NEOVASKOLER GLOKOMLU OLGULARDA AHMED GLOKOM VALFiMPLANTASYONU
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1 DicLE TIP DERGiSI (JOURNAL OF MEDIcAL SCHOOL) C:27 S: NEOVASKOLER GLOKOMLU OLGULARDA AHMED GLOKOM VALFiMPLANTASYONU Yrd.Do~.Dr. Kaan ONLO 1 Dr. ihsan f;af;a 3 Do~.Dr. Ahmet AKSONGER 2 Dr. Kubilay BiLEK 4 OZET Bu retrospektif yal1$mada neovasko/er g/okom nedeniy/e Ahmed valf imp/ante edilen 14 hastanm 14 gozo deger/endiri/mi$tir. Operasyon sonrasl goz iyi basmcl (GIB) 21 mmhg'nin a/tmda ve 5 mmhg'nin Ozerinde o/an ve ek bir g/okom cerrahisi gerektirmelen vaka/ar ba$afl/i o/arak deger/endirilmi$tir. Orta/ama takip soresi 12,9 5,6 al (8-27 ay) o/an o/gu/arm son kontro/onde 9 gozde (%64,2) ba$afl sag/andl. Cerrahi oncesi orta/ama 34, 1 7,3 mmhg o/an GIB'I, son kontro/de 17,8 7,0 mmhg o/arak saptandl (P=0.001). Operasyon oncesi kullam/an orta/ama antig/okomatoz ilay saylsl 2,9 0,8'den 1,2 1,2'e do$tu (P=0.001). Postoperatif donemde en slk gorolen komplikasyon 3 gozde (%21,4) geli$en hifemaydl. Ahmed g/okom valfi neovasko/er g/okom/u o/gu/arda GIB'm do$ormede etkili o/arak bu/undu. Anahtar Ke/ime/er: NeovaskO/er g/okom, Ahmed g/okom valf. GiRi~ Akoz drenaj implantlan slkhkla goz i9i basmclnm (GIB) kontrol altma ahnamadlgl olgularda kullamlmaktadlr. Endikasyonlan arasmda onceden ba~anslz olan trabekulektomi, juvenil glokom, uveitik glokom, neovaskuler glokom, on kamarada hucre proliferasyonu (iridokorneal endotelyal proliferasyon gibi), a~1rikonjonktival skatrizasyon, limbal incelme sayllmaktadlr (1). Gunumuzde bir 90k tipte akoz drenaj implantlan mevcuttur (Molteno, Ahmed, Krupin-Denver, Baerveldt vb). Bunlardan Ahmed glokom implantmda (New World Medical, Inc., Rancho Cucamonga, CA) erken postoperatif donemdeki hipotoni ve buna bagh komplikasyon oranlannm diger glokom drenaj implantlanna gore daha du~uk oldugu ileri surulmu~tur(1,2). LiteratUrde Ahmed valf ile ilgili 9ah~malann mevcut olmasma kar~m neovaskuler glokomda kullamml hakkmda az saylda rapor mevcuttur. Bu 9ah~mada Ahmed glokom valf implante edilen neovaskuler glokomlu olgulann degerlendirilmesi ama9lanml~tlr. MATERYAL VE METOD Bu retrospektif 9ah~mada Kaslm 1997-Nisan 1999 tarihleri arasmda neovaskuler glqkomnedeniyle Ahmed glokom valf implante edilen hastalarm (1,3,4)Dicle universitesi Tip Fakultesi GOzHastahklan Anabilim Dah DlvARBAKIR (2) Diyarbaklr Devlet Hastahanesi GOzHastahklan Klinigi DlvARBAKIR
2 64 dosyalan taranml~ ve cerrahi somasl minimum 6 ay soreyle takip edilen 14 hastanm 14 gozo ~ah~ma kapsamma ahnml~tlr. Sekiz kadm, 6 erkekten olu~an hastalarm cerrahi slrasmda ya~ ortalamasl 59,7 8,2 (44-71 YII arasl) Ylldl. NeovaskOler glokom 8 olguda diabetik retinopati, 6 olguda ise santral retinal ven tlkamkhgl sonucu geli~mi~ti. Preoperatif en iyi dozeltilmi~ gorme keskinligi 4 MPS olan olgulanmlzln 6'slnda gorme derecesi P-P-, 4'Onde P+P+ veya el hareketleri dozeyindeydi. Aralannda katarakt cerrahisi ge~irmi~ 3 olgunun da bulundugu hastalarm 7'sinde (%50) daha ewe I glokoma yonelik cerrahi giri~im uygulanml~tl (4 olgu trabekolektomi,2 olgu siklokrioterapi, 1 olgu trabekolektomi ve siklokrioterapi). Altl olguya implant cerrahisi oncesinde pametinal fotokoagulasyon uygulandl. Cerrahi Teknik: Tek cerrah (KO) tarafmdan opere edilen hastalann tomondeahmed valf implanti (Model S-2) Ost temporal kadrana yerle~tirildi. Ost