Saudi Journal of Ophthalmology (2011) 25, 317–327
King Saud University
Saudi Journal of Ophthalmology www.saudiophthaljournal.com www.ksu.edu.sa www.sciencedirect.com
GLAUCOMA UPDATE
Ahmed glaucoma valve in children: A review
q
Nariman Nassiri, MD; Kouros Nouri-Mahdavi, MD, MSc; Anne L. Coleman, MD, PhD *
Glaucoma Division, Jules Stein Eye Institute, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, United States Received 8 July 2011; revised 17 July 2011; accepted 18 July 2011 Available online 30 July 2011
KEYWORDS Ahmed glaucoma valve; Children; Glaucoma; Management
Abstract Pediatric glaucoma is potentially a blinding disease. Although goniotomy and trabeculotomy are associated with good early success rates, eventually 20% of these procedures fail and many children will require additional surgery to control the IOP in the long-term. In this review, we reported that adequate IOP control can be achieved with the placement of Ahmed glaucoma valve and can last 5 or more years. However, most patients will need one or more glaucoma medications at some point after surgery. In addition, the implants may be associated with pupillary irregularities, lenticular opacification as well as tube-related complications, particularly in the first year of life, as the globe is enlarging with age. ª 2011 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.
q The authors did not receive any financial support from any public or private sources. The authors have no financial or proprietary interest in a product, method, or material described herein. * Corresponding author. Address: Jules Stein Eye Institute, David Geffen School of Medicine, University of California at Los Angeles, and School of Public Health, University of California at Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095, United States. Tel.: +1 310 794 9442; fax: +1 310 794 5541. E-mail address:
[email protected] (A.L. Coleman).
1319-4534 ª 2011 King Saud University. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of King Saud University. doi:10.1016/j.sjopt.2011.07.002
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N. Nassiri et al.
Contents 1. 2.
3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Surgical management of pediatric glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Predictors of surgical failure after AGV implantation in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Subsequent surgical procedure after AGV implantation in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Medical treatment after AGV implantation in children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications of AGV implantation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Tube-related complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Ocular hypotony. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Motility disturbances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Infectious endophthalmitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5. Delayed suprachoroidal hemorrhage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. Pupillary irregularities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Pediatric glaucoma is a potentially blinding disease, accounting for about 18% of blindness in blind institutions and 5% of overall pediatric blindness worldwide (Gilbert et al., 1994; Gilbert et al., 2003). It has heterogeneous etiologies characterized by elevated intraocular pressure (IOP). It is defined as primary when an isolated, idiopathic developmental anomaly of the anterior chamber angle exists, and secondary when aqueous outflow is impaired due to preexisting ocular or systemic disease (Papadopoulos and Khaw, 2005; Ben-Zion et al., 2010). In a recent study in the United States, the incidence of childhood glaucoma was 2.29 per 100,000 (or 1 per 43,575) residents younger than 20 years of age (Aponte et al., 2010). Acquired (traumatic or surgical, drug-induced and uveitic) and secondary (e.g. Sturge–Weber syndrome) forms of glaucoma were the most common, whereas congenital and juvenile glaucoma were rare (Aponte et al., 2010). Primary congenital glaucoma (PCG) is the most common type of glaucoma in infancy (Taylor et al., 1999), and has been estimated to comprise P5% of the general glaucoma popula tion of adult Caucasians (Ben-Zion et al., 2011). The incidence of PCG in Western countries has been estimated at 1 per 10,000 to 1 per 30,200 population (Taylor et al., 1999; Kipp, 2003; deLuise and Anderson, 1983; Miller, 1966; Papadopoulos et al., 2007; Bermejo and Martinez-Frias, 1998; MacKinnon et al., 2004). As the disease has an autosomal-recessive pattern of transmission, it is reported to occur more frequently in certain ethnic and religious groups where consanguineous marriage is common (Miller, 1966; Papadopoulos et al., 2007). The highest reported prevalence has been among individuals of Slovakian Roma (1 per 1250) (Gencˆı´ k, 1989) and of Saudi Arabian racial descent (1 per 2500) (Jaafar, 1988).
