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Purpose To report successful treatment of refractive glaucoma in a patient submitted to osteo-odonto-keratoprosthesis surgery for Stevens-Johnson syndrome. Methods An interventional case report. Results The patient is a 62-year-old Indian man with known Stevens-Johnson syndrome since 1972 secondary to tetracycline therapy, with bilateral dry eye and corneal blindness. He underwent symblepharon release surgery with mucous membrane graft in both eyes. Osteo-odonto-keratoprosthesis surgery was later performed on the left eye. He was submitted to 2 Ahmed valve implants to control secondary glaucoma but visual fields continued to worsen; hence, he underwent endoscopic 140° cyclophotocoagulation with a good control of IOP. Conclusion Endoscopic cyclophotocoagulation as alternative treatment provides good results in refractory glaucoma after osteo-odonto-keratoprosthesis surgery.

Glaucoma is the optic nerve damage often associated with an increased intraocular pressure that leads to progressive and irreversible loss of vision. The Ahmed valve is a passive device constructed from two opposed deformable silicone elastomers sheets, commonly used for the regulation of intraocular pressure in patients with glaucoma. In this work the dynamic response of the Ahmed valve to different flow conditions and gravity test of FDA is analyzed. This is carried out by means of the numerical simulation using the Finite Element Method, considering a partitioned Fluid-Structure coupling between the fluid and the structure of the valve. The fluid is described by the incompressible Navier-Stokes equations, written in an arbitrary time dependent coordinate system and the structure is described by a constitutive linear elastic solid assuming large displacements and rotations. In order to decrease the computational cost of the simulation, a reduced order model of the system is also presented. This model is developed using data from a previous characterization process using the partitioned fluid-structure solver. With the aim to validate the numerical simulation, the results are compared with experimental ones. Fil: Sassetti, Fernando. Universidad Nacional de Entre Rios. Facultad de Ingenieria. Departamento de Bioingenieria; Argentina Fil: Garelli, Luciano. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico. Centro de Investigación de Métodos Computacionales; Argentina Fil: Guarnieri, Fabio Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico. Centro de Investigación de Métodos Computacionales; Argentina

Background: We report 2 cases in which ultrasound biomicroscopy (UBM) was used to diagnose Ahmed valve obstruction by the iris. Methods: Two patients underwent unilateral placement of Ahmed implants, one into the anterior chamber and the other into the ciliary sulcus. Results: Intraocular pressures increased in the early postoperative period. In each case, a clear view of the aqueous drainage tube was precluded. Occlusion of the end of the tube by iris tissue was demonstrated by UBM. An iridectomy over the tip of the tube instituted filtration in each case. Interpretation: UBM was instrumental in diagnosing the presence and cause of occlusion of aqueous drainage tubes.

To analyze the control of intraocular pressure (IOP) and corneal graft survival after implantation of Ahmed glaucoma device (AGD) in eyes that had high-risk penetrating keratoplasty (PK).This is a retrospective noncomparative case series of 59 eyes that had high-risk PK and underwent AGD insertion. The primary outcome measures are the control of IOP between 6 and 21 mm Hg and corneal graft survival. The secondary outcome measures are risk factors associated with IOP control and corneal graft survival.The mean IOP reduced significantly after the AGD procedure (26.45 ± 6.8 mm Hg preoperatively vs. 16.85 ± 7.4 mm Hg, 16.95 ± 4.6 mm Hg, 17.97 ± 5.7 mm Hg, 15.78 ± 5.2 mm Hg, and 15.59 ± 5.5 mm Hg, at 1 month, 6 months, 1 year, 2 years, and at the last follow-up postoperatively; P0.0001). Over a median follow-up of 78 months (range, 9-175 months) after AGD insertion, IOP control was successful in 44 eyes (75.8%). IOP control was successful in 96% of the eyes at 1 year, 87% at 2 years, 83% at 3 years, and 83% at 5 years. The percentage of clear corneal grafts after 1, 2, 3, and 5 years following the AGD insertion were 87%, 77%, 65%, and 47%, respectively. Further surgery after AGD insertion was associated with 1.79 times greater risk of failure of IOP control.AGD was effective in controlling the IOP associated with high-risk PK over a 5-year period. Postvalve surgery doubles the risk of failure of IOP control.

