Goniotomy versus circumferential trabeculotomy with an illuminated microcatheter in congenital glaucoma

Outcome of illuminated microcatheter-assisted circumferential trabeculotomy following failed angle surgery in PAX6 aniridic glaucoma: a case report and literature review

BACKGROUND

Aniridia is a rare eye disorder with a high incidence of glaucoma, and surgical intervention is often needed to control the intraocular pressure (IOP). Here, we reported a case of illuminated microcatheter-assisted circumferential trabeculotomy (MAT) performed on an aniridic glaucoma patient following a previous failed angle surgery. The surgical procedures for aniridic glaucoma were also reviewed.

CASE PRESENTATION

A 21-year-old man, diagnosed with aniridic glaucoma, came to our hospital consulting for the poor control of left eye's IOP despite receiving goniotomy surgery 3 years ago. The IOP was 26 mmHg with maximum topical antiglaucoma eyedrops. The central cornea was opaque and the majority of iris was absent. The gonioscopy and ultrasound biomicroscopy (UBM) demonstrated that 360° anterior chamber angle was closed. The whole exome sequencing of peripheral blood confirmed a 13.39 Mb copy number loss at chromosome 11p15.1p13, containing PAX6 and WT1 gene. The 360° MAT surgery was performed on his left eye. At 1-year follow-up, the IOP was 19mmHg with 2 kinds of topical antiglaucoma medications, and the postoperative UBM demonstrated the successful incision of the anterior chamber angle.

CONCLUSIONS

The case presented here exhibited a case of aniridic glaucoma treated by MAT surgery. The MAT surgery may be an effective option for IOP control in aniridic glaucoma patients following a previous failed angle surgery.

Microcatheter-Assisted Circumferential Trabeculotomy After Failed Glaucoma Surgeries in Childhood Glaucoma

PURPOSE

To evaluate the outcomes of microcatheter-assisted trabeculotomy (MAT) in childhood glaucoma (primary congenital glaucoma [PCG], juvenile open-angle glaucoma [JOAG], and secondary childhood glaucoma [SCG]) after failed glaucoma surgery.

DESIGN

Retrospective interventional case series.

METHODS

Patients with childhood glaucoma who underwent MAT after failed glaucoma surgery with at least 12 months of follow-up were evaluated. Pre- and postoperative intraocular pressure (IOP) and the number of glaucoma medications were recorded and compared. Success was defined as an IOP ≤21 mm Hg with or without glaucoma medication. Analysis of variance was used to compare the glaucoma subgroups.

RESULTS

Forty-five eyes (42 patients) with a median follow-up period of 19 months were included. The median age at the time of MAT was 10 (range, 0.8-33) years. The mean number of previous surgeries was 1.3 ± 0.5. The IOP had significantly reduced from baseline in all PCG, JOAG, and SCG patients (27.9 ± 4.5 vs 16.3 ± 8.0 mm Hg, P = .001; and 30.8 ± 9.4 vs 13.5 ± 3.0 mm Hg, P < .001; and 31.5 ± 7.1 vs 16.5 ± 5.3 mm Hg, P = .001, respectively). Fewer glaucoma medications were needed after MAT in all 3 groups (each P < .001). At the last visit, the total success rates in PCG, JOAG, and SCG were 93.8%, 100%, and 88.9%, respectively. No severe complications were observed.

CONCLUSION

MAT can effectively manage PCG, JOAG, and SCG after failed surgeries, providing successful outcomes and no serious complications. Following failed glaucoma surgeries, MAT may offer these patients with childhood glaucoma an excellent opportunity to achieve IOP control.

Long-term Outcomes in Patients Undergoing Surgery for Primary Congenital Glaucoma between 1991 and 2000: A Single-Center Database Study

PURPOSE

To estimate the long-term surgical and visual outcomes in patients with primary congenital glaucoma (PCG) who completed at least 20 years of follow-up.

DESIGN

Retrospective study.

PARTICIPANTS

Two hundred twenty eyes of 121 patients undergoing surgery for PCG between January 1991 and December 2000 and who returned for a follow-up visit from January 2021 through January 2022.

METHODS

Retrospective review of medical records of patients who underwent primary combined trabeculotomy-trabeculectomy (CTT) without mitomycin C as an initial procedure. Success was defined as complete when intraocular pressure (IOP) was ≥ 6 mmHg and ≤ 21 mmHg without glaucoma medication and as qualified when up to 2 glaucoma medications were required. Failure was defined as uncontrolled IOP with more than 2 glaucoma medications, need for a second IOP-lowering procedure, chronic hypotony (IOP < 6 mmHg on 2 consecutive visits), or any sight-threatening complication. A mixed-effects model using maximum likelihood estimation was used in estimation of eye-based variables and to make comparisons between different visits. Kaplan-Meier survival analysis was used to estimate the probabilities of surgical and functional successes. Cox proportional hazards regression using sandwich clustered estimation was used to evaluate risk factors for failure and poor visual outcome.

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of patients who demonstrated complete success over the 20-year follow-up. Secondary outcome measures included rate of surgical failure and need for reoperation for glaucoma, visual acuity, refractive errors, risk factors for poor outcome, and complications.

RESULTS

Kaplan-Meier survival analysis revealed 1-year, 10-year, and 20-year complete success rates of 90.7%, 78.9%, and 44.5%, respectively. In univariate analysis, surgical failure was higher among patients with any additional non-glaucoma intraocular surgery. None of the clinical parameters were associated significantly with failure in multivariable analysis. Overall, the proportion of eyes with good, fair, and poor visual outcomes was 33.2%, 16.4%, and 50.4%, respectively. Myopia was seen in 68.9% eyes. Twenty-eight eyes of those who underwent primary CTT (14.4%) required second surgery for IOP control. No significant intraoperative complications occurred. Six eyes required enucleation because of painful blind eye.

CONCLUSIONS

In this large cohort of patients with PCG, CTT is a useful procedure. It provides good IOP control and moderate visual recovery that remained over a 20-year follow-up after surgery.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Approach to primary congenital glaucoma: A perspective

Primary congenital glaucoma (PCG) occurs worldwide and has a broad range of ocular manifestations. It poses a therapeutic challenge to the ophthalmologist. A proper diagnostic evaluation under anesthesia is advisable for all children who do not cooperate for an office examination. Medical therapy only serves as a supportive role, and surgical intervention remains the principal therapeutic modality. Angle incision surgery such as goniotomy or trabeculotomy ab externo is the preferred choice of surgery in the Caucasian population. Primary combined trabeculotomy-trabeculectomy with or without antifibrotic therapy is the preferred choice in certain regions such as India and the Middle East where the disease usually presents with severe forms of corneal edema along with megalocornea. In refractory cases, trabeculectomy with antifibrotic therapy or glaucoma drainage devices are available options in the armamentarium. Cycloablative procedures should be reserved for eyes with poor visual potential. Myopia is common among children with PCG, and appropriate optical refractive correction in the form of glasses or contact lenses should be provided. Amblyopia therapy should be instituted to ensure overall visual development in the early developmental years. Low-vision rehabilitation services should be provided to children with vision impairment. Long-term follow-up is mandatory and carers of children with PCG should be counseled and educated about this need. Regardless of the visual outcomes, clinicians should emphasize the need for education of these children during the clinic visit. The overall goal of the management should be to improve the overall quality of life of the children with PCG and their carers.

Current surgical techniques for the management of pediatric glaucoma: A literature review

Pediatric glaucoma surgery is challenging due to its diverse and complex pathophysiology, altered anterior segment anatomy, greater potential for failure, and complications compared to adult patients. Moreover, numerous challenges are associated with long-term postoperative management. Thus, when dealing with childhood glaucoma, it is important to consider the potential complications in addition to the benefits of each intervention. The purpose of this article is to review recently published literature to shed light on the most recent surgical techniques for the safe and effective treatment of childhood glaucoma. Current literature shows that goniotomy and trabeculotomy are the first choices for the management of primary congenital glaucoma. Although older children with phakic eyes seem to benefit from trabeculectomy with adjunctive mitomycin C, it carries a long-term risk of bleb-related endophthalmitis. Glaucoma drainage devices may be preferred for patients with secondary or refractory glaucoma. However, hypotony or tube-related complications are common and encountered more often in children than in adults. Cyclodestructive procedures are also an option for cases in which filtering surgery has failed, but they can also be used as a temporizing measure to reduce the rate of complications in high-risk patients. However, their outcomes can be unpredictable, in terms of efficiency and complications. Finally, minimally invasive glaucoma surgery (MIGS) as the sole alternative treatment or as an adjunctive surgical procedure is a relatively new path for pediatric patients.

