[Trabeculotomy as first-line surgical treatment in pediatric glaucoma: surgical and visual outcomes from a 7-year retrospective study]

Pediatric Glaucoma-From Screening, Early Detection to Management

Pediatric glaucoma (PG) covers a rare and heterogeneous group of diseases with variable causes and presentations. Delayed diagnosis of PG could lead to blindness, bringing emotional and psychological burdens to patients' caregivers. Recent genetic studies identified novel causative genes, which may provide new insight into the etiology of PG. More effective screening strategies could be beneficial for timely diagnosis and treatment. New findings on clinical characteristics and the latest examination instruments have provided additional evidence for diagnosing PG. In addition to IOP-lowering therapy, managing concomitant amblyopia and other associated ocular pathologies is essential to achieve a better visual outcome. Surgical treatment is usually required although medication is often used before surgery. These include angle surgeries, filtering surgeries, minimally invasive glaucoma surgeries, cyclophotocoagulation, and deep sclerectomy. Several advanced surgical therapies have been developed to increase success rates and decrease postoperative complications. Here, we review the classification and diagnosis, etiology, screening, clinical characteristics, examinations, and management of PG.

Congenital Refractory Glaucoma: A New Ophthalmic Association of Kabuki Syndrome and its Management With Glaucoma Drainage Devices

INTRODUCTION

Kabuki syndrome (KS) is a rare congenital and polymalformative condition, traditionally associated with mental retardation, unusual facial features, and skeletal abnormalities. We hereby describe a case of bilateral congenital glaucoma associated with MLL2-mutation KS. To the best of our knowledge, this is the first association of KS with congenital glaucoma.

CASE REPORT

The patient was a 3-year-old male of North African ethnicity diagnosed with KS and bilateral congenital glaucoma at the age of 3 months and the first child of a nonconsanguineous healthy couple, with no known genetic conditions within the family. The patient was referred to our tertiary glaucoma center with uncontrollable intraocular pressures between 50 and 60 mm Hg in both eyes. Past ophthalmic history included bilateral trabeculectomies and right retinal detachment with phthisis bulbi. We performed left lensectomy combined with Baerveldt tube insertion in the vitreous cavity, revealing extensive posterior synechiae. Postoperatively, he developed intense inflammation with fibrin and vitreous strand formation, requiring subsequent surgeries and subconjunctival injections of betamethasone. Despite these complications, IOP stabilized between 3 and 6 mm Hg.

DISCUSSION

This case confirms congenital glaucoma as a rare association of KS, and highlights the potential high-risk nature of such cases. In our opinion, the presence of high levels of inflammation perioperatively and postoperatively is an indication for primary glaucoma drainage device surgery given the high risk of bleb scarring resulting in recurrent surgical revisions. In view of these observations, we also advocate the use of intensive postoperative anti-inflammatory therapy.

Contemporary management of refractory pediatric glaucoma

PURPOSE OF REVIEW

The management of pediatric glaucoma poses a unique challenge in terms of maintaining lifelong vision and combating an aggressive scarring response from surgery. Contemporary literature regarding the surgical management of children with pediatric glaucoma who fail, or are at a high risk of failure, from conventional surgery is limited. The aim of this review is to highlight recent developments in relation to the current opinion regarding the management of children with refractory pediatric glaucoma.

RECENT FINDINGS

Some studies have reported impressive success rates with circumferential trabeculotomy, even in eyes with previous failed surgery. Early results of deep sclerectomy in populations which may not respond well to conventional angle surgery are encouraging but data is limited for the pediatric age group. In compliant patients in whom multiple postoperative examinations under anesthesia are possible, trabeculectomy remains an effective procedure. Multiple recent studies have demonstrated that glaucoma drainage device (GDD) surgery is associated with 5-year success rates of over 70% in primary childhood glaucomas.

SUMMARY

Glaucoma drainage device surgery is likely to remain a mainstay of surgical management for refractory glaucoma in older children. More prospective data are needed on the success of circumferential trabeculotomy, deep sclerectomy and micropulse laser in pediatric eyes with previous failed surgery. VIDEO ABSTRACT: http://links.lww.com/COOP/A34.

[Congenital glaucoma: Intraocular pressure and visual prognosis after trabeculectomy and functional rehabilitation for amblyopia]

The goal of our work is to analyze the clinical aspects, study the change in intraocular pressure and functional prognosis after trabeculectomy and amblyopia treatment of children followed for congenital glaucoma. The present study is a retrospective study including 86 patients (143 eyes) followed over a period from March 2009 to September 2015. The median age at diagnosis was 6 months. The mean intraocular pressure was 25±5mmHg preoperatively and 11.6±4mmHg at the conclusion. The average initial cup was 0.5. Trabeculectomy was performed in all cases. Twelve eyes were operated twice. After a follow-up of 4 years, normalization of the intraocular pressure was obtained in 35% after the first surgery, in 44% on mono or dual therapy, in 10% after a surgical revision. Cycloplegic refraction was performed; myopia was found in 55% of cases, the mean was -6.5 diopters. 20% of children were hyperopic with a mean of 2.5D. A mean 2D of astigmatism was found in 60 eyes (42%). Anisometropia was present in 10 children. Corrected visual acuity was quantified in 37% of children. The mean was 2/10±3 initially and 4/10 at the conclusion. It was≥4/10 in 41% of cases and≤1/10 in 56%. Unilateral amblyopia was found in 40% of the children. Seventy percent of the patients had strabismus. This study highlights the need for prolonged treatment of amblyopia in congenital glaucoma to achieve the best possible visual recovery.