Early Clinical Experience With the
Baerveldt Implant in Complicated Glaucomas
MICHAEL J. HODKIN, MD., WARREN S. GOLDBLATT, MD.,
CLAUDE F. BURGOYNE, MD., STUART F. BALL, MD.,
AND MICHAEL S. INSLER, M.D.
• PURPOSE: To evaluate our early experience with
the Baerveldt implant in patients with complicated
glaucoma.
• METHODS: We reviewed the charts of all pa-
tients with more than six months of follow-up
after placement of a Baerveldt implant at LSU Eye
Center. Surgery was considered a success if intra-
ocular pressure was 21 mm Hg or less (with or
without antiglaucoma medications) at the last
postoperative visit, except when further glaucoma
surgery had been performed or when loss of light
perception occurred.
• RESULTS: Fifty eyes (50 patients) were divided
into six diagnostic groups, with mean follow-up
times of 16.1 to 19.2 months. Success was
achieved in 36 of 50 patients (72%): 26 of 35
(74%) patients with aphakia or pseudophakia,
nine of 12 (75%) patients with previously failed
filtering surgery, three of seven patients with
neovascular glaucoma, all three patients under the
age of 13 years, nine of 13 (69%) patients who
underwent penetrating keratoplasty, and four of
five phakic patients. Overall, visual acuity im-
proved or remained within one line of the preoper-
ative acuity in 32 (64%) patients. The most
frequently observed short- and long-term compli-
cations were serous choroidal effusion associated
Accepted for publication Jan. 12, 1995.
From the LSU Eye Center, Louisiana State University Medical
Center School of Medicine, New Orleans, Louisiana. This study was
supported in part by United States Public Health Service grants
EY02580 and EY02377 from the National Eye Institute, National
Institutes of Health, Bethesda, Maryland, and by a Career Develop-
ment Award (Dr. Burgoyne) from Research to Prevent Blindness, Inc.,
New York, New York.
Reprint requests to Claude F. Burgoyne, M.D., LSU Eye Center,
2020 Gravier St., Suite B, New Orleans, LA 70112.
32 © AMERICAN JOURNAL OF OPHTHALMOLOGY 1995,-120:32-40
with hypotony in 13 (26%) patients and corneal
graft failure in six of 13 (46%) corneal transplant
patients, respectively.
• CONCLUSION: Within the study follow-up time,
the Baerveldt implant appeared to be safe and
effective, with success rates for intraocular pres-
sure control similar to those reported in a recent
retrospective study of the Molteno implant.
MPLANTATION OF A SETON, DEFINED AS A FOREIGN
implantable material applied to an organ system to
create a fistulous pathway, is an effective surgical
option to control recalcitrant glaucoma. Decreased
intraocular pressure is attained by the shunting of
aqueous from the anterior chamber to a conjunctival
bleb overlying the implant. Commonly used setons
include the single- and double-plate Molteno im-
plant, anterior chamber tube shunt to encircling band
(Schocket procedure), and the valved Krupin-Denver
shunt.
See also p. 23.
In February 1990, the Baerveldt implant (Iovision,
Inc., Irvine, California), which consists of a non-
valved silicone tube (internal and external diameters
of 0.30 and 0.64 mm, respectively) connected to a
large-surface-area (200, 350, or 500 mm2) silicone
plate, was introduced. The implant is placed in a
single quadrant, usually superotemporally, by tucking
the ends of the flexible plate beneath adjacent recti
muscles (Fig. 1). The large filtration surface area
combined with ease of insertion is a presumed
advantage over other setons.1 Recently, Lloyd and
JULY 1995

