eMedicine Specialties > Ophthalmology > Intraocular Pressure

Glaucoma, Drainage Devices: Follow-up

Author: Rajesh Shetty, MD, Assistant Professor of Ophthalmology, College of Medicine, Mayo Clinic; Consultant, Department of Ophthalmology, Mayo Clinic, Jacksonville
Coauthor(s): Edney de Resende Moura Filho, MD, Fellow, Department of Ophthalmology, Mayo Clinic, Jacksonville; Ramesh S Ayyala, MD, FRCS, FRCOphth, Chief, Section of Ophthalmology, Charity Hospital of New Orleans; Director of Glaucoma Services, Assistant Professor, Department of Ophthalmology, Tulane University School of Medicine; Chian Hong, MD, Staff Physician, Department of Ophthalmology, Tulane University Medical Center; Jessica Laursen, MD, Resident in Ophthalmology, Tulane University
Contributor Information and Disclosures

Updated: Dec 17, 2008

Outcome and Prognosis

Overall, both the success rates and the complication rates following any glaucoma drainage device (GDD) implantation are similar (see Table). The choice of the GDD in the treatment of recalcitrant glaucoma depends upon the patient and the surgeon.

Currently, 5 GDDs are available. The Ahmed glaucoma valve (AGV) and the Krupin implant offer resistance to the outflow in the form of a sheet valve and a slit valve, respectively. The Molteno implant and the Baerveldt implant offer no resistance to the outflow and may lead to hypotony; however, the problem can be overcome using the ripcord technique. Long-term success and complications associated with the Ex-PRESS shunt have yet to be demonstrated.

Meta-Analysis of the Glaucoma Drainage Devices*

Open table in new window

[ CLOSE WINDOW ]
Table
 Molteno Without RipcordMolteno With RipcordBaerveldtAhmed Glaucoma Valve
Number of published studies62383
Preoperative IOP (mm Hg)35.640.732.733.4
Postoperative IOP (mm Hg)16.517.014.216.2
Change in IOP (%)53585751
Surgical success (%)71 (10)71 (7)75 (10)75 (12)
Transient hypotony (%)26 (10)11 (3)19 (5)9 (5)
Chronic hypotony (%)5 (5)6 (3)4 (3)2 (2)
Diplopia (%)NR2 (2)18 (5)2 (2)
Suprachoroidal hemorrhageNR5 (2)3 (2)3 (2)
 Molteno Without RipcordMolteno With RipcordBaerveldtAhmed Glaucoma Valve
Number of published studies62383
Preoperative IOP (mm Hg)35.640.732.733.4
Postoperative IOP (mm Hg)16.517.014.216.2
Change in IOP (%)53585751
Surgical success (%)71 (10)71 (7)75 (10)75 (12)
Transient hypotony (%)26 (10)11 (3)19 (5)9 (5)
Chronic hypotony (%)5 (5)6 (3)4 (3)2 (2)
Diplopia (%)NR2 (2)18 (5)2 (2)
Suprachoroidal hemorrhageNR5 (2)3 (2)3 (2)

*Values are based on the weighted mean of the published studies in the respective GDD group. For mean percentages, standard deviations are shown in parentheses.

NR = not recorded

Advantages of the valved implants

The advantages of the valved implants, especially of the AGV, appear to be easy insertion following 1-quadrant dissection and low incidence of hypotony in the immediate postoperative phase. However, it is associated with a high incidence of the hypertensive phase (as much as 80%) that occurs 1-3 months after the operation. On the other hand, GDDs with larger surface areas, such as the double-plate Molteno (DPM) implant and the Baerveldt implant, appear to exhibit a lower incidence of the hypertensive phase and may achieve slightly lower IOP.

Recommendations

The AGV is easy to insert, has 1-quadrant dissection, requires less operative time as compared to other GDD operations, and has a low incidence of hypotony in the postoperative period. The AGV has a higher incidence of the hypertensive phase postoperatively that might require additional glaucoma medications or needling of the bleb. This implant is ideal for patients with diseases presenting with high IOP and minimal damage to the optic nerve, such as neovascular glaucoma, PKP with glaucoma, glaucoma following retinal detachment surgery, and uveitic glaucoma.

