Advice On Glaucoma Drainage

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ONLINE SURVEY
Advice on
Glaucoma
Drainage Devices
Technical pearls and advice on selecting a device for tube shunt surgery.
By Boris Dilman, MD, and Anjali S. Hawkins, MD, P h D
T
hanks to recent research such as the Tube Versus It had previously been suggested that the IOP after
Trabeculectomy (TVT) Study, the popularity of tube shunt surgery typically settles in the mid- to upper
glaucoma drainage devices (GDDs) as initial sur- teens, but the results of the TVT Study suggest that
gical therapy for glaucoma is rising even in eyes this modality achieves a similar IOP to trabeculectomy.
with strong visual potential and patients who are consid- According to subgroup analysis, 63.9% of eyes in the
ered to be good candidates for trabeculectomy. All GDDs tube shunt group had an IOP of 14 mm Hg or less
drain fluid through a silicone tube that is attached to a 5 years postoperatively.
silicone or polypropylene explant or plate.1,2 The surface
area of the plate, plate material, and presence of a valved Studies Comparing the Ahmed and Baerveldt Implants
mechanism are the main differences between GDDs.3 Two studies have compared the failure rates and
At present, surgeons use four main tube shunts: safety of the Ahmed Glaucoma Valve model FP-7 and
Ahmed Glaucoma Valve (New World Medical, Inc.), the Baerveldt 350-mm2 glaucoma implant. The Ahmed
Baerveldt (Abbot Medical Optics Inc.), Krupin Eye Valve Baerveldt Comparison (ABC) Study assessed 276 pa
(Hood Laboratories), and Molteno (Molteno Ophthalmic tients with refractory glaucoma who had previously
Limited).3,4 Interest has been rising, however, in the newly
introduced Molteno 3 (Molteno Ophthalmic Limited; see A New Glaucoma Drainage Device
A New Glaucoma Drainage Device).
The Molteno 3 (Molteno Ophthalmic Limited) is
RESEARCH available as a 175- or 230-m single plate. The thin
Five-Year Results of the TVT Study profile of this polypropylene shunt makes it more
The TVT Study compared the results of a 350-mm2 flexible than the original Molteno tube shunt. The
Baerveldt glaucoma implant to those of trabeculectomy Molteno 3 is a dual-chamber implant, with a superior
using mitomycin C (0.4 mg/mL for 4 minutes) in 212 eyes subsidiary ridge that restricts flow to the main cham-
with medically uncontrolled glaucoma.5 Five-year data ber until the IOP is high enough to overcome the
show that the tube shunt group had a lower probability valved mechanism. It thus avoids early hypotony and
of failure than the trabeculectomy group (29.8% vs 46.9%). promotes a thinner bleb. The secondary subsidiary
The IOP at 5 years was similar in both groups (14.4 mm Hg ridge prevents glaucomatous proinflammatory aque-
in the tube group and 12.6 mm Hg in the trabeculectomy ous from developing a thick encapsulated bleb over
group), and both treatment arms required a similar num- the plate, which leads to a lower IOP and reduces the
ber of glaucoma medications postoperatively (1.4 and 1.2, need for postoperative hypotensive medication.
respectively).
july/august 2012Glaucoma today49

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choroidal effusion, and this GDD is highly effective for