Fig. 1 (Hodkin and associates). Diagram of Baerveldt
implant positioned beneath adjacent rectus muscles in
the superotemporal quadrant. A scierai graft is sutured
over the exposed drainage tube. The overlying conjuncti-
va and Tenon's capsule are not shown.
associates2 reported their initial results with the
implant in 13 patients, as well as intermediate-term
results comparing two sizes of implant in a total of 73
patients.3
On the basis of our early clinical experience with
the Baerveldt implant in 50 patients with complicated
glaucomas, we compare the outcomes with those of a
previous retrospective study of the Molteno implant.4
PATIENTS AND METHODS
A CHART REVIEW WAS CONDUCTED FOR ALL PATIENTS
who received a Baerveldt implant at the LSU Eye
Center, New Orleans, Louisiana. Only patients with
more than six months of postoperative follow-up were
included. From July 1991 through January 1993,
Baerveldt implantation was performed in one eye
each of 50 patients with complicated glaucoma,
which is denned as having previously failed conven-
tional medical, laser, or (nonseton) surgical treat-
ment, or some combination thereof. All patients (or
their parents) gave informed consent before surgery.
To allow a more direct comparison of our results
with those of a recent Molteno implant study,4 similar
VOL. 120, No. i BAERVELDT IMPLANT IN COMPLICATED GLAUCOMAS
patient groupings and surgical outcome criteria were
adopted. Patients older than 13 years of age with
nonneovascular glaucomas were grouped into the
following categories: aphakic or pseudophakic,
phakic, failed filtering surgery, and previous penetrat-
ing keratoplasty surgery. The remaining groups in-
cluded all neovascular glaucomas and all glaucomas
in patients younger than 13 years of age.
The categories of surgical outcome are as follows: a
complete success is defined as intraocular pressure of
21 mm Hg or less without medication; qualified
success, intraocular pressure of 21 mm Hg or less with
one or more medications; qualified failure, intraocular
pressure greater than 21 mm Hg with one or more
medications; and complete failure, additional opera-
tions for glaucoma, development of phthisis bulbi, or
loss of light perception attributed to glaucoma. The
final intraocular pressure levels and visual acuities
were those of the most recent examination at either
the LSU Eye Center or the referring ophthalmolo-
gist's office. Both conventional methods and life-table
analysis were used to determine surgical outcomes.
All patients underwent Baerveldt implantation in a
similar fashion. A 90-degree, fornix-based peritomy
through the conjunctiva and Tenon's capsule, with
radial relaxing incisions, was performed in the in-
tended quadrant of placement (most commonly
superotemporal). Bare sciera was exposed by dissect-
ing Tenon's capsule as well as any scar tissue from
previous surgery. Hemostasis was achieved with wet-
field cautery. A muscle hook was used to isolate the
exposed adjacent recti muscles, for example, lateral
and superior recti muscles for supratemporal place-
ment.
The ends of a 350-mm2 Baerveldt implant were
positioned beneath the recti muscles 2 mm posterior
to the muscle insertions. Interrupted 6-0 polyglactin
sutures placed through the two anterior fixation holes
secured the implant to the sciera. For Cases 13
through 50, to enable titration of intraocular pressure
control better in the early postoperative period, the
needle-free end of a 5-0 nylon suture was threaded
through the Baerveldt tube lumen to serve as a partial
occlusion stent. To reduce excessive drainage and
hypotony in the immediate postoperative period for
all patients, a single 6-0 polyglactin ligature was tied
around the part of the drainage tube most proximal to
the plate.
33
 A paracentesis was performed 90 degrees away from
the intended tube entry site to allow injection of air,
balanced saline solution, or sodium hyaluronate dur-
ing the procedure. To create the tube entry site, a
22-gauge needle was passed through sciera 1.5 mm
from the corneoscleral limbus to enter the anterior
chamber at an angle directed slightly away from the
iris plane. The Baerveldt tube was cut with enough
length to extend approximately 3 to 4 mm into the
anterior chamber. A sharp bevel created on the cut
end of the tube facilitated entry into the scierai tract.
Approximately six to ten microfenestrations were
created in the tube wall with the needle of a 10-0
polyglactin suture in approximately one half of the
patient^ to allow some aqueous drainage in the early
postoperative period. The microfenestrations were
placed midway between the anterior chamber tube
entrance site and the tube connection with the
Baerveldt implant. A glycerin-preserved donor sciera
graft was thoroughly rinsed and then sutured to host
sciera over the tube with four interrupted 10-0
polyglactin sutures to prevent erosion of the tube
through conjunctiva.
To facilitate removal of the 5-0 nylon stent suture
postoperatively, the needle end was externalized
through conjunctiva near the inferior fornix and
fixated to bulbar conjunctiva with interrupted 10-0
polyglactin sutures. The quadrant peritomy was closed
by reapproximating conjunctiva to the corneoscleral
limbus with interrupted 10-0 polyglactin sutures.
At the conclusion of surgery, a collagen shield
soaked in vancomycin (50 mg/ml) was placed on the
eye, followed by instillation of 1% atropine sulfate
ointment and combined neomycin, polymyxin b
sulfate, and dexamethasone ointment. The eye was
loosely patched.
Postoperative examinations were performed one
day after surgery, then weekly (or more frequently, if
necessary), and finally at longer intervals, gradually
increasing to several months. Topical medications
consisted of antibiotics for one week, 1% atropine
sulfate drops for two weeks, and 1% prednisolone
acetate. The prednisolone acetate was typically given
four to six times a day and tapered over a four- to
six-week period or until anterior chamber inflamma-
tion had resolved.
The 5-0 nylon stent suture was removed within two
to five weeks postoperatively, or earlier if intraocular
pressure was judged to be unacceptably high. Removal
of the suture was usually followed by a prompt
decrease in intraocular pressure and expansion of the
bleb overlying the implant. Either topical antiglauco-
ma medications or a combination of topical and
systemic antiglaucoma medications were added dur-
ing follow-up as deemed necessary by the surgeon.
RESULTS
FIFTY BAERVELDT IMPLANTS WERE PLACED IN 50 EYES BY
a total of six LSU Eye Center faculty. A total of 38
(76%) operations were performed by one of us
(S.F.B.); the remaining five surgeons placed from one
to four Baerveldt implants each.
Except for the neovascular and under-age-13-years
groups, which were mutually exclusive categories,