ve lateral rektus kaslan arasmda forniks tabanh Tenon/konjonktival flep hazlrlandl. Ahmed valf,bss ile irrige edildikten soma valfin govdesi limbusun yakla~lk 8-10 mm 'gerisine sklera Ozerine9-0 prolen sotorile sotoreedildi. Tabam limbusta olacak ~ekilde, 2/3 sklera kahnhgmda, 4x5 mm bolutlannda skleral flep kaldmldl. Skleral flebin altmdan 23 gauge igne ile irise paralel olacak ~ekilde on kamaraya girildi. TOp, u~ a~lkhgl korneaya bakacak ve 2 mm kadar on kamara i~erisinde uzanacak ~ekilde tlra~landl ve on kamaraya yerle~tirildi. Skleral fleb yerine yayllarak 2 adet 10-0 naylon sotorile sotoreedildi. Konjonktiva yerine yayllarak sotore edildi ve subkonjonktival antibiotik ve steroid enjeksiyonu uygulandl. Operasyon slrasmda olgulann hi~birine antifibrotik ajan kullamlmadl. Cerrahi somasl topikal steroid ve antibiyotik kullanan tom olgularda aplanasyon tonometresi ile ahnan GIB ol~omlerive biomikroskopi muayenesini de i~eren kontrollerin slkhgl hastanm klinigine gore ayarlandl. Degerlendirme oncesinde, operasyon somasi GIB'nm 21 mmhg'nin altmda ve 5 mmhg'nin Ozerindeolan ve ek bir glokom cerrahisi gerektirmeyen vakalarda giri~im ba~anh olarak kabul edildi. Postoperatif antiglokomatoz medikasyon kullamlmasl veya kullamlmamasl ba~anda bir kriter olarak goz onone ahnmadl. GIB'lmn 5 mmhg veya altmda olmasl hipotoni olarak degerlendirildi. Istatistiksel degerlendirme Wilcoxon e~le~tirilmi~ iki ornek testi ile ger~ekle~tirildi. Sonu~lar Ortalama takip soresi 12,9 5,6 ay (8-27 ay) olan olgulann son kontrolonde ba~an oram %64,2 (9 goz) idi. Cerrahi oncesi ortalama 34,1 7,3 (25-53) mmhg olan GIB'!, son kontrolde 17,8 7,0 (8-30) mmhg olarak saptandl, bu fark istatistiksel olarak anlamhydl (P=0.001). Hastalann operasyon somasl ortalama GIB'lan ~ekil 1'de gosterilmi~tir. Postoperatif 1. gonde 10,8 5,3 mmhg olan ortalama GIB'I 3. ayda ,3 mmhg'e yokseldi, 9. ayda ise minimal bir do~o~ile 15,8 6,1 mmhg oldu. 3 ve 9. aylardaki bu degerler arasmdaki fark istatistiksel olarak anlamh degildi (P>0.05). Operasyon somasl 9. aydan itibaren ortalama GIB'da dereceli bir artl~ oldu, 1. Ylhm
3 65 tamamlaml~ olgularda (7 goz) ortalama GIB'I 17,1 6,9 mmhg olarak saptandl. Son kontrolde hastalarda operasyon oncesi kullanllan ortalama antiglokomatoz ilay saylsl 2,9 0,8'den 1,2 1,2'e do~to.bu fark istatistiksel olarak anlamhydl (P=0.001). GYB'I kontrolo ba~anh olarak kabul edilen 9 hastadan ikisi (%22,2) antiglokomatoz ilay kullanmlyordu. Operasyon somasl GIB'I antiglokomatoz medikal tedaviye ragmen 20 mmhg'nin Ozerindeolan 5 hastanm (%35,7) birinde agn nedeniyle postoperatif 1. Yllda enokleasyonuygulandl. Postoperatif donemde en slk gorolen komplikasyon 3 gozde (%21,4) geli~en hifemaydl (Tablo 1). Hifema 2 gozde postoperatif 1. gonde, 1 gozde ise 23.haftada geli~ti. Birinci gon hifemasl olan olgulann birinde top obstroksiyonu geli~ti ve bu olguya postoperatif 3. gonde on kamara lavajl ile birlikte top irrigasyonu uygulandl. Diger 2 olguda hifema herhangi bir cerrahi modahaleye gerek kalmadan spontan olarak dozeldi.. Operasyonsomasl 1. gonde2 gozde (%14,2) hipotoni saptandl. Bu. gozlerden birinde on kamara tamamen silikti ve top ile kornea arasmda temas vardl. TOp insersiyon yerinden Slzmtl olan bu olgu aynl gon cerrahi revizyona ahndl ve top kenanna bir adet sotorkonuldu. Cerrahi revizyon somasl 1. gonde