Zotarolimus alleviates post-trabeculectomy fibrosis via dual functions of anti-inflammation and regulating AMPK/mTOR axis

OBJECTIVE

Postoperative scar formation is the primary cause of uncontrolled intraocular pressure following trabeculectomy failure. This study aimed to evaluate the efficacy of zotarolimus as an adjuvant anti-scarring agent in the experimental trabeculectomy.

METHODS

We performed differential gene and Gene Ontology enrichment analysis on rabbit follicular transcriptome sequencing data (GSE156781). New Zealand white Rabbits were randomly assigned into three groups: Surgery only, Surgery with mitomycin-C treatment, Surgery with zotarolimus treatment. Rabbits were euthanized 3 days or 28 days post-trabeculectomy. Pathological sections were analyzed using immunohistochemistry, immunofluorescence, and Masson staining. In vitro, primary human tenon's capsule fibroblasts (HTFs) were stimulated by transforming growth factor-β1 (TGF-β1) and treated with either mitomycin-C or zotarolimus. Cell proliferation and migration were evaluated using cell counting kit-8, cell cycle, and scratch assays. Mitochondrial membrane potential was detected with the JC-1 probe, and reactive oxygen species were detected using the DCFH-DA probe. RNA and protein expressions were quantified using RT-qPCR and immunofluorescence.

RESULTS

Transcriptome sequencing analysis revealed the involvement of complex immune factors and metabolic disorders in trabeculectomy outcomes. Zotarolimus effectively inhibited fibrosis, reduced proinflammatory factor release and immune cell infiltration, and improved the surgical outcomes of trabeculectomy. In TGF-β1-induced HTFs, zotarolimus reduced fibrosis, proliferation, and migration without cytotoxicity via the dual regulation of the TGF-β1/Smad2/3 and AMPK/AKT/mTOR pathways.

CONCLUSION

Our study demonstrates that zotarolimus mitigates fibrosis by reducing immune infiltration and correcting metabolic imbalances, offering a potential treatment for improving trabeculectomy surgical outcomes.

Mitomycin C 0.2 mg/ml versus Mitomycin C 0.4 mg/ml during the Implantation of an Ab Externo Polystyrene-isobutylene-styrene Microshunt: A Mega-analysis

PURPOSE

To compare the effectiveness and adverse event profile of standalone polystyrene-isobutylene-styrene (SIBS) microshunt implantation with adjunct mitomycin C (MMC) 0.2 mg/ml and MMC 0.4 mg/ml.

DESIGN

Mega-analysis using individual patient data from international prospective and retrospective clinical studies.

PARTICIPANTS

Patients with glaucoma who underwent implantation of a SIBS microshunt with MMC as a standalone procedure.

METHODS

A comparison of eyes that received MMC 0.2 mg/ml or 0.4 mg/ml.

MAIN OUTCOMES MEASURES

Primary outcome was complete success defined as the proportion of eyes at 1 year with all of the following: (1) no 2 consecutive intraocular pressures (IOPs) > 17 mmHg; (2) no clinical hypotony; (3) ≥ 20% IOP reduction from baseline; and (4) no use of glaucoma medications. Secondary outcomes included IOP thresholds of 12 mmHg, 14 mm Hg, and 21 mmHg, median IOP, number of medications, risk factors for failure, interventions, adverse events, and reoperations.

RESULTS

At 1 year, the complete success rate was significantly higher (71.3% vs. 50.46%; P < 0.001) and the median IOP was significantly lower (13.0 vs 14.2 mmHg; P < 0.05) in the MMC 0.4 mg/ml group. Mitomycin C 0.2 mg/ml was found to be a significant risk factor for failure (hazard ratio 1.75; 95% confidence interval 1.14-2.67). Needling and surgical revision occurred at a lower rate in the MMC 0.4 mg/ml group (7% vs 18.8%; P = 0.002 and 4.3% vs 13.7% P = 0.0087, respectively). Adverse events occurred at a similar frequency in both groups (26.6% MMC 0.2 mg/ml vs 29.6% MMC 0.4 mg/ml; P = 0.46), most of which were early and transient.