TABLE 1

PATIENT OVERLAP AMONG DIAGNOSTIC GROUPS*

APHAKIA OR FAILED UNDER

PSEUDOPHAKIA FILTERS NEOVASCULAR AGE 13 YEARS KERATOPLASTY PHAKIC
CATEGORY (N ■ 35) (N = 12) (N = 7) (N-3) (N = 13) {N=5)

Aphakia or pseudophakia — 11 0 0 13 0
Failed filters 11 — 0 0 1 1
Neovascular 0 0 — 0 0 0
Under age 13 years 0 0 0 — 0 0
Keratoplasty 13 1 0 0 — 0
Phakic 0 1 0 0 0 —
"One patient was included in three categories: aphakia or pseudophakia, keratoplasty, and failed filters

34 AMERICAN JOURNAL OF OPHTHALMOLOGY JULY 1995

 TABLE 2

PATIENT DATA AND OUTCOMES

APHAKIA OR FAILED UNDER

PSEUDOPHAKIA FILTERS* NEOVASCULAR AGE 13 YEARS KERATOPLASTV PHAKIC
(N = 35) (N = 12) (N = 7) IN = 3 ) IN = 13) (N = S)

CATEGORY NO. (%) NO. (%) NO. pi) NO. <%) NO. (%) NO. (%)

