Non-Penetrating Deep Sclerectomy versus Trabeculectomy in Primary Congenital Glaucoma

Effect of Trabeculodescemetic Window Perforation in Deep Sclerectomy on Intraocular Pressure in Primary Congenital Glaucoma

INTRODUCTION

Primary congenital glaucoma causes vision loss if intraocular pressure is uncontrolled. Nonpenetrating deep sclerectomy is effective in treating primary congenital glaucoma. However, the effects of inadvertent trabeculodescemetic window perforation remain unclear.

METHODS

This retrospective cohort study included patients with primary congenital glaucoma who underwent nonpenetrating deep sclerectomy between 2014 and 2021. The perforation group had intraoperative trabeculodescemetic window perforations; the non-perforation group did not. The primary outcome was intraocular pressure between the groups over 15 months. The secondary outcomes included surgical success and complications.

RESULTS

The study included 74 eyes of 44 patients. The cohort comprised 31 perforated and 43 non-perforated eyes. Both groups showed significant intraocular pressure reduction without significant between-group differences in complete (68 vs. 77%), qualified (19 vs. 9%), or failed (13 vs. 14%) treatments. The median intraocular pressure decreased from 39 to 14 mmHg in the perforation group and 35 to 12 mmHg in the non-perforation group. Of the 74 treated eyes, 68 (92%) showed no complications.

CONCLUSIONS

An inadvertent trabeculodescemetic window perforation during nonpenetrating deep sclerectomy for primary congenital glaucoma did not significantly affect intraocular pressure outcomes compared to non-perforated cases over 15 months. Nonpenetrating deep sclerectomy reduced intraocular pressure regardless of intraoperative perforation in patients with primary congenital glaucoma. Perforation of the trabeculodescemetic window was associated with a low incidence of postoperative complications.

Non-penetrating deep sclerectomy versus combined trabeculotomy-trabeculectomy in primary congenital glaucoma

Background

The primary mode of therapy in children with primary congenital glaucoma (PCG) and mild or no corneal edema is goniotomy, which has a high success rate. However, in developing countries, the diagnosis of PCG is usually delayed, and corneal cloudiness interferes with goniotomy. Therefore, trabeculotomy may be the best choice in such eyes. We compared the short-term efficacy and safety of primary combined trabeculotomy-trabeculectomy (primary CTT) with that of non-penetrating deep sclerectomy (NPDS) in managing PCG.

Methods

This prospective, randomized, comparative study included patients with PCG referred to Al-Azhar University Hospitals within a 1-year period. Eyes were randomly allocated to one of two groups: eyes in NPDS group underwent NPDS, and those in primary CTT group underwent primary CTT. Baseline and frequent postoperative assessments of intraocular pressure (IOP), cup-to-disc ratio (C/D ratio), corneal diameter, and axial length were performed for up to 6 months. The success rates were recorded in both groups.

Results

Forty eyes of 26 patients were included, with 20 eyes allocated to each group. The mean (standard deviation) age of all patients was 12.9 (9.5) months, with comparable ages and sex ratios between groups (both P > 0.05). Both groups demonstrated a significant reduction in IOP and C/D ratio at each postoperative visit compared to the baseline visit (all P < 0.001), with no significant difference detected between the groups (all P > 0.05), except for a significantly lower IOP in NPDS group at 1 month (P < 0.05). The corneal diameter and axial length were comparable between groups at baseline and remained unchanged at all postoperative visits (all P > 0.05). The groups had comparable success rates (P > 0.05). No serious complications were detected.

Conclusions

CTT and NPDS both yielded reasonable IOP control and reversal of cupping in eyes with PCG. We observed equal effectiveness of the surgical procedures without major safety concerns. Further large-scale clinical trials with longer follow-up periods are needed to verify our preliminary findings.

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.

Outcomes of Non-Penetrating Deep Sclerectomy for Primary Congenital Glaucoma Performed by Experienced versus Trainee Surgeons: A Cohort Study

Purpose

To compare the outcomes of non-penetrating deep sclerectomy (NPDS) for primary congenital glaucoma (PCG) performed by experienced vs trainee surgeons.

