Ahmed Valve Implant Surgery with Adjunctive Mitomycin C and Selective 5-Fluorouracil Injection

Il Suk Yun; Jung Dong Lee; Yong Hyun Kim; Jae Hong Ahn

doi:10.3341/jkos.2016.57.3.468

Journal List > J Korean Ophthalmol Soc > v.57(3) > 1010535

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Yun, Lee, Kim, and Ahn: Ahmed Valve Implant Surgery with Adjunctive Mitomycin C and Selective 5-Fluorouracil Injection

Original Article

J Korean Ophthalmol Soc 2016;57(3):468-476.

Published online: 3 September 2016

DOI: https://doi.org/10.3341/jkos.2016.57.3.468

Ahmed Valve Implant Surgery with Adjunctive Mitomycin C and Selective 5-Fluorouracil Injection

Il Suk Yun, MD¹, Jung Dong Lee, MS², Yong Hyun Kim, MD¹, Jae Hong Ahn, MD, PhD¹

¹Department of Ophthalmology, Ajou University School of Medicine1, Suwon, Korea

²Department of Biostatistics, Ajou University School of Medicine, Suwon, Korea

Address reprint requests to Jae Hong Ahn, MD, PhD, Department of Ophthalmology, Ajou University Hospital, #164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea, Tel: 82-31-219-5261, Fax: 82-31-219-5909, E-mail: chrisahn@ajou.ac.kr

Received 3 September 2015 Revised 30 September 2015 Accepted 9 December 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the surgical results of Ahmed valve implant surgery with adjunctive mitomycin C and selective postoperative 5-fluorouracil (5-FU) subconjunctival injection with a needling procedure.

Methods

In this retrospective study, 40 eyes of 40 patients who had undergone Ahmed valve implant surgery with adjunctive mitomycin C were observed for at least 1 year. The Ahmed valve was implanted after 5-minute application of 0.04% mitomycin C. Selective 5-FU injection with a needling procedure was performed during the follow- up period based on intraocular pressure (IOP). Hypertensive phase was defined as IOP higher than 21 mm Hg within 3 months after operation. IOP higher than 18 mm Hg regardless of IOP-lowering medications at 2 consecutive visits was considered to be a surgical failure.

Results

The mean follow-up period was 35.5 ± 12.4 months. Preoperative intraocular pressure was 32.8 ± 7.5 mm Hg, which decreased to 14.0 ± 4.2 mm Hg postoperatively. The number of glaucoma medications decreased significantly from 3.8 ± 0.5 to 2.0 ± 1.0. Eleven of 40 eyes (27.5%) experienced hypertensive phase at 6.0 ± 3.1 weeks after surgery. Kaplan-Meier survival analysis showed cumulative probability of surgical success rates of 82.5%, 79.6%, 72.7%, and 58.8% at 1, 2, 3, and 4 postoperative years respectively. There were no risk factors that affecting surgical failure except age (hazard ratio = 0.17, p = 0.02). Conclusions: Ahmed valve implant surgery with adjunctive mitomycin C and selective 5-FU injection with a needling procedure showed good success in refractory glaucoma.

Keywords: Ahmed valve implant, 5-Fluorouracil, Mitomycin C, Needling, Refractory glaucoma

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Figure 1.

Intraocular pressure following Ahmed valve implantation with adjunctive intraoperative mitomycin C and selective postoperative 5-fluorouracil injection and needling revision.

Figure 2.

Kaplan-Meier curve of the cumulative probability of valve success for Ahmed valve-implanted eyes. Study group (40 eyes) received Ahmed valve implantation and intraoperative MMC. Failure was defined as the first occurrence of any of the following events during initial postoperative period: 1) IOP >18 mm Hg or <6 mm Hg for two consecutive visits or <20% IOP reduction from baseline, 2) need for additional surgery to repair a malfunctioning Ahmed valve except 5-fluorouracil injection, or 3) serious postoperative complications including visual acuity loss. MMC = mitomycin C; IOP = intraocular pressure.

Table 1.

Baseline characteristics for Ahmed valve-implanted eyes

	Ahmed valve implanted
	eyes (N = 40)
Age (years)	56.57 ± 15.38
Gender (N, %)
Male	24 (60.0)
Female	16 (40.0)
Diagnosis (N, %)
Neovascular	14 (35.0)
Uveitic	13 (32.5)
Open angle	6 (15.0)
Traumatic	2 (5.0)
ICE syndrome	2 (5.0)
Pseudoexfoliative	2 (5.0)
Complex	1 (2.5)
Previous glaucoma surgery (N, %)
Yes	10 (25.0)
No	30 (75)
No. of preoperative medication	3.82 ± 0.45
Follow up period (months)	35.5 ± 12.4
Eyes of 5-FU injections (N, %)	14 (35)

Values are presented as mean ± SD or N (%).

SD = standard deviation; ICE = iridocorneal endothelial syndrome; 5-FU = 5- fluorouracil.

Table 2.

U nivariate Cox regression analyses of predictors of surgical failure with the Ahmed valve implantation

Variable	HR	95% CI	p-value
Age (years)
55 ≤ vs. <55 (ref.)	0.16	0.04-0.74	0.01
Gender
Male vs. Female (ref.)	0.69	0.22-2.17	0.53
Diagnosis
Uveitic vs. Others (ref.)	1.72	0.41-7.18	0.45
NVG vs. Others (ref.)	1.58	0.35-7.20	0.55
DM
Yes vs. No (ref.)	1.12	0.35-3.59	0.85
HTN
Yes vs. No (ref.)	0.30	0.07-1.38	0.12
Previous glaucoma surgery
Yes vs. No (ref.)	0.54	0.12-2.48	0.43
Lens
Pseudophakic vs Phakic (ref.)	0.88	0.24-3.26	0.84
Preop IOP	1.02	0.95-1.11	0.54
No. of preop medication	0.37	0.12-1.16	0.08
IOP of postop day 1	1.03	0.95-1.10	0.47
IOP of postop week 1	1.07	0.95-1.21	0.25
Hypertensive phase
Yes vs. No (ref.)	0.60	0.13-2.73	0.50
Hypotony
Yes vs. No (ref.)	0.43	0.09-1.99	0.28
Preop VA (log MAR)	0.51	0.23-1.13	0.09

HR = hazard ratio; CI = confidence interval; ref. = reference value; NVG = neovascular glaucoma; DM = diabetes mellitus; HTN = hypertension; IOP = intraocular pressure; preop = preoperative; postop = postoperative; VA = visual acuity.

