Glaucoma drainage devices in children: an updated review.

Implantation of glaucoma drainage devices is a valuable therapeutic option, particularly in children with glaucoma refractory to primary surgical treatment. Glaucoma drainage devices are typically used when conjunctival scarring hampers filtration surgery or prior angle procedures are not effective in controlling intraocular pressure. Despite known complications, the use of glaucoma drainage devices in children has increased in recent years, even as the primary surgical option. In this review, we evaluate the results of recent studies involving the implantation of glaucoma drainage devices in children, discussing new advances, and comparing the success rates and complications of different devices.

Bilateral total iris atrophy, corneal decompensation and glaucoma following bilateral cosmetic artificial iris implantation: A case report of severe sequela and successful management.

PURPOSE: Cosmetic iris implants have a record of high ocular complications and are no longer in use. These complications include glaucoma, corneal decompensation, iris atrophy, uveitis, cataract and retinal detachment. CASE PRESENTATION: We report a case of a 44-year-old lady presented with bilateral total iris atrophy, glaucoma and corneal decompensation after cosmetic artificial iris implantation. The patient underwent bilateral artificial iris removal, glaucoma drainage device for the right eye, and micropulse laser for the left eye. In addition, she underwent phacoemulsification with iris-diaphragm intraocular lens implant for the right. The cornea of the right eye ended up with successful Boston keratoprosthesis after rejection of previous 2 grafts. CONCLUSIONS: To the best of our knowledge, we describe the first report of bilateral total iris atrophy following a cosmetic iris implant accompanied by bilateral glaucoma and corneal decompensation.

A comparative study of cystoid macula edema following glaucoma drainage device surgery versus trabeculectomy.

PURPOSE: To assess and compare the risk for development of cystoid macula edema (CME) after glaucoma drainage device (GDD) implantation versus conventional trabeculectomy with mitomycin (trab) for glaucoma. METHODS: Retrospective review of consecutive patients receiving trab or GDD implantation between 2016 and 2018. Inclusion criteria were availability of pre- and postoperative spectral domain optical coherence tomography (SD-OCT) of the macula. SD-OCT images were evaluated for presence of CME qualitatively, central subfield thickness (CST) and macular volume (MV). RESULTS: 73 eyes could be included, 42 received trab and 31 GDD surgery. Eyes receiving trab on average had 0.8 ± 0.8 previous intraocular operations, while eyes with GDD implantation had 3.1 ± 1.9 (p < 0.001). Occurrence of postoperative CME was significantly more frequent after GDD implantation (6 out of 31 (19.4%)) than after trab (2 out of 42 eyes = 4.8%), (p = 0.049). Mean preoperative CST as well as MV was comparable in both groups (CST before trab: 282.7 ± 23.0 µm, CST before GDD 284.2 ± 27.3 µm, p = 0.287; MV before trab: 7.8 ± 1.1 mm3, MV before GDD: 8.0 ± 0.8mm3, p = 0.305). Mean postoperative CST and MV were significantly higher after GDD (CST 338.5 ± 129.3 µm, MV 8.8 ± 2.6 mm3) than after trabeculectomy (CST 290.6 ± 60.2 µm, p = 0.038; MV 7.8 ± 1.2mm3, p = 0.039). CONCLUSIONS: In real-life conditions, GDD surgery seems to be associated with a higher risk to develop CME when compared to conventional trabeculectomy. This information may be helpful for glaucoma surgeons to advise the patients on postoperative risks of surgery.

Evaluation of early ocular discomfort after glaucoma surgery: trabeculectomy versus Ahmed glaucoma valve implantation.