2. Management 2.1. Surgical management of pediatric glaucoma The mainstay of treatment in pediatric glaucoma is the surgical reduction of intraocular pressure (IOP) (Alsheikheh et al.,
318 318 318 322 323 323 323 323 324 324 324 325 325 325 325
2007; Turach et al., 1995), although medical therapy is often used adjunctively (Maris et al., 2005; Portellos et al., 1998; Enyedi and Freedman, 2002; Sabri and Levin, 2006). The ultimate goal of IOP reduction is to prevent progressive optic nerve damage and to maintain visual functioning. However, even with adequate IOP control, these patients, especially those with advanced stage of glaucoma, may still have poor visual function because of prolonged deprivation amblyopia, corneal opacities, high astigmatism, uncorrected high myopia, and possible lens subluxation (Ben-Zion et al., 2011; Alsheikheh et al., 2007; Robin et al., 1979). PCG is typically treated with angle surgery first. Initial goniotomy or trabeculotomy have been found to have comparable success rates (deLuise and Anderson, 1983; Meyer et al., 2000; Yalvac et al., 2007; McPherson and Berry, 1983). Although goniotomy and trabeculotomy are associated with good early success rates, eventually 20% of these procedures fail and many children will require additional surgery to control the IOP in the long-term (deLuise and Anderson, 1983; Anderson, 1983; Tanimoto and Brandt, 2006). Furthermore, some forms of pediatric glaucoma respond poorly to angle surgery and are difficult to treat (deLuise and Anderson, 1983; Dascotte et al., 1991) Currently, there is no general agreement as to the preferred surgical algorithm after failure of angle surgery and there is a wide variation in recommended treatment by centers experienced in the treatment of PCG. Various surgical approaches have been proposed for surgical treatment of pediatric glaucoma including trabeculectomy with or without adjunctive antimetabolites (Fulcher et al., 1996; Rodrigues et al., 2004), nonpenetrating deep sclerectomy (Roche et al., 2007), combined trabeculotomy and trabeculectomy (Mullaney et al., 1999), glaucoma drainage devices (Ben-Zion et al., 2011; Netland and Walton, 1993; Budenz et al., 2004; van Overdam et al., 2006; Donahue et al., 1997; Coleman et al., 1997; Englert et al., 1999; Hamush et al., 1999; Djodeyre et al., 2001; Hill et al., 2003; Beck et al., 2003; Morad et al., 2003; Al-Torbak, 2004; Kirwan et al., 2005; Chen et al., 2005; Kafkala et al., 2005; Pakravan et al., 2007; O’Malley Schotthoefer et al., 2008; Ou et al., 2009; Al-Mobarak and Khan, 2009; Yang and Park, 2009), and cyclodestructive procedures (Al Faran et al., 1990; Phelan and Higginbotham,
Studies in which Ahmed glaucoma valve implants were used for the management of pediatric glaucoma.
