Ординатура / Офтальмология / Английские материалы / Atlas of Glaucoma, Second Edition_Choplin, Lundy_2007

Table 18.6 Complications Associated with Non-Penetrating Glaucoma Surgery and Trabeculectomy

glaucoma of Atlas 292

Table 18.6 (Continued)

DS: deep sclerectomy, DSCI: deep sclerectomy with collagen implant, VC: viscocanalostomy, Trab: trabeculectomy, Phaco: phacoemulsification, DSASI: deep sclerectomy with autologous scleral implant, DSSK: Deep sclerectomy with SKGEL implant, DSTF: Deep scleretomy with T-Flux implant, POp: Postoperative, IOp: Intraoperative, 5FU: 5-fluorouracil, GP: goniopuncture, NR: not reported, NA: not applicable.

1 A 1-0 chromic suture was used as a collagen implant. * in patients under 40 years of age.

293 surgery penetrating-Non

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INTRODUCTION

Aqueous shunts are drainage devices designed to lower intraocular pressure by draining aqueous humor from the interior of the eye to an encapsulated reservoir near the equator of the globe. In general, aqueous shunts have been used in eyes with poor surgical prognoses, as listed in Table 19.1. The devices consist of one or more plates connected to a tube; the tube not only serves as the means of egress of aqueous from the eye but also prevents the opening into the eye from closing. Although there have been several devices used to keep an opening in the eye patent, Anthony Molteno was the first to design an implant that helped with the formation of a posterior episcleral filtering bleb.

Most aqueous shunts have a similar design. There is a silicone or Silastic tube that is placed into the eye (through the limbus or pars plana) and through which aqueous humor passes into the episcleral– subconjunctival space near the globe’s equator. In this area there is an episcleral plate that is designed to help form and maintain a filtering bleb. Three key design features distinguish different implants:

(1) the presence of a valve or mechanism to restrict

Table 19.1 Clinical indications for aqueous shunts

1.Prior failed glaucoma filtering surgery

2.Aphakic/pseudo-phakic glaucoma

3.Neovascular glaucoma

4.Uveitic glaucoma

5.Congenital glaucoma after failed angle surgery

6.Prior penetrating keratoplasty

7.Angle closure glaucoma

8.Epithelial downgrowth

9.ICE syndrome

the flow of aqueous humor from the eye; (2) the surface area of the episcleral plate; and (3) the material used.

The restriction of flow of aqueous humor from the eye is important in the prevention of immediate postoperative hypotony and its attendant complications. Implants that do not have such a mechanism, the Molteno, Baerveldt, and Schocket band implants, are usually inserted in either a twostage procedure, where encapsulation of the bleb is allowed to occur before a second surgery to actually insert the tube into the eye, or a one-stage procedure, where the flow of aqueous is restricted by a suture ligature around the tube or an internal stent. Several aqueous shunts, specifically the Krupin Valve implant, Joseph implant, White pump-shunt, Optimed Glaucoma Pressure Regulator, and Ahmed Glaucoma Valve implant, have pressure-sensitive valves or internal mechanisms to restrict the flow of aqueous from the eye, with the goal being to prevent ocular hypotony in the immediate postoperative period. Prata and co-authors reported that the Ahmed and Krupin implants function as flow-restricting devices at flow rates of 2–25 l/min. In vitro tests with human plasma showed that the Ahmed and Krupin implants had greater resistance (change in pressure/change in flow) than partially ligated Baerveldt implants.

The surface area of the episcleral plate may influence the amount of intraocular pressure reduction because of its effect on filtering bleb size. In animal eyes with Molteno implants, Minckler and co-authors found that the pressure within the filtration bleb surrounding the episcleral plate was similar to the pressure in the anterior chamber. Since the main resistance to aqueous flow and pressure reduction is the capsular wall surrounding the episcleral plate, a potential advantage of a larger filtration bleb is a larger surface area for diffusion. Heuer and co-authors have reported that there is a greater reduction in intraocular pressure

Table 19.3 Cumulative probability of success of different types of aqueous shunt

Continued

299 shunts Aqueous

Table 19.3 Continued

IOL, intraocular lens; NVG, neovascular glaucoma; OAG, open-angle glaucoma; ACG, angle-closure glaucoma; PKP, penetrating keratoplasty; CMG, chronic mixed glaucoma; ICE, iridocorneal endothelial syndrome.

glaucoma of Atlas 300