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      Long-term clinical outcomes of Ahmed valve implantation in patients with refractory glaucoma

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          Abstract

          Purpose

          To evaluate the long-term efficacy of intraocular pressure (IOP) reduction and complications of Ahmed Glaucoma Valve (AGV) implantation in patients with refractory glaucoma.

          Design

          Retrospective study.

          Subjects

          The study involved 302 refractory glaucoma patients who underwent AGV implantation and had a minimum follow-up of 6 months between March 1995 and December 2013.

          Methods

          An operation was defined as successful when (1) the postoperative IOP remained between 5 and 21 mmHg and was reduced 30% compared to the baseline IOP with or without medication, (2) there was no loss of light perception or vision-threatening severe complications, and (3) no additional filtering or aqueous drainage surgery was required. Clinical records were reviewed.

          Main outcome measures

          IOP, anti-glaucoma medications, and complications

          Results

          The mean follow-up period was 62.25 months (range, 6 to 190 months). The cumulative probability of success was 89% at 6 months, 81% at 1 year, 66% at 3 years, 44% at 10 years, and 26% at 15 years. IOP was reduced from a mean of 32.2 ± 10.5 mmHg to 18.6 ± 9.1 mmHg at 1 month, 15.2 ± 7.0 mmHg at 6 months, and 14.2 ± 3.5 mmHg at 15 years. Surgical failures were significantly increased when preoperative IOP was high, and when severe complications occurred after AGV implantation (P < 0.05).

          Conclusion

          AGV implantation was successful for IOP control in patients with refractive glaucoma in the long term. However, the success rate of surgery decreased over time. Preoperative high IOP and severe complications related to the operation were significant risk factors for failure.

          Related collections

          Most cited references 25

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          A clinical study of the Ahmed glaucoma valve implant in advanced glaucoma.

          To assess clinical outcomes and establish the incidence and management of a hypertensive phase (HP) (defined as intraocular pressure [IOP] > 21 mmHg in the first 6 postoperative months) in patients with Ahmed glaucoma valve implant. Retrospective noncomparative case series. A total of 85 patients were included in the current study, including consecutive patients who had intractable glaucoma and underwent Ahmed valve implant insertion at the University Glaucoma Center, Tampa, Florida (DWR and WEL) and the Massachusetts Eye and Ear Infirmary (PAN) between January 1993 and June 1997. Only patients with a minimum of 6 months' follow-up were included. Ahmed glaucoma valve implant insertion to control intractable glaucoma was performed. Success was defined as IOP less than 22 mmHg and greater than 4 mmHg on the last two visits, a decrease of no more than two lines in the visual acuity and no additional surgical interventions to control IOP. The cumulative probability of success at 12 months was 77%. A total of 26 patients (30.6%) failed during the study period, and 70 patients (82%) exhibited HP. Hypertensive phase peaked at 1 month after the operation and stabilized at 6 months. There were 34 patients (48%) with HP who were controlled with additional medications: 14 (20%) with needling and 5-fluorouracil injections and 20 (28%) who needed secondary surgical intervention. There were 8 patients (9.4%) who exhibited hypotony (< 5 mmHg) on postoperative day 1 and 3 (3.5%) at 3 months. Visual acuity returned to baseline between 3 and 6 months after the operation. The major complications associated with the valve were hyphema in 14 cases (16.5%), suprachoroidal hemorrhage in 4 cases (4.7%), end-plate exposure in 10 cases (11.7%), tube exposure in 6 cases (7%), tube block in 4 cases (4.7%), loss of vision in 5 cases (5.8%), and corneal graft failure in 4 (30%) of 13 cases with clear grafts. The overall success rate is comparable to that of prior studies using different implants. The majority of the patients exhibit an HP that peaks at 1 month, with gradual stabilization over 6 months. One third of the patients needed secondary surgical intervention to control the HP. The incidence of postoperative hypotony and flat or shallow anterior chambers is very low after Ahmed glaucoma valve insertion.
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            Initial clinical experience with the Ahmed Glaucoma Valve implant.