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

Purpose: To report serial cases of patients who received surgical treatment for tube erosion after Ahmed valve implantation. Methods: In this retrospective and longitudinal study, surgical outcomes of reconstruction for tube erosion after Ahmed valve implantation were evaluated. Tube erosion occurred in 7 of 125 eyes (121 patients) at 60.5 ± 67.5 months (2 to 196 months). To prevent recurrence of tube erosion, the tube was repositioned backward in 4 eyes. Scleral allograft was used in all cases. Partial thickness scleral flap, collagen matrix implant, or bovine pericardium was used to cover the exposed tube in selected cases. In eyes with large conjunctival defects or severe adhesions between surrounding conjunctiva and episclera, rotational conjunctival flap, conjunctival autograft, or amniotic membrane graft was used to reconstruct the ocular surface. Results: Three of 7 eyes (42.9%) with tube erosion were successfully repaired by the first surgical treatment. No recurrence of tube erosion was found after the second and the fourth surgical procedure in 3 and 1 eyes, respectively. There was no case of explantation of the Ahmed valve in our series. Tube erosion recurred in 1 of the 4 eyes in which tube-repositioning was required and in 3 of the 5 eyes in which a partial thickness scleral flap was made to cover a tube. One eye experienced recurrent tube erosion in a relatively short-term interval and was repaired successfully using both collagen matrix implantation and amniotic membrane transplantation. Conclusions: Tube erosion after Ahmed valve implantation was successfully treated by various methods including tube repositioning, partial thickness scleral flap combined with scleral allograft, biodegradable collagen implant, pericardial graft, and/or amniotic membrane transplantation. J Korean Ophthalmol Soc 2016;57(3):453-460

Purpose Glaucoma drainage implants are a useful alternative in treating glaucomas that are resistant to medical therapy and conventional glaucoma filtration surgery. The aim of this study is to evaluate flexible Ahmed glaucoma valve implant for selected cases of refractory glaucoma regarding its efficiency in controlling intraocular pressure (IOP) and possible postoperative complications of its implantation and their management. Method Patients included in this study were selected from patients with uncontrolled IOP by conventional filtration surgery as well as maximum tolerable topical medical treatment when surgery or laser is unlikely to control IOP. For every patient, complete history of age, sex, and history of previous ocular disease was done. Ocular examination for IOP measurement, best-corrected visual acuity measurement, and condition of conjunctiva was done. Ahmed glaucoma valve flexible plate implant (FP7 and FP8) was used. Results The present study included 40 eyes of 40 patients and preoperative IOP ranged from 32 mmHg to 58 mmHg with a mean of 40.36 ± 7.78 mmHg. The postoperative IOP ranged between 14.0 mmHg and 28.0 mmHg with a mean of 18.73 ± 4.8 mmHg. The criteria of success were applied in 37 eyes of 40 eyes (92.5%); they included 30 eyes (81.8%) with absolute success and 7 eyes (18.9%) with partial success. Conclusions Flexible Ahmed glaucoma valve plate implant is a satisfactory method for controlling elevated IOP in cases of refractory glaucoma with success rate of 92.5% and lower incidence of immediate postoperative and implant-related complications.

BACKGROUND AND OBJECTIVE: Changes in corneal endothelial cell (CEC) indices 24 months after Ahmed valve (New World Medical, Inc., Rancho Cucamonga, CA) and single-plate Molteno implants (Molteno Ophthalmic Limited, Dunedin, New Zealand) were evaluated. PATIENTS AND METHODS: This cohort included Ahmed valve (29 eyes) or single-plate Molteno (28 eyes) implants. Preoperative and postoperative central CEC indices were compared. Main outcome measure was endothelial cell count. RESULTS: Twenty-four months postoperatively, no difference in visual acuity improvement or decrease in antiglaucoma medications was observed between groups. The Molteno group showed better postoperative intraocular pressure control ( P < .001). An 11.52% (Ahmed) and 12.37% (Molteno) reduction in CEC density (cells/mm 2 ) and 3.78 (Ahmed) and 2.48 (Molteno) increase in CEC area (mm 2 ) was observed, but no significant between-group difference in CEC density and area or corneal thickness. CONCLUSION: Twenty-four months after Ahmed valve or Molteno implant, statistically significant quantitative (cell density) and minor qualitative (cell area) changes in central CEC were observed. Both groups appeared to have similar CEC damage.

