Present-day glaucoma implants, i.e.

, long-tube implants, were

introduced by Molteno in 1976. The basic concept of the long-tube
implants is the creation of a filtering bleb over the distal plate.
The devices are designed to shunt the aqueous through a tube
from the anterior chamber to a reservoir sutured posteriorly on
the sclera. A fibrous capsule forms a filtering bleb around the
external /scleral portion of the draining device. The morphology of
this filtering bleb is different from that of the blebs seen after
trabeculectomy . After insertion of the drainage device, a thin
collagenous capsule, surrounded by a granulomatous
reaction, is present at 1 month. The granulomatous reaction
resolves after 4 months, capsule thickness remains relatively
stable, and the collagen stroma becomes less compact. Bleb
formation occurs on both sides of the plate in successful cases.
The glaucoma drainage implant tube maintains a channel for
aqueous flow in the setting of exuberant fibrovascular wound
healing and improves the surgical prognosis in refractory
glaucomas. Glaucoma drainage implant surgery avoids the
development of a thin, avascular, filtering bleb associated with
trabeculectomy and MMC, thus minimizing the risk of delayed
infection. In buphthalmic eyes with thin sclera, a glaucoma
drainage implant (especially when implanted in two stages) may
be a safer surgical option compared with MMC trabeculectomy.
The most commonly used implants include:
Molteno and Ahmed single- and doubleplate implants, and the
Baerveldt and Krupin implants.
The Ahmed and Krupin implants are valved implants.
The most recent addition to tube-shunt devices has been the Ex-
Press shunt, a non-valved flow restricting implant made of
stainless steel.

Open-tube (nonrestrictive): Molteno, Baerveldt, Schocket

Flow-restrictive devices/Valved: Ahmed and Krupin

Indications:
• Failed previous glaucoma surgery
• Glucomas known to do poorly with conventional
glaucoma surgery. {PAPU Scarred Conjunctiva IN failed
glaucoma Sx }
 o uveitic glaucoma - now treated with conventional
surgery first along with antimetabolite use
o aphakic and pseudophakic glaucoma;
o neovascular glaucoma;
o glaucoma associated with corneal transplants;
and
o congenital glaucoma with iridocorneal dysgenesis
• Severe conjunctival scarring is a clear indication for
glaucoma drainage implant surgery

Which Implants to Use:

The choices are valved or non-valved, and size. The Ahmed and
Krupin implants are valved implants
Advantage of the valved implant is less postoperative hypotony,
in most cases.
Disadvantages include
• Valve blockage, occurring early or late following
implantation. Both circumstances result in a failure of
aqueous drainage.
• Hypotony: The valve systems of the Krupin and Ahmed
devices are designed to open at 11 and 8 mmHg,
respectively; however, this is not always the case, and
hypotony can still occur with these valved implants.
• Intense hypertensive phase and subsequent thicker
bleb with less pressure lowering.

The Molteno and Baerveldt implants are nonvalved:

The major disadvantage is hypotony in the immediate
postoperative period, but this has been largely eliminated by
occluding the tube in the immediate postoperative period (allow
the opening of the tube to be facilitated at a later time, when a
fine capsule has already formed over the plate, eliminating
hypotony when aqueous reaches the plate surface). This also
allows normal aqueous to reach the plate surface, resulting in a
decreased hypertensive phase and a thinner, more functional
bleb.

Significance of Plate Size

Molteno proposed the concept that larger plate area resulted in
greater pressure lowering. With the knowledge that larger surface
was better, the double-plate implant became more used than the
single plate, and larger single plates were developed, such as the
various-sized Baerveldt implants. These larger-sized single-plate
implants became more popular because surgical implantation is
easier when compared with double-plate implants.
Advantage of the double-plate implant: Egress of aqueous
to either plate can be controlled, by ligating the
connecting tube. This cannot be done with large-size single
plates, and the larger the plate the more likely the occurrence of
hypotony and associated complications such as suprachoroidal
hemorrhage
Disadvantages of the double-plate implants: difficulty of
insertion, and if failure occurs, the upper quadrants are no
longer available for further drainage surgery or implant
use.

