Otago Glaucoma Surgery Outcome Study: Examining the Development of Strabismus Causing Diplopia in Patients Who Have Received Molteno Implant Surgery.

OBJECTIVE: To evaluate the development of postoperative strabismus causing diplopia in patients who received Molteno implant surgery for the treatment of glaucoma. METHODS: The Otago Glaucoma Surgery Outcome study (OGSOS) was used to select cases who had undergone Molteno implant surgery to examine the effect on the development of strabismus causing diplopia. Information was collected on treatments provided to correct motility disturbance, and their success, in this retrospective non-comparative study. RESULTS: 32 cases (3.3%) were found to have developed diplopia following the Molteno implant surgery from a total of 977 cases. Of these, the strabismus in 23 cases was described in sufficient detail to permit clinical categorization. Most (19/23) demonstrated an exodeviation, hyperdeviation, or a combination thereof, although 2/6 cases with superonasal plate location demonstrated a hypodeviation. Diplopia generally resolved spontaneously (20/32 cases). Treatment was required in eight cases, usually conservative and successful (6/8 cases), but strabismus surgery was required in two cases, and was unsuccessful. CONCLUSIONS: This study found a low incidence of diplopia developing post-Molteno implant surgery. Strabismus features suggested a restrictive etiology, and spontaneous recovery was common (62.5%). Surgical correction proved unsuccessful - confirming persistent postoperative diplopia after Molteno implant surgery to be a rare but surgically challenging complication.

Aqueous shunts for glaucoma.

