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202]

Review Article

Glaucoma drainage devices

Parul Singh, Krishna Kuldeep, Manoj Tyagi, Parmeshwari D Sharma, Yogesh Kumar

Glaucoma drainage devices (GDD) occupy an important place in the surgical management of glaucoma that is not Access this article online
responding to medications and trabeculectomy operations. In certain conditions, such as neovascular glaucoma, Website:
pediatric glaucoma, iridocorneal endothelial syndrome, penetrating keratoplasty with glaucoma, glaucoma following [Link]
retinal detachment surgery, it has become the preferred operation. GDD create an alternate aqueous pathway from DOI:
anterior chamber by channeling aqueous out of the eye through a tube to subconjunctival space. Glaucoma drainage 10.4103/2320-3897.112174
implants that have been used extensively include the non-restrictive and restrictive drainage devices. This article Quick Response Code:
outlines history of implants, types of implant, surgical technique of implantation, various complications following
GDD insertion and their management.

Key words: Ahmed glaucoma valve, baerveldt glaucoma valve, drainage devices, glaucoma, surgery

Glaucoma drainage devices (GDDs) work by creating an alternate 1973 when Molteno improved his device with the idea of draining
pathway for aqueous outflow by channeling aqueous from anterior the fluid away from the limbus to increase the success rate. All
chamber (AC) through a tube of implant towards sub-conjunctival of the currently available GDD are based on these fundamentals
space. Trabeculectomy, the procedure of choice in conventional which were basis of Molteno implants.[17] The Molteno implants,
glaucoma filtration surgery, has remained essentially unchanged for however, offer no resistance to the outflow and post-operative
over a quarter of a century. Local control over wound healing with complications like hypotony, flat ACs, and choroidal effusions were
anti-metabolites has improved the prognosis for cases with high a regular phenomenon.[18] In 1976, Krupin developed a pressure
risk of filtration failures; but flow control remains inexact despite sensitive, unidirectional valve that provides resistance to the
the introduction of a variety of suture adjustment techniques. flow of aqueous. In 1981, Molteno introduced the double plate
GDD occupy an important place for treatment of complicated and implant with a surface area of 270 mm2.[19] In 1992, Baerveldt
refractory glaucomas, both as primary surgical modality and as a introduced a non-valved silicone tube attached to a large
secondary procedure where trabeculectomy with or without anti- barium-impregnated silicone plate with surface area of 250 mm2,
metabolite treatment has either failed or is reported to have very 350 mm2 or 500 mm2.[20,21] In 1993, Ahmed introduced the Ahmed
low chances of success.[1-7] The latter group consists of pediatric glaucoma valve (AGV), a pressure sensitive unidirectional valve.[3,4,7]
glaucomas,[8-9] neo-vascular glaucomas,[10] uveitic glaucoma,[11] Then there was development of Ex-Press R50-single piece, stainless
aphakic and pseudo-phakic glaucoma, [12] post-vitreoretinal steel translimbal implant that is placed with the help of an inserter.
surgery,[13] and post-penetrating keratoplasty surgery.[14] This article
outlines the history of implants, types of implants, medication and Types of implants
contra-indication, surgical techniques of implantation, various 1. Non-valved/Non-restrictive implants: These GDDs consist of
complications following GDD insertion and their management. a silicone tube attached to an endplate that acts as a surface
for the bleb formation.
History
• Single plate Molteno implant is a silicone tube attached to
The first attempt to implant a drainage device was made by 135 mm2 polypropylene endplate.
Rollet and Moreau in 1907, when they performed a double • Double plate Molteno (DPM) is same as the single plate
paracentesis and used horse hair through the corneal punctures Molteno except that a second end plate is attached to the
to treat patients with painful absolute glaucoma.[15] Later attempts right or left of the original endplate, thus doubling its
include insertion of a polythene tube by Epstein in 1959, and surface area.
silicon tube by MacDonald and Pearce in 1965. Molteno in 1969 • Baerveldt implant is a silicone tube attached to soft pliable,
scientifically explained the pathophysiology of bleb resistance barium impregnated silicone endplate of various sizes (i.e.,
and designed a tube.[16] Another significant development was in 250 mm2, 350 mm2 or 500 mm2).
• Schocket implant is a silastic tube, one end of which is
Department of Ophthalmology, V. C. S. G. Government Medical inserted into the AC, and the other end is tucked beneath
Sciences and Research Institute, Srinagar Garhwal, Uttarakhand, India a No. 20 retinal encircling band.
Address for correspondence: Dr. Parul Singh, Department of • Ex-Press R50 implant is a single piece, stainless steel,
Ophthalmology, V. C. S. G. Government Medical Sciences translimbal implant that is placed with the help of an
and Research Institute, Srinagar Garhwal, Uttarakhand, India. inserter.
E-mail: parulophtha@[Link] 2. Valved/Restrictive implants:
Manuscript received: 17.09.2012; Revision accepted: 10.02.2013 • AGV is a silicone tube connected to a silicone sheet valve held