CONCLUSION

Polystyrene-isobutylene-styrene microshunt implantation with MMC 0.4 mg/ml resulted in a higher success rate with greater IOP reduction compared with MMC 0.2 mg/ml. Higher MMC concentration was not associated with increased serious adverse events.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Clinical and Histopathological Effects of Intracameral Ranibizumab in Experimental Trabeculectomy

Post-surgical scarring is a known cause of trabeculectomy failure. The aim of this study was to investigate the effectiveness of ranibizumab as an adjuvant anti-scarring agent in experimental trabeculectomy. Forty New Zealand white rabbits were randomised into four eye treatment groups: groups A (control), B (ranibizumab 0.5 mg/mL), C (mitomycin C [MMC] 0.4 mg/mL), and D (ranibizumab 0.5 mg/mL and MMC 0.4 mg/mL). Modified trabeculectomy was performed. Clinical parameters were assessed on post-operative days 1, 2, 3, 7, 14, and 21. Twenty rabbits were euthanised on day 7, and the other twenty were euthanised on day 21. Eye tissue samples were obtained from the rabbits and stained with haematoxylin and eosin (H&E). All treatment groups showed a significant difference in IOP reduction compared with group A (p < 0.05). Groups C and D showed a significant difference in bleb status on days 7 (p = 0.001) and 21 (p = 0.002) relative to group A. H&E staining showed significantly low fibrotic activity (p < 0.001) in group C on both days and inflammatory cell grade in group B on day 7 (p < 0.001). The grade for new vessel formation was significantly low in groups B and D on day 7 (p < 0.001) and in group D on day 21 (p = 0.007). Ranibizumab plays a role in reducing scarring, and a single application of the ranibizumab-MMC combination showed a moderate wound-modulating effect in the early post-operative phase.

Controversies in Pediatric Angle Surgery and Secondary Surgical Treatment

Pediatric glaucoma is a constellation of challenging ophthalmic conditions that, left untreated, can result in irreversible vision loss. The mainstay of treatment for primary congenital glaucoma and select secondary glaucoma subtypes is angle surgery, either trabeculotomy or goniotomy. More recently, MIGS devices have been utilized to enhance the efficacy of these procedures. Despite the high success rates of these primary surgical options, refractory cases are challenging to manage. There is no consensus on the next step of treatment following primary angle surgery. Glaucoma drainage devices and trabeculectomies have been the traditional options, with laser treatment reserved for more severe cases. The benefits and disadvantages of each of these options are discussed.

Glaucoma management in congenital ectropion uveae: Surgical outcomes from a large tertiary referral center in South India

PURPOSE

To evaluate the long-term outcomes of glaucoma management in patients with congenital ectropion uveae (CEU) over a period of three decades at a single large referral tertiary eye care center.

METHODS

Retrospective chart review of all patients with CEU treated surgically from 1990 to 2019 was performed. Primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with and without mitomycin-C (MMC) (0.2 mg/mL for 1 min) and transscleral cyclophotocoagulation (TSCPC) were performed. Intraocular pressure (IOP) ≥6 and ≤16 mmHg without medications was considered as complete success and IOP≤ 16 mmHg with the use of upto 2 medications as qualified success.

RESULTS

A total of 26 eyes of 21 patients were identified with a median age of 7 years (range, 6 days to 19 years) at the time of glaucoma surgery. Median follow-up was 51.1 months (range, 7-244.6 months). Primary CTT was performed in 17 eyes (65%), trabeculectomy in 5 eyes (19%) with application of MMC in 2 eyes, and 3 eyes (12%) underwent TSCPC. One painful blind eye (4%) underwent evisceration. Mean IOP reduced from 30.8 ± 7.6 mmHg on a mean of 1.3 ± 0.8 glaucoma medications preoperatively to a mean IOP of 15.2 ± 5.9 mmHg (P < 0.0001) on a mean of 0.2 ± 0.5 medications postoperatively at final follow-up (P = 0.0009). Complete success was achieved in 20 eyes, and qualified success in 2 eyes.

CONCLUSIONS

CTT is a safe and efficacious primary procedure for management of early-onset glaucoma in CEU. Trabeculectomy with or without adjuvant MMC is a viable second line of treatment in late-onset glaucoma with CEU for IOP control.

Efficacy and safety of the PreserFlo implant with mitomycin C in childhood glaucoma after previous failed glaucoma surgeries

PURPOSE

This study aims to evaluate the efficacy and safety of the PreserFlo MicroShunt (Santen, Osaka, Japan) in lowering intraocular pressure (IOP) in childhood glaucoma patients with previous failed glaucoma surgeries.

METHODS

This is a prospective case review of consecutive PreserFlo procedures performed in childhood glaucoma patients after failed surgeries. Age, sex, diagnosis, and previous glaucoma surgeries, as well as visual acuity, IOP, and treatment in the preoperative visit and all follow-up visits were collected. Outcome measures included IOP reduction from baseline, mean IOP change from baseline at month 6, medication use at 6 months, complications, adverse events, and need for further procedures.