PURPOSE: This study aims to compare the initial ocular discomfort symptoms resulting from trabeculectomy and Ahmed glaucoma valve implantation surgeries. METHODS: A prospective comparative study was conducted. The evaluation of ocular discomfort employed a questionnaire designed to identify the frequency and severity of distinct symptoms: ocular pain, general discomfort, tearing, foreign body sensation, and burning. This questionnaire was administered prior to surgery as a baseline, and subsequently at 7, 30, and 90 days post-surgery. Simultaneously, the Ocular Surface Disease Index (OSDI) was applied at these same time intervals. RESULTS: The study encompassed a total of 17 patients (9 undergoing trabeculectomy and 8 undergoing Ahmed glaucoma valve implantation). The Ahmed glaucoma valve implantation group exhibited higher tearing levels at baseline (p=0.038). However, no statistically significant differences in symptoms were observed between the two surgeries at 7 and 30 days post-surgery. At the 90-day mark following surgery, patients who had undergone trabeculectomy reported a significantly higher foreign body sensation (p=0.004). Although OSDI scores did not differ between groups at baseline, the trabeculectomy group showed significantly higher OSDI scores than the Ahmed glaucoma valve implantation group at 7, 30, and 90 days after surgery (p<0.05). CONCLUSION: Post-surgery, patients who had undergone trabeculectomy experienced increased foreign body sensation. Trabeculectomy appears to cause greater early postoperative ocular discomfort compared to the Ahmed glaucoma valve implantation group.

In vivo evaluation of a nanotechnology-based microshunt for filtering glaucoma surgery.

To carry out the preclinical and histological evaluation of a novel nanotechnology-based microshunt for drainage glaucoma surgery. Twelve New Zealand White rabbits were implanted with a novel microshunt and followed up for 6 weeks. The new material composite consists of the silicone polydimethylsiloxane (PDMS) and tetrapodal Zinc Oxide (ZnO-T) nano-/microparticles. The microshunts were inserted ab externo to connect the subconjunctival space with the anterior chamber. Animals were euthanized after 2 and 6 weeks for histological evaluation. Ocular health and implant position were assessed at postoperative days 1, 3, 7 and twice a week thereafter by slit lamp biomicroscopy. Intraocular pressure (IOP) was measured using rebound tonometry. A good tolerability was observed in both short- and medium-term follow-up. Intraocular pressure was reduced following surgery but increased to preoperative levels after 2 weeks. No clinical or histological signs of inflammatory or toxic reactions were seen; the fibrotic encapsulation was barely noticeable after two weeks and very mild after six weeks. The new material composite PDMS/ZnO-T is well tolerated and the associated foreign body fibrotic reaction quite mild. The new microshunt reduces the IOP for 2 weeks. Further research will elucidate a tube-like shape to improve and prolong outflow performance and longer follow-up to exclude medium-term adverse effects.

A computational fluid dynamics investigation of endothelial cell damage from glaucoma drainage devices.

Glaucoma drainage devices (GDDs) are prosthetic-treatment devices for treating primary open-angle glaucoma. Despite their effectiveness in reducing intraocular pressures (IOP), endothelial cell damage (ECD) is a commonly known side-effect. There have been different hypotheses regarding the reasons for ECD with one being an induced increase in shear on the corneal wall. A computational fluid dynamics (CFD) model was used to investigate this hypothesis in silico. The Ahmed Glaucoma Valve (AGV) was selected as the subject of this study using an idealised 3D model of the anterior chamber with insertion angles and positions that are commonly used in clinical practice. It was found that a tube-cornea distance of 1.27 mm or greater does not result in a wall shear stress (WSS) above the limit where ECD could occur. Similarly, a tube-cornea angle of 45° or more was shown to be preferable. It was also found that the ECD region has an irregular shape, and the aqueous humour flow fluctuates at certain insertion angles and positions. This study shows that pathological amounts of WSS may occur as a result of certain GDD placements. Hence, it is imperative to consider the associated fluid force interactions when performing the GDD insertion procedure.

Complications after CyPass® Micro-Stent explantation: a case series.

PURPOSE: To describe the in toto explantation of the CyPass® Micro-Stent and its conceivable complications. METHODS: This is a case series of eighteen eyes from fourteen patients who underwent CyPass® Micro-Stent implantation due to mild to moderate glaucoma and who subsequently suffered from loss of endothelial cell density. Consequently, the CyPass® Micro-Stent was in toto explanted. The surgical procedure and its complications are described and compared with trimming of the CyPass® Micro-Stent. RESULTS: A postoperative hyphema was developed in 8 of the 18 eyes. In four of them the hyphema was self-limiting, while in two patients an anterior chamber irrigation was necessary. One patient suffered from a severe intracameral bleeding and iridodialysis during explantation, so that the base of the iris had to be scleral fixated. The remaining explantations were without complications. CONCLUSION: Dealing with implanted CyPass® Micro-Stents poses a challenge for ophthalmic surgeons. An in toto removal can be traumatic, since the CyPass stent often is fibrotic encapsulated and fused with the surrounding tissue. Alternatively, trimming of the CyPass is also a viable option to avoid further endothelial damage. Reported complications of CyPass trimming are consistent with those that can occur after explantation. Further data on the development of the endothelial cells after trimming or explantation are not yet available. Therefore, it remains open whether trimming of the CyPass, in contrast to complete removal, carries the risk of further endothelial cell loss.

Clinical outcomes of Ahmed glaucoma valve implantation in primary open-angle glaucoma and pseudoexfoliative glaucoma.

PURPOSE: To investigate the clinical outcomes of Ahmed glaucoma valve (AGV) implantation in primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG). METHODS: The patients who underwent AGV implantation for POAG and PEXG between January 2015 and December 2021 in a single tertiary center eye clinic were reviewed retrospectively. Thirty-one eyes with the diagnosis of POAG constituted Group 1 and 40 eyes with the diagnosis of PEXG constituted Group 2. The primary outcome measures were intraocular pressure (IOP) changes after AGV implantation and surgical success at the last visit. We evaluated complete and qualified surgical success using the following three criteria: (1) IOP ≤ 21mmH g, (2) IOP ≤ 18 mmHg, and (3) IOP ≤ 15 mmHg, as well as the absence of any serious complications, such as light perception loss and phthisis bulbi, and additional de novo glaucoma surgery. RESULTS: The mean follow-up times were 25.2 (± 21.4) months and 27.6 (± 19.8) months for Groups 1 and 2, respectively (p > 0.05). In Groups 1 and 2, the mean preoperative IOPs were 31.9 ± 9.4 mmHg and 32.3 ± 8.4 mmHg, respectively, which significantly reduced to 14.5 ± 0.7 mmHg and 11.6 ± 0.6 mmHg, respectively at the last postoperative visit (p < 0.001 for both). The mean IOP value at the last visit was statistically significantly lower in Group 2 (p = 0.006). At the last visit, the number of eyes with qualified success according to criteria 1, 2, and 3 was 26 (83.9%), 25 (80.6%), and 18 (58.1%), respectively, in Group 1 and 39 (97.5%), 39 (97.5%), and 32 (80%), respectively, in Group 2. The comparison of the qualified success rates showed statistically significantly higher rates in Group 2 for criterion 2 (p = 0.038). CONCLUSION: AGV implantation had high success rates in both POAG and PEXG, but at the final visit, lower IOP levels were reached in the latter.

