ORIGINAL STUDY
Long-Term Results of Ahmed Glaucoma Valve in Association With Intravitreal Bevacizumab in Neovascular Glaucoma Marwan Sahyoun, MD,*w Georges Azar, MD,*wz Ziad Khoueir, MD,*z Joelle Antoun, MD,*z Hampig Kourie, MD,z Joseph Nehme, MD,*w and Alexandre Jalkh, MD*wz
Purpose: Evaluate the long-term results of the Ahmed glaucoma valve (AGV) surgery in association with bevacizumab (Avastin) in neovascular glaucoma (NVG) patients. Design and Methods: This retrospective institutional study reviewed 39 eyes of 34 patients with NVG who underwent AGV implantation. The intravitreal bevacizumab (IVB) group included 19 eyes that received an injection of IVB 7 days preoperatively, whereas the no-IVB group included 20 eyes that did not receive any antivascular endothelial growth factor therapy. Findings such as intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), and surgical outcomes were reviewed over a period of 5 years. Results: There were no significant differences in the preoperative characteristics between the 2 groups. At last follow-up visit, IOP was 16.37 ± 5.72 mm Hg in the IVB group and 20.05 ± 9.75 mm Hg in the no-IVB group (P = 0.16). The number of postoperative antiglaucoma medications was significantly lower in the IVB group (P = 0.02). Last visit’s mean BCVA was 2.34 ± 1.00 logMAR in the IVB group and 2.66 ± 1.04 logMAR in the control group (P = 0.33). Hyphema was significantly less observed in the IVB group (P = 0.02). The probability of success was 63.2% in the IVB group and 70.0% in the control group (P = 0.37). Conclusions: Preoperative IVB before AGV was not associated with a better surgical success, IOP control, or BCVA. Its administration significantly decreased postoperative hyphema and number of last visit’s antiglaucoma medications. Key Words: neovascular glaucoma, drainage implant, Ahmed glaucoma valve, intraocular pressure, bevacizumab
(J Glaucoma 2015;24:383–388)
D
espite therapeutic advances and continuous discovery of new molecules and targeted therapies, neovascular glaucoma (NVG) remains to this day a medical and surgical challenge. The main causes of NVG are central retinal vein occlusion, diabetic retinopathy, and ocular ischemic syndrome.1,2 It is a particularly severe form of glaucoma, which is essentially characterized by poor visual prognosis3–5 and resistance to conventional antiglaucoma Received for publication April 6, 2014; accepted January 8, 2015. From the *Eye and Ear Hospital International, Naccache, Dbayeh; wHoly Spirit University of Kaslik (USEK), Faculty of Medicine, Kaslik; and zSaint Joseph University (USJ), Faculty of Medicine, Beirut, Lebanon. Disclosure: The authors declare no conflict of interest. Reprints: Marwan Sahyoun, MD, Eye and Ear Hospital International, Saint Vincent street, Naccache, Dbayeh 70-933, Lebanon (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000234
J Glaucoma
treatment.6,7 Often diagnosed at a late stage when visual acuity is already severely diminished, its treatment is firstly based on managing the underlying ischemic drive that is causing neovascularization and then on intraocular pressure (IOP) control through antiglaucoma medications or surgery. In refractory cases, drainage implants are of particular use, with the Ahmed glaucoma valve (AGV; New World Medical Inc., Rancho Cucamonga, CA) and its venturi system introduced in 1993.8 It now appears that such procedures allow only a transient control of the IOP postoperatively, with its reincrease during longer follow-up.2,9 In NVG, the new vessels invade the anterior angle and form a fibrovascular membrane that blocks the trabecular meshwork, reducing filtering of the aqueous humor. In advanced cases of inadequately controlled diabetes, more neovessels develop over time and lead to irreversible anterior synechia due to the proliferation and contraction of the myofibroblasts present in the fibrovascular tissue. All of this leads to progressive closure of the iridocorneal angle, along with a fibrinous reaction that may block the tube or occur around the plate of the device causing IOP to increase despite tube patency.1,2,10 The role of the vascular endothelial growth factor (VEGF) type A isotype 165 is now well established in the pathogenesis of NVG, particularly in the development of rubeosis iridis after retinal ischemia.11 Bevacizumab (Avastin; Genentech Inc., South San Francisco, CA) was FDA approved in 2004 for treatment of metastatic colorectal cancer. Its intravitreal or intracameral administration in NVG is done in a regulated setting.4 Once injected, bevacizumab induces rapid regression of neovascularization after a week6 and a drop in the IOP.11 It is often used as an adjuvant to surgical treatment with panretinal photocoagulation (PRP) or drainage implant, resulting in a rapid improvement of ocular pain,12 a less aggressive postoperative hypertensive period,13 and an increase in the rate of surgical success.14,15 The aim of this retrospective study was to note the long-term results of the AGV surgery on IOP, best-corrected visual acuity (BCVA), and the number of antiglaucoma medications used in patients with NVG, and to study the effect of bevacizumab to conclude on its effectiveness concerning a better control of the IOP, and a higher surgical success rate.
