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EYE

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Transcript of EYE

Risk Factors for Glaucoma Drainage Devices Exposure
Ali Al-Bishri
Rizwan Malik
Alia Freida
Sameer Ahmad

KKESH experience
a
Background
Glaucoma drainage devices (GDD) reserved for failed trab/high risk situations
Purpose
The aim was to study potential risk factors for tube exposure at KKESH targeting for the first time our unique
Middle-Eastern population.

A retrospective case-control study was undertaken for a eight-year period (2008-2015).

All patients who presented with a GDD exposure were identified and were matched to a similar number of controls (without exposure) during the same period.
Study design
GDDs complications
Intraoperative :
Hyphema
Scleral perforation
Suprachoroidal hemorrhage
Early postoperative complications:
Rd
Flat AC
Hypotony
Choroidal detachment
Suprachoroidal hemorrhage
Late complications:
Corneal decompensation
Cataract
Tube exposure
Device malposition
Diplopia
Phthisis bulbi
Endophthalmitis
Purpose
The aim was to study the risk factors for tube exposure at KKESH targeting for the first time Middle-Eastern population in order to confirm risk factors reported by others.
In addition, we wished to study other potential risk factors such as ocular drop allergy and type of suture used during the GDD insertion, which have not been studied before.
Methods:
A retrospective case-control study was undertaken for a eight-year period (2008-2015 inclusive).
All patients who presented with a GDD exposure were identified and were matched to a similar number of controls (without exposure) during the same period.
Methods:
Demographic factors, past ocular history, treatment and surgical technique were recorded for both groups.
Univariate and multivariate analysis were used to identify possible risk factors for GDD exposure.
Study Design
We conducted a retrospective case-control study at KKESH.
Hospital procedural codes were used to identify all possible patients who presented with a history of tube exposure during the period (2008-2015).
For comparison, we randomly selected the same number of patients during this time period who had tube surgery (without complications).
Results
836 eyes
2008
2015
53 eyes with GDD exposure (6.3%) - (0.8% per year)
9 excluded
The mean age (51 years) was similar to controls
(p=0.95)
Median number of previous surgeries was ( 3 )
The most frequent previously performed surgeries were:
Other Results
Average time to exposure
Univariate Analysis:
No clinical significant results in:
Specific Diagnosis
Surgical technique or materials
Implant location
MMC/5-FU use
Surgeons experience
Ocular allergy to drops
Contact lens use
Discussion
Muir and colleagues found female gender has experience of GDD exposure compared to male.

Discussion
CAI
use was interestingly a risk factor in our study. (p=0.02)


We speculate that this risk may be related to both
low pH (Dorzolamide)
causing stinging and patients rubbing their eyes or because of local toxic effects on the conjunctiva.

Russ HH et al described that
lymphocytic inflammatory response
was observed only in animals treated with
dorzolamide 2% + timolol maleate 0.5%BAK
, suggesting some toxic effect of this association.
Russ HH, Turner-Gianicco A, Montiani-Ferreira F, Lima L . Clinical and Histologic Comparison of Conjunctival Changes Induced by Antiglaucoma Beta Blockers, Carbonic Anhydrase Inhibitors, Alfa Agonists and Fixed Combinations with and without Preservatives. Journal of Clinical and Experimental Ophthalmology 07(05) · January 2016
Lockington D, Macdonald EC, Stewart P, Young D, Caslake M, Ramaesh K. Free radicals and the pH of topical glaucoma medications: a lifetime of ocular chemical injury?
Eye (Lond). 2012 May;26(5):734-41. doi: 10.1038/eye.2012.25. Epub 2012 Mar 2.

This study is not without limitations…
Some studies reported the location of implant could be a risk factor of GDD exposure as mentioned by Levinson et al.

They found that implant location approached, but did not reach, statistical significance as a risk factor for exposure.

Exposures over inferior implants place patients at a higher risk of infection than superior exposures.

As the Saudi population is not very heterogenous in terms of race, we did not look at race as a risk factor in this study, although this has been identified as a risk factor by others.

Koval MS et al identified Hispanic ethnicity as potential risk factors for tube shunt exposure.
Koval MS, El Sayyad FF, Bell NP et al . Risk factors for tube shunt exposure: a matched case-control study. Journal of Ophthalmology. Volume 2013 (2013), Article ID 196215
To the best of our knowledge, this study is first study to look at other risk factors such as ocular allergy, contact lens use.


However, none of them found to approach a statistically significant risk factor.

