Viscocanalostomy combined with nearly 360-degree suture trabeculotomy for the treatment of primary congenital glaucoma: a preliminary report of a novel technique for trabeculotomy

Visco-Circumferential-Suture-Trabeculotomy Versus Rigid-Probe Viscotrabeculotomy in Neonatal-Onset Primary Congenital Glaucoma

PRCIS

Angle procedures are safe and relatively effective for neonatal onset PCG. Watchful delay in intervention to close to the second month of life is helpful in ensuring diagnosis and making surgery more successful and easier.

PURPOSE

The purpose of this study was to compare the surgical outcomes of visco-circumferential-suture-trabeculotomy (VCST) to rigid-probe double-entry viscotrabeculotomy (DEVT) and rigid-probe single-entry viscotrabeculotomy (SEVT) in infants with neonatal-onset primary congenital glaucoma (PCG).

DESIGN

This was a retrospective chart review.

PATIENTS AND METHODS

Retrospective chart review of 64 eyes of 64 infants with neonatal-onset PCG referred to Mansoura Ophthalmic Center in Mansoura, Egypt between February 2008 and November 2018. Study groups included VCST, DEVT, and SEVT, and follow-up covered 4 postoperative years. Complete (qualified) success was defined as intraocular pressure (IOP) ≤18 mm Hg and with 35% IOP reduction from baseline without (with) IOP-lowering medications or further surgical interventions, and without any sign of progression in corneal diameter, axial length, or optic disc cupping and without visual devastating complications.

RESULTS

The mean±SD age at presentation and at the surgery of the study children was 3.63±1.74 and 55.23±1.60 days, respectively. The mean±SD IOP and cup/disc ratio of all study eyes at presentation and at final follow-up were 34.91±0.82 mm Hg and 0.70±0.09 and 17.04±0.74 mm Hg and 0.63±0.08, respectively. Complete success was achieved in 54.5%, 43.5%, and 31.6% in the VCST, DEVT, and SEVT groups, respectively. A self-limited hyphema was the commonest complication in all groups.

CONCLUSIONS

Angle procedures are safe and marginally effective for the surgical treatment of neonatal-onset PCG, bringing IOP under control for at least 4 years of follow-up. Circumferential trabeculotomy as a first-line treatment has more favorable outcomes than rigid-probe SEVT. Rigid-probe viscotrabeculotomy offers an alternative to the noncompleted circumferential procedure.

Outcomes of Penetrating Canaloplasty in Childhood Glaucoma

PRCIS

Penetrating canaloplasty was safe and effective for the management of refractory childhood glaucoma.

PURPOSE

The purpose of this paper is to report the safety and efficacy of penetrating canaloplasty for the management of childhood glaucoma.

MATERIALS AND METHODS

This single-center prospective interventional case series enrolled 50 eyes of 32 patients with childhood glaucoma between July 2017 and July 2020. Penetrating canaloplasty to create direct communication between the anterior chamber and tensioning suture-dilated the Schlemm canal was performed through a trabecular meshwork ostium in the affected eyes. Preoperative and postoperative intraocular pressure (IOP), number of glaucoma medications, and procedure-related complications were recorded. Qualified and complete success was defined as IOP≥5 and ≤21 mm Hg with or without glaucoma medications, respectively.

RESULTS

A total of 43 eyes (86.0%) achieved 360 degrees catheterization of Schlemm canal and completed penetrating canaloplasty. The median age at surgery was 5 years (range, 10 d-17 y, mean 6.20±5.46 y). The mean IOP decreased from 33.11±10.89 mm Hg on 2 medications (median, range: 0-5) before surgery to 13.46±4.71 mm Hg on 0 medications (median, range:0-2) postoperatively at 12 months ( P <0.001). Complete and qualified success rates were 81.08% and 89.19%, respectively, at the 12-month follow-up. Hyphema (6/43, 13.95%) and a transient shallow anterior chamber with hypotony (5/43, 11.63%) were the most commonly observed early complications.

CONCLUSION

Penetrating canaloplasty demonstrated good safety and efficacy in eyes with childhood glaucoma, and may be considered an option for managing refractory childhood glaucoma.

Viscocanalostomy combined with trabeculotomy for management of refractory primary congenital glaucoma

PURPOSE

To investigate the outcome of viscocanalostomy combined with trabeculotomy (VCO+tbo) in primary congenital glaucoma (PCG) with history of failed trabeculotomy.

