ORIGINAL STUDY
Trabeculectomy With Mitomycin C or Ahmed Valve Implantation in Eyes With Uveitic Glaucoma Daniel I. Bettis, MD, Richard G. Morshedi, MD, Craig Chaya, MD, Jason Goldsmith, MD, Alan Crandall, MD, and Norm Zabriskie, MD
Purpose: To report and compare the results of trabeculectomy with mitomycin C (MMC) and Ahmed valve implantation in the management of uveitic glaucoma. Patients and Methods: The records of 41 eyes of 29 patients who underwent trabeculectomy with MMC or Ahmed valve implantation for uveitic glaucoma were retrospectively reviewed. Seventeen eyes underwent trabeculectomy with MMC, and 24 eyes underwent Ahmed valve implantation. Outcomes included postoperative intraocular pressure (IOP), percent reduction from preoperative IOP, postoperative number of medications, time to failure, and complications. Results: Mean follow-up was 21.2 months in the trabeculectomy group and 23.8 months in the valve group (P = 0.06). Mean IOP was reduced from 29.2 to 18.4 mm Hg in the trabeculectomy group (31.3%), compared with a reduction from 33.4 to 15.5 mm Hg in the Ahmed valve group (42.7%, P = 0.53). Postoperatively, 1.76 medications were used in the trabeculectomy group, compared with 1.83 medications in the Ahmed valve group (P = 0.89). Cumulative success at 1 year was 66.7% in the trabeculectomy group, compared with 100% in the Ahmed valve group (P = 0.02). Mean time to failure was 8.36 months with trabeculectomy, and 21.8 months with Ahmed valve (P = 0.02). Complications in both groups were typically rare and self-limited, with recurrent inflammation being most common. Conclusions: Although both trabeculectomy with MMC and Ahmed valve implantation are reasonable surgical options in the management of uncontrolled uveitic glaucoma, Ahmed valve implantation was associated with higher cumulative success rate at 1 year and a longer mean time to failure. Key Words: uveitis, glaucoma, trabeculectomy, Ahmed valve, glaucoma drainage implant
(J Glaucoma 2015;24:591–599)
U
veitis can cause elevated intraocular pressure (IOP) and glaucomatous optic neuropathy through a variety of mechanisms.1 In fact, uveitic glaucoma has been estimated to occur in 4% to 19% of patients with uveitis overall, and can even approach 100% in certain uveitic entities.1–3 Received for publication March 4, 2014; accepted October 8, 2014. From the Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT. Supported in part by an unrestricted grant from Research to Prevent Blindness Inc., New York, NY, to the Department of Ophthalmology and Visual Sciences, University of Utah. Disclosure: The authors declare no conflict of interest. Reprints: Norm Zabriskie, MD, Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT 84132 (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000195
J Glaucoma
Despite aggressive treatment with topical and systemic medications, some patients may require surgical intervention. Surgical management of patients with uveitic glaucoma is a complex and challenging problem for the ophthalmic surgeon. Any such intervention can lead to worsening inflammation and complications, and is ideally only performed when the inflammation is adequately controlled. However, impending optic neuropathy may necessitate surgical intervention even in the face of active inflammation. The choice of which operation to perform depends on a number of factors, such as age, inflammatory activity, prior ocular surgeries, conjunctival scarring, and the postoperative IOP goal. Several studies have retrospectively examined the results of trabeculectomy with mitomycin C (MMC)4–10 as well as Ahmed valve implantation11–16 in eyes with uveitic glaucoma. In addition, 1 study has retrospectively compared unenhanced trabeculectomy (no antimetabolites) with Molteno device implantation.17 However, to our knowledge, no studies have compared the results of trabeculectomy with MMC and Ahmed valve implantation in eyes with uveitic glaucoma. To explore the role these procedures may play in the management of uveitic glaucoma, we reviewed our surgical experience with 29 patients over a 9-year period.
