more postoperative clinic interventions. The rate of reoperation for complications was similar between the 2 groups. Importantly, over 40% of patients overall lost 2 or more lines of Snellen visual acuity over 5 years. This was not significantly different between the trabeculectomy and tube implant groups and was most commonly caused by cataract progression and per sis tent corneal edema.

    The ongoing Primary Tube Versus Trabeculectomy Study is similar to the TVT Study, except that the participants had no prior intraocular surgery. At 3 years, both the mean IOP and number of glaucoma medications were significantly lower in the trabeculectomy group. In addition, more patients were able to achieve the target IOP without medical therapy with trabeculectomy (44%) than with tube shunt (13%). There were no significant differences in complication rates between the groups at 3 years.

    • Gedde SJ, Feuer WJ, Shi W, et al; Primary Tube Versus Trabeculectomy Study Group. Treatment outcomes in the Primary Tube Versus Trabeculectomy Study after 1 year of follow-up. Ophthalmology. 2018; 125(5):650–663.

    • Gedde SJ, Herndon LW, Brandt JD, Budenz DL, Feuer WJ, Schiffman JC; Tube Versus Trabeculectomy Study Group. Postoperative complications in the Tube Versus Trabeculectomy (TVT) Study during five years of follow-up. Am J Ophthalmol. 2012;153(5):804–814.

    • Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL; Tube Versus Trabeculectomy Study Group. Treatment outcomes in the Tube Versus Trabeculectomy (TVT) Study after five years of follow-up. Am J Ophthalmol. 2012;153(5):789–803.

    • Kotecha A, Feuer WJ, Barton K, Gedde SJ; Tube Versus Trabeculectomy Study Group. Quality of life in the Tube Versus Trabeculectomy Study. Am J Ophthalmol. 2017;176:228–235.

    Valved Versus Nonvalved Plate-Based Tube Implants

    The Ahmed Baerveldt Comparison (ABC) Study and Ahmed Versus Baerveldt (AVB) Study compared the efficacy of the Ahmed FP7 and Baerveldt 350 implants over 5 years. A pooled data analysis showed that, at 5 years, the Baerveldt group had lower mean IOP (13.2 ± 4.8 mm Hg vs 15.8 ± 5.2 mm Hg) and were on fewer glaucoma medications (1.5 ± 1.4 vs 1.9 ± 1.5) than the Ahmed group. Visual acuity loss of 2 or more Snellen lines was similar between the groups (47% in the Ahmed group, 46% in the Baerveldt group). Failure rates (defined as IOP <6 or >18 mm Hg, IOP reduction <20% below baseline at 2 consecutive visits after 3 months, additional glaucoma procedures needed, or loss of light perception) were higher in the Ahmed group than in the Baerveldt group at 5 years (49% vs 37%). The most common reason for failure in both groups was elevated IOP.

    More patients had serious complications (defined as a complication requiring reoperation or a loss of visual acuity of 2 or more lines) in the Baerveldt group than in the Ahmed group. Of note, 4% of patients in the Baerveldt group had failure due to hypotony.

    • Budenz DL, Feuer WJ, Barton K, et al; Ahmed Baerveldt Comparison Study Group. Postoperative complications in the Ahmed Baerveldt Comparison Study during five years of follow-up. Am J Ophthalmol. 2016;163:75–82.e3.

    • Christakis PG, Zhang D, Budenz DL, Barton K, Tsai JC, Ahmed IIK; ABC-AVB Study Groups. Five-year pooled data analysis of the Ahmed Baerveldt Comparison Study and the Ahmed Versus Baerveldt Study. Am J Ophthalmol. 2017;176:118–126.

    Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.

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