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Singh, et al.: Glaucoma drainage devices

in a polypropylene body. The endplate measures 185 mm2 • Vitreous in AC

(16 mm long × 13 mm wide × 1.9 mm thick). The valve • Intra-ocular silicone oil-Implant if required is placed in inferio-
consists of thin silicon elastomer membranes (18 mm long temporal quadrant
× 7 mm wide). The valve is designed to open when intra-
ocular pressure (IOP) is 8 mmHg. Surgical procedure
• Krupin slit valve consists of a silicone tube with a slit valve
AGV insertion
attached to a silicone oval endplate with a surface area of
180 mm2. The opening pressure of the slit valve is designed The conjunctiva is undermined posteriorly by blunt dissect
to be 11-14 mmHg and the closing pressure is designed to in superior-temporal quadrant. Adequate surgical exposure is
be 2 mmHg.[22] done by placement of traction sutures and dissection of partial
• Others: Joseph, Optimed and White GDD. thickness scleral flap to cover the tube in case where preserved
3. GDD with variable resistance: sclera/pericardium is not used. The AGV implant is irrigated with
• Molteno dual ridge device limits the initial drainage area 2 ml of balanced saline solution (priming). The plate is secured to
by dividing the top portion of the plate into two separate superficial sclera using two interrupted non-absorbable sutures
spaces with a thin V-shaped ridge. 8 mm from limbus. The tube is cut to extend 1-3 mm beyond
• Baerveldt bioseal is a flap that overhangs the silicone tube posterior surgical limbus. The AC is entered 0.5 mm posterior
as it opens on the endplate. to the limbus by 23 gage needle directed parallel to and just
• SOLX Goldshunt is an investigational device consisting of a anterior to iris plane. The tube is inserted with a smooth forceps
flat, 24 carat gold implant (5.2 mm long and 3.2 mm wide) through the needle tract ensuring that no iris or corneal touch
with numerous microtubular channels that bridge the AC was present. The tube is secured against sclera using figure of
and the suprachoroidal space. eight suture. Then, either scleral flap is approximated or donor
graft is used to cover it. Conjunctival closure is then performed
Pathophysiology using 8-0 or 9-0 Nylon suture.
Following implantation of GDD, a fibrous capsule forms around DPM or Baerveldt implant insertion
the endplate over a period of several weeks. A feature common To insert DPM, a fornix based conjunctival flap is made between
to all glaucoma drainage implants is the construction of the medial and lateral rectus muscles. The DPM is irrigated with
plate from materials to which fibroblasts cannot adhere. Aqueous saline solution to verify patency. A 4-0 Nylon stent is inserted
humor pools in the potential space between the endplate and into the silicone tube. The end plates are secured to the sclera
surrounding non-adherent fibrous capsule when flow occurs 8 mm from limbus in supra-temporal and supranasal quadrants
through the AC tube. Aqueous then passes through the capsule with 9-0 suture. AC is entered with 23 gage needle, silicone tube
by the process of passive diffusion and is absorbed by peri-ocular trimmed and inserted into AC through needle tract. A 10-0 Nylon
capillaries and lymphatics. It is the fibrous capsule around the figure of eight suture tied around tube and donor scleral patch
end-plate that offers the major resistance to aqueous flow with graft placed on the tube. The long end 4-0 Nylon stent is passed
drainage implants. underneath lateral rectus or medial rectus muscle and tucked
Indications into the subconjunctival space inferiorly. The conjunctiva is then
sutured.
Glaucoma drainage device implantation is usually reserved for
cases with refractory glaucoma, or those unlikely to respond The single plate Molteno implant and Baerveldt implant are
successfully to a conventional filtration surgery. The indications inserted in similar fashion as AGV; however, with the Baerveldt
for GDD implantation include the following: implant, the endplate is tucked underneath the adjacent rectus
muscles.
• Neovascular glaucoma
• Penetrating keratoplasty with glaucoma Ex-Press shunt implant insertion
• Retinal detachment surgery with glaucoma The technique involves limbal peritomy and a 3 mm × 3 mm
• Iridocorneal endothelial syndrome partial thickness scleral flap. Sponge pieces soaked in the desired
• Traumatic glaucoma concentration of Mitomycin-C should be placed under the scleral
• Uveitic glaucoma flap and the conjunctiva for desired time followed by copious
• Open angle glaucoma with failed trabeculectomy irrigation. Paracentesis is done, followed by an injection of high
• Epithelial down growth molecular weight visco-elastic. A 27 gage needle is used to create
• Refractory infantile glaucoma needle tract into AC under scleral flap. The express shunt is then
• Contact lens wearers who need glaucoma filtration surgery placed into the AC through the needle tract. The scleral flap is
• Sturge-Weber’s syndrome. secured with two interrupted 10-0 Nylon sutures. The conjunctiva
is closed with 10-0 Vicryl.
Contraindications:
• Eyes with severe scleral or sclera-limbal thinning Gold micro-shunt implantation
• Extensive fibrosis of conjunctiva Gold shunt is typically inserted through a scleral incision 4 mm
• Ciliary block glaucoma. in length, 2.5 mm from limbus. The device enters AC through a
scleral tunnel directly above scleral spur, with rear tabs placed
Relative Contraindications: in suprachoroidal space.