BACKGROUND: Aqueous shunts are employed to control intraocular pressure (IOP) for people with primary or secondary glaucomas who fail or are not candidates for standard surgery. OBJECTIVES: To assess the effectiveness and safety of aqueous shunts for reducing IOP in glaucoma compared with standard surgery, another type of aqueous shunt, or modification to the aqueous shunt procedure. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 8), MEDLINE Ovid (1946 to August 2016), Embase.com (1947 to August 2016), PubMed (1948 to August 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to August 2016), ClinicalTrials.gov (www.clinicaltrials.gov); searched 15 August 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 15 August 2016. We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 15 August 2016. We also searched the reference lists of identified trial reports and the Science Citation Index to find additional trials. SELECTION CRITERIA: We included randomized controlled trials that compared various types of aqueous shunts with standard surgery or to each other in eyes with glaucoma. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results for eligibility, assessed the risk of bias, and extracted data from included trials. We contacted trial investigators when data were unclear or not reported. We graded the certainty of the evidence using the GRADE approach. We followed standard methods as recommended by Cochrane. MAIN RESULTS: We included 27 trials with a total of 2099 participants with mixed diagnoses and comparisons of interventions. Seventeen studies reported adequate methods of randomization, and seven reported adequate allocation concealment. Data collection and follow-up times varied.Four trials compared an aqueous shunt (Ahmed or Baerveldt) with trabeculectomy, of which three reported one-year outcomes. At one-year, the difference in IOP between aqueous shunt groups and trabeculectomy groups was uncertain (mean difference (MD) 2.55 mmHg, 95% confidence interval (CI) -0.78 to 5.87; 380 participants; very low-certainty evidence). The difference in logMAR visual acuity was also uncertain (MD 0.12 units, 95% CI -0.07 to 0.31; 380 participants; very low-certainty evidence). In two trials, the difference in visual field score was uncertain (MD -0.25, 95% CI -1.91 to 1.40; 196 participants; very low-certainty evidence). The mean number of antiglaucoma medications was higher in the aqueous shunt group than the trabeculectomy group in one trial (MD 0.80, 95% CI 0.48 to 1.12; 184 participants; low-certainty evidence). The effect on needing additional glaucoma surgery was uncertain between groups in two trials (risk ratio (RR) 0.24, 95% CI 0.04 to 1.36; 329 participants; very low-certainty evidence). In one trial, fewer total adverse events were reported in the aqueous shunt group than the trabeculectomy group (RR 0.59, 95% CI 0.43 to 0.81; 212 participants; very low-certainty evidence). No trial reported quality-of-life outcomes at one-year follow-up.Two trials that compared the Ahmed implant with the Baerveldt implant for glaucoma found higher mean IOP in the Ahmed group at one-year follow-up (MD 2.60 mmHg, 95% CI 1.58 to 3.62; 464 participants; moderate-certainty evidence). The difference in logMAR visual acuity was uncertain between groups (MD -0.07 units, 95% CI -0.27 to 0.13; 501 participants; low-certainty evidence). The MD in number of antiglaucoma medications was within one between groups (MD 0.35, 95% CI 0.11 to 0.59; 464 participants; moderate-certainty evidence). More participants in the Ahmed group required additional glaucoma surgery than the Baerveldt group (RR 2.77, 95% CI 1.02 to 7.54; 514 participants; moderate-certainty evidence). The two trials reported specific adverse events but not overall number of adverse events. Neither trial reported visual field or quality-of-life outcomes at one-year follow-up.One trial compared the Ahmed implant with the Molteno implant for glaucoma over two-year follow-up. Mean IOP was higher in the Ahmed group than the Molteno group (MD 1.64 mmHg, 95% CI 0.85 to 2.43; 57 participants; low-certainty evidence). The differences in logMAR visual acuity (MD 0.08 units, 95% CI -0.24 to 0.40; 57 participants; very low-certainty evidence) and mean deviation in visual field (MD -0.18 dB, 95% CI -3.13 to 2.77; 57 participants; very low-certainty evidence) were uncertain between groups. The mean number of antiglaucoma medications was also uncertain between groups (MD -0.38, 95% CI -1.03 to 0.27; 57 participants; low-certainty evidence). The trial did not report the proportion needing additional glaucoma surgery, total adverse events, or quality-of-life outcomes.Two trials compared the double-plate Molteno implant with the Schocket shunt for glaucoma; one trial reported outcomes only at six-month follow-up, and the other did not specify the follow-up time. At six-months, mean IOP was lower in the Molteno group than the Schocket group (MD -2.50 mmHg, 95% CI -4.60 to -0.40; 115 participants; low-certainty evidence). Neither trial reported the proportion needing additional glaucoma surgery, total adverse events, or visual acuity, visual field, or quality-of-life outcomes.The remaining 18 trials evaluated modifications to aqueous shunts, including 14 trials of Ahmed implants (early aqueous suppression versus standard medication regimen, 2 trials; anti-vascular endothelial growth factor agent versus none, 4 trials; corticosteroids versus none, 2 trials; shunt augmentation versus none, 3 trials; partial tube ligation versus none, 1 trial; pars plana implantation versus conventional implantation, 1 trial; and model M4 versus model S2,1 trial); 1 trial of 500 mm2 Baerveldt versus 350 mm2 Baerveldt; and 3 trials of Molteno implants (single-plate with oral corticosteroids versus single-plate without oral corticosteroids, 1 trial; double-plate versus single-plate, 1 trial; and pressure-ridge versus double-plate with tube ligation, 1 trial). AUTHORS' CONCLUSIONS: Information was insufficient to conclude whether there are differences between aqueous shunts and trabeculectomy for glaucoma treatment. While the Baerveldt implant may lower IOP more than the Ahmed implant, the evidence was of moderate-certainty and it is unclear whether the difference in IOP reduction is clinically significant. Overall, methodology and data quality among existing randomized controlled trials of aqueous shunts was heterogeneous across studies, and there are no well-justified or widely accepted generalizations about the superiority of one surgical procedure or device over another.

Diplopia after glaucoma drainage device implantation.

