ORIGINAL STUDY
Ahmed Glaucoma Valve Implantation for Uveitic Glaucoma Secondary to Behc¸et Disease Banu Satana, MD,* Ilgaz S. Yalvac, MD,w Gulten Sungur, MD,z Umit Eksioglu, MD, PhD,z Berna Basarir, MD,* Cigdem Altan, MD,* and Sunay Duman, MDz
Purpose: To evaluate outcomes of patients with uveitic glaucoma secondary to Behc¸et disease (BD) who underwent Ahmed glaucoma valve (AGV) implantation. Patients and Methods: A retrospective chart review of 14 eyes of 10 patients with uveitic glaucoma associated with BD who underwent AGV implantation at a tertiary referral center. Treatment success was defined as intraocular pressure (IOP) between 6 and 21 mm Hg with or without antiglaucoma medication, without further additional glaucoma surgery or loss of light perception. The main outcome measures were IOP, best-corrected visual acuity measured with Snellen charts, and number of glaucoma medications. Results: Mean duration of postoperative follow-up was 18.2 ± 6.6 months (range, 6 to 31 mo). Of the 14 eyes, 10 (71.4%) were pseudophakic and 5 (35.7%) had primary AGV implantation without a history of previous glaucoma surgery. At the most recent follow-up visit, 13 of the 14 eyes had an IOP between 6 and 21 mm Hg. Mean IOP was significantly reduced during follow-up, as compared with preoperative values (Pr0.005). The cumulative probability of surgical success rate was 90.9% at 18 months based on Kaplan-Meier survival analysis. The mean number of antiglaucoma medications required to achieve the desired IOP decreased from 3.4 ± 0.5 preoperatively to 1.0 ± 1.1 postoperatively (Pr0.05). Visual acuity loss of >2 lines occurred in 4 eyes (28.5%) due to optic atrophy associated with retinal vasculitis. Temporary hypotony developed during follow-up in 4 eyes (28.5%) at first postoperative week. Conclusions: For the management of uveitic glaucoma associated with BD, AGV implantation is a successful method for glaucoma control but requires additional surgical interventions for high early hypotony rates. Key Words: Behc¸et disease, uveitic glaucoma, Ahmed glaucoma valve
(J Glaucoma 2015;24:607–612)
B
ehc¸et disease (BD) is clinically characterized by recurrent oral aphthous ulcers, skin lesions, ocular inflammation, and genital ulcers. The disease bears the name of Hulusi Behc¸et, a Turkish dermatologist.1 BD is the leading cause of endogenous uveitis and is one of the major causes of acquired blindness in Turkey and Japan.2 One of the Received for publication March 21, 2013; accepted March 5, 2014. From the *Beyoglu Eye Research and Training Hospital; wYeditepe University Medical School, Eye Clinic, Istanbul; and zAnkara Training and Research Hospital, Eye Clinic, Ankara, Turkey. Presented as a poster at the American Academy of Ophthalmology Annual Meeting, November, 2008. Disclosure: The authors declare no conflict of interest. Reprints: Banu Satana, MD, Atakoy 9. Kisim, Blok: A3-B, No: 132, Bakirkoy, Istanbul, Turkey (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000062
J Glaucoma
major complications of ocular BD is glaucoma, which is difficult to manage when it develops as a consequence of chronic uveitis, and medical therapy often fails to maintain desirable intraocular pressure (IOP).3 Several therapies have been used in the treatment of uveitic glaucoma, but success rates vary according the type of uveitis. Trabeculectomy with wound-healing modulators, such as 5-flourouracil and mitomycin-C (MMC), has been advocated in last decade for minimizing scarring of the filtration bleb.4 Nonetheless, even with such therapy, a marked postoperative inflammatory response in uveitic eyes or recurrence of uveitis can result in bleb fibrosis. Artificial aqueous drainage devices have been used for primary surgical treatment of uveitis, but the reported success rates are inconsistent.5–8 Herein we report the outcomes of 14 consecutive unselected eyes that developed uveitic glaucoma associated with BD, did not respond to medical treatment, and were treated with Ahmed glaucoma valve (AGV) implantation.
PATIENTS AND METHODS A retrospective, noncomparative study of AGV implantation was undertaken and included patients who had uveitis associated with BD. Upon approval of the study protocol by the Ankara Research and Education Hospital Ethics Committee, the charts of BD patients who underwent AGV implantation surgery were retrospectively reviewed. The study included 14 eyes of 10 BD patients who were diagnosed according to the International Society for Behc¸et’s Disease criteria, were classified as panuveitis according to the Standardization of Uveitis Nomenclature,9 and underwent AGV implant surgery between April 2006 and April 2008 due to glaucoma that was uncontrolled despite previous medical treatment with or without glaucoma surgery. Even if the uveitis of included patients in the study was clinically in remission, each patient received oral prednisone that was started on the day before surgery at a dose of 1 mg/kg/d and was tapered for 4 weeks, started tapering a week after surgery. All patients had an ophthalmic examination, including best-corrected visual acuity with Snellen charts, slit-lamp examination, dilated fundus examination, visual field analysis with Humprey Field Analyser (Carl Zeiss Meditec, Dublin, CA) using central 30-2 threshold test and SITA (Swedish Interactive Threshold Algorithm) strategy, and IOP measurement with a Goldmann applanation tonometer.
Surgical Technique All AGV implant operations were performed superotemporally by the same surgeon (B.S.), with the use of a fornix-based conjunctival and Tenon capsule flap. An AGV FP7 single-plate silicone implant (New World Medical Inc.,
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Rancho Cucamonga, CA) was used in all patients. The implant was primed by the injection of saline solution through a 26 G blunt cannula. The body of the implant was secured 8 to 10 mm from the limbus with two 5/0 polyester sutures. A paracentesis was performed temporally for the injection of viscoelastic material. At 2 mm posterior to the limbus, a 23 G sharp needle was used to enter the anterior chamber (AC). Next, the drainage tube was inserted 2 to 3 mm into the AC through this needle track, which was secured to the sclera with three 10/0 nylon sutures, and was covered with donor pericardium and sutured to the sclera with 4 interrupted 10/0 nylon sutures. The conjunctiva was then closed with 10/0 nylon sutures. Each patient received prednisolone acetate (1%) (Pred-Forte Allergan, Westport Co., Mayo, Ireland) topically every 2 hours for 1 week while awake, followed by tapering starting at 1 week after surgery. Topical ketorolac tromethamine (0.5%) (Acular Allergan) and ofloxacin (0.3%) (Exocin Allergan, Westport Co.) were also administered 4 times daily during the first postoperative week. Systemic immunosuppressive agents were continued if the patient had been receiving these before surgery.
Mean preoperative and postoperative CDRs were, respectively, 0.58 ± 0.16 (range, 0.4 to 0.8) and 0.56 ± 0.15 (range, 0.4 to 0.8) (P = 0.32).