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Modifications to prevent hypotony with non-valved implants: daily and continued for 5-6 weeks. Initial follow-up is at one week
• Two stage procedure: To prevent post-operative hypotony, a and further frequency of visits depends on the clinical status of
shunt procedure may be performed in two stages. In the first the eye. For valved implants, pre-operative glaucoma medications
stage, the plate is attached to the globe and the tube is left in are discontinued to prevent hypotony. For non-valved implants,
the subconjunctival space without entering the eye. Four to the glaucoma medications are usually continued until a fibrous
six weeks later, after a capsule has formed around the implant, capsule forms around the plate.
the conjunctiva is opened and a tube is inserted into the AC
Post-operative sequels
to complete the procedure.
• Internal tube occlusion (stent): Aqueous drainage through a Implantation of GDDs may be followed by all or one of the
non-valved device can be regulated in the early post-operative following phases:
period by passing a 4-0 or 5-0 prolene or nylon suture through Hypotensive phase
the lumen of the implant. Once the fibrous capsule is formed From day 1-3-4 weeks following the operation, clinical
around the implant, the stent suture is removed at slit lamp examination during this phase reveals a diffuse and thick walled
under local anesthesia. bleb with minimally engorged blood vessels. The IOP is low, i.e.,
• External tube occlusion (Ligature): The flow of aqueous humor from 2-3 mmHg to 10-12 mmHg.
through a non-valved device can also be restricted by placing
a suture ligature around the external aspect of the tube. Hypertensive phase
The external occlusion may be accomplished using a non- Starts 3-6 weeks after the operation and lasts from 4 to 6 months.
absorbable 7-0 suture with a releasable knot or a 7-0 or 8-0 It is more commonly seen with the AGV. On examination, an
absorbable vicryl suture tied around the tube. Alternatively, inflamed and dome shaped bleb is seen and increased IOP, at times
9-0 nylon or 10-0 prolene suture may be used to ligate the tube greater than 30 mmHg may be noted. During the hypertensive
inside the AC to allow for laser suture lysis with argon laser. phase, when the IOP is too high (usually >21 mmHg), anti-
• Pars plana insertion: The tube of the glaucoma drainage glaucoma medications may be initiated, along with digital
implant is most commonly placed in the AC. However, the massage. In case the patient doesn’t respond needling may be
tube may also be placed in the sulcus in a pseudophakic eye indicated. A subconjunctival injection of 5-FU(5-fluorouracil) in
or in pars plana in a vitrectomized eye. opposite quadrant may also be given.

