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.

Prospective Evaluation of Two iStent® Trabecular Stents, One iStent Supra® Suprachoroidal Stent, and Postoperative Prostaglandin in Refractory Glaucoma: 4-year Outcomes.

INTRODUCTION: This study evaluates long-term outcomes of two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin in eyes with refractory open angle glaucoma (OAG). METHODS: Prospective ongoing 5-year study of 80 eligible subjects (70 with 4-year follow-up) with OAG and IOP ≥ 18 mmHg after prior trabeculectomy and while taking 1-3 glaucoma medications. Subjects received two iStent® trabecular micro-bypass stents, one iStent Supra® suprachoroidal stent, and postoperative travoprost. Postoperative IOP was measured with medication and annually following medication washouts. Performance was measured by the proportion of eyes with ≥ 20% IOP reduction on one medication (the protocol-specified prostaglandin) versus preoperative medicated IOP (primary outcome); and the proportion of eyes with postoperative IOP ≤ 15 and ≤ 18 mmHg on one medication (secondary outcome). Additional clinical and safety data included medications, visual field, pachymetry, gonioscopy, adverse events, visual acuity, and slit-lamp and fundus examinations. RESULTS: Preoperatively, mean medicated IOP was 22.0 ± 3.1 mmHg on 1.2 ± 0.4 medications, and mean unmedicated IOP was 26.4 ± 2.4 mmHg. Postoperatively, among eyes without later cataract surgery, mean medicated IOP at all visits through 48 months was ≤ 13.7 mmHg (≥ 37% reduction), and annual unmedicated IOP was ≤ 18.4 mmHg (reductions of ≥ 30% vs. preoperative unmedicated IOP and ≥ 16% vs. preoperative medicated IOP). At all postoperative visits among eyes without additional surgery or medication, ≥ 91% of eyes had ≥ 20% IOP reduction on one medication versus preoperative medicated IOP. At month 48, 97 and 98% of eyes achieved IOP ≤ 15 and ≤ 18 mmHg, respectively, on one medication. Six eyes required additional medication, no eyes required additional glaucoma surgery, and safety measurements were favorable throughout follow-up. CONCLUSION: IOP control was achieved safely with two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin. This microinvasive, ab interno approach introduces a possible new treatment option for refractory disease. TRIAL REGISTRATION: NCT01456390. FUNDING: Glaukos Corporation.

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.

Otago Glaucoma Surgery Outcome Study: Further Histology and Immunohistochemistry of Molteno Implant Blebs.

PURPOSE: To describe findings of light microscopic examination of Molteno implant bleb capsules. METHODS: Histological and immunohistochemical features of bleb capsules including distribution of apoptotic cells and cell fragments were examined in 11 eyes 0.2 to 30.4 years after Molteno implants. RESULTS: In the superficial layer of capsules, high proportions of cells showed cytological features of apoptosis, with a higher proportion of cells showing specific immunohistochemical features of apoptosis with a mean of 22% (range, 3%-40%) of cells staining positively for Fas ligand. This demonstrated that cells migrating into the superficial capsule were replaced over approximately 1 to 6 days. In the deeper layer a mean of 8% (range, 3%-38%) of apoptosing cells stained positively for Fas ligand. These lower proportions of positively staining cells and cell fragments in the deeper layers, and the presence of occasional positively staining cells on the inner surface of capsules, demonstrated continuous migration of cells into the deeper layers associated with breakdown of connective tissue matrix and the release of numerous membrane-bound vesicles. CONCLUSIONS: These findings demonstrated unexpectedly rapid turnover of cells in the superficial layer of the bleb capsule, where most cells were efficiently phagocytosed by nearby monocytic cells, macrophages, and histiocytes; the remaining cells migrating into the deeper layers completed apoptosis and disintegrated with release of collagenolytic enzymes and Fas ligand positive presumed "death messengers" that were carried toward the superficial layers by the aqueous.

