Histopathologic findings in early encapsulated blebs of young patients treated with the ahmed glaucoma valve.
OBJECTIVE
Uncontrolled glaucoma presents a challenge for the ophthalmic surgeon especially in children and juvenile patients. For many patients who have undergone failed surgical procedures before, episcleral implants remain the last choice. Encapsulated blebs forming over antiglaucoma devices present a complication leading to malfunctioning or even failure with reincrease in intraocular pressure. We report our histopathologic findings of such blebs developing around the Ahmed glaucoma valve (AGV) after a short time period in young patients.


METHODS
Nine young patients (2 to 17 y of age) with otherwise uncontrollable glaucoma were treated with AGV (models FP-7 and FP-8, silicone base plate) by 1 surgeon (H.T.). Four eyes needed surgical revision 2 to 6 months after initial implantation owing to encapsulated bleb development over the valve with total loss of function. The dense capsule around the device was surgically removed and investigated macroscopically, microscopically, and ultrastructurally.


RESULTS
The cystic wall of these encapsulated blebs had an overall thickness of 1.5 to 2 mm. Macroscopically, the tissue was split into 2 layers. Histopathologically, the smooth inner surface (facing the base plate of the AGV) consisted of compressed collagen fibers with signs of elastoid degeneration and with formation of a pseudoendothelium toward the base plate. There was a pronounced transformation of fibroblasts into myofibroblasts in this inner layer. The outer area was highly vascularized. In these vessels electron microscopy revealed thrombosis. Inflammatory responses were nearly absent in all areas of the excised material. Intraocular pressure could be controlled by removal of the encapsulated blebs in all 4 cases.


CONCLUSIONS
Encapsulation of the AGV is an early complication in young patients, leading to inhibition of fluid exchange and failure of the procedure. The valve mechanism is blocked by contracted scar tissue, but the device itself is not affected by the encapsulation. Surgical excision of the capsule immediately leads to an aqueous flow and drop of intraocular pressure.
Department of Ophthalmology, Mainz University Medical Center, Mainz, Germany. thieme@augen.klinik.uni-mainz.de
Hagen
H
Thieme
Lars
L
Choritz
Carmen
C
Hofmann-Rummelt
Ursula
U
Schloetzer-Schrehardt
Ulrike B
UB
Kottler
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003229:Conjunctival Diseases / Q000209:etiology / Q000473:pathology* / Q000601:surgery; D003560:Cysts / Q000209:etiology / Q000473:pathology* / Q000601:surgery; D005901:Glaucoma / Q000601:surgery*; D020327:Glaucoma Drainage Implants; D006801:Humans; D007429:Intraocular Pressure; D058628:Myofibroblasts / Q000648:ultrastructure; D011183:Postoperative Complications; D019919:Prosthesis Implantation; D058475:Tenon Capsule / Q000473:pathology*