Age (yrs)
Range 34.9-97.8 34.9-82.2 51.7-90.2 0.6-7.3 57.6-87.8 39.3-57.4
Mean ± S.D. 68.4 ± 12.1 62.6 ± 15.4 70.4 ± 15.5 3.2 ± 3.6 71,1 ± 8.6 47.9 ± 8.5
Race
Black 11 (31) 5(42) 2(29) 1(33) 4(31) —
White 24 (69) 7(58) 5(71) 2(67) 9(69) 5 (100)
Lens status
Phakic — 1(8) 2(29) 3 (100) — 5(100)
Aphakic 8(23) 2(17) 3(43) — 3(23) —
Pseudophakic 27 (77) 9(75) 2(29) — 10 (77) —
Anterior chamber intraocular lens 6(17) 2(17) 1(14) — 2(15) —
Posterior chamber intraocular lens 21 (60) 7(58) 1 (14) — 8(62) —
Diagnosis
Open-angle glaucoma 21 (60) 5(42) — — 10 (77) 2(40)
Secondary angle-closure glaucoma 10 (29) — — — 3(23) —
Combined mechanism 1(3) 3(25) — — — —
Anterior cleavage syndrome 2(6) 2(17) — — — 1(20)
Uveitis-glaucoma-hyphema syndrome 1(3) 1(8) — — — —
Angle recession — 1(8) — — — —
Neovascular glaucoma — — 7 (100)T — — —
Congenital glaucoma — — — 2(67) — —
Glaucoma associated with Sturge-Weber syncIrome — — — 1(33) — —
Iridocorneal endothelial syndrome — — — — — 2(40)
Surgical outcome
Success 26 (74) 9(75) 3(43) 3(100) 9(69) 4(80)
Complete success 13(37) 1(8) 2(29) 2(67) 5(38) 1(20)
Qualified success 13(37) 8(67) 1(14) 1(33) 4(31) 3(60)
Failure 9(26) 3(25) 4(57) — 4(31) 1(20)
Qualified failure 3(9) 1(8) 3(43) — KB) —
Complete failure 6(17) 2(17) 1(14) — 3(23) 1(20)
Further glaucoma surgery 5(14) 2(17) — — 3(23) 1(20)
Follow-up (mos)
Range 6.1-26.1 7.1-26.1 10.6-24.7 17.0-20.4 8.2-24.0 9.3-18.4
Mean ± S.D. 16.3 ± 6 . 1 16.1 ± 6.5 18.3 ± 5.6 19.2 ± 1.9 15.2 ± 5.7 13.7 ± 3.6
Visual outcome
Improved (gain of two or more lines) 6(17) 1(8) — — 4(31) —
No change (± one line) 16 (46) 5(42) 3(43) 1(33) 7(54) 2(40)
Worse (loss of two or more lines) 13 (37)* 7(58) 4(57) 2(67) 2(15) 3 (60)'

*Eight patients (67%) had one failed filtering procedure, and four patients (33%) had two failed filtering procedures.
♦Associated diagnoses were diabetes, two (29%); central retinal vein occlusion, two (29%); siderosis, one (14%); and unknown, two
(29%).
'Attributable to fibrous membrane covering intraocular lens in one patient and uncorrected aphakic visual acuity in one patient.
'Attributable to decompensated cornea in one patient.

