Eur J Ophthalmol 2012 ; 22 ( 1): 90-94

DOI: 10.5301/ejo.5000027

ORIGINAL ARTICLE

23-Gauge pars plana vitrectomy with pars plana Baerveldt tube placement for refractory glaucoma
Anton M. Kolomeyer, Robert D. Fechtner, Marco A. Zarbin, Neelakshi Bhagat
The Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey - USA
The Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey - USA The Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey - USA The Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey - USA

purpose. To describe a case series of combined 23-gauge vitrectomy and pars plana Baerveldt tube insertion for intraocular pressure (IOP) control in eyes with glaucoma resistant to maximum tolerated medical therapy and/or having failed previous IOP-lowering procedures. methods. Eight consecutive patients (8 eyes) undergoing a combined procedure were identified and included in this study. Outcome measures included preoperative and final best-corrected visual acuity (VA), IOP, number of glaucoma medications, and complications. Changes in IOP and glaucoma medications were compared by a paired t test. A Kaplan-Meier survival curve was constructed to evaluate IOP control as a function of time. results. Mean patient age was 70.9 years while the mean follow-up time was 12.1 months. Open angle glaucoma was diagnosed in 5 (68%) eyes. Six (75%) eyes were pseudophakic. All eyes received a 250-mm2 pars plana Baerveldt tube. Vision remained the same or improved in 6 (75%) eyes. Mean preoperative IOP and number of glaucoma medications were significantly (p<0.05) reduced by the combined procedure. Visual acuity of 5 (63%) eyes improved or remained unchanged. Six (75%) eyes encountered minor complications not requiring a return to the operating room. One (13%) eye underwent drainage of hemorrhagic choroidals on postoperative day 12. ConClusions. A combined 23-gauge vitrectomy and pars plana Baerveldt tube insertion could be considered a useful procedure in reducing IOP and the number of glaucoma medications in eyes with refractory glaucoma. Key Words. 23-Gauge pars plana vitrectomy, Baerveldt drainage device, Refractory glaucoma
Accepted: June 21, 2011

INTRODUCTION
Glaucoma drainage implants (GDIs) are indicated for the treatment of glaucoma refractory to intraocular pressure (IOP)lowering measures, including medication and surgical procedures (1, 2). While these devices usually are placed in the anterior chamber, indications for pars plana placement of GDIs include corneal disease, anterior chamber and/or angle abnormalities, angle neovascularization, failure of a GDI placed in the anterior chamber, and others (3-5). Pars plana GDI placement requires a concurrent pars 90

plana vitrectomy (PPV) to prevent tube occlusion (6). Numerous studies have shown a beneficial effect of combined 20-gauge PPV-GDI placement on the reduction of IOP and the number of required glaucoma medications in eyes with refractory glaucoma (4, 7-9). Studies describing the combination of small-gauge (i.e., 23- or 25-gauge) vitrectomy with pars plana GDI placement to control IOP in eyes with uncontrolled glaucoma are emerging (10, 11). Some benefits of small-gauge vs 20-gauge vitrectomy include increased patient comfort, reduced tissue trauma and inflammation, reduced flow rate of intraocular fluid,

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decreased conjunctival scarring, faster visual recovery, and decreased operative time (12, 13). We report our experience with 8 eyes of 8 patients who underwent a 23-gauge PPV with 250 mm2 Baerveldt tube placement (herein referred to as combined procedure) and our evaluation of surgical complications and functional outcomes.