METHODS

In this prospective study, VCO+tbo was performed in 75 eyes of 46 patients with PCG who had not responded adequately to one angle surgery. Success was defined as intraocular pressure (IOP) of 6-21 mm Hg and at least 20% IOP drop at the last postoperative visit with (qualified) or without (complete) glaucoma medications.

RESULTS

Patients completed a mean follow-up of 31 ± 11 months. Complete success was achieved in 6 eyes (8%); qualified success, in 38 eyes (51%). In the 44 successfully treated eyes, IOP was reduced from a preoperative mean of 29.0 ± 5.8 to 15.7 ± 2.6 mm Hg, and the number of medications dropped from 2.6 ± 0.9 to 2.0 ± 1.0 (P < 0.001). In univariate analysis, the success rate was lower in patients with neonatal onset disease than subjects whose age at onset was 1-12 months (HR = 0.22; 95% CI, 0.05-0.93; P = 0.039). Children whose disease was first diagnosed after 1 year of age responded better than neonatal onset patients but worse than those with age of onset of 1-12 months; however, the difference was not statistically significant. Hyphema occurred in 27 eyes (36%) on day 1 and resolved spontaneously. Iatrogenic cyclodialysis occurred in one eye, which was surgically repaired after 1 month of treatment with cycloplegic agents.

CONCLUSIONS

In our study cohort, VCO+tbo was associated with successful outcomes in the majority of treated eyes.

Modified suture-assisted canaloplasty in Asians with primary open-angle glaucoma: a prospective study with 12-month follow-up

BACKGROUND

To evaluate the efficacy and safety of modified suture-assisted canaloplasty in Asians with primary open-angle glaucoma (POAG).

METHODS

A prospective, consecutive cases study, evaluating a modified canaloplasty by twisted 6/0 suture was performed on Asian POAG patients. Three modifications of this canaloplasty included opening the Schlemm's canal by viscocanalostomy, circumferential probing by a twisted 6/0 suture and loose suture of the superficial scleral flap. The twisted 6/0 suture was selected as a prober based on characteristical analysis of size and contact measurement as well as chemical composition conducted among 5/0, twisted 6/0 polypropylene sutures and the microcatheter. Success criteria were defined as intraocular pressure (IOP) ≤ 21 mmHg, 18 mmHg, 15 mmHg, and ≥ 20% reduction without (complete success) or with medications (qualified success). Efficacy was assessed by the success rate of circumferential catheterization, IOP values, the success rate of the surgery, the number of IOP-lowering medications, best-corrected vision acuity (BCVA), cup-to-disc ratio (C/D), and mean deviation (MD). Safety was evaluated by adverse events.

RESULTS

Forty eyes from 40 consecutive patients were included with a mean follow-up of 14.8 ± 3.0 months. Circumferential catheterization was successfully conducted in 36 eyes (90%). Mean IOP decreased from 26.2 ± 6.9 mmHg to 14.5 ± 2.7 mmHg at 12 months postoperatively. While medication numbers were reduced from 3.2 ± 0.6 to 0.5 ± 0.8 at month 12 (both p < 0.001). Qualified success rate was 97.2% [95% confidence interval (CI) 0.92-1.03], 86.1% (95% CI 0.74-0.98) and 66.7% (95% CI 0.51-0.83) at 12 months with three criteria. BCVA, C/D and MD did not show progression at 1-year follow-up (p > 0.05). Age, baseline IOP, and spherical equivalent negatively influenced the success rate significantly (all p < 0.05). Adverse events included hyphema (30.6%), IOP spike > 25 mmHg (8.3%), and peripheral synechia to the trabecular-Descemet's membrane (2.7%).

CONCLUSION

Twisted 6/0 suture can be an ideal material for cannulation. Modified suture-assisted canaloplasty is an effective, safe alternative with a cost-efficient feature for patients with POAG, especially in developing countries.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trial Registry ( ChiCTR1900028618 , 29/12/2019).

Comparison of viscocanalostomy plus suture-assisted near-360-degree trabeculotomy and viscocanalostomy plus rigid probe trabeculotomy in primary congenital glaucoma

PURPOSE

To compare the efficacy and safety of viscocanalostomy plus near-360-degree suture trabeculotomy (VST) with viscocanalostomy plus rigid probe trabeculotomy (VT) in treating primary congenital glaucoma (PCG) over a one-year follow-up.

METHODS

This consecutive retrospective study included patients with PCG confirmed within 3 years of age from March 2017 to October 2019. Efficacy was evaluated by comparing the postoperative intraocular pressure (IOP) curve and the success rate at one year after surgery. Safety was assessed by comparing the postoperative complications. The number of anti-glaucoma agents, horizontal corneal diameter (HCD) and cup-to-disc ratio (C/D) of the two surgical methods were also compared.

