Long-Term Outcome of Ahmed Valve Implantation Combined with 23-Gauge Vitrectomy in Eyes with Neovascular Glaucoma

Young Ho Jung; Yong Woo Kim; Jang Won Heo; Ki Ho Park; Jin Wook Jeoung

doi:10.3341/jkos.2016.57.5.808

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Jung, Kim, Heo, Park, and Jeoung: Long-Term Outcome of Ahmed Valve Implantation Combined with 23-Gauge Vitrectomy in Eyes with Neovascular Glaucoma

Original Article

J Korean Ophthalmol Soc 2015;57(5):808-814.

Published online: 7 September 2015

DOI: https://doi.org/10.3341/jkos.2016.57.5.808

Long-Term Outcome of Ahmed Valve Implantation Combined with 23-Gauge Vitrectomy in Eyes with Neovascular Glaucoma

Young Ho Jung, MD¹, Yong Woo Kim, MD², Jang Won Heo, MD, PhD¹, Ki Ho Park, MD, PhD¹, Jin Wook Jeoung, MD, PhD¹

¹Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

²Department of Ophthalmology, Armed Forces Busan Hospital, Busan, Korea

Address reprint requests to Jin Wook Jeoung, MD, PhD Department of Ophthalmology, Seoul National University Hospital, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: 82-2-2072-2438, Fax: 82-2-741-3187 E-mail: neuroprotect@gmail.com

Received 8 October 201530 March 2016 Accepted 22 April 2016

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 perm its unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate the surgical outcome of Ahmed glaucoma valve implantation (AVI) combined with 23-gauge vitrectomy in eyes with medically uncontrolled neovascular glaucoma (NVG).

Methods

Thirty six eyes of 35 NVG patients who underwent AVI combined with 23-gauge vitrectomy and have been followed-up at least 6 months after surgery and were retrospectively reviewed. Surgical success was defined as the control of intraocular pressure (IOP) between 6 and 21 mm Hg, irrespective of the use of topical IOP lowering medications. Surgical failure was defined as the failure of IOP control or visual acuity aggravated to no light perception after the surgery. Overall success rate, median survival time, and clinical factors associated with survival time were investigated.

Results

The overall success rate was 63.2% after a mean of 34.0 ± 31.7 months postoperative fdlow-up. The success rate was 83.3% at postoperative 6 months, 72.7% at postoperative 12 months and 63.2% at postoperative 3 years. The underlying retinal diseases were proliferative diabetic retinopathy (PDR; n = 20, 55.5%), central retinal vein occlusion (CRVO; n = 12, 33.3%), ocular ischemic syndrome (n = 2, 5.6%), and other retinal vascular diseases (n = 2, 5.6%). The survival times were significantly shorter in eyes with CRVO (20.2 ± 30.5 months) compared to PDR (33.1 ± 30.8 months), and in phakic eyes (33.1 ± 30.8 months) compared to pseudophakic eyes (37.7 ± 35.4 months) (p < 0.05). In the multivariate analysis, preoperative phakic eyes were significantly associated with a shorter survival time (hazard ratio = 5.626, p = 0.030).

Conclusions

Combined surgery of Ahmed glaucoma valve implantation and 23-gauge vitrectomy showed favorable outcome in the treatment of medically uncontrolled NVG. Preoperative lens status may affect the long-term success rate in such patients.

Keywords: Ahmed valve implantation, Combined surgery, Neovascular glaucoma, Vitrectomy

References

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Figure 1.

Kaplan-Meier survival curve following Ahmed valve implantation and 23 gauge vitrectomy. The success rates were 83.3% at 6 months and 72.7% at 12 months, 63.2% at 36 months, respectively.

Figure 2.

Kaplan-Meier survival curves according to the underlying retinal disease. The mean survival time was significantly different between central retinal vein occlusion (CRVO) (20.2 ± 30.5 months) and proliferative diabetic retinopathy (PDR) (33.1 ± 30.8 months, p = 0.028).

Figure 3.

Kaplan-Meier survival curves according to the preoperative lens status. The mean survival time was significantly different between preoperative phakic (34.2 ± 32.9 months) and pseudophakic eyes (18.8 ± 25.5 months, p = 0.011).

Table 1.

