Surgical Results in the Management of Advanced Primary Congenital Glaucoma in a Rural Pediatric Population

The impact of childhood glaucoma on psychosocial functioning and quality of life: a review of the literature

We present a novel comprehensive literature review of studies of the psychosocial functioning (PF) and quality of life (QoL) of patients with childhood glaucoma and their caregivers. Our findings demonstrate variable study quality and approach, as well as inconsistent results relating to the association of glaucoma-specific factors and sociodemographic variables with measured PF and QoL. Future studies should focus on the development of culturally cognizant and standardized assessment tools, execution of multi-center longitudinal studies with global representation, evaluation of PF and QoL among siblings and childhood glaucoma providers, and implementation of interventions to improve patient and caregiver PF and QoL.

Deep Learning Segmentation, Visualization, and Automated 3D Assessment of Ciliary Body in 3D Ultrasound Biomicroscopy Images

Purpose

This study aimed to develop a fully automated deep learning ciliary body segmentation and assessment approach in three-dimensional ultrasound biomicroscopy (3D-UBM) images.

Methods

Each 3D-UBM eye volume was aligned to the optic axis via multiplanar reformatting. Ciliary muscle and processes were manually annotated, and Deeplab-v3+ models with different loss functions were trained to segment the ciliary body (ciliary muscle and processes) in both en face and radial images.

Results

We trained and tested the models on 4320 radial and 3864 en face images from 12 cadaver eye volumes. Deep learning models trained on radial images with Dice loss achieved the highest mean F1-score (0.89) for ciliary body segmentation. For three-class segmentation (ciliary muscle, processes, and background), radial images with Dice loss achieved the highest mean F1-score (0.75 for the ciliary process and 0.82 for the ciliary muscle). Part of the ciliary muscle (10.9%) was misclassified as the ciliary process and vice versa, which occurred owing to the difficulty in differentiating the ciliary muscle–processes border, even by experts. Deep learning segmentation made further editing by experts at least seven times faster than a fully manual approach. In eight cadaver eyes, the average ciliary muscle, process, and body volumes were 56 ± 9, 43 ± 13, and 99 ± 18 mm³, respectively. The average surface area of the ciliary muscle, process, and body were 346 ± 45, 363 ± 83, and 709 ± 80 mm², respectively. We performed transscleral cyclophotocoagulation in cadaver eyes to shrink the ciliary processes. Both manual and automated measurements from deep learning segmentation show a decrease in volume, surface area, and 360° cross-sectional area measurements.

Conclusions

The proposed deep learning segmentation of the ciliary body and 3D measurements showed transscleral cyclophotocoagulation-related changes in the ciliary body.

Translational Relevance

Automated ciliary body assessment using 3D-UBM has the translational potential for ophthalmic treatment planning and monitoring.

Profile of primary childhood glaucoma at a child eye health tertiary facility in Malawi

BACKGROUND

To describe the clinical characteristics and treatment of primary childhood glaucoma at Queen Elizabeth Central Hospital in Blantyre, Malawi.

METHODS

A retrospective case notes review was undertaken of all medical records of patients aged less than 16 years with a diagnosis of primary glaucoma according to the Childhood Glaucoma Research Network Classification (CGRN) who presented from January 2016 to December 2018. The parameters extracted from the case files included age at presentation, sex, type of glaucoma, presenting complaints, laterality of ocular involvement, examination findings and the treatment modality instituted. The Mann-Whitney test was used to investigate factors associated with the intraocular pressure (IOP) in eyes that had a higher presenting IOP value compared to contralateral eyes.

RESULTS

A total of 45 subjects (80 eyes) were identified, 42 with primary congenital glaucoma (PCG) and 3 with juvenile open angle glaucoma (JOAG). The mean age for the population was 2.6 years (S.D ± 3.7) and most of the patients were male, with a male-female ratio of 2:1. The majority of patients had bilateral disease (n = 35, 77.8%) with the commonest presenting complaint being a whitish appearance of the eye (57.5%). The eyes studied had a mean IOP of 30.1 mmHg (CI 27.4-32.9), a mean horizontal corneal diameter (HCD) of 13.6 mm (CI 13.1-14.2) and a mean cup-disc-ratio `(CDR) of 0.73 (CI 0.66-0.79). In addition, 62 eyes (77.5%) had corneal haze on examination. Most patients (n = 59, 73.8%) underwent a combined trabeculotomy - trabeculectomy surgery within the study period. The median presenting IOP was significantly higher with JOAG compared to PCG (P = 0.02).

CONCLUSION

PCG was the most common primary childhood glaucoma at Queen Elizabeth Central Hospital and most patients presented with bilateral eye involvement. Most of the eyes had corneal haze and JOAG was associated with a higher presenting IOP compared to PCG. Further studies to investigate the outcomes of combined trabeculotomy - trabeculectomy surgery in primary childhood glaucoma in Malawi are recommended.