RESULTS

Data of 90 eyes from 61 patients were analysed. The baseline parameters of the two groups were similar. The IOP at 12 months after surgery in the VST group was 12.7 ± 4.8 mmHg, while that in the VT group was 15.8 ± 6.5 mmHg. The IOP at 6, 9 and 12 months postoperatively in the VST group was significantly lower than in the VT group (p < 0.05). Viscocanalostomy plus near-360-degree suture trabeculotomy (VST) remained a significant favourable factor for complete one-year success (93.6% versus 74.4%, p = 0.005) but not qualified one-year success (97.9% versus 88.4%, p = 0.06). The number of anti-glaucoma agents, HCD and C/D were reduced in both groups. Postoperative complications were not significantly different between the two groups.

CONCLUSIONS

In children with PCG, VST provides a more durable IOP control than VT over the one-year follow-up, with a similar safety profile.

Clinical outcomes of penetrating canaloplasty in patients with traumatic angle recession glaucoma: a prospective interventional case series

BACKGROUND/AIM

To evaluate the clinical outcomes of penetrating canaloplasty in traumatic angle recession glaucoma at 1 year.

METHODS

Patients with angle recession glaucoma underwent penetrating canaloplasty, a new Schlemm's canal-based internal drainage procedure, which creates a direct canal for flow of aqueous humour from the anterior chamber to the ostia of Schlemm's canal via a window created at the corneal scleral bed without use of antimetabolites. Postoperative intraocular pressure (IOP), number of glaucoma medications, and procedure-related complications were evaluated. Success was defined as an IOP ≤21 mm Hg without (complete) or with (qualified) use of glaucoma medication.

RESULTS

Forty eyes in 40 patients with angle recession glaucoma underwent successful circumferential catheterisation. The mean patient age was 42±13 years. In patients with penetrating canaloplasty that was deemed to be completely successful, the mean IOP decreased from a preoperative value of 37.8±12.3 mm Hg on 3.3±1.2 anti-glaucoma medications to 18.5±6.4 mm Hg on 1.2±1.4 medications, 14.9±4.6 mm Hg on 0.1±0.5 medications, 15.7±5.4 mm Hg on 0.1±0.4 medications and 14.8±3.6 mm Hg on 0.1±0.5 medications at 1, 3, 6 and 12 months postoperatively (p<0.05). Complete success was achieved in 35/40 eyes (87.5%) at 6 months and in 34/38 (89.5%) at 12 months. Hyphema (18/40, 45.0%) and transient IOP elevation (≥30 mm Hg, 9/40, 22.5%) were the most common postoperative complications.

CONCLUSION

Penetrating canaloplasty significantly reduces IOP and has a high success rate in angle recession glaucoma.

TRIAL REGISTRATION NUMBER

ChiCTR1900020511.

Microcatheter-Assisted Circumferential Trabeculotomy versus Conventional Trabeculotomy for the Treatment of Childhood Glaucoma: A Meta-analysis

Background

The aim of the current meta-analysis was to compare the efficacy of microcatheter-assisted circumferential trabeculotomy (Group 1) with that of conventional trabeculotomy (Group 2) for the treatment of childhood glaucoma.

Methods

Published studies were systematically searched via the Web of Science, PubMed, Embase, and Cochrane Library databases. Odds ratios and 95% confidence intervals were calculated for dichotomous variables. Mean ± the standard deviation, mean difference, and 95% confidence intervals were calculated for continuous variables. Heterogeneity was assessed. Random effects modeling and RevMan version 5.30 were used to analyze the data.

Results

Five eligible studies were included in the meta-analysis. Mean postoperative intraocular pressures were significantly lower in Group 1 than in Group 2 at 3 months (P = 0.03), 6 months (P = 0.03), and 12 months (P = 0.007) postoperatively. The complete success rates were higher in Group 1 than in Group 2 at 3 months (P = 0.008), 6 months (P = 0.01), and 12 months (P = 0.004) postoperatively, as were the respective qualified success rates (P = 0.04, P = 0.0007, and P = 0.001). The pooled estimate indicated lower antiglaucoma medication use in Group 1, especially at 1 month postoperatively (P = 0.003).

Conclusions

Microcatheter-assisted circumferential trabeculotomy resulted in excellent intraocular pressure control, higher success rates, and the utilization of less medication than conventional trabeculotomy for childhood glaucoma. Therefore, microcatheter-assisted circumferential trabeculotomy may be recommended as the initial procedure for the treatment of childhood glaucoma.