Combined trabeculotomy-trabeculectomy versus Ahmed valve implantation for refractory primary congenital glaucoma in Egyptian patients: a long-term follow-up

Long-Term Results of Combined Trabeculotomy Trabeculectomy in Primary Congenital Glaucoma

PRCIS

Primary congenital glaucoma (PCG) in Tunisian children seems to be characterized by a high prevalence of inherited and advanced forms of the disease. Primary combined trabeculotomy trabeculectomy (CTT) allowed satisfactory long-term intraocular pressure (IOP) control and reasonable visual outcome.

PURPOSE

To report the long-term outcome of CTT as the initial glaucoma surgery in children with PCG.

METHODS

Retrospective analysis of children who underwent primary CTT for PCG between January 2010 and December 2019. The main outcome measures were IOP reduction, corneal clarity, complications, refractive errors, and visual acuity (VA). Success was defined as IOP <16 mm Hg without (complete) or with (qualified) antiglaucoma medication. The WHO criteria of vision loss were used to categorize visual impairment (VI).

RESULTS

Of 62 patients, 98 eyes were enrolled. At the last follow-up, the mean IOP was reduced from 22.7 ± 4.0 mm Hg to 9.7 ± 3.9 mm Hg ( P < 0.0001). The complete success rate was 91.6%, 88.4%, 84.7%, 71.6%, 59.7%, and 54.3%, at the first, second, fourth, sixth, eighth, and tenth year, respectively. Follow-up averaged 42.1 ± 28.4 months. Preoperatively, 72 eyes (73.5%) had significant corneal edema versus 11 eyes (11.2%) at the end of the follow-up ( P < 0.0001). Endophthalmitis was encountered in one eye. Myopia was the most common refractive error (80.6%). Data on Snellen VA were available for 53.2% of the patients; 33.3% achieved a VA ≥6/12, 21.2% had mild VI, 9.1% had moderate VI, 21.2% had severe VI, and 15.2% were blind. The failure rate was statistically correlated to the early disease onset (<3 mo) and to preoperative corneal edema ( P = 0.022 and P = 0.037, respectively).

CONCLUSION

Primary CTT seems to be a good procedure in a population with advanced PCG at presentation, problematic follow-up visits, and limited resources.

Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery

PRCIS

Repeat trabeculectomy is associated with similar postoperative intraocular pressure (IOP), a lower complication rate, and a lower need for medications when compared with Ahmed valve implantation (AVI) when performed after initially failed trabeculectomy.

OBJECTIVE

The goal of this study was to compare the efficacy of repeat trabeculectomies and AVI after an initial failed trabeculectomy.

METHODS

All studies that investigated the postoperative success of patients who underwent AVI or repeat trabeculectomy with mitomycin- C after a prior failed trabeculectomy with mitomycin- C found in PubMed, Cochrane Library, Scopus, and CINAHL were included. Mean preoperative and postoperative IOP, proportions of complete and qualified successes, and proportions of complications were extracted from each study. Meta-analyses were performed to compare the differences between the two surgical approaches. Methods of measuring complete and qualified success were too heterogeneous among the included studies to allow for meta-analysis.

RESULTS

The literature search yielded 1305 studies, and 14 studies were included in the final analysis. Mean IOP was not significantly different between the two groups preoperatively and then after 1, 2, and 3 years. Mean number of medications between the two groups was similar preoperatively. After 1 and 2 years, the mean amount of glaucoma medications in the AVI group was approximately twice that of the trabeculectomy group; however, this relationship was only significant at 1 year of follow-up ( P = 0.042). In addition, the cumulative proportion of overall and sight-threatening complications was significantly higher in the AVI group.

CONCLUSION

Repeat trabeculectomy with mitomycin- C and AVI may both be considered after failed primary trabeculectomy. However, our analysis suggests that repeat trabeculectomy may be the preferred method as it provides similar efficacy with fewer disadvantages.