Changes of Peripapillary Retinal Nerve Fiber Layer in Childhood Glaucoma: A Systematic Review and Meta-Analysis

Objectives: Retinal nerve fiber layer (RNFL) thickness has been detected by numerous studies about alterations and abnormalities in childhood glaucoma, but these studies have yielded inconsistent results about the RNFL thinning region. The investigation of characteristics of RNFL in pediatric patients would contribute to the deep understanding of the neuropathic mechanisms of childhood glaucoma. Thus, the degree of thinning in different quadrants deserves further discussion and exploration. Method: A systematic literature search was conducted using the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed databases to identify clinical studies published from inception to April 1, 2021. Results: Ten studies were included in this review with a total of 311 children with glaucoma and 444 in nonglaucomatous controls. The results revealed that average peripapillary RNFL (pRNFL) thickness was attenuated in pediatric patients with glaucoma [weighted mean difference (WMD) = -20.75; 95% CI -27.49 to -14.01; p < 0.00001]. Additionally, pRNFL thickness in eight quadrants (superior, inferior, temporal, nasal, superotemporal, inferotemporal, superonasal, and inferonasal) had different levels of reduction in the pediatric group of glaucoma. Conclusion: This study indicates that eight regions of RNFL thickness show various degrees of thinning in childhood glaucoma. However, caution is required in the interpretation of results due to marked heterogeneity. Future studies, especially larger samples and multicenter, need to confirm our results.

Surgical Outcomes of Primary Congenital Glaucoma in Children Under One Year from the Nile Delta

Purpose

To present outcomes of surgical management of primary congenital glaucoma (PCG) in children less than one year of age in a population based at the Nile Delta.

Methods

A retrospective review of medical records of patients with PCG less than one year of age at presentation who underwent surgical intervention in a tertiary care facility based at the Nile Delta. All patients underwent measurement of intraocular pressure (IOP), horizontal corneal diameter (HCD), cup-to-disc ratio (CDR) before and after surgery and a minimum of 6 months follow up was required. Surgical success was defined as IOP less than 22mmHg without medications and without progression of main disease parameters.

Results

The review revealed 44 eyes of 26 consecutive patients who underwent surgical treatment for PCG. Average age at surgery was 5.2 months and mean follow up was 18.5 months. Preoperative IOP was 28.5±4 mmHg, HCD was 13.7±0.7mm, and CDR (when visible) was 0.65±0.18. A total of 69 surgical procedures were performed with an average of 1.56 procedures per eye. Postoperative IOP was 13.3±4.8 mmHg, HCD was 12.8±0.9mm, and CDR was 0.3±0.2 (P<0.0001). Surgical success was achieved in 32 eyes (72.7%) while sight-threatening postoperative complications were reported in 3 eyes.

Conclusion

Surgical management of PCG younger than one year of age achieved good success rate in the region of the Nile Delta with low rate of visually significant postoperative complications. However, larger studies with longer follow up are needed to fully reveal the overall characteristics of PCG in the region.

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.

The impact of late-treated pediatric cataract on intraocular pressure

PURPOSE

To assess the intraocular pressure and visual acuity before and after pediatric congenital cataract surgery performed at a relatively older age.

METHODS

A retrospective analysis of all consecutive pediatric patients diagnosed and operated for bilateral congenital cataracts during a seven-year period (2012-2018) in rural southern Ethiopia. Non-ambulatory vision was defined as hand motion or worse. The main outcome measures were intraocular pressure (IOP) and visual acuity.

RESULTS

Thirty-two children were included, 17 females (53.1%), with a mean age of 11 years (± 2.83) [range, 7-18]. A total of 59 eyes were operated on. The mean follow-up was 4.8 ± 1.8 years (range, 2-8). VA improved from 20/1400 preoperatively to 20/440 postoperatively OD and 20/540 OS (p < 0.001). More eyes had ambulatory vision after cataract surgery than pre-surgery (56 eyes [95%] vs. 29 eyes [49%], p < 0.001). The IOP decreased from a mean preoperative value of 18.4 ± 7.1 mmHg to 14.5 ± 2.9 postoperatively OD (p < 0.001) and 16.3 ± 5.9 mmHg to 13.9 ± 3.5 OS (p < 0.001). Fifteen eyes (24%) had increased IOP (> 21 mmHg) preoperatively, of which three remained high after surgery. Positive correlations were found between IOP, axial length and cup-to-disc ratio. None of the patients required pressure-lowering procedures.

CONCLUSION

Bilateral congenital cataracts may be associated with ocular hypertension, with possible progression to glaucoma if left untreated. Surgery at a relatively older age often was associated with a significant improvement in intraocular pressure and ambulatory vision.

Long-term outcomes of the Ahmed glaucoma valve surgery in childhood glaucoma

PURPOSE

To report the rates of success of Ahmed glaucoma valve (AGV) surgery in early childhood glaucoma and factors associated with success.