PATIENTS AND METHODS We retrospectively reviewed the records of 29 patients who underwent trabeculectomy with MMC or Ahmed valve implantation for medically uncontrolled uveitic glaucoma at the John A. Moran Eye Center in Salt Lake City, Utah (a tertiary uveitis center), between April 2003 and September 2012. Exclusion criteria included likely steroid-induced glaucoma (based on a review of the medical record) and patients with 21 mm Hg despite medications on 2 consecutive visits, IOP < 6 mm Hg with structural complications of hypotony (choroidal effusions or hemorrhage, hypotony maculopathy, corneal folds, optic nerve edema, etc.), reoperation due to inadequately controlled IOP, or loss of light perception. Laser suture lysis was considered a part of the normal postoperative care of trabeculectomy and was therefore not considered a reoperation or failure. However, bleb revision or needling performed due to need for lower IOP (even if performed in the clinic) was considered a reoperation and failure. This study was reviewed and approved by the Institutional Review Board at the University of Utah (protocol # 00058536), and informed consent was not required.
chamber was reformed with an ophthalmic viscosurgical device (Viscoat; Alcon), which was left in place at the end of the surgery to avoid early postoperative hypotony. The tube was secured to the sclera using an 8-0 or 10-0 Vicryl mattress suture (TG140-8 or CS 140-6 needle, respectively; Ethicon), then human donor pericardium or sclera (Tutoplast; IOP Ophthalmics Inc., Costa Mesa, CA) was used to cover the tube and secured to the sclera using the same suture. The conjunctiva was then closed over the valve, tube, and donor tissue using the same suture.
Surgical Technique All trabeculectomies were performed using a fornixbased conjunctival peritomy. MMC was applied to the scleral bed beneath conjunctiva and Tenon’s capsule either before or after the creation of the scleral flap, depending on surgeon preference. Sponges soaked with 0.2 mg/mL MMC were applied for 90 seconds to 4 minutes at the discretion of the surgeon, followed by irrigation with balanced salt solution. The scleral flap was dissected anteriorly into the peripheral cornea, and an internal ostomy was created with a punch. A peripheral iridectomy was rarely needed, and only performed if deemed necessary due to narrow angles and potential for postoperative ostomy occlusion by iris tissue. Two to 4 10-0 nylon sutures (CS 160-6 needle; Ethicon, Blue Ash, OH) were used to secure the scleral flap until minimal leakage was noted during reformation of the anterior chamber. The conjunctiva and Tenon’s capsule were then reattached to the limbus using a 10-0 Vicryl running horizontal mattress suture (VAS 100-4 needle; Ethicon). Postoperatively, laser suture lysis was performed if there was noted to be an inadequate filtering bleb. One patient underwent implantation of an ExPress minishunt (Model P-50; Alcon, Fort Worth, TX), and this patient was analyzed with the trabeculectomy group. The surgery was performed as described above for trabeculectomy, except the minishunt was inserted into the anterior chamber underneath the scleral flap and just anterior to the scleral spur through an incision created by a 26-G needle. No trabecular block was excised. Ahmed valve implantation was performed in the superotemporal quadrant in all patients except one, in whom it was placed superonasally as it was his second glaucoma drainage implant (GDI). A fornix-based conjunctival peritomy was created with relaxing incisions superiorly and temporally, and dissection was carried down to bare sclera. After priming the Ahmed valve [model FP-7 or S2 (1 pediatric case); New World Medical Inc., Rancho Cucamonga, CA] with balanced salt solution, the leading edge of the plate was secured to the sclera 7 to 9 mm posterior to the limbus with 2 9-0 nylon sutures (TG 160-6 needle; Ethicon) through the suture eyelets. The tube was trimmed with the bevel up, and inserted into the anterior chamber through a 23-G needle incision. The anterior
Volume 24, Number 8, October/November 2015