VOL.120, No. I BAERVELDT IMPLANT IN COMPLICATED GLAUCOMAS 35

each of the remaining groups shared at least one
patient in common with at least one other group
(Table 1). One patient was included in three catego-
ries: aphakia or pseudophakia, penetrating kerato-
plasty, and failed trabeculectomy.
Demographic, preoperative, and postoperative data
for the six patient groups are summarized in Table 2.
Overall, complete or qualified success was achieved in
36 of the 50 patients (72%): 26 of 35 patients (74%)
with aphakia or pseudophakia, nine of 12 patients
(75%) with previously failed filtering surgery, three of
the seven patients with neovascular glaucoma, all
three of the patients under the age of 13 years, nine of
the 13 penetrating keratoplasty patients (69%), and
four of the five phakic patients. Best-corrected visual
acuity improved or remained within one line of
preoperative levels in 21 patients (60%) with aphakia
or pseudophakia, six patients (50%) with previously
failed filtering surgery, three of seven patients with
neovascular glaucoma, one of three patients under
the age of 13 years, 11 penetrating keratoplasty
patients (85%), and two of five phakic patients.
Overall, best-corrected visual acuity improved or
remained within one line of the preoperative acuity in
32 of 50 patients (64%). One patient (2%) with
neovascular glaucoma (final intraocular pressure of 16
mm Hg) lost light perception, presumably because of
progression of optic nerve damage.
For the 36 successful procedures, intraocular pres-
sure was reduced by surgery and medications from a
mean ± S.D. preoperative value of 33.7 ± 10.7 mm
Hg to 12.6 ± 4.3 mm Hg postoperatively. For the 14
failed procedures, intraocular pressure declined from
33.9 ± 10.6 mm Hg to 21.6 ± 10.6 mm Hg (Fig. 2).
For the entire study population, life-table analysis
of success after Baerveldt implantation showed a
steady decline over time (Fig. 3), with a median (50th
percentile) time to failure of 721 days. Because of the
small number of patients per clinical grouping, group-
specific life-table analysis could not be performed.
Table 3 lists all complications by diagnostic groups.
Overall, the most frequently observed short-term
complication was serous choroidal effusion, which
was seen in 13 patients (26%). The most frequent
long-term complication was corneal graft failure,
which was seen in six of 13 patients (46%) with
previous penetrating keratoplasty.
36 AMERICAN JOURNAL OF OPHTHALMOLOGY
0 10 20 30 40 50 60 70
Preoperative IOP (mmHg)
Fig. 2 (Hodkin and associates). Successes (open circles)
were defined as patients with intraocular pressure (IOP)
21 mm Hg or less with or without medication. Failures
(closed circles) were defined as patients with intraocular
pressure greater than 21 mm Hg with medications and
those requiring further glaucoma surgery, as well as
those who developed phthisis bulbi or lost light percep-
tion as a result of the glaucoma.
To determine the intraocular pressure response
after initiation of maximum aqueous flow, the intra-
ocular pressure change was evaluated over time for 19
successful cases with documented stent suture remov-
al for pressure control during the early postoperative
period (mean time to suture removal, 19.2 days; range,
five to 59 days) (Fig. 4). Intraocular pressure tended to
increase slowly for up to six months, followed by a
slow decline.
DISCUSSION
THE BAERVELDT IMPLANT IS COMPOSED OF A LOW-
profile, soft (radiopaque) silicone plate that conforms
to the shape of the globe after implantation. A
nonvalved silicone tube drains aqueous from the
anterior chamber to the filtering bleb overlying the
200-, 350-, or 500-mm2 surface area plate.
Although the Molteno implant (Optomat Sup-
plies, Dunedin, New Zealand) is currently the most
widely used artificial aqueous drainage device, its
surface area (as measured on one side) is limited to
135 mm2 and 270 mm2 for the single- and double-
plate models, respectively. Furthermore, implantation
JULY 1995
of the double-plate Molteno implant for patients
requiring maximum intraocular pressure control re-
quires dissection in two quadrants.4,5 In contrast,
placement of even the largest (500 mm2) Baerveldt
implant is easily accomplished by tucking the seton
ends beneath adjacent recti muscles in a single
quadrant. Finally, the Baerveldt implant is composed
of silicone, which may be less inflammatory than the
polypropylene Molteno plate.6
Comparing the results of shunt device studies is
difficult, in part because of differences in patient
population, success criteria, data analysis, operating
surgeons, surgical techniques, postoperative medica-
tions, and length of follow-up. To facilitate compari-
son of our study with a large retrospective Molteno
study by Minckler and associates,4 similar success
criteria, data analysis, and patient groupings were
adopted (Table 4). Although follow-up times were
similar, the numbers of patients in the neovascular
and younger-than-age-13 -years groups were substan-
tially lower in the present study, thus possibly skewing
the results. Also, whereas all patients were phakic in
the failed-filtering group in the Molteno study, in this
study, only one of the 12 patients in our correspond-
ing group was phakic.
In comparing rates of significant complications, we
found a higher incidence of serous choroidal effusion
and hypotony in our study for patients in the aphakia
or pseudophakia group (31% vs 4% in theirs) and in
the failed-filtering group (42% vs 10% in theirs).
However, these differences may in part result from
differing criteria, since the choroidal effusions noted

TABLE 3

COMPLICATIONS BY DIAGNOSTIC GROUP

APHAKIA OR FAILED UNDER

PSEUDOPHAKIA FILTERS NEOVASCULAR AGE 13 YEARS KERATOPLASTY PHAKIC
(N - 35) (N = 121 (N = 7) (N-3) (N = 13) (N = 5)