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Visual Field Examination Preoperative and postoperative mean MD and PSD results were, respectively, 11.81 ± ( 9.37) (range, 28.58 to 1.89) and 14.45 ± ( 12.77) (range, 33.21 to 1.92) (P = 0.21) and 2.88 ± 1.65 (range, 1.15 to 7.95) and 2.80 ± 1.55 (range, 1.05 to 6.44) (P = 0.38). PSD were not able to be calculated in 3 patients who had loss of vision to counting fingers in postoperative last follow-ups. The differences were not statistically significant.
Glaucoma Medications There was a significant decrease in the number of postoperative glaucoma medications used at all follow-up visits (Pr0.001, Table 2). At the last postoperative follow-up visit, IOP was controlled without medication in 8 (57.14%) eyes, with 2 glaucoma medications in 4 (28.57%) eyes, and with 3 medications in 1 (7.14%) eye.
Systemic Treatment
Statistical Analysis The results were statistically analyzed through the paired t test to determine the differences between continuously scaled variables before and after surgery. KaplanMeier life-table analysis was used to assess cumulative probability of success. P-values 5 mm Hg, without further additional glaucoma surgery or loss of light perception. Postoperative use of antiglaucoma medications was not a criterion for success or failure. Hypotony was defined as an IOP of r5 mm Hg for 2 consecutive follow-up visits.
RESULTS In total, 14 eyes of 10 patients who underwent AGV implantation for uveitic glaucoma associated with BD between April 2006 and April 2008 were included. Seven (70%) of the 10 patients were male and 3 (30%) were female. Age, sex, follow-up period, diagnosis, laterality, previous surgeries, preoperative and last postoperative IOP, optic nerve cup to disc ratios (CDR), visual acuity, pattern standard deviation (PSD) of visual field, number of medications used, and surgical complications for each patient are summarized in Table 1. Mean age at the time of surgery was 24.21 ± 5.68 years (range, 15 to 30 y) and mean followup time was 18.62 ± 6.65 months (range, 6 to 31 mo). Ten (71.4%) eyes were pseudophakic and 4 (28.6%) eyes were phakic. AGV implant surgery was performed as primary glaucoma surgery in 5 (35.70%) eyes and as secondary glaucoma surgery after a failed trabeculectomy with MMC in 9 (64.30%) eyes.
IOP and Glaucomatous Cupping Mean preoperative and postoperative IOP and CDR results are summarized in Table 2. Preoperative and postoperative IOP differences were statistically significant at all follow-up times (Pr0.001).
Systemic treatment included a combination of azathiopurine and cyclosporine A in 6 patients (60%), cyclosporine A alone in 3 patients (30%), and azathiopurine alone in 1 patient (10%). Patients who were on systemic treatment regimens before surgery continued these postoperatively (Table 1).
Visual Acuity Before surgery, visual acuity ranged from 20/200 to 20/20. Mean preoperative and postoperative log MAR visual acuities were 0.70 ± 0.39 (range, 0.05 to 1.00) and 0.94 ± 0.73 (range, 0.00 to 2.10), respectively (P = 0.10). Visual acuity improved by >1 line in 3 (21.42%) eyes, decreased by >1 line in 4 (28.57%) eyes, and did not change in 7 (50.0%) eyes, in terms of measurements obtained at the last follow-up visits. Among the patients with loss of vision, the visual acuity decreased from 20/200 to counting fingers (3 patients) and from 20/50 to 20/200 (1 patient). Loss of visual acuity was connected to, respectively, optic atrophy and retinal atrophy secondary to vasculitis and cystoid macular edema in BD (Table 1).
Surgical Success The cumulative probability of success was 90.9% at 18 months and 72.7% at 24 months (95% confidence interval, 24.73-31.62) after surgery by Kaplan-Meier survival analysis (Fig. 1). According to our success criteria 2 eyes were defined as failure; 1 eye developed encapsulated cystic bleb, had bleb revision, and continued uncontrolled IOP with glaucoma medications and other eye developed early postoperative hypotony requiring tube ligation (Table 1). The IOP was between 6 and 21 mm Hg in 13 (92.8%) of the 14 eyes at the last follow-up visit. AGV implantation was performed as primary glaucoma surgery in 5 eyes (35.7%) and was performed after unsuccessful trabeculectomy in 9 eyes (64.3%). The mean IOP at last follow-up between these 2 groups was not statistically significant (P = 0.45).
Complications The most common complications that required treatment within the first postoperative week were transient hypotony and hypotony-induced complications (4 eyes,
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Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
OS
10
Male
29
28
27
Male
Male
Male
30 Female
29
Male
TRAB CE + IOL NONE
TRAB
NONE
NONE
TRAB
20/20
20/200
20/200
20/100
20/200
20/200
35
40
30
42
46
34
32
30
30 32
32
34
50
30
3
3
3
4
4
3
3
3
3 3
4
4
4
4
0.6
0.8
0.8
0.4
0.5
0.7
0.8
0.8
0.5 0.4
0.4
0.6
0.5
0.4
2.18
7.18
7.95
1.63
2.83
3.58
6.64
6.44
7.15 1.78
3.52
3.60
2.11
2.19
6
7
19
19
18
10
31
23
22 22
18
18
22
20
20/20
20/100
CF
20/70
20/200
20/100
CF
CF
20/20 20/200
20/100
20/100
20/20
20/200
12
7
14
12
23
12
13
12
16 18
12
21
14
14
0
0
2
2
3
3
0
0
0 0
0
0
2
2
0.6
0.7
0.8
0.4
0.5
0.5
0.8
0.8
0.4 0.4
0.4
0.6
0.5
0.5
2.11
6.44
N/A
1.19
2.95
4.02
N/A
N/A
1.05 1.64
3.60
3.52
2.19
2.11
Retinal vasculitis Optic atrophy
Postoperative early hypotony Wound leak Retinal vasculitis Optic atrophy Retinal vasculitis Optic atrophy Postoperative early hypotony Cataract Encapsulated bleb
Descemet membrane detachment
Postoperative CME early hypotony Postoperative early hypotony, wound leak
CSA
AZO
CSA AZO CSA AZO CSA AZO
CSA AZO
CSA AZO
CSA
CSA
CSA AZO
Complications Systemic of Uveitis Treatment
*Data of most recent follow-up. AZO indicates azathioprine; CDR, cup to disc ratio; CE, cataract extraction; CF, counting fingers; CME, cystoid macular edema; CSA, cylosporine-A; FT, follow-up time; IOL, intraocular lens; IOP, Intraocular pressure; M, antiglaucomatous medication; PSD, pattern standard deviation; TRAB, trabeculectomy; VA, visual acuity.