RESULTS

Fourteen patients were included, 8 (57%) males and 6 (43%) females; the mean age was 27.5 ± 13.5 years. Nine patients (64%) had at least two trabeculectomies, and 6 patients (43%) had at least one trabeculectomy and a glaucoma drainage implant. The mean IOP change from baseline was 11.3 ± 4.9 mmHg at 12 months. At 12 months, 12 patients (86%) presented ≥ 20% IOP lowering from baseline, and 11 patients (79%) presented ≥ 30%. The mean medication count decreased from 3.9 ± 0.7 (baseline) to 0.7 ± 1.3 (12 months). No intraoperative complications were reported. No adverse events were noted. No secondary filtration surgery was required, although bleb needling was required in one case, 1 month after the surgery.

CONCLUSIONS

PreserFlo with MMC can be used successfully to treat uncontrolled IOP in childhood glaucoma cases with previous failed surgeries. Larger studies with longer follow-up are needed to further explore the role of the device in resistant childhood glaucoma cases.

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.

Outcomes of Glaucoma Drainage Device Implantation and Trabeculectomy With Mitomycin C in Glaucoma Secondary to Aniridia

PURPOSE

To compare the outcomes of Aurolab aqueous drainage implant (AADI; Aurolab) placement and trabeculectomy with mitomycin C (MMC) in patients with glaucoma secondary to aniridia.

DESIGN

Retrospective comparative interventional case series.

METHODS

This study included patients with congenital aniridia who underwent AADI implantation or trabeculectomy with MMC. Surgical failure was defined as IOP > 21 mm Hg or reduced <20% from baseline, IOP ≤ 5 mm Hg, reoperation for glaucoma or a complication, or loss of light perception vision.

RESULTS

A total of 30 eyes of 30 patients underwent surgical treatment, including 18 eyes that received an AADI and 12 eyes that had a trabeculectomy with MMC. The cumulative probability of failure at 2 years was 11.1% (95% CI = 2.9%-37.6%) in the AADI group and 58.3% (95% CI = 33.5%-84.8%) in the trabeculectomy group (P = .05, log-rank). At 2 years, IOP (mean ± SD) was 14.1 ± 2.8 mm Hg in the AADI group and 19.6 ± 6.6 mm Hg in the trabeculectomy group (P = .02), and the number of glaucoma medications was 1.7 ± 0.9 in the AADI group and 2.2 ± 0.8 in the trabeculectomy group (P = .25). Surgical complications developed in 1 patient in each treatment group (P = .65). Cataract surgery was performed in 5 (42%) patients in the trabeculectomy group and no patients in the AADI group (P = .01).

CONCLUSIONS

Placement of an AADI resulted in lower IOP and a higher rate of surgical success compared to trabeculectomy with MMC in eyes with glaucoma associated with aniridia. Cataract extraction was more frequently required after trabeculectomy with MMC than AADI implantation.

Outcomes of Management of Glaucoma in Phacomatosis Pigmentovascularis Over the Last Three Decades: A Single-Center Experience

PURPOSE

To report the clinical outcomes of glaucoma management in patients with phacomatosis pigmentovascularis (PPV) treated over a period of 3 decades.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Fifty-five eyes of 38 patients (21 unilateral and 17 bilateral) with glaucoma in PPV managed at one institution between January 1990 and December 2019 with a minimum follow-up of 1 year.

METHODS

Medical records of children with glaucoma in PPV were reviewed, and demographic and clinical data were collected. Surgical interventions included primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with mitomycin C (MMC), and transscleral cyclophotocoagulation (TSCPC). Complete success was defined as intraocular pressure (IOP) ≥ 6 and ≤ 16 mmHg without medications and qualified success as IOP ≤ 16 mmHg with the use of up to 2 medications.

MAIN OUTCOME MEASURES

Intraocular pressure, best-corrected visual acuity (BCVA), corneal clarity, antiglaucoma medications at preoperative and postoperative visits (last visit), and complications.

RESULTS

Median age was 4 months (range, 0.2-252 months) at the time of glaucoma surgery. Thirty-nine eyes (74%) had primary CTT, 10 eyes (19%) had trabeculectomy with MMC, and 4 eyes (7%) with advanced glaucoma had TSCPC. Two eyes (3.6%) received medical treatment. Preoperative IOP reduced from a mean of 25.7 ± 8.4 mmHg on 0.8 ± 0.6 medications to 14.6 ± 5.2 mmHg on 0.4 ± 0.5 medications (P < 0.0001) at last follow-up after surgery (77.7 ± 56.5 months). Thirty-seven eyes (67.3%) required medications preoperatively, and 22 eyes (40%) required medications at the last follow-up. Of 25 patients with available BCVA at last follow-up, 9 (36%) had ≥ 20/60; of these, 6 had > 20/40. Four of 10 eyes that underwent trabeculectomy with MMC developed retinal detachment and were managed surgically; however, all of these eyes had poor visual outcomes. There was no incidence of bleb leakage, bleb-related infection, or endophthalmitis.