COMPLICATION NO. (%) NO. (%) NO. (%) NO. (%) NO. (%) NO. (%)

Serous choroidal effusion 11 (31) 5(42) — — 4(31) 1(20)

Corneal graft failure 7(20) 1(8) 1(14) — 6 (46)* —
Epiretinal membrane 5(14) — — — 4(31) —
Corneal edema 2(6) 1(8) — — — —
Hyphema 1(3) 1(8) 1 (14) — 1(8) —
Bacterial keratitis 1(3) — — — 1(8) —
Cystoid macular edema 1(3) — — — — —
Epithelial ingrowth 1 (3) — — — 1(8) —
Exposed Baerveldt implant 1 (3) — — — 1(8) 1(20)
Exposed Baerveldt tube — — — — — 1(20)
Exposed donor sciera 1 (3) — — — 1(8) —
Flat anterior chamber 1(3) 2(17) 1(14) — — 1(20)
Occlusion of tube by 1 (3) — — — 1(8) —
retrocorneal membrane
Occlusion of tube by vitreous 1 (3) — — — 1(8) —
Retinal detachment 1(3) — 1 (14) — — —
Superior oblique tendon 1 (3) 1 (8) 1(14) — — 1(20)
syndrome
Vertical diplopia 1 (3) — — — — —
Vitreous hemorrhage 1(3) 1(8) — — — —
Macular edema — — 1(14) — — —
Cataract — — — 1 (33) — —
Bleb leak — — — — — 1 (20)
Corneal decompensation — — — — — 1(20)

*ln two patients (15%), failure was related to Baerveldt-tube touch, with postoperative times to failure of 2,3 and 2.5 months. In four
patients (31%), failure was not directly Baerveldt related, with postoperative times to failure ranging from 0.9 to 22.4 months.

VOL.120, No. I BAERVELDT IMPLANT IN COMPLICATED GLAUCOMAS 37

 1
^ thelial touch, while the remaining four graft failures
κ
h 1
1
0.8
0.6
L=
I 0.4
Fig. 3 (Hodkin and associates). Kaplan-Meier analysis
for implants in all patients in all groups after Baerveldt
implantation. Median (50th percentile) time to failure
was 721 days.
by Minckler and associates4 were advanced enough to
be labeled "kissing choroidals," whereas we recorded
choroidal effusions of any size as a complication.
In our study, five of the 13 postoperative serous
choroidal effusions with hypotony (intraocular pres-
sure less than 5 mm Hg) were observed to occur 12.4
± 1 1 . 6 (mean ± S.D.) days after stent removal, and
one was seen five days after lysis of the ligature suture
with a laser. Three cases occurred spontaneously 4-7
± 2.6 days after Baerveldt implantation, despite
ligature placement during surgery. The remaining
four cases were not related closely in time (greater
than one month) either to Baerveldt implantation or
to stent removal. After long-term follow-up, four of
the 13 patients with choroidal effusions (31%) were
eventually classified as having graft failures. Two of
the failures were caused by high final intraocular
pressure, and the remaining two required choroidal
drainage surgery and removal of an exposed Baerveldt
implant.
In patients with previous penetrating keratoplasty,
a graft failure rate of 36% to 60% at a mean follow-up
of about one to two years has been observed in
previous studies of Molteno implantation and
Schocket procedures.7'10 We observed graft failure in
six of 13 patients (46%) at a mean follow-up of 15.2
months, a rate similar to that of the Molteno implant
studies. Two of the graft failures (mean time to failure,
2.4 months) were attributed to Baerveldt-tube endo-
38 AMERICAN JOURNAL OF OPHTHALMOLOGY
(mean time to failure, 10.0 months) were thought not
to be directly related to the presence of the Baerveldt
implant. Overall, the 69% success rate that we
obtained for intraocular pressure control with the
Baerveldt implant after penetrating keratoplasty is
comparable to the 7 1 % to 96% range of success rates
reported for various studies of Molteno and Schocket
implants.7'10
Recently, studies of restrictive strabismus after
Baerveldt implantation have been published.1,11'12 Pro-
posed explanations include an increase in the length-
tension curve of the muscle(s) induced by the under-
lying Baerveldt implant plate, its fibrous cocoon, or
both; incorporation of the rectus muscle(s) into the
fibrous cocoon surrounding the plate; or possibly a
posterior fixation effect caused by scarring posterior to
the implant. 11112 Smith and associates1 studied 30
eyes examined retrospectively for strabismus after
placement of a 350-mm 2 Baerveldt implant; 23 (77%)
were found to have a marked heterotropia in primary
gaze and restriction of gaze into the quadrant of the
implant. As a result, 11 (65%) of 17 functionally
binocular patients had diplopia in primary gaze. Most
commonly, supratemporal Baerveldt placement re-
sulted in a hypertropia with exotropia, whereas supra-
50
40
30
E
E_
20
o
10
pre post 1 wk 1 mo 6 mo 1 yr 2 yrs >2 yrs
Time Interval After Aqueous Flow Initiated
Fig. 4 (Hodkin and associates). Mean intraocular pres-
sure (± S.D.) for 19 patients with Baerveldt implants
who were considered to be successes and who also had
documented stent suture removal for control of intraocu-
lar pressure (IOP) in the postoperative period. Pre
indicates immediately before stent suture removal; post,
immediately after stent suture removal.
JULY 1995
 TABLE 4