OS
8
OD
6
OD
OS
5
23
20/200
20/200
20/20 20/200
20/100
20/100
20/20
20/50
Postoperative Complications
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7
OD
4
20
OS
TRAB CE + IOL
20 Female TRAB CE + IOL
OD
TRAB TRAB
9
28 Male 28
OD OS
15
OS
TRAB CE + IOL TRAB CE + IOL
TRAB
None
3
15 Female
Male
Sex
OD
29
OS
2
29
OD
1
Age
Eye
Patient #
PostPreoperative PostPost Postoperative PrePrePrePre VA Postop operative operative operative VA operative operative operative operative FT CDR* PSD* Snellen IOP No. M CDR PSD (m) Snellen* IOP* No. M*
Previous Surgeries
TABLE 1. Demographic Data of Patients
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TABLE 2. IOP and AGM Before and After AGV Implantation
Period Preoperative Postoperative 1 wk 1 mo 3 mo 6 mo 9 mo 12 mo 15 mo 18 mo
Mean IOP ± SD (Range) (mm Hg)
Medication ± SD (Range)
No. Eyes
No. Eyes With AGM
35.50 ± 6.4 (30-50)
3.42 ± 0.51 (3-4)
14
14
8.78 ± 4.31 10.57 ± 3.17 12.07 ± 3.97 13.64 ± 3.31 13.08 ± 3.47 15.09 ± 3.83 15.00 ± 3.43 14.45 ± 2.58
0.21 ± 0.80 0.42 ± 1.08 0.64 ± 1.27 0.23 ± 0.83 0.58 ± 0.80 0.45 ± 1.03 1.27 ± 1.00 1.0 ± 1.18
14 14 14 14 12 11 11 11
1 2 3 1 3 2 8 5
(2-18) (6-16) (6-18) (8-20) (8-20) (8-21) (12-21) (12-20)
(0-3) (0-3) (0-3) (0-3) (0-2) (0-3) (0-3) (0-3)
P
r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w
*Referring preoperative and postoperative mean IOP difference. wReferring preoperative and postoperative mean AGM difference. AGM indicates antiglaucomatous medications; AGV, Ahmed glaucoma valve; IOP, Intra ocular pressure.
28.7%). Three of the hypotonic eyes with flat ACs were treated with sodium chondroitin sulfate and sodium hyaluronate (Viscoat Alcon Laboratories, Fort Worth, TX) injection into the AC. One patient with persistent hypotony and peripheral choroidal detachment was treated with surgical AGV tube ligation with 6/0 Vicryl suture. Although IOP control was successful after ligation, it was defined as failure. Other complications included Descemet membrane detachment (1 eye, 7.14%), wound leak (2 eyes, 14.2%), cataract (1 eye, 7.14%), and cystic bleb encapsulation (1 eye, 7.14%). Descemet membrane detachment originated through side-corneal incisions for viscoelastics. This patient had vision loss the first postoperative week. After an unsuccessful air and viscoelastics trial, the patient underwent full-thickness corneal suturing with 10/0 nylon sutures. Three months after corneal suturing the patient’s vision returned to baseline status. Wound leaks were repaired surgically with suturing of the conjunctiva with 10/0 nylon suture at the leakage site. One patient developed cataract 6 months after AGV surgery and underwent phacoemulsification
FIGURE 1. Cumulative probability of success by Kaplan-Meier life-table analysis. Figure 1 can be viewed in color online at www.glaucomajournal.com.
and IOL implantation through a clear corneal temporal incision, and experienced no additional complications. Encapsulated cystic bleb formation over the AGV body required capsulectomy of Tenon capsule through a conjunctival incision lateral to the encapsulated bleb. As the IOP remained over 21 mm Hg despite topical antiglaucomatous medication, it was defined as failure (Table 1).
DISCUSSION BD is a multisystemic disorder caused by occlusive vasculitis and is characterized by recurrent intraocular inflammation, oral aphthous ulcers, skin lesions, ocular inflammation, and genital ulcers. Inomata et al10 reported ocular involvement in 78.6% of BD cases. Ocular involvement is usually bilateral, can affect both the anterior and posterior segments, and manifestations appear 2 to 3 years after the initial symptoms. Anterior nongranulomatous uveitis is generally associated with a sterile hypopyon. Retinal disease is characterized by recurrent retinal vascular occlusions and ischemia, which may lead to vision loss.2,3 Glaucoma is among the major complications of ocular BD and arises from obstruction of the trabeculum by inflammatory cells, posterior synechiae with iris bombe, peripheral anterior synechiae, and rubeosis iridis. Elgin et al11 reported a secondary glaucoma incidence rate of 10.9% in BD with ocular involvement and Yalvac¸ et al12 reported a similar incidence rate (10.4%) for uveitic glaucoma in BD. The management of uveitic glaucoma can be difficult because of the mechanisms mentioned above, which also occur in Behc¸et uveitis. Active uveitis, pseudophakia, and a history of previous glaucoma surgery increase the rate of failure of glaucoma surgery, even with antimetabolite administration in uveitis patients. As Keino and Okada13 reported, BD is limited to certain geographic regions. The English language literature on patients with BD who undergo glaucoma surgery, including AGV implantation, is limited. In the treatment of uveitic glaucoma associated with BD, trabeculectomy with MMC has had variable success. Yalvac et al12 achieved overall 1-, 2-, 3-, 4-, and 5-year success rates of 83%, 76%, 70%, 66%, and 62%, respectively, in 26 eyes treated with trabeculectomy and MMC. Almost same success rate with BD, 82%, was achieved for the first year of trabeculectomy and MMC by Elgin et al.14 Similar results have been reported for nonselective uveitic
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TABLE 3. Glaucoma Implant Studies With Uveitic Glaucoma Patients
References Gil-Carrasco et al5 Da Mata and Foster6 Ozdal et al8 Rachmiel et al17 Hill et al18 Ceballos et al19 Molteno et al20 This study
Type of Implant
No. Eyes
Succes Rate (%)
Follow-up Time
Ahmed
14
57
22 mo
Ahmed
21
94
1y
Ahmed Ahmed Molteno Bearveldt Molteno Ahmed
19 15 10 24 40 14
60 66 79 91 76 90
2y 30 mo 2y 24 mo 5y 18 mo
glaucoma by Patitsas et al15 and by Towler et al16 with success rates of 70% at 34 months and 50% at 5 years, respectively. Late failure rates are higher than those reported for trabeculectomy in patients with nonuveitic glaucoma.6,7,17 In the last 10 years, drainage implants have been advocated for the treatment of uveitic glaucoma. Published success rates for drainage implants in uveitic glaucoma series17–20 range between 57% and 94% (Table 3). As a glaucoma drainage device, the AGV implant has a unidirectional valve mechanism designed to prevent hypotony and related complications. In a study that compared the use of AGV implants, Krupin valves, and Molteno implants in patients with complicated glaucoma, Taglia et al21 reported a lower complication rate with AGV implants. We defined success as an IOP between 6 and 21 mm Hg with or without glaucoma medication, and without additional glaucoma surgery or loss of light perception. Accordingly, 72.7% of our patients had treatment success at 2 years. When preoperative and postoperative MD and PSD results were compared, it was shown that visual field defects also did not progress significantly. In our patients, the success rate did not differ significantly between primary tube implantation glaucoma surgery and secondary implantation after bleb failure. Ozdal et al8 reported AGV implantation in19 eyes, in 16 of which this procedure was primary glaucoma surgery. Success of the AGV implant in that study is also indicated by the reduction in the number of antiglaucoma medications used postoperatively. In our study, reduction in the number of medications was not used as a measure of treatment success; nonetheless, at 18 months after surgery, patients required on average 1 medication, which represents a reduction of approximately 2.4 medications per eye. Same postoperative average number of medications were reported by Ozdal et al8 and Da Mata and Foster6 for uveitic patients at 18 months of follow-up. Antiglaucoma medication needed for our uveitic study group with BD is relatively lower compared with studies of AGV of same follow-up periods.22 Postoperative tendency of hypotony and hypotony-related complications should be considered for this group of patients. Aggressive anti-inflammatory therapy and valve implantation in nonactive uveitic eyes are recommended by some researchers.6,8,20 As mentioned in the Patients and methods section, active uveitis was not present in our study group, and if a patient had been receiving systemic immunosuppressive agents before surgery, these were continued in addition to perioperative adjunctive prednisone treatment. Our study is Copyright
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thus consistent with the idea that good outcomes are closely related to the control of inflammation before surgery. The most common complication in the present study was transient hypotony (28.4%). This is similar to the 26% incidence of transient hypotony reported by Rachmiel et al17 for patients with uveitic glaucoma. Three of the eyes with transient hypotony in the present study had resolution after viscoelastics were injected into the AC. One eye with peripheral choroidal effusion (7.14%) due to prolonged hypotony was treated with tube ligation with 6/0 Vicryl sutures. In eyes with uveitis, postoperative hypotony is closely related to ciliary body shutdown followed by reduced production of aqueous. Potential methods for reducing the incidence of postoperative transient hypotony include more extensive injections of viscoelastic materials and/or tube ligation with Vicryl sutures at the end of surgery. Corneal-tube touch did not develop in any of our patients, which has been reported to occur in 5% of patients with AGV implantation by Huang et al.23 Occlusion of the valve, a complication reported by Ozdal et al,8 was also not encountered in our patients. Descemet membrane detachment occurred in 1 eye of patient 2 (Table 1), but 3 months after treatment of this complication visual acuity returned to the pre-AGV surgery level. Corneal edema and other corneal complications were reported as the most common type of serious complication by Papadaki et al24 in their study of patients with uveitic glaucoma who underwent AVG implantation. Corneal complications were not encountered in our group of patients. Hemorrhagic choroidal detachment was also not seen among our patients.25 One of our patients developed an encapsulated bleb (7.14%), which was successfully treated with capsulectomy. Morad et al26 reported an incidence of 7% for Tenon cysts, which were treated with either needling or excision in their study of AGV implants in pediatric glaucoma patients. The Ahmed Baerveldt Comparison22 and The Ahmed Versus Baerveldt27 as the large-scale comparative studies, reveal higher success rate with Baerveldt implant than AGV after 1-year follow-up,22,27 but a greater number of patients in the Baerveldt group required interventions (26% Ahmed vs. 42% Baerveldt, P = 0.009).27 Nonspecified uveitis patients (18 patients) had either AGV (11 patients, 8%) or Baerveldt (7 patients, 5%) glaucoma implant surgery at Ahmed Baerveldt Comparison study. Limitations of the present study include the number of patients, the short duration of follow-up, the retrospective design, and the inclusion of >1 eye from 4 patients. Nonetheless, we aimed to report the IOPs and reductions in the number of antiglaucoma medications, as well as complication types and rates after AGV implantation in BD patients with uveitic glaucoma as a specific panuveitis patient group. Large-scale prospective, controlled, and randomized multicenter studies are needed to confirm these results. In conclusion, AGV implant surgery is effective for intractable glaucoma secondary to Behc¸et uveitis. Among the complications of the procedure, hypotony is the major one which requires additional surgical interventions. REFERENCES 1. Behc¸et H. About recurrent aphthous ulcers caused by a virus on or around the mouth, eyes and genitals. Dermatol Wochenschr. 1937;105:1152–1157.
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2. Mochizuki M, Akduman L, Nusenblatt RB. Behc¸et disease. In: Pepose JS, Holland GN, Williams KR, eds. Ocular Infection and Immunity. St Louis: Mosby; 1996:663–675. 3. Nussenblatt RB, Whitcup SM, Palestine AG. Uveitis Fundamentals and Clinical Practice. St Louis: Mosby; 1996:334–353. 4. Ceballos EM, Beck AD, Lynn MJ. Trabeculectomy with antiproliferative agents in uveitic glaucoma. J Glaucoma. 2002;11:189–196. 5. Gil-Carrasco F, Salinas-VanOrman E, Recillas-Gispert C, et al. Ahmed valve implant for uncontrolled uveitic glaucoma. Ocul Immunol Inflamm. 1998;6:27–37. 6. Da Mata AP, Foster CS. Ahmed valve and uveitic glaucoma. Int Ophthalmol Clin. 1999;39:155–167. 7. Da Mata A, Burk SE, Netland PA, et al. Management of uveitic glaucoma with Ahmed glaucoma valve implantation. Ophthalmology. 1999;106:2168–2172. 8. Ozdal PC, Vianna RN, Descheˆnes J. Ahmed valve implantation in glaucoma secondary to chronic uveitis. Eye. 2006;20: 178–183. 9. Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005;140:509–516. 10. Inomata H, Yoshikawa H, Rao NA. Phacoanaphylaxis in Behcet’s disease. A clinicopathologic and immunuhistochemical study. Ophthalmology. 2003;110:1942–1945. 11. Elgin U, Berker N, Batman A. Incidence of secondary glaucoma in Behc¸et disease. J Glaucoma. 2004;13:441–444. 12. Yalvac¸ IS, Sungur G, Turhan E, et al. Trabeculectomy with mitomycin-C in uveitic glaucoma associated with Behc¸et disease. J Glaucoma. 2004;13:450–453. 13. Keino H, Okada AA. Behc¸et’s disease: global epidemiology of an Old Silk Road disease. Br J Ophthalmol. 2007;91: 1573–1574. 14. Elgin U, Berker N, Batman A, et al. Trabeculectomy with mitomycin C in secondary glaucoma associated with Behc¸et disease. J Glaucoma. 2007;16:68–72. 15. Patitsas CJ, Rockwood EJ, Meisler DM, et al. Glaucoma filtering surgery with postoperative 5-fluorouracil in patients
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16. 17. 18. 19. 20.
21. 22.
23. 24. 25. 26. 27.