Comparative study of the outcomes of newly developed polypropylene-based modified trabeculectomy and glaucoma shunt surgery in neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a secondary glaucoma with a poor visual prognosis. Trabeculectomy with antifibrotic agents, glaucoma drainage devices (GDDs), and cyclo-destructive procedures are recommended in patients who are refractory to medical management. However, due to the poor success rate of conventional trabeculectomy and the higher cost of GDDs, alternative procedures need to be looked at. PURPOSE: To compare the surgical outcomes and economic aspects of a newly developed polypropylene suture bed-based modified trabeculectomy to Ahmed glaucoma valve (AGV) implantation for NVG. METHODS: It was a prospective interventional study conducted at a tertiary care center between 2018 and 2020. Consecutive patients with NVG with a minimum follow-up of 18 months were included. Surgical outcomes are mainly based on intraocular pressure (IOP) control and the cost of surgery. RESULTS: Sixty eyes were included out of which 40 (60.6%) underwent modified trabeculectomy and 20 (33.7%) underwent AGV. At the final follow-up, no significant difference (P < 0.05) was found between the surgical outcomes of both groups. The complete success rate (IOP < 21 mm Hg without antiglaucoma medications) was 60 and 65% while the qualified success rate (IOP < 21 mm Hg with antiglaucoma medications) was 30 and 25% in modified trabeculectomy and AGV groups, respectively, at final follow-up. The cost of surgery was significantly higher in the AGV group (P < 0.0001). CONCLUSION: Modified trabeculectomy as described might be a better alternative for NVG eyes.

XEN-45 in the management of early glaucoma surgery: A national Delphi consensus study.

BACKGROUND AND OBJECTIVE: Recommendations on general glaucoma management and the use of early minimally invasive and microincisional surgeries are limited. This study aimed to establish consensus regarding glaucoma management, focusing on the XEN-45 gel stent implant. METHODS: A Delphi consensus-driven process was used. The scientific committee led the study, identified the expert panel, and participated in elaborating the questionnaire. Fifty-one panelists were invited to complete, on a nine-point Likert scale, an 89-item questionnaire covering three topic blocks. Two Delphi rounds were performed. Consensus was achieved if ≥66.6% of panelists reached agreement or disagreement. RESULTS: Panelists agreed on 84 items related to the patients' quality of life, the therapeutic algorithm and patient profile, and surgical and pre- and post-operative management. Panelists agreed on the suitability of XEN stent implants to treat glaucoma at different stages and for different patient profiles: young patients, elderly or with significant comorbidities, and with myopic glaucoma, patients who failed previous surgeries, and with previous poor post-operative experience. XEN surgery was considered a therapeutic step prior to classic filtering surgery and a possible first surgical option in elderly patients with comorbidities and uncontrolled intraocular pressure. XEN surgery allows the patient to return to routine daily activities faster than conventional filtering surgeries and to reduce and/or eliminate topical treatments. CONCLUSIONS: This Delphi-driven consensus resulted in a series of general recommendations for glaucoma management, including those related to patient quality of life, therapeutic algorithm, and patient profile, and specific ones regarding the use of XEN stent gel surgery.

Concurrent adjacent strabismus surgery with glaucoma drainage device placement in childhood glaucomas.

BACKGROUND: Determine outcomes of concurrent strabismus surgery with placement of a glaucoma drainage device (GDD) in children. METHODS: Retrospective review of pediatric patients who underwent simultaneous lateral rectus (LR) muscle surgery with superotemporal GDD placement. Strabismus and GDD success were defined as residual horizontal misalignment < 10 prism diopter (PD) and intraocular pressure (IOP) < 21 mmHg, no visually devastating complications, and no additional IOP-lowering surgeries. RESULTS: Fifteen eyes of 13 patients (69% male) underwent LR surgery (14 recessions, 1 resection) for exotropia or esotropia simultaneous with GDD placement (13 Baerveldt, 2 Ahmed) at 8.34 ± 5.26 years. Preoperative visual acuity (VA) in operative eye (0.89 ± 0.54) was worse than non-operative eye (0.23 ± 0.44, p = 0.0032). Preoperative horizontal deviation was 38.3 ± 9.4 PD and LR recession was 7.4 ± 1.1 mm. At final follow-up, VA in operative eye (0.87 ± 0.52) was unchanged from preoperative (p = 0.4062). Final IOP was significantly decreased (12.4 ± 4.7 mmHg vs. 31.1 ± 11.4 mmHg, p = 0.0001) as was number of glaucoma medications (2.7 ± 1.7 vs. 1.1 ± 1.3, p = 0.0037). Five (38%) and 9 patients (69%) met criteria for strabismus and GDD success, respectively. Two eyes required tube revision and endoscopic cyclophotocoagulation and 2 eyes had additional strabismus surgery. CONCLUSIONS: Concurrent strabismus and GDD surgery decreased horizontal deviation and obtained IOP control. It is important to consider correction of strabismus at time of GDD placement to maximize visual development and improve cosmesis in children with glaucoma.