Studies/Groups
No. of eyes (patients; male: female)
Type of glaucoma
Race
Mean age ± SD (range)
Mean follow-up time ± SD (range)
Mean preoperative IOP ± SD (mm Hg)
Mean last follow-up IOP ± SD (mm Hg)
No. of preoperative medications ± SD
No. of Last follow-up medications ± SD
Cumulative probability of success and Causes of failure
Coleman et al. 199738
24 (21; 11:10)
Asian = 6 Hispanic = 5 Black = 4 Arab = 3 White = 3
6.61 ± 5.67 years
16.3 ± 11.2 months
30.7 ± 8 (16–46)
19.3 ± 8
1.5 (0–3)
0.8 (0–2.3)
12 months = 77.9% 24 months = 60.6% Failures = 7 (extrusion of implant = 3; inadequate IOP control = 3; suprachoroidal hemorrhage = 1)
Englert et al. 199939
27 (23; 10:13)
White = 11 Black = 15 AmericanIndian = 1
6.44 ± 5.88 (0.3–16.8) years
12.6 ± 8.2 (3–31) months
32.8 ± 7.5
16.4 ± 6.9
2.7 ± 1
0.8 ± 0.7
12 months = 91% 24 months = 58% Failures = 4 (inadequate IOP control = 2; retinal detachment = 1; intraocular tumor = 1)
Hamush et al. 199940
11 (10; 5:5)
Congenital = 13 Sturge-Weber syndrome = 3 Congenital rubella = 2 Traumatic = 2 Osteogenesis imperfecta = 1 Uveitic = 1 Pesistent hyperplastic primary surgery = 1 Peter anomaly = 1 Congenital = 14 Aphakic = 7 Aniridic = 2 Uveitic = 2 Sturge-Weber Syndrome = 1 Neovascular = 1 All Sturge-Weber syndrome
Hispanic = 5 Caucasian = 3 Asian = 1 Arabian = 1
10 days to 25 years
30.35 ± 19.13 months
27.7 4.6
18.5 4.4
1.5 1.4
0.9 0.7
Djodeyre et al. 200141
35 (18:17)
Congenital = 17 All white Sturge-Weber syndrome = 5 Persistence of fetal vasculature = 4 Congenital cataract = 3 Uveititis in Juvenile Rheumatoid arthritis = 2 Keratoplasty = 1 Pars planttis = 1 Retinopathy of prematurity = 1 Stickler syndrome = 1
4.4 ± 4.7 years
12.6 ± 10.8 months
28.8 ± 4.5 (22–40)
18.1 ± 2.4
24 months = 79% 48 months = 59% 60 months = 30% Failure = 4 (implant extrusion = 1; inadequate IOP control = 3) 12 months: Total = 70.1% Complete = 67.4% 24 months: Total = 63.7% Complete = 44.5% 9 failures = 6 tube malposition (4 cases tube retracted out of the AC, 1 tube block due to tube-endothelium contact and 1 tube-iris contact), 3 inadequate IOP control
Hill et al. 200342 AGV group
38 (34) 18
Congenital = 12 Frank Kamenetsky Syndrome = 3 Reiger’s Syndrome = 3
Armenians
12.5 ± 2.8 (6–16) years
18.8 ± 9.6 (6–60) months
32 ± 10.1
14.8 ± 5.4
1.9 ± 0.8
0.7 ± 0.8
Total = 16 (88%) Complete = 10 (55%); Qualified = 6 (33%); Failure = 2 (12%)
Trab with MMC group Beck et al. 200343 AGV group
20
White
12.5 ± 2.4 (10–17) years
16 ± 12.5 (6–60) months
30.1 ± 7.4
13.5 ± 7
2.2 ± 1.1
0.4 ± 0.75
Total = 18 (86%) Complete = 16 (76%); Qualified = 2 (10%); failure = 3 (14%)
7 5.1 (1–22) months
31.5 ± 22.6 (1– 60) months
32.9 ± 6.5
20.8 ± 8.6
2.4 ± 0.6
1.1 ± 1.1
12 months = 87 ± 10% 72 months = 53 ± 22%
5.3 4.8 (0.5–24) months
11.5 15 (1–60) months
36.4 ± 7.6
27.3 ± 12.2
1.6 ± 0.8
1±1
12 months = 37 ± 16% 72 months = 19 ± 13%
20 (17; 7:10)
Kirwan et al. 200546
19 (13; 7:6)
Aphakic
24 (19)
Morad et al. 200344 60 (44; 25:19)
6 ± 4.9 years (1.5 months 24.3 ± 16 (3–60) months to 16 years)
32.8 ± 6.2 (21–50)
16.6 ± 8 (2–57)
4.45 ± 1.97
2±2
12 months = 93% 24 months = 86% 36 months = 71% 48 months = 45%
11.7 (2–60) months