MATERIALS AND METHODS Inclusion Criteria This retrospective institutional study collected the records of patients admitted to the ophthalmology department of the Eye and Ear Hospital (Naccash, Lebanon) for
Volume 24, Number 5, June/July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.glaucomajournal.com |
383
Sahyoun et al
J Glaucoma
AGV implantation between January 2002 and August 2012. Six patients underwent bilateral implantation, in which data were collected for both eyes separately. Among a total of 98 consecutive eyes operated, only those who had NVG were kept. The diagnosis of NVG was made by a specialist and defined as neovascularization of the iris (NVI) and/or anterior chamber of the eye and/or iridocorneal angle as diagnosed with gonioscopy, with elevated IOP (Z21 mm Hg). Exclusion criteria were age younger than 18 years and the use of earlier cyclodestructive procedures or drainage implants. Similarly, patients with a follow-up duration of
Long-Term Results of Ahmed Glaucoma Valve in Association With Intravitreal Bevacizumab in Neovascular Glaucoma Marwan Sahyoun, MD,*w Georges Azar, MD,*wz Ziad Khoueir, MD,*z Joelle Antoun, MD,*z Hampig Kourie, MD,z Joseph Nehme, MD,*w and Alexandre Jalkh, MD*wz
Purpose: Evaluate the long-term results of the Ahmed glaucoma valve (AGV) surgery in association with bevacizumab (Avastin) in neovascular glaucoma (NVG) patients. Design and Methods: This retrospective institutional study reviewed 39 eyes of 34 patients with NVG who underwent AGV implantation. The intravitreal bevacizumab (IVB) group included 19 eyes that received an injection of IVB 7 days preoperatively, whereas the no-IVB group included 20 eyes that did not receive any antivascular endothelial growth factor therapy. Findings such as intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), and surgical outcomes were reviewed over a period of 5 years. Results: There were no significant differences in the preoperative characteristics between the 2 groups. At last follow-up visit, IOP was 16.37 ± 5.72 mm Hg in the IVB group and 20.05 ± 9.75 mm Hg in the no-IVB group (P = 0.16). The number of postoperative antiglaucoma medications was significantly lower in the IVB group (P = 0.02). Last visit’s mean BCVA was 2.34 ± 1.00 logMAR in the IVB group and 2.66 ± 1.04 logMAR in the control group (P = 0.33). Hyphema was significantly less observed in the IVB group (P = 0.02). The probability of success was 63.2% in the IVB group and 70.0% in the control group (P = 0.37). Conclusions: Preoperative IVB before AGV was not associated with a better surgical success, IOP control, or BCVA. Its administration significantly decreased postoperative hyphema and number of last visit’s antiglaucoma medications. Key Words: neovascular glaucoma, drainage implant, Ahmed glaucoma valve, intraocular pressure, bevacizumab
(J Glaucoma 2015;24:383–388)
D
espite therapeutic advances and continuous discovery of new molecules and targeted therapies, neovascular glaucoma (NVG) remains to this day a medical and surgical challenge. The main causes of NVG are central retinal vein occlusion, diabetic retinopathy, and ocular ischemic syndrome.1,2 It is a particularly severe form of glaucoma, which is essentially characterized by poor visual prognosis3–5 and resistance to conventional antiglaucoma Received for publication April 6, 2014; accepted January 8, 2015. From the *Eye and Ear Hospital International, Naccache, Dbayeh; wHoly Spirit University of Kaslik (USEK), Faculty of Medicine, Kaslik; and zSaint Joseph University (USJ), Faculty of Medicine, Beirut, Lebanon. Disclosure: The authors declare no conflict of interest. Reprints: Marwan Sahyoun, MD, Eye and Ear Hospital International, Saint Vincent street, Naccache, Dbayeh 70-933, Lebanon (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000234