Pro-inflammatory cytokines in glaucomatous aqueous and encysted Molteno implant blebs and their relationship to pressure.

PURPOSE: To ascertain the presence of additional pro-inflammatory cytokines in glaucomatous aqueous, and their relationship with IOP. METHODS: To quantify the levels of 23 pro-inflammatory cytokines, and correlate levels with IOP, aqueous humor samples were analyzed from 23 eyes with open angle glaucoma (OAG) undergoing glaucoma filtration procedures, and from 24 Molteno blebs during the hypertensive phase. Control aqueous was derived from 13 eyes without glaucoma undergoing cataract removal. RESULTS: A significant difference (P<0.05) was noted between hypertensive bleb aqueous and controls in the amount TGF-ß2, interleukins IL-6, IL-10, and chemokine (C-X-C motif) ligand 1 (CXCL1; GROα). The levels of these cytokines were higher in the glaucomatous aqueous, but not significantly so. A significant difference was noted in levels of chemokine (C-C motif) ligand 2 (CCL2; MCP-1, monocyte chemotactic protein-1) in the glaucoma eye and bleb aqueous compared with controls. Of the 23 cytokines tested for, 19 were found in the bleb group, 14 in the glaucoma group, and 16 in the control group. Compared with controls, all cytokines levels were higher in the glaucoma group and highest in the bleb group. CONCLUSIONS: The study confirms the well documented presence of TGF-ß2 in glaucomatous aqueous. The presence of significant levels of CCL2 in glaucomatous aqueous is a new finding. The finding of higher levels of all the cytokines in the aqueous from the encysted blebs, in which the IOP was the highest, suggests that their levels increase with an increase in IOP, as well as the possibility that encysted blebs form cytokines.

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.

Otago glaucoma surgery outcome study: comparative results for the 175-mm2 Molteno3 and double-plate molteno implants.

OBJECTIVE: To evaluate the efficacy of the 175-mm2 Molteno3 implant in patients with nonneovascular glaucoma. METHODS: A hospital-based, retrospective historical control comparative case series comparing results in the first 87 eyes to receive the 175-mm(2) Molteno3 implant with those in a control group of 115 eyes receiving the 274-mm(2) double-plate Molteno implant. RESULTS: Success was defined as an intraocular pressure (IOP) of at least 6 mm Hg but not more than 21 mm Hg with or without hypotensive medication. The mean postoperative follow-up was 3.0 years (range, 13 days to 5.6 years) in the Molteno3 implant group and 6.2 years (range, 1 day to 13.9 years) in the double-plate Molteno implant group. The mean (SD) preoperative IOP was 25.6 (7.1) mm Hg in the Molteno3 implant group in eyes treated with a mean of 2.3 ocular hypotensive medications, and 25.7 (8.0) mm Hg in the double-plate Molteno implant group in eyes treated with a mean of 2.2 medications. The mean (SD) postoperative IOP at 36 months was 13.9 (3.2) mm Hg in the Molteno3 implant group in eyes treated with a mean of 0.9 ocular hypotensive medications, and 14.5 (3.4) mm Hg in the double-plate group in eyes treated with a mean of 0.7 medications. The probability of IOP control at 3 years was 0.79 in both groups. There was significantly more postoperative hypotony in eyes without a polyglactin 910 tie in the Molteno3 implant group (P= .04); however, significantly more eyes with flat anterior chambers in the double-plate group required anterior chamber reformation (P= .03). CONCLUSION: The 175-mm(2) Molteno3 implant provided intermediate-term successful treatment of nonneovascular glaucoma comparable to that provided by the double-plate Molteno implant.

A model to measure fluid outflow in rabbit capsules post glaucoma implant surgery.

