Abstract
Purpose :
The management of advanced glaucoma (MD >-12dB) in patients at high risk of primary trabeculectomy failure (e.g. Afro-Caribbean patients, severely injected or immobile conjunctiva) is challenging, and requires aggressive and early intraocular pressure (IOP) lowering. Early flow restriction is needed to mitigate against hypotony in the valve less Baerveldt glaucoma implant (BGI), but leaves IOP at preoperative high levels and may result in progression in patients with advanced field loss. We describe our surgical experience with combined BGI and trabeculectomy with mitomycin C (MMC) and present our clinical outcomes.
Methods :
Hospital records of consecutive patients who underwent combined BGI & trabeculectomy with MMC (0.4mg for 4 minutes), by a single surgeon (SG) with at least a 1-year follow up were reviewed. A 3.0 intraluminal rip chord suture (Supramid) was used to stent the tube & a further 10.0 Nylon ligating suture to completely block the tube. Outcome measures include IOP, number of medications and complications.
Results :
21 eyes of 18 patients, with a mean pre-operative MD of -21.5 ± 6.9 & follow up period of 24.7 ± 12.1 months, were included in analysis. 19 (90.5%) eyes were Afro-Caribbean. During follow-up, 6 eyes (47.6%) required removal of the Supramid suture. IOP was reduced from a mean of 23.8 ± 8.3 mmHg at baseline to 12.1 ± 5.3 mmHg at 1 week, 15.2 ± 4.8 mmHg at 1 month, 12.7 ± 3.6 mmHg at 3 months, 11.7 ± 3.1 mmHg at 1 year and 11.6 ± 2.0 mmHg at last follow-up (p<0.001 for all time points, compared to baseline). There was a significant reduction in number of medication from 3.5 ± 0.6 at baseline to 0.7 ± 2.4 at 1 week, 1.1 ± 1.5 at 1 month, 1.5 ± 1.4 mmHg at 3 months, 1.4 ± 1.4 at 1 year and 1.2 ± 1.2 at last follow-up (p<0.001 for all time points). One eye each (5%) had tube obstruction by iris that resolved with laser iridoplasty, motility disorder requiring prism, endophthalmitis with reduced vision, corneal infiltrate that resolved with topical antibiotics. No patient had persistent hypotony or required a 2nd operation for complications or inadequate IOP control.
Conclusions :
Combined BGI & trabeculectomy with MMC allows excellent early and mid term IOP control in patients with advanced glaucoma at high risk of trabeculectomy failure. Complications are similar to those expected with tube & trabeculectomy.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.