Managing & Avoiding Post-Op Complications in Tube Surgeries
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1 Managing & Avoiding Post-Op Complications in Tube Surgeries K. Sheng Lim St. Thomas Hospital, London
2 Current GDD Molteno 1969 Baerveldt 1990 Ahmed 1993
3 Current GDD GDD Plate Material Plate Size Resistance Molteno (1969) Polypropylene & Silicone Mechanism 135 mm 2 No Baerveldt (1990) Silicone 250 & 350 mm 2 No Ahmed (1993) Polypropylene & Silicone 185 mm 2 Yes
4 Post operative Mx main issues Early Hypotony Tube Related Corneal decompentsation Tube/Plate Erosion Bleb Encapsulation
5 Post operative Mx main issues Early Hypotony Tube Related Corneal decompensation Tube/Plate Erosion Bleb Encapsulation
6 Post-op IOP Week 6 Bleb resistance IOP Hypotony Time
7 Hypotony Flat Anterior Chamber Suprachoroidal Haemorrhage
8
9 Current GDD GDD Plate Material Plate Size Resistance Molteno (1969) Baerveldt (1990) Polypropylene & Silicone Silicone 250 & 350 mm 2 Mechanism 135 mm 2 No No Ahmed (1993) Polypropylene & Silicone 185 mm 2 Yes
10 Strategies to prevent hypotony Ahmed valve Molteno & Baerveldt Vicryl tube tie Molteno & Baerveldt - Supramid stenting
11 Does flow control mechanism in Ahmed work? Prata et al. Ophthalmology 1995; 102: 894 No Porter et al. Ophthalmology. 1997; 104(10): 1701 Yes Francis et al. Ophthalmology 1998;105:1708 Yes Eisenberg et al. Ophthalmic-Surg-Lasers. 1999; 30(8): 662 Yes Ahmed valve has consistent flow control mechanism
12 Does flow control mechanism in Ahmed work? Evaluation of Closing Pressure in Ahmed Glaucoma Valve Moss, G.E. Trope. Journal of Glaucoma 2008 Purpose: Ahmed Glaucoma Valve closing pressure using a gravitydriven flow system Methods: 6 FP7, primed with BSS then assessed in flow rig Results: All 6 AGV exhibited valve closure, with mean closing pressure was 8.2 ± 5.0 mmhg with a range of 2.5 to 14.6 mmhg. Conclusions: Ahmed FP7 is prone to variations in closing pressure FP7 can have inconsistent closing pressure
13 K. Barton
14 Ahmed Valve Mechanism
15 In vivo Flow Testing of Ahmed Valve From July 2008 Single surgeon St Thomas Hospital Uveitic, previous cyclodiode & neovascular i.e. low aqueous production rate Goyal, Jones,Alaghband, Beltran-Agullo, Lim ARVO 2010
16 Constant Pressure Flow Test 13.6 cm H 2 O = 10 mmhg BSS bottle Giving set 26 gauge cannula Primed Ahmed Valve before testing
17 Constant Pressure Flow Test 13.6 cm H 2 O = 10 mmhg BSS bottle Giving set 26 gauge cannula Primed Ahmed Valve before testing
18 Ahmed Valve constant pressure flow test
19 Gravity-driven Flow Test 13.6 cm H 2 O = 10 mmhg
20 Constant Pressure Flow Test 10 cm 13.6 cm H 2 O = 10 mmhg
21 Ahmed Glaucoma Valve - Rejection Free flow of fluid at 7 mmhg No flow of fluid at 15 mmhg 24 AGV since July rejections; 3 hypotony, 1 high opening pressure Goyal, Jones,Alaghband, Beltran-Agullo, Lim ARVO 2010
22 In vivo flow testing Ahmed Valve Number of eyes 20 Rejection 4 Male: female 13:7 Age mean (range) 62 (29-82) Mean pre-op IOP (range) 29 (10-57) Mean post-op IOP range) 15 (3-52) Hypotony 2 Choroidal effusion 2 IOP > 15mmHg 6 (IOP mmhg) Goyal, Jones,Alaghband, Beltran-Agullo, Lim ARVO 2010
23 In vivo flow testing Ahmed Valve Number of eyes 20 Rejection 4 Male: female 13:7 Age mean (range) 62 (29-82) Mean pre-op IOP (range) 29 (10-57) Mean post-op IOP range) 15 (3-52) Hypotony 2 Choroidal effusion 2 IOP > 15mmHg 6 (IOP mmhg) Goyal, Jones,Alaghband, Beltran-Agullo, Lim ARVO 2010
24 Strategies to prevent hypotony Ahmed valve Molteno & Baerveldt Vicryl tube tie Molteno & Baerveldt - Supramid stenting
25 Post-op IOP Tube Vicryl Tie Hypertensive IOP Combine resistance Hypotony Time
26 Post-op IOP Tube Vicryl Tie & Perforation Hypertensive IOP Combine resistance Hypotony Time
27 Lim KS, Wells AP, Khaw PT. Needle perforations of molteno tubes. Journal of Glaucoma Unpredictable results May still have risk of hypotony
28 Strategies to prevent hypotony Ahmed valve Molteno & Baerveldt Vicryl tube tie Molteno & Baerveldt - Supramid stenting
