Drainage devices in glaucoma surgery.

Glaucoma drainage devices, also termed aqueous shunts (AS), are widely used in the USA. Indications for AS include excessive conjunctival scarring diminishing the success of another filtration surgeries, abnormalities of the iridocorneal angle, neovascular glaucoma, presence of corneal grafts, and inflammatory glaucoma. Qualified success has been achieved for many years in 50 to 100 % of the treated eyes, depending on the patient selection. An AS consists of a silicone tube that is inserted into the anterior chamber and a plate (explant) made of silicone or polypropylene. The latter is positioned between the recti muscles. Within some weeks the surrounding tissue forms a fibrous bleb around the plate. This serves as a permanent filtration reservoir. The most serious complication is postoperative hypotonia, that can lead to serious choroidal detachment, suprachoroidal hemorrhage, anterior chamber flattening, and corneal decompensation. To avoid this complication some devices, e.g. the Ahmed Glaucoma valve and the Krupin valve, have integrated mechanisms to sustain a residual intraocular pressure. With other devices such as the Molteno and the Baerveldt devices the tube has to be temporarily ligated until a scar area forms around the explant. On the other hand, fibrous infiltration of the wall of the bleb often leads to a reversible rise in intraocular pressure about one to four months after surgery which can be treated by massaging the bulb, needling the bleb, or injection of antimetabolites. There are no obvious differences between the different AS regarding the success of pressure control. With appreciation of indications and therapy of complications, AS are an useful option in the management of complicated glaucoma, where conventional filtration surgery is considered to carry a high risk of failure.