Gonioscopy-assisted transluminal trabeculotomy for congenital glaucoma secondary to Klippel-Trenaunay-Weber Syndrome: A case report

Purpose

To describe the case of a 9-year-old boy with congenital glaucoma secondary to Klippel - Trenaunay - Weber Syndrome (KTW) with a history of trabeculotomy in both eyes (BE) and further trabeculectomy in the left eye (LE) presented with high intraocular pressure (IOP) and progression in the LE despite maximum tolerated medical therapy.

Observations

GATT surgery was performed firstly in the LE, followed by the right eye (RE) two months apart since the IOP in the RE started to increase later on. First post-operative day the IOP was under 15 mmHg. In the last visit, 6 months after the first surgery, IOPs were 10 and 11 mmHg RE and LE, on one fixed combination; slit lamp examinations were normal with wide open angles and a good view of the Schlemm's Canal (SC) posterior wall.

Conclusions and Importance

GATT surgery can be done after failed incisional surgery in children with glaucoma secondary to KTW syndrome.

Illuminated Microcatheter Passage Assisted Circumferential Trabeculotomy and Trabeculectomy (IMPACTT): An improved surgical procedure for Primary Congenital Glaucoma

PURPOSE

To report an improved surgical procedure for primary congenital glaucoma (PCG).

CASE REPORT

An apparently healthy 4-month-old male child was referred by an ophthalmologist with the preliminary diagnosis of congenital glaucoma. Office examination followed by evaluation under anaesthesia confirmed the diagnosis of advanced PCG in both eyes. Horizontal corneal diameter was 13.5 mm in both eyes and intraocular pressure was 36 mmHg in both eyes. The child was operated on both eyes in the same session. An illuminated microcatheter passage assisted circumferential trabeculotomy and trabeculectomy (IMPACTT) was performed. Two months postoperatively, the IOPs were 12 and 10 mmHg in the right and left eye, respectively, and the cornea was clear except for the presence of Haab's striae in both eyes. The child's visual acuity (binocularly) was 4 cycles/degree as recorded with Teller acuity cards.

CONCLUSIONS

Illuminated microcatheter passage assisted circumferential trabeculotomy and trabeculectomy (IMPACTT) is safe and effective and may represent an improved surgical procedure for the management of advanced PCG.

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.

Combined nasal goniotomy - temporal trabeculotomy (NGTT) for circumferential angle surgery in primary congenital glaucoma

PURPOSE

To assess the safety and efficacy of combining nasal goniotomy with temporal trabeculotomy in the management of primary congenital glaucoma.

DESIGN

Case series.

METHODS

Fifteen eyes of eleven children (3-12 months old at presentation) were enrolled in this study after the establishment of PCG diagnosis based on the criteria placed by the World Glaucoma Association. Combined nasal goniotomy and temporal trabeculotomy were done on each eye in an attempt to perform almost 360 degrees circumferential angle surgery without disturbing the superior 180 degrees of conjunctiva to preserve it for future filtering glaucoma surgeries.

RESULTS

By first month, average IOP was 10.5 ± 4.3 mmHg with a 65.3% reduction from average pre-operative IOP. Almost the same percentage of reduction was maintained at 3^rd,6^th and 12^th months postoperative visits with average IOP of 11.9 ± 4.65, 11.8 ± 2.77 and 13 ± 2.82 mmHg (60.7%, 61.1% and 57.2% reduction from pre-operative average). According to success rates, complete success has been achieved in all eyes but one (93.3%), with minor complications in 4 out of 15 eyes (26.6%) that did not affect IOP outcome. Nine out of fifteen eyes completed 18 months post-operative follow-up visits with a successfully, maintained target average IOP of 13.3 ± 3.0 mmHg (57.2% reduction). All of the mean IOP readings during post-operative follow-up period were significantly lower when compared to pre-operative IOP (p < 0.0001). Only one eye had persistently elevated IOP of 26 mmHg at 1^st and 3^rd months post-operatively that necessitated a subsequent subscleral trabeculectomy which succeeded in controlling the pressure bringing it down to 15 mmHg on topical medications.

CONCLUSION

Nasal goniotomy - temporal trabeculotomy (NGTT) is the combination of two well established surgeries that exploits the advantages of circumferential angle surgery while sparing the superior conjunctiva completely for future surgeries if needed. This new procedure was safe and effective in lowering IOP by an average of 60% from pre-operative IOP with a sustained effect till 18 months post-operatively. We believe that this surgery might be added to the armentarium of the surgical management of infantile glaucomas with other circumferential angle surgeries.

Results of childhood glaucoma surgery over a long-term period

PURPOSE

To evaluate long-term results of glaucoma surgery in newborn and infants with glaucoma.

METHODS

Seventy-nine eyes of 52 children (age: 3 weeks-15.3 years) with primary congenital or secondary glaucoma treated between 2015 and 2017 were included. The median follow-up time was 3.9 years. Conventional probe trabeculotomy, 360° catheter-assisted trabeculotomy, filtering and cyclodestructive surgery were compared. Strict criteria for surgical success were applied: Complete surgical success (IOP below target IOP, no further surgery) and incomplete surgical success (additional surgery allowed) were analyzed, and IOP at baseline and last follow-up was compared.

RESULTS

Intraocular pressure (IOP) was significantly reduced in primary congenital (preoperative IOP: 27.8 ± 7.5 mmHg vs. postoperative IOP: 14.2 ± 4.5 mmHg) and secondary glaucoma (preoperative IOP: 29.2 ± 9.1 mmHg vs. postoperative IOP: 16.6 ± 4.7 mmHg). 90% of all eyes reached target IOP with or without medication allowing for additional surgeries. As first surgery, 360° catheter-assisted trabeculotomy had a tendency to higher surgical success than other surgical approaches, while cyclodestructive procedures had lowest.

CONCLUSIONS

We found very promising surgical results in our childhood glaucoma patient group. Surgical success in both congenital and secondary glaucoma was high.

Microcatheter-Assisted Circumferential Trabeculotomy in Primary Congenital Glaucoma: Long-Term Clinical Outcomes

Purpose: The purpose of this study was to report the long-term efficacy and clinical outcomes of microcatheter-assisted circumferential trabeculotomy (MCT) in children with primary congenital glaucoma (PCG). Methods: This is a single-center retrospective study including consecutive children with PCG who underwent MCT with > two years follow up. The primary outcome was surgical success, defined as intraocular pressure (IOP) ≤ 21 mmHg with (qualified) or without (complete) medications, measured at six months, one year, and then annually. Secondary outcomes were visual acuity (VA), refraction, axial length (AXL), complications, reinterventions, and number of medications. Results: Twelve eyes of ten patients were included. In eight children only one eye was affected. The mean ± standard deviation (SD) age at surgery was 6.3 ± 4.1 months. The mean postoperative follow-up was 66 ± 35 months. The mean IOP was 34.3 ± 9.6 mmHg preoperatively and 14.6 ± 2.3 mmHg postoperatively at the last visit (p < 0.001). Complete success was achieved at all time points in 10 out of 12 eyes, while 2 eyes had a qualified success. At three years of age, the mean VA of the operated eyes was 0.25 ± 0.12 logMAR, the mean spherical equivalent was −0.78 ± 1.43 diopters, and the mean AXL was 23.78 mm. Transient hyphema was the only complication observed. None of the children required additional glaucoma surgery. Conclusions: Circumferential trabeculotomy for PCG effectively lowers the IOP at more than two years after surgery. Following this procedure, the prognosis for the visual function is good, and the refractive error is low. Postoperative complications were not significant.

Ab Interno vs. Ab Externo Microcatheter-Assisted Circumferential Trabeculotomy in Treating Patients With Primary Open-Angle Glaucoma

Background: Circumferential trabeculotomy have evolved from ab externo to ab interno approach. Both procedures may lower IOP, but it is unclear which maybe a superior approach.

Purpose: To compare the outcomes of ab interno and ab externo circumferential trabeculotomy in patients with primary open-angle glaucoma.