PURPOSE: To determine incidence of diplopia after glaucoma drainage device (GDD) surgery and to report treatment outcomes. METHODS: Financial claims data were used to identify patients who underwent GDD surgery (CPT [Current Procedural Terminology] 66180) at the Bascom Palmer Eye Institute from January 2, 1991, through December 31, 2005. After a second claims data search, the medical records of patients diagnosed with diplopia (International Classification of Diseases, 9th Revision code 368.2) and those who underwent extraocular muscle surgery (CPT-4 code 67311-67335) after GDD implantation were reviewed retrospectively. RESULTS: A total of 2,661 patients underwent GDD surgery during the study period. Charges were submitted for 59 patients for strabismus surgery or office visits relating to diplopia. Of these, 27 patients were excluded because medical records did not document diplopia or included pre-existing diplopia, cranial nerve palsy, or diplopia attributed to another ocular procedure. The remaining 32 patients developed diplopia secondary to GDD. Superotemporal quadrant GDDs were identified in 23 eyes and inferonasal quadrant placement in 9 eyes. The 1-year cumulative incidence of diplopia was 1.4%. No patient developed diplopia after 1 year. The mean follow-up after diagnosis for patients with diplopia was 48 ± 27 months (range, 1-124 months). The mean time of onset of diplopia after GDD implantation was 66 ± 62 days, with median onset of 42 days (range, 8-278 days). Treatment of diplopia included prisms in 17 cases (53.1%), no treatment in 13 (40.6%), other therapies in 2 (6.3%), and surgery after prismatic treatment failed in 3 (9.4%). CONCLUSIONS: The incidence of diplopia after GDD surgery is low, and most patients are treated with prisms.

[Intermediate results on the use of drainage devices for paediatric glaucoma]. / Resultados a medio plazo de dispositvos de drenaje para glaucoma en pacientes pediátricos.

PURPOSE: To evaluate the results and long-term complications of glaucoma drainage devices (GDD) in paediatric patients (0-15 years). METHODS: Retrospective cohort study was conducted on 17 implanted glaucoma drainage devices from July 1994 to April 2007 in 14 patients (17 eyes). In two patients (3 eyes) a Molteno GDD (MGDD) was implanted, and in 12 patients (14 eyes) an Ahmed GDD (AGDD) was used. We studied the demographic and glaucoma related patient data, as well as the probability of surgical success. The time which intraocular pressure (IOP) was controlled and the postoperative complications were also studied. RESULTS: Of the fourteen patients, 9 (64.28%) showed congenital glaucoma, and 5 (35.71%) aphakic glaucoma. The pre-aqueous drainage device median IOP was 29.82 mmHg (SD: 6.98), and 14.05 mmHg (SD: 7.57) postoperative. The median follow-up was 3.14 years (3 months-8.3 years). Success of aqueous drainage device was defined as an IOP less than 21 mmHg with or without medication on the last two follow-up visits, and without severe complications or further glaucoma surgery. Using a Kaplan Meier analysis there was success in 76%, 63% and 55% at the six months, 1-3 years and 4-8 years respectively. The GDD was a failure in 41.17%. CONCLUSIONS: GDDs are a good surgery option for refractory paediatric glaucoma when other surgery procedures have failed or have bad prognosti.

Molteno aqueous shunt as a primary surgical intervention for uveitic glaucoma: long-term results.

PURPOSE: To evaluate the efficacy of Molteno aqueous shunt as a primary surgical treatment in uveitic glaucoma. METHODS: Nonrandomized, interventional, retrospective clinical study. The intraocular pressure (IOP), survival rate and complications were analyzed in 30 patients with uveitic glaucoma treated with Molteno implant. RESULTS: The mean follow-up time was 59.3 +/- 18.4 months. Preoperatively, the mean +/- SD IOP was 32.8 +/- 7.5 mmHg (range 20-48), and the mean number of medications was 3.1 +/- 0.6. The mean IOP decreased significantly (p < 0.001) to 17.7 and 15 mmHg at 3 and 6 months postoperatively. The mean number of medications decreased statistically significantly (p < 0.001) from the preoperative number 3.1 to 1.9 three months postoperatively. The number of medications continued to decrease significantly up to 3 years postoperatively. The qualified success rate (Kaplan-Meier estimate) was 97%, 93%, 90% and 85% at 1, 2, 3 and 4 years, respectively. Two patients failed because of hypotony, two patients developed conjunctival erosion and one patient had corneal decompensation. CONCLUSIONS: Molteno aqueous shunt as the first glaucoma procedure decreased IOP effectively in uveitic glaucoma. Even after 4 years, the survival estimate was quite high. The IOP decreased continuously during the first year after the surgery, and the medication was slowly tapered even up to 3 years postoperatively. It is suggested that it may be possible to postpone further surgical intervention during the first postoperative year after Molteno implantation even if the IOP is not quite optimal.