Advantage of the single plate is ease of insertion.

Disadvantages of the large single plate implants:
development of motility problems & Hypotony
Molteno et al. reported no significant difference between single-
and double-plate implants in the control of pressure in a series of
patients followed for 20 years. A recent study comparing the
device with the smallest surface area, the single-plate Molteno
(surface area 130 mm2), to the device with the largest surface
area, the Baerveldt (350 mm2), was unable to show any statistical
difference in any of the parameters tested.
The use of smaller surface implants, i.e., single plate Molteno
implants, with tissue modification, such as supra-Tenon’s
placement, may achieve a comparable pressure-lowering effect
as that obtained with the larger surface implants, but with the
advantage of a lesser incidence of complications, and with
preservation of one of the upper quadrants for further glaucoma
surgery, should it become necessary.
Smaller implant size is desirable in :
• Patients who may have diminished aqueous production, such
as those patients with glaucoma secondary to uveitis, or
those who have undergone cyclodestructive therapy
 • Pediatric patients

External portions of glaucoma drainage devices are made from

materials that prevent fibroblast adherence. Different
materials may influence the amount of inflammation in
surrounding tissues. Polypropylene, used in Ahmed and
Molteno implants, appears to cause more inflammation than
silicone that is used in Baerveldt and Krupin implants.
Alternative materials, such as hydroxylapatite and expanded
polytetrafluoroethylene (ePTFE) , which increase
vascularization of the fibrous capsule around the plate,
may offer a theoretical advantage by enhancing the efficacy,
decreasing the capsule size, and increasing the functional lifetime
of the implant.
Molteno glaucoma drainage implant
Single-plate Molteno implant
• Nonrestrictive silicone tube with an outer diameter of
0.63 mm and an inner diameter of 0.33 mm that connects to
a polypropylene plate 13 mm in diameter with a surface
area of 135 mm2.
• The single plate is inserted between two rectus muscles in
the chosen quadrant
Double-plate Molteno implant consists of two plates
connected by a 10-mm silicone tube, giving a total plate surface
area of 270 mm2.
• double-plate implant provides better IOP control but is
associated with a greater risk of hypotony.
Dual-chamber, single-plate implant is a modification, which
addresses the problem of hypotony, in which a V-shaped pressure
ridge on the upper surface of the plate encases an area of 10.5
mm2 around the opening of the silicone tube . In concept, the
pressure ridge and overlying Tenon's capsule regulate the flow of
aqueous into the main bleb cavity during the early postoperative
period, thereby minimizing excessive filtration and hypotony

Baerveldt Glaucoma Implant

• Nonrestrictive silicone tube with an outer diameter of 0.64
mm and an inner diameter of 0.3 mm that is connected to a
 variable-sized (250 mm2, 350 mm2, or 425 mm2) silicone
plate.
• Large surface area of the plates which can fit in a
single quadrant- most remarkable feature
• The plate contains fenestration holes intended to limit the
bleb height by allowing growth of fibrous tissue through the
plate , which may decrease the risk of postoperative motility
disorders.( Barium-impregnated silicone plate)
• 350-mm2 Baerveldt device had similar efficacy compared
with the double-plate Molteno implant in complicated
glaucomas
• Among various sized Baerveldt devices, the 350-mm2
implant seems to be optimum for IOP control and has been
most commonly used for adult and pediatric patients. A
special adaptor is also available for insertion of the tube
through the pars plana.
• Inserted between two rectus muscles typically in the
superotemporal quadrant
Ahmed Glaucoma Valve implant