Purpose Evaluate the use of bevacizumab (avastin) injected around valve body intraoperatively versus the use of mitomycin C as a single intraoperative application at the site of Ahmed valve implantation to enhance the survival of Ahmed valve in cases of pediatric glaucoma's as regarding the efficacy and complications. Method Twenty eyes of 16 patients with pediatric glaucoma underwent Ahmed valve implantation with bevacizumab (avastin) (1.25 mg in 0.05 mL) injected around the valve body after completing the surgery compared with 20 eyes of 14 patients with pediatric glaucoma who underwent Ahmed valve implantation with application of mitomycin C (0.4 mg/mL for 3 min) before valve implantation and 20 eyes of 18 patients managed by Ahmed valve only (control group). The follow-up period was 12 months. Results The results revealed that 80% total success (70% complete success and 10% qualified success) in first group in which avastin augmented Ahmed valve was performed compared with group II in which mitomycin C was used during Ahmed valve implantation 90% total success (80% complete success and 10% qualified success) and this difference between the 2 groups was nonsignificant (P>0.05), but in group III complete success occurred in (60%) only with no cases of qualified success (P>0.05). Conclusions The adjunctive use of bevacizumab or mitomycin C during Ahmed valve implantation significantly enhances the valve survival and the first drug seems to be much safer with no visually devastating complications.

Purpose To examine the role of ocular massage during the hypertensive phase after Ahmed valve surgery Methods Nonrandomized prospective study. Results Eighteeen patients with intraocular pressure (IOP) above target 1 to 8 weeks after Ahmed glaucoma drainage device surgery underwent digital ocular massage. The mean IOP 1 hour after massage was 4.3 mm Hg lower than before massage (18.8%, P=0.0008). We used a 20% reduction in IOP at 1-hour postmassage to differentiate responders from nonresponders and by this definition 50% responded to ocular massage. One patient (5.6%) responded well but was unable to perform massage at home. The remaining 8 patients (44.4%) performed regular digital massage and the 20% drop in IOP was maintained at the 2-week, 6-week, and 6-month review, although by 6 months 50% required glaucoma drops to achieve target IOP. There were no massage-associated complications in this series. Conclusions Digital ocular massage has a useful role to play in the management of the hypertensive phase after Ahmed glaucoma drainage device surgery. In this series 50% of patients achieved a 20% drop in IOP with massage.

To examine the results of Ahmed glaucoma drainage device (GDD) implantation in patients with a preoperative intraocular pressure (IOP) of 20 mm Hg or less.Noncomparative retrospective case series.Sixty-six surgeries in 63 patients were analyzed. Mean follow-up was 51 months. The mean drop in IOP was 3.8 mm Hg (23.3%, P0.0001) at 12 months and 3.9 mm Hg (24.0%, P0.0001) at final follow-up. The number of glaucoma medications used postoperatively was significantly less than preoperatively. Although the mean visual acuity was poorer postoperatively this did not reach statistical significance. Surgical success was defined as IOPor =5 mm Hg and 20% lower than preoperatively with or without hypotensive therapy, visual acuity perception of light or better and no further glaucoma surgery. About 57.6% and 53.0% of patients were considered a success at 12 months and final follow-up, respectively. Fourteen patients (21.2%) underwent additional glaucoma surgery, 8 of which had a second Ahmed GDD inserted whereas 6 had cyclodestruction. All failures were due to inadequate IOP control or further glaucoma surgery, with no cases considered failures due to vision loss or hypotony. Perioperative complications developed in 6 cases (9.1%) whereas long-term problems related to surgery occurred in 8 cases (12.1%).In patients with IOPs of 20 mm Hg or less who require IOPs in the low teens and below Ahmed GDD surgery does seem to be an effective option. The success rates of surgery, however, must be balanced against the risk of complications. In addition, the relative merits of Ahmed GDD implantation versus mitomycin trabeculectomy and/or nonvalved GDDs requires further investigation.

BACKGROUND AND OBJECTIVE: To evaluate the safety and efficacy of residents performing glaucoma valve surgery at a metropolitan county hospital. PATIENTS AND METHODS: A retrospective analysis was performed of consecutive resident-performed Ahmed valve (New World Medical, Inc., Rancho Cucamonga, CA) glaucoma surgeries from 1993 to 2005. Data of 50 eyes of 48 patients were evaluated for intraocular pressure (IOP) and best-corrected visual acuity. RESULTS: The mean follow-up period was 34.7 ± 30.5 months, with an IOP decrease from 30.8 ± 11.3 mm Hg preoperatively to 15.3 ± 11.6 mm Hg at last visit. Success, defined by a postoperative IOP of greater than 5 mm Hg and at most 21 mm Hg or less or a decreased postoperative IOP of at least 25% if the pre-operative IOP was already 21 mm Hg or less, occurred in 78% of eyes. Best-corrected visual acuity decreased in 58% of eyes. Four eyes (8%) required subsequent penetrating glaucoma procedures. CONCLUSION: This retrospective study suggests that placement of an Ahmed valve can be a safe and effective procedure in the hands of residents under appropriate attending physician supervision. [Ophthalmic Surg Lasers Imaging 2010;41:222–227.]

