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      Safety and Efficacy of Second Ahmed Valve Implant in Refractory Glaucoma

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          Abstract

          Background: Refractory glaucoma still represents a challenge for ophthalmologists to manage intraocular pressure. The present study aimed to evaluate long term efficacy and safety of a second Ahmed valve implantation after the failure of a first implant in patients with refractory glaucoma and elevated intraocular pressure (IOP). Methods: Retrospective, multicenter non-comparative case series. Twenty-eight patients were retrospectively recruited between January 2011 and December 2017. Demographic data, glaucoma type, visual acuity, intraocular pressure, medical therapy, and complications were registered. Three criteria of success were established: Type 1 surgical success: IOP ≤ 15 mmHg and a reduction of IOP ≥ 40% from baseline; Type 2 surgical success: IOP ≤ 18 mmHg and a reduction of IOP ≥ 30% from baseline; and Type 3 surgical success: IOP ≤ 21 mmHg and a reduction of IOP ≥ 20% from baseline. Surgical failure has been established as IOP less than 5 mmHg or over 21 mmHg and less than a 20% reduction of IOP from baseline despite medications in two consecutive visits, light perception loss referable to glaucoma, and the necessity for further glaucoma surgery. Failure was observed in six (21%) patients. (3) Results: Mean IOP and mean glaucoma medication number significantly reduced from baseline after the second implantation, and the surgical success rate at 72 months ranged from 10% to 78% based on the different criteria of success. Failure was observed in six (21%) patients. Conclusions: This study confirmed the safety and efficacy of a second Ahmed valve implantation in patients with refractory glaucoma and elevated IOP at baseline.

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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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            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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              Long-term outcomes of Ahmed glaucoma valve implantation in refractory glaucomas.

              To evaluate the long-term efficacy of intraocular pressure (IOP) reduction and complications of Ahmed glaucoma valve (AGV) implantation (New World Medical, Inc, Rancho Cucamonga, California, USA) in refractory glaucoma. Retrospective cohort study. Retrospective medical records from 64 patients (78 eyes) with refractory glaucoma who underwent AGV implantation with a minimum of three years of follow-up were reviewed. Data regarding age, gender, race, eye laterality, specific glaucoma diagnosis, best-corrected visual acuity (BCVA), number of medications, IOP, visual fields, surgical complications, and follow-up interval were collected from all visits and were analyzed. The primary outcome measure was cumulative probability of success defined as IOP of less than 21 mm Hg and of 5 mm Hg or more with a minimum of 15% reduction from baseline IOP, without additional glaucoma surgery or loss of light perception. Secondary outcomes included IOP and number of medications at three, six, 12, 24, 36, 48, and 60 months after surgery, surgical complications, and final BCVA. The cumulative probability of success was 80% and 49% at one and five years, respectively. IOP was reduced from a mean of 30.4 +/- 10.7 mm Hg to 17.0 +/- 5.0 mm Hg at 12 months and 15.9 +/- 3.0 mm Hg at 60 months (P < .001). The number of medications decreased from 3.2 +/- 1.0 medications at baseline to 1.6 +/- 0.4 at 12 months and 2.1 +/- 0.2 at 60 months (P < .001). Prior glaucoma surgery and the silicone type of AGV were statistically significant risk factors for failure (P < .001). Approximately 50% of single-plate AGV implantations in refractory glaucoma were considered successful after five years of follow-up. Prior glaucoma surgery was a statistically significant risk factor for failure.
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                Author and article information

                Journal
                J Clin Med
                J Clin Med
                jcm
                Journal of Clinical Medicine
                MDPI
                2077-0383
                29 June 2020
                July 2020
                : 9
                : 7
                : 2039
                Affiliations
                [1 ]Department of Surgical, Medical and Molecular Pathology and of the Critical Area, University of Pisa, 56126 Pisa, Italy; marco.nardi@ 123456med.unipi.it (M.N.); michele.figus@ 123456unipi.it (M.F.)
                [2 ]Department of General Ophthalmology and Pediatric Ophthalmology Service, Medical University of Lublin, 20079 Lublin, Poland; toro.mario@ 123456email.it (M.D.T.); robertrejdak@ 123456yahoo.com (R.R.)
                [3 ]Faculty of Medical Sciences, Collegium Medicum Cardinal Stefan Wyszyński University, 01815 Warsaw, Poland
                [4 ]Department of Diagnostics and Microsurgery of Glaucoma, Medical University, 20079 Lublin, Poland; zarnowskit@ 123456poczta.onet.pl (T.Ż.); dpozarowska@ 123456wp.pl (D.P.)
                [5 ]Eye Clinic, University of Catania, 20079 Catania, Italy; antlongo@ 123456unict.it
                [6 ]Department of Clinical and Experimental Medicine, University of Pisa, 95123 Pisa, Italy; mario.miccoli@ 123456med.unipi.it
                Author notes
                [* ]Correspondence: chiara.posarelli@ 123456med.unipi.it ; Tel.: +39-050-997-675
                Author information
                https://orcid.org/0000-0003-0222-5177
                https://orcid.org/0000-0001-7152-2613
                https://orcid.org/0000-0002-6978-7417
                https://orcid.org/0000-0003-2243-9033
                Article
                jcm-09-02039
                10.3390/jcm9072039
                7408983
                32610602
                a98c9a81-0e36-436b-96ed-4660c5df1672
                © 2020 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 09 June 2020
                : 28 June 2020
                Categories
                Article

                refractory glaucoma,ahmed glaucoma valve implantation,intraocular pressure

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