eyes that need a low IOP quickly, such as in cases of
advanced open-angle glaucoma, uveitic glaucoma, and
neovascular glaucoma. We have found that Baerveldt
shunts can have a more complicated postoperative
course, including a high initial IOP and hypotony after
the Vicryl suture (Ethicon, Inc.) dissolves. If an eye can
tolerate a high IOP for 4 to 6 weeks after surgery, how-
ever, a Baerveldt implant may be a better choice, based
on the aforementioned studies. The Baerveldt may also
be preferable if an Ahmed device has already failed in
the eye.
For example, the figure shows the anterior chamber
of a patient with an Ahmed Glaucoma Valve supero-
temporally and a Baerveldt implant inferonasally. We
Figure. An eye with an Ahmed Glaucoma Valve supero placed the former initially, but it failed to lower the IOP
temporally and a Baerveldt implant inferonasally. adequately. We implanted a Baerveldt device inferona-
sally a few months later, and the patients IOP is now
undergone a trabeculectomy for secondary glaucoma.6 well controlled.
One year after tube shunt surgery, the Baerveldt group
had a lower IOP than the Ahmed group (13.2 vs Technique
15.4 mm Hg), had a lesser need for additional surgery, Although it can be placed in any quadrant, we usu-
and used a lower number of glaucoma medications ally implant the GDD in the superotemporal quadrant
(1.5 vs 1.8).6 The incidence of early and serious postop- using two interrupted 90 nylon sutures located 8
erative complications (hyphema, occlusion of the tube, to 10 mm posterior to the limbus. Our usual choice
corneal edema), however, was more common in the for covering the tube is donor sclera, but many other
Baerveldt group. materials may be used, including pericardium and
The Ahmed Versus Baerveldt (AVB) Study evaluated donor cornea.
238 patients with uncontrolled refractory glaucoma.7 The Ahmed device requires priming before insertion
One year postoperatively, the Baerveldt group had a to make sure the valve is functional. We use a 30-gauge
lower IOP than the Ahmed group (13.6 vs 16.5 mm Hg) needle for this purpose and apply just enough force
and used fewer glaucoma medications (1.2 vs 1.6).7 The to express balanced salt solution out of the valve. It
Baerveldt group required more postoperative interven-
tions such as manipulation of the tube, paracentesis,
and phacoemulsification.
Weigh in on
OUR APPROACH
Trabeculectomy or Tube Shunt? this topic now!
For patients with advanced open-angle glaucoma Direct link: https://www.research.net/s/GT3.
who have elevated IOP that is not controlled by maxi-
mal tolerated medical and laser therapy, our initial 1. During the past 4 years, have you become more likely
to consider a tube shunt as initial surgical therapy for
surgical procedure of choice is still a trabeculectomy glaucoma?
with mitomycin C. In cases where one or two trabecu- Yes
lectomies have already failed or if the patient has neo- No
vascular or uveitic glaucoma, we consider a GDD with a
scleral patch graft. 2. If yes, how great an influence have the results of
research such as the TVT Study, ABC Study, and ABV
Study had on your current thinking?
How We Determine Which Shunt to Use Major
In our practice, we use the Baerveldt 350-mm2 Moderate
glaucoma implant and the FP-7 model of the Ahmed Minor
Glaucoma Valve. In our experience, the valved shunt No influence
minimizes the risk of postoperative hypotony and
50Glaucoma todayjuly/august 2012

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is important not to be too vigorous during this test,

because the valved mechanism can be destroyed.
We enter the anterior chamber with a 23-gauge
needle positioned parallel to the iris. Ideally, the tube
will not touch the iris or cornea.
Because Baerveldt implants have no resistance to
outflow, to prevent immediate postoperative hypot-
ony, we ligate the silicone tube intraoperatively with
a Vicryl suture that dissolves in 4 to 6 weeks. Often,
patients must use all of their preoperative glaucoma
medications for this period.
CONCLUSION
Although trabeculectomy is still the most common
surgical procedure to treat elevated IOP, tube shunts
are slowly gaining popularity for the surgical manage-
ment of glaucoma. New data from the TVT Study
and the willingness of a growing number of glaucoma
specialists to use tube shunts earlier in the course of
the disease mean that GDDs have become a primary
surgical option for some patients. We tend to use
the Ahmed Glaucoma Valve more than the Baerveldt
implant, because we have found that the former
reduces the IOP more quickly, has a higher level of pre-
dictability, and is associated with fewer postoperative
complications. n
Boris Dilman, MD, is an ophthalmology

resident at Rush University Medical Center in
Chicago. He acknowledged no financial interest
in the products or companies mentioned herein.
Dr. Dilman may be reached at (312) 942-5315;
[email protected].
Anjali S. Hawkins, MD, PhD, is an assistant
professor of ophthalmology at Rush University
Medical Center in Chicago. Dr. Hawkins is also
in private practice at the Geneva Eye Clinic in
Geneva, Illinois. She acknowledged no financial
interest in the products or companies mentioned herein.
Dr. Hawkins may be reached at (312) 942-5315;
[email protected].
1. Patel S, Pasquale LR. Glaucoma drainage devices: a review of the past, present, and future. Semin
Ophthalmol. 2010;25(5-6):265-270.
2. Schwartz KS, Lee RK, Gedde SJ. Glaucoma drainage implants: a critical comparison of types. Curr Opin
Ophthalmol. 2006;17(2):181-189.
3. Minckler DS, Francis BA, Hodapp EA, et al. Aqueous shunts in glaucoma. Ophthalmology.
2008;115(6):1089-1097.
4. Mosaed S, Minckler DS. Aqueous shunts in the treatment of glaucoma. Expert Rev Med Devices.
2010;7(5):661-666.
5. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the Tube Versus Trabeculectomy Study
after five years of follow-up. Am J Ophthalmol. 2012;153(5):789-803.
6. 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(3):443-452.
7. Christakis PG, Kalenak JW, Zurakowski D, et al. The Ahmed Versus Baerveldt study: one-year treatment
outcomes. Ophthalmology. 2011;118(11):2180-2189.
July/August 2012Glaucoma today51

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cover story

By Boris Dilman, MD, and Anjali S. Hawkins, MD, P h D

july/august 2012Glaucoma today49

choroidal effusion, and this GDD is highly effective for

50Glaucoma todayjuly/august 2012

is important not to be too vigorous during this test,

Boris Dilman, MD, is an ophthalmology

July/August 2012Glaucoma today51

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