PURPOSE: Prior models of glaucoma filtration surgery assess bleb morphology, which does not always reflect function. Our aim is to establish a model that directly measures tissue hydraulic conductivity of postsurgical outflow in rabbit bleb capsules following experimental glaucoma filtration surgery. METHODS: Nine rabbits underwent insertion of a single-plate pediatric Molteno implant into the anterior chamber of their left eye. Right eyes were used as controls. The rabbits were then allocated to one of two groups. Group one had outflow measurements performed at 1 week after surgery (n = 5), and group two had measurements performed at 4 weeks (n = 4). Measurements were performed by cannulating the drainage tube ostium in situ with a needle attached to a pressure transducer and a fluid column at 15 mm Hg. The drop in the fluid column was measured every minute for 5 minutes. For the control eyes (n = 6), the anterior chamber of the unoperated fellow eye was cannulated. Animals were euthanized with the implant and its surrounding capsule dissected and fixed in 4% paraformaldehyde, and embedded in paraffin before 6-µm sections were cut for histologic staining. RESULTS: By 7 days after surgery, tube outflow was 0.117 ± 0.036 µL/min/mm Hg at 15 mm Hg (mean ± SEM), whereas at 28 days, it was 0.009 ± 0.003 µL/min/mm Hg. Control eyes had an outflow of 0.136 ± 0.007 µL/min/mm Hg (P = 0.004, one-way ANOVA). Hematoxylin and eosin staining demonstrated a thinner and looser arrangement of collagenous tissue in the capsules at 1 week compared with that at 4 weeks, which had thicker and more densely arranged collagen. CONCLUSIONS: We describe a new model to directly measure hydraulic conductivity in a rabbit glaucoma surgery implant model. The principal physiologic endpoint of glaucoma surgery can be reliably quantified and consistently measured with this model. At 28 days post glaucoma filtration surgery, a rabbit bleb capsule has significantly reduced tissue hydraulic conductivity, in line with loss of implant outflow facility, and increased thickness and density of fibrous encapsulation.

[Artificial drainage devices--history, indications]. / Sisteme artificiale de drenaj, istoric, indicatii.

Glaucoma is a degenerative optic neuropathy progressive, multifactorial, which can lead to blindness. Blindness in patients with glaucoma is defined as visual field reduction below 10 degrees. Artificial drainage systems are a solution for refractory to medication, laser treatment or conventional surgery. Used by over 100 years, improved with good surgical technique and careful patient follow-up surgery, postoperative results are satisfactory.

[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.

Surgical management of glaucoma with Molteno3 implant.

PURPOSE: To evaluate the outcome of 40 consecutive patients with Molteno3 implantation in uncontrolled glaucoma with at least a 6-month follow-up. MATERIALS AND METHODS: Nonrandomized, interventional, and retrospective clinical study. Failure was defined as IOP >21 mm Hg or less than 20% reduction of intraocular pressure (IOP) from baseline on 2 consecutive follow-up visits, IOP ≤5 mm Hg on 2 consecutive follow-up visits, reoperation of glaucoma or loss of light perception vision. RESULTS: The mean preoperative IOP was 34.3±9.1 mm Hg, and the mean postoperative IOP at the last follow-up visit was 16.8±7.5 mm Hg with a pressure drop of 19.1±11.5 mm Hg (56%) (P=0.000; 95% CI 13.5-21.4). The Kaplan-Meier life-table analysis showed a 95% success rate after 6 months and a 71% success rate after 12 months of follow-up. Postoperative complications included cataract (6 eyes), choroidal detachment (3 eyes), flat anterior chamber (2 eyes), malignant glaucoma (2 eyes), encapsulated bleb (2 eyes), corneal decompensation (2 eyes), hyphaema (1 eye), uveitis (1 eye), retinal detachment (1 eye), suprachoroidal hemorrhage (1 eye), tube erosion (1 eye), and phthisis bulbi (1 eye). CONCLUSION: The Molteno3 dual-chamber implant is useful and well tolerated in controlling IOP, but it does not seem to reduce the risk of postoperative hypotony.