Efficacy of Ahmed and Baerveldt glaucoma drainage device implantation in the pediatric population: A systematic review and meta-analysis

Glaucoma drainage devices (GDD) are increasingly utilized in the management of childhood glaucoma. This systematic review and meta-analysis assesses the efficacy of first-time Ahmed or Baerveldt implantation in children. PubMed, Embase, and Cochrane Library were searched for relevant English-language, peer-reviewed literature. Postoperative outcomes were pooled using random effects regression models with restricted maximum likelihood estimation. Thirty-two studies (1,221 eyes, 885 children) were included. Mean ± standard deviation preoperative IOP was 31.8 ± 3.4 mm Hg. Pooled mean IOP at 12 and 24 months postoperatively were 16.5 mm Hg (95% CI, 15.5-17.6) and 17.6 mm Hg (95% CI, 16.4-18.7), respectively. Pooled proportions of success were 0.87 (95% CI, 0.83-0.91) at 12 months, 0.77 (95% CI, 0.71-0.83) at 24 months, 0.54 (95% CI, 0.44-0.65) at 48 months, 0.60 (95% CI, 0.48-0.71) at 60 months, and 0.37 (95% CI, 0.32-0.42) at 120 months. There were no differences in proportion of success at 12 and 24 months among eyes that received Ahmed and Baerveldt tube shunts, nor between eyes with primary glaucoma, glaucoma following cataract surgery, or other secondary glaucoma. Our findings show that Ahmed and Baerveldt shunts substantially reduced IOP for at least 24 months in childhood glaucoma, with similar findings among device types and glaucoma etiologies.

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.

Surgical interventions for primary congenital glaucoma

BACKGROUND

Primary congenital glaucoma (PCG) is an optic neuropathy with high intraocular pressure (IOP) that manifests within the first few years of a child's life and is not associated with other systemic or ocular abnormalities. PCG results in considerable morbidity even in high-income countries.

OBJECTIVES

To compare the effectiveness and safety of different surgical techniques for PCG.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2020, Issue 4); Ovid MEDLINE; Embase.com; PubMed; metaRegister of Controlled Trials (mRCT) (last searched 23 June 2014); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 27 April 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs comparing different surgical interventions in children under five years of age with PCG.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We included 16 trials (13 RCTs and three quasi-RCTs) with 587 eyes in 446 children. Eleven (69%) trials were conducted in Egypt and the Middle East, three in India, and two in the USA. All included trials involved children younger than five years of age, with follow-up ranging from six to 80 months. The interventions compared varied across trials. Three trials (on 68 children) compared combined trabeculotomy and trabeculectomy (CTT) with trabeculotomy. Meta-analysis of these trials suggests there may be little to no evidence of a difference between groups in mean IOP (mean difference (MD) 0.27 mmHg, 95% confidence interval (CI) -0.74 to 1.29; 88 eyes; 2 studies) and surgical success (risk ratio (RR) 1.01, 95% CI 0.90 to 1.14; 102 eyes; 3 studies) at one year postoperatively. We assessed the certainty of evidence as very low for these outcomes, downgrading for risk of bias (-1) and imprecision (-2). Hyphema was the most common adverse outcome in both groups (no meta-analysis due to considerable heterogeneity; I² = 83%). Two trials (on 39 children) compared viscotrabeculotomy to conventional trabeculotomy. Meta-analysis of 42 eyes suggests there is no evidence of between groups difference in mean IOP (MD -1.64, 95% CI -5.94 to 2.66) and surgical success (RR 1.11, 95% CI 0.70 to 1.78) at six months postoperatively. We assessed the certainty of evidence as very low, downgrading for risk of bias and imprecision due to small sample size. Hyphema was the most common adverse outcome (38% in viscotrabeculotomy and 28% in conventional trabeculotomy), with no evidence of difference difference (RR 1.33, 95% CI 0.63 to 2.83). Two trials (on 95 children) compared microcatheter-assisted 360-degree circumferential trabeculotomy to conventional trabeculotomy. Meta-analysis of two trials suggests that mean IOP may be lower in the microcatheter group at six months (MD -2.44, 95% CI -3.69 to -1.19; 100 eyes) and at 12 months (MD -1.77, 95% CI -2.92 to -0.63; 99 eyes); and surgical success was more likely to be achieved in the microcatheter group compared to the conventional trabeculotomy group (RR 1.59, 95% CI 1.14 to 2.21; 60 eyes; 1 trial at 6 months; RR 1.54, 95% CI 1.20 to 1.97; 99 eyes; 2 trials at 12 months). We assessed the certainty of evidence for these outcomes as moderate due to small sample size. Hyphema was the most common adverse outcome (40% in the microcatheter group and 17% in the conventional trabeculotomy group), with greater likelihood of occurring in the microcatheter group (RR 2.25, 95% CI 1.25 to 4.04); the evidence was of moderate certainty due to small sample size (-1). Of the nine remaining trials, no two trials compared the same two surgical interventions: one trial compared CTT versus CTT with sclerectomy; three trials compared various suturing techniques and adjuvant use including mitomycin C, collagen implant in CTT; one trial compared CTT versus Ahmed valve implant in previously failed surgeries; one trial compared CTT with trabeculectomy; one trial compared trabeculotomy to goniotomy; and two trials compared different types of goniotomy. No trials reported quality of life or economic data. Many of the included trials had limitations in study design, implementation, and reporting, therefore the reliability and applicability of the evidence remains unclear.