            We studied the Ahmed Glaucoma Valve implant, an aqueous shunting device that has a unidirectional valve mechanism designed to prevent postoperative hypotony in eyes with intractable glaucoma. In this multicenter, prospective clinical trial, we studied 60 eyes (60 patients) with increased intraocular pressure or glaucoma that had not responded to medical treatment, laser photocoagulation, or previous glaucoma surgery, in which the Ahmed Glaucoma Valve implant was placed to decrease intraocular pressure. Success was defined as intraocular pressure less than 22 mm Hg and greater than 4 mm Hg for two months or longer, intraocular pressure that was lowered by at least 20% from preoperative values (in eyes with preoperative intraocular pressures less than 22 mm Hg), and no additional glaucoma surgery or visually devastating complications. Cumulative probability of success at 12 months was 78%. Eight (13%) of 60 eyes had intraocular pressure less than 5 mm Hg the first postoperative day. Two other eyes had shallow anterior chambers, which required anterior chamber reformation. The major complications associated with the use of the valve were serous choroidal detachments in 13 eyes (22%), blockage of the tube in six eyes (10%), malposition of the tube in four eyes (7%), a suprachoroidal hemorrhage in one eye (2%), and corneal graft rejections in three (19%) of 16 eyes with corneal grafts. Although the 12-month success with the Ahmed Glaucoma Valve implant is similar to that reported for other drainage devices, the complications associated with overfiltration in the immediate postoperative period appear to be less frequent than with other valved drainage devices. Randomized, prospective studies to compare the Ahmed Glaucoma Valve implant with other drainage devices are needed to make clinical comparisons of the different devices.
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              Evaluation of the hypertensive phase after insertion of the Ahmed Glaucoma Valve.

              To investigate the postoperative hypertensive phase (HP) in patients undergoing glaucoma drainage implant surgery. Interventional case series. A retrospective chart review of 156 consecutive eyes (139 patients) who underwent placement of an Ahmed Glaucoma Valve (AGV) with a follow-up of >or=3 months was performed. Main outcome measures were occurrence and resolution of the HP and intraocular pressure (IOP) control. The HP was defined as IOP > 21 mm Hg during the first 3 months after surgery. Resolution of the HP was defined as an IOP < 22 mm Hg and an IOP reduction of 3 mm Hg with the same or fewer number of glaucoma medications. An HP was observed in 88 eyes (56%). It occurred after a mean of 5.0 weeks (median, 4 weeks; range, 1-13 weeks) with an average (+/- standard deviation) peak IOP of 30.1 (+/- 7.5) mm Hg. Resolution of the HP occurred in 19 of 68 eyes (28%) with available data. Eyes with an HP had a higher mean IOP and needed more medications 6 to 12 months after surgery than eyes without an HP (17.2 +/- 5.6 vs 14.3 +/- 5.8 mm Hg; P =.012 and 1.7 +/- 1.2 vs 0.3 +/- 0.6 medications; P <.001, respectively). A hypertensive phase occurs frequently after implantation of the AGV. However, it resolves in only a minority of eyes. The majority of eyes with an HP have no significant improvement of IOP control and continue to require the same number of glaucoma medications as they did during the HP.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: Validation
                Role: ConceptualizationRole: Data curationRole: Investigation
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                2 November 2017
                2017
                : 12
                : 11
                Affiliations
                [1 ] Department of Ophthalmology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
                [2 ] Jeil Eye Clinic, Soowon, Korea
                [3 ] Nune Eye Hospital, Seoul, Korea
                [4 ] Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea
                Boston University School of Medicine, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-17-18978
                10.1371/journal.pone.0187533
                5667863
                29095931
                © 2017 Lee et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 4, Tables: 4, Pages: 13
                Product
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Ophthalmology
                Eye Diseases
                Glaucoma
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Ophthalmic Procedures
                Biology and Life Sciences
                Anatomy
                Head
                Eyes
                Medicine and Health Sciences
                Anatomy
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                Eyes
                Biology and Life Sciences
                Anatomy
                Ocular System
                Eyes
                Medicine and Health Sciences
                Anatomy
                Ocular System
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                Biology and Life Sciences
                Neuroscience
                Sensory Perception
                Vision
                Visual Acuity
                Biology and Life Sciences
                Psychology
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                Social Sciences
                Psychology
                Sensory Perception
                Vision
                Visual Acuity
                Biology and Life Sciences
                Anatomy
                Ocular System
                Ocular Anatomy
                Cornea
                Medicine and Health Sciences
                Anatomy
                Ocular System
                Ocular Anatomy
                Cornea
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Musculoskeletal System Procedures
                Trabeculectomy
                Medicine and Health Sciences
                Ophthalmology
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