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with intraocular inflammatory disease. Ophthalmology. 1992; 99:594–599. Towler HM, McCluskey P, Shaer B, et al. Long-term followup of trabeculectomy with intraoperative 5-fluorouracil for uveitis-related glaucoma. Ophthalmology. 2000;107:1822–1828. Rachmiel R, Trope GE, Buys YM, et al. Ahmed glaucoma valve implantation in uveitic glaucoma versus open-angle glaucoma patients. Can J Ophthalmol. 2008;43:462–467. Hill RA, Nguyen QH, Baerveldt G, et al. Trabeculectomy and Molteno implantation for glaucomas associated with uveitis. Ophthalmology. 1993;100:903–908. Ceballos EM, Parrish RK, Schiffman JC. Outcome of Baerveldt glaucoma drainage implants for the treatment of uveitic glaucoma. Ophthalmology. 2002;109:2256–2262. Molteno ACB, Sayawat N, Herbison P. Otago glaucoma surgery outcome study long-term results of uveitis with secondary glaucoma drained by Molteno implants. Ophthalmology. 2001;108:605–613. Taglia DP, Perkins TW, Gangnon R, et al. Comparison of the Ahmed Glaucoma Valve, the Krupin Eye Valve with Disk, and the double-plate Molteno implant. J Glaucoma. 2002;11:347–353. Budenz DL, Barton K, Feuer WJ, et al. Ahmed Baerveldt Comparison Study Group. Treatment outcomes in the Ahmed Baerveldt Comparison Study after 1 year of follow-up. Ophthalmology. 2011;118:443–452. Huang MC, Netland PA, Coleman AL, et al. Intermediateterm clinical experience with the Ahmed Glaucoma Valve implant. Am J Ophthalmol. 1999;127:27–33. Papadaki TG, Zacharopoulos IP, Pasquale LR, et al. Longterm results of Ahmed glaucoma valve implantation for uveitic glaucoma. Am J Ophthalmol. 2007;144:62–69. Kafkala C, Hynes A, Choi J, et al. Ahmed valve implantation for uncontrolled pediatric uveitic glaucoma. J AAPOS. 2005;9:336–340. Morad Y, Donaldson CE, Kim YM, et al. The Ahmed drainage implant in the treatment of pediatric glaucoma. Ophthalmology. 2003;135:821–829. Christakis PG, Kalenak JW, Zurakowski D, et al. The Ahmed Versus Baerveldt study: one-year treatment outcomes. Ophthalmology. 2011;118:2180–2189.
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Ahmed Glaucoma Valve Implantation for Uveitic Glaucoma Secondary to Behc¸et Disease Banu Satana, MD,* Ilgaz S. Yalvac, MD,w Gulten Sungur, MD,z Umit Eksioglu, MD, PhD,z Berna Basarir, MD,* Cigdem Altan, MD,* and Sunay Duman, MDz
Purpose: To evaluate outcomes of patients with uveitic glaucoma secondary to Behc¸et disease (BD) who underwent Ahmed glaucoma valve (AGV) implantation. Patients and Methods: A retrospective chart review of 14 eyes of 10 patients with uveitic glaucoma associated with BD who underwent AGV implantation at a tertiary referral center. Treatment success was defined as intraocular pressure (IOP) between 6 and 21 mm Hg with or without antiglaucoma medication, without further additional glaucoma surgery or loss of light perception. The main outcome measures were IOP, best-corrected visual acuity measured with Snellen charts, and number of glaucoma medications. Results: Mean duration of postoperative follow-up was 18.2 ± 6.6 months (range, 6 to 31 mo). Of the 14 eyes, 10 (71.4%) were pseudophakic and 5 (35.7%) had primary AGV implantation without a history of previous glaucoma surgery. At the most recent follow-up visit, 13 of the 14 eyes had an IOP between 6 and 21 mm Hg. Mean IOP was significantly reduced during follow-up, as compared with preoperative values (Pr0.005). The cumulative probability of surgical success rate was 90.9% at 18 months based on Kaplan-Meier survival analysis. The mean number of antiglaucoma medications required to achieve the desired IOP decreased from 3.4 ± 0.5 preoperatively to 1.0 ± 1.1 postoperatively (Pr0.05). Visual acuity loss of >2 lines occurred in 4 eyes (28.5%) due to optic atrophy associated with retinal vasculitis. Temporary hypotony developed during follow-up in 4 eyes (28.5%) at first postoperative week. Conclusions: For the management of uveitic glaucoma associated with BD, AGV implantation is a successful method for glaucoma control but requires additional surgical interventions for high early hypotony rates. Key Words: Behc¸et disease, uveitic glaucoma, Ahmed glaucoma valve
(J Glaucoma 2015;24:607–612)
B
ehc¸et disease (BD) is clinically characterized by recurrent oral aphthous ulcers, skin lesions, ocular inflammation, and genital ulcers. The disease bears the name of Hulusi Behc¸et, a Turkish dermatologist.1 BD is the leading cause of endogenous uveitis and is one of the major causes of acquired blindness in Turkey and Japan.2 One of the Received for publication March 21, 2013; accepted March 5, 2014. From the *Beyoglu Eye Research and Training Hospital; wYeditepe University Medical School, Eye Clinic, Istanbul; and zAnkara Training and Research Hospital, Eye Clinic, Ankara, Turkey. Presented as a poster at the American Academy of Ophthalmology Annual Meeting, November, 2008. Disclosure: The authors declare no conflict of interest. Reprints: Banu Satana, MD, Atakoy 9. Kisim, Blok: A3-B, No: 132, Bakirkoy, Istanbul, Turkey (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000062
J Glaucoma
major complications of ocular BD is glaucoma, which is difficult to manage when it develops as a consequence of chronic uveitis, and medical therapy often fails to maintain desirable intraocular pressure (IOP).3 Several therapies have been used in the treatment of uveitic glaucoma, but success rates vary according the type of uveitis. Trabeculectomy with wound-healing modulators, such as 5-flourouracil and mitomycin-C (MMC), has been advocated in last decade for minimizing scarring of the filtration bleb.4 Nonetheless, even with such therapy, a marked postoperative inflammatory response in uveitic eyes or recurrence of uveitis can result in bleb fibrosis. Artificial aqueous drainage devices have been used for primary surgical treatment of uveitis, but the reported success rates are inconsistent.5–8 Herein we report the outcomes of 14 consecutive unselected eyes that developed uveitic glaucoma associated with BD, did not respond to medical treatment, and were treated with Ahmed glaucoma valve (AGV) implantation.