Site of implantation Stable phase

With the exception of the two plate implants, most glaucoma This phase follows the hypertensive phase and is characterized
implants are placed in single quadrants. Whenever possible, by stabilization of IOP usually in early teens.
single plate implants should be placed in the superior-temporal Post-operative complications and management:
quadrant. This area provides the easiest access for the surgeon 1. Hypotony/choroidal detachment: Low IOP (<5 mmHg) with
to implant the plate and is least likely to produce motility a shallow AC in the immediate post-operative period may be
disturbances. In eyes containing silicon oil, the implant is placed due to-overfiltration, wound leaks, or choroidal effusions.
in the inferior quadrant to minimize loss of oil, which is lighter Hypotony due to overfiltration is seen in 20-30% of the cases
than aqueous and floats up. with non-valved implants. Modifications like placement of a
Role of anti-fibrosis agents suture in the lumen of the tube (Ripcord technique) have been
devised to lower its incidence.
Using anti-metabolites with improved success in trabeculectomy
2. Management: Hypotony from overfiltration generally does
led to considerable interest in using these agents with GDD. One
not require treatment unless flat AC develops with lens cornea
early study indicated that patients receiving mitomycin-c at the
touch. AC may be reformed with visco-elastic. In persistent
time of glaucoma implant surgery has lower final IOP, required
cases GDD may be revised. If persistent wound leaks, repair
fewer post-operative medications and has less pronounced
is done with sutures. Choroidal effusions may be treated
hypertensive phase. However, the duration of the post-operative
with topical and oral steroids. However, if choroidal effusions
hypotensive phase was prolonged and was associated with an
increase in choroidal effusions, flat AC and other post-operative are kissing or involving the macula, they must be drained
complications.[23] But, subsequent studies have failed to show surgically.
effectiveness of these agents. Two retrospective studies reported 3. Tube obstruction: Obstruction of tube may be caused by blood,
no benefit of intra-operative use of mitomycin-c with Baerveldt fibrin, vitreous or iris plug or it may be related to tight external
implants.[24,25] Two post-operative randomized trials studied the ligature around the tube. Tube obstruction because of the
effectiveness of intra-operative use of mitomycin-c with Molteno kinking of the tube has been reported after pars plana AGV
and AGV implants. Neither of the trials demonstrated higher insertion.[28] It manifests as IOP rise associated with deep AC.
success rates in terms of final IOP, visual acuity and number of 4. Management: Blood or fibrin clot-Intracameral injection of
anti-glaucoma medications required post-operatively.[26,27] 5-10 mg of tissue plasminogen activator in 0.1 ml of balanced
salt solution. Vitreous incarceration-Neodymium-yttrium
Post-operative course aluminum garnet (Nd-YAG) laser is used to dissipate the
Following GDD surgery, the patient is examined on post-operative vitreous strands.[29] Iris incarceration-peripheral argon laser
day one and attention is paid to the tube position and wound iridoplasty applied to the base of the plug. Tight external
architecture. Topical antibiotic and steroids are started 4 times ligature can be cut with argon laser.

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Singh, et al.: Glaucoma drainage devices