CONCLUSIONS

Combined trabeculotomy-trabeculectomy is safe and effective as a primary procedure for management of glaucoma in PPV. Trabeculectomy augmented with MMC as a second procedure was associated with a higher rate of complications.

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.

The rare Axenfeld-Rieger syndrome with systemic anomalies: A case report and brief review of literature

RATIONALE

Axenfeld-Rieger syndrome (ARS) is a rare autosomal dominant disorder with ocular anterior segment dysgenesis and systemic anomalies.

PATIENT CONCERNS

A 28-year-old Chinese Han female was referred to Beijing Tongren Eye Center for progressive decrease of the visual acuity on her right eye in the past month.

DIAGNOSES

The patient was diagnosed as ARS with retinal detachment based on series of ophthalmic examinations performed.

INTERVENTIONS

A pars plana vitrectomy was performed to manage the retinal detachment.

OUTCOMES

Her best-corrected visual acuity was slightly improved after surgery.

LESSONS

ARS is a developmental defect of ocular anterior segment with various clinical manifestations which might cause misdiagnosis.

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.

Early-onset glaucoma in Axenfeld-Rieger anomaly: long-term surgical results and visual outcome

PurposeTo determine the long-term surgical and visual outcomes in Indian children with early-onset glaucoma associated with Axenfeld-Rieger anomaly (ARA).MethodsThis is a retrospective analysis of 44 eyes of 24 consecutive children with early-onset glaucoma (within 3 years of age) and ARA who underwent glaucoma surgery over a 20-year period (1991-2010) by a single surgeon. Main outcome measures were pre- and postoperative intraocular pressures (IOPs), corneal clarity, visual acuities (VAs), refractive errors, success rate, time of surgical failure, and complications.ResultsThe series consisted of 38 primary combined trabeculotomy-trabeculectomy (CTT) and 6 primary trabeculectomy procedures (Schlemm's canal could not be identified in these eyes). There was a statistically significant reduction in IOP postoperatively (27.07±4.88 vs 14.88±3.62 mm Hg; P<0.0001) with a mean reduction of 45.14%. Success probability by Kaplan-Meier survival analysis was 93% till 5 years, and then 88.1%, 82.3%, 70.5%, 56.4%, and 42.3% at year 6, 7, 8, 9, and 10, respectively. Preoperative corneal edema was present in 43/44 eyes (97.72%) and cleared in 42 eyes (97.67%). There was one case each with intraoperative hyphema and with shallow chamber postoperatively and both were successfully managed successfully. There was no incidence of endophthalmitis or any other sight-threatening complication. Data on VA were available in 34 eyes (77.3%). At final follow-up visit, 15 (44.1%) eyes had best corrected VA ⩾6/18.ConclusionsPrimary CTT is safe and effective for early-onset glaucoma associated with ARA. It leads to excellent IOP control and satisfactory visual outcome.

Pathobiology of wound healing after glaucoma filtration surgery

Conjunctival and subconjunctival fibrogenesis and inflammation are sight compromising side effects that can occur subsequent to glaucoma filtration surgery. Despite initial declines in intraocular pressure resulting from increasing aqueous outflow, one of the activated responses includes marshalling of proinflammatory and pro-fibrogenic cytokine mediator entrance into the aqueous through a sclerostomy window and their release by local cells, as well as infiltrating activated immune cells. These changes induce dysregulated inflammation, edema and extracellular matrix remodeling, which occlude outflow facility. A number of therapeutic approaches are being taken to offset declines in outflow facility since the current procedure of inhibiting fibrosis with either mitomycin C (MMC) or 5-fluorouracil (5-FU) injection is nonselective. One of them entails developing a new strategy for reducing fibrosis induced by wound healing responses including myofibroblast transdifferentiation and extracellular matrix remodeling in tissue surrounding surgically created shunts. The success of this endeavor is predicated on having a good understanding of conjunctival wound healing pathobiology. In this review, we discuss the roles of inappropriately activated growth factor and cytokine receptor linked signaling cascades inducing conjunctival fibrosis/scarring during post-glaucoma surgery wound healing. Such insight may identify drug targets for blocking fibrogenic signaling and excessive fibrosis which reduces rises in outflow facility resulting from glaucoma filtration surgery.

Surgical results of trabeculectomy and Ahmed valve implantation following a previous failed trabeculectomy in primary congenital glaucoma patients

Purpose

To compare the surgical results of trabeculectomy and Ahmed glaucoma valve implantation after a previous failed trabeculectomy.

Methods

A retrospective comparative case series review was performed on 31 eye surgeries in 20 patients with primary congenital glaucoma who underwent trabeculectomy or Ahmed glaucoma valve implantation after a previous failed trabeculectomy with mitomycin C.