METHODS

Children with primary congenital or early childhood secondary glaucoma who underwent AGV surgery over a 10-year period (one eye per child) at a single institution were identified. Surgical failure was defined as having one or more of the following: intraocular pressure of >21 mm Hg 3 months postoperatively, reoperation for glaucoma, and vision loss to no light perception.

RESULTS

A total of 178 patients were identified (median age, 5.8 ± 5.5 years): 125 with primary congenital and 53 with secondary childhood glaucoma. The success rate at 1 year was 92% (95% CI, 88%-96%); at 5 years, 64% (95% CI, 55%-73%); and at 10 years, 36% (95% CI, 25%-52%). Younger age at baseline (P = 0.003) and secondary childhood glaucoma (P = 0.045) were associated with lower success.

CONCLUSIONS

The AGV is associated with high short-term success in children with primary congenital glaucoma, but the 10-year success rates are poor. Younger age and secondary childhood glaucoma may be associated with a more refractory outcome.

Clinical Characteristics and Prognostic Factors of Visual Outcomes in Childhood Glaucoma

PURPOSE

To determine the prognostic factors for poor visual outcomes in childhood glaucoma.

METHODS

The medical records of patients with childhood glaucoma diagnosed at age 4 years or younger who were treated surgically from 2002 to 2019 at Songklanagarind Hospital, Hatyai, Thailand, were retrospectively reviewed. Glaucoma subtypes, clinical characteristics, final visual acuity, and etiology of visual impairment were recorded. The generalized estimating equation for logistic regression analysis was used to determine prognostic factors for final visual acuity of worse than 20/200.

RESULTS

Forty-five eyes of 31 patients were included (33.3% had primary glaucoma and 66.7% had secondary glaucoma). At the final visit (mean: 6.8 years), 20.5% had good visual acuity (20/50 or better), 15.9% had fair visual acuity (worse than 20/50 to 20/200), and 63.6% had poor visual acuity (worse than 20/200). The major cause of visual impairment (worse than 20/50) was deprivation amblyopia. Prognostic factors for poor final visual acuity (worse than 20/200) were secondary glaucoma, age at diagnosis of younger than 3 months, and interval to surgery of more than 3 months. Eyes with a final visual acuity of better than 20/200 had higher mean intraocular pressure preoperatively that tended to increase postoperatively and every visit afterward compared to the other group.

CONCLUSIONS

Two-thirds of eyes with childhood glaucoma ended up with poor final vision. Early surgery to control intraocular pressure, along with amblyopia treatment, should be considered to prevent poor visual outcome. The prognostic factors for poor visual outcome can contribute to parental advice and planning of patient care. [J Pediatr Ophthalmol Strabismus. 2020;57(5):283-291.].

Surgical Outcomes in Children With Primary Congenital Glaucoma: An Eight-Year Experience

Background

Primary congenital glaucoma (PCG) is a congenital anomaly arising from an unusual development of the filtration angle, causing a remarkable rise in intraocular pressure (IOP) that is irrelevant to other ocular or systemic deformities.

Purpose

The aim of the current study was to evaluate the surgical outcome in PCG patients between 2011 and February 2019.

Methods

This was a retrospective study of PCG patients who underwent trabeculotomy, trabeculectomy, deep sclerectomy, Ahmed valve, and/or cyclophotocoagulation (CPC) at a tertiary hospital. The IOP must be equal or less than 21 mmHg with or without medication to be designated a successful surgery.

Results

A total of 80 eyes (41 patients) were included in the study, with a slight male predominance of 65.9%. At presentation, the most reported age group was under 30 days (46.3%). Moreover, deep sclerotomy was the most common procedure, followed by CPC, which were performed in 48 (58.5%) and 18 (21.9%) eyes, respectively. In the overall group, the mean initial IOP was 23.65±8.52 mmHg, while the mean IOP was 16.73±8.56 mmHg at final follow-ups (p < 0.001), with a 46% reduction. The mean axial length showed a slight progression from 21.11±2.58 at the initial visit to 22.92±3.57 mm at the last follow-up (p<0.001). However, the mean horizontal diameter increased from 12.63±1.83 mm at the initial visit to 13.31±1.13 mm at the final visit (p=0.004).

Conclusion 

An excellent IOP reduction could be accomplished in the majority of eyes. Deep sclerectomy can effectively reduce IOP in PCG without the occurrences of serious complications that are commonly seen after other procedures like trabeculectomy or trabeculotomy.

Severity of visual field defects in primary congenital glaucoma and their risk factors

PURPOSE

The primary objective of the study was to assess the frequency and severity of visual field defects (VFD) in primary congenital glaucoma (PCG). The secondary objective was to ascertain any associated risk factors.

METHODS

An ambispective review of patients with PCG on follow-up with a 'target' intraocular pressure (IOP) of ≤ 15 mmHg. Age, sex, laterality, duration of follow-up, baseline IOP, baseline cup-disc ratio (CDR), central corneal thickness (CCT), age during filtering surgery, second surgery if any, yearly IOP, glaucoma medications and best corrected visual acuity from 2013 (year 1) to the final review and final CDR were noted down. Children ≥ 5 years of age with best corrected visual acuity ≥ 6/60 were subjected to manual kinetic Goldmann perimetry, and visual field defects (VFD) were identified.

