Aqueous shunts in glaucoma: a report by the American Academy of Ophthalmology.
OBJECTIVE
To provide an evidence-based summary of commercially available aqueous shunts currently used in substantial numbers (Ahmed [New World Medical, Inc., Rancho Cucamonga, CA], Baerveldt [Advanced Medical Optics, Inc., Santa Ana, CA], Krupin [Eagle Vision, Inc, Memphis, TN], Molteno [Molteno Ophthalmic Ltd., Dunedin, New Zealand]) to control intraocular pressure (IOP) in various glaucomas.


METHODS
Seventeen previously published randomized trials, 1 prospective nonrandomized comparative trial, 1 retrospective case-control study, 2 comprehensive literature reviews, and published English language, noncomparative case series and case reports were reviewed and graded for methodologic quality.


RESULTS
Aqueous shunts are used primarily after failure of medical, laser, and conventional filtering surgery to treat glaucoma and have been successful in controlling IOP in a variety of glaucomas. The principal long-term complication of anterior chamber tubes is corneal endothelial failure. The most shunt-specific delayed complication is erosion of the tube through overlying conjunctiva. There is a low incidence of this occurring with all shunts currently available, and it occurs most frequently within a few millimeters of the corneoscleral junction after anterior chamber insertion. Erosion of the equatorial plate through the conjunctival surface occurs less frequently. Clinical failure of the various devices over time occurs at a rate of approximately 10% per year, which is approximately the same as the failure rate for trabeculectomy.


CONCLUSIONS
Based on level I evidence, aqueous shunts seem to have benefits (IOP control, duration of benefit) comparable with those of trabeculectomy in the management of complex glaucomas (phakic or pseudophakic eyes after prior failed trabeculectomies). Level I evidence indicates that there are no advantages to the adjunctive use of antifibrotic agents or systemic corticosteroids with currently available shunts. Too few high-quality direct comparisons of various available shunts have been published to assess the relative efficacy or complication rates of specific devices beyond the implication that larger-surface-area explants provide more enduring and better IOP control. Long-term follow-up and comparative studies are encouraged.
Minckler
Don S
DS
Francis
Brian A
BA
Hodapp
Elizabeth A
EA
Jampel
Henry D
HD
Lin
Shan C
SC
Samples
John R
JR
Smith
Scott D
SD
Singh
Kuldev
K
D000047:Academies and Institutes / Q000458:organization & administration; D000477:Alkylating Agents / Q000008:administration & dosage; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D001082:Aqueous Humor / Q000378:metabolism*; D005472:Fluorouracil / Q000008:administration & dosage; D005901:Glaucoma / Q000378:metabolism / Q000601:surgery*; D020327:Glaucoma Drainage Implants; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007429:Intraocular Pressure; D016685:Mitomycin / Q000008:administration & dosage; D009885:Ophthalmology; D011183:Postoperative Complications; D013673:Technology Assessment, Biomedical; D014130:Trabeculectomy; D014481:United States
D000477:Alkylating Agents; D000894:Anti-Inflammatory Agents, Non-Steroidal; D005938:Glucocorticoids; D016685:Mitomycin; D005472:Fluorouracil