Results

The preoperative mean intraocular pressure was 25.5 mmHg in the trabeculectomy group and 26.9 mmHg in the Ahmed glaucoma valve implantation group (p = 0.73). The 48-month postoperative mean intraocular pressure was 19.6 mmHg in the trabeculectomy group and 20.2 mmHg in the Ahmed glaucoma valve implantation group (p = 0.95). The 12-month trabeculectomy success rate was 69%, compared with 64% for Ahmed glaucoma valve implantation, and the 48-month success rates were 42% and 36% for trabeculectomy and valve implantation, respectively. The success rates following the entire follow-up period were not significantly different between the two groups (p > 0.05 by log rank test). Postoperative complications occurred in 25% of the trabeculectomy-operated eyes and 9% of the Ahmed-implanted eyes (p = 0.38).

Conclusions

There was no significant difference in surgical outcome between the trabeculectomy and Ahmed glaucoma valve implantation groups, neither of which had favorable results. However, the trabeculectomy group demonstrated a higher prevalence of adverse complications such as post-operative endophthalmitis.

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.

Surgical interventions for primary congenital glaucoma

BACKGROUND

Primary congenital glaucoma (PCG) manifests within the first few years of a child's life and is not associated with any other systemic or ocular abnormalities. PCG results in considerable morbidity even in developed countries. Several surgical techniques for treating this condition, and lowering the intraocular pressure (IOP) associated with it, have been described.

OBJECTIVES

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

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2014, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2014), EMBASE (January 1980 to June 2014), (January 1982 to June 2014), PubMed (January 1946 to June 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 June 2014.

SELECTION CRITERIA

We included all randomized and quasi-randomized trials in which different types of surgical interventions were compared in children under five years of age with PCG.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures specified by The Cochrane Collaboration.

MAIN RESULTS

We included a total of six trials (four randomized and two quasi-randomized) with 102 eyes in 61 children. Two trials were conducted in the USA and one trial each in Egypt, Israel, Lebanon and Saudi Arabia. All trials included children aged younger than one year when diagnosed with PCG, and followed them for periods ranging from six months to five years.No two trials compared the same pair of surgical interventions, so we did not perform any meta-analysis. One trial compared trabeculotomy versus goniotomy; a second trial compared combined trabeculectomy-trabeculotomy with mitomycin C versus trabeculectomy-trabeculotomy with mitomycin C and deep sclerectomy; a third trial compared combined trabeculotomy-trabeculectomy versus trabeculotomy; a fourth trial compared one goniotomy versus two goniotomies; a fifth trial compared trabeculotomy versus viscocanalostomy; and the sixth trial compared surgical goniotomy versus neodymium-YAG laser goniotomy. For IOP change and surgical success (defined by IOP achieved), none of the trials reported a difference between pairs of surgical techniques. However, due to the limited sample sizes for all trials (average of 10 children per trial), the evidence as to whether a particular surgical technique is effective and which surgical technique is better still remains uncertain. Adverse events, such as choroidal detachment, shallow anterior chamber and hyphema, were reported from four trials. None of the trials reported quality of life or economic data.These trials were neither designed nor reported well overall. Two trials were quasi-randomized trials and judged to have high risk of selection bias; four trials were at unclear or high risk for performance bias and detection bias; and we judged one trial to have high risk of attrition bias due to high proportions of losses to follow-up. Due to poor study design and reporting, the reliability and applicability of evidence remain unclear.

AUTHORS' CONCLUSIONS

No conclusions could be drawn from the trials included in this review due to paucity of data. More research is needed to determine which of the many surgeries performed for PCG are effective.

Efficacy and safety of deep sclerectomy in childhood glaucoma in Saudi Arabia

PURPOSE

To evaluate the efficacy and safety of deep sclerectomy in childhood glaucoma.

METHODS

A prospective cohort of 120 children presenting with glaucoma to King Abdul Aziz University Hospital (KAUH) was subjected to nonpenetrating deep sclerectomy surgery (NPDS). Eventually, 57 patients had macro perforation and converted to penetrating deep sclerectomy (PDS). Intra-operative mitomycin C (MMC) 0.2 mg/ml was used in all patients. Pre- and postintervention glaucoma indices were assessed. Complete success rate (CSR) was identified as achieving an end-point of intraocular pressure <21 without any antiglaucoma medications. Data were analysed to compare pre- and postintervention changes and to compare both procedures.