RESULTS

Seventy-one of 90 eyes completed a reliable kinetic perimetry. The mean age of children was 12.34 ± 4.86 years, and the mean follow-up duration was 10.77 ± 4.69 years. Baseline IOP and CDR were 29.07 ± 8.83 mmHg and 0.66 ± 0.22, respectively. 86.67% of eyes underwent a trabeculotomy + trabeculectomy with mitomycin-C. Thirty-one eyes (34.44%) required a second surgery, 25 of which were bleb revisions and 3 trabeculectomies. Mean IOP and CDR during last visit were 10.23 ± 2.76 mmHg and 0.52 ± 0.25, p < 0.001 as compared with baseline. On Goldmann perimetry, 19 eyes, 26.76%, had defects, arcuate scotoma being most frequent. On the Fisher exact test, a baseline/final CDR > 0.8, undergoing just a trabeculectomy with MMC, needing ≥ 2 glaucoma medications on review or a repeat trabeculectomy was associated with greater severity of VFD. On univariate logistic regression, eyes that needed a bleb revision [OR, 95% CI 9.75 (2.66-35.67), p = 0.001], a repeat trabeculectomy with mitomycin-C [OR (CI) 18 (1.31-245.58), p = 0.03] and final CDR of > 0.8 [OR (CI) 23.1 (3.7-144.21), p = 0.001] were associated with VFD. On multivariable regression analysis, female sex [OR (CI) 18 (2.01-161.04), p = 0.01] was identified as the single most important risk factor for development of a VFD.

CONCLUSION

At a 'target' IOP of ≤ 15 mmHg, 26.76% of PCG eyes manifested a VFD over 10 years. Baseline and/or final CDR > 0.8, necessity for ≥2 medications or a repeat glaucoma surgery, and female sex were identified as risk factors for development and greater severity of glaucomatous VFD.

Referral patterns of children with glaucoma and their caretakers in Northern Tanzania

AIM

To describe the referral patterns of children with primary childhood glaucoma (PCG) or secondary childhood glaucoma (SCG) and their presenting symptoms in Northern Tanzania.

METHODS

A retrospective observational study of children <17y with PCG or SCG who were referred to Kilimanjaro Christian Medical Centre (KCMC) Eye Department between 2000 and 2013 was conducted. Presenting symptoms, age at presentation, place of origin, distance to hospital, type of glaucoma, visual acuity, optic disc appearance (vertical cup-to-disc ratio) and type of referral were described.

RESULTS

Seventy patients with PCG and 27 patients with SCG were included in the study. Median age at first presentation was 1y in the PCG group (range 0-16y) and 9y in the SCG group (range 1-15y). In both groups around 87% of the children presented already with low vision (logMAR>0.48, better eye). Most of the children (60%) and their caretakers presented on their own initiative, while 24% were sent by different general health cadres and 16% by eye care professionals. Buphthalmos was the main symptom mentioned as a trigger for presentation.

CONCLUSION

The study shows that most of the children presented late resulting in advanced stages of glaucoma at the time of initiation of treatment. The majority attended the referral eye department on their own initiative with buphthalmos being the most commonly described symptom. Awareness creation among caretakers of children, general health and eye care providers, ideally embedded in general child health promotion activities, is needed to increase and accelerate referrals.

Trabeculotomy versus combined trabeculotomy-trabeculectomy for primary congenital glaucoma: study protocol of a randomised controlled trial

INTRODUCTION

Trabeculotomy and combined trabeculotomy-trabeculectomy (CTT) are major surgical options for primary congenital glaucoma (PCG). However, it is unclear which of these two surgical procedures should be recommended as the optimum first-line treatment for PCG. This trial aims to determine whether the outcomes of trabeculotomy are non-inferior to those of CTT in moderate PCG with a horizontal corneal diameter (HCD) of 12-14 mm.

METHODS AND ANALYSIS

This is a 3-year, non-inferiority, prospective, randomised controlled trial. We plan to recruite 248 participants (aged ≤3 years) with PCG with an HCD of 12-14 mm from the Department of Glaucoma, Zhongshan Ophthalmic Center, Guangzhou, China. One eye per participant will be randomly (1:1) assigned to receive trabeculotomy or CTT. The primary outcome is the 3-year postoperative success rate in lowering intraocular pressure (IOP), and the secondary clinical outcomes will include IOP reduction, visual acuity, HCD, central corneal thickness, axial length, cup-disc ratio, refractive error and postoperative complications. Data will be analysed by the intention-to-treat principle.

ETHICAL APPROVAL AND DISSEMINATION

The study protocol has been approved by the ethics committee of Zhongshan Ophthalmic Center (2014MEKY023) and the '5010 Plan' evaluation committee at Sun Yat-Sen University, Guangzhou, China. The results will be disseminated in international academic meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR-IOR-14005588; Date registered: 20 November 2014.

