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Baerveldt - risks of secondary effects

Article ID: 52
Last updated: 10 Mar, 2018
Revision: 1
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Question

My son was born with bilateral congenital cataracts at age 3 mo got lenses removed. After he turned 3 yrs old, he was diagnosed with glaucoma.

The path since has been tortuous, with 4 surgeries in each eye involving for each: 2 trabeculectomies, 1 ECP and 1 Ahmed valve implant. The right eye is after all that and full medication (Cosopt 3x/d, Zioptan, and Diamox 3x/d.. we are even trying Preservative free meds in case that helps) still spiking in IOP (today up to 40). We did buy an iCare to be able to track IOP frequently.

The Dr. is recommending to implant a Baerveldt tube in his right eye. He mentioned some of the risks are that due to the size of it, it could affect the muscles and cause amblyopia. My question is how frequent/prevalent this happens? Would he be better off with another Ahmed valve? It makes me nervous that the tube doesn't have a valve... is there a risk of hipotony?

He also has nystagmus. His vision may be around 130/20. And his irises have abnormal shape after the multiple surgeries. We are doing whatever we can to preserve his vision, but the surgeries themselves have a risk. His doctor has excellent track record and we trust his opinion, we just want to gain further information.

Any information around this is greatly appreciated.

Answer

It does sound like a long road, but this is not uncommon. It is difficult to render an opinion without seeing your child but here are a few thoughts

  1. Yes all tubes (even Ahmed) have a risk of hypotony.
  2. Is the Ahmed draining? That can be determined on exam. If not, there are things that be done sometimes to get it working (e.g. needling, flush)
  3. Be careful with ICare. It often reads high, especially in eyes like this that may have thick or abnormal corneas, and once you get above 30 it gets increasingly inaccurate.
  4. Yes we sometimes need to put in a second tube

Alex V. Levin, MD, MHSc, FRCSC
Chief, Pediatric Ophthalmology and Ocular Genetics
Robison D. Harley, MD Endowed Chair in Pediatric Ophthalmology and Ocular Genetics
Wills Eye Hospital, Ste. 1210
840 Walnut Street                    
Philadelphia, PA 19107-5109

Chair, Scientific Advisory Board
Pediatric Glaucoma and Cataract Family Association
 

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