Scleral patch graft calcification and erosion following Molteno implant surgery.

A case of dystrophic calcification of a scleral patch graft and conjunctival tissue erosion 17 years following the implantation ofa Molteno drainage device is described.

Mitomycin C eliminates the short-term intraocular pressure rise found following Molteno tube implantation.

PURPOSE: Molteno implants remain popular for treating recalcitrant glaucomas. This study aimed to assess the effect of mitomycin C (MMC) use with Molteno tube implantation upon intraocular pressure (IOP) control and complication rates. In particular, the study aimed to assess any change that MMC might have upon the postoperative hypertensive phase. METHODS: A retrospective case record study was conducted of all patients undergoing double plate Molteno implant surgery by one surgeon over 5 years. Eyes with recalcitrant glaucoma unresponsive to previous surgery, or deemed unlikely to succeed with trabeculectomy, underwent double plate Molteno tube implantation. Eyes that had MMC (0.3 mg/mL, 3 min) applied to Tenon's capsule over the secondary plate were compared with eyes that underwent surgery without adjunctive MMC application. RESULTS: Twenty-seven eyes received MMC and were similar to 26 eyes not receiving MMC in terms of glaucoma subtype, age, sex, previous surgery, preoperative IOP and postoperative IOP lowering agents. Those not receiving MMC had raised IOP 31-90 days post implantation compared with MMC treated eyes (P < 0.01) and more often received oral antifibrosis medication (P < 0.05). Complications were no more common with MMC except for initial overdrainage. Significant systemic complications from the use of oral antifibrosis medication were common. CONCLUSIONS: The findings suggest a useful role for MMC. Caution is advised in case selection for MMC use. Mitomycin C treatment over the secondary plate alone permits removal of this plate if MMC-related complications occur without requiring removal of the whole implant.

Comparison of different biomaterials for glaucoma drainage devices: part 2.

BACKGROUND: Inflammation associated with biomaterials may contribute to the failure of glaucoma drainage devices. OBJECTIVE: To compare the inflammatory reaction associated with the insertion of Krupin silicone, Molteno polypropylene, and Acrosof end plates in the subconjunctival space of rabbits. METHODS: Similar-sized glaucoma end plates made of 3 different biomaterials were sutured to the sclera in the superotemporal quadrant of the rabbit eye. Thirty eyes of 15 albino New Zealand rabbits were randomly assigned to the 3 groups. Conjunctival vascular hyperemia was graded in a masked fashion among the 3 groups. At the end of 3 weeks, the enucleated eyes were examined histologically and by scanning electron microscopy. RESULTS: Molteno polypropylene was associated with more inflammation both in clinical observations and based on histological grading. Silicone and Acrosof were associated with less intense inflammation. One polypropylene end plate was extruded on day 21. CONCLUSIONS: Polypropylene appears to be more inflammatory than silicone. Flexible biomaterials appear to be less inflammatory than rigid ones. CLINICAL RELEVANCE: Bleb failure following glaucoma drainage device implantation could be related to the biomaterial-associated inflammation. Choosing a biomaterial with the least inflammatory potential might enhance the success rate of the glaucoma drainage device. Arch Ophthalmol. 2000;118:1081-1084

Prospective evaluation of extraocular motility following double-plate molteno implantation.