Childhood glaucoma genes and phenotypes: Focus on FOXC1 mutations causing anterior segment dysgenesis and hearing loss

Childhood glaucoma is an important cause of blindness world-wide. Eleven genes are currently known to cause inherited forms of glaucoma with onset before age 20. While all the early-onset glaucoma genes cause severe disease, considerable phenotypic variability is observed among mutations carriers. In particular, FOXC1 genetic variants are associated with a broad range of phenotypes including multiple forms of glaucoma and also systemic abnormalities, especially hearing loss. FOXC1 is a member of the forkhead family of transcription factors and is involved in neural crest development necessary for formation of anterior eye structures and also pharyngeal arches that form the middle ear bones. In this study we review the clinical phenotypes reported for known FOXC1 mutations and show that mutations in patients with reported ocular anterior segment abnormalities and hearing loss primarily disrupt the critically important forkhead domain. These results suggest that optimal care for patients affected with anterior segment dysgenesis should include screening for FOXC1 mutations and also testing for hearing loss.

Detection and characterisation of optic nerve and retinal changes in primary congenital glaucoma using hand-held optical coherence tomography

Objective

To investigate (1) the feasibility of scanning the optic nerve (ON) and central retina with hand-held optical coherence tomography (HH-OCT) without sedation or anaesthesia in primary congenital glaucoma (PCG), (2) the characteristics of ON changes in comparison with adult primary open-angle glaucoma (POAG) in comparison with matched controls, (3) the sensitivity and specificity of ON parameters for diagnosis, and (4) changes of foveal morphology.

Methods and analysis

HH-OCT (Envisu 2300; Leica Microsystems) was used to investigate ON and foveal morphology of 20 children with PCG (mean age 4.64±2.79) and 10 adult patients with POAG (mean age 66.8±6.94), and compared with age-matched, gender-matched and ethnicity-matched healthy controls without sedation or anaesthesia.

Results

HH-OCT yielded useful data in 20 out of 24 young children with PCG. Patients with PCG had significantly deeper cup changes than patients with POAG (vs respective age-matched controls, p=0.014). ON changes in PCG are characterised by significant increase in cup depth (165%), increased cup diameter (159%) and reduction in rim area (36.4%) as compared with controls with high sensitivity (81.5, 74.1% and 88.9%, respectively) and specificity (85.0, 80.0% and 75.0%, respectively). Patients with PCG have a significantly smaller width of the macula pit (p<0.001) with non-detectable external limiting membrane.

Conclusion

HH-OCT has the potential to be a useful tool in glaucoma management for young children. We have demonstrated the use of HH-OCT in confirming a diagnosis of glaucoma within the studied cohort and found changes in disc morphology which characterise differently in PCG from POAG.

The Prevalence of Glaucoma in Young People

BACKGROUND

Earlier information on the prevalence of glaucoma among children in Germany was based solely on estimates. Reported values for congenital glaucoma range from 1 in 10 000 to 1 in 68 000 depending on ethnic origin. The estimate for juvenile glaucoma is 1 in 44 000.

METHODS

The Gutenberg Health Study is a populationbased, prospective, monocentric cohort study with 15 010 participants aged 35 to 74. To determine the history-based prevalence of childhood glaucoma, participants were asked about the diagnosis of glaucoma, any operations for glaucoma that were performed, regular use of drugs for glaucoma, and the age of onset of glaucoma. The affected individuals were classified in four groups based on the age of onset: congenital (<2 years), juvenile (2 to <18 years), late juvenile (18 to <40 years), and early adult (40 to <45 years). In the identified glaucoma patients, the visual acuity, intraocular pressure, corneal thickness, visual fields, and optic discs were evaluated.

RESULTS

352 persons were identified from their medical history as having glaucoma. The weighted prevalences in the four groups were 0% in the congenital group, 0.01% (95% confidence interval [0, 0.03]) in the juvenile group, 0.16 % ([0.09; 0.23]) in the late juvenile group, and 0.17% ([0.15; 0.19]) in the early adult group. For participants over age 45, the weighted prevalence of glaucoma was 1.98% [1.7; 2.2].

CONCLUSION

In our cohort, the history-based prevalence of juvenile glaucoma was 0.01% (2 patients). The prevalence was an order of magnitude higher (0.16%) between the ages of 18 and 40, and two orders of magnitude higher at later ages (1.98%). The burden of disease seems to be markedly higher than previously assumed.

Prognostic factors of pediatric glaucoma: a retrospective study

PURPOSE

To correlate the features of certain types of infantile glaucoma with the progression and the prognosis of the disease, highlighting probable risk factors.