COMPARABLE GROUPS IN CURRENT BAERVELDT STUDY AND A RETROSPECTIVE MOLTENO IMPLANT STUDY*

VISUAL OUTCOME
FOLLOW-UP (MOS) SUCCESS SAME OR BETTER

DIAGNOSTIC GROUP NO. OF PATIENTS RANGE MEAN ± S.D. NO. (%) NO. (%(

Aphakia or pseudophakia
Minckler and associates4 48 7-30 16.2 ± 5.9 26 (63) 31 (65)
Current study 35 6-26 16.3 ± 6.1 26 (74) 22 (63)
Failed filters
Minckler and associates' 10 6-25 12.3 ± 6.1 7 (70) 3 (30)
Current study 12 7-26 16.1 ± 6.5 9 (75) 6 (50)
Neovascular glaucomas
Minckler and associates4 18 7-39 20.2 ±12.1 7 (47) 10 (56)
Current study 7 11-25 18.3 ± 5.6 3 (43) 3 (43)
Under age 13 years
Minckler and associates' 14 12-34 22.8 ± 7.8 7 (54) 9 (64)
Current study 3 17-20 19.2 ± 1.9 3 (100). 1 (33)

'Minckler and associates.'

nasal placement resulted in a hypotropia with exotro-
pia and restricted elevation in adduction, similar to
Brown's syndrome. The latter manifestation was at-
tributed to a taut superior oblique tendon.1
Our review of 50 patients disclosed only four cases
of ocular motility disturbance. Three of them simulat-
ed a superior oblique tendon syndrome. Notably, all
three were among a subset of seven patients with
supranasal placement of the Baerveldt implant. The
fourth case involved vertical diplopia in a patient with
supratemporal implantation. Overall, this incidence
of strabismus was much lower than that reported by
Smith and associates.1 At least four factors may
account for this difference. First, in the present study,
strabismus complications were not actively investigat-
ed during routine patient examinations. As a result,
strabismus may have been underreported, particularly
in functionally monocular patients, who are much less
likely to complain spontaneously of ocular muscle
imbalance. Second, during implantation we tight-
ened the tube ligature to prevent any flow to the
Baerveldt implant plate in the early postoperative
period, whereas Smith and associates1 allowed mini-
mal flow. As stated in their discussion, allowing early
flow before the development of the fibrous cocoon
may have been a factor in the development of
prominent heterotropia.1 Third, we used a fornix-
based, rather than a limbal-based, conjunctival inci-
sion for implantation. A limbal-based flap may pro-
mote formation of scar tissue beneath the posterior
incision site, possibly leading to muscle scarring with
motility restriction (Paul Palmberg, M.D., oral com-
munication, April 1994). Fourth, since the study by
Smith and associates1 was published, first two and
then four fenestrations were added to the design of
the plate to promote fibrous adhesions between the
sciera and the inner surface of the bleb (oral commu-
nication, Iovision, Inc., Irvine, California, January
1994). Theoretically, such adhesions might reduce
bleb height by securing the inner surface of the bleb
closer to the underlying sciera.112 In our study, 18 of
the 50 implants had the two-fenestration modifica-
tion to the plate. None of the ocular motility distur-
bances occurred in the patients who received fenes-
trated plates.
In general, we found that our results, in terms of
intraocular pressure control and visual outcome, were
similar to those of a recent Molteno implant review4
and not widely dissimilar to those of the recently
published early studies by the Baerveldt group.2,3 Our
success rate (74%; 36 of 50 cases) was somewhat
better than the 62% success rate (eight of 13 cases) in
their initial experience2 in which essentially the same
criteria were used, but was somewhat worse than the