OBJECTIVE: To determine the incidence and type of extraocular motility disturbance after double-plate Molteno implantation. METHODS: In a prospective clinical series, we evaluated preoperative and postoperative ocular motility at 3 and 6 months in 24 eyes of 24 patients undergoing double-plate Molteno implantation. Visual acuity, motility testing, and subjective and objective diplopia were evaluated at each examination. RESULTS: Within the first 6 months postoperatively, new or worse strabismus developed in 11 (46%) of the 24 study patients. Three of the 11 patients had a generalized restriction of the superior rectus and the superior oblique muscles, all of which persisted 6 months after surgery. Four patients had clinical features consistent with an acquired Brown syndrome, and 6 months after surgery, 3 of the 4 patients had a residual deviation, although the deviation in 1 patient resolved. A superior oblique palsy developed in 3 patients, and a lateral rectus palsy developed in 1 patient. All 4 of the muscle palsies resolved or were resolving during the follow-up period, which ranged from 6 to 12 months. CONCLUSIONS: Extraocular motility disturbances are not rare after double-plate Molteno surgery. Muscle palsies, acquired Brown syndromes, and generalized restrictions occurred in similar proportions. CLINICAL RELEVANCE: Patients should be counseled before Molteno surgery concerning the risk of strabismus and diplopia.

Assessment of corneal decompensation in eyes having undergone molteno shunt procedures compared to eyes having undergone trabeculectomy.

PURPOSE: To compare the incidence of corneal decompensation after Molteno shunt to trabeculectomy. METHODS: We conducted a retrospective analysis of the corneal status of 55 patients with primary open angle glaucoma. We compared 24 eyes of 24 patients who underwent Molteno tube shunt placement (Group 1) to fifteen eyes of 14 patients with multiple surgical procedures, including a trabeculectomy (Group 2). We also compared Group 1 to 28 eyes of 17 patients who underwent only one trabeculectomy (Group 3). RESULTS: The three groups were similar with respect to age, sex, and intraocular pressure (IOP). The average follow-up time from the last surgery in Group 1 was 17.9 months (1-90 months), 22.4 months (2-63 months) in Group 2, and 19.6 months (1-37 months) in Group 3. The average number of surgeries was 3.0 (1-4) in Group 1 and 2.53 (1-4) in Group 2. The surgeries included trabeculectomy, cataract extraction, combined procedures, penetrating keratoplasty, pars plana vitrectomy, and scleral buckle. The incidence of corneal edema was 50% (12/24)in Group 1, 6.7% (1/15) in Group 2, and 0% in Group 3 (0/28). The average time to corneal decompensation was 21 months in Group 1 (1-120 months) and 15 months in Group 2. CONCLUSION: Patients undergoing Molteno shunt placement have a higher rate of corneal decompensation compared to patients undergoing trabeculectomy.

[Effect of AHMED valve implantation surgery for the treatment of neovascular glaucoma].

PURPOSE: To evaluate the efficacy of the valve implantation for the treatment of neovascular glaucoma. METHODS: 15 cases (15 eyes) neovascular glaucoma were treated with AHMED valve implantation surgery, and followed up for 6 to 42 months. RESULTS: The IOP of the cases is lowered from 6.01 +/- 1.28 kPa (1 kPa = 7.5 mmHg) preoperatively to 1.96 +/- 0.68 kPa postoperatively. The success rate was 80.0% (The criteria of success is 0.80 kPa < or = IOP < or = 2.80 kPa and without severe complication that influence the visual acuity). The common postoperative complications included hyphema, shallow anterior chamber. CONCLUSION: The AHMED valve implantation surgery can lower the IOP, increase the operative success rate and preserve the visual function effectively. It is regarded to be an effective, safe method to treat neovascular glaucoma.

A comparison of postoperative complications from pressure-ridge Molteno implants versus Molteno implants with suture ligation.