RESULTS

After follow-up of 35.8 (34.5) months, NPDS procedure went smooth in 74 eyes of 63 patients. The complete success rate was 79.7%, whereas the overall success rate was 82.4%. Thirteen cases failed. The probability to survive was 74.6% after the 12th month. The mean intraocular pressure (IOP) went down to 11.5 ± 3.0 mmHg compared to 31.9 mmHg preoperatively. Comparing cases with NPDS to those with PDS, the magnitude of IOP reduction (15.8) was higher than that of the PDS (14.8); however, this difference was not statistically significant (p = 0.259). Apart from involuntary perforation of trabeculodescemetic window (TDW), neither intra-operative nor early postoperative complications were observed.

CONCLUSIONS

Deep sclerectomy in childhood glaucoma can effectively reduce the IOP, without the occurrence of serious complications that are commonly seen after trabeculotomy or combined trabeculotomy trabeculectomy.

Trabeculectomy versus combined trabeculotomy-trabeculectomy in pediatric glaucoma

PURPOSE

To compare outcomes between trabeculectomy and combined trabeculotomy-trabeculectomy in children with glaucoma.

METHODS

This was a retrospective, comparative study of 40 eyes in 33 patients with pediatric glaucoma: 17 eyes treated with trabeculectomy and 23 eyes treated with combined trabeculotomy-trabeculectomy. Both groups were treated with intraoperative mitomycin C. Success was defined as intraocular pressure (IOP) of 21 mm Hg or less and greater than 5 mm Hg with no additional glaucoma surgery.

RESULTS

Mean follow-up was 38.3 months. There was no significant difference in mean IOP lowering between groups during the follow-up period. Log-rank survival analysis showed a significantly higher success rate after combined surgery compared with trabeculectomy (P = .027). Treatment failures occurred in 5 patients with trabeculectomy and in 2 patients undergoing combined trabeculotomy-trabeculectomy. Failures resulted from increased IOP (n = 3) or hypotony (n = 4). There were no significant differences in complications observed after surgery in both groups.

CONCLUSION

Trabeculectomy and combined trabeculotomy-trabeculectomy with mitomycin C were equally effective at lowering average IOP in children. Combined trabeculotomy-trabeculectomy was associated with greater long-term success.

Comparison of the outcomes of limbal-based trabeculectomy with and without anchor sutures

BACKGROUND AND OBJECTIVE

To retrospectively evaluate the efficacy and safety of limbal-based trabeculectomy with anchor sutures compared to standard limbal-based trabeculectomy. Limbal-based trabeculectomy was performed with a new technique using anchor sutures, which involved tying the conjunctiva to the sclera at a deep fornix incision to prevent bleb localization induced by slippage of the conjunctival suture scar toward the scleral flap.

PATIENTS AND METHODS

In this retrospective, comparative, interventional case series, 45 eyes that underwent limbal-based trabeculectomy with anchor sutures and 27 eyes that underwent standard limbal-based trabeculectomy were analyzed (primary surgery).

RESULTS

At a target intraocular pressure of 15 mm Hg, the 3-year survival rate using Kaplan-Meier analysis was 76.2% in the limbal-based trabeculectomy with anchor sutures group and 55.6% in the standard limbal-based trabeculectomy group. Bleb morphology analysis using the Moorfields Bleb Grading System showed that blebs in the limbal-based trabeculectomy with anchor sutures group were more diffused than those in the standard limbal-based trabeculectomy group.

CONCLUSION

Limbal-based trabeculectomy with anchor sutures appears to be an effective method for decreasing intraocular pressure and improving morphology of blebs.

Glaucoma drainage implants in the treatment of refractory glaucoma in pediatric patients

PURPOSE

The aim of this study is to report the clinical course, effectiveness, and safety of glaucoma drainage implants (Molteno and Baerveldt devices) in primary and secondary childhood glaucomas refractory to conventional surgical treatments and medical therapy.

METHODS

This retrospective study included 76 children (76 eyes) younger than 18 years who underwent glaucoma drainage device (GDD) implantation in our clinic between 1990 and 2004. The mean age at time of surgery was 6.9+/-5.3 years (range: 4 months to 17.5 years). Intraocular pressure (IOP), visual acuity, corneal diameter, axial length, intraoperative and postoperative complications, and number of glaucoma medications were evaluated. Criteria for success were defined as IOP between 7 and 22 mmHg with or without glaucoma medications, no further glaucoma surgery, the absence of visually threatening complications, and no loss of light perception. Results were compared for children with primary and secondary glaucomas. The mean follow-up was 7.1+/-6.5 years (range: 1.6 to 15.2 years).