Inferior implant of XEN63 Gel stent in a refractory open-angle glaucoma due to silicone oil tamponade: A case report.

BACKGROUND: To discuss the efficacy of an inferior implant of XEN 63 gel stent in a patient with refractory glaucoma after trabeculectomy failure and vitreoretinal surgery with silicone oil tamponade. CASE DESCRIPTION: We report the case of a 73-year-old man with a history of refractory open glaucoma with trabeculectomy failure. He experienced recurrent retinal detachments with silicone oil tamponade, with uncontrolled intra-ocular pressure (IOP) after silicone oil removal. Due to the presence of oil emulsion in the anterior chamber, the chosen location for XEN 63 implantation was the infero-temporal quadrant. Mild hyphema and vitreous hemorrhage were seen post-operatively, but were self-limiting. At week 1, the intraocular pressure was 8 mmHg with a well-formed bleb seen in anterior segment optical coherence tomography (AS-OCT). At 6 month follow up, the patient maintained a IOP of 12 mmHg without topical hypotensive drugs. Slit lamp examination revealed a widespread, developed bleb with no signs of inflammation. CONCLUSION: In this case of refractory glaucoma in a vitrectomized eye with previous oil tamponade, the inferior placement of the XEN 63 gel stent delivered an adequate intraocular pressure even at 6-months follow up, with a diffuse functional infero-nasal bleb seen with AS-OCT.

Efficacy and Safety of an Adjustable Glaucoma Drainage Device (eyeWatch System) for Refractory Glaucoma: A 2-Year Prospective Study.

PRCIS: In this study, we report a 2-year follow-up after implantation of an adjustable glaucoma drainage device combined with a novel orbital filtering plate. The IOP was efficiently controlled postoperatively with limited complications and an excellent safety profile. PURPOSE: To report the clinical results at 2 years after implantation of an eyeWatch (eW) system, which comprises an adjustable glaucoma drainage device (eW implant) combined with a novel orbital filtering plate (eyePlate), in refractory glaucoma. PATIENTS AND METHODS: Monocentric, prospective, noncomparative clinical trial. Patients suffering from refractory glaucoma after several failed surgeries were operated using the eW system. The primary outcome was the success rate, defined as an IOP ≤18 mm Hg and reduction of more than 20% from baseline, IOP ≥6 mm Hg. Secondary outcomes were mean IOP, visual acuity, the number of antiglaucoma medications, and the number and type of complications. RESULTS: Forty-two eyes from 42 patients were included. The mean follow-up time was 22.0±4.0 months. The mean baseline IOP decreased from 23.2±7.2 mm Hg before surgery to 11.9±4.4 mm Hg at 12 months ( P <0.001) and 11.5±3.0 at 24 months. The mean number of glaucoma medications decreased from 2.9±0.9 before surgery to 0.7±0.9 at 12 months ( P <0.001) and 1.0±0.9 at 24 months. The qualified success rate was 93% at 12 months and 90% at 24 months whereas the complete success rate was 46% and 40% at 12 and 24 months, respectively. Complications occurred in 7 patients. CONCLUSIONS: Implantation of the eW system effectively lowered IOP and reduced glaucoma medications for a 2-year period in patients who had previously failed glaucoma surgery. Persistent hypotony was not observed and the number of complications was low.

Comparing Outcomes of 45 Xen Implantation Ab Interno With Closed Conjunctiva to Ab Externo With Open Conjunctiva Approaches.