Purpose To examine the results of same-eye second Ahmed glaucoma drainage device (GDD) insertion in eyes with refractory glaucoma despite previous Ahmed GDD insertion and maximal tolerated medical therapy. Methods Noncomparative retrospective case series. Results Twenty-one patients who had undergone 2 GDD surgeries in the same eye were identified. Following chart review, 19 patients had follow-up of at least 1 year and were included in the analysis. All surgeries involved Ahmed valves. The mean drop in intraocular pressure (IOP) at 12 months and at final follow-up was 8 (43%) and 7.9 mm Hg (42%), respectively. The mean number of glaucoma medications used postoperatively (2.4 at 12 mo and 2.6 at final follow-up) was significantly less than preoperatively (4.1). Although the mean visual acuity was poorer postoperatively, this did not reach statistical significance. Sixteen of the 19 patients (84.2%) were defined as complete or partial success, as they achieved IOP of >/=5 and /=20% decrease on preoperative IOP with or without glaucoma drops. Three patients were considered complete failures at 12 months and final follow-up. There were no significant intraoperative complications. One patient (5.3%) required anterior chamber reformation on day 1 postoperatively. One patient (5.3%) suffered a decrease in vision from 20/70 preoperatively to counting fingers postoperatively owing to corneal decompensation. Conclusions Second Ahmed GDD surgery seems to be a safe and effective option when IOP remains uncontrolled despite previous GDD implantation.

Objetivos: Analizar los resultados a medio plazo de los dispositivos de drenaje para glaucoma (DDG) en cuanto a control de la presión intraocular (PIO), del glaucoma y del mantenimiento de la visión preoperatoria. Métodos: Estudio de cohortes retrospectivo de 86 ojos de 77 pacientes en los que se ha implantado un DDG. Se ha empleado estadística descriptiva y análisis de supervivencia. Resultados: Se han considerado como éxito 53 ojos (61,6%), completo (sin tratamiento) en 34 ojos (39,5%); y relativo (con tratamiento) en 19 ojos (22,1%). Las causas de fracaso han sido: mal control de la PIO en 13 ojos - (15,1%), y complicaciones en 20 ojos (23,2%) con reducción severa o pérdida de visión (extrusión del reservorio, hemorragia supracoroidea, desprendimiento de retina). Se ha obtenido control de la PIO en 66 ojos (76,7%), en 47 de ellos sin tratamiento (54,6%), aunque 13 de estos han sido fracasos por complicaciones. A pesar del control de la PIO, en siete ojos (8,1%) se ha observado progresión del glaucoma. En cuanto a la visión, en 46 ojos (53,5%) se ha mantenido estable y en 40 ha disminuido 3 o más líneas (46,5%), siendo la causa más frecuente la descompensación corneal. En 21 ojos (24,4%) se ha perdido la percepción de la luz, y cuatro ojos (4,6%) han sido eviscerados. Discusión: Los DDG son una opción quirúrgica eficaz para el control de la PIO en ojos con mal pronóstico para la cirugía convencional de glaucoma, pero presentan complicaciones graves y deterioro visual en un porcentaje elevado de casos. Objective: To study the intermediate-term results of glaucoma drainage devices (DDG) with respect to control of intraocular pressure (IOP), control of glaucoma, and maintenance of pre-operative visual acuity. Methods: This was a retrospective cohort study of 86 eyes in 77 patients in whom a DDG was implanted, using descriptive statistics and survival analysis. Results: Success was achieved in 53 eyes (61.6%), complete (without treatment) in 34 eyes (39.5%) and qualified (needing treatment) in 19 eyes (22.1%). In the 33 eyes where the DDG treatment was unsuccessful, poor IOP control occurred in 13 eyes - (15.1%), and complications occurred in 20 eyes (23.2%) resulting in a severe reduction or loss of visual acuity (plate exposure, suprachoroidal hemorrhage, retinal detachment). IOP control was obtained in 66 eyes (76.7%), 47 of them without treatment (54.6%), although on 13 occasions the overall treatment failed due to complications occurring. Despite IOP control, glaucoma progression occurred in 7 eyes (8.1%). Preoperative vision was maintained in 46 eyes (53.5%), but decreased by 3 or more lines in 20 eyes (46.5%); bullous kerathopathy was the most frequent cause of the worsening. Loss of light perception occurred in 21 eyes (24.4%) and 4 eyes (4.6%) were eviscerated. Conclusions: DDG are an effective surgical option for control of IOP when conventional surgery has a poor prognosis, but they are associated with an increased risk of serious complications and loss of visual acuity in a significant proportion of cases.

