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  • Aqueous Shunts with Extraocular Reservoir for Open-Angle Adult Glaucoma

    AAO OTAC Glaucoma Panel, Hoskins Center for Quality Eye Care
    Glaucoma
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    Abstract

     A report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Glaucoma Panel.

    Vikas Chopra, MD;1 
    Hana L. Takusagawa, MD;    2 
    Jullia A. Rosdahl, MD, PhD;    3
    Arthur J. Sit, SM, MD;4 
    Grace M. Richter, MD, MPH;    5,6 
    Yvonne Ou, MD;    7 
    Stephen J. Kim, MD;8 Darrell WuDunn, MD, PhD9

    Ophthalmology, Vol. 131, Issue 2, P227-239 © 2023 by the American Academy of Ophthalmology. Click here for free access to the OTA.

    Purpose: To evaluate the recently published literature on the efficacy and safety of the use of aqueous shunts with extraocular reservoir for the management of adult open-angle glaucomas (OAGs).

    Methods: A search of peer-reviewed literature was last conducted in April 2023 of the PubMed database and included only articles published since the last aqueous shunt Ophthalmic Technology Assessment, which assessed articles published before 2008. The abstracts of these 419 articles were examined, and 58 studies were selected for full-text analysis. After inclusion and exclusion criteria were applied, 28 articles were selected and assigned ratings by the panel methodologist according to the level of evidence. Twenty-five articles were rated level I and 3 articles were rated level II. There were no level III articles.

    Results: Implantation of aqueous shunts with extraocular reservoir can lower intraocular pressure (IOP) by between one-third and one-half of baseline IOP, depending on whether it is undertaken as the primary or secondary glaucoma surgery. Success rates for aqueous shunts were found to be better than for trabeculectomies in eyes with prior incisional surgery. Conversely, in eyes without prior incisional surgery, implantation of aqueous shunts was found to have an overall lower success rate as the primary glaucoma procedure compared with trabeculectomy. Although both valved and nonvalved aqueous shunts with extraocular reservoir were effective, the nonvalved device generally achieved slightly lower long-term IOPs with fewer glaucoma medications and less need for additional glaucoma surgery. Both devices slow the rates of visual field progression with efficacy comparable with that of trabeculectomy. Early aqueous humor suppression after aqueous shunt implantation is recommended for the management of the postoperative hypertensive phase and long-term IOP control. No strong evidence supports the routine use of mitomycin C with aqueous shunt implantation for OAG.

    Conclusions: Implantation of aqueous shunts with extraocular reservoir, including valved or nonvalved devices, has been shown to be an effective strategy to lower IOP. Strong level I evidence supports the use of aqueous shunts with extraocular reservoir by clinicians for the management of adult OAG.

    1Doheny Eye Centers UCLA and Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California 
    2VA Eugene Healthcare Center, Eugene, Oregon and Casey Eye Institute, Oregon Health & Sciences University, Portland, Oregon
    3Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina 
    4Mayo Clinic, Department of Ophthalmology, Rochester, Minnesota
    5Department of Ophthalmology, Southern California Permanente Medical Group, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California 
    6USC Roski Eye Institute, Keck Medicine of University of Southern California, Los Angeles, California
    7Department of Ophthalmology, University of California San Francisco, San Francisco, California 
    8Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, TN 
    9University of Florida College of Medicine—Jacksonville, Department of Ophthalmology, Jacksonville, Florida