VOL.120, No. I BAERVELDT IMPLANT IN COMPLICATED GLAUCOMAS 39

84% (31 of 37 cases) and 83% (30 of 36 cases)
success rates in their subsequent prospective compari-
3.
son of 350-mm2 and 500-mm2 implants, on the basis
of conventional outcome analysis by final intraocular
pressure.3
4.
In conclusion, the Baerveldt implant appears to be
an effective means of lowering intraocular pressure in
patients with complicated glaucoma. Subjectively (but 5.
without an objective basis for comparison), we found
the Baerveldt implant easier to place than the Mol-
teno implant, especially for surgeons who do not 6.
routinely implant setons. Except for a high incidence
of superior oblique tendon syndrome in the subset of
7.
patients with supranasal placement, we did not ob-
serve the high percentage of ocular motility problems 8.
reported by others after Baerveldt implantation. Fi-
nally, our 26% incidence of temporary serous choroi-
dal effusions with hypotony after stent suture removal 9.
indicates that a modification of our technique is
required to more finely titrate initial filtration.
10.
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11.
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experience with the Baerveldt 350-mm2 glaucoma implant
12.
and associated extraocular muscle imbalance. Ophthalmolo-
gy 1993;100:914-8.
2. Lloyd MAE, Baerveldt G, Heuer DK, Minckler DS, Martone
40 AMERICAN JOURNAL OF OPHTHALMOLOGY
JF. Initial clinical experience with the Baerveldt implant in
complicated glaucomas. Ophthalmology 1994;101:640-50.
Lloyd MA, Baerveldt G, Fellenbaum PS, Sidoti PA, Minckler
DS, Martone JF, et al. Intermediate-term results of a random-
ized clinical trial of the 350- versus the 500-mmz Baerveldt
implant. Ophthalmology 1994;101:1445-64.
Minckler DS, Heuer DK, Hasty B, Baerveldt G, Cutting RC,
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teno implant in complicated glaucomas. Ophthalmology
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Lloyd MA, Sedlak T, Heuer DK, Minckler DS, Baerveldt G,
Lee MB, et al. Clinical experience with the single-plate
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study. Ophthalmology 1992;99:679-87.
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McDonnell PJ, Robin JB, Schanzlin DJ, Minckler D,
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ogy 1988;95:364-9.
Beebe WE, Starita RJ, Fellman RL, Lynn JR, Gelender H.
The use of Molteno implant and anterior chamber tube
shunt to encircling band for the treatment of glaucoma in
keratoplasty patients. Ophthalmology 1990;97:1414-22.
Sherwood MB, Smith MF, Driebe WT Jr, Stern GA, Beneke
JA, Zam ZS. Drainage tube implants in the treatment of
glaucoma following penetrating keratoplasty. Ophthalmic
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Ball SF, Ellis GS Jr, Herrington RG, Liang K. Brown's
superior oblique tendon syndrome after Baerveldt glaucoma
implant [letter]. Arch Ophthalmol 1992;110:1368.
Munoz M, Parrish RK II. Strabismus following implantation
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JULY 1995