METHODS
Eight consecutive patients who underwent a combined 23-gauge PPV and pars plana Baerveldt tube placement at the Institute of Ophthalmology and Visual ScienceNew Jersey Medical School between 2005 and 2010 were identified. None of the patients had undergone a previous PPV. For each patient, demographics, ocular characteristics, preoperative and final best corrected visual acuity (VA), IOP, number of glaucoma medications used, and complications were noted. The surgeries were performed by one retina specialist (N.B.) and one glaucoma specialist (R.D.F.). Twenty-three gauge PPV followed by a 250 mm2 Baerveldt drainage device placement (Abbott Medical Optics, Inc., Abbott Park, IL) was performed in all eyes. The procedure consisted of a superior and temporal conjunctival peritomy followed by anchoring of the implant to the episclera in the superotemporal quadrant (8-10 mm posterior to the limbus). For the vitrectomy, the sclerotomy sites were beveled and biplanar except for the superotemporal one, which was created perpendicular to the sclera. This superotemporal sclerotomy was used for Baerveldt tube placement. All sclerotomies (except for the superotemporal one) were closed using one 9-0 Vicryl suture. The conjunctiva over the non-Baerveldt sclerotomy sites was barely disturbed with this technique and was sutured with the sclerotomy at the end of the surgery, while the conjunctiva over the temporal sclerotomy was undermined and draped back before the PPV to place the Baerveldt tube. The 4-0 Prolene stents were placed in the tube, which was ligated with an 8-0 Vicryl suture near the tube-plate junction (in 3 [38%] eyes under the discretion of the surgeon). Pericardium or an irradiated scleral graft was used to cover the tube insertion site. Final vs preoperative VA was considered improved if it increased by 2 or more Snellen lines or one low-vision category, unchanged if it was within 2 Snellen lines or same low-vision category, and decreased if it worsened by 2 or

Fig. 1 - Kaplan-Meier survival graph of the overall success rate (median, 12.1 months; 95% confidence interval 6-13 months) for 8 eyes. Success rate was defined as the fraction of patients with intraocular pressure of 6-21 mmHg, with or without medications, without the need for glaucoma reoperation, progression to no light perception, phthisis, or enucleation.

more Snellen lines or one low-vision category. Definitions of success, qualified success, qualified failure, and failure were used as previously defined in the literature (4). Briefly, success was defined as IOP 6-21 mmHg without medication; qualified success as IOP 6-21 mmHg on medication; qualified failure as IOP >22 on medication; and failure as IOP <6 mm Hg, IOP >22 mmHg with a need for glaucoma reoperation, progression to no light perception VA, development of phthisis, or need for enucleation. Hypotony was defined as IOP <6 mm Hg. Final vs preoperative IOP and the number of glaucoma medications were evaluated for statistically significant change (p<0.05) using a paired t test after passing the ShapiroWilks normality test and the Equal Variance Test (SigmaPlot 11, Systat Software, Inc., San Jose, CA). Kaplan-Meier survival curves were constructed to evaluate long-term IOP control using JMP statistical software (version 9; SAS Institute Inc., Cary, NC).

RESULTS
Patient characteristics are presented in Table I. Mean SD patient age was 70.923.1 years (range 19-97 years). Mean SD follow-up period was 12.16.4 months (range 6-27 mon91

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TABLE I - PATIENT DEMOGRAPHICS

Case no. A/G/E Glaucoma type Lens status Indications Baerveldt Follow- Preop Postop Preop Postop Final Preop no. Final no. Complications for combined tube up, mo BCVA BCVA IOP day 1 IOP glaucoma glaucoma procedure ligated (mmHg) IOP (mmHg) meds meds (mmHg) PKP, BK, aphakia Angle closure PKP Vitreous prolapse Yes Yes No No 10 9 13 10 20/200 20/80 20/50 20/150 29 22 16 27 22 26 6 2 20 12 13 13 3 5 5 2 2 5 3 0 None Choroidal detachmenta None Transient hypotony, choroidal detachment Transient hypotony, corneal edema Vitreous hemorrhage, intraretinal hemorrhage, decompression retinopathy Transient hypotony, choroidal detachment Hemorrhagic choroidals,b decompression retinopathy, intraretinal hemorrhage

