Jornal de Oftalmologia Clínica e Experimental
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Abstrato

Clinical Audit of Glaucoma Drainage Device Insertions for the Treatment of Refractory Glaucoma in the Setting of Corneal Transplant

Chian Chiang Nicholas Chow

Purpose: To evaluate clinical outcomes of Glaucoma Drainage Device (GDD) insertions at three anatomical sites; Anterior Chamber (AC), Ciliary Sulcus (CS) and Pars Plana (PP), with respect to various corneal transplantation techniques; Penetrating Keratoplasty (PK), Deep Anterior Lamellar Keratoplasty (DALK), Descemet’s Membrane Endothelial Keratoplasty (DMEK) and Descemet’s Stripping Endothelial Keratoplasty (DSEK). Design: Single-centre, nonrandomized retrospective case series. Participants: Patients aged 18 years or older who had GDD insertion at Sydney Eye Hospital (SEH) between 2006 to 2015, and who also had a corneal transplant at any time period in the same eye. Methods: Patients in this study either had a Baerveldt 101-350 GDD or a Molteno-R2 GDD placed into one of the anterior chamber (AC), ciliary sulcus (CS) or pars plana (PP) from 2006 to 2015. GDD data was combined with the type of corneal transplant performed, either penetrating keratoplasty (PK) or endothelial keratoplasty (DSEK/DMEK), at any time before or after GDD insertion. Patient data was collected preoperatively for each procedure and postoperatively up to a total of five years where possible. Surgical outcome measures were recorded in the form of intraocular pressure (IOP), visual acuity (VA), number of glaucoma medications and surgical complications at each follow-up visit. The timing between GDD insertion and corneal transplantation along with method of GDD stent occlusion, use of antimetabolites and total follow-up duration was noted as well. Results: 25 eyes from 25 patient records that met study inclusion criteria were identified. All GDD insertions at the three sites (AC/CS/PP) resulted in a postoperative reduction in IOP. Mean IOP pre-GDD insertion was 25.8 mmHg and mean IOP post-GDD insertion at one year was 13.0 mmHg. The number of glaucoma medications also decreased post-GDD insertion. CS-GDD with keratoplasty had the largest IOP reduction post-GDD insertion on the least number of glaucoma medications. Visual acuity was also best preserved in this group. Overall graft failure rate at six months and one year was 16.7% and 20.8% respectively. Corneal decompensation was highest in AC-GDDs (43%). GDD with endothelial grafts (DSEK/DMEK) had higher graft failure rates in the first year of follow-up compared to PK (37.5% versus 13.3% respectively). Combined qualified GDD and keratoplasty success rate at one year was 82.6%. Conclusion: GDD insertion is an effective means of IOP control in patients with corneal transplants. CS-GDD insertion with keratoplasty was shown to have the best clinical outcomes in terms of IOP reduction and reduction of number of glaucoma medications. CS-GDD with DSEK graft was associated with best postoperative visual acuity. PPGDD with PK graft was shown to have the best graft survival rate in the long-term. There was no statistical significance in GDD and corneal graft outcomes by having GDD insertion prior to keratoplasty, no previous glaucoma surgery or by being pseudophakic.