Design: Retrospective, comparative case series.

Participants: Primary open angle glaucoma patients undergoing ab interno (40 patients in Group 1) or ab externo (54 patients in Group 2) circumferential trabeculotomy, with about one half of them having prior incisional glaucoma surgery.

Methods: Outcomes including intraocular pressure (IOP), glaucoma medications and surgical complications were analyzed.

Main Outcome Measures: IOP, medications and surgical success defined as an IOP of ≤ 21 mmHg and a reduction of IOP ≥20% from baseline (criterion A) or IOP ≤ 18 mmHg and a reduction of IOP 20% from baseline (criterion B) with (qualified success) or without (complete success) medications.

Results: At 1 year, IOP decreased by 37.1% (26.0–14.8 mmHg) in Group 1 and 39.5% (28.5–15.1 mmHg) in Group 2. Medications decreased from 3.5 in Group 1 and 3.6 in Group 2 pre-operatively to 0.6 ± 1.0 and 0.3 ± 0.6 post-operatively, respectively. Success rates did not differ significantly between groups based on criterion A (complete and qualified success: 68.7 and 81.9% in Group 1, and 75.3 and 90.4% in Group 2, respectively) or criterion B (complete and qualified success: 58.2 and 79.3%in Group 1, and 69.5 and 88.4% in Group 2, respectively). For eyes with prior filtration surgeries, the mean percent reduction of IOP (41.7 ± 32.7% in Group 1, 39.7 ± 27.8% in Group 2, P = 0.724) and the mean medication reduction (2.9 ± 1.6 in Group 1, 3.4 ± 1.0 in Group 2, P = 0.454) were not significantly different.

Conclusions: Ab interno circumferential trabeculotomy achieved comparable outcomes to ab externo trabeculotomy and may be an effective surgical option for patients with primary open-angle glaucoma.

Microcatheter-Assisted Trabeculotomy Combined With Deep Sclerectomy and Trabeculectomy in Young to Middle-Aged Adults With Advanced Primary Open-Angle Glaucoma: 1-Year Result

Objective: We aimed to evaluate the safety and clinical efficacy of ab externo microcatheter-assisted trabeculotomy combined with deep sclerectomy and trabeculectomy (MATT-DS-Trab) in the surgical management of advanced primary open-angle glaucoma (POAG).

Methods: According to the inclusion criteria, we retrospectively collected and analyzed 37 POAG cases in advanced stage who received MATT-DS-Trab. The intraocular pressure (IOP), best corrected visual acuity (BCVA), use of anti-glaucoma drugs, shape of the filtering bleb, size of the scleral lake, complications, and the surgical success rate were recorded.

Results: The mean IOP was 37.50 ± 8.11 mmHg before the operation, while it depleted to 10.08 ± 2.01 and 11.43 ± 2.07 mmHg at 1 week and 12 months after the operation, respectively (both P < 0.001 compared to preoperative IOP). From none to two kinds of anti-glaucoma drugs were used 12 months after surgery on the patients, which were significantly reduced compared with that preoperatively (P < 0.001). An L-type filtering bleb was the main form at all time points after the operation. At 12 months following surgery, an F-type filtering bleb accounted for 5.41% and no E-type filtering bleb was recorded. The length and height of the scleral lake shrunk with time, but there was no statistical significance (P > 0.05). Also, there was no correlation between the size of the scleral pool and the IOP (P > 0.05). At 12 months after the operation, the complete success rates were 94.59, 83.78, and 72.97% according to standards A (≤18 mmHg), B (≤15 mmHg), and C (≤12 mmHg), respectively. Intraoperative complications were mainly anterior chamber hemorrhage, and no complications related to the filtration bleb were observed after the operation.

Conclusion: Based on multichannel mechanisms, MATT-DS-Trab is able to effectively reduce IOP in advanced POAG patients, with few serious complications and a high success rate.

Ab Interno Goniotomy Combined with Ab Externo Trabeculotomy in Advanced Primary Congenital Glaucoma Patients: 2-Year Follow-Up

Introduction

Primary congenital glaucoma (PCG) is a challenging disease that needs to be surgically managed with more innovative methods. Conventional incisional surgery, such as goniotomy and trabeculotomy, has a primary high success rate, but does not seem to be a very effective treatment in advanced stages.

Design

A prospective clinical case study.

Purpose

To qualify the outcome, in terms of success rate, of goniotomy combined with trabeculotomy as a surgical option to treat eyes affected by PCG with a corneal diameter larger than 14 mm.

Patients and Methods

This study included 50 eyes of 50 patients diagnosed with PCG with corneal diameter larger than 14 mm who underwent ab interno goniotomy combined with ab externo trabeculotomy. Intraocular pressure (IOP) was measured preoperatively and 24 months postoperatively. A statistical analysis was performed to detect correlations between the success rate and corneal diameter, preoperative IOP, age of onset, axial length, and consanguinity. The main outcome was reduction in IOP; secondary outcomes were factors affecting the success rate, complications, and the need for additional surgical intervention to control IOP.

Results

The mean age of the patients was 18.86±9.94 months. Males made up 52% of cases and females 48% of cases. Positive consanguinity was present in 38% of cases. Axial length ranged between 20 and 22 mm, with a mean of 20.98±0.8 mm. Mean preoperative IOP was 29.56±3.36 mmHg, which decreased postoperatively to 12.6±2.5, 14.1±3.2, 16.8±5.5, 14.4±2.3, 14.3±1.6, 14.3±1.6, 14.3±1.6, 14.3±1.7, and 14.3±1.7 mmHg at 1, 3, 6, 9, 12, 15, 18, 21, and 24 months respectively (p˂0.001). Use of medical treatment was decreased from 2.7±0.4 preoperatively to 1.4±0.7 postoperatively (p˂0.001). Hyphema was the only complication that appeared, occurring in 47% of cases. The success rate was 94%. Complete success (IOP <21 mmHg without treatment) was achieved in 70% of cases, 24% were considered a qualified success (IOP <21 mmHg with treatment), while failure was documented in 6% of cases (IOP >21 mmHg with treatment). The success rate was significantly related to preoperative IOP, corneal diameter, axial length, consanguinity, and age of onset (p˂0.001). All cases were followed for 24 months.

Conclusion

Ab interno goniotomy combined with ab externo trabeculotomy improves the success rate of buphthalmos surgery. A significant correlation was detected between success rate and preoperative IOP, corneal diameter, axial length, consanguinity, and age of onset.

Comparison of Gonioscopy-assisted Transluminal Trabeculotomy Versus Trabeculectomy With Mitomycin C in Patients With Open-angle Glaucoma

PRCIS

Trabeculectomy (TRAB) lowers the intraocular pressure (IOP) more than gonioscopy-assisted transluminal trabeculotomy (GATT) at 18 months, with a reduction in IOP of 30% or more and a significant reduction in the number of glaucoma medications compared with baseline.

PURPOSE

To compare the IOP-lowering efficacy of GATT with mitomycin-C augmented TRAB in patients with uncontrolled open-angle glaucoma.

METHODS

Single-center, retrospective, comparative cohort study. One hundred ten consecutive patients (110 eyes) underwent GATT (n=61) or TRAB (n=49). The primary outcome measure was IOP reduction, defined as a percentage decrease ≥30% and absolute IOP≤18 mm Hg at 18 months with (qualified) or without (complete) medications. Secondary outcomes were visual field change, number of glaucoma medications, complications, and reintervention.

RESULTS

The mean±SD baseline IOP was 30.04±7.5 and 27.59±4.70 (P=0.072) with the mean number of medications of 3.08±0.73 and 2.92±0.91 (P=0.310) in TRAB and GATT, respectively. At 18 months, the mean±SD IOP was 15.26±3.47 mm Hg and 12.48±4.58 mm Hg after GATT and TRAB, respectively (P=0.002). The percentage of IOP lowering from baseline was 56.05±17.72 after TRAB and 42.04±15.56 after GATT (P<0.001). Percentages of complete and qualified success were 59% and 27% after TRAB and 46% and 31% after GATT (P=0.353). No change in visual field loss was observed in both groups. The mean reduction in medications was 2.3±1.4 and 2.1±1.5 in TRAB and GATT, respectively (P=0.493). The most frequent complication after TRAB was hypotony and after GATT hyphema. Reintervention occurred in 8.2% of cases after TRAB and in 14.8% after GATT (P=0.341).