5. Elevated IOP: Early operative IOP elevation may be due to areas of aqueous leakage, in children and following needling
obstruction of tube by fibrin, blood, iris tissue or vitreous. of the bleb.[34]
Management for these conditions is described under tube 16. Loss of vision: This may occur due to hypotonous maculopathy,
obstruction heading. Late IOP elevation is usually due to progression of cataract, glaucoma, corneal decompensation,
excessively thick fibrous capsule. This can be dealt by removing suprachoroidal hemorrhage, and endophthalmitis.
a portion of capsule beneath the conjunctival flap.
6. Overhanging bleb: If the patch graft is too thick or the plate Comparison of glaucoma drainage devices
is too anterior, an overhanging bleb may be created resulting A meta-analysis of various studies published between 1966 and
in chronic dellen formation and ocular irritation. This 2002 were carried out by Hong et al.[35] A total of 147 articles
complication is best prevented by appropriate plate and patch were reviewed and 54 articles were included in final analysis (29
graft placement during surgery. with Molteno, single and double plate with some form of intra-
7. Bleb encapsulation: Failure to control IOP after GDD implant operative modification to prevent hypotony, 6 with single plate
surgery may occur secondary to encapsulation of the Molteno without any form of surgical modification to prevent
bleb around the plate. This complication is analogous to hypotony, 9 with Baerveldt, 8 with AGV and 2 with Krupin). The
encapsulated bleb that develops after trabeculectomy and is overall surgical success rate averaged between 72% and 79%
treated in similar fashion with anti-glaucoma medication. among the five devices with no statistically significant difference
8. Tube exposure/migration/extrusion: The incidence of tube at the last follow-up. All five implants significantly lowered IOP
exposure varies from 0-15%. Management: To prevent tube (P < 0.001).
exposure, prophylactically use for donor sclera, adequate
anchorage to scleral bed by sutures and superficial flap must There was no statistically significant difference between in
be evenly dissected. Treatment of this complication may be either the percentage change in IOP or the overall surgical success
initially by rotating an adjacent partial thickness flap to cover rate at the last follow-up among the five devices or within the
the tube but ultimately a fresh site may be needed. sub-division of the Molteno group or the size of the endplate.
9. Tube retraction: Retraction of the tube from AC may be Diplopia was seen more frequently with the use of Baerveldt
managed by placing an extender sleeve with larger inner implant (P = 0.01).[36] Plate size of various implants has been
diameter over the existing tube.
investigated to determine its influence on the final IOP. Heuer
10. Corneal endothelial touch: It is usually seen when the tube
et al. reported improved IOP control the Molteno double plate
has not been placed accurately or the bevel has not been cut
when compared with the single plate in a prospective study
in the proximal orifice. The other reason for this complication
assessing outcomes in aphakic and pseudophakic glaucoma.[37]
is shallow AC. Corneal endothelial touch lead to corneal
In a retrospective study, the DPM demonstrated lower mean
decompensation, which is cause of long term visual outcome.
IOP when compared with a single plate AGV, 13.3 ± 5.1 mmHg
11. Ocular motility disturbance: Exotropia, hypertropia or
versus 19 ± 5.8 mmHg (P = 0.009) respectively at 24 months.[38]
limitation of ocular rotation usually occurs with larger plates,
In a prospective study comparing 350 mm square and 500 mm
e.g., Baerveldt and Krupin implant, but can also occur with
square Baerveldt implants, Llyod et al. reported statistically
smaller plates. Diplopia was noted to be significantly higher
comparable results with respect to IOP control, visual acuity and
with Baerveldt implant than with AGV or Molteno implant.
complications.[20]
This extra-ocular muscle imbalance with diplopia results
from mass effect of plate and surrounding bleb on adjacent The Ahmed Baerveldt Comparison Study is a multi-center
extra-ocular muscle. Other possible causes include Faden randomized, prospective clinical trial. Two hundred seventy six
effect, entrapment of superior oblique muscle, fat fibrosis subjects with uncontrolled glaucoma received either an AGV
syndrome[30,31] or pseudo-brown syndrome.[32,33] (model FP7) or a Baerveldt implant (model 350 mm square). The
12. Suprachoroidal hemorrhage: Sudden excruciating pain with majority of subjects had either primary open angle glaucoma or
increased IOP in the operated eye during the operation or in neo-vascular glaucoma. Forty two percent of the subjects had
the post-operative period might indicate a suprachoroidal previously failed trabeculectomy. The mean baseline IOP was 30
hemorrhage. Clinical signs include a shallow AC, increased mmHg. Failure was defined as IOP greater than 21 mmHg and less
IOP, and choroidal elevations. B-scan is helpful in diagnosing than 6 mmHg, less than 20% of IOP reduction from baseline, repeat
this condition. Management: Includes supportive therapy, surgery or loss of light perception. At one year, the mean IOP was
followed by topical and oral steroids, glaucoma medications, 15.4 ± 5.5 mmHg in the Ahmed group and 13.2 ± 6.8 mmHg in
cycloplegic agents and painkillers. Baerveldt group (P = 0.007). The cumulative probability of failure
13. Indications for drainage: Involvement of the macula by the was 16.4% and 12.3% in AGV and Baerveldt groups respectively.
hemorrhage kissing choroids, corneo-lenticular touch and The Baerveldt group required more surgical interventions post-
severe pain. operatively.[39]
14. Corneal graft failure: GDD surgery appears to be associated
with high incidences of graft failure in patients with glaucoma. Tube Versus Trabeculectomy (TVT) study
The presence of chronic inflammation, extensive peripheral Tube shunt surgery had a higher success rate compared to
synechiae and multiple previous surgeries may compromise trabeculectomy with MMC during 5 years of follow-up in the TVT
the graft. Study. Both procedures were associated with similar IOP reduction
15. Endophthalmitis: Endophthalmitis following GDD operation is and use of supplemental medical therapy at 5 years. A total of
very rare, and is more common through thin walled blebs or 212 eyes of 212 patients were enrolled, including 107 in the tube