Statistical Methods The qualitative and quantitative variables tested included the patients’ baseline characteristics and the results obtained at all available postoperative appointments. Descriptive statistics for baseline and study variables were performed. To analyze the first surgery in each subject, logistic regression was used to model the probability of either failure as defined by IOP > 21 mm Hg or the combination of failure plus those who required antiglaucoma medications for IOP control. Model covariates included sex, age, level of inflammation, and preoperative CAIs. Inflammation was recorded as 3 levels: quiet for >3 months, quiet for
Trabeculectomy With Mitomycin C or Ahmed Valve Implantation in Eyes With Uveitic Glaucoma Daniel I. Bettis, MD, Richard G. Morshedi, MD, Craig Chaya, MD, Jason Goldsmith, MD, Alan Crandall, MD, and Norm Zabriskie, MD
Purpose: To report and compare the results of trabeculectomy with mitomycin C (MMC) and Ahmed valve implantation in the management of uveitic glaucoma. Patients and Methods: The records of 41 eyes of 29 patients who underwent trabeculectomy with MMC or Ahmed valve implantation for uveitic glaucoma were retrospectively reviewed. Seventeen eyes underwent trabeculectomy with MMC, and 24 eyes underwent Ahmed valve implantation. Outcomes included postoperative intraocular pressure (IOP), percent reduction from preoperative IOP, postoperative number of medications, time to failure, and complications. Results: Mean follow-up was 21.2 months in the trabeculectomy group and 23.8 months in the valve group (P = 0.06). Mean IOP was reduced from 29.2 to 18.4 mm Hg in the trabeculectomy group (31.3%), compared with a reduction from 33.4 to 15.5 mm Hg in the Ahmed valve group (42.7%, P = 0.53). Postoperatively, 1.76 medications were used in the trabeculectomy group, compared with 1.83 medications in the Ahmed valve group (P = 0.89). Cumulative success at 1 year was 66.7% in the trabeculectomy group, compared with 100% in the Ahmed valve group (P = 0.02). Mean time to failure was 8.36 months with trabeculectomy, and 21.8 months with Ahmed valve (P = 0.02). Complications in both groups were typically rare and self-limited, with recurrent inflammation being most common. Conclusions: Although both trabeculectomy with MMC and Ahmed valve implantation are reasonable surgical options in the management of uncontrolled uveitic glaucoma, Ahmed valve implantation was associated with higher cumulative success rate at 1 year and a longer mean time to failure. Key Words: uveitis, glaucoma, trabeculectomy, Ahmed valve, glaucoma drainage implant
(J Glaucoma 2015;24:591–599)
U
veitis can cause elevated intraocular pressure (IOP) and glaucomatous optic neuropathy through a variety of mechanisms.1 In fact, uveitic glaucoma has been estimated to occur in 4% to 19% of patients with uveitis overall, and can even approach 100% in certain uveitic entities.1–3 Received for publication March 4, 2014; accepted October 8, 2014. From the Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT. Supported in part by an unrestricted grant from Research to Prevent Blindness Inc., New York, NY, to the Department of Ophthalmology and Visual Sciences, University of Utah. Disclosure: The authors declare no conflict of interest. Reprints: Norm Zabriskie, MD, Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT 84132 (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000195
J Glaucoma
Despite aggressive treatment with topical and systemic medications, some patients may require surgical intervention. Surgical management of patients with uveitic glaucoma is a complex and challenging problem for the ophthalmic surgeon. Any such intervention can lead to worsening inflammation and complications, and is ideally only performed when the inflammation is adequately controlled. However, impending optic neuropathy may necessitate surgical intervention even in the face of active inflammation. The choice of which operation to perform depends on a number of factors, such as age, inflammatory activity, prior ocular surgeries, conjunctival scarring, and the postoperative IOP goal. Several studies have retrospectively examined the results of trabeculectomy with mitomycin C (MMC)4–10 as well as Ahmed valve implantation11–16 in eyes with uveitic glaucoma. In addition, 1 study has retrospectively compared unenhanced trabeculectomy (no antimetabolites) with Molteno device implantation.17 However, to our knowledge, no studies have compared the results of trabeculectomy with MMC and Ahmed valve implantation in eyes with uveitic glaucoma. To explore the role these procedures may play in the management of uveitic glaucoma, we reviewed our surgical experience with 29 patients over a 9-year period.
