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Editors Selection IGR 19-4

Surgical Treatment: Baerveldt Implant and Endothelial Cell Loss

Comment by Robert Feldman on:

78195 Prospective cohort study of corneal endothelial cell loss after Baerveldt glaucoma implantation, Iwasaki K; Arimura S; Takihara Y et al., PLoS ONE, 2018; 13: e0201342

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Aqueous shunt surgery is an increasingly prevalent treatment option for glaucoma. Decrease in endothelial cell density (ECD) is a serious and unfortunately common complication of this procedure. Iwasaki et al. describe a prospective study evaluating changes in ECD after Baerveldt glaucoma implantation with tube insertion in the anterior chamber versus the pars plana. The study also analyzed whether tube position affected ECD with anterior segment optical coherence tomography (ASOCT).

This study included 59 eyes with Baerveldt glaucoma implantation, with the tube inserted in the anterior chamber in 45 eyes and the pars plana in 14 eyes. Included patients were 20 years of age or older and had a diagnosis of refractory glaucoma. Eyes where the primary surgery was a Baerveldt implant, with a previous aqueous shunt, or with congenital glaucoma were excluded. Baerveldt implants with a 350-mm² plate were used. ECD was calculated overall, in the central cornea, and for the quadrants where the tube was inserted and contralateral to the tube. ASOCT was used to image the tube at one month postoperatively, with tube-cornea distance and tube-cornea angle calculated by the instrument's software.

Forty-one eyes had adequate corneal ECD measurements from all follow-up visits. ECD overall decreased significantly from baseline at three months (5.2%), six months (6.4%), and 12 months (9.2%) after surgery, with decreases in the tube insertion quadrant at all postoperative visits and at six months and 12 months postoperatively in the central and contralateral to the tube quadrants. In 32 eyes with anterior chamber tube insertion, corneal ECD decreased significantly from baseline in the tube insertion quadrant at 3 months (9.6%), six months (10.7%), and 12 months (9.2%) postoperatively. ECD at the central cornea decreased significantly at six months (7.2%) and 12 months (12.1%) postoperatively; contralateral cornea ECD decreased significantly at only 12 months (10.3%) postoperatively. Eyes with pars plana tube insertion had no decrease in ECD density at any corneal areas postoperatively.

ASOCT analysis found that the tube-cornea angle was negatively correlated with the decrease in ECD at the tube insertion quadrant and central cornea only. No correlation was found with tube-cornea distance and ECD decrease. Multivariate analysis showed that exfoliation glaucoma and narrow tube-cornea angle were associated with severe ECD decrease.

This study analyzes the relationship between ECD decrease and Baerveldt implantation with tubes in the anterior chamber and pars plana prospectively. It is a good start at determining the risk factors for this complication.

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