This study is not without limitations…
Retrospective
Varying levels of documentation
Surgical technique
Different surgeons and preferences
Post-operative care
Sometimes missing data

This was minimized whenever possible by calling the patients to retrieve information about ocular allergy and contact lens use.
In a large tertiary eye care center (KKESH) the cases of exposure and controls may not be wholly representative of the general treatment population undergoing glaucoma shunts, as such, an element of selection bias of our population is a possibility.

As the Saudi population is not very heterogenous in terms of race, we did not look at race as a risk factor in this study, although this has been identified as a risk factor by others.

Koval MS et al identified Hispanic ethnicity as potential risk factors for tube shunt exposure.
Koval MS, El Sayyad FF, Bell NP et al . Risk factors for tube shunt exposure: a matched case-control study. Journal of Ophthalmology. Volume 2013 (2013), Article ID 196215
To the best of our knowledge, this study is first study to look at other risk factors such as ocular allergy, contact lens use.
However, none of them found to approach a statistically significant risk factor.
This study is not without limitations…
Retrospective
varying levels of documentation,
Surgical technique
Different surgeons and preferences.
Post-operative care
Sometimes missing data.
This was minimized whenever possible by calling the patients to retrieve information about ocular allergy and contact lens use.
There is an increasing trend for GDD use.
Background
Tube exposure represents a major risk factor for the development of late endophthalmitis and subsequent vision loss.
Late endophthalmitis associated with glaucoma drainage implants.
Gedde SJ, Scott IU, Tabandeh H, Luu KK, Budenz DL, Greenfield DS, Flynn HW Jr. Ophthalmology. 2001 Jul;108(7):1323-7.
Endophthalmitis associated with the Ahmed glaucoma valve implant
A A Al-Torbak, S Al-Shahwan, I Al-Jadaan, A Al-Hommadi, and D P Edward. Br J Ophthalmol. 2005 Apr; 89(4): 454–458.
An understanding of predisposing risk factors for tube exposure is vitally important
Existing literature regarding risk factors for tube exposure is scarce and often conflicting.
Factors such as female gender, younger age group , whites, Hispanic race, NVG , uveitis, previous ocular surgeries & implant location have been described in the literature.
Levinson JD, Giangiacomo AL, Beck AD et al. Glaucoma drainage devices: risk of exposure and infection. Am J Ophthalmol. 2015 Sep;160(3):516-521
Muir KW, Lim A, Stinnett S et al . Risk factors for exposure of glaucoma drainage devices: a retrospective observational study. BMJ Open. 2014 May 2;4(5):e004560. doi: 10.1136/bmjopen-2013-004560.
Trubnik V, Zangalli C, Moster MR et al. Evaluation of Risk Factors for Glaucoma Drainage Device-related Erosions: A Retrospective Case-Control Study. J Glaucoma. 2015 Sep;24(7):498-502
Geffen N, Buys YM, Smith M et al. Conjunctival complications related to Ahmed glaucoma valve insertion. J Glaucoma. 2014 Feb;23(2):109-14
Koval MS, El Sayyad FF, Bell NP et al . Risk factors for tube shunt exposure: a matched case-control study. Journal of Ophthalmology. Volume 2013 (2013), Article ID 196215
Byun YS, Lee NY, Park CK. Risk factors of implant exposure outside the conjunctiva after Ahmed glaucoma valve implantation. Jpn J Ophthalmol. 2009 Mar;53(2)
Huddleston SM, Feldman RM, Budenz DL et al . Aqueous shunt exposure: a retrospective review of repair outcome. J Glaucoma. 2013 Aug;22(6)
Chaku M et al . Risk factors for tube exposure as a late complication of glaucoma drainage implant surgery. Clin Ophthalmol. 2016 Mar 30;10:547-53

Methods:
Demographic factors, past ocular history, treatment and surgical technique were recorded for both groups.

Univariate and multivariate analysis were used to identify possible risk factors for GDD exposure
For comparison, we randomly selected the same number of patients during this time period who had tube surgery
(without complications).
Results
Female gender :
(p=0.028).
Multivariate analysis
The most frequent previously performed surgeries were:
Ahmed implants
Pericardium
Supero-temporal location
9-0 prolene (plate/tube)
Older age
and
female gender
are likely to be related to a higher risk of tube exposure via conjunctival dryness.
mean goblet cell conjunctival density decreases both with age and is less in women.
Wei et al.
Evaluation of age-related changes in human palpebral conjunctiva and Meibomian gland by in vivo confocal microscopy. Cornea 2011; 30: 1007-12.