PRCIS: Ab externo with open conjunctiva placement may lead to improved gelatin stent (XEN Gel Stent; Allergan) success rate compared with ab interno with closed conjunctiva because it conferred more favorable intraocular pressure (IOP) and medication burden reduction based on our complete and qualified success criteria. PURPOSE: To compare outcomes of a gelatin stent (XEN 45 Gel Stent; Allergan) placed either ab interno with closed conjunctiva (AIC) or ab externo with open conjunctiva (AEO) with or without cataract surgery in patients with glaucoma. DESIGN: Retrospective, nonrandomized comparative study of 85 eyes from 85 glaucoma patients who received XEN 45 Gel Stent placed either AIC (N=32) or AEO (N=53) with or without cataract surgery between July 2018 and January 2022 at Massachusetts Eye and Ear. Patients were included if they were 18 years of age or above and had at least 30 days of follow-up without any disqualifying event. RESULTS: Baseline demographics were similar between both groups, except for the glaucoma type. Both AIC and AEO procedures resulted in significant patterns of IOP and medication reduction from baseline up to 1 year. At postoperative year (POY)1, mean IOP was reduced to 11.34±4 mmHg on 1.29±1.34 medications after AEO and 13.70±3.32 mmHg on 2±1.81 medications after AIC. The average IOP reduction was significantly greater in the AEO group at all postoperative time points beyond postoperative week 2. There were significant differences in the survival curves of AEO and AIC groups under both the complete success criteria and the qualified success criteria. Under the complete success criteria, the cumulative probability of survival at POY1 was 28.5% in the AEO group and 3.8% in the AIC group. Under the qualified success criteria, the cumulative probability of survival at POY1 was 60.3% in the AEO group and 21.9% in the AIC group. CONCLUSIONS: In our study, we demonstrate that both placements reduce IOP and medication from baseline, with AEO placement having more favorable success rates compared with AIC placement.

Five-Year Outcomes of Graft-Free Tube Shunts and Risk Factors for Tube Exposures in Glaucoma.

PRCIS: Use of a scleral tunnel technique instead of a patch graft can be considered in most cases of tube shunt implantation. Grafts may still be considered in younger (<65 y old) East Asians. PURPOSE: (1) To assess the risk factors for tube exposure with a graft-free implantation technique and (2) to examine 5-year outcomes of graft-free tube shunt insertion. METHODS: This was a retrospective case series of 204 consecutive eyes undergoing a glaucoma tube shunt implantation with a scleral tunnel technique in lieu of a graft. Preoperative and postoperative best-corrected visual acuity, intraocular pressure, and number of glaucoma medications were compared. Failure was defined as the following: (1) intraocular pressure >21 mm Hg or ≤5 mm Hg on 2 consecutive visits after 3 mo; (2) required additional glaucoma surgery; (3) loss of light perception. Univariable and multivariable regression analyses were conducted to identify risk factors of tube exposures. RESULTS: Intraocular pressure and the number of glaucoma medications were significantly decreased at all postoperative time points ( P <0.001). Success rates were 91% at year 1, 75% at year 3, and 67% at year 5. The most common early (<3 mo) complication was tube malpositioning. The most common late (>3 mo to 5 y) complications were corneal complications and uncontrolled intraocular pressure. By year 5, 6.9% of tubes were exposed. Multivariable regression showed that age less than 65 years old (odds ratio: 3.66, P =0.04) and East Asian ethnicity (odds ratio: 3.36, P =0.04) were associated with significantly increased risk of tube exposure. CONCLUSIONS: Graft-free glaucoma tube implantation has comparable long-term outcomes and complication rates to shunts with a graft. Younger (<65 y old) East Asians are at greater risk of tube exposure without a graft.

Effectiveness and safety of XEN45 implant over 12 months of follow-up: data from the XEN-Glaucoma Treatment Registry.