PATIENTS AND METHODS We retrospectively reviewed the records of 29 patients who underwent trabeculectomy with MMC or Ahmed valve implantation for medically uncontrolled uveitic glaucoma at the John A. Moran Eye Center in Salt Lake City, Utah (a tertiary uveitis center), between April 2003 and September 2012. Exclusion criteria included likely steroid-induced glaucoma (based on a review of the medical record) and patients with 21 mm Hg despite medications on 2 consecutive visits, IOP < 6 mm Hg with structural complications of hypotony (choroidal effusions or hemorrhage, hypotony maculopathy, corneal folds, optic nerve edema, etc.), reoperation due to inadequately controlled IOP, or loss of light perception. Laser suture lysis was considered a part of the normal postoperative care of trabeculectomy and was therefore not considered a reoperation or failure. However, bleb revision or needling performed due to need for lower IOP (even if performed in the clinic) was considered a reoperation and failure. This study was reviewed and approved by the Institutional Review Board at the University of Utah (protocol # 00058536), and informed consent was not required.
chamber was reformed with an ophthalmic viscosurgical device (Viscoat; Alcon), which was left in place at the end of the surgery to avoid early postoperative hypotony. The tube was secured to the sclera using an 8-0 or 10-0 Vicryl mattress suture (TG140-8 or CS 140-6 needle, respectively; Ethicon), then human donor pericardium or sclera (Tutoplast; IOP Ophthalmics Inc., Costa Mesa, CA) was used to cover the tube and secured to the sclera using the same suture. The conjunctiva was then closed over the valve, tube, and donor tissue using the same suture.
Surgical Technique All trabeculectomies were performed using a fornixbased conjunctival peritomy. MMC was applied to the scleral bed beneath conjunctiva and Tenon’s capsule either before or after the creation of the scleral flap, depending on surgeon preference. Sponges soaked with 0.2 mg/mL MMC were applied for 90 seconds to 4 minutes at the discretion of the surgeon, followed by irrigation with balanced salt solution. The scleral flap was dissected anteriorly into the peripheral cornea, and an internal ostomy was created with a punch. A peripheral iridectomy was rarely needed, and only performed if deemed necessary due to narrow angles and potential for postoperative ostomy occlusion by iris tissue. Two to 4 10-0 nylon sutures (CS 160-6 needle; Ethicon, Blue Ash, OH) were used to secure the scleral flap until minimal leakage was noted during reformation of the anterior chamber. The conjunctiva and Tenon’s capsule were then reattached to the limbus using a 10-0 Vicryl running horizontal mattress suture (VAS 100-4 needle; Ethicon). Postoperatively, laser suture lysis was performed if there was noted to be an inadequate filtering bleb. One patient underwent implantation of an ExPress minishunt (Model P-50; Alcon, Fort Worth, TX), and this patient was analyzed with the trabeculectomy group. The surgery was performed as described above for trabeculectomy, except the minishunt was inserted into the anterior chamber underneath the scleral flap and just anterior to the scleral spur through an incision created by a 26-G needle. No trabecular block was excised. Ahmed valve implantation was performed in the superotemporal quadrant in all patients except one, in whom it was placed superonasally as it was his second glaucoma drainage implant (GDI). A fornix-based conjunctival peritomy was created with relaxing incisions superiorly and temporally, and dissection was carried down to bare sclera. After priming the Ahmed valve [model FP-7 or S2 (1 pediatric case); New World Medical Inc., Rancho Cucamonga, CA] with balanced salt solution, the leading edge of the plate was secured to the sclera 7 to 9 mm posterior to the limbus with 2 9-0 nylon sutures (TG 160-6 needle; Ethicon) through the suture eyelets. The tube was trimmed with the bevel up, and inserted into the anterior chamber through a 23-G needle incision. The anterior
Volume 24, Number 8, October/November 2015
Statistical Methods The qualitative and quantitative variables tested included the patients’ baseline characteristics and the results obtained at all available postoperative appointments. Descriptive statistics for baseline and study variables were performed. To analyze the first surgery in each subject, logistic regression was used to model the probability of either failure as defined by IOP > 21 mm Hg or the combination of failure plus those who required antiglaucoma medications for IOP control. Model covariates included sex, age, level of inflammation, and preoperative CAIs. Inflammation was recorded as 3 levels: quiet for >3 months, quiet for