Objetivo: Comunicar diez casos con retinopatía por descompresión (RDC) después de realizar cirugía intraocular. Métodos: Serie de casos. Nueve sujetos (diez ojos) participaron en el estudio. La RDC se observó posterior a cirugía de trabeculectomía (cuatro ojos), facoemulsificación (tres ojos), colocación de válvula de Ahmed (un ojo), extracción de silicona (un ojo) y vitrectomía (un ojo). Fueron realizados evaluación del fondo de ojo y angiografía fluoresceinica. Resultados: Hemorragias retinianas superficiales, subhialoideas y profundas se desarrollaron en el polo posterior y retina periférica, algunas con centro blanquecino. Nueve (90%) de diez ojos tenían diagnóstico previo de glaucoma; de ellos seis con glaucoma primario de ángulo abierto, dos glaucoma neovascular y un glaucoma secundario por aceite de silicona. El paciente sin glaucoma tenia antecedente de cirugía de catarata y vitrectomía por agujero macular. La presión intraocular (PIO) preoperatoria media fue de 36,6 mm Hg (rango: 15 a 58 mm Hg) con terapia medica máxima en los sujetos con glaucoma. La angiografía fluoresceínica demostró hipofluorescencia durante todo el estudio asociado a hemorragias retinianas superficiales y profundas. En el primer día postoperatorio la agudeza visual disminuyo en mas de 2 líneas ETDRS en todos los casos. Una vitrectomía vía pars plana (VPP) fue realizada en cinco de los ojos. Todos los sujetos después del episodio de RDC, mejoraron la agudeza visual en mas de 2 líneas ETDRS en un promedio de 9 meses de evolución. Conclusiones: Una disminución gradual de la PIO preoperatoria e intraoperatoria es recomendada para evitar esta complicación. La vitrectomía temprana representa un tratamiento útil en algunos casos. Historia previa de glaucoma parece ser un factor de riesgo para el desarrollo de RDC. Objective: To report 10 instances of decompression retinopathy (DCR) developing after intraocular surgery. Methods: This was a case series of 9 patients (10 eyes). Decompression retinopathy occurred after trabeculectomy (4 eyes), phacomulsification (3 eyes), Ahmed valve placement (1 eye), silicone oil removal (1 eye) and vitrectomy (1 eye). Fundus evaluation and fluorescein angiography were performed in all instances. Results: Superficial, subhyaloidal, and deep retinal hemorrhages were noted in the posterior pole and peripheral retina; some of these had a white center. Nine (90%) of 10 eyes had a previous diagnosis of glaucoma, 6 having primary open-angle glaucoma, 2 neovascular glaucoma and 1 secondary glaucoma associated with intravitreal silicone oil. The patient without glaucoma had a history of cataract surgery and a vitrectomy to close a macular hole. The mean preoperative intraocular pressure (IOP) was 36.6 mm Hg (range: 15 to 58 mm Hg) despite maximal medical therapy in those patients with glaucoma. Fluorescein angiography demonstrated hypofluorescence throughout the study associated with superficial, and deep retinal hemorrhages. On the first post-operative day, visual acuity (VA) decreased more than 2 ETDRS lines in all cases. A pars plana vitrectomy (PPV) was performed in 5 eyes. All patients improved more than 2 ETDRS lines at a mean of 9 months after DCR. Conclusions: A gradual decrease of IOP pre-operatively and intra-operatively is recommended in order to avoid this complication. Early vitrectomy represents a useful treatment in many cases. A previous history of glaucoma seems to be an important risk factor for the development of DCR.