Patient demographics

Age (years)	57.6 ± 17.5
Gender (malefemale)	21:15
Past medical history
DM	31 (86.1%)
HTN	12 (33.3%)
Underlying retinal disease
PDR	20 (55.5%)
CRVO	12 (33.3%)
OIS	2 (5.6%)
Eales disease	1 (2.8%)
NF-1 with retinal vascular abnormality	1 (2.8%)
Preoperative lens status
Phakic eye	19 (52.8%)
Pseudophakic eye	17 (47.2%)
Previous vitrectomy history
Nonvitrectomized eye	27 (75%)
Vitrectomized eye	9 (25%)
Preoperative PRP	25 (69.4%)
Preoperative intravitreal Avastin injection	15 (41.7%)
Preoperative visual acuity (log MAR)	2.49 ± 0.60

Values are presented as mean ± SD or n (%) unless otherwise indicated. DM = diabetes mellitus; HTN = hypertension; PDR = proliferative diabetic retinopathy; CRVO = central retinal vein occlusion; OIS = ocular ischemic syndrome; NF-1 = neurofibromatosis type-1; PRP = panretinal photocoagulation.

Table 2.

Data summary according to the underlying retinal disease

	PDR (n = 20)	CRVO (n = 12)	OIS (n = 2)	Eales disease (n = 1)	NF-1 related retinal vascular abnormality (n = 1)
Age (years)	57.1 ± 15.1	62.0 ± 16.3	66.5 ± 5.5	28	12
Follow-up period (months)	38.4 ± 32.1	34 ± 33.29	14 ± 7	10	12
Phakic eye (n, %)	7 (35.0)	9 (75.0)	1 (50.0)	1 (100.0)	1 (100.0)
Vitrectomized eyes (n, %)	8 (40.0)	1 (8.3)	2 (100.0)	1 (100.0)	0 (0.0)
Preoperative PRP (n, %)	17 (85.0)	5 (41.6)	2 (100.0)	1 (100.0)	0 (0.0)
Preoperative IVB (n, %)	11 (55.0)	6 (50.0)	2 (100.0)	1 (100.0)	1 (100.0)
VA (log MAR)
Preop	2.46 ± 0.63	2.66 ± 0.31	2.65 ± 0.05	2.6	0.7
Postop	2.03 ± 0.96^∗	2.69 ± 0.33	2.65 ± 0.05	1.22	2.7
IOP (mm Hg)
Preop	35.7 ± 8.7	37 ± 13.6	32.5 ± 8.5	31	48
Postop	17.5 ± 4.1^∗	20 ± 7.8^∗	11.5 ± 5.5	18	13
Number of medication
Preop	3.1 ± 0.7	3.0 ± 0.4	2	3	3
Postop	1.5 ± 1.2^∗	0.9 ± 1.2^∗	0	0	0
Number of failure (n, %)	5 (25.0)	6 (50.0)	1 (50.0)	0	0
Uncontrolled IOP	2	3	1	0	0
Changed to NLP	3	3	0	0	0

Values are presented as mean ± SD unless otherwise indicated.

PDR = proliferative diabetic retinopathy; CRVO = central retinal vein occlusion; OIS = ocular ischemic syndrome; NF-1 = neurofibromatosis type-1; PRP = panretinal photocoagulation; IVB = intravitreal bevacizumab injection; VA = visual acuity; Preop = preoperative; Postop = postoperative; IOP=intraocular pressure; NLP = no light perception.

^∗ p < 0.05 in paired t-test.

Table 3.

Postoperative complications

Postoperative complications	Incidence (%)
Endothelial dysfunction (n = 3)	8.3
Tube exposure (n = 1)	2.8
Tube obstruction (n = 1)	2.8
Hypotony (n = 2)	5.6
Choroidal detachment (n = 1)	2.8
Hyphema (n = 2)	5.6

Table 4.

Outcomes of Cox’s proportional hazard regression model

	Univariate		Multivariate^∗
	Risk ratio and 95% CI	p-value	Risk ratio and 95% CI	p-value
Age (years)	1.000 (0.967-1.034)	0.996	-	-
Gender	1.233 (0.360-4.220)	0.739	-	-
DM	0.401 (0.078-2.045)	0.271	-	-
HTN	1.090 (0.282-4.220)	0.901	-	-
Preoperative PRP	0.335 (0.095-1.175)	0.088^∗	0.749 (0.188-2.88)	0.658
Preoperative IVB	0.710 (0.205-2.464)	0.590	-	-
Preoperative lens status	5.626 (1.187-26.678)	0.030^∗	5.626 (1.187-26.678)	0.030
Underlying disease (CRVO)	3.824 (1.052-13.892)	0.042^∗	2.198 (0.715-10.629)	0.127
Intraoperative IVB	2.186 (0.560-8.523)	0.260	-	-
Preoperative vitrectomized eyes	2.032 (0.429-9.615)	0.371	-	-

CI = confidence interval; DM = diabetes mellitus; HTN = hypertension; PRP = panretinal photocoagulation; IVB = intravitreal bevacizumab injection; CRVO = central retinal vein occlusion.

^∗ Factors with p < 0.10 in the univariate analysis were included in the multivariate analysis.

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