METHODS

Seventy-six patients with pediatric glaucoma were recruited in this retrospective study. All patients underwent ophthalmological examination in the Department of Ophthalmology of the Saarland University Medical Center from January 2001 to December 2012. Our pediatric patients were classified into four different categories of glaucoma: (1) primary congenital glaucoma (presenting buphthalmus), (2) aniridia-related glaucoma, (3) Peters/Rieger's anomaly-related glaucoma and (4) congenital cataract-related glaucoma. Personal data comprised age, sex, nationality, systemic diseases and gestational age. The best-corrected visual acuity (BCVA), the cup-disk ratio (CDR), the intraocular pressure (IOP), the corneal diameter and thickness, along with the Haab striae and corneal haze, were recorded.

RESULTS

The majority of the children were male (58%) and suffered from aniridia-related glaucoma (38%). Children with aniridia exhibited the worst BCVA. The CDR and IOP were significantly higher in children with primary congenital glaucoma, compared to the other groups, at the first visit. Those children also were with the largest corneal diameter and prevalence of Haab striae compared to the rest groups, whereas corneal haze was found more often and was more pronounced in children with Peters/Rieger's syndrome.

CONCLUSIONS

We concluded that glaucoma was earlier detected in children with primary congenital glaucoma, who exhibited increased corneal diameter and high percentage of Haab striae comparing to the other groups. However, these children responded successfully to any therapeutic intervention, exhibiting better BCVA and IOP values than the rest groups at the second visit.

Trabeculectomy or Transscleral Cyclophotocoagulation as Initial Treatment of Secondary Childhood Glaucoma in Northern Tanzania

PURPOSE

The purpose is to describe the outcome of trabeculectomy with transscleral cyclophotocoagulation (TSCPC) as an initial intervention for secondary childhood glaucoma in Northern Tanzania.

METHODS

A retrospective, consecutive case series was analyzed of all children with secondary childhood glaucoma who underwent initial trabeculectomy or TSCPC between 2000 and 2013 at a referral eye unit in Northern Tanzania. Retrospective data were collected on causes of glaucoma, intraocular pressure (IOP), visual acuity, complications, and subsequent interventions. Outcomes were evaluated using Kaplan-Meier survival analysis and compared with Cox regression analysis. The main outcome measure was failure (IOP>21 mm Hg).

RESULTS

Thirty-six eyes of 27 children (male, 21; median age, 9 y; range, 0.3 to 15 y) with secondary childhood glaucoma underwent trabeculectomy (19 eyes, 53%) or TSCPC (17 eyes, 47%). Causes included ocular trauma (13, 36%), previous cataract surgery (12, 33%), congenital aniridia (5, 14%), Sturge-Weber syndrome (2, 6%), steroid-induced glaucoma (2, 6%), uveitis (1, 3%), and unspecified leucoma (1, 3%). After 12 months, success was achieved in 48% after trabeculectomy and 18% after TSCPC, with visual acuity remaining unchanged in 11 of 14 (79%) and 4 of 5 eyes (80%), respectively. One third of the children did not return for follow-up after 1 year. Distance to the hospital (>100 km) was a significant risk factor for trabeculectomy failure (P=0.031).

CONCLUSIONS

A high proportion of secondary childhood glaucoma in Northern Tanzania was caused by trauma and previous cataract surgery. Trabeculectomy was associated with better IOP control but also a higher complication rate. The ability to maintain visual function was comparable after both interventions. Failure was associated with a journey to the eye hospital (>100 km) possibly leading to late presentation with advanced disease and erratic follow-up.

Evaluation of preoperative speed of progression and its association with surgical outcomes in primary congenital glaucoma patients: a retrospective study

Background

Surgeries are inevitable for treating primary congenital glaucoma (PCG) and risk factors of surgical failure play a key role in surgical decision making. The aim of this study was to investigate the influence of delay of surgery and preoperative speed of progression (SP) on the surgical outcomes in these patients.

Methods

Medical records of 83 eyes of 51 PCG patients with trabeculotomy within 3 years were retrospectively observed. Surgical outcomes, demographic and clinical data were compared after separating the eyes into two groups based on the interval (between onset of PCG and trabeculotomy) and SP index (SPI) respectively. Student’s t-test, Wilcoxon rank-sum test, Pearson’s chi-square test and Kaplan-Meier survival analysis were used in the statistical analysis.

Results

Comparative analysis showed better outcomes in the group with longer interval and lower SPIs. Better intraocular pressure (IOP) control was found in patients with lower SPI at 1, 3, 6, 12 and 24 months postoperatively (19.54 ± 4.84 mmHg vs. 24.75 ± 8.87 mmHg, p = 0.004; 19.88 ± 7.78 mmHg vs. 23.19 ± 6.74 mmHg, p = 0.089; 17.45 ± 6.23 mmHg vs. 21.31 ± 7.28 mmHg, p = 0.031; 15.09 ± 6.21 mmHg vs. 19.18 ± 6.66 mmHg, p = 0.008; 14.95 ± 2.95 mmHg vs. 18.10 ± 3.96 mmHg, p = 0.004). The correlation between SPI and IOP at 1, 3, 6, 12 and 24 months postoperatively was 0.328 (CI = 0.105 to 0.529, p = 0.005), 0.192 (CI = −0.070 to 0.429, p = 0.149), 0.261 (CI = 0.010 to 0.481, p = 0.042), 0.046 (CI = −0.183 to 0.270, p = 0.70), and 0.230 (CI = −0.072 to 0.493, p = 0.134), respectively. Patients with lower SPI were less likely to fail (χ2 = 22.71, p = 0.000, OR: 0.174; 95%CI: 0.059–0.510). Kaplan-Meier analysis showed a much slower decline of success rate in patients with lower SPI (χ2 = 25.52, p = 0.000).