Patients and Methods

This retrospective cohort study was conducted in 2022 in Saudi Arabia. Consultants (Gr-1) and trainee pediatric ophthalmologists (Gr-2) performed NPDS on pediatric patients with PCG. Success was defined as an intraocular pressure (IOP) less than 21 mmHg at 6 months after surgery. Complications, glaucoma medications, and additional procedures were also observed in the two groups.

Results

Gr-1 and Gr-2 operated on 14 and 39 eyes with PCG, respectively. The absolute success rates were 90.9% (95% confidence interval [CI]: 73.9, 100) in Gr-1 and 96.7% (95% CI: 90.2, 100) in Gr-2 (odds Ratio=1.1; 95% CI: 0.87, 1.3; P=0.54). Survival analysis suggested that the failure rate in the first 6 months after NPDS was not significantly different between the two groups (hazard ratio=1.45; 95% CI: 0.13, 16.0; P=0.767). The complications included hypotony (2 cases), vitreous hemorrhage (1 case), and total flap penetration (1 case). Only one eye in Gr-2 needed glaucoma medication after surgery. There was no significant difference in the success rates of one surgeon before and after training (P=0.43). The age (P=0.59) and sex (P=0.77) of patients, type of surgeon (P=0.94), and preoperative IOP (P=0.59) were not significant predictors of a stable IOP at 6 months after NPDS.

Conclusion

At 6 months after NPDS surgery performed by experienced and trainee pediatric ophthalmologists, the outcomes (stabilization of IOP) were similar between the two groups.

CO2 Laser-Assisted Sclerectomy Surgery Alone or Combined with Phacoemulsification in Primary Open-Angle Glaucoma: Comparison of 1-Year Outcomes

Introduction

To compare 1-year outcomes of CO₂ laser-assisted sclerectomy surgery (CLASS) alone or combined with phacoemulsification (CLASS + Phaco) in eyes with primary open-angle glaucoma (POAG).

Methods

This was a prospective, comparative, case series study. A total of 46 eyes with POAG underwent CLASS or CLASS + Phaco were followed up for 1 year. The primary outcomes included changes in intraocular pressure (IOP), medication and best corrected visual acuity (BCVA). The secondary outcomes were success rate, functional bleb, postoperative laser intervention and complications.

Results

CLASS alone resulted in a greater IOP reduction compared with CLASS + Phaco. BCVA improved remarkably in CLASS + Phaco group, but there was no difference in BCVA before and after CLASS. The number of antiglaucoma medications significantly decreased at 12 months postoperatively in both groups. Functional blebs were more commonly seen in the CLASS than combination group. The overall success rate was higher in the CLASS than CLASS + Phaco group at 1 year after surgery. The incidence of peripheral anterior synechiae (PAS) in CLASS + Phaco group was significantly lower than that of CLASS alone.

Conclusion

CLASS alone achieved a greater IOP reduction, more common functional bleb formation and a higher success rate compared to CLASS combined with Phaco, while combination surgery yielded a better BCVA improvement and a lower PAS incidence than CLASS alone. Both surgical strategies have favorable safety and efficacy among POAG patients. Combined surgery could be a viable option for patients with co-existing POAG and cataract.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00539-2.

Viscocanalostomy combined with trabeculotomy for management of refractory primary congenital glaucoma

PURPOSE

To investigate the outcome of viscocanalostomy combined with trabeculotomy (VCO+tbo) in primary congenital glaucoma (PCG) with history of failed trabeculotomy.

METHODS

In this prospective study, VCO+tbo was performed in 75 eyes of 46 patients with PCG who had not responded adequately to one angle surgery. Success was defined as intraocular pressure (IOP) of 6-21 mm Hg and at least 20% IOP drop at the last postoperative visit with (qualified) or without (complete) glaucoma medications.

RESULTS

Patients completed a mean follow-up of 31 ± 11 months. Complete success was achieved in 6 eyes (8%); qualified success, in 38 eyes (51%). In the 44 successfully treated eyes, IOP was reduced from a preoperative mean of 29.0 ± 5.8 to 15.7 ± 2.6 mm Hg, and the number of medications dropped from 2.6 ± 0.9 to 2.0 ± 1.0 (P < 0.001). In univariate analysis, the success rate was lower in patients with neonatal onset disease than subjects whose age at onset was 1-12 months (HR = 0.22; 95% CI, 0.05-0.93; P = 0.039). Children whose disease was first diagnosed after 1 year of age responded better than neonatal onset patients but worse than those with age of onset of 1-12 months; however, the difference was not statistically significant. Hyphema occurred in 27 eyes (36%) on day 1 and resolved spontaneously. Iatrogenic cyclodialysis occurred in one eye, which was surgically repaired after 1 month of treatment with cycloplegic agents.