The Baerveldt implant and the DPM implant require more extensive dissection, additional operative time, and the use of a stent to avoid postoperative hypotony and a shallow anterior chamber. The larger surface area of the end plate results in larger blebs and lower IOPs.

 


More on Glaucoma, Drainage Devices

Overview: Glaucoma, Drainage Devices
Treatment: Glaucoma, Drainage Devices
Follow-up: Glaucoma, Drainage Devices
Multimedia: Glaucoma, Drainage Devices
References
[ CLOSE WINDOW ]

References

  1. Molteno AC, Straughan JL, Ancker E. Long tube implants in the management of glaucoma. S Afr Med J. Jun 26 1976;50(27):1062-6. [Medline].

  2. Ayyala RS, Zurakowski D, Smith JA, et al. A clinical study of the Ahmed glaucoma valve implant in advanced glaucoma. Ophthalmology. Oct 1998;105(10):1968-76. [Medline].

  3. Huang MC, Netland PA, Coleman AL, et al. Intermediate-term clinical experience with the Ahmed Glaucoma Valve implant. Am J Ophthalmol. Jan 1999;127(1):27-33. [Medline].

  4. Topouzis F, Coleman AL, Choplin N, et al. Follow-up of the original cohort with the Ahmed glaucoma valve implant. Am J Ophthalmol. Aug 1999;128(2):198-204. [Medline].

  5. Freedman J. Clinical experience with the Molteno dual-chamber single-plate implant. Ophthalmic Surg. Apr 1992;23(4):238-41. [Medline].

  6. Lloyd MA, Baerveldt G, Fellenbaum PS, et al. Intermediate-term results of a randomized clinical trial of the 350- versus the 500-mm2 Baerveldt implant. Ophthalmology. Aug 1994;101(8):1456-63; discussion 1463-4. [Medline].

  7. Smith MF, Sherwood MB, McGorray SP. Comparison of the double-plate Molteno drainage implant with the Schocket procedure. Arch Ophthalmol. Sep 1992;110(9):1246-50. [Medline].

  8. Mills RP, Reynolds A, Emond MJ, et al. Long-term survival of Molteno glaucoma drainage devices. Ophthalmology. Feb 1996;103(2):299-305. [Medline].

  9. Smith SL, Starita RJ, Fellman RL, et al. Early clinical experience with the Baerveldt 350-mm2 glaucoma implant and associated extraocular muscle imbalance. Ophthalmology. Jun 1993;100(6):914-8. [Medline].

  10. Siegner SW, Netland PA, Urban RC Jr, et al. Clinical experience with the Baerveldt glaucoma drainage implant. Ophthalmology. Sep 1995;102(9):1298-307. [Medline].

  11. Nguyen QH, Budenz DL, Parrish RK 2nd. Complications of Baerveldt glaucoma drainage implants. Arch Ophthalmol. May 1998;116(5):571-5. [Medline].

  12. Hong CH, Arosemena A, Zurakowski D, et al. Glaucomadrainage devices: a systematic literature review and current controversies. Surv Ophthalmol. 2005;40:48–60. [Medline].

  13. Gedde SG, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the Tube Versus Trabeculectomy study after one year of follow-up. Am J Ophthalmol. 2007;143:9 –22. [Medline].

  14. Gedde SG, Herndon LW, Brandt JD, et al. Surgical complications in the Tube Versus Trabeculectomy study during the first year of follow-up. Am J Ophthalmol. 2007;143:23-31. [Medline].

  15. Kurnaz E, Kubaloglu A, Yilmaz Y, et al. The effect of adjunctive Mitomycin C in Ahmed glaucoma valve implantation. Eur J Ophthalmol. Jan-Feb 2005;15(1):27-31. [Medline].

  16. Hodkin MJ, Goldblatt WS, Burgoyne CF, et al. Early clinical experience with the Baerveldt implant in complicated glaucomas. Am J Ophthalmol. Jul 1995;120(1):32-40. [Medline].

  17. Ayyala RS. Penetrating keratoplasty and glaucoma. Surv Ophthalmol. Sep-Oct 2000;45(2):91-105. [Medline].

  18. Ayyala RS, Michelini-Norris B, Flores A, et al. Comparison of different biomaterials for glaucoma drainage devices: part 2. Arch Ophthalmol. Aug 2000;118(8):1081-4. [Medline].