GYB'I 8 mmhg olan bu olguda on kamaranm derinle~tigi gozlendi. Hipotoni geli~en ve slg on kamarasl olan diger goz ise cerrahi giri~ime gerek kalmadan 1. haftada dozeldi. Operasyon oncesi GIB'I yoksekligine bagll oldugu do~onolen2 olgudaki korneal odem, 1 olguda cerrahi somasl dozeldi, digerinde ise devam etti. Operasyon somasl GIB'I 20 mmhg'nin altmda seyreden bir olguda da 1. aydan itibaren yaygm korneal odem geli~ti. Olgulardan birinde postoperatif 9. ayda retina dekolmanl geli~ti. Hipotoni ve silik on kamarasl olan olgu dl~mda hastalann hiybirinde top-kornea temasl gozlenmedi. Bir olguda 10. ayda tobe bagh erozyon geli~ti (%7,1). Tablo 1. Postoperatif komplikasyonlar Komplikasyon No. (%) Komplikasyonlu goz saylsl 8 (57,4) Hifema 3 (21,4) Hipotoni 2 (14,2) Slg on kamara 2 (14,2) Kornea odemi 1 (7,1) Tup obstruksiyonu 1 (7,1) Kornea-tup temasl 1 (7,1) Tup erozyonu 1 (7,1) Retina dekolmam 1 (7,1)
4 66 4{} 'I [:.-Ort ~~ ' 0 [ :: 'iș... «~,!... t... ~ (1"\ ~, vs t ~ ->,... 1, N ~ekil1. Operasyon sonrasl olgulardaki ortalama GIB (mmhg). TARTI~MA Ortalama takip soresi 12,9 5,6 ay olan hastalanmlzm postoperatif donemdeki son kontrollerinde elde edilen ortalama GIB'nm (17,8 7,0 mmhg) ve kullanllan ortalama antiglokomatoz ila9 saylslmn (1,2 1,2 adet) preoperatif degerlere gore istatistiksel olarak anlamll derecede do~ok olmasl Ahmed glokom valf implantasyonunun neovaskoler glokomlu olgularda GIB'm do~ormedeetkili oldugunu gostermektedir. LiteratOrdege~itli glokom tiplerinin dahil edildigi hasta gruplannda Ahmed glokom valf implantasyonu sonrasmda benzer ba~an oranlan bildirilmektedir; 9all~malannda cerrahi sonrasl 1. Yllda komolatif ba~an olaslllgml Coleman ve ark (2) %78, Ayyala ve ark (3) %77 ve Huang ve ark (4) ise %87 olarak bildirmi~lerdir. Vine 9all~malarda bildirilen sonu91arkar~lla~tlrlldlgmda, Ahmed glokom valf ile elde edilen ba~an oranlannm diger drenaj implantlanmn sonu91an ile benzerlik gosterdigi gorolmektedir; Ayala ve ark (3) kendi sonu9lanm, diger tipte drenaj implantl kullamlan 9all~malarm (5-7) sonu91anile kar~lla~tlrml~lar ve ba~an oranlannm benzer oldugunu belirtmi~lerdir. Ancak Ahmed glokom valfi implante edilen neovaskoler glokomlu olgulardaki ba~an hakkmda geli~kili sonu91arbildirilmi~tir. Ayala ve ark (3) bir 90k degi~keni analiz ettikleri 9all~malannda, glokom tipini sonu9 ba~an oram Ozerine etki eden bir faktor olarak saptamadlklanm rapor etmi~lerdir. Huang ve ark (4) ise glokomu ge~itli etiyolojilere bagll olarak geli~en olgulannm igerisinde (ortalama takip soresi 13,4 ay ve son kontrollerindeki ba~an oram %82) en do~okba~an oramnl neovaskoler glokomlu hasta grubunda saptaml~lar (%68) ve bu farkm istatistiksel olarak anlamll derecede oldugunu bildirmi~lerdir. Bizim
5 9ah~mamlzda ortalama yakla~lk 13 ay takip soresi olan olgulanmlzm son kontrollerinde elde edilen %64,2'lik ba~an oram ge~itli glokom tiplerinin dahil edildigi 9ah~malarda (2-4) bildirilen sonu91aragore daha do~oktorve Huang ve ark'nm (4) sonu91an ile uyumlu gozokmektedir. Farkh tipteki drenaj implantlanmn kullamldlgl 9ah~malarda da neovaskoler glokomlu olgularda ba~an prognozu do~okbildirilmi~tir (5,8,9). Operasyondan yakla~lk 2-9 hafta sonra GIB'daki ge9ici artl~ hipertansif faz olarak adlandmlmaktadlr (1,3,4,7,9). Huang ve ark (4) Ahmed glokom valf implante ettikleri ge~itli tipteki glokom