Antimetabolite and releasable suture augmented filtration surgery in refractory pediatric glaucomas

Outcome of Bleb Needling With 5-Fluorouracil in Failed Filtering Procedures in Pediatric Glaucoma

PURPOSE

To determine the surgical outcomes of bleb needling and the risk factors of failure of needling after failed filtration surgeries in patients with pediatric glaucoma.

METHODS

The medical records of patients who underwent needling with 5-fluorouracil following filtering surgeries (trabeculectomy, combined trabeculectomy, and trabeculotomy) between January 2012 and December 2016 were retrospectively reviewed. At the 1-year follow-up visit, complete success and qualified success were defined as an intraocular pressure (IOP) of less than 18 mm Hg with and without antiglaucoma medication, respectively.

RESULTS

Forty-five eyes that underwent needling and fulfilled the study criteria were included in the analysis. The mean age at needling was 9.6 years. The mean time interval between filtration surgery and the first needling procedure was 57.3 days. Thirty-eight of 45 eyes (84.4%) had undergone needling within 3 months after the primary surgery. Cumulative success was achieved in 35 eyes (77.7%) after needling (complete success in 22 eyes and qualified success in 13 eyes). Mean follow-up after needling was 18.9 months. The mean IOP before and after needling was 31.7 ± 9.45 and 16.6 ± 5.68 mm Hg, respectively (P < .00001). Steroid-induced glaucoma (P = .01), high IOP prior to the first filtration surgery (P = .01), and an inability to achieve low IOP (< 9 mm Hg, P = .04) immediately after needling were significant risk factors associated with failure.

CONCLUSIONS

Bleb needling is an efficient method for lowering IOP after a failed trabeculectomy or combined trabeculectomy and trabeculotomy in the pediatric population. [J Pediatr Ophthalmol Strabismus. 2021;58(2):118-125.].

Decompression retinopathy following nonpenetrating deep sclerectomy for primary congenital glaucoma

BACKGROUND

To describe a unique case of decompression retinopathy manifesting as pre-macular subhyaloid hemorrhage that occurs in a nine-day old child after undergoing a non-penetrating deep sclerectomy for primary congenital glaucoma.

CASE PRESENTATION

We report a single case of a 9-day-old boy who was referred to our department of ophthalmology for bilateral buphtalmia and corneal edema. He presented marked elevation of the intraocular pressure in both eyes (22 mmHg and 26 mmHg, in the right eye and left eye respectively) associated with significant optic nerve cupping. Non-penetrating deep sclerectomy was performed for each eye, with effective reduction of the intraocular pressure during the first week postoperatively (11 mmHg and 7 mmHg in the right eye and left eye respectively). The right eye presented an isolated subhyaloid hemorrhage located in the pre-macular area, persisting 3 weeks after the initial surgery and requiring pars-plana vitrectomy to clear the visual axis. This uncommon complication was identified as decompression retinopathy. The intraocular pressure remained controlled in the normal range three years after initial surgery in both eyes, with reversal of optic disc cupping.

CONCLUSIONS

Decompression retinopathy is a potential complication after non-penetrating deep sclerectomy in primary congenital glaucoma, requiring prompt treatment strategy to prevent potential organic amblyopia.

Regular Versus Releasable Sutures in Surgery for Primary Congenital Glaucoma

PURPOSE

To compare releasable and regular sutures in combined angle and filtering surgery for primary congenital glaucoma.

METHODS

A prospective study was conducted on 39 eyes (26 right eyes) of 39 children (20 boys; 19 girls) who had primary congenital glaucoma treated with combined trabeculotomy-trabeculectomy with mitomycin C and scleral flap closure with regular or releasable sutures. Follow-up was 24 months. Success rates (defined as an intraocular pressure [IOP] < 16 mm Hg without hypotony-related complications and/or lack of IOP-related progression of the disease) were studied and complications were noted.

RESULTS

The mean age of the study participants was 6.7 ± 5.8 months (range: 1 to 24 months; median: 5 months) in the regular suture group (20 eyes) and 5.3 ± 2.8 months (range: 1 to 13 months; median: 5 months) in the releasable suture group (19 eyes). The initial glaucoma surgery was successful in 13 (65%) and 13 (68.4%) eyes in the regular suture and releasable suture groups, respectively. The mean IOP was 17.4 ± 7.3 and 16.0 ± 5.4 mm Hg (P = .84) preoperatively and 8.0 ± 9.7 and 5.8 ± 3.6 mm Hg (P = .40) at the end of follow-up in the regular suture and releasable suture groups, respectively. There was no statistically significant difference in the clinical parameters between the two groups. Complications included rhegmatogenous retinal detachment, cataract, and superior lens subluxation, with each complication developing in one eye.

CONCLUSIONS

Releasable sutures were not more advantageous than regular sutures in combined trabeculotomy-trabeculectomy with mitomycin C surgery for primary congenital glaucoma. [J Pediatr Ophthalmol Strabismus. 2017;54(5):295-301.].

Excision of Tenon Capsule in Pediatric Trabeculectomy: A Controlled Study

PURPOSE

To compare the results of trabeculectomy alone and combined with partial tenonectomy in pediatric glaucoma patients.