PURPOSE. To evaluate the Ahmed valve for decrease elevated pressure associated with black diaphragm lenses for aniridia. METHODS. Drainage devices are useful to obtain good control of intraocular pressure in patients with aniridia and the authors often use them because of the poor results of medical therapy or filtering surgery. However, when the elevated intraocular pressure is associated with black diaphragm lenses for aniridia, most authors decide to carry out a filtering technique. The current authors opted for the implantation of an Ahmed valve in three patients, two with traumatic aniridia and the other with a congenital case. Every patient had a different kind of black diaphragm lens for aniridia. RESULTS. The Ahmed valve controlled the intraocular pressure in levels below 20 mmHg for a follow-up year with no complications derived from its application. CONCLUSIONS. Ahmed valve implantation was the best technique to decrease intraocular pressure in patients with aniridia. The authors have used it successfully for cases with elevated pressure associated with black diaphragm lenses for aniridia. (Eur J Ophthalmol 2007; 17: 437-40)

PURPOSE. Orbital cellulitis (OC) as a complication of implanted aqueous drainage devices (ADD) for glaucoma is an uncommon phenomenon. The authors report two cases of infectious OC in patients with a history of congenital glaucoma and placement of ADD. METHODS. Clinical records of two patients with ADD who subsequently developed OC were reviewed for presenting symptoms, signs, medical and surgical management, and final outcome. RESULTS. In the first case, an 11-year-old girl was found to have evidence of OC 9 days after the implantation of a Krupin-Denver valve. In the second case, a 14-month-old girl presented with similar findings 8 months following the implantation of an Ahmed valve. In both cases, ultrasonography demonstrated evidence of orbital inflammation and in one patient computed tomography scan was consistent with OC. In both cases, prompt institution of systemic antibiotics resulted in resolution of the clinical signs. In the first case, diagnosis was made early and the patient was promptly treated with systemic antibiotics, resulting in resolution of her symptoms without the need for implant removal. Because of the delayed presentation in the second case, an infected implant had to be removed to achieve resolution in addition to aggressive treatment with antibiotics. CONCLUSIONS. Although rare, infectious OC may occur following implantation of ADD. Early recognition and intervention may be required to achieve resolution of the infection. (Eur J Ophthalmol 2007; 17: 136-40)

Purpose The aim of the study was to evaluate the efficacy and safety of decapsulation of the fibrous capsule around the valve body versus valve reimplantation in another site in refractory glaucoma cases. Patients and methods We studied 25 cases with refractory glaucoma that had been implanted with an Ahmed glaucoma valve; their intraocular pressure (IOP) was greater than 21 mmHg and had undergone additional maximum topical antiglaucoma therapy. Patients were divided into two groups according to the surgical treatment that had been performed: group I included 12 eyes that had been treated by surgical decapsulation of the cyst around the valve body without removal of the valve and group II included 13 eyes treated by removal of the valve and reimplantation in another quadrant of the eye. Results Of the 25 patients included in the study, 15 were male and 10 were female, with a mean age of 19.2 ± 9.2 years in group I and 22.1 ± 10.3 years in group II. Recurrent congenital glaucoma was the most common preoperative diagnosis in both groups (50 and 53.8% in groups I and II, respectively). There was no statistically significant difference between the two groups regarding preoperative patient demographic characteristics (P < 0.05). The surgical results revealed that the mean operation time was significantly lower in group I than in group II (30 ± 12 and 45 ± 13.5 min, respectively; P = 0.023). However, there were no statistically significant differences in the success (complete and partial) and failure rates between the two groups (P < 0.05). There was marked reduction in IOP from preoperative values in both groups but there were no significant differences in IOP levels between the two groups over the follow-up visits. Tube-related complications occurred in group II only and included corneal tube touch in one (7.7%) case and erosion of the tube covering in two (15.4%) cases. One of them developed endophthalmitis and then lost the perception of light (PL) and ended in phthisis bulbi. Recurrence of encapsulation occurred more in group I (three cases, 25%) than in group II (two cases, 15.4%), after a mean postoperative time of 23 ± 2 weeks. The incidence of valve re-encapsulation was statistically insignificant between the two groups (P = 0.09). Conclusion Both surgical techniques were effective in controlling IOP in cases with encapsulated Ahmed valve; however, the decapsulation technique was simpler with shorter operation time and no probability for tube-related complications. Although the other technique of valve reimplantation had a longer operation time and more tube-related complications, it was associated with less incidence of re-encapsulation. However, larger multicenter studies with longer follow-up are needed for validation of these treatment strategies.