• Valved drainage implant design

• Silicone tube is connected to a silicone sheet valve, which is
held in a polypropylene body
• The body of a most commonly used S2 model has a surface
area of 184 mm2 and is 1.9 mm thick.
• The valve mechanism consists of two thin silicone elastomer
membranes, 8 mm long and 7 mm wide, which allows one-
way regulation of the flow with a goal of keeping the IOP
between 8 and 10 mm Hg in the early postoperative period
• Calculations indicate that there is no significant pressure
drop across the valve and that the critical site for pressure
drop is at the capsule surrounding the glaucoma implants
• The Ahmed implant, as with other implants, has a
hypertensive phase, which is a transient phase of low
capsule permeability seen at 4 to 8 weeks postoperatively
• no-touch zone on the AGV- site of the valve attachment- the
area of the implant covering the chamber with the silicone
leaflets. If the implant is grasped with forceps along the
center line, it may separate the valve cover from the
 implant. The external pressure on the valve chamber can
cause a defect in closure of the valve with consequent early
postoperative hypotony and fibrovascular membrane
ingrowth between the leaflets . This may lead to a failure of
the valve due to adhesion of the valve membranes.

Krupin Implants/ Krupin Eye Valve with Disc

• Valved drainage implant design

• A silastic tube is attached to an oval silastic disc, conformed
to the curvature of the globe, 13 — 18 mm, with 1.75-mm
high side walls.
• The valve at the distal end of the tube is manometrically
calibrated to open at pressures between 10 and 12 mm Hg.

Surgical technique of implantation

• The basic steps of glaucoma drainage implant surgery are
similar in all types of devices
• fornix-based conjunctival flap is created in the
superotemporal or superonasal quadrant. (For implantation
of the double-plate Molteno device, a 1800superior
conjunctival flap is created.)
• With any glaucoma drainage device that contains a flow-
restrictive mechanism, the tube should be primed with
balanced salt solution (BSS) through a 30-gauge cannula to
confirm that the valve is functioning properly
• The plate is placed into the sub-Tenon’s space
• The Ahmed Glaucoma Valve and single-plate Molteno
implant are placed between rectus muscles
• For the Baerveldt Glaucoma Implant, the superior and lateral
or medial rectus muscles are exposed with muscle hooks
and the plate is placed between and beneath muscles
• The plate is sutured to the sclera, with the anterior edge
measured 8 to 10 mm posterior to the surgical limbus using
9-0 monofilament nylon or similar suture so as to minimize
the risk of tube or plate migration
• The tube is laid over the cornea and is trimmed with the
bevel facing up to extend 3 mm into the anterior chamber
 • When the tube is inserted into the vitreous cavity at the pars
plana after extensive vitrectomy, the tube should be cut
bevel down
• A 23-gauge needle is used to enter the anterior chamber at
the corneoscleral limbus parallel to the iris plane and slightly
above the level of the iris
• Special care should be taken that the tube does not touch
the cornea, iris, or lens. The tube is secured to the sclera
with one or two sutures to avoid the risk of tube migration.
• A rectangular piece of patch graft (eg, Tutoplast
pericardium, glycerin-preserved sclera, dura, fascia lata,
donor cornea) is used to cover the exposed tube to diminish
the chance of conjunctival erosion
• The conjunctival flap is sutured closed using 9-0 polyglactin
or similar sutures. Finally, antibiotics and steroids are
injected subconjunctivally away from the surgical site.

Surgical Complications
Intraoperative complications
• Conjunctival buttonhole
• Scleral perforation
• Cornea, iris, or lens damage
• Hyphema
• Shallow anterior chamber and hypotony
Early postoperative complications
1. Hypotony and shallow anterior chamber
2. Choroidal effusion
3. Suprachoroidal hemorrhage
4. Tube occlusion
5. Retinal detachment
6. Transient motility disorders
7. Intraocular inflammation
8. Endophthalmitis
9. Aqueous misdirection and
10. Pupillary block
Late postoperative complications
1. Tube migration
2. Tube occlusion
3. Exposed tube or plate
4. Chronic iritis or uveitis
5. Cataract formation or progression
6. Corneal decompensation or graft failure
7. Motility disorders and strabismus
8. Retinal detachment
9. Endophthalmitis
10. Chorioretinal folds
11. Hypotony maculopathy
12. Dellen
13. Phthisis
14. Increased IOP
15. Corectopia