J Glaucoma
treatment.6,7 Often diagnosed at a late stage when visual acuity is already severely diminished, its treatment is firstly based on managing the underlying ischemic drive that is causing neovascularization and then on intraocular pressure (IOP) control through antiglaucoma medications or surgery. In refractory cases, drainage implants are of particular use, with the Ahmed glaucoma valve (AGV; New World Medical Inc., Rancho Cucamonga, CA) and its venturi system introduced in 1993.8 It now appears that such procedures allow only a transient control of the IOP postoperatively, with its reincrease during longer follow-up.2,9 In NVG, the new vessels invade the anterior angle and form a fibrovascular membrane that blocks the trabecular meshwork, reducing filtering of the aqueous humor. In advanced cases of inadequately controlled diabetes, more neovessels develop over time and lead to irreversible anterior synechia due to the proliferation and contraction of the myofibroblasts present in the fibrovascular tissue. All of this leads to progressive closure of the iridocorneal angle, along with a fibrinous reaction that may block the tube or occur around the plate of the device causing IOP to increase despite tube patency.1,2,10 The role of the vascular endothelial growth factor (VEGF) type A isotype 165 is now well established in the pathogenesis of NVG, particularly in the development of rubeosis iridis after retinal ischemia.11 Bevacizumab (Avastin; Genentech Inc., South San Francisco, CA) was FDA approved in 2004 for treatment of metastatic colorectal cancer. Its intravitreal or intracameral administration in NVG is done in a regulated setting.4 Once injected, bevacizumab induces rapid regression of neovascularization after a week6 and a drop in the IOP.11 It is often used as an adjuvant to surgical treatment with panretinal photocoagulation (PRP) or drainage implant, resulting in a rapid improvement of ocular pain,12 a less aggressive postoperative hypertensive period,13 and an increase in the rate of surgical success.14,15 The aim of this retrospective study was to note the long-term results of the AGV surgery on IOP, best-corrected visual acuity (BCVA), and the number of antiglaucoma medications used in patients with NVG, and to study the effect of bevacizumab to conclude on its effectiveness concerning a better control of the IOP, and a higher surgical success rate.
MATERIALS AND METHODS Inclusion Criteria This retrospective institutional study collected the records of patients admitted to the ophthalmology department of the Eye and Ear Hospital (Naccash, Lebanon) for
Volume 24, Number 5, June/July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.glaucomajournal.com |
383
Sahyoun et al
J Glaucoma
AGV implantation between January 2002 and August 2012. Six patients underwent bilateral implantation, in which data were collected for both eyes separately. Among a total of 98 consecutive eyes operated, only those who had NVG were kept. The diagnosis of NVG was made by a specialist and defined as neovascularization of the iris (NVI) and/or anterior chamber of the eye and/or iridocorneal angle as diagnosed with gonioscopy, with elevated IOP (Z21 mm Hg). Exclusion criteria were age younger than 18 years and the use of earlier cyclodestructive procedures or drainage implants. Similarly, patients with a follow-up duration of