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Singh, et al.: Glaucoma drainage devices

group and 105 in the trabeculectomy group. At 5 years, IOP (mean glaucoma. Since their introduction, numerous modifications in
± SD) was 14.4 ± 6.9 mmHg in the tube group and 12.6 ± 5.9 design and improvements in surgical technique have enhanced
mmHg in the trabeculectomy group (P = 0.12). The number of clinical outcomes and minimized complications. These devices are
glaucoma medications (mean ± SD) was 1.4 ± 1.3 in the tube available in different sizes, materials, and designs. The decision to
group and 1.2 ± 1.5 in the trabeculectomy group (P = 0.23). choose a particular type of drainage device depends on a patient’s
The cumulative probability of failure during 5 years of follow-up underlying characteristic in terms of pre-operative IOP and optic
was 29.8% in the tube group and 46.9% in the trabeculectomy nerve status, desired long-term IOP control and the surgeon’s
group (P = 0.002; hazard ratio = 2.15; 95% confidence interval comfort and preference. Careful pre-operative screening and
= 1.30-3.56). The rate of reoperation for glaucoma was 9% in the planning along with meticulous surgical technique help minimize
tube group and 29% in the trabeculectomy group (P = 0.025).[40] post-operative complications.
Newer glaucoma drainage devices References
MIDI Arrow: It is made from proprietary material called poly 1. Wilson MR, Mendis U, Paliwal A, Haynatzka V. Long-term follow-
styrene-block-isobutylene-block-styrene (SIBS). It has been up of primary glaucoma surgery with Ahmed glaucoma valve
demonstrated in over 60 rabbit studies that ophthalmic implants implant versus trabeculectomy. Am J Ophthalmol 2003;136:464-70.
made from SIBS are significantly less irritating, less inflammatory, 2. Wilson MR, Mendis U, Smith SD, Paliwal A. Ahmed glaucoma valve
less capsule forming and non-occluding as compared to similarly implant vs trabeculectomy in the surgical treatment of glaucoma:
shaped silicon rubber controls.[41] Human clinical studies are also A randomized clinical trial. Am J Ophthalmol 2000;130:267-73.
demonstrating encouraging performance but results are yet to 3. Coleman AL, Hill R, Wilson MR, Choplin N, Kotas-Neumann R,
be published. Tam M, et al. Initial clinical experience with the Ahmed Glaucoma
Valve implant. Am J Ophthalmol 1995;120:23-31.
iStent 4. Huang MC, Netland PA, Coleman AL, Siegner SW, Moster MR,
The iStent is a very small titanium tube, approximately 1 mm in Hill RA. Intermediate-term clinical experience with the Ahmed
Glaucoma Valve implant. Am J Ophthalmol 1999;127:27-33.
length. It is surgically placed into the eye through an incision in
the cornea and inserted through the filtering tissue meshwork. 5. Kook MS, Yoon J, Kim J, Lee MS. Clinical results of Ahmed
glaucoma valve implantation in refractory glaucoma with
This creates an opening between the eyes AC and Schlemm’s adjunctive mitomycin C. Ophthalmic Surg Lasers 2000;31:100-6.
canal that bypasses the damaged drainage system and directs
6. Lai JS, Poon AS, Chua JK, Tham CC, Leung AT, Lam DS. Efficacy
aqueous fluid into deeper tissues potentially decreasing IOP. and safety of the Ahmed glaucoma valve implant in Chinese eyes
The Food and Drug administration (FDA) reviewed effectiveness with complicated glaucoma. Br J Ophthalmol 2000;84:718-21.