CONCLUSIONS

IOP lowering was greater after TRAB than after GATT at 18 months with a significant reduction in the number of medications after both procedures. Complications and reintervention occurred equally in both groups but differed in type.

Abdallah R, Abdelhalim A. Microcatheter-assisted circumferential trabeculotomy in primary congenital glaucoma

PURPOSE:

To study circumferential trabeculotomy for congenital glaucoma using Glaucolight illuminated microcatheter.

METHODS:

This was a prospective, uncontrolled, consecutive interventional study of 25 eyes of 25 patients with primary congenital glaucoma (PCG) underwent circumferential trabeculotomy done with an illuminated microcatheter through a period of 18–24 months in ophthalmology department, faculty of medicine, Minia University, Egypt. Patients’ data of 12 months’ follow-up were recorded. The primary target was the mean intraocular pressure (IOP) study in which complete success was defined as an IOP ≤21 mm Hg and at least a 30% reduction without the use of antiglaucoma drugs and a qualified success when medications were used to reach this aim. The secondary target was studying the corneal diameter and cup disc ratio change.

RESULTS:

The mean IOP (mm Hg) was reduced from 27.28 ± 3.46 preoperatively to 17.50 ± 5.09 at the final postoperative visit (P < 0.001). The mean follow-up period length was (18 months). A qualified success rate was reached to 88%, complete success in 76% and failure in 12%. No serious surgical complications were observed.

CONCLUSION:

Circumferential trabeculotomy accomplished by an illuminated microcatheter achieved a significant IOP lowering with either qualified or complete success in most of eyes with no significant ocular complications and it can be the first option in pediatric PCG surgery.

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.

From Conventional Angle Surgery to 360-Degree Trabeculotomy in Pediatric Glaucoma

PURPOSE

To describe the transition from conventional angle surgery (CAS), trabeculotomy with rigid probe or goniotomy, to 360-degree trabeculotomy assisted with microcatheter (MCT).

DESIGN

Retrospective comparative interventional case series.

METHODS

Review of consecutive children with glaucoma undergoing angle surgery, including cases with previous surgery, from January 2012 until March 2018 at Moorfields Eye Hospital. Main outcome measure was success rate, defined as intraocular pressure (IOP) ≤21 mm Hg with a minimum of 20% of IOP reduction and no further glaucoma surgery (complete success: without the need of glaucoma drops; qualified success: drops were needed to keep the IOP under control).

RESULTS

Among the 106 eyes (77 patients) included were 54 MCT and 52 CAS eyes. At last visit, after a single surgery, qualified success was 85% (46 eyes) in MCT and 37% (19 eyes) in CAS. Complete success was 69% (37 cases) in MCT and 23% (12 cases) in CAS. The mean (95% confidence interval) change in axial length after surgery was -0.03 mm (-0.34 to 0.40) for MCT and +1.35 mm (-0.64 to 1.62) for CAS (P < .001). The percentage of IOP reduction was 52.1% in MCT and 45.5% in CAS (P = .1616). Further glaucoma surgery was required in 5.5% (3) in MCT and 63.4% (33) in CAS. At 1 year, 94.3% of MCT cases achieved qualified success compared to 34.6% of CAS (P < .0001). No significant complications were found on either group.

CONCLUSION

MCT achieved better results with significantly lower reoperation rates. The transition from CAS to MCT can be easily achieved, even in difficult cases or those previously operated.

Surgical Outcomes of Microcatheter-assisted Trabeculotomy as a Secondary Procedure in Patients with Primary Congenital Glaucoma

PURPOSE

To investigate the efficacy and safety of illuminated microcatheter-assisted trabeculotomy as a secondary procedure in patients with primary congenital glaucoma (PCG).

METHODS

This retrospective case series included patients with PCG who underwent trabeculotomy using an illuminated microcatheter with the intent of catheterizing the full circumference of Schlemm's canal in a single procedure. Success was defined as intraocular pressure (IOP) ≤21 mmHg, with or without the use of glaucoma medications. Clinical examination data were collected for up to 36 months postoperatively.

RESULTS

Surgery was performed on 16 eyes of 16 patients. The mean patient age was 75.1 ± 69.4 months (range: 4.0-216.0 months). Complete catheterization was achieved in 11 of the 16 eyes (69%), whereas partial catheterization was achieved in five of the 16 eyes (31%). All eyes had previously undergone surgery for PCG. The mean follow-up duration was 20.3 ± 9.0 months (range, 12.0-36.0 months). IOP was reduced from a mean of 31.8 ± 6.6 mmHg preoperatively to 15.6 ± 3.7 mmHg at the final follow-up (P < 0.001). The mean preoperative number of glaucoma medications was 3.9 ± 0.5, which was reduced to 1.1 ± 1.6 at the final follow-up (P = 0.001). Ten (62.5%) of the 16 eyes did not require glaucoma medication by the final follow-up. Early transient postoperative hyphema occurred in six eyes (37.5%). No other complications were noted. All corneas were clear at the final follow-up.

CONCLUSION

Ab externo circumferential trabeculotomy using an illuminated microcatheter may be safe and effective as a secondary surgical option for children with PCG after unsuccessful glaucoma surgery.

Ab interno vs ab externo microcatheter-assisted trabeculotomy for primary congenital glaucoma with clear cornea

Importance

This is the first comprehensive comparison between ab interno approach and ab externo approach for microcatheter‐assisted trabeculotomy in primary congenital glaucoma with clear cornea.

Background

Ab externo microcatheter‐assisted trabeculotomy is considered to be the gold standard for primary congenital glaucoma. The novel ab interno approach would intuitively be similar to ab externo approach for microcatheter‐assisted trabeculotomy in eyes with clear cornea; however, there is no evidence yet.

Design

Non‐contemporary comparison of retrospective case series.

Participants

Fifty‐eight and fifty‐seven consecutive primary congenital glaucoma eyes with clear corneas underwent ab interno and ab externo microcatheter‐assisted trabeculotomy, respectively.

Methods

Retrospective comparison of clinical outcomes.

Main Outcome Measures

Surgical success was defined as a postoperative intraocular pressure of ≤21 mmHg with at least a 30% reduction from preoperative IOP with or without the use of anti‐glaucoma medication (qualified and complete success, respectively).

Results

The qualified success rate (87.9% vs 82.2%, P = .40) and complete success rates (81.0% vs 73.3%, P = .32) were comparable between groups. Complications were minimal and comparable. Less than 360° trabeculotomy (P = .009) and a higher number of previous surgeries (P = .03) were both associated with worse surgical outcomes.

Conclusions and Relevance

Ab interno approach provide good and comparable outcomes as ab externo approach for microcatheter‐assisted trabeculotomy in primary congenital glaucoma eyes with clear cornea. It should be considered as the initial choice in these patients with the benefit of sparing conjunctiva. Successful trabeculotomy with either technique during the first attempt is critical to overall success and underscores the need for proficiency before independent practice.

Gonioscopy-assisted transluminal trabeculotomy using an illuminated catheter for infantile primary congenital glaucoma. Case series

Purpose

To describe our experience of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in four eyes with infantile primary congenital glaucoma (PCG).

Observations

We report the first two GATT procedures performed in six-month-old infants with PCG. We also report the same procedure in two eyes of a two-year-old boy with PCG who had previous goniotomies with subsequent peripheral anterior synechiae formation. In all four eyes, the IOP remained under 20 mmHg at years three and four postoperatively, without glaucoma medication or conjunctival surgery.

Conclusions and importance

Our cases confirm that GATT is an alternative to traditional ab externo glaucoma surgery in PCG and can be successfully performed within the first months of life, or in infants with failed or partially functioning goniotomies, avoiding the need for invasive conjunctival or scleral surgery.

Rate of Complete Catheterization of Schlemm's Canal and Trabeculotomy Success in Primary and Secondary Childhood Glaucomas

PURPOSE

Despite the increasing use of microcatheters to perform 360-degree trabeculotomy, the rate of complete Schlemm's canalization in different forms of pediatric glaucoma is under-reported.

DESIGN

Retrospective institutional observational case series.

