| Glaucoma is a leading cause of blindness. By2020, it has been estimated that over11.1million people world-wide will be bilaterally blind from glaucoma1. Glaucoma treatments are directed at reducing intraocular pressure (IOP). When medication and laser treatment cease to control IOP, surgery is performed.However, trabeculectomy is still associated with a significant rate of postoperative complications, which has prompted calls for a better and safer operation, although it has been the standard IOP-lowering procedure since the1970s9.EX-PRESS, which is a small, stainless steel, non-valved shunt, is used in one of the most recently developed antiglaucomatous filtration surgical techniques. The theoretical advantage of this approach was increased reproducibility, simplicity, and reduced possibility of trauma to the ocular tissue. Over the last decade, EX-PRESS has been used successfully in approximately60,000implantations worldwide.Management of adult refractory glaucoma is a challenging task for any glaucoma surgeon. Ahmed glaucoma valve (AGV) drainage devices are widely used in providing reduction of IOP in cases of adult refractory glaucomas in recent years. At present, clinical data is still a lack regarding EX-PRESS used in refractory glaucoma. Part I was designed to compare the safety and efficacy of EX-PRESS and AGV for refractory glaucoma.Several studies have compared EX-PRESS with trabeculectomy". The inconsistent results make it difficult to draw conclusions that could be applied in clinical practice. Therefore, to assess the efficacy and tolerability of these two surgical procedures for the management of uncontrolled open-angle glaucoma, we undertook a Meta-analysis of all available controlled clinical trials in part II.Part I The efficacy and safety of two different glaucoma drainage implants (EX-PRESS and AGV) in treatment of refractory glaucoma.Objective:To compare the efficacy and safety of two different glaucoma drainage implants (EX-PRESS and AGV) in treatment of refractory glaucoma.Methods:This retrospective study compared outcomes of69eyes that underwent EX-PRESS (EX-PRESS group;32eyes) and AGV (AGV group;37eyes) implantation. Complete surgical success is defined as an intraocular pressure (IOP) between5-21mmHg without any antiglaucoma medication; qualified surgical success is defined as an IOP between5-21mmHg with or without topical antiglaucoma medication.Results:After a follow-up of9months, the IOP decreased from36.6±9.5mmHg to14.1±5.1mmHg in EX-PRESS group and from35.4±9.1mmHg to17.4±5.8mmHg in AGV group. From3months after operation until to the end of the follow-up, IOP of EX-PRESS group was lower than that of AGV group, the results were significant (P=0.037; P=0.015). The mean number of antiglaucoma medications was3.1±0.9and2.9±1.1preoperatively (P=0.350), whereas0.3±0.4and0.7±0.7at9months (P=0.010). At the end of the follow-up, the number of antiglaucoma medications used in the EX-PRESS group was less than that in the AGV group (P=0.010). In both groups, the difference of BCVA (best corrected visual acuity) between preoperative and9months’ follow-up after operation was not statistically significant (P=0.07; P=0.09, respectively). At the end of the follow-up, corneal endothelial cell count of two groups declined compared with preoperative, the results were statistically significant difference (EX-PRESS group:P=0.043; AGV group:p=0.018); at the end of the follow-up, the corneal endothelial cell count between two groups was no statistical difference (P=0.754). The difference of complete surgical success between the two group was not statistically significant different at9months’follow-up (P=0.273, log-rank test). The difference of qualified surgical success between the two group was not statistically significant different at9months’follow-up (P=0.713, log-rank test). The frequency of complications was comparable between the two groups.Conclusion:Lower mean IOP and less mean number of antiglaucoma medications were noted for the EX-PRESS group. Other results, including success (as defined in this study) and frequency of complications, were comparable between the two groups.Part Ⅱ Meta-Analysis of Comparing EX-PRESS Implantation with Trabeculectomy for Open-Angle GlaucomaObjective:To evaluate the efficacy and safety of EX-PRESS implantation compared with trabeculectomy for uncontrolled open-angle glaucoma.Methods:Pertinent studies were identified through systematic searches. Revman5.2was applicated for this Meta analysis. The efficacy measures utilized were the weighted mean differences (WMDs) for the intraocular pressure reduction (IOPR); the safety measures utilized were risk ratios (RRs) for operative success rates. The safety measures utilized were odds ratios (ORs) for postoperative complications.Results:10trials of778eyes were included in this Meta-analysis. The WMDs of the IOPR%comparing the EX-PRESS with trabeculectomy were6.15(95%Cl:-2.06to14.37) at12month. The pooled RRs comparing EX-PRESS with trabeculectomy were1.14(0.92to1.41) for the complete operative success rate and1.04(0.94to1.15) for the qualified operative success rate. EX-PRESS and trabeculectomy were associated with similar incidences in most complications with the exception of hypotony and hyphema, with ORs being0.36(0.16to0.80) and0.24(0.10to0.58).Conclusions:EX-PRESS implantation and trabeculectomy have similar efficacy in IOP-lowering and operative success rates. EX-PRESS associated with fewer hypotony and hyphema than trabeculectomy. However, these should be interpreted with caution because of the inherent limitations of the included studies. |
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