data from a study on total of 240 eyes for 239 participants. The 7. Ayyala RS, Zurakowski D, Smith JA, Monshizadeh R, Netland PA,
FDA also reviewed the safety data for these and an additional Richards DW, et al. A clinical study of the Ahmed glaucoma valve
fifty participants. At 1 year following procedure, 68% of the implant in advanced glaucoma. Ophthalmology 1998;105:1968-76.
participants with iStent had target pressure of 21 mmHg or lower 8. Netland PA, Walton DS. Glaucoma drainage implants in pediatric
without the use of eye pressure lowering medication, compared to patients. Ophthalmic Surg 1993;24:723-9.
50% of participants who underwent cataract surgery alone. The 9. Englert JA, Freedman SF, Cox TA. The Ahmed valve in refractory
iStent may be considered as a new option in treatment of open pediatric glaucoma. Am J Ophthalmol 1999;127:34-42.
angle glaucoma patients needing cataract extraction. 10. Sidoti PA, Dunphy TR, Baerveldt G, LaBree L, Minckler DS, Lee PP,
et al. Experience with the Baerveldt glaucoma implant in treating
Hydrus stent neovascular glaucoma. Ophthalmology 1995;102:1107-18.
The Hydrus stent is one of several promising mini-drainage 11. Da Mata A, Burk SE, Netland PA, Baltatzis S, Christen W, Foster
devices now in clinical trials in the United States and other CS. Management of uveitic glaucoma with Ahmed glaucoma valve
implantation. Ophthalmology 1999;106:2168-72.
countries. If future trials confirm micro-stents’ effectiveness, they
could someday help protect millions of glaucoma patients from 12. Varma R, Heuer DK, Lundy DC, Baerveldt G, Lee PP, Minckler DS.
Pars plana Baerveldt tube insertion with vitrectomy in glaucomas
vision loss or blindness. In this particular study of 69 patients associated with pseudophakia and aphakia. Am J Ophthalmol
suffering from mild to moderate open-angle glaucoma, IOP was 1995;119:401-7.
reduced to acceptable levels in 100% of participants after they 13. Gandham SB, Costa VP, Katz LJ, Wilson RP, Sivalingam A,
received minimally invasive stent implant surgery. In 40 patients Belmont J, et al. Aqueous tube-shunt implantation and pars plana
the stent was placed during cataract surgery, a procedure that also vitrectomy in eyes with refractory glaucoma. Am J Ophthalmol
reduces IOP. Twenty-nine patients had the Hydrus stent placed 1993;116:189-95.
without cataract surgery to assess whether the stent would be 14. Coleman AL, Mondino BJ, Wilson MR, Casey R. Clinical experience
effective on its own. No significant complications occurred in with the Ahmed Glaucoma Valve implant in eyes with prior
or concurrent penetrating keratoplasties. Am J Ophthalmol
either patient group. At the 6-month follow-up, 85% of combined 1997;123:54-61.
surgery and 70% of stent-only patients no longer needed eye drop
15. Rollet M. Treatment da 1’ hyperpyonpan le drainage capillaire de
medications to control their IOP. Reductions in IOP were consistent lar chamber antericive Rev Gen Ophthalmol 1906;25:481-9.
among all patients and remained stable at the one year follow-up. 16. Molteno AC. New implant for draining in glaucoma. Br J
Ophthalmol 1969;53:609.
Conclusion
17. Molteno AC, Straughan JL, Ancker E. Long tube implants in the
GDD have been successful in controlling IOP in eyes with management of glaucoma. S Afr Med J 1976;50:1062-6.
previously failed trabeculotomy and for cases with refractory 18. Brown RD, Cairns JE. Experience with the Molteno long tube