METHODS

Ocular diagnoses and surgical details of 60 pediatric patients (≤18 years old) who underwent trabeculotomy between 2013 and 2019 were collected. Surgical success was defined as an intraocular pressure (IOP) of 5-20 mm Hg and no additional IOP-lowering surgery.

RESULTS

Eighty-five eyes of 60 patients underwent trabeculotomy. For bilateral cases, the first eye to undergo surgery was included for analysis. Diagnoses included primary congenital glaucoma (PCG n = 22), juvenile open angle glaucoma (JOAG n = 16), glaucoma following cataract surgery (GFCS n = 15), and other secondary forms of glaucoma (n = 7). Canalization using a microcatheter was attempted in 52 of 60 eyes (87%) of which 21 (40%) achieved full 360-degree. Complete canalization was attained in 69% of JOAG patients, which was significantly higher than in PCG patients (22%; P = 0.007), but not GFCS (36%) and other secondary glaucoma (29%). The 5-year survival rate for all eyes was 75% with 95% confidence interval (CI), 57 to 86. Survival curves for 360-degree catheter, 270-degree to 360-degree combined catheter/Harms trabeculotome, and <180-degree Harms trabeculotome trabeculotomies were significantly different (P < 0.001) with 5-year survival rates of 100%, 69% with 95% CI, 16 to 93, and 48% with 95% CI, 29 to 64, respectively.

CONCLUSIONS

A 360-degree catheter trabeculotomy is highly effective in obtaining IOP control; however, complete canalization of Schlemm's canal is most frequently achieved in JOAG patients. Congenital anomalies or scarring from previous surgeries, which prevents full canalization, may inherently decrease success of angle surgery in other glaucoma.

Circumferential canal surgery: a brief history

PURPOSE OF REVIEW

Most microinvasive glaucoma surgery (MIGS) procedures bypass outflow resistance residing proximally in the trabecular meshwork and inner wall of Schlemm's canal. A novel procedure combining trabeculotomy with viscodilation adds to this by also addressing distal resistance of the canal and collector channel ostia. This review examines the development and evidence for both trabeculotomy and canaloplasty separately and the combination in a single procedure.

RECENT FINDINGS

Recent aqueous angiography studies have confirmed the segmental nature of outflow through Schlemm's canal highlighting the need to address distal outflow pathway resistance. Combined trabeculotomy and viscodilation ab interno is a novel approach with a new purpose-designed device (OMNI Surgical System) becoming available to surgeons in early 2018. Recent results as both a standalone and combined with cataract procedure demonstrate significant intraocular pressure reductions with an average 41% reduction from baseline in the pseudophakic group.

SUMMARY

Targeting both distal as well as proximal points of outflow resistance in the conventional pathway may prove to be a highly efficacious MIGS modality. Additional large prospective studies are currently ongoing to confirm these preliminary results.

Trabeculotomy Ab Interno With the Trab360 Device for Childhood Glaucomas

PURPOSE

To report outcomes and complications of trabeculotomy ab interno using the Trab360 device (Trab360; Sight Sciences, Menlo Park, California, USA) in eyes with childhood glaucomas.

DESIGN

Multicenter retrospective interventional case series.

METHODS

Eyes with childhood glaucomas that underwent Trab360 with at least 3 months follow-up were evaluated. Postoperative intraocular pressure (IOP) less than or equal to 24 mm Hg with or without medications and no additional surgery defined success.

RESULTS

Forty-six eyes of 41 patients were included. Median age at surgery was 12 months (range 1-325 months, mean 71 months); 54% prior to 20 months. A total of 48% were right eyes; 48% were male. Mean treatment was 290°. Median follow-up was 14.5 months (range 6-34 months, mean 16.2 months). Median preoperative IOP was 30 mm Hg (range 18-49 mm Hg, mean 30.9 mm Hg); median postoperative IOP was 18 mm Hg (range 5-40 mm Hg, mean 20.3 mm Hg]. Median number of preoperative glaucoma medications was 2.5 (range 0-5, mean 2.6); median number postoperatively was 1 (range 0-4, mean 1.6). Success was achieved in 67.4% (95% CI: 51.9%-80.0%) of eyes. Among 40 eyes for which Trab360 was the first glaucoma surgery, success rate was 70% (95% CI 53.3%-82.9%). Success was achieved in 81% (95% CI 57.4%-93.7%) of primary congenital glaucoma (PCG) eyes. Among 18 PCG eyes for which Trab360 was the first glaucoma surgery, success rate was 83.3% (95% CI 57.7%-95.6%). Two eyes (4.3%) suffered cyclodialysis. There were no other significant complications.

CONCLUSIONS

Trab360 success resembles literature on other angle surgeries for childhood glaucomas. Good surgical technique and caution in high-risk angles is imperative to avoid cyclodialysis. Our study is limited by the imperfections inherent in any retrospective analysis. Single-incision ab interno trabeculotomy with the Trab360 device is effective and safe for treating childhood glaucomas, especially PCG.

Microcatheter-assisted Trabeculotomy Versus 2-site Trabeculotomy With the Rigid Probe Trabeculotome in Primary Congenital Glaucoma

PURPOSE

The purpose of this study was to compare the outcomes of microcatheter-assisted trabeculotomy to circumferential trabeculotomy using the rigid probe trabeculotome in primary congenital glaucoma.

METHODS

This retrospective study was performed in an institutional setting. The medical records of primary congenital glaucoma patients who underwent circumferential trabeculotomy (≥270 degrees incised) using Glaucolight-illuminated microcatheter or a rigid probe trabeculotome were reviewed. The primary outcomes were the percent reduction of intraocular pressure (IOP) and success rates. Complete success was defined as achieving an IOP<18 mm Hg without medications. Secondary outcomes were the postoperative IOP and glaucoma medications.

RESULTS

The study included 92 eyes of 92 patients. Of these, 33 eyes of 33 patients aged 6.4±8.7 months underwent microcatheter-assisted trabeculotomy creating a 336±34-degree incision, with 19 eyes (58%) having a complete 360-degree incision. The other 59 eyes of 59 patients aged 8.2±13.1 months underwent 2-site trabeculotomy, using a rigid probe trabeculotome through a combined superonasal and inferotemporal approach, creating a 338±29-degree incision, with 33 eyes (56%) having a complete incision. After a follow-up of 21.2±8.9 months, there was a 42%±25% IOP reduction and a 73% rate of complete success in the microcatheter group, compared with 40%±22% IOP reduction and an 80% success rate in the rigid probe group (P=0.7 and 0.3, respectively). There was no significant difference in survival time in both groups (P=0.6).

CONCLUSION

Circumferential trabeculotomy using either the illuminated microcatheter or rigid probe trabeculotome yielded comparable results; however, the added cost of the microcatheter should be considered.

Factors influencing the outcome of goniotomy and trabeculotomy in primary congenital glaucoma

PURPOSE

To study the prognostic factors influencing intraocular pressure (IOP) reduction and success rates of paediatric goniotomy and trabeculotomy.

PATIENTS

Data from patients aged ≤12 years who underwent goniotomy or trabeculotomy for primary congenital glaucoma from 2013 to 2016 were reviewed. The analysis included 452 eyes of which 120 eyes of patients with a median age (IQR) of 6 months (4.1-11 months) underwent goniotomy, and 332 eyes of patients with a median age of 5.2 months (2.3-9.3 months) underwent trabeculotomy.

METHODS

Multivariate linear regression analysis was used to predict the correlation of preoperative and operative risk factors to the per cent IOP reduction, while multivariate logistic regression was done to determine independent predictors of failure. Failure was defined as a final IOP >18 mm Hg while on medications or the need for another glaucoma procedure.

RESULTS

In the goniotomy group, the median IOP reduction was 19.4% and was positively correlated to a high initial IOP (p≤0.001) while in the trabeculotomy group, it was 36.8% and mostly influenced by preoperative IOP (p≤0.001), corneal clarity (p=0.04), gender (p=0.04) and consanguinity (p=0.03). The failure rate in the goniotomy group was 56% and was influenced by the preoperative cup-to-disc ratio, while in the trabeculotomy group it was 30% and strongly correlated to positive consanguinity (p≤0.001), higher preoperative IOP (p=0.003), female gender (p=0.01) and younger age at surgery (p=0.03).