METHODS

This was a prospective, controlled, cohort study that included 64 eyes of 46 children younger than 12 years with uncontrolled glaucoma, who underwent trabeculectomy with mitomycin C in an institutional setting. Patients were randomized to undergo a trabeculectomy either with (group A) or without (group B) tenonectomy. Children were followed up prospectively for 24 months. Kaplan-Meier survival analysis and mean survival times with 95% confidence intervals (CIs) were calculated. Postoperative results were compared at 3, 6, 12, and 24 months of follow-up. The main outcome measures were: intraocular pressure (IOP), surgical success, postoperative interventions, and complications in both groups.

RESULTS

Mean postoperative IOP was lower in group A at all postoperative visits (19.2 mm Hg in group A vs. 22.1 mm Hg in group B at 24 mo, P=0.05). There was a tendency toward greater use of glaucoma medications in group B (P<0.001). Cumulative probability of survival at 24 months was 70% (95% CI, 48%-86%) for group A, and 45% (95% CI, 28%-63%) for group B (P=0.09). Mean survival time was significantly longer (P=0.04) in group A (16.6 mo) than in group B (11.6 mo). Encapsulation occurred more frequently (P=0.03) in group B (25%) than in group A (3%).

CONCLUSIONS

Excision of the Tenon capsule could help achieve better IOP control in pediatric glaucoma surgery.

Updates on the Surgical Management of Pediatric Glaucoma

Childhood glaucoma is known to be one of the most challenging conditions to manage. Surgical management is more complicated than in adults because of differences in anatomy from adults along with variations in anatomy caused by congenital and developmental anomalies, wide-ranging pathogenetic mechanisms, a more aggressive healing response, and a less predictable postoperative course. Challenges in postoperative examination and management in less cooperative children and the longer life expectancies preempting the need for future surgeries and reinterventions are also contributing factors. Angle surgery is usually the first-line treatment in the surgical management of primary congenital glaucoma because it has a relatively good success rate with a low complication rate. After failed angle surgery or in cases of secondary pediatric glaucoma, options such as trabeculectomy, glaucoma drainage devices, or cyclodestructive procedures can be considered, depending on several factors such as the type of glaucoma, age of the patient, and the severity and prognosis of the disease. Various combinations of these techniques have also been studied, in particular combined trabeculotomy-trabeculectomy, which has been shown to be successful in patients with moderate-to-advanced disease. Newer nonpenetrating techniques, such as viscocanalostomy and deep sclerectomy, have been reported in some studies with variable results. Further studies are needed to evaluate these newer surgical techniques, including the use of modern minimally invasive glaucoma surgeries, in this special and diverse group of young patients.

Outcomes of Ahmed glaucoma valve implantation in advanced primary congenital glaucoma with previous surgical failure

Purpose

The purpose of this study was to evaluate the intermediate surgical results of Ahmed glaucoma valve (AGV) implantation in patients less than 7 years of age, with advanced primary congenital glaucoma who have failed previous surgeries.

Patients and methods

Consecutive patients with advanced primary congenital glaucoma that failed previous operations and had undergone subsequent AGV implantation were evaluated retrospectively. Surgical success was defined as 1) intraocular pressure (IOP) ≥6 and ≤21 mmHg; 2) IOP reduction of at least 30% relative to preoperative values; and 3) without the need for additional surgical intervention for IOP control, loss of light perception, or serious complications.

Results

Fourteen eyes of eleven patients were studied. Preoperatively, the average axial length was 27.71±1.52 (25.56–30.80) mm, corneal diameter was 14.71±1.07 (13.0–16.0) mm, cup-to-disc ratio was 0.95±0.04 (0.9–1.0), and IOP was 39.5±5.7 (30–55) mmHg. The mean follow-up time was 18.29±10.96 (5–44, median 18) months. There were significant reductions in IOPs and the number of glaucoma medications (P<0.001) postoperatively. The IOPs after operation were 11.3±3.4, 13.6±5.1, 16.3±2.7, and 16.1±2.6 mmHg at 1 month, 6 months, 12 months, and 18 months, respectively. Kaplan–Meier estimates of the cumulative probability of valve success were 85.7%, 71.4%, and 71.4% at 6, 12, and 18 months, respectively. Severe surgical complications, including erosion of tube, endophthalmitis, retinal detachment, choroidal detachment, and delayed suprachoroidal hemorrhage, occurred in 28.6% cases.

Conclusion

AGV implantation remains a viable option for patients with advanced primary congenital glaucoma unresponsive to previous surgical intervention, despite a relatively high incidence of severe surgical complications.

A Surgical Approach to Pediatric Glaucoma

Glaucoma in children differs from adult-onset disease and typically requires surgical intervention. However, affected children exhibit a spectrum of disease severity and prospective data guiding the choice of operation are lacking. This article reviews common procedures and a surgical approach to pediatric glaucoma.