Journal of Clinical Ophthalmology and Research - May-Aug 2013 - Volume 1 - Issue 2 81

[Downloaded free from [Link] on Wednesday, September 28, 2016, IP: [Link]]

Singh, et al.: Glaucoma drainage devices

implant. Trans Ophthalmol Soc U K 1983;103:297-312. 32. Ball SF, Ellis GS Jr, Herrington RG, Liang K. Brown’s superior
19. Airaksinen PJ, Aisala P, Tuulonen A. Molteno implant surgery in oblique tendon syndrome after Baerveldt glaucoma implant. Arch
uncontrolled glaucoma. Acta Ophthalmol (Copenh) 1990;68:690-4. Ophthalmol 1992;110:1368.
20. Britt MT, LaBree LD, Lloyd MA, Minckler DS, Heuer DK, Baerveldt 33. Ventura MP, Vianna RN, Souza Filho JP, Solari HP, Curi RL.
G, et al. Randomized clinical trial of the 350-mm2 versus the 500- Acquired Brown’s syndrome secondary to Ahmed valve implant
mm2 Baerveldt implant: Longer term results: Is bigger better? for neovascular glaucoma. Eye (Lond) 2005;19:230-2.
Ophthalmology 1999;106:2312-8. 34. Al-Torbak AA, Al-Shahwan S, Al-Jadaan I, Al-Hommadi A, Edward
21. Hodkin MJ, Goldblatt WS, Burgoyne CF, Ball SF, Insler MS. Early DP. Endophthalmitis associated with the Ahmed glaucoma valve
clinical experience with the Baerveldt implant in complicated implant. Br J Ophthalmol 2005;89:454-8.
glaucomas. Am J Ophthalmol 1995;120:32-40. 35. Hong CH, Arosemena A, Zurakowski D, Ayyala RS. Glaucoma
22. The Krupin Eye Valve Filtering Surgery Study Group. Krupin eye drainage devices: A systematic literature review and current
valve with disk for filtration surgery. Ophthalmology 1994;101: controversies. Surv Ophthalmol 2005;50:48-60.
651-8. 36. Smith SL, Starita RJ, Fellman RL, Lynn JR. Early clinical experience
23. Gross FJ. Six month success of Krupin valve with and without with the Baerveldt 350-mm2 glaucoma implant and associated
mitomycin-C in the treatment of complicated glaucomas. Invest extraocular muscle imbalance. Ophthalmology 1993;100:914-8.
Ophthalmol Vis Sci 1994;35:1422. 37. Heuer DK, Lloyd MA, Abrams DA, Baerveldt G, Minckler DS,
24. Trible JR, Brown DB. Occlusive ligature and standardized Lee MB, et al. Which is better? One or two? A randomized clinical
fenestration of a Baerveldt tube with and without antimetabolites for trial of single-plate versus double-plate Molteno implantation
early postoperative intraocular pressure control. Ophthalmology for glaucomas in aphakia and pseudophakia. Ophthalmology
1998;105:2243-50. 1992;99:1512-9.
25. Irak I, Moster MR, Fontanarosa J. Intermediate-term results of 38. Ayyala RS, Zurakowski D, Monshizadeh R, Hong CH, Richards
Baerveldt tube shunt surgery with mitomycin C use. Ophthalmic D, Layden WE, et al. Comparison of double-plate Molteno and
Surg Lasers Imaging 2004;35:189-96. Ahmed glaucoma valve in patients with advanced uncontrolled
26. Cantor L, Burgoyne J, Sanders S, Bhavnani V, Hoop J, Brizendine glaucoma. Ophthalmic Surg Lasers 2002;33:94-101.
E. The effect of mitomycin C on Molteno implant surgery: A 1-year 39. Budenz DL, Barton K, Fever WJ, et al. Treatment outcomes in the
randomized, masked, prospective study. J Glaucoma 1998;7:240-6. Ahmed Baerveldt comparison (ABC) study during the first year of
27. Costa VP, Azuara-Blanco A, Netland PA, Lesk MR, Arcieri ES. follow-up. Paper presented at: The 20th Annual American Glaucoma
Efficacy and safety of adjunctive mitomycin C during Ahmed Society Meeting; March 4,; Naples,FL. 2010.
Glaucoma Valve implantation: A prospective randomized clinical 40. Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD,
trial. Ophthalmology 2004;111:1071-6. Budenz DL, et al. Treatment outcomes in the Tube Versus
28. Netland PA, Schuman S. Management of glaucoma drainage Trabeculectomy (TVT) study after five years of follow-up. Am J
implant tube kink and obstruction with Pars Plana Clip. Ophthalmol 2012;153:789-803.e2.
Ophthalmic Surg Lasers Imaging 2005;36:167-8. 41. Acosta AC, Espana EM, Yamamoto H, Davis S, Pinchuk L, Weber
29. Tessler Z, Jluchoded S, Rosenthal G. Nd: YAG laser for Ahmed BA, et al. A newly designed glaucoma drainage implant made
tube shunt occlusion by the posterior capsule. Ophthalmic Surg of poly(styrene-b-isobutylene-b-styrene): Biocompatibility and
Lasers 1997;28:69-70. function in normal rabbit eyes. Arch Ophthalmol 2006;124:1742-9.
30. Christmann LM, Wilson ME. Motility disturbances after Molteno
implants. J Pediatr Ophthalmol Strabismus 1992;29:44-8.
Cite this article as: Singh P, Kuldeep K, Tyagi M, Sharma PD, Kumar Y.
31. Dobler-Dixon AA, Cantor LB, Sondhi N, Ku WS, Hoop J. Glaucoma drainage devices. J Clin Ophthalmol Res 2013;1:77-82.
Prospective evaluation of extraocular motility following double-
Source of Support: Nil. Conflict of Interest: None declared.
plate molteno implantation. Arch Ophthalmol 1999;117:1155-60.

82 Journal of Clinical Ophthalmology and Research - May-Aug 2013 - Volume 1 - Issue 2