Otago glaucoma surgery outcome study: electron microscopy of capsules around Molteno implants.

UNLABELLED: PURPOSE. To report the ultrastructure of cells and extracellular matrix components in Molteno implant capsules examined by scanning and transmission electron microscopy. METHODS: Ultrastructural features including cytology, distribution of apoptotic cells, collagens, basement membranes, elastic fibrils, and glycoproteins were examined by scanning and transmission electron microscopy. Findings were correlated with the clinical features of 31 specimens of glaucomatous eyes treated with Molteno implants 0.3 to 14.9 years previously. RESULTS: Capsules showed two layers: an outer, moderately cellular vascular layer of normal-appearing cells and collagen and an inner, avascular, hypocellular layer of altered cells and collagen. Cells included fibroblasts, myofibroblasts, and tissue histiocytes that showed features indicating metabolic activity, with swelling, vacuolation, and apoptosis, and the formation of numerous membrane-bound vesicles. These features, together with alteration and disintegration of extracellular matrix, increased with time after surgery. CONCLUSION: The results support those in previous light microscopic studies and indicate that the normal life cycle of capsules in both primary and secondary glaucoma include continual outer surface renewal balanced by inner surface degeneration associated with apoptosis and breakdown of tissue matrix components which become more marked over time.

Corneal endothelial cell changes after Ahmed valve and Molteno glaucoma implants.

BACKGROUND AND OBJECTIVE: Changes in corneal endothelial cell (CEC) indices 24 months after Ahmed valve (New World Medical, Inc., Rancho Cucamonga, CA) and single-plate Molteno implants (Molteno Ophthalmic Limited, Dunedin, New Zealand) were evaluated. PATIENTS AND METHODS: This cohort included Ahmed valve (29 eyes) or single-plate Molteno (28 eyes) implants. Preoperative and postoperative central CEC indices were compared. Main outcome measure was endothelial cell count. RESULTS: Twenty-four months postoperatively, no difference in visual acuity improvement or decrease in antiglaucoma medications was observed between groups. The Molteno group showed better postoperative intraocular pressure control (P < .001). An 11.52% (Ahmed) and 12.37% (Molteno) reduction in CEC density (cells/mm(2)) and 3.78 (Ahmed) and 2.48 (Molteno) increase in CEC area (mm(2)) was observed, but no significant between-group difference in CEC density and area or corneal thickness. CONCLUSION: Twenty-four months after Ahmed valve or Molteno implant, statistically significant quantitative (cell density) and minor qualitative (cell area) changes in central CEC were observed. Both groups appeared to have similar CEC damage.

Supra-tenon capsule placement of original Molteno vs Molteno 3 tube implants in black patients with refractory glaucoma: a single-surgeon experience.

OBJECTIVE: To evaluate the efficacy of supra-Tenon capsule placement of original Molteno vs Molteno 3 tube implants (Molteno Ophthalmic, Dunedin, New Zealand) in black patients with refractory glaucoma. METHODS: A retrospective study comparing the efficacy of supra-Tenon capsule placement of the original Molteno tube implant (130-mm(2) plate size) with the newer Molteno 3 tube implant (175-mm(2) plate size). Original Molteno tube implants were placed into 17 eyes and Molteno 3 tube implants into 27 eyes. RESULTS: Success was defined as an intraocular pressure of 18 mm Hg or less with or without adjuvant medical therapy. The median follow-up periods were 24 months (range, 12-48 months) for the original Molteno-implanted group (hereafter referred to as the original Molteno group) and 18 months (range, 12-48 months) for the Molteno 3-implanted group (hereafter referred to as the Molteno 3 group). The median preoperative intraocular pressures were 30 mm Hg for the original Molteno group and 24 mm Hg for the Molteno 3 group. The median postoperative intraocular pressures were 13 mm Hg for the original Molteno group and 14 mm Hg for the Molteno 3 group. Using Kaplan-Meier analysis, survival percentages were 71% for the original Molteno group and 88% for the Molteno 3 group. Log-rank test for comparison of survival indicated no significant difference between the 2 groups (P > .25). CONCLUSIONS: Supra-Tenon capsule placement of single-plate Molteno tube implants of different sizes can adequately control intraocular pressure in a group of patients with refractory glaucoma. Tenon capsule elimination seems to negate the effect of plate size.

