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Abstract #8655 Published in IGR 5-1
Molteno implant and refractory glaucoma: evaluation of postoperative IOP control and complications with a modified surgical procedure
Hamard P; Koison-Dayma K; Kopel J; Hamard H; Baudouin CJournal Français d'Ophtalmologie 2003; 26: 15-23
BACKGROUND: Management of refractory glaucoma is difficult because classic medical and surgical treatments are ineffective in controlling highly elevated intraocular pressure (IOP). Drainage implands are an alternative to cyclodestructive procedures in refractory glaucoma. The double-plate Molteno implant, a tube linked to two polypropylene plates, allows aqueous humor drainage from the anterior chamber towards the posterior subconjunctival spaces. The main postoperative complication is severe hypotony, which is potentially responsible for a decrease in visual acuity in cases of advanced glaucoma. Surgical modifications such as external tube occlusion can reduce postoperative hypotony. However, tube occlusion may lead to transient postoperative hypertony. This retrospective study reports on double-plate Molteno implantation with intraoperative external tube occlusion associated with trabeculectomy in some cases. MATERIAL AND METHODS: Thirty eyes of 13 patients with refractory glaucoma were included in the study (five cases of open angle glaucoma, seven of secondary glaucoma, one of primary congenital glaucoma). All had ocular hypertony despite maximal tolerable medical treatment, 84.5% had previously undergone trabeculectomy with mitomycin (one to five procedures), and 61% had undergone cyclophotocoagulation (one to four sessions). All had undergone double-plate Molteno implantation with external tube occlusion between 1993 and 2001. In three cases, intraoperative trabeculectomy was also performed. Visual acuity, IOP, relevant medical treatment and potential complications were reported at each follow-up visit. Complete success was defined as IOP of less than 21 mmHg without treatment, while iOP control with medical treatment was considered a relative success. RESULTS: Mean (± SD) follow-up was 2.9 ± 2.1 years (range, nine months to eight years). Mean (± SD) initial and final IOP was 35.2 ± 7 and 17.1 ± 5 mmHg, respectively, i.e., a 50% decrease in IOP. Mean (± SD) initial and final medical treatments were 4.3 ± 1.5 (61%)with systemic acetazolamide) and 1.3 ± 1.4 (without acetazolamide), respectively. The complete success rate was 38.5% and relative success 92.3%. Immediate postoperative hypertony occurred in 60% of the cases with external tube occlusion alone (ten cases). This hypertony was controlled with medical treatment in two-thirds of the cases, but required surgical reintervention in one-third of the cases. For patients with intraoperative trabeculectomy (three cases), immediate postoperative IOP without medical treatment was 2, 5, and 8 mmHg, respectively. Complications reported were flat anterior chamber (one case), decrease in visual acuity (four cases), lens opacification (one case), macular edema (one case), corneal edema (two cases: one transient, one corneal decompensation), and long-term refractory hypertony (one case). CONCLUSIONS: The double-plate Molteno implant is effective in controlling IOP in refractory glaucoma. External tube occlusion prevents complications related to excessive filtration; however, it may lead to transient postoperative hypertony. This hypertony can be avoided with simultaneous trabeculectomy is performed. Corneal decompensation remains the major complication of this surgical procedure.
Dr. P. Hamard, Service d'Ophtalmologie, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, 28 rue de Chareton, 75012 Paris, France. pascale-hamard@quinze-vingts.fr
Classification:
12.8.2 With tube implant or other drainage devices (Part of: 12 Surgical treatment > 12.8 Filtering surgery)