30.9 ± 1.1 (18– 60) months
32.3 ± 11.6
19.7 ± 10.6
2.35 ± 0.49
1.6 ± 1.2
96 (9–189) months
32 (3–84) months
29.7
12.6
2 months = 85% 24 months = 44% 48 months = 33% 100%
319
Al-Torbak 200445
Congenital = 18 Anterior chamber anomalies = 12 Aphakia = 10 Other = 6 Congenital = 11 Anterior chamber anomalies = 6 Aphakia = 4 Other = 3 Congenital/ infantile = 25/60; Aphakia = 9/60; SturgeWeber synd = 9/60; Uveitic = 8/60; Aniridia = 4/60; Anterior segment dysgenesia = 3/ 60; Juvenile = 2/60 All congenital
Trab with MMC group
46 (32)
Ahmed glaucoma valve in children: A review
Table 1
(continued on next page)
320
Table 1 (continued) Studies/Groups
No. of eyes (patients; male: female)
Type of glaucoma
Race
Mean age ± SD (range)
Mean follow-up time ± SD (range)
Mean preoperative IOP ± SD (mm Hg)
Mean last follow-up IOP ± SD (mm Hg)
No. of preoperative No. of Last medications ± SD follow-up medications ± SD
Cumulative probability of success and Causes of failure
Chen et al. 200547
52 (41; 20:21)
White = 44 AfricanAmerican = 3 Asian = 3 Arab = 1
4.9 ± 6.5 (0.02– 18.0) years
2.2 ± 1.8 years (3 months to7.5 years)
38.1 ± 6.4
21.6 ± 5.9
1 ± 0.8
0.6 ± 0.7
12 months = 85.1% 24 months = 63.2% 36months = 51.7% 48 months = 41.8%
Kafkala et al. 200548
7 (6; 2:4)
Congenital = 20/52; Aphakic aft. Cong Cat = 19/52; SturgeWeber Syndrome = 5/52; Aniridia = 4/52; Uveitic = 2/52; Persistent hyperplastic primary vitreous = 2/52 All uveitis due to: Juvenile idiopathic arthritis associated with iridocyclitis = 4 patients Sarcoidosis = 1 patient Pars plantitis = 1 patient
11 (9–13) years
36.8 (6–60) months
37 ± 8
12.1 ± 3.4
3 ± 0.8
0.7 ± 0.7
100%
Pakravan et al. 200749 AGV with MMC group
15 (1512:3)
Aphakic
10.9 ± 5.1 (1.5–16) years
13.1 months
31 ± 7.5
14.4 ± 3.5
3.3 ± 0.5
1.6 ± 0.5
15 (13; 6:7)
Aphakic
9.1 ± 4.1 (2–16) years
16.3 months
31 ± 10.7
14.7 ± 4
3 ± 0.6
1.7 ± 0.5
Complete = 20%; Qualified = 66.7%; Total = 86.7%; Failure: 2 (2 suprachoroidal hemorrhage) Complete = 33.3; Qualified = 40%; Total = 73.3; Failures (1 choroidal hemorrhage, 1 inadequate IOP control)
29
14
Trabeculectomy with MMC group
38 (30)
Aphakic group
41 (32)
Ou et al. 200951
30 (19; 12:7)
Primary congenital glaucoma
Al-Mobarak and Khan 200952 AGV with MMC group
16 (8:8)
AGV without MMC group
15 (9:6)
Yang and Park 200953
34 (29)
Ben-Zion et al. 20117
AVG = 6 eyes Trabeculectomy = 31 eyes
Congenital (7/16); Aphakic (3/16); Peters anomaly (4/16); Aniridia (1/16); congenital rubella (1/16) Congenital (10/15); Aphakic (2/15); Peters anomaly (1/15);SturgeWeber syndrome (1/15); Steroid-induced (1/15) Congenital = 12 Glaucoma following lensectomy for congenital cataracts = 11 Aphakic = 5 Pseudophakic = 6 Aniridia = 1 Microphthalmia = 1 Axenfeld-Rieger anomaly = 3 Neovascular = 4 Develomental glaucoma with associated systemic disease = 1 Glaucoma associated with cicatrical ROP = 1 PCG Rural Southern Ethiopia
White = 8; Asian: 3; Hispanic = 8
SD: Standard deviation; AGV: Ahmed glaucoma valve; MMC: Mitomycin C.
12 months = 92% 10 years = 42% 12 months = 90% 10 years = 55% 12 months = 63% 2–3 years = 50% 4 years = 41% 5 years = 33% Failures = 16 (5 inadequate IOP control; 1 IOP