Conclusions

In PCG patients, lower preoperative SPI was associated with better short-term IOP control and success rate. Evaluation of preoperative SPI may help with surgical decision. However, early detection and treatment are important given the same SPI.

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.

Viscocanalostomy combined with trabeculotomy and mitomycin C in the treatment of primary congenital glaucoma

AIM

To evaluate the long-term outcome of viscocanalostomy combined with trabeculotomy and mitomycin C in the treatment of primary congenital glaucoma.

METHODS

This is a retrospective study. Forty-two eyes of 26 patients with primary congenital glaucoma were enrolled. Intraocular pressure (IOP), corneal diameter (mm) and cup/disc (C/D) were measured before and after the surgery respectively. Follow-up period was 30mo.

RESULTS

The mean preoperative IOP was 30.6±7.35 mm Hg. Of the 42 eyes, 2 eyes were required conversion to trabeculectomy for the absence of Schlemm's canal. Of remained 40 eyes, 38 eyes (95%) achieved successful IOP control. The average postoperative IOP was 11.69±4.18 mm Hg at 12mo. The mean reduction was 18.91 mm Hg (P<0.0001). Eighteen (75%) eyes presented a reduction in corneal diameter, and 25 (62.5%) eyes presented a C/D ratio reversal after the surgery. There was no serious complication in any patients over the follow-up period.

CONCLUSION

Viscocanalostomy combined with trabeculotomy and mitomycin C is useful in the management of primary congenital glaucoma.

Primary Congenital Glaucoma Versus Glaucoma Following Congenital Cataract Surgery: Comparative Clinical Features and Long-term Outcomes

PURPOSE

To report and compare visual and glaucoma outcomes in primary congenital glaucoma (PCG) vs glaucoma following congenital cataract surgery (GFCS).

DESIGN

Retrospective, observational, comparative case series.

METHODS

Setting: Emory Eye Center, Atlanta, Georgia.

STUDY POPULATION

Pediatric glaucoma patients (age 0-18 years) treated at Emory by 1 clinician with ≥2-year follow-up. Glaucoma was defined according to the 9th Consensus Report of the World Glaucoma Association.

MAIN OUTCOME MEASURES

Snellen-equivalent logMAR visual acuity (VA) and glaucoma control (IOP ≤21, no devastating complications, no recommendation for further glaucoma surgery). Asymptotic Wilcoxon-Mann-Whitney rank sum tests were employed to compare glaucoma subgroups.

RESULTS

Included were 72 PCG and 56 GFCS cases, with mean follow-up time of 7.4 ± 4.1 and 8.0 ± 3.8 years, respectively. At last follow-up, PCG showed better median VA than GFCS in worse-seeing eyes (20/60 [interquartile range (IQR) 20/30-20/200] vs 20/400 [IQR 20/70-hand motion], respectively, P < .0001) and in better-seeing eyes of bilaterally-affected children (20/30 [IQR 20/20-20/60] vs 20/70 [IQR 20/35-20/100], respectively, P = .024).The following variables characterized the PCG and GFCS groups' glaucoma status, respectively: mean age at diagnosis (years), 0.70 ± 1.3 vs 3.3 ± 3.5 (P < .0001); median IOP (mm Hg), 15.50 [IQR 12.1-19.4] vs 17.50 [IQR 14.9-22], P = .037; median number of glaucoma medications at last follow-up, 1.49 [IQR 0-2] vs 2.54 [IQR 1-4], P < .0001; median number of glaucoma surgeries, 1.0 [IQR 1-2] vs 1.25 [IQR 0.5-2.0], P = .09.

CONCLUSIONS

Children with PCG (vs those with GFCS) presented earlier, had better vision, required fewer medications to control disease, and had lower IOP at last follow-up.

Outcomes of surgical interventions for primary childhood glaucoma in Northern Tanzania

AIM

To evaluate goniotomy, trabeculotomy, transscleral cyclophotocoagulation (TSCPC) and trabeculectomy as initial procedures in children with primary childhood glaucoma from Northern Tanzania.

METHODS

A retrospective analysis of consecutive interventions for primary childhood glaucoma from 2000 to 2013 was conducted at the Kilimanjaro Christian Medical Centre. Success was defined as postoperative intraocular pressure (IOP) below 22 mmHg. Success rates, IOP, visual acuity (VA), subsequent interventions and potential risk factors for failure were reported for the respective interventions.