Table 3.

Multivariate Cox regression analyses of predictors of surgical failure with the Ahmed valve implantation^*

Variable	HR	95% CI	p-value
Age (years)
55≤ vs. <55 (ref.)	0.17	0.04-0.81	0.02
Gender
Male vs. Female (ref.)	0.45	0.14-1.45	0.18
Preop VA (log MAR)	0.56	0.26-1.17	0.12

HR = hazard ratio; CI = confidence interval; ref. = reference value; Preop = preoperative; VA= visual acuity.

^* Multivariate Cox regression analyses: Harrell's C-index = 0.750 (standard error [se] = 0.09).

Table 4.

Univariate logistic regression analyses of predictors of visual acuity loss with the AGV implantation

Variable	OR	95% CI	p-value
Age (years)	1.67	0.35-9.25	0.53
55 ≤ vs. <55 (ref.)
Gender
Male vs. Female (ref.)	2.33	0.46-17.63	0.34
Diagnosis
Uveitic vs. Others (ref.)	3.27	0.36-71.80	0.33
NVG vs. Others (ref.)	5.33	0.65-114.31	0.16
DM
Yes vs. No (ref.)	2.44	0.51-13.62	0.27
HTN
Yes vs. No (ref.)	2.78	0.58-15.60	0.21
Trabeculectomy history
Yes vs. No (ref.)	1.80	0.31-9.18	0.48
No. of preop medication	0.99	0.88-1.10	0.84
Hypertensive phase
Yes vs. No (ref.)	3.57	0.69-19.05	0.12
IOP of postop day 1	0.98	0.84-1.08	0.71
IOP of postop week 1	1.10	0.92-1.33	0.29
Preop VA (log MAR)	0.87	0.34-1.96	0.74

AGV = Ahmed glaucoma valve; OR = odds ratio; CI = confidence interval; ref. = reference value; NVG = neovascular glaucoma; DM = diabetes mellitus; HTN = hypertension; preop = preoperative; IOP = intraocular pressure; postop = postoperative; VA= visual acuity.

Table 5.

Complications after implantation of Ahmed valves

Complication	No. of patients (n, %)
Hyphema	4 (10.0)
Hypotony	11 (27.5)
Choroidal detachment	4 (10.0)
Shallow A/C	3 (7.5)
Tube reposition	3 (7.5)
Tube exposure	2 (5.0)
Hypertensive phase	11 (27.5)

A/C = anterior chamber.

Table 6.

Previously published estimated probability of valve success from studies of Ahmed valve implantation

	Postoperative year				Definition of failure (consecutive visits)^*	Subject	Antimetabolite		Plate
	1st year	2nd year	3rd year	5th year	Definition of failure (consecutive visits)^*	Subject	MMC	5-FU	Plate
Netland et al¹³	0.73	0.62		0.20	>21 (2) mm Hg	NVG	−	−	Silicone/polypropylene
	0.89	0.81		0.81		Refractory glaucoma without NVG	−	−
Souza et al¹⁴	0.8	0.73	0.63	0.49	>21 (2) mm Hg or <15%	Refractory glaucoma	−		Silicone/polypropylene
Kim and Shin¹⁵	0.88		0.71	0.62	>21 (2) mm Hg	NVG	−		−
Lee et al¹⁶	0.58		0.47	0.4	>21 mm Hg or <30%	Refractory glaucoma	−	+	Polypropylene
Lim et al¹⁷	0.38	0.19			>18 (3) mm Hg or <20%	NVG	−	−	Silicone
	0.83	0.44					+	+
Yoon and Park¹⁸	0.76				>18 (3) mm Hg or <20%	NVG	+	+	Silicone
Alvarado et al⁷	0.92	0.87	0.82	0.72	>18 (3) mm Hg or <20%	Refractory glaucoma	+	+	Polypropylene
This study	0.85	0.79	0.72	0.58 (4 year)	>18 (2) mm Hg or <20%	Refractory glaucoma	+	+	Silicone

MMC = intraoperative mitomycin C use; 5-FU = 5-fluorouracil injection; NVG = neovascular glaucoma.

^* Number of consecutive visits to define surgical failure.

Table 7.

Rate and onset of postoperative hypertensive phase

	Intraoperative mitomycin C use		Onset of hypertensive phase
	Yes (%)	No (%)	Onset of hypertensive phase
Alvarado et al⁷	14.3-28.4		−
Susanna et al⁸	40.0-46.0		−
Yoon and Park¹⁸	22.5		2-6 months
Lim et al¹⁷	20.0	35.0	2-6 months
Ayyala et al²²		820	−
Won and Sung²⁶		31.1	−
Nouri-Mahdavi and Caprioli²⁷		56.4	5 weeks (1-13 weeks)
Souza et al¹⁴		40.4	−
Kim and Shin¹⁵		50.0-82.0	−
This study	27.5		6.0 ± 3.1 weeks (2-12 weeks)

Values are presented as mean ± SD unless otherwise indicated.

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