hastalannda postoperatif 2. aydaki ortalama GIB'ml 1 ve 2. Ylllardakine gore istatistiksel olarak anlamh derecede yoksek bulduklanm bildirmi~lerdir. Bizim 9ah~mamlzda ise 3. aydaki ortalama GIB'I degeri 6 ve 9. aydaki degerlere gore biraz daha yoksek olmasma kar~m aralarmdaki fark istatistiksel olarak anlamh degildi (P>0.05). Iki 9ah~mada da hipertansif fazda GIB'daki tepe degerlerin birbirine yakm olmasma kar~m (Huang ve ark'nm 9ah~masmda 2. ayda 16,9 mmhg, bizim 9ah~mamlzda 3. ayda 16,1 mmhg) bu iki 9ah~ma arasmdaki fark, neovaskoler glokomda hipertansif faz somasl GIB'daki do~menindiger glokom tiplerine gore daha az.' miktarda oldugunu do~ondormektedir.bu ise neovaskoler glokomlu olgularda daha do~okba~an prognozu oldugu sonucuyla Ulumlu gozokmektedir. Nitekim ortalama GIB', Huang ve ark'nm (4) 9ah~masmda 2. aydan itibaren dereceli olarak do~me gosterirken, neovaskoler glokomu olan olgulanmlzda 9. aydan itibaren dereceli olarak yokselmegostermi~tir($ekil1). 9ah~mamlzda erken postoperatif donemde gorolen hipotoni oram (%14,2), Ahmed glokom valf kullamlan diger 9ah~malarda bildirilen degerlerle uyumludur. Hipotoni oramm Coleman ve ark (2) %13, Huang ve ark (4) %8, Ayyala ve ark (3) %9,4, Englert ve ark (10) ise %11,1 olarak bildirmi~lerdir. Bu degerlerin diger tipte drenaj implanty uygulanan 9ah~malardaki hipotoni oramna gore daha do~ok oldugu gozlenmektedir. Siegner ve ark (5) Baerveldt implantmdan soma %32, Mastropasqua ve ark (11) Krupin-Denver implantmdan sonra %57,1 oramnda hipotoni saptaml~lardlr. Wilson ve ark (12) ise olgulannda Molteno implantlndan soma %20 oranmda hipotoniye bagh koroidal dekolman geli~tigini bildirmi~lerdir. 9ah~mamlzda postoperatif donemde en slk gorolen komplikasyon 3 gozde (%21,4) geli~en hifemaydl. Kanamaya bagh olarak tap obstroksiyonu geli~en bir olguya cerrahi modahale gerekti. Olgulanmn yakla~lk 1/3'Onde neovaskolerglokom olan Ayyala ve ark (3) erken postoperatif donemde en slk kar~lla~tlklan komplikasyonun hifema (%16,5) oldugunu ve hifemaly olgulanmn da %90'nmda neovaskoler glokom oldugunu bildirmi~lerdir. Huang ve ark (4) %6 oramnda hifema gozlemlemi~ler ve tap obstroksiyonu geli~en 17 gozon 6'smda nedenin kanama oldugunu (5'inde neovaskoler glokom mevcut) belirtmi~lerdir. Sidoti ve ark (13) Baerveldt implantl kullandlklan neovaskoler glokomlu olgulannda %11 oramnda fibrovaskoler doku nedeniyle top obstroksiyonu geli~tigini rapor etmi~lerdir. Batman ve ark (14) neovaskoler glokomda Molteno implantasyonu somasi erken donemde hifema oramm %15,7, topblokajlm ise %5,2 oranmda bildirmi~lerdir. Bir olgumuzda geli~en retina dekolmammn nedeni olarak altta yatan 67
6 68 hastallk sorumlu tutuldu. Operasyon sonrasl gozlemledigimiz diger komplikasyonlar olan korneada diffuz Odem (%7,1), tope bagll erozyon (%7,1) ve top-kornea temasl (%7,1) Ahmed glokom valfi implante edilen diger 9all~malarda da benzer oranlarda bildirilmi~tir (2-4,10). Sonu9 olarak yakla~lk ortalama 13 ayllk takip soresi olan neovaskoler glokomlu olgularda Ahmed glokom valfi GIS'nl do~ormedeetkili olarak bulundu. Ancak Ahmed glokom implantl kullamlan neovaskolerglokomlu olgularda daha uzun soreli takipler sonrasmdaki degerlendirmelere de gereksinim oldugunu do~onmekteyiz. SUMMARY THE AHMED GLAUCOMA VALVE IN NEOVASCULAR GLAUCOMA In this retrospective study aimed to evaluate the efficacy of the