espanolCaso Clinico: Mujer de 71 anos, con historia de glaucoma del afaquico en ojo derecho que requirio implantacion de una valvula de Ahmed. El postoperatorio evoluciono favorablemente, con una AV de 0,5, y presion intraocular de 12 mmHg en tratamiento con tartrato de brimonidina 0,2%. Acudio a los 9 meses con un cuadro de tres dias de evolucion compatible con conjuntivitis, por lo que se instauraron medidas higienicas y tratamiento antibiotico topico. Cuatro dias despues desarrollo un cuadro de endoftalmitis aguda y se comenzo tratamiento antibiotico topico, sistemico e intravitreo de vancomicina y ceftazidima. El cultivo fue positivo para Haemophilus influenzae. A las 72 horas, se procedio a retirar la vavula de Ahmed, a pesar de lo cual, siguio evolucionando de forma negativa por lo que se decidio la evisceracion del ojo derecho. Discusion: La endoftalmitis tras dispositivo de drenaje es un proceso infrecuente. El mecanismo patogenico mas probable es la migracion del microorganismo a traves de una erosion conjuntival provocada por el tubo valvular. El pronostico visual es variable, lograndose los mejores resultados cuando la retirada del dispositivo se produce dentro de las primeras 24-48 horas. EnglishCase report: A 71-year-old woman with a history of aphakic glaucoma underwent implantation of an Ahmed valve and scleral grafting in her right eye. Postoperative visual acuity was 0.5 and intraocular pressure was 12 mmHg during treatment with brimonidine tartrate (0.2%). Nine months after implantation she suffered a conjunctival infection which was treated with hygienic measures and topical antibiotic therapy. Four days later, she developed an endophthalmitis which was treated with topical, intravitreous and intravenous vancomycin and ceftazidime. The Ahmed drainage implant was replaced at 72 hours. Laboratory culture yielded Haemophilus influenzae. Four days later, the eye was enucleated. Discussion: Endophthalmitis is an uncommon complication of glaucoma drainage implant surgery. Exposure of the drainage tube represents the greatest risk factor for this condition. Removal of the implant in the first 24 hours is recommended if a good visual prognosis is to be achieved.

PURPOSE To compare the efficacy of intraocular pressure (IOP) control of the Baerveldt-350 implant with tube ligature and the Ahmed valve in patients with refractory glaucoma. PATIENTS AND METHODS Four hundred seventy glaucoma drainage device procedures from July 1995 to July 2001 (6 years) were reviewed retrospectively. Thirty-two cases of Baerveldt-350 implantation performed in patients with glaucoma refractory to medical treatment and filtering procedures, without previous drainage device or cyclodestructive procedures, and with a minimum of 1-year follow-up were identified. Thirty-two cases of Ahmed valve implantation were matched case by case with 32 Baerveldt-350 cases for age, race, gender, glaucoma subtype, previous ocular history, preoperative IOP, and surgeon who performed the implantation. The two groups were compared for IOP control, visual outcome, complication rate, and surgical success rate. Surgical success rate was defined as an IOP reduction greater than or equal to 30% and final IOP more than 5 mm Hg and less than 22 mm Hg, without devastating complications. RESULTS Over a follow-up period of 1 year, no statistically significant differences were detected between the Baerveldt-350 implant versus Ahmed valve for IOP control (12.1 +/- 5.3 mm Hg vs. 13.6 +/- 5.6 mm Hg respectively, at a power of 90% to detect a difference of 3.2 mm Hg between the two groups and P = 0.05), surgical success rate (65.6% vs. 65.6% respectively, complete and qualified combined), postoperative hypotony rate (37.5% vs. 34.4% respectively), and visual acuity changes of more than 1 line in Snellen visual acuity (43.3% vs. 29.0% respectively). CONCLUSION In a case-controlled comparison, the Baerveldt-350 implant and the Ahmed valve had similar IOP control and surgical outcomes in patients with refractory glaucoma at 1-year follow-up.

espanolCaso clinico: Mujer de 16 anos afecta de glaucoma inflamatorio secundario a artritis reumatoide juvenil, intervenida con exito con una valvula de Ahmed. Dos anos despues presenta un aumento severo de presion intraocular (PIO) por retraccion y migracion anterior del tubo, por lo que se reinterviene colocando un extensor del tubo, obteniendo de nuevo un buen control de la PIO. Discusion: Si la longitud del tubo implantado es insuficiente hay tres opciones terapeuticas: utilizar un espaciador, insertar el tubo via pars plana o colocar un nuevo implante. Se han descrito diversos espaciadores (tubos de silastic, angiocateteres, etc.), pero la disponibilidad de un extensor especialmente disenado para la valvula de Ahmed, simplifica la cirugia, permitiendo dejar la valvula en su localizacion original, minimizando el riesgo de desplazamientos ulteriores. EnglishCase report: We describe the case of a 16 year-old woman, with inflammatory glaucoma secondary to juvenile rheumatic arthritis, successfully treated by Ahmed glaucoma valve implant. Two years later, a severe increase of intraocular pressure related to anterior tube migration occurred. The Ahmed valve tube extender was successfully used to lengthen the tube. Discussion: If the tube length is too short to reintroduce it into the eye, there are three surgical options: to use a tube extender, to insert the tube via the pars plana or to insert a new drainage implant. A piece of an angiocatheter or a silastic tube have been used for lengthening the tube of the valve implant; however the Ahmed valve tube extender design makes surgery easier and allows keeping the valve in the original place, minimizing the risk of postoperative migration.