BACKGROUND AND OBJECTIVES: The pressure-ridge Molteno implant incorporates a ridge on the proximal episcleral plate to limit aqueous outflow during the immediate postoperative period. This modification is intended to decrease the high incidence of postoperative hypotony and flat anterior chambers following Molteno tube implantation, while avoiding the pressure spikes that can occur with suture ligation of the Molteno tube. This study was devised to compare postoperative intraocular pressure control and complications associated with pressure-ridge Molteno implantation versus a standard Molteno implantation with suture ligation of the tube. PATIENTS AND METHODS: Thirty eyes were prospectively randomized to receive either a pressure-ridge, double-plate Molteno implant or a standard, double-plate Molteno Molteno implant with suture ligation of the tube. RESULTS: Postoperative intraocular pressure was significantly higher at day 1 and week 2 in the suture-ligation implant group, although the final pressure at 12 weeks was not different between the two groups. Six of 15 eyes from the pressure-ridge implant group experienced shallow or flat anterior chambers with hypotony, whereas 5 of 15 eyes from the suture-ligation implant group had significant postoperative pressure spikes. CONCLUSION: Because the ridge effect is unpredictable, further modifications are necessary to prevent postoperative hypotony.

Propionibacterium endophthalmitis following Molteno tube repositioning.

PURPOSE: We describe an aphakic patient who developed recurrent Propionibacterium acnes endophthalmitis after Molteno tube revision. PATIENT AND METHOD: The patient presented with a red painful right eye, decreased vision, and a hypopyon. A moderate anterior chamber reaction and mild vitritis were present. Two weeks earlier, the patient had undergone Molteno tube repositioning. A diagnosis of P. acnes endophthalmitis was made after positive culture of anterior chamber needle aspirate. RESULTS: Initially the patient was treated with repeated intraocular vancomycin injections, to which the eye "responded poorly." Temporary clearance of the infection was achieved after placement of the tube in the subconjunctival space. The patient required explantation of the implant to achieve complete resolution of the infection. CONCLUSION: Tube reinsertion into the anterior chamber resulted in recurrence of the infection. The evaluation of alternative therapies of aqueous tube shunt-related endophthalmitis would require a large case-controlled series of patients.

Capsule excision after failed Molteno surgery.

BACKGROUND AND OBJECTIVES: To determine the frequency of scar tissue formation requiring surgical intervention after single-plate Molteno implantation and the outcome of excision of the encapsulated bleb. PATIENTS AND METHODS: A retrospective study was performed on 95 eyes of 79 consecutive patients who underwent a single-stage Molteno implantation for refractory glaucoma. Fourteen eyes of 12 patients developed an encapsulated bleb. A successful outcome after bleb excision was defined as final intraocular pressure (IOP) between 6 and 22 mm Hg with the same amount of medication as preoperatively or less. RESULTS: At the end of the mean follow-up of 30 months (range 8 to 75), the mean IOP (19.7 +/- 3.8 mm Hg) after bleb excision was significantly lower than the preoperative IOP (35.2 +/- 10.1 mm Hg; P < .001). The overall conventional success rate was 75%. CONCLUSION: Excision of the encapsulated Molteno bleb offers an alternative in severely damaged eyes that have undergone several surgical procedures.

Histopathologic and immunohistochemical analysis of the filtration bleb after unsuccessful glaucoma seton implantation.

