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Editors Selection IGR 7-3

Surgical treatment: Molteno implants in yougsters

Comment by Donald Minckler on:

13146 Otago Glaucoma Surgery Outcome Study: follow-up of young patients who underwent Molteno implant surgery, Ah-Chan JJ; Molteno AC; Bevin TH et al., Ophthalmology, 2005; 112: 2137-2142

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Ah-Chan et al. (1086) report in a prospective non-comparative case series from New Zealand reports outcomes to 25 years among 18 females and 37 males, aged 9-49, with non-neovascular glaucomas after Molteno implants between 1976-2003. The case mix included uveitis (12), congenital anomalies including congenital cataract (12), pigment dispersion (1), primary juvenile glaucoma (12), ICE (2), and trauma (16). All eyes had undergone prior glaucoma or cataract surgeries. Pre-operative visions ranged from 20/15 to light perception. Outcome data analysis included survival curves which did not differ comparing all eyes treated to the group with only the first eye treated. Seven patients had bilateral surgeries and three repeat Molteno implants. Seven eyes had single-plate (five as two-stage procedures without polygalactin tie) and 48 eyes received double-plates (27 as single-stage procedures with polygalactin ties - 3 with ligature of the interconnecting tube). The authors concluded that 71% (95% CI, 0.58 - 0.85) of patients at five, ten, and 15 years postoperatively were successfully controlled (IOP ≤ 21 mmHg). Five eyes of four patients were lost to follow-up, and eight patients remained under follow-up through 25 years. The mean preoperative IOP was 29.7 + 10.6 mmHg (average of 2.1 medications) and the mean IOP at one year 17.9 + 4.8 mmHg (average of 0.8 medications). Vision was maintained or improved in 21 eyes and deteriorated in 17. One eye went phthisical and five were enucleated. Postoperative complications were relatively few and did not include infection. Pars plana insertion was not utilized. This report is of interest to all who manage congenital and complex adult glaucomas. The follow-up far exceeds that in other reports and the success rates are equivalent or better than those reported by others with alternative aqueous shunts. The small numbers of cases in various sub-groups makes stratification of success by diagnostic categories and by surgical technique relatively meaningless. However the results reinforce the wide applicability of Molteno implants to surgical management of complicated glaucomas.

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