Current surgical options for the management of pediatric glaucoma

Currently, there are numerous choices for the treatment of pediatric glaucoma depending on the type of glaucoma, the age of the patient, and other particularities of the condition discussed in this review. Traditionally, goniotomy and trabeculotomy ab externo have been the preferred choices of treatment for congenital glaucoma, and a variety of adult procedures adapted to children have been utilized for other types of pediatric glaucoma with variable results and complications. More recently, seton implantations of different types have become more popular to use in children, and newer techniques have become available including visualized cannulation and opening of Schlemm's canal, deep sclerectomy, trabectome, and milder more directed cyclodestructive procedures such as endolaser and transcleral diode laser cyclophotocoagulation. This paper reviews the different surgical techniques currently available, their indications, results, and most common complications to allow the surgeon treating these conditions to make a more informed choice in each particular case. Although the outcome of surgical treatment in pediatric glaucoma has improved significantly, its treatment remains challenging.

Polypropylene vs silicone Ahmed valve with adjunctive mitomycin C in paediatric age group: a prospective controlled study

PURPOSE

To compare the results of silicone and polypropylene Ahmed glaucoma valves (AGV) implanted during the first 10 years of life.

METHODS

A prospective study was performed on 50 eyes of 33 patients with paediatric glaucoma. Eyes were matched to either polypropylene or silicone AGV. In eyes with bilateral glaucoma, one eye was implanted with polypropylene and the other eye was implanted with silicone AGV.

RESULTS

Fifty eyes of 33 children were reviewed. Twenty five eyes received a polypropylene valve, and 25 eyes received a silicone valve. Eyes implanted with silicone valves achieved a significantly lower intraocular pressure (IOP) compared with the polypropylene group at 6 months, 1 year, and 2 years postoperatively. The average survival time was significantly longer (P=0.001 by the log-rank test) for the silicone group than for the polypropylene group and the cumulative probability of survival by the log-rank test at the end of the second year was 80% (SE: 8.0, 95% confidence interval (CI): 64-96%) in the silicone group and 56% (SE: 9.8, 95% CI: 40-90%) in the polypropylene group. The difference in the number of postoperative interventions and complications between both groups was statistically insignificant.

CONCLUSION

Silicone AGVs can achieve better IOP control, and longer survival with less antiglaucoma drops compared with polypropylene valves in children younger than 10 years.

Deep sclerectomy in pediatric glaucoma filtering surgery

PURPOSE

To study the additive value of deep sclerectomy to the procedure of combined trabeculotomy-trabeculectomy with mitomycin C (CTTM) for the treatment of primary congenital glaucoma.

STUDY DESIGN

This study is a prospective, randomized case series.

PATIENTS AND METHODS

The study was conducted on 20 eyes of 20 children with primary congenital glaucoma presenting to the Department of Ophthalmology of the Alexandria Main University Hospital. Preoperative examination under anesthesia was followed by surgical intervention. Postoperative examinations were conducted immediately after surgery and at 1, 2, 3, 6, 9, and 12 months. Intraoperative and postoperative complications, as well as operative time, were recorded.

RESULTS

The mean (±SD, range) age of the study patients in the CTTM group and in the combined trabeculotomy-trabeculectomy with mitomycin C with deep sclerectomy (CTTM-DS) group was 4.7 (±2.0, 2-8) and 7.0 (±3.8, 3-13) months, respectively. The mean (±SD, range) preoperative intraocular pressure (IOP) in the CTTM and CTTM-DS groups was 16.7 (4.3, 10-26) and 16.4 (8.4, 8-36), respectively, and these dropped at 12 months of follow-up to 4.9 (2.0, 2-8) and 5.6 (3.3, 2-10), respectively. The mean (±SD, range) of the duration of the operation in the CTTM and the CTTM-DS was 57 (±8, 50-71) min and 53 (±7, 42-64) min, respectively (P=0.428). Two eyes (20%) in the CTTM-DS group developed hypotony disc edema at the first 2 months and resolved spontaneously thereafter. No other complications were noted in either of the groups.

CONCLUSION

The addition of deep sclerectomy to the procedure of CTTM in pediatric glaucoma surgery facilitates the finding of Schlemm's canal, shortens the duration of surgery, and is not associated with any additional complications. Hence, the author recommends the addition of deep sclerectomy to CTTM surgery for primary congenital glaucoma.

[Glaucoma surgery in childhood]

Technical characteristics and a long-term therapeutic strategy due to a long life expectancy play a key role in pediatric glaucoma surgery. The well-established angle surgery (goniotomy and trabeculotomy) achieves successful results in primary childhood glaucoma. Trabeculectomy seems to have been displaced as a secondary approach by glaucoma drainage devices (GDD) in primary childhood glaucoma due to inferior results, especially for children under 3 years of age. Even for secondary childhood glaucoma the results of GDD are encouraging, especially for therapy refractory aphakic glaucoma. In the first 2 years after GDD surgery success rates are about 80% for pediatric glaucoma and the results appear to be independent of the type of glaucoma and implant used. The complications of GDD are balanced to the faster intraocular pressure (IOP) control during the phase of visual acuity development. Cyclodestructive procedures may be applied as a secondary adjuvant approach but they increase the risk of conjunctival scarring and hypotony for subsequent procedures.