PURPOSE: To analyze histopathologically and immunohistochemically the filtration bleb after unsuccessful glaucoma seton implantation. METHODS: A von Denffer implant and two Molteno implants that were nonfunctional at three months, at 11 months, and at five years after implantation, respectively, were compared by evaluating the adjacent bleb with light microscopy and a panel of 11 antibodies to epithelial, mesenchymal, and inflammatory cells. RESULTS: The wall of the filtration bleb three months after implantation consisted of loosely arranged collagenous connective tissue with relatively abundant fibroblasts labeled with monoclonal antibodies (MAbs) V9 and Vim 3B4 to vimentin. At 11 months and at five years, the collagenous layers had become increasingly thick and the fibroblasts scarce. All blebs showed metaplastic myofibroblasts surrounded by tenascin, as identified by MAb 1A4 to alpha-smooth muscle actin and TN2 to tenascin, respectively. One bleb was lined by a monolayer of cells that reacted with MAb CAM 5.2 and CY-90 to cytokeratin 8 and 18, respectively, and was apparently derived from the identically reacting proliferating corneal endothelial cells. Another bleb harbored many macrophages and foreign-body giant cells. Little evidence of chronic inflammation around the seton was detected. CONCLUSIONS: A glaucoma seton may induce several processes that potentially decrease filtration. In addition to formation of a collagenous cyst, presence of myofibroblasts suggests long-standing scar modulation that potentially leads to compaction of the filtration membrane. Furthermore, macrophages and corneal endothelial cells may invade the filtration bleb.

Long-term survival of Molteno glaucoma drainage devices.

PURPOSE: To evaluate the long-term outcome of the Molteno implant drainage device using survival analysis. METHODS: A retrospective chart review was performed on 77 eyes of 71 patients that underwent Molteno implantation for intractable glaucoma unresponsive to conventional management from October 1984 to April 1990 at the University of Washington Eye Center and had at least 6 months of follow-up data. Success was defined as a postoperative intraocular pressure of 22 mmHg or lower with (qualified success) or without (complete success) glaucoma medications and no additional glaucoma surgery, phthisis, or loss of light perception. RESULTS: The median follow-up was 44 months (range, 6-107 months). Indications for Molteno implantation were aphakia/pseudophakia (n=24), neovascular glaucoma (n=20), uveitic glaucoma (n=12), failed trabeculectomy (n=9), traumatic glaucoma (n=8), and congenital glaucoma (n=4). The total success was 57% (23% complete; 34% qualified) at the last follow-up. Kaplan-Meier survival curves demonstrated a continuous and relatively linear attrition of success over at least 5 1/2 postoperative years. The uveitic glaucoma group had the highest success rate of 75%. Eyes with neovascular glaucoma failed significantly more frequently than those with uveitic glaucoma (P<0.01). There was no significant difference in outcome based on sex, race, single versus double plate, anterior chamber versus posterior chamber tube placement, or two-stage versus single-stage surgery. Younger age was associated with a significantly higher failure rate after controlling for glaucoma category (P<0.01). CONCLUSION: The Molteno implant drainage device offers a reasonable long- term outcome in eyes with intractable glaucomas. However, an ongoing rate of failure, not unlike that seen after other filtration surgery, is to be expected.

Postoperative manipulation of the Krupin valve.

Five patients were noted to have elevated intraocular pressure following implantation of the Krupin glaucoma tube-to-plate device. In each, conjunctiva was draped flat over the plate. A muscle hook was used to manipulate conjunctiva over the tube-plate junction at the site of the valve, producing immediate increased flow through the tube, reduction of intraocular pressure, and bleb formation. In all five cases, intraocular pressure has been controlled at longest follow-up. One cause of elevated intraocular pressure following implantation of the Krupin tube-to-plate device is excessive resistance at the valve site, which can be relieved by manipulation with a muscle hook.

Molteno implant surgery for advanced glaucoma.

PURPOSE: The use of adjunctive antimitotics with conventional filtering surgery appears to have decreased the need for Molteno implants in glaucomas with a poor prognosis. We review the current status, results and complications of Molteno implants. METHODS: Review of the literature and practical experience from two university departments of ophthalmology. RESULTS: Improvements in the design and surgical techniques for Molteno implants have decreased the incidence of over filtration, but this and other complications continue to pose problems. Increased success rates may be possible if antimitotics are used with Molteno implants. CONCLUSION: Molteno implants continue to be an option when conventional filtration with or without antimitotics has failed; they continue to be regarded as a last resort for filtration. The use of antimitotics to increase the success rate of Molteno implants is not proven, but merits further investigation.