CONCLUSIONS

In our study cohort, VCO+tbo was associated with successful outcomes in the majority of treated eyes.

Factors affecting the surgical success of trabeculectomy performed as the first surgery in primary pediatric glaucoma

PURPOSE

To present the outcomes and factors affecting the success of trabeculectomy performed as the first surgery in primary pediatric glaucoma.

METHODS

Pediatric patients with primary glaucoma who underwent trabeculectomy as the first surgery were retrospectively reviewed. Age, gender, preoperative intraocular pressure (IOP), operation age, axial length, corneal diameter, anterior segment findings, antimetabolite used, complications, and 1-month, 3-months, 1-year, and most recent postoperative findings were recorded. Postoperative IOP with/without medication of 18 mmHg or less was considered successful. Factors that may have affected surgical success were also evaluated using multivariate analysis.

RESULTS

Included in the study were 48 patients, of whom 30 had primary congenital glaucoma and 18 had juvenile glaucoma. The mean preoperative IOP was 36.84 ± 6.30 mmHg, and the mean follow-up time was 7.95 ± 6.93 years. The median operation age value was 100.00 ± 100.83 (median: 60; IQR: 153) months. The postoperative IOP at the 1-month, 3-months, 1-year, and most recent follow-ups were 15.39 ± 6.88, 15.70 ± 7.36, 16.28 ± 7.86, and 17.48 ± 8.44 mmHg, respectively (p = 0.565). While there were no postoperative complications in 24 of the patients (50.0%), the most common complications were choroidal detachment and hypotony. Postoperative complication development was found to be significant as a factor affecting surgical success in the multivariate logistic regression analysis. Surgical success rates for all of the patients were 71.7%, 65.9%, 65.0%, and 61.4% at the 1-month, 3-months, 1-year, and most recent follow-ups, respectively. A significant difference was found between the congenital and juvenile groups in terms of surgical success only at 3 months (p = 0.953, p = 0.042, p = 0.191, p = 0.218; respectively).

DISCUSSION/CONCLUSION

The fact that surgical success was partially higher in the juvenile group confirmed the idea that the results of trabeculectomy will be more favorable in patients of older age and without anterior segment anomalies.

Management of Intraocular Pressure Elevation After CO2 Laser-Assisted Sclerectomy Surgery in Patients With Primary Open-Angle Glaucoma

Purpose: To report the safety and efficiency of carbon dioxide (CO₂) laser-assisted sclerectomy surgery (CLASS) in Chinese patients with primary open-angle glaucoma (POAG) and the management of unexpected postoperative intraocular pressure (IOP) elevation.

Methods: This was a prospective case series study. A total of 23 eyes from 23 patients with POAG who underwent CLASS were involved and followed-up for 12 months. The primary outcomes included the changes in best corrected visual acuity (BCVA), IOP, and medications before and after CLASS. The secondary outcomes were success rate and postoperative laser interventions.

Results: The mean age of the patient was 42.6 ± 16.0 years. There was no significant change in BCVA and visual field at baseline and 12 months after CLASS. The number of medications was significantly reduced after CLASS. The IOP was also significantly decreased and remained well controlled during the follow-up period, except for a transient elevation at 1 month postoperatively, due to the occurrence of peripheral anterior synechiae (PAS). Generally, 17 patients (73.9%) were treated with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser synechiolysis to remove iris obstruction in the filtration site and seven patients (30.4%) underwent Nd:YAG laser goniopuncture to deal with scleral reservoir reduction. Only one patient (4.3%) received surgical repositioning due to iris incarceration. The complete success rate and total success rate at 12 months were 69.6 and 95.7%, respectively.

Conclusion: CLASS was a safe and effective approach for Chinese patients with POAG. Peripheral anterior synechiae (PAS), iris incarceration, and scleral reservoir reduction were common causes of unexpected postoperative IOP elevation. Individualized Nd:YAG laser intervention helps to improve the long-term outcomes after CLASS.