CONCLUSION

Several factors can predict the outcome of angle surgery and can help in deciding the appropriate surgical intervention in paediatric glaucoma. Trabeculotomy seems to be superior to goniotomy in primary congenital glaucoma.

Correlation Between Trabeculodysgenesis Assessed by Ultrasound Biomicroscopy and Surgical Outcomes in Primary Congenital Glaucoma

PURPOSE

To evaluate ultrasound biomicroscopy (UBM) characteristics of trabeculodysgenesis and explore its correlation with the outcomes of microcatheter-assisted trabeculotomy (MAT) in eyes with primary congenital glaucoma (PCG).

DESIGN

A prospective, interventional case series.

METHODS

Patients with newly diagnosed PCG were consecutively recruited, and subsequently MAT was tried as their first glaucoma surgery. All participants underwent UBM prior to surgery. The trabeculodysgenesis was classified into 3 types according to the severity of the anterior insertion of iris and ciliary processes (type 1, severe trabeculodysgenesis; type 2, moderate trabeculodysgenesis; type 3, mild trabeculodysgenesis). Surgical success was defined as a postoperative intraocular pressure of ≤ 21 mm Hg with at least a 30% reduction from preoperative intraocular pressure without additional medical or surgical therapy, and with decreased corneal edema, stabilized corneal diameter, and no additional optic nerve damage for at least 6 months after surgery.

RESULTS

MAT was tried on 49 eyes with PCG (33 patients) as the first glaucoma surgery. The ratios of the type of trabeculodysgenesis (type 1: type 2: type 3) were 1:1:1.7 among eyes. In multivariate analysis, age (at the time of operation) (P < .001) and sex (P = .002) were factors associated with the type of trabeculodysgenesis. At 24-month follow-up, type 1 achieved a 57.1% surgical success rate, type 2 achieved 70.5%, and type 3 achieved 95.5% (P = .022). Severe trabeculodysgenesis (P = .014), as well as poorer corneal transparency (P = .037), was associated with worse surgical outcome.

CONCLUSIONS

UBM grading of trabeculodysgenesis in PCG is helpful for MAT prognosis. Combined with preoperative corneal opacity score, it may be used to predict the outcome of MAT surgery.

Microcatheter-assisted Trabeculotomy for Primary Congenital Glaucoma After Failed Glaucoma Surgeries

PURPOSE

To evaluate the effectiveness of microcatheter-assisted trabeculotomy (MAT) to treat primary congenital glaucoma after failed previous glaucoma surgeries.

MATERIALS AND METHODS

Retrospective, noncomparative, interventional case series conducted at Beijing Tongren Eye Center, China. Outcome measures were compared between 3 groups: successful and complete (≥330 degrees) MAT; successful and partial (<330 degrees) MAT; or cases converted to traditional trabeculotomy when the Schlemm's canal could not be catheterized >180 degrees. Success was defined as final intraocular pressure ≤21 mm Hg, with (qualified success) or without (complete success) glaucoma medications.

RESULTS

In total, 74 eyes of 63 consecutive patients were included. MAT was performed in 50 eyes (67.6%). Postoperative intraocular pressure and number of glaucoma drops (17.7±8.6 mm Hg, 0.6±1.2 medications) was significantly less than the preoperative values (35.3±7.2 mm Hg, 2.7±0.8 medications; P<0.001). Cumulative probabilities of qualified and complete success were 84.0% and 80.0% at 3-year follow-up with no difference between complete and partial trabeculotomies. MAT was not successfully performed in 24 eyes (32.4%), requiring conversion to traditional trabeculotomy and associated with greater incidence of previous surgeries (P<0.001), earlier age of disease onset (P=0.024) and worse corneal transparency (P=0.010). Cumulative probabilities of qualified and complete success were 37.0% and 29.2% at 3-year follow-up.

CONCLUSIONS

Both complete and partial MAT achieved significant pressure reduction in cases of primary congenital glaucoma with previous failed glaucoma surgeries in intermediate term.

Mitomycin C in Filtering Surgery for Primary Congenital Glaucoma: A Comparison of Exposure Durations

PURPOSE

To compare the effect of two exposure durations of mitomycin C in combined angle and filtering surgery for primary congenital glaucoma.

METHODS

This was a prospective study conducted in the Department of Ophthalmology at Alexandria Main University Hospital, Alexandria, Egypt, on 75 eyes with primary congenital glaucoma that underwent combined trabeculotomy-trabeculectomy with intraoperative mitomycin C application for 1 minute (MMC 1) or 2 minutes (MMC 2) and were followed up for 24 months. Success rates were studied and complications noted. Success was defined by a composite primary end point of an intraocular pressure (IOP) of less than 16 mm Hg under general anesthesia, without any IOP-lowering medications and with no hypotony-related complications and/or lack of IOP-related progression of the disease as evidenced by worsening of the ocular biometric characteristics.

RESULTS

The mean age of the study participants was 6.7 ± 4.1 months (range: 2 to 16 months; median: 6 months) in the MMC 1 group (35 eyes) and 7.7 ± 5.7 months (range: 1 to 32 months; median: 6.5 months) in the MMC 2 group (40 eyes). The initial surgery was successful in 32 (91.5%) and 31 (77.5%) eyes in the MMC 1 and MMC 2 groups, respectively. The mean IOP was 18.4 ± 5.1 and 18.1 ± 6.1 mm Hg preoperatively and 5.5 ± 3.5 and 4.8 ± 2.8 mm Hg at the end of follow-up in the MMC 1 and MMC 2 groups, respectively. There was no statistically significant difference in the clinical parameters between the two groups. Complications included cataracts in each group and hypotony optic disc edema in 3 eyes (7.5%) in the MMC 2 group.

CONCLUSIONS

Both mitomycin C application durations were effective in combined trabeculotomy-trabeculectomy with mitomycin C for primary congenital glaucoma. The longer duration was not advantageous in disease control and there were no significant differences in complications. [J Pediatr Ophthalmol Strabismus. 2018;55(3):164-170.].

Two-year results of microcatheter-assisted trabeculotomy in paediatric glaucoma: a randomized controlled study

PURPOSE

To compare the outcomes of microcatheter-assisted circumferential trabeculotomy to standard rigid probe trabeculotomy in childhood glaucomas.

METHODS

Eyes of children requiring trabeculotomy for primary congenital or secondary paediatric glaucoma were randomized to undergo either trabeculotomy using the Glaucolight illuminated microcatheter, or a rigid probe trabeculotomy. Complete success was defined as an intraocular pressure (IOP) of <18 mmHg without medications.

RESULTS

A total of 62 eyes of 62 patients were included. Of these 30 eyes of 30 patients aged 5.6 ± 4.8 months underwent microcatheter-assisted trabeculotomy, with 15 eyes (50%) having a complete 360° cut, while 15 eyes (50%) had an incomplete cut ranging from 250 to 350 degrees. The rigid probe trabeculotomy group included 32 eyes of 32 patients aged 4.4 ± 3.8 months. At the end of the 2-year follow-up period, the complete success and the failure rates were 67% and 15%, respectively, in the microcatheter-assisted group versus 47% and 50% in the rigid probe trabeculotomy group (p = 0.006). There was a tendency towards lower IOP in the microcatheter group at 1, 3, 6, 12 and 24 months postoperatively, with the difference in IOP reaching statistical significance at 6 months (p = 0.004). The mean survival time was significantly longer for the microcatheter group (p = 0.01).

CONCLUSION

At 2 years postoperatively, microcatheter-assisted trabeculotomy still yielded superior results in terms of IOP control and success rates in children with primary congenital glaucoma. The need for reoperation for glaucoma was significantly lower in the microcatheter group.

Circumferential Trabeculotomy Versus Conventional Angle Surgery: Comparing Long-term Surgical Success and Clinical Outcomes in Children With Primary Congenital Glaucoma

PURPOSE

This study compares the long-term efficacy of circumferential trabeculotomy to that of conventional angle surgeries in primary congenital glaucoma (PCG), as judged by glaucoma and visual outcomes.

DESIGN

Retrospective observational case series.

METHODS

Setting: Emory Eye Center, Atlanta, Georgia.

STUDY POPULATION

This was a single-institution retrospective study involving children with PCG who underwent circumferential trabeculotomy, standard trabeculotomy, or goniotomy with ≥2-year follow-up.