1 2 3 4

97/F/AA 78/M/C 66/F/C 75/F/C

POAG POAG AOAG POAG

Aphakic PCIOL PCIOL PCIOL

20/200 20/60 20/50 20/40

67/F/H

ACG

ACIOL

Synechial angle closure, BK Aphakia

Yes

27

CF 4ft

HM

37

15

19/M/C

Traumatic

Aphakic

No

HM

20/60

38

14

13

83/M/C

POAG

PCIOL

Failed AC shunt

No

13

CF 8ft

HM

29

14

82/F/H

Uveitic

PCIOL

Shallow AC, vitreous at pupil margin

No

20/40

20/60

35

42

10

A/G/E = age/gender/ethnicity; AA = African American; AC = anterior chamber; ACG = angle closure glaucoma; ACIOL = anterior chamber intraocular lens; AOAG = advanced open angle glaucoma; BCVA = best-corrected visual acuity; BK = band keratopathy; C = Caucasian; CF = finger counting; H = Hispanic; HM = hand motions; IOP = intraocular pressure; PCIOL = posterior chamber intraocular lens; PKP = penetrating keratoplasty; POAG = primary open angle glaucoma. a Stent was removed on postoperative day 32 for persistently high IOP. b Patient underwent choroidal drainage on postoperative day 12.

ths). All eyes received a 250-mm2 Baerveldt drainage tube. Mean SD preoperative IOP of 29.17.6 mmHg (range 16-38 mmHg) was reduced to a mean SD final IOP of 13.82.9 mmHg (range 10-20 mmHg), while mean SD number of glaucoma medications was reduced from 3.91.1 (range 2-5) preoperatively to 1.91.6 (range 0-3) at last follow-up. Both of these reductions were statistically significant (p<0.05). Kaplan-Meier survival curve analysis of IOP pressure control for all eyes is shown in Figure 1. The median period of successful IOP control was 12.1 months (95% CI 6-13 months). Two (25%) eyes were a complete success (IOP 13 and 14 mmHg) and 6 (75%) were a qualified success (mean SD IOP of 13.83.4 mmHg on mean SD 2.51.4 glaucoma medications). Preoperative vs final 92

VA improved or remained unchanged in 5 (63%) eyes and decreased in 3 (37%) eyes. Six (75%) eyes developed mild self-resolving complications and 1 (13%) eye required a return to the operating room. Hypotony (IOP <6 mmHg) developed in 3 (38%) eyes. It was associated with shallow peripheral serous choroidals on postoperative day 1 in 2 eyes in which the Baerveldt tube was not ligated. These resolved as the IOP normalized within a week. No sclerotomy leaks were identified in any eye. The pressures normalized in all eyes within a week. At last follow-up, the IOPs for all these eyes were controlled with or without glaucoma medications. Two (25%) eyes were diagnosed with decompression retinopathy on postoperative day 1 with intraretinal hemor-

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rhages that resolved slowly over 4 months. Both eyes had an unligated Baerveldt tube. One (13%) eye had mild VH on postoperative day 1 that resolved spontaneously within a few weeks. Another eye (13%), with a prior history of cornea problems, developed progressive corneal edema during the second postoperative month. One month after the combined surgery, a stent was removed in an eye due to persistently high IOP. A week later, the IOP decreased to 6 mmHg and the eye developed peripheral serous choroidal detachment, which resolved within a week. The final IOP in this eye was 12 mmHg on 5 glaucoma medications. Extensive, nonappositional hemorrhagic choroidals were identified in 1 (13%) eye on postoperative day 1 with an IOP of 42 mmHg. No choroidals had been noted at the end of the surgery; the Baerveldt tube was not ligated intraoperatively in this eye. This complication was treated successfully with choroidal drainage on postoperative day 12. At last follow-up, this eye had an IOP of 10 mmHg on one glaucoma medication and 20/60 visual acuity.