AUTHORS' CONCLUSIONS

The evidence suggests that there may be little to no evidence of difference between CTT and routine conventional trabeculotomy, or between viscotrabeculotomy and routine conventional trabeculotomy. A 360-degree circumferential trabeculotomy may show greater surgical success than conventional trabeculotomy. Considering the rarity of the disease, future research would benefit from a multicenter, possibly international trial, involving parents of children with PCG and with a follow-up of at least one year.

Ab externo 240-degree trabeculotomy versus trabeculotomy-trabeculectomy in primary congenital glaucoma

OBJECTIVE

This prospective study aimed to compare the surgical outcomes of ab externo 240-degree trabeculotomy and trabeculotomy-trabeculectomy in managing primary congenital glaucoma (PCG).

PATIENTS AND METHODS

The study included 30 eyes of 30 patients aged less than 3 years who were diagnosed with PCG and was conducted in Menofia University Hospital between November 2018 and January 2020. The studied eyes were divided into two equal groups. Ab externo 240-degree trabeculotomy and combined trabeculotomy with trabeculectomy with MMC were performed for groups I and II, respectively. Post-operative measurements included intraocular pressure (IOP), optic disc changes, alteration in corneal clarity and transverse corneal diameter, as they are needed for antiglaucoma therapy. Post-operative complications were followed up for 1-year.

RESULTS

There was significant reduction in IOP in both groups during the follow-up period. The reduction was higher in group I, where mean preoperative IOP was 28.20 ± 1.74 mmHg. The IOP in the group II was 28.07 ± 3.51 mmHg. The mean IOP decreased to 13.93 ± 1.8 mmHg and 14.60 ± 1.24 mmHg in groups I and II, respectively, after 1 year (P < 0.001); however, the difference between the two groups was not significant. Regarding post-operative complications, post-operative hypotony was more common in group I. Other complications such as shallow anterior chamber, choroidal detachment and blebitis occurred more frequently in group II. However, post-operative hyphema was more common in group I. Corneal clarity improved significantly in both groups, but more so in group I, where an improvement was seen in 13 cases (86.6%), compared to 11 cases in group II (73.3%).

CONCLUSION

Ab externo 240° trabeculotomy and trabeculotomy-trabeculectomy are effective techniques in primary congenital glaucoma with more reduction in IOP in Ab Externo 240° trabeculotomy. Ab externo 240° trabeculotomy provided more better surgical outcome with limited complications, especially those related to bleb formation.

Long-term outcome of combined trabeculotomy-trabeculectomy by a single surgeon in patients with primary congenital glaucoma

PurposeAssess long-term outcome of combined trabeculotomy-trabeculectomy (CTT) in primary congenital glaucoma (PCG).MethodsData of PCG patients treated with CTT by a single surgeon between 1976 and 1993 were reviewed for reduction in intraocular pressure (IOP), visual acuities, surgical success rates, and need for repeat surgeries at last follow-up (FU). At the last FU, IOP<21 mm Hg without any topical antiglaucoma medication (TAM) was complete success and with 1-2 TAMs was qualified success. IOP reduction ≥30% without any TAM was modified complete success and with 1-2 TAMs was modified qualified success. IOP>21 mm Hg, IOP reduction <30%, or use of >2 TAM at last FU, or need for additional surgery was considered as failure.ResultsTwo hundred thirty eyes of 121 patients had been followed up for 21.5-38 years (mean 28.87±2.77 years). Eyes that were pthisical (3), had immeasurable IOP (2), or IOP<6 mm Hg (3) were excluded from the success analysis. At last FU, mean IOP reduction was 22.71±11.28 mm Hg and TAM score was 1.71 (0-4). Complete success was achieved in 14 (6.3%), modified complete success in 14 (6.3%), qualified success in 148 (66.7%), and modified qualified success in 140 (63.1%). Success probability was 95% till 25 years and 92, 90, 85, 79 and 68% at 26, 27, 28, 29, and 30 years, respectively. Severe visual impairment or functional blindness was found in only 13 (10.7%) patients.ConclusionCTT shows long-term success in PCG patients. All patients must be monitored for IOP control to avoid need for repeat surgeries.