RESULTS

The study included 116 eyes of 70 children (age 4.6±5.9 years) with primary childhood glaucoma; 46 (65.7%) children were male. The preoperative IOP was 33.1±10.2 mmHg, the preoperative cup/disc (CD) ratio 0.71±0.3 and the corneal diameter 13.3±1.4 mm. As a primary intervention, 61 (52.6%) eyes underwent goniotomy, 10 (8.6%) eyes trabeculotomy, 12 (10.3%) TSCPC and 33 (28.4%) trabeculectomy. Follow-up data after 12 months were available for 63 (54.3%) eyes. Success rates at 12 months were 38% (goniotomy), 30% (trabeculotomy), 17% (TSCPC) and 64% (trabeculectomy). All interventions achieved a statistically significant IOP reduction at 3, 6 and 12 months, except for trabeculotomy after 6 months and TSCPC at all time points. Postoperative endophthalmitis occurred in one child treated with trabeculectomy. VA in 82% of all eyes was maintained or had improved after 12 months.

CONCLUSIONS

Based on the success rates of this retrospective analysis, goniotomy or trabeculotomy for younger and trabeculectomy for older children can be recommended in our setting to reduce IOP. Late presentation in combination with advanced glaucomatous damage as well as erratic postoperative follow-up and treatment were likely factors that compromised overall success rates. More efforts are necessary to detect the blinding disease earlier and improve adherence to follow-up.

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.

Traumatic pediatric cataract in southern Ethiopia--results of 49 cases

PURPOSE

To report the experience of two tertiary care facilities in southern Ethiopia in the treatment of traumatic pediatric cataract for a period of more than 1 year.

METHODS

The medical records of consecutive traumatic pediatric cataract patients who underwent surgery at the Hawassa University and the Yirgalem University schools of medicine from July 2007 to August 2008 were retrospectively reviewed. All patients with a follow-up of at least 12 months were included.

RESULTS

A total of 49 children were included. Mean patient age was 8.6 ± 0.3 years (range, 5-15 years). Of the 49 cases, 32 (65%) were caused by blunt trauma. Average follow-up period was 15 months. Postoperative visual acuity of counting fingers or better was achieved in 43 (88%) eyes compared with 5 (10%) at presentation (P < 0.0001). Better visual acuity at presentation and blunt trauma were associated with better final visual acuity. Only blunt trauma was found by multivariate analysis to influence final visual acuity (P = 0.0001).

CONCLUSIONS

Visual acuity of counting fingers or better visual can be achieved in most cases. Blunt trauma is a good independent prognostic factor for visual acuity.

Late-recognized primary congenital glaucoma

PURPOSE

To describe a cohort of children with late-recognized primary congenital glaucoma (LRPCG), including age of presentation, age-related diagnostic signs, clinical abnormalities, and results of glaucoma surgery.

METHODS

The medical records of 31 patients (49 eyes) with PCG recognized after 1 year of age were reviewed retrospectively. Patients were confirmed to have PCG based on their increased intraocular pressure (IOP), anterior segment abnormalities including findings on gonioscopy, and the absence of other causes of childhood glaucoma. The outcome of glaucoma surgery was reviewed and success measured by assessment of the relative control of IOP, occurrence of significant complications, and need for additional glaucoma surgery.

RESULTS

Average age at diagnosis of glaucoma was 4.7 years (36% diagnosed at > 4 years of age). The most common initial diagnostic signs were corneal enlargement (46%, average age of 2.0 years), photophobia (20%, average age of 3.3 years), and suspected poor visual acuity (32%, average age of 9.9 years). Corneal cloudiness was not an initial sign for any patient. Haab's striae were present in 60% of the affected 49 eyes. Gonioscopy findings were abnormal in 82%, but the ciliary body band was seen in 81% and the scleral spur was visible in 47%. Sixty-one goniotomy procedures were performed for 39 eyes with overall success in 95% (37 eyes) and complete success in 65% (27 eyes). The final visual acuity was 20/200 or worse in 31% (15 eyes) and 20/40 or better in 60% (29 eyes).

CONCLUSIONS

An awareness of and familiarity with the subtle diagnostic signs of LRPCG can enable its differentiation from primary juvenile glaucoma and contribute to earlier recognition and treatment. Glaucoma surgery is often required for LRPCG and goniosurgery is the recommended initial procedure.

Ahmed glaucoma valve in children: A review

Pediatric glaucoma is potentially a blinding disease. Although goniotomy and trabeculotomy are associated with good early success rates, eventually 20% of these procedures fail and many children will require additional surgery to control the IOP in the long-term. In this review, we reported that adequate IOP control can be achieved with the placement of Ahmed glaucoma valve and can last 5 or more years. However, most patients will need one or more glaucoma medications at some point after surgery. In addition, the implants may be associated with pupillary irregularities, lenticular opacification as well as tube-related complications, particularly in the first year of life, as the globe is enlarging with age.