29 The Baerveldt Glaucoma Implant: A new technique for more consistent IOP control. Heatley C, Lim KS, Barton K. October AAO video
30 Post-op IOP Supramid stent Hypertensive IOP Supramid removal Hypotony Time
31 AC Formed Shallow Flat No other complication Maculopathy or Effusion No other complication Maculopathy or Effusion 1 week review 1 week review/healon in AC 1 week review Healon in AC
32 AC Formed Shallow Flat No other complication Maculopathy or Effusion No other complication Maculopathy or Effusion Tube Tie 1 week review 1 week review/healon in AC 1 week review Healon in AC
33 Tube Tie 8.0 Prolene
34 Post operative Mx main issues Early Hypotony Tube Related Corneal decompensation Tube/Plate Erosion Bleb Encapsulation
35 Tube Blockage K. Barton
36 Post operative Mx main issues Early Hypotony Tube Related Corneal decompensation Tube/Plate Erosion Bleb Encapsulation
37 44 year-old lady Congenital glaucoma Multiple trabeculectomies Bilateral Molteno 1990 RVA PL RVA 6/60
38 Corneal Endothelial Loss following Tube Surgery Beebe WE et al. Ophthalmology Nov;97(11): Molteno implant for the treatment of glaucoma in keratoplasty patients 60% failed PK or progressive endothelial loss Topouzis et al. Am J Ophthalmol Aug;128(2): Follow up of the original cohort with the Ahmed glaucoma valve implant 30% corneal complication rate at 4 years McDermott ML, et al. Am J Ophthalmol Jan;115(1):93-6. Corneal endothelial cell counts after Molteno implantation. No significant cell loss
39 Corneal Endothelial Loss following Tube Surgery Alvarenga LS, et al. Am J Ophthalmol Aug;138(2): The long-term results of keratoplasty in eyes with a glaucoma drainage device. GDD is an independent risk factor for graft failure Kim CS, et al. Clin Experiment Ophthalmol Mar;36(2): Changes in corneal endothelial cell density and morphology after Ahmed glaucoma valve implantation during the first year endothelial cell progressively decreased after AGV
40 What causes corneal decompensation? Prior corneal endothelial damage IOP related Physical attrition by the tube
41 What causes corneal decompensation? Prior corneal endothelial damage IOP related Physical attrition by the tube
42 Video from K. Barton
43 Tips to avoid corneal complications Careful gonioscopy pre-op Do not over inflate anterior chamber Place tube as close as possible to the iris Revised tube position if touching cornea
44 Tips to avoid corneal complications Careful gonioscopy pre-op Do not over inflate anterior chamber Place tube as close as possible to the iris Revised tube position if touching cornea
45
46 Tips to avoid corneal complications Careful gonioscopy pre-op Do not over inflate anterior chamber - Avoid combine surgery if possible Place tube as close as possible to the iris Revised tube position if touching cornea
47 Tips to avoid corneal complications Careful gonioscopy pre-op Do not over inflate anterior chamber Place tube as close as possible to the iris Revised tube position if touching cornea
48 Corneal Decompensation
49 Post operative Mx main issues Early Hypotony Tube Related Corneal decompensation Tube/Plate Erosion Bleb Encapsulation
50 Tube Erosion Technique Risk of Erosion No covering 20% Trabeculectomy flap 10% Long needle track 2.5% Graft Scleral/Cornea/Tutoplast 2%
51 Long Needle Track Oscar Albis Donado, MD
52 Corneal Patch Graft
53 Tutoplast Patch Graft
54 Which patch graft? Advantages Disadvantages Scleral Patch Expensive ( 400) Short shelf life (1 day) Cosmesis Corneal Patch Cosmesis Expensive ( 400) Short shelf life (1 day) Tutoplast Cheap ( 90) Long shelf life (4 years) Cosmesis
55 Tube Erosion
56 Tube Erosion
57 Post operative Mx main issues Early Hypotony Tube Related Corneal decompensation Tube/Plate Erosion Bleb Encapsulation
58 Bleb Encapsulation Needling Bleb excision Another shunt or Cyclodiode
59 Bleb Encapsulation Needling Bleb excision Another shunt or Cyclodiode
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