OBJECTIVES: To evaluate the 1-year effectiveness and safety of the XEN45, either alone or in combination with phacoemulsification, in glaucoma patients. METHODS: This multicentre, prospective, observational study included consecutive eyes of glaucoma patients from the Italian XEN-Glaucoma Treatment Registry (XEN-GTR) who underwent XEN45 alone or in combination with phacoemulsification, with at least 1 year of follow-up. Surgical success was defined as intraocular pressure (IOP) < 18 mmHg and ≥20% reduction from preoperative IOP, over 1 year of follow-up. RESULTS: Two hundred thirty-nine eyes (239 patients) were analyzed, 144 (60.2%) eyes in the XEN-solo and 95 (39.8%) eyes in the XEN+Phaco groups. One hundred-sixty-eight (70.3%) eyes achieved overall success, without statistically significant differences between study groups (p = 0.07). Preoperative IOP dropped from a median (IQR) of 23.0 (20.0-26.0) mmHg to 14.0 (12.0-16.0) mmHg at month 12 (p < 0.001), with overall 39.9 ± 18.3% IOP reduction. The mean number of preoperative ocular hypotensive medications (OHM) was significantly reduced from 2.7 ± 0.9 to 0.5 ± 0.9 at month 12 (p < 0.001). Preoperative IOP < 15 mmHg (HR: 6.63; 95%CI: 2.61-16.84, p < 0.001) and temporal position of the surgeon (HR: 4.25; 95%CI: 2.62-6.88, p < 0.001) were significantly associated with surgery failure. One hundred-forty-six (61.1%) eyes had no intraoperative complications, whereas 91 (38.1%) and 56 (23.4%) eyes experienced at least one complication, respectively early (< month 1) and late (≥ month 1), all self-limiting or successfully treated without sequelae. Needling occurred in 55 (23.0%) eyes at least once during follow-up. CONCLUSION: Over 1-year follow-up, XEN45 alone or in combination with phacoemulsification, had comparable success rates and effectively and safely lowered IOP and the need for OHM.

Contributing factors for intraocular pressure control in patients with mostly normal-tension glaucoma after initial Ex-PRESS drainage device implantation.

PURPOSE: To investigate the postoperative intraocular pressure (IOP) control and identify the factors associated with failure of initial Ex-PRESS surgery in patients with open-angle glaucoma for 3 years. METHODS: A total of 79 patients with medically uncontrolled open-angle glaucoma (55 normal-tension glaucoma and 24 primary open-angle glaucoma) were enrolled. All patients underwent Ex-PRESS implantation (including combined cataract surgery). The outcome measure was the survival rate using life table analysis, the failure was defined as IOP of > 18 mmHg (criterion A), > 15 mmHg (criterion B) or > 12 mmHg (criterion C) and/or IOP reduction of < 20% from baseline (each criterion) without any glaucoma medications. The Cox proportional hazards model was used to identify risk factors for IOP management defined as the above criterion.  RESULTS: The mean preoperative IOP was 19.3 ± 5.8 mmHg. At 36 months, the mean IOP was 11.8 ± 3.6 mmHg with a mean IOP change of 7.5 mmHg (reduction rate 39.0%). The cumulative probability of success was 58% (95%CI: 42-64%) (criterion A), 48% (95%CI: 37-59%) (criterion B) and 30% (95%CI: 20-40%) (criterion C). In multivariate analyses, factors that predicted poor IOP control included the intervention of bleb needling after 6 months after the surgery (HR: 2.43; 95%CI: 1.35-4.37; P = 0.032). Transient hypotony was observed in 4 patients. CONCLUSION: The implementation of bleb needling after Ex-PRESS surgery in the late postoperative period was suggested to be the main risk factor for achieving lower IOP.

Baerveldt-350 with 3-0 Prolene Ripcord to Minimize Hypotony-Associated Complications after Spontaneous Ligature Dissolution.