MAIN OUTCOME MEASURES

Postoperative success (intraocular pressure [IOP] < 22 mm Hg ± glaucoma medications, without glaucoma progression/additional IOP-lowering surgery), Snellen-equivalent visual acuity (VA), and IOP at last follow-up. Kaplan-Meier method estimated the probability of glaucoma control vs time postoperatively, and values were compared between angle surgery cohorts using Wilcoxon signed rank tests, Mann-Whitney U tests, and Fisher exact tests.

RESULTS

Included were 58 eyes (33 children) after circumferential trabeculotomy and 42 eyes (27 children) after standard trabeculotomy/goniotomy, with mean follow-up of 7.2 ± 4.0 and 8.2 ± 4.5 years, respectively. Postoperative success at last follow-up in the circumferential vs conventional cohorts was 81% (47 of 58 eyes) vs 31% (13 of 42 eyes) (P < .0001). At last follow-up, the circumferential cohort had better median VA than the conventional cohort (20/30 (interquartile range [IQR] 20/25 to 20/70) vs 20/70 (IQR 20/40 to 20/200), P = .009), required fewer glaucoma medications (0.55 ± 1.2 vs 1.61 ± 1.51, P < .0001), had lower IOP in first operated eye (15.2 ± 3.6 vs 18.2 ± 7.0, P = .048), and had comparable incidence of devastating complications (P = .065).

CONCLUSIONS

In this retrospective study, circumferential trabeculotomy afforded better long-term success and visual outcomes than conventional angle surgery for children with PCG.

Randomized Trial on Illuminated-Microcatheter Circumferential Trabeculotomy Versus Conventional Trabeculotomy in Congenital Glaucoma

PURPOSE

To compare 1-year outcomes of illuminated microcatheter-assisted circumferential trabeculotomy (IMCT) vs conventional partial trabeculotomy (CPT) for primary congenital glaucoma (PCG).

DESIGN

Randomized clinical trial.

METHODS

Forty eyes of 31 patients with unilateral or bilateral primary congenital glaucoma aged less than 2 years were randomized to undergo IMCT (20 eyes) or CPT (20 eyes). Primary outcome measure was intraocular pressure (IOP) reduction. The success criterion was defined as IOP ≤ 12 mm Hg without and with antiglaucoma medications (absolute success and qualified success, respectively).

RESULTS

The mean age of our study population was 8.35 ± 1.2 months. The mean preoperative IOP was 24.70 ± 3.90 mm Hg in the IMCT group and 24.60 ± 3.31 mm Hg in the CPT group. Both groups were comparable with respect to preoperative IOP, corneal clarity, corneal diameter, vertical cup-to-disc ratio, and refractive error. In the IMCT group, 360-degree cannulation was achieved in 80% (16/20) of eyes. For the IMCT group and CPT groups, respectively, the absolute success rates were 80% (16/20) and 60% (12/20) (P < .001) and qualified success rates were 90% (18/20) and 70% (14/20) (P < .001). Both procedures produced a statistically significant reduction in IOP, and eyes undergoing IMCT achieved a lower IOP than CPT group eyes at 12 months follow-up (9.5 ± 2.4 mm Hg and 11.7 ± 2.1 mm Hg, respectively, P < .001).

CONCLUSION

In primary congential glaucoma, illuminated microcatheter-assisted 360-degree circumferential trabeculotomy performed better than conventional partial trabeculotomy at 1 year follow-up and resulted in significantly lower IOP measurements.

Surgical Outcomes of Trabeculotomy in Newborns with Primary Congenital Glaucoma

Background:

Early surgical intervention is required for the primary congenital glaucoma (PCG). There are currently few reports on the surgical outcomes in infants with PCG. This study aimed to evaluate the efficacy and safety of trabeculotomy and the postoperative visual outcomes in Chinese newborns with PCG within 4 weeks of birth.

Methods:

A total of 21 eyes of 12 patients with PCG who underwent primary trabeculotomy within 4 weeks of birth were retrospectively studied. Preoperative and postoperative intraocular pressure (IOP), corneal clarity and diameter, axial length and optic disc cupping, visual acuity and postoperative refractive error, success rates, and complications were evaluated. Kaplan-Meier survival analysis was applied to evaluate the success rates.

Results:

The mean follow-up time was 46.9 ± 34.4 months (range: 12–122 months). The postoperative IOP was significantly lower than the preoperative IOP at all of the follow-up visits (P < 0.001). The complete success rates for all eyes at 1, 2, 3, and 5 years postoperatively were 90.5%, 85.7%, 85.7%, and 85.7%, respectively. The IOPs of the three patients who needed antiglaucomatous medications postoperatively were also well controlled. At the last visit, the cornea became clear, and the cup-to-disc ratio decreased significantly (P = 0.01) although the horizontal corneal diameter did not change significantly (P = 0.11). Visual acuities were able to be recorded in eight eyes at the last visit, among which six eyes had a best-corrected visual acuity of 20/40 or better. There were no severe intraoperative or postoperative complications.

Conclusions:

Trabeculotomy proves to be a safe and effective treatment in reducing IOP in this group of Chinese newborns with PCG. The outcomes of vision function were satisfactory in most of the patients.

360-Degree Trabeculotomy for Medically Refractory Glaucoma Following Cataract Surgery and Juvenile Open-Angle Glaucoma

PURPOSE

Although angle surgeries show good success in primary congenital glaucoma, reported success in glaucoma following cataract surgery (GFCS) and juvenile open-angle glaucoma (JOAG) is variable and with relatively short follow-up. We evaluated longer-term outcomes of 360-degree trabeculotomy for medically refractory GFCS and JOAG.

DESIGN

Retrospective case series.

METHODS

First operated eyes of consecutive patients with medically refractory GFCS and JOAG in a single-surgeon pediatric glaucoma practice who underwent illuminated microcatheter-assisted 360-degree trabeculotomy from February 2008 to June 2015 were reviewed. Baseline characteristics, time to failure or last visit, surgical details, final intraocular pressure (IOP), and complications were recorded. Success required IOP ≤22 mm Hg and 20% reduction without additional glaucoma surgery or devastating complication.

RESULTS

Thirty-five eyes (35 patients) were included: 25 GFCS and 10 JOAG (mean age at surgery 5.6 vs 16.7 years, respectively, P < .001). Success for GFCS and JOAG was 18 of 25 (72%) vs 6 of 10 (60%) eyes at mean follow-up of 31.9 ± 26.1 vs 24.5 ± 19.7 months, respectively. IOP was significantly reduced from baseline for both GFCS and JOAG (31.5 ± 7.5 mm Hg vs 19.2 ± 7.7 mm Hg, P < .001; and 29.5 ± 10.3 mm Hg vs 15.8 ± 6.6 mm Hg, P < .001, respectively). Fewer glaucoma medications were needed after surgery (P = .01) for GFCS but not JOAG. Complications (all but 2 spontaneously resolving) included choroidal effusion (1), vitreous hemorrhage (3), Descemet detachment (1), and persistent hyphema (2). Three-year Kaplan-Meier success for GFCS vs JOAG was 75.3% vs 53.3%, respectively.

CONCLUSIONS

Illuminated microcatheter-assisted 360-degree trabeculotomy is a useful, low-risk, modestly successful initial surgical treatment for both medically refractory GFCS and JOAG.

Outcomes of microcatheter-assisted trabeculotomy following failed angle surgeries in primary congenital glaucoma

PurposeTo report surgical outcomes of microcatheter-assisted trabeculotomy following failed angle surgeries, and compare those with no previous angle surgery, in primary congenital glaucoma (PCG).MethodsThe early postoperative (12 months) results of 42 eyes of 36 patients who underwent microcatheter-assisted trabeculotomy by single surgeon for PCG were retrospectively analyzed. Group 1, 20 eyes of 16 patients, had no previous angle surgery. Group 2, 22 eyes of 20 patients, had one or two previous failed angle surgeries. Success was defined as an intraocular pressure (IOP) <21 mm Hg with at least a 30% reduction from preoperative IOP with (qualified success) or without (complete success) the use of antiglaucoma medication.ResultsMean IOP decreased from 31.5±7.2 mm Hg on 3 (median, range: 1-5) medications in Group 1 and 34.6±7.3 mm Hg on 3 (median, range: 1-4) medications in Group 2 preoperatively to 15.6±3.1 mm Hg on 0 (median, range: 0-4) medications in Group 1 and 16.0±4.6 mm Hg on 0 (median, range: 0-2) medications in Group 2 postoperatively at 12 months (both P<0.001), respectively. The mean percentage of IOP reduction from preoperative to last postoperative visit was 46.0±20.1% in Group 1 and 45.5±25.0% in Group 2, P=0.947. Qualified and complete successes were comparable between Group 1 and Group 2 (qualified success: 90.0% vs 77.3%, P=0.294; complete success: 78.9% vs 77.3%, P=0.853). Complications were minimal.ConclusionsMicrocatheter-assisted trabeculotomy achieved significant pressure-lowering effects with a reduction in medication use in PCG, and it represents a reasonable choice of initial and repeat surgical treatment for PCG.