Long-term results of primary trabeculectomies and Molteno implants for primary open-angle glaucoma.

OBJECTIVE: To describe the long-term outcomes of primary trabeculectomies and primary Molteno implants performed in cases of primary open-angle glaucoma at Dunedin Hospital. METHODS: Prospective comparative case series of 718 eyes (500 patients) and 260 eyes (195 patients) that had trabeculectomy and Molteno implants, respectively, at Dunedin Hospital as the first drainage operation for primary open-angle glaucoma between 1976 and 2007, and followed up for a mean of 7.7 (range, 0.0-28.0) and 5.0 (range, 0.0-27.4) years, respectively. RESULTS: The probability of intraocular pressure (IOP) control at 21 mm Hg or less following trabeculectomy at 1, 2, 5, 10, 15, and 20 years was 0.95 (95% confidence interval [CI], 0.94-0.97), 0.93 (95% CI, 0.91-0.96), 0.89 (95% CI, 0.86-0.92), 0.82 (95% CI, 0.78-0.86), 0.74 (95% CI, 0.68-0.80), and 0.68 (95% CI, 0.59-0.77), respectively. There were 96 (13%) failures (using the >21-mm Hg definition of failure) in the trabeculectomy group by the final follow-up. The probability of IOP control at 21 mm Hg or less following Molteno implant insertion at 1, 2, 5, 10, 15, and 20 years was 0.98 (95% CI, 0.97-1.0), 0.97 (95% CI, 0.96-1.0), 0.96 (95% CI, 0.92-0.99), 0.96 (95% CI, 0.92-0.99), 0.91 (95% CI, 0.81-1.00), and 0.91 (95% CI, 0.81-1.00), respectively. In the Molteno implant group, there were 8 (3%) failures (using the >21-mm Hg definition of failure) by the final follow-up. CONCLUSION: Insertion of a Molteno implant provided superior IOP control to trabeculectomy when carried out as a first operation in cases of primary glaucoma.

[Simultaneous pars plana vitrectomy and glaucoma drainage device implant]. / Vitrectomía vía pars plana e implante simultáneo de dispositivo de drenaje para glaucoma.

PURPOSE: To evaluate intraocular pressure (IOP) and visual acuity (VA) results after glaucoma drainage device (GDD) implantation combined with simultaneous pars plana vitrectomy (PPV). MATERIAL AND METHODS: Retrospective review of 8 eyes (7 patients). The diagnosis was neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy in 4 eyes, in a which a double plate Molteno implant was placed, and glaucoma secondary (GS) to complicated cataract surgery in 3 eyes and penetrating trauma in one eye, in which a glaucoma Ahmed valve was implanted. RESULTS: Mean preoperative IOP was 35.77 mmHg (20-50) and 11.5 mmHg (2-20) postoperatively, and mean number hypotensive drugs was decreased from 2.33 (0-3) before surgery to 0.62 (0-3) after it. Preoperative VA in NVG was light perception or counting fingers, and it was lost in three eyes. In GS, VA before surgery was below 0.1 in all eyes, and three months after surgery mean VA was 0.42 (0.1-0.8). Mean follow-up was 10.12 months (5-27). The complications were tube obstruction in two cases, one of these presenting also a suprachoroidal hemorrage and ptisis bulbi, plate exposure in one case, and bullous keratopathy as a late complication in another eye. CONCLUSIONS: The VA and IOP were well controlled with this procedure in GS. In NVG, IOP was controlled, but visual results were poor due to complications and the underlying pathology.