PURPOSE: To describe the technique and demonstrate the utility and outcomes of using a thick 3-0 Prolene ripcord in the lumen of a Baerveldt-350 aqueous shunt until after the ligature suture dissolves. DESIGN: Single-center, noncontrolled, retrospective case series. PARTICIPANTS: A total of 50 eyes from 50 patients with glaucoma undergoing placement of Baerveldt-350 aqueous shunts with 3-0 Prolene ripcords. METHODS: A retrospective chart review was performed for all eyes of adult patients that had undergone a Baerveldt-350 aqueous shunt placement by a single surgeon at a single academic center between October 1, 2019 and June 30, 2022. MAIN OUTCOME MEASURES: Data collected included demographic and clinical characteristics of the patients, preoperative and postoperative clinical data including intraocular pressure (IOP) and glaucoma medications, postoperative timepoints of ligature suture dissolution, and timepoints of 3-0 Prolene ripcord removal or whether they were permanently left in place. RESULTS: In total, 50 eyes from 50 patients were included; mean age was 69.5 years, 54.0% of patients were female, 92% of patients were Black, and 66% of eyes had primary open-angle glaucoma. Twenty-six of 50 (52%) eyes had ripcord removal at the soonest postoperative visit after spontaneous ligature dissolution, 19/50 (38%) eyes had delayed ripcord removal, and 5/50 (10%) eyes had no ripcord removal. There were no cases of hypotony-associated complications (shallow anterior chamber, hypotony maculopathy, choroidal effusion, suprachoroidal hemorrhage) in this subgroup of eyes that underwent no ripcord removal. CONCLUSIONS: Our results demonstrate that routine use of a 3-0 Prolene ripcord to partially occlude the lumen of a Baerveldt-350 is a useful strategy to minimize sudden hypotony-associated complications when the ligature suture dissolves. This strategy allows for a more controlled postoperative course and a safe 2-step decrease in IOP (1: when the ligature dissolves, and 2: when the ripcord is removed). FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Techniques and Preferences for Nonvalved Aqueous Shunts: A Survey of American Glaucoma Society Members.

PURPOSE: To assess practice patterns and opinions of glaucoma specialists regarding indications, surgical technique, and postoperative management for nonvalved aqueous shunts. DESIGN: Anonymous online survey study. PARTICIPANTS: American Glaucoma Society (AGS) members. METHODS: An anonymous online survey was distributed to glaucoma specialists via the AGS forum from June to August 2022. MAIN OUTCOME MEASURES: Survey questions and responses were assessed in 4 sections: (1) general demographics and practice patterns; (2) nonvalved tubes vs. trabeculectomy; (3) nonvalved tubes vs. valved tubes; and (4) nonvalved tube techniques. RESULTS: There were 132 respondents; nonvalved tubes were reported to be performed more often than trabeculectomy by 61% of respondents within 5 years of completing training and 23% of respondents with more than 15 years since completing training. The most frequently preferred types of nonvalved tubes were Baerveldt-350 (41%), Baerveldt-250 (27%), and ClearPath-250 (18%). In patients with lower target intraocular pressure (IOP), 92% of respondents preferred trabeculectomy over nonvalved tube; 33% cited a cutoff of < 12 mmHg, and 31% cited a cutoff of < 15 mmHg. In patients with higher preoperative IOP, 50% of respondents preferred valved over nonvalved tubes; 29% cited a cutoff of > 40 mmHg, and 38% cited a cutoff of > 30 mmHg. The most frequently used ligature was 7-0 Vicryl (69%). The most frequently used strategies for early IOP lowering were fenestrations without wicks (70%) and with wicks (22%), with one 10-0 Nylon being the most used wick technique (22%). Overall, 37% of respondents use a ripcord; among ripcord users, 55% use it for hypotony prevention (3-0 Prolene most common for this purpose at 35%), and 40% use it for optional early IOP lowering (4-0 Nylon most common for this purpose at 21%). If IOP is too high at postoperative week 4, 38% of respondents do not open the tube early. CONCLUSIONS: We demonstrate significant heterogeneity regarding specific indications, surgical technique, and postoperative management for nonvalved tubes. Future work is needed to identify and develop standardized guidelines alongside best practices. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.