PATIENTS AND METHODS A retrospective, noncomparative study of AGV implantation was undertaken and included patients who had uveitis associated with BD. Upon approval of the study protocol by the Ankara Research and Education Hospital Ethics Committee, the charts of BD patients who underwent AGV implantation surgery were retrospectively reviewed. The study included 14 eyes of 10 BD patients who were diagnosed according to the International Society for Behc¸et’s Disease criteria, were classified as panuveitis according to the Standardization of Uveitis Nomenclature,9 and underwent AGV implant surgery between April 2006 and April 2008 due to glaucoma that was uncontrolled despite previous medical treatment with or without glaucoma surgery. Even if the uveitis of included patients in the study was clinically in remission, each patient received oral prednisone that was started on the day before surgery at a dose of 1 mg/kg/d and was tapered for 4 weeks, started tapering a week after surgery. All patients had an ophthalmic examination, including best-corrected visual acuity with Snellen charts, slit-lamp examination, dilated fundus examination, visual field analysis with Humprey Field Analyser (Carl Zeiss Meditec, Dublin, CA) using central 30-2 threshold test and SITA (Swedish Interactive Threshold Algorithm) strategy, and IOP measurement with a Goldmann applanation tonometer.
Surgical Technique All AGV implant operations were performed superotemporally by the same surgeon (B.S.), with the use of a fornix-based conjunctival and Tenon capsule flap. An AGV FP7 single-plate silicone implant (New World Medical Inc.,
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Rancho Cucamonga, CA) was used in all patients. The implant was primed by the injection of saline solution through a 26 G blunt cannula. The body of the implant was secured 8 to 10 mm from the limbus with two 5/0 polyester sutures. A paracentesis was performed temporally for the injection of viscoelastic material. At 2 mm posterior to the limbus, a 23 G sharp needle was used to enter the anterior chamber (AC). Next, the drainage tube was inserted 2 to 3 mm into the AC through this needle track, which was secured to the sclera with three 10/0 nylon sutures, and was covered with donor pericardium and sutured to the sclera with 4 interrupted 10/0 nylon sutures. The conjunctiva was then closed with 10/0 nylon sutures. Each patient received prednisolone acetate (1%) (Pred-Forte Allergan, Westport Co., Mayo, Ireland) topically every 2 hours for 1 week while awake, followed by tapering starting at 1 week after surgery. Topical ketorolac tromethamine (0.5%) (Acular Allergan) and ofloxacin (0.3%) (Exocin Allergan, Westport Co.) were also administered 4 times daily during the first postoperative week. Systemic immunosuppressive agents were continued if the patient had been receiving these before surgery.
Mean preoperative and postoperative CDRs were, respectively, 0.58 ± 0.16 (range, 0.4 to 0.8) and 0.56 ± 0.15 (range, 0.4 to 0.8) (P = 0.32).
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Visual Field Examination Preoperative and postoperative mean MD and PSD results were, respectively, 11.81 ± ( 9.37) (range, 28.58 to 1.89) and 14.45 ± ( 12.77) (range, 33.21 to 1.92) (P = 0.21) and 2.88 ± 1.65 (range, 1.15 to 7.95) and 2.80 ± 1.55 (range, 1.05 to 6.44) (P = 0.38). PSD were not able to be calculated in 3 patients who had loss of vision to counting fingers in postoperative last follow-ups. The differences were not statistically significant.
Glaucoma Medications There was a significant decrease in the number of postoperative glaucoma medications used at all follow-up visits (Pr0.001, Table 2). At the last postoperative follow-up visit, IOP was controlled without medication in 8 (57.14%) eyes, with 2 glaucoma medications in 4 (28.57%) eyes, and with 3 medications in 1 (7.14%) eye.
Systemic Treatment
Statistical Analysis The results were statistically analyzed through the paired t test to determine the differences between continuously scaled variables before and after surgery. KaplanMeier life-table analysis was used to assess cumulative probability of success. P-values 5 mm Hg, without further additional glaucoma surgery or loss of light perception. Postoperative use of antiglaucoma medications was not a criterion for success or failure. Hypotony was defined as an IOP of r5 mm Hg for 2 consecutive follow-up visits.
RESULTS In total, 14 eyes of 10 patients who underwent AGV implantation for uveitic glaucoma associated with BD between April 2006 and April 2008 were included. Seven (70%) of the 10 patients were male and 3 (30%) were female. Age, sex, follow-up period, diagnosis, laterality, previous surgeries, preoperative and last postoperative IOP, optic nerve cup to disc ratios (CDR), visual acuity, pattern standard deviation (PSD) of visual field, number of medications used, and surgical complications for each patient are summarized in Table 1. Mean age at the time of surgery was 24.21 ± 5.68 years (range, 15 to 30 y) and mean followup time was 18.62 ± 6.65 months (range, 6 to 31 mo). Ten (71.4%) eyes were pseudophakic and 4 (28.6%) eyes were phakic. AGV implant surgery was performed as primary glaucoma surgery in 5 (35.70%) eyes and as secondary glaucoma surgery after a failed trabeculectomy with MMC in 9 (64.30%) eyes.
IOP and Glaucomatous Cupping Mean preoperative and postoperative IOP and CDR results are summarized in Table 2. Preoperative and postoperative IOP differences were statistically significant at all follow-up times (Pr0.001).
Systemic treatment included a combination of azathiopurine and cyclosporine A in 6 patients (60%), cyclosporine A alone in 3 patients (30%), and azathiopurine alone in 1 patient (10%). Patients who were on systemic treatment regimens before surgery continued these postoperatively (Table 1).
Visual Acuity Before surgery, visual acuity ranged from 20/200 to 20/20. Mean preoperative and postoperative log MAR visual acuities were 0.70 ± 0.39 (range, 0.05 to 1.00) and 0.94 ± 0.73 (range, 0.00 to 2.10), respectively (P = 0.10). Visual acuity improved by >1 line in 3 (21.42%) eyes, decreased by >1 line in 4 (28.57%) eyes, and did not change in 7 (50.0%) eyes, in terms of measurements obtained at the last follow-up visits. Among the patients with loss of vision, the visual acuity decreased from 20/200 to counting fingers (3 patients) and from 20/50 to 20/200 (1 patient). Loss of visual acuity was connected to, respectively, optic atrophy and retinal atrophy secondary to vasculitis and cystoid macular edema in BD (Table 1).
Surgical Success The cumulative probability of success was 90.9% at 18 months and 72.7% at 24 months (95% confidence interval, 24.73-31.62) after surgery by Kaplan-Meier survival analysis (Fig. 1). According to our success criteria 2 eyes were defined as failure; 1 eye developed encapsulated cystic bleb, had bleb revision, and continued uncontrolled IOP with glaucoma medications and other eye developed early postoperative hypotony requiring tube ligation (Table 1). The IOP was between 6 and 21 mm Hg in 13 (92.8%) of the 14 eyes at the last follow-up visit. AGV implantation was performed as primary glaucoma surgery in 5 eyes (35.7%) and was performed after unsuccessful trabeculectomy in 9 eyes (64.3%). The mean IOP at last follow-up between these 2 groups was not statistically significant (P = 0.45).