Connor et al
. The influence of gender on the ocular surface. J Am Optom Assoc 1999;70: 182-6
Tighter orbit
compared to men
Hormonal changes
at postmenopausal period
Retrospective
Varying levels of documentation
Surgical technique
Different surgeons and preferences
Post-operative care
Sometimes missing data
Selection bias in a large tertiary hospital
Levinson JD, Giangiacomo AL, Beck AD et al. Glaucoma drainage devices: risk of exposure and infection. Am J Ophthalmol. 2015 Sep;160(3):516-521
Conclusion
older age (p=0.03)
(p=0.028)
The number of previous surgeries (p=0.013)
(p=0.023)
Take home messages …
Try to avoid long term CAI use.
Choose implant (valved or nonvalved) based on clinical situation and risk factors.
Use the most economical suture available.
Take care in cases with history of multiple ocular surgeries
Further prospective longitudinal study required to verify these risk factors.

In particular, the effect of CAI (Dorzolamide)
References
Gedde SJ, Singh K, Schiffman JC, Feuer WJ. The Tube Versus Trabeculectomy Study: interpretation of results and application. Curr Opin Ophthalmol 2012 23:118-126.
Christakis PG, Tsai JC, Zurakowski D, Kalenak JW, Cantor LB, Ahmed II. The Ahmed Versus Baerveldt study: design, baseline patient characteristics, and intra-operative complications. Ophthalmology 2011;118:2172-2179.
Budenz DL, Feuer WJ, Barton K, et al. Postoperative Complications in the Ahmed Baerveldt Comparison Study During Five. Am J Ophthalmol 2016;163:75-82.
Gedde SJ, Scott IU, Tabandeh H, et al. Late endophthalmitis associated with glaucoma drainage implants. Ophthalmology 2001;108:1323-1327.
Koval MS, El-Sayyad FF, Bell NP, et al. Risk factors for tube shunt exposure: a matched case-control study. J Ophthalmol 2013;2013:196215.
Byun YS, Lee NY, Park CK. Risk factors of implant exposure outside the conjunctiva after Ahmed glaucoma. Jpn J Ophthalmol 2009;53:114-119.
Trubnik V, Zangalli C, Moster MR, et al. Evaluation of Risk Factors for Glaucoma Drainage Device-related Erosions: A. J Glaucoma 2015;24:498-502. .
Chaku M, Netland PA, Ishida K, Rhee DJ. Risk factors for tube exposure as a late complication of glaucoma drainage. Clin Ophthalmol 2016;10:547-553.
Levinson JD, Giangiacomo AL, Beck AD, et al. Glaucoma drainage devices: risk of exposure and infection. Am J Ophthalmol 2015;160:516-521.
Muir KW, Lim A, Stinnett S, Kuo A, Tseng H, Walsh MM. Risk factors for exposure of glaucoma drainage devices: a retrospective observational study. BMJ Open 2014;4:e004560.
Geffen N, Buys YM, Smith M, et al. Conjunctival complications related to Ahmed glaucoma valve insertion. J Glaucoma 2014;23:109-114.
Huddleston SM, Feldman RM, Budenz DL, et al. Aqueous shunt exposure: a retrospective review of repair outcome. J Glaucoma 2013;22:433-438.
Gaton DD, Lichter H, Avisar I, Slodovinic D, Solomon AS. Lymphocytic reaction to ultraviolet radiation on rabbit conjunctiva. Ann Ophthalmol 2007;39:128-133.
Wei A, Hong J, Sun X, Xu J. Evaluation of age-related changes in human palpebral conjunctiva and meibomian. Cornea 2011 30:1007-1012.
Connor CG, Flockencier LL, Hall CW. The influence of gender on the ocular surface. J Am Optom Assoc 1999 70:182-186.
Lockington D, Macdonald EC, Stewart P, Young D, Caslake M, Ramaesh K. Free radicals and the pH of topical glaucoma medications: a lifetime of ocular. Eye (Lond) 2012;26:734-741.
Russ HH, Turner-Gianicco A, Montiani-Ferreira F, Lima L. Comparison of Conjunctival Changes Induced by Antiglaucoma Beta Blockers, Carbonic Anhydrase Inhibitors, Alfa Agonists and Fixed Combinations with and without Preservatives. J Clin Exp Ophthalmol 2016;7:606.
Acknowledgments:

Dr. Sameer Ahmed (KKESH)
Dr. Rizwan Malik (KKESH)
Alia Freida

Medical Records department at KKESH for retrieving the case note for this study
52.4±50.05 months
CAI
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