  19. Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, et al. Endophthalmitis associated with the Ahmed glaucoma valve implant. Br J Ophthalmol. Apr 2005;89(4):454-8. [Medline].

  20. Gedde SJ, Scott IU, Tabandeh H, et al. Late endophthalmitis associated with glaucoma drainage implants. Ophthalmology. Jul 2001;108(7):1323-7. [Medline].

  21. Ayyala RS, Harman LE, Michelini-Norris B, et al. Comparison of different biomaterials for glaucoma drainage devices. Arch Ophthalmol. Feb 1999;117(2):233-6. [Medline].

  22. Ayyala RS, Layden WE, Slonim CB, et al. Anatomic and histopathologic findings following a failed ahmed glaucoma valve device. Ophthalmic Surg Lasers. May-Jun 2001;32(3):248-9. [Medline].

  23. Britt MT, LaBree LD, Lloyd MA, et al. Randomized clinical trial of the 350-mm2 versus the 500-mm2 Baerveldt implant: longer term results: is bigger better?. Ophthalmology. Dec 1999;106(12):2312-8. [Medline].

  24. Egbert PR, Lieberman MF. Internal suture occlusion of the Molteno glaucoma implant for the prevention of postoperative hypotony. Ophthalmic Surg. Jan 1989;20(1):53-6. [Medline].

  25. Hill RA, Pirouzian A, Liaw L. Pathophysiology of and prophylaxis against late ahmed glaucoma valve occlusion. Am J Ophthalmol. May 2000;129(5):608-12. [Medline].

  26. Hoare Nairne JE, Sherwood D, Jacob JS, et al. Single stage insertion of the Molteno tube for glaucoma and modifications to reduce postoperative hypotony. Br J Ophthalmol. Nov 1988;72(11):846-51. [Medline].

  27. Lim KS, Allan BD, Lloyd AW, et al. Glaucoma drainage devices; past, present, and future. Br J Ophthalmol. Sep 1998;82(9):1083-9. [Medline].

  28. Molteno ACB, Dempster AG. Methods of controlling bleb fibrosis around drainage implants. In: Mills KB, ed. Glaucoma: Proceedings of Fourth International Symposium of the North Eye Institute, Manchester, UK. Elmsford, NY: Pergamon Press Inc; 1988:192-211.

  29. Price FW Jr, Whitson WE. Polypropylene ligatures as a means of controlling intraocular pressure with Molteno implants. Ophthalmic Surg. Nov 1989;20(11):781-3. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

glaucoma drainage devices, glaucoma drainage device, tube shunt, glaucoma tube, glaucoma drainage device insertion, GDD, GDDs, GDD insertion, Molteno implant, Baerveldt implant, long tube implant, Ahmed glaucoma valve, AGV, Krupin implant, bleb, iridocorneal endothelial syndrome, ICE, neovascular glaucoma, penetrating keratoplasty, PKP

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Rajesh Shetty, MD, Assistant Professor of Ophthalmology, College of Medicine, Mayo Clinic; Consultant, Department of Ophthalmology, Mayo Clinic, Jacksonville
Rajesh Shetty, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, American Society of Cataract and Refractive Surgery, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Edney de Resende Moura Filho, MD, Fellow, Department of Ophthalmology, Mayo Clinic, Jacksonville
Edney de Resende Moura Filho, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Ramesh S Ayyala, MD, FRCS, FRCOphth, Chief, Section of Ophthalmology, Charity Hospital of New Orleans; Director of Glaucoma Services, Assistant Professor, Department of Ophthalmology, Tulane University School of Medicine
Ramesh S Ayyala, MD, FRCS, FRCOphth is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association
Disclosure: Nothing to disclose.

Chian Hong, MD, Staff Physician, Department of Ophthalmology, Tulane University Medical Center
Disclosure: Nothing to disclose.

Jessica Laursen, MD, Resident in Ophthalmology, Tulane University
Disclosure: Nothing to disclose.

Medical Editor

Bradford Shingleton, MD, Assistant Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
Bradford Shingleton, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Louis E Probst, MD, Medical Director of Refractive Surgery, Chicago, Madison, Milwaukee, and Windsor Centers, TLC the Laser Eye Centers
Louis E Probst, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.