RESULTS

Mean preoperative and postoperative IOP was 33.6+/-11.4 mmHg and 17.1+/-6.5 mmHg (p<0.001), respectively. Kaplan-Meier survival analysis showed cumulative probability of success: 93% at 6 months, 91% at 1 year, 82% at 2 years, 76% at 3 years, 71% at 4 years, 67% at 5 years, and 65% at 6 years. There was no difference between patients with primary (n=31 eyes) and secondary glaucoma (n=45 eyes) in terms of cumulative success (p=0.186), final IOP, number of medications, or length of follow-up. On average, the GDI surgery was successful for a mean period of 6.7 years. Fourteen eyes of 76 (18.4%) failed: 10 eyes with uncontrolled IOP, 2 eyes with retinal detachment, and 2 eyes with no light perception. Statistical regression model did not show influence of gender and previous surgery. Lower age at the time of surgery was found to be associated with higher probability of treatment failure.

CONCLUSIONS

Molteno and Baerveldt glaucoma drainage implants surgery seems to be safe and effective treatment for primary and secondary pediatric glaucoma refractory to the initial surgical procedure and medical therapy.

Mitomycin: clinical applications in ophthalmic practice

Mitomycin (mitomycin C; MMC) is an antibiotic isolated from Streptomyces caespitosus. The drug is a bioreductive alkylating agent that undergoes metabolic reductive activation, and has various oxygen tension-dependent cytotoxic effects on cells, including the cross-linking of DNA. It is widely used systemically for the treatment of malignancies, and has gained popularity as topical adjunctive therapy in ocular and adnexal surgery over the past 2 decades. In ophthalmic medicine, it is principally used to inhibit the wound healing response and reduce scarring of surgically fashioned ostia. Hence, it has been used as adjunctive therapy in various ocular surgeries, such as glaucoma filtering surgeries, dacryocystorhinostomy, corneal refractive surgery and surgeries for ocular cicatrisation. In addition, it has been used as an adjunct in the surgical management of pterygia, ocular surface squamous neoplasia, primary acquired melanosis with atypia and conjunctival melanoma. In many of these surgeries and ophthalmic pathologies, MMC showed a significant beneficial effect.

Options in pediatric glaucoma after angle surgery has failed

PURPOSE OF REVIEW

Congenital glaucoma is primarily a surgical disease with medical management serving as a temporizing measure before surgery or as postoperative adjunctive treatment. First-line surgery for congenital glaucoma consists of incisional procedures on the anterior chamber angle: goniotomy and trabeculotomy. Angle surgery has a high success rate with few complications. Despite the high initial success rate, almost 20% of angle procedures eventually fail, and surgeons are confronted with a choice of what procedure to do next: a trabeculectomy with or without adjunctive antifibrosis therapy, glaucoma drainage surgery, or cyclodestructive procedures. This review will discuss and compare these procedures as reported in recent studies and how variables such as age, number of prior procedures, and type of glaucoma have clarified the order in which these procedures might be performed after failed angle surgery.

RECENT FINDINGS

Clinical reports in refractory pediatric glaucoma consist solely of retrospective studies of varying size and quality. Recent studies of trabeculectomy in this population suggest mitomycin C is associated with increased risk of late infectious complications. Trabeculectomy has worse outcome among younger patients Glaucoma drainage devices have a success rate approaching 80% at 1 year, but less with longer follow-up. Cyclodestructive procedures are generally reserved for advanced cases, but low-dose cyclodiode therapy and endocyclophotocoagulation may prove useful earlier in the disease (< 2 years).

SUMMARY

Refractory pediatric glaucoma remains a challenge. Glaucoma drainage devices appear to be the most predictable and possibly safest procedure to consider after failed conventional angle surgery.

Surgical outcome of primary developmental glaucoma: a single surgeon's long-term experience from a tertiary eye care centre in India

PURPOSE

To determine the surgical outcome after initial surgery in children with primary developmental glaucoma (PDG).

METHODS

Six hundred and twenty-four eyes of 360 consecutive patients who underwent primary combined trabeculotomy-trabeculectomy (CTT) for PDG from January 1990 to June 2004 were studied. The main outcome measures were pre- and postoperative intraocular pressures (IOPs), corneal clarity, visual acuities, refractive errors, success rate, time of surgical failure, complications, and factors associated with poor outcome.

RESULTS

IOP reduced from 28.1+/-7.5 to 14.9+/-5.9 mmHg (P<0.0001). Probability of success (IOP<21 mmHg) was 85.2, 80.4, 77.2, 72.6, 66.2, and 57.5% at first, second, third, fourth, fifth, and sixth years, respectively (Kaplan-Meier analysis). The mean follow-up period was 20.3+/-25.6 months (median, 6 months). Preoperatively, 243 eyes (67.5%) had significant corneal oedema. Postoperatively, normal corneal transparency was achieved in 162 eyes (46.0%). Data on Snellen visual acuity were available in 100 patients (27.8%). At the final follow-up visit, 42 patients (42.0%) had normal visual acuity (>or=20/60). Myopia (mean spherical equivalent, 6.1 D) was the most common (75.0%) refractive error. In multivariate analyses, failure increased by three-fold in the presence of preoperative IOP>35 mmHg (hazards ratio (HR)=3.12; 95% confidence interval (CI), 1.4-6.7) and two-fold in cases with a history of prior glaucoma surgery (HR=2.57; 95% CI, 1.1-6.0). There were no major intraoperative complications, bleb-related infection, or endophthalmitis.