Complications The most common complications that required treatment within the first postoperative week were transient hypotony and hypotony-induced complications (4 eyes,
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Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
OS
10
Male
29
28
27
Male
Male
Male
30 Female
29
Male
TRAB CE + IOL NONE
TRAB
NONE
NONE
TRAB
20/20
20/200
20/200
20/100
20/200
20/200
35
40
30
42
46
34
32
30
30 32
32
34
50
30
3
3
3
4
4
3
3
3
3 3
4
4
4
4
0.6
0.8
0.8
0.4
0.5
0.7
0.8
0.8
0.5 0.4
0.4
0.6
0.5
0.4
2.18
7.18
7.95
1.63
2.83
3.58
6.64
6.44
7.15 1.78
3.52
3.60
2.11
2.19
6
7
19
19
18
10
31
23
22 22
18
18
22
20
20/20
20/100
CF
20/70
20/200
20/100
CF
CF
20/20 20/200
20/100
20/100
20/20
20/200
12
7
14
12
23
12
13
12
16 18
12
21
14
14
0
0
2
2
3
3
0
0
0 0
0
0
2
2
0.6
0.7
0.8
0.4
0.5
0.5
0.8
0.8
0.4 0.4
0.4
0.6
0.5
0.5
2.11
6.44
N/A
1.19
2.95
4.02
N/A
N/A
1.05 1.64
3.60
3.52
2.19
2.11
Retinal vasculitis Optic atrophy
Postoperative early hypotony Wound leak Retinal vasculitis Optic atrophy Retinal vasculitis Optic atrophy Postoperative early hypotony Cataract Encapsulated bleb
Descemet membrane detachment
Postoperative CME early hypotony Postoperative early hypotony, wound leak
CSA
AZO
CSA AZO CSA AZO CSA AZO
CSA AZO
CSA AZO
CSA
CSA
CSA AZO
Complications Systemic of Uveitis Treatment
*Data of most recent follow-up. AZO indicates azathioprine; CDR, cup to disc ratio; CE, cataract extraction; CF, counting fingers; CME, cystoid macular edema; CSA, cylosporine-A; FT, follow-up time; IOL, intraocular lens; IOP, Intraocular pressure; M, antiglaucomatous medication; PSD, pattern standard deviation; TRAB, trabeculectomy; VA, visual acuity.
OS
8
OD
6
OD
OS
5
23
20/200
20/200
20/20 20/200
20/100
20/100
20/20
20/50
Postoperative Complications
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7
OD
4
20
OS
TRAB CE + IOL
20 Female TRAB CE + IOL
OD
TRAB TRAB
9
28 Male 28
OD OS
15
OS
TRAB CE + IOL TRAB CE + IOL
TRAB
None
3
15 Female
Male
Sex
OD
29
OS
2
29
OD
1
Age
Eye
Patient #
PostPreoperative PostPost Postoperative PrePrePrePre VA Postop operative operative operative VA operative operative operative operative FT CDR* PSD* Snellen IOP No. M CDR PSD (m) Snellen* IOP* No. M*
Previous Surgeries
TABLE 1. Demographic Data of Patients
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TABLE 2. IOP and AGM Before and After AGV Implantation
Period Preoperative Postoperative 1 wk 1 mo 3 mo 6 mo 9 mo 12 mo 15 mo 18 mo
Mean IOP ± SD (Range) (mm Hg)
Medication ± SD (Range)
No. Eyes
No. Eyes With AGM
35.50 ± 6.4 (30-50)
3.42 ± 0.51 (3-4)
14
14
8.78 ± 4.31 10.57 ± 3.17 12.07 ± 3.97 13.64 ± 3.31 13.08 ± 3.47 15.09 ± 3.83 15.00 ± 3.43 14.45 ± 2.58
0.21 ± 0.80 0.42 ± 1.08 0.64 ± 1.27 0.23 ± 0.83 0.58 ± 0.80 0.45 ± 1.03 1.27 ± 1.00 1.0 ± 1.18
14 14 14 14 12 11 11 11
1 2 3 1 3 2 8 5
(2-18) (6-16) (6-18) (8-20) (8-20) (8-21) (12-21) (12-20)
(0-3) (0-3) (0-3) (0-3) (0-2) (0-3) (0-3) (0-3)
P
r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w r0.001*,w
*Referring preoperative and postoperative mean IOP difference. wReferring preoperative and postoperative mean AGM difference. AGM indicates antiglaucomatous medications; AGV, Ahmed glaucoma valve; IOP, Intra ocular pressure.
28.7%). Three of the hypotonic eyes with flat ACs were treated with sodium chondroitin sulfate and sodium hyaluronate (Viscoat Alcon Laboratories, Fort Worth, TX) injection into the AC. One patient with persistent hypotony and peripheral choroidal detachment was treated with surgical AGV tube ligation with 6/0 Vicryl suture. Although IOP control was successful after ligation, it was defined as failure. Other complications included Descemet membrane detachment (1 eye, 7.14%), wound leak (2 eyes, 14.2%), cataract (1 eye, 7.14%), and cystic bleb encapsulation (1 eye, 7.14%). Descemet membrane detachment originated through side-corneal incisions for viscoelastics. This patient had vision loss the first postoperative week. After an unsuccessful air and viscoelastics trial, the patient underwent full-thickness corneal suturing with 10/0 nylon sutures. Three months after corneal suturing the patient’s vision returned to baseline status. Wound leaks were repaired surgically with suturing of the conjunctiva with 10/0 nylon suture at the leakage site. One patient developed cataract 6 months after AGV surgery and underwent phacoemulsification
FIGURE 1. Cumulative probability of success by Kaplan-Meier life-table analysis. Figure 1 can be viewed in color online at www.glaucomajournal.com.
and IOL implantation through a clear corneal temporal incision, and experienced no additional complications. Encapsulated cystic bleb formation over the AGV body required capsulectomy of Tenon capsule through a conjunctival incision lateral to the encapsulated bleb. As the IOP remained over 21 mm Hg despite topical antiglaucomatous medication, it was defined as failure (Table 1).