DISCUSSION
In the present study of 8 eyes, final vs preoperative IOP and number of glaucoma medications were reduced significantly (p < 0.05). The IOP in all 8 eyes was controlled successfully for a median period of 12.1 months (range 6-13 months). Visual acuity remained unchanged or improved in 5/8 (68%) eyes. Only 1 (13%) eye required a return to the operating room for drainage of hemorrhagic choroidals. Overall, our functional results are similar to those of other studies on combined 20-gauge or small-gauge PPV-GDI procedures (4, 7-11). At last recorded follow-up visit, all 8 eyes had an IOP <21 mm Hg. Two (25%) of these did not require any glaucoma medications. Six (75%) eyes used a mean of 2.5 glaucoma medications, with 2 (25%) eyes needing >2 glaucoma medications. Seven (88%) of 8 eyes used a smaller number of glaucoma medications at the final vs preoperative visit. Two series of small gauge PPV-GDI combined procedures have been reported. Reichstein et al (11), describing 10 eyes undergoing combined 25-gauge PPV and AhmedFP7 (n=8) or 350 mm2 Baerveldt (n=2) posterior tube shunt placement, reported corneal edema (n=2 [20%]) as the most common complication, while none of the eyes developed hypotony, endophthalmitis, or vitreous occluding

the tube. Recchia et al (10) described 29 eyes undergoing combined 23-gauge PPV with Ahmed-FP7 or 350 mm2 Baerveldt drainage device placement. Only 13 (45%) eyes had the GDI tube in the vitreous cavity. Irrespective of the GDI location, the reported complications in the 29 eyes included 5 (17%) cases of corneal edema, 4 (14%) eyes requiring additional IOP-lowering procedures, and 1 (3.4%) eye with vitreous hemorrhage and choroidal folds resolving in postoperative week 1. As in the study by Reichstein et al (11), there were no cases of hypotony, endophthalmitis, retinal detachment, or vitreous tube occlusion. In the above-described series, both valved (Ahmed) and non-valved (Baerveldt) GDIs were used. All Baerveldt tubes were initially ligated in the series by Reichstein and associates but the ligation status is unknown in the series by Recchia and coworkers (10, 11). The differences in location of GDI placement, types of GDIs used, and status of Baerveldt tube ligation in these studies vs ours make clinical comparisons difficult. The most common complications encountered in our series were 3 (38%) eyes with transient hypotony (2 of which were associated with choroidal detachment in the 2 eyes in which the GDI tube was not ligated) and 2 (25%) eyes with shallow, peripheral choroidal detachments (1 eye developed serous choroidals at day 32 after the stent was removed). Hypotony resolved within a week and choroidals within 3 weeks in all cases. Corneal edema was seen in 1 (13%) eye, which may have been a result of progressive preexisting corneal disease. Additional commonly reported complications of combined PPV-GDI procedures such as retinal tears and detachment, vitreous tube occlusion, cystoid macular edema, diplopia, and others were not observed in our study (4, 8, 14). The strengths of this study include the facts that the same retinal and glaucoma surgeon operated on all eyes, and identical vitrectomy procedure and Baerveldt tube size were employed for all eyes. Limitations of this study include its retrospective design, small sample size, heterogeneity of glaucomatous disease, corneal and anterior segment abnormalities, and lack of controls. In this study we showed that combined 23-gauge pars plana vitrectomy and vitreous cavity placement of a 250 mm2 Baerveldt tube can effectively reduce IOP and the number of required glaucoma medications in eyes with corneal and/or anterior segment abnormalities and glaucoma refractory to medical and/or previous surgical therapy. 93

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Supported in part by Research to Prevent Blindness, Inc., the New Jersey Lions Eye Research Foundation, the Eye Institute of New Jersey. The authors report no proprietary interest or financial support. Address for correspondence: Neelakshi Bhagat, MD, MPH The Institute of Ophthalmology and Visual Science New Jersey Medical School Doctors Office Center, Suite 6100 90 Bergen St. Newark, NJ 07013 bhagatne@umdnj.edu

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