Ahmed glaucoma valve in patients with neovascular glaucoma. For this purpose the medical records of 14 patients (14 eles) with uncontrolled neovascular glaucoma who underwent Ahmed Glaucoma Valve.implant surgery were reviewed. Success of surgery was defined as an intraocular pressure less than 21 mm Hg and greater than 5 mm Hg without additional glaucoma surgery. The mean follow-up time was months (range, 8 to 27 months). Success was achieved in nine of 14 eyes (64.2%). Intraocular pressure was reduced from a mean of mm Hg before surgery to mm Hg at the most recent follow-up after surgen (P=0.001). The number of antiglaucoma medications was decreased from a preoperative mean of to postoperatively (P =0.001). The most common postoperative complication was hyphema, which occurred in 3 eyes (21.4%). Ahmed glaucoma valve implant was found effective in lowering intraocular pressure in patients with neovascular glaucoma. Key words: Neovascular glaucoma, Ahmed glaucoma valve. KAYNAKLAR 1. Da Mata AP, Foster CS. Ahmed valve and uveitic glaucoma. Int Ophthalmol Clin 1999 Winter; 39(1): Coleman AL, Hill R, Wilson MR, Choplin N, Kotas-Neumann R, Tam M, et al. Initial clinical experience with the Ahmed glaucoma valve implant. Am J Ophthalmol 1995;120: Ayyala RS, Zurakowski D, Smith JA, Monshizadeh R, Netland PA, Richards DW, Layden WE. A clinical study of the Ahmed Glaucoma Valve implant in advanced glaucoma. OphthalmologI1998;105(10): Huang MC, Netland PA, Coleman AL, Siegner SW, Moster MR, Hill RA. Intermediate-term clinical experience with the Ahmed Glaucoma Valve implant. Am J OphthalmoI1999;127: Siegner SW, Netland PA, Urban RC Jr, Williams AS, Richards DW, Latina
7 MA, Brandt JO. Clinical experience with the Baerveldt glaucoma drainage implant. Ophthalmology 1995;102(9): Krupin eye valve with disk for filtration surgery. The Krupin Eye Valve Filtering Surgery Study Group. Ophthalmology 1994;101: Heuer OK, LlOId MA, Abrams OA, Baerveldt G, Minckler OS, Lee MB, Martone JF. Which is better? One or two? A randomized clinical trial of single-plate versus double-plate Molteno implantation for glaucomas in aphakia and pseudophakia. Ophthalmology 1992;99: Krupin T, Ritch R, Camras CB, Brucker AJ, Muldoon TO, Serle J, et a!. A long Krupin-Oenver valve implant attached to a 180 degree scleral explant for glaucoma surgery. Ophthalmology 1988;95: Minckler OS, Heuer OK, Hasty B, Baerveldt G, Cutting RC, Barlow WE. Clinical experience with the single-plate Molteno implant in complicated glaucomas. Ophthalmology 1988;95:1181-8,,10. Englert JA, Freedman SF, Cox TA. The Ahmed Valve in refractory pediatric glaucoma. Am J Ophthalmo11999;127(1): Mastropasqua L, Carpineto P, Ciancaglini M, Zuppardi E. Long-term results of Krupin-Oenver valve implants in filtering surgery for neovascular glaucoma. Ophthalmologica 1996;210(4): Wilson RP, Cantor L, Katz LJ, Schmidt CM, Steinmann WC, Allee S. Aqueous shunts. Molteno versus Schocket. Ophthalmology 1992;99: Sidoti PA, Ounphy TR, Baerveldt G, LaBree L, Mincler OS, Lee PP, Heuer OK. Experience with the Baerveldt glaucoma implant in treating neovascular glaucoma. Ophthalmologl 1995; 102(7): Batman A, Batman C, Zilelioglu 0, Ozkan S, Cetin E. NeovaskOler glokomda Molteno topimplantasyonu. T Klin Oftalmoloji 1996;5:
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