Acute Corneal Hydrops in Children with Primary Infantile Glaucoma: A Report of 31 Cases over 23 Years at the LVPEI

Purpose

Relatively little data exist regarding the outcomes of children with primary infantile glaucoma presenting with acute corneal hydrops. The aim of our study was to determine the surgical outcome of children of infantile glaucoma who presented with acute corneal hydrops.

Methods

In total, 38 eyes of 31 consecutive children of infantile glaucoma presented with acute corneal hydrops who underwent primary combined trabeculotomy-trabeculectomy (CTT) by a single surgeon from January 1990 to December 2012 at the LV Prasad Eye Institute (LVPEI), a tertiary eye care centre in Southern India were enrolled in this retrospective study. Primary outcome measures were intraocular pressure (IOP) control (IOP ≤ 16 mmHg under anaesthesia or IOP ≤ 21 mmHg without anaesthesia) and clearance of corneal edema. Secondary outcome measures were visual acuity (VA), corneal diameter, bleb appearance, intraoperative and postoperative complications.

Results

Mean age at presentation was 6.4 months (range, 2–11 months) and seven eyes (23%) had bilateral affliction. At presentation, all eyes (100%) had moderate to severe degree of corneal edema with a mean preoperative IOP of 25.6 ±5.1 mmHg. Postoperatively, the IOP reduced to 12.0 ± 3.8 mmHg (difference = -13.6, 95% CI = -15.7 to -11.5, t = -13.18, p<0.0001), and the percentage reduction in IOP was 53.05%. Preoperatively 83% of the eyes were on antiglaucoma medication, and postoperatively 2 eyes (5.3%) required 1 antiglaucoma medication for control of IOP. Preoperatively, corneal edema was present in all eyes and postoperatively it cleared in all of them. Significant myopic astigmatism was present in 28 eyes (74%), the commonest being compound myopic astigmatism (75%) followed by simple myopic astigmatism (21%). Normal VA (best-corrected VA; BCVA ≥ 20/60) was achieved in 44.4% of the eyes and 22.2% eyes had low vision (BCVA, <20/60 to 20/400). Complete success (IOP control and clearance of corneal oedema) was obtained in 94.7% eyes. There were no significant intraoperative or postoperative complications. Two thirds of the patients showed low, elevated functional filtering bleb. No patient had any bleb leak, blebitis or bleb related endophthalmitis. The median follow-up was 36 months (range 2–228 months).

Conclusions

Primary CTT is safe and effective in controlling IOP, resulting in complete clearance of corneal edema with modest visual improvement in children of infantile glaucoma presenting with acute corneal hydrops. The outcome of the study will have a positive impact on counseling the parents preoperatively.

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.

Characteristics of Children With Primary Congenital Glaucoma Receiving Trabeculotomy and Goniotomy

PURPOSE

To describe the groups of patients who received trabeculotomy or goniotomy for the treatment of primary congenital glaucoma (PCG) regarding age at treatment, intraocular pressure (IOP) outcome, and medication burden.

METHODS

A retrospective chart review of patients with PCG seen at Rutgers New Jersey Medical School, Newark, New Jersey, from 1998 to 2012 was conducted. Inclusion criteria were patients who received trabeculotomy or goniotomy with at least 9 months of follow-up. Presenting examination, surgical intervention, IOP, and number of medications at 1 and 2 years postoperatively were recorded. Absolute and qualified success, defined as IOP greater than 5 and less than 21 mm Hg without and with medications, respectively, was determined.

RESULTS

Fifty eyes of 29 patients were diagnosed as having PCG. Of those, 25 eyes received trabeculotomy or goniotomy, with 19 fulfilling inclusion criteria. Average age at the time of trabeculotomy was 8 months versus 21 months for patients undergoing goniotomy. Mean IOP was significantly reduced (P < .001) for both trabeculotomy and goniotomy by 29.5% at 1 year and 33.3% at 2 years. There was no significant difference in IOP control between trabeculotomy and goniotomy groups. Patients in the goniotomy group were treated with significantly more medications before and after surgery compared to patients receiving trabeculotomy (P < .01), resulting in a greater rate of absolute success in trabeculotomy at 1 and 2 years.

CONCLUSIONS

Patients with PCG who underwent trabeculotomy had higher IOP and were treated at an earlier age than those who had goniotomy. Both effectively lowered IOP up to 2 years with greater medication burden in patients receiving goniotomy.

Illuminated microcatheter circumferential trabeculotomy versus combined trabeculotomy-trabeculectomy for primary congenital glaucoma: a randomized controlled trial

PURPOSE

To compare outcomes of illuminated microcatheter-assisted circumferential trabeculotomy vs combined mitomycin C-augmented trabeculotomy-trabeculectomy for primary congenital glaucoma.

DESIGN

Prospective, randomized trial.

METHODS

Of the 30 patients (60 eyes) analyzed with bilateral primary congenital glaucoma aged ≤2 years, 1 eye of each patient was randomized to: illuminated microcatheter-assisted trabeculotomy (Group I) or combined trabeculotomy with trabeculectomy augmented with mitomycin C (Group II). Primary outcome measure was intraocular pressure (IOP) reduction. Categorization into absolute success (IOP ≤15 mm Hg without medication) and qualified success (IOP ≤15 mm Hg with medication) was done. Secondary outcomes included change in corneal diameter and clarity, optic disc status, refraction, need for anti-glaucoma therapy, and occurrence of complications.

RESULTS

Mean age of patients was 6.63 ± 5.74 months. IOP fell by 49.3% (22.25 ± 10.88 to 11.56 ± 3.33 mm Hg) in Group I and 46.6% in Group II (21.73 ± 8.89 to 11.60 ± 3.03 mm Hg) (P < .001 in both). At 1 year, absolute success was achieved in 86.7% (26/30) and 90.0% (27/30) in Groups I and II, respectively (P >.99) and qualified success in 93.3% (28/30) in both groups (P = 1). There was significant improvement in corneal clarity (P < .001) and cup-to-disc ratio (P ≤ .01) in both groups at 1 year. Though incidence of hyphema was significantly more in Group I (P = .0001), no vision-threatening complications occurred in either group.

CONCLUSIONS

Illuminated microcatheter-assisted circumferential trabeculotomy achieved comparable surgical outcomes to mitomycin C-augmented combined trabeculotomy-trabeculectomy and may be recommended as the initial surgical procedure for primary congenital glaucoma.

Childhood glaucoma surgery in the 21st century

Most children with glaucoma will require surgery in their lifetime, often in their childhood years. The surgical management of childhood glaucoma is however challenging, largely because of its greater potential for failure and complications as compared with surgery in adults. The available surgical repertoire for childhood glaucoma has remained relatively unchanged for many years with most progress owing to modifications to existing surgery. Although the surgical approach to childhood glaucoma varies around the world, angle surgery remains the preferred initial surgery for primary congenital glaucoma and a major advance has been the concept of incising the whole of the angle (circumferential trabeculotomy). Simple modifications to the trabeculectomy technique have been shown to considerably minimise complications. Glaucoma drainage devices maintain a vital role for certain types of glaucoma including those refractory to other surgery. Cyclodestruction continues to have a role mainly for patients following failed drainage/filtering surgery. Although the prognosis for childhood glaucoma has improved significantly since the introduction of angle surgery, there is still considerable progress to be made to ensure a sighted lifetime for children with glaucoma all over the world. Collaborative approaches to researching and delivering this care are required, and this paper highlights the need for more high-quality prospective surgical trials in the management of the childhood glaucoma.