Caso clínico: Mujer de 16 años afecta de glaucoma inflamatorio secundario a artritis reumatoide juvenil, intervenida con éxito con una válvula de Ahmed. Dos años después presenta un aumento severo de presión intraocular (PIO) por retracción y migración anterior del tubo, por lo que se reinterviene colocando un extensor del tubo, obteniendo de nuevo un buen control de la PIO. Discusión: Si la longitud del tubo implantado es insuficiente hay tres opciones terapéuticas: utilizar un espaciador, insertar el tubo vía pars plana o colocar un nuevo implante. Se han descrito diversos espaciadores (tubos de silastic, angiocateteres, etc.), pero la disponibilidad de un extensor especialmente diseñado para la válvula de Ahmed, simplifica la cirugía, permitiendo dejar la válvula en su localización original, minimizando el riesgo de desplazamientos ulteriores. Case report: We describe the case of a 16 year-old woman, with inflammatory glaucoma secondary to juvenile rheumatic arthritis, successfully treated by Ahmed glaucoma valve implant. Two years later, a severe increase of intraocular pressure related to anterior tube migration occurred. The Ahmed valve tube extender was successfully used to lengthen the tube. Discussion: If the tube length is too short to reintroduce it into the eye, there are three surgical options: to use a tube extender, to insert the tube via the pars plana or to insert a new drainage implant. A piece of an angiocatheter or a silastic tube have been used for lengthening the tube of the valve implant; however the Ahmed valve tube extender design makes surgery easier and allows keeping the valve in the original place, minimizing the risk of postoperative migration.

Angela V Turalba,1,2 Louis R Pasquale1,2 1Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; 2Department of Ophthalmology, Harvard Medical School, Boston, MA, USA Objective: To evaluate intraoperative subtenon triamcinolone acetonide (TA) as an adjunct to Ahmed glaucoma valve (AGV) implantation. Design: Retrospective comparative case series. Participants: Forty-two consecutive cases of uncontrolled glaucoma undergoing AGV implantation: 19eyes receiving intraoperative subtenon TA and 23eyes that did not receive TA.Methods: A retrospective chart review was performed on consecutive pseudophakic adult patients with uncontrolled glaucoma undergoing AGV with and without intraoperative subtenon TA injection by a single surgeon. Clinical data were collected from 42eyes and analyzed for the first 6months after surgery.Main outcome measures: Primary outcomes included intraocular pressure (IOP) and number of glaucoma medications prior to and after AGV implantation. The hypertensive phase (HP) was defined as an IOP measurement of greater than 21mmHg (with or without medications) during the 6-month postoperative period that was not a result of tube obstruction, retraction, or malfunction. Postoperative complications and visual acuity were analyzed as secondary outcome measures. Results: Five out of 19(26%) TA cases and 12out of 23(52%) non-TA cases developed the HP (P=0.027). Mean IOP (14.2±4.6in TA cases versus [vs] 14.7±5.0mmHg in non-TA cases; P=0.78), and number of glaucoma medications needed (1.8±1.3in TA cases vs 1.6±1.1in the comparison group; P=0.65) were similar between both groups at 6months. Although rates of serious complications did not differ between the groups (13% in the TA group vs 16% in the non-TA group), early tube erosion (n=1) and bacterial endophthalmitis (n=1) were noted with TA but not in the non-TA group.Conclusions: Subtenon TA injection during AGV implantation may decrease the occurrence of the HP but does not alter the ultimate IOP outcome and may pose increased risk of serious complications within the first 6months of surgery. Keywords: Ahmed valve, hypertensive phase, triamcinolone

We read with interest the comparison by Tran et al of success rates of Ahmed valve implantation versus trabeculectomy in open-angle glaucoma.1 As the authors know, the retrospective nature of the study may result in selection bias. The validity of the comparison depends critically on the two groups of patients being similar preoperatively, and we feel this may not have been adequately shown. The mean baseline visual acuities (table 1) of the …