DISCUSSION BD is a multisystemic disorder caused by occlusive vasculitis and is characterized by recurrent intraocular inflammation, oral aphthous ulcers, skin lesions, ocular inflammation, and genital ulcers. Inomata et al10 reported ocular involvement in 78.6% of BD cases. Ocular involvement is usually bilateral, can affect both the anterior and posterior segments, and manifestations appear 2 to 3 years after the initial symptoms. Anterior nongranulomatous uveitis is generally associated with a sterile hypopyon. Retinal disease is characterized by recurrent retinal vascular occlusions and ischemia, which may lead to vision loss.2,3 Glaucoma is among the major complications of ocular BD and arises from obstruction of the trabeculum by inflammatory cells, posterior synechiae with iris bombe, peripheral anterior synechiae, and rubeosis iridis. Elgin et al11 reported a secondary glaucoma incidence rate of 10.9% in BD with ocular involvement and Yalvac¸ et al12 reported a similar incidence rate (10.4%) for uveitic glaucoma in BD. The management of uveitic glaucoma can be difficult because of the mechanisms mentioned above, which also occur in Behc¸et uveitis. Active uveitis, pseudophakia, and a history of previous glaucoma surgery increase the rate of failure of glaucoma surgery, even with antimetabolite administration in uveitis patients. As Keino and Okada13 reported, BD is limited to certain geographic regions. The English language literature on patients with BD who undergo glaucoma surgery, including AGV implantation, is limited. In the treatment of uveitic glaucoma associated with BD, trabeculectomy with MMC has had variable success. Yalvac et al12 achieved overall 1-, 2-, 3-, 4-, and 5-year success rates of 83%, 76%, 70%, 66%, and 62%, respectively, in 26 eyes treated with trabeculectomy and MMC. Almost same success rate with BD, 82%, was achieved for the first year of trabeculectomy and MMC by Elgin et al.14 Similar results have been reported for nonselective uveitic
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TABLE 3. Glaucoma Implant Studies With Uveitic Glaucoma Patients
References Gil-Carrasco et al5 Da Mata and Foster6 Ozdal et al8 Rachmiel et al17 Hill et al18 Ceballos et al19 Molteno et al20 This study
Type of Implant
No. Eyes
Succes Rate (%)
Follow-up Time
Ahmed
14
57
22 mo
Ahmed
21
94
1y
Ahmed Ahmed Molteno Bearveldt Molteno Ahmed
19 15 10 24 40 14
60 66 79 91 76 90
2y 30 mo 2y 24 mo 5y 18 mo
glaucoma by Patitsas et al15 and by Towler et al16 with success rates of 70% at 34 months and 50% at 5 years, respectively. Late failure rates are higher than those reported for trabeculectomy in patients with nonuveitic glaucoma.6,7,17 In the last 10 years, drainage implants have been advocated for the treatment of uveitic glaucoma. Published success rates for drainage implants in uveitic glaucoma series17–20 range between 57% and 94% (Table 3). As a glaucoma drainage device, the AGV implant has a unidirectional valve mechanism designed to prevent hypotony and related complications. In a study that compared the use of AGV implants, Krupin valves, and Molteno implants in patients with complicated glaucoma, Taglia et al21 reported a lower complication rate with AGV implants. We defined success as an IOP between 6 and 21 mm Hg with or without glaucoma medication, and without additional glaucoma surgery or loss of light perception. Accordingly, 72.7% of our patients had treatment success at 2 years. When preoperative and postoperative MD and PSD results were compared, it was shown that visual field defects also did not progress significantly. In our patients, the success rate did not differ significantly between primary tube implantation glaucoma surgery and secondary implantation after bleb failure. Ozdal et al8 reported AGV implantation in19 eyes, in 16 of which this procedure was primary glaucoma surgery. Success of the AGV implant in that study is also indicated by the reduction in the number of antiglaucoma medications used postoperatively. In our study, reduction in the number of medications was not used as a measure of treatment success; nonetheless, at 18 months after surgery, patients required on average 1 medication, which represents a reduction of approximately 2.4 medications per eye. Same postoperative average number of medications were reported by Ozdal et al8 and Da Mata and Foster6 for uveitic patients at 18 months of follow-up. Antiglaucoma medication needed for our uveitic study group with BD is relatively lower compared with studies of AGV of same follow-up periods.22 Postoperative tendency of hypotony and hypotony-related complications should be considered for this group of patients. Aggressive anti-inflammatory therapy and valve implantation in nonactive uveitic eyes are recommended by some researchers.6,8,20 As mentioned in the Patients and methods section, active uveitis was not present in our study group, and if a patient had been receiving systemic immunosuppressive agents before surgery, these were continued in addition to perioperative adjunctive prednisone treatment. Our study is Copyright
r
AGV Implantation for Uveitic Glaucoma
thus consistent with the idea that good outcomes are closely related to the control of inflammation before surgery. The most common complication in the present study was transient hypotony (28.4%). This is similar to the 26% incidence of transient hypotony reported by Rachmiel et al17 for patients with uveitic glaucoma. Three of the eyes with transient hypotony in the present study had resolution after viscoelastics were injected into the AC. One eye with peripheral choroidal effusion (7.14%) due to prolonged hypotony was treated with tube ligation with 6/0 Vicryl sutures. In eyes with uveitis, postoperative hypotony is closely related to ciliary body shutdown followed by reduced production of aqueous. Potential methods for reducing the incidence of postoperative transient hypotony include more extensive injections of viscoelastic materials and/or tube ligation with Vicryl sutures at the end of surgery. Corneal-tube touch did not develop in any of our patients, which has been reported to occur in 5% of patients with AGV implantation by Huang et al.23 Occlusion of the valve, a complication reported by Ozdal et al,8 was also not encountered in our patients. Descemet membrane detachment occurred in 1 eye of patient 2 (Table 1), but 3 months after treatment of this complication visual acuity returned to the pre-AGV surgery level. Corneal edema and other corneal complications were reported as the most common type of serious complication by Papadaki et al24 in their study of patients with uveitic glaucoma who underwent AVG implantation. Corneal complications were not encountered in our group of patients. Hemorrhagic choroidal detachment was also not seen among our patients.25 One of our patients developed an encapsulated bleb (7.14%), which was successfully treated with capsulectomy. Morad et al26 reported an incidence of 7% for Tenon cysts, which were treated with either needling or excision in their study of AGV implants in pediatric glaucoma patients. The Ahmed Baerveldt Comparison22 and The Ahmed Versus Baerveldt27 as the large-scale comparative studies, reveal higher success rate with Baerveldt implant than AGV after 1-year follow-up,22,27 but a greater number of patients in the Baerveldt group required interventions (26% Ahmed vs. 42% Baerveldt, P = 0.009).27 Nonspecified uveitis patients (18 patients) had either AGV (11 patients, 8%) or Baerveldt (7 patients, 5%) glaucoma implant surgery at Ahmed Baerveldt Comparison study. Limitations of the present study include the number of patients, the short duration of follow-up, the retrospective design, and the inclusion of >1 eye from 4 patients. Nonetheless, we aimed to report the IOPs and reductions in the number of antiglaucoma medications, as well as complication types and rates after AGV implantation in BD patients with uveitic glaucoma as a specific panuveitis patient group. Large-scale prospective, controlled, and randomized multicenter studies are needed to confirm these results. In conclusion, AGV implant surgery is effective for intractable glaucoma secondary to Behc¸et uveitis. Among the complications of the procedure, hypotony is the major one which requires additional surgical interventions. REFERENCES 1. Behc¸et H. About recurrent aphthous ulcers caused by a virus on or around the mouth, eyes and genitals. Dermatol Wochenschr. 1937;105:1152–1157.
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