CONCLUSIONS

This series shows that prolonged IOP control can be achieved in patients with PDG and 42% of the patients gained normal visual acuity.

[Congenital glaucoma and trabeculodysgenesis. Clinical and genetic aspects]

Congenital glaucoma is generally related to an iridocorneal angle malformation, with an obstacle to aqueous humor outflow. This spectrum of diseases can involve the angle, the iris and the cornea. The diagnosis relies on characteristic signs and is confirmed by an examination under general anaesthesia and paraclinical examinations (especially echography). An early diagnosis is essential for beginning surgical treatment. Several filtering surgery techniques with equivalent intraocular pressure results are available, but visual function must be protected in all cases. In many cases, genetic counseling relies on a careful clinical analysis and sometimes on a molecular analysis. A number of ocular and/or general abnormalities can be accompanied by glaucoma in infants and children. They must be screened in case of associated signs, but the existence of these abnormalities leads to suspicion of associated glaucoma.

Success of trabeculotomy in patients with congenital glaucoma operated on within 3 months of birth

AIMS

To determine the efficacy and safety of trabeculotomy in congenital glaucoma patients operated on within first 3 months of birth.

METHODS

A total of 36 eyes of 24 patients with congenital glaucoma, who underwent primary trabeculotomy within first 3 months of birth were included. Preoperative and postoperative intraocular pressures (IOP), corneal clarity, diameter, axial length, success rates, and complications were evaluated in this study.

RESULTS

The mean follow-up was 38.38+/-11.77 months (range 12-48 months). Mean IOP was 33.16+/-7.28 mmHg (range 23-50 mmHg) preoperatively. At the final follow-up visit, the mean IOP was 21.41+/-7.34 mmHg (range 8-38 mmHg). Pre-and postoperative IOP differences were statistically significant at all examination periods (P<0.001). A12-, 24-, and 36-month success rates were 92, 82, and 74%, respectively. Survival analysis regarding to gender, preoperative corneal diameter and consaguinity were not statistically significant. Only preoperative axial length was a statistically significant parameter (P=0.024) for success. Postoperatively normal corneal clarity was achieved in 29 eyes (80.5%). The main complications were shallow anterior chamber in one (4.2%) eye and detachment of Descement's membrane in two (8.4%) eyes.

CONCLUSIONS

Primary trabeculotomy is a safe and effective procedure for congenital glaucoma patients when operated within 3 months of birth. It has a favourable IOP control and a low rate of complications in three year period.

Otago Glaucoma Surgery Outcome Study

OBJECTIVE

To provide data on the results of patients with nonneovascular juvenile glaucoma who had Molteno implant surgery in the province of Otago, New Zealand.

DESIGN

Prospective noncomparative case series.

PARTICIPANTS

Fifty-five operations in 52 eyes of 45 patients with nonneovascular juvenile glaucoma who had Molteno implant surgery between the ages of 9 and 49 years from 1976 to 2003 at Dunedin Hospital and were observed for a mean of 12.2 years (range, 0.1-25).

INTERVENTION

Insertion of a Molteno implant.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and visual acuity (VA).

RESULTS

Insertion of a Molteno implant controlled IOP at < or =21 mmHg with probabilities of 0.89 (95% confidence interval [CI], 0.81-0.97) at both 1 and 2 years and 0.85 (95% CI, 0.75-0.95), 0.78 (95% CI, 0.66-0.90), and 0.71 (95% CI, 0.58-0.85) at 5, 10, and 15 years, respectively. Mean VA was 20/100 preoperatively; improved to 20/60 at 1 year; and stabilized at 20/120 at 5, 10, and 15 years postoperatively. Twenty-nine eyes had their preoperative VA maintained or improved at final follow-up, and the VAs of 17 eyes deteriorated but were at least light perception at final follow-up.

CONCLUSION

The use of Molteno implants in cases of nonneovascular juvenile glaucoma controlled IOP with a probability of 0.71 15 years postoperatively, whereas 53% maintained or improved their vision from their preoperative VA at final follow-up.

Results of the Susanna implant in patients with refractory primary congenital glaucoma

PURPOSE

To evaluate the results of the Susanna implant in children with primary congenital glaucoma.

PATIENTS AND METHODS

The authors report a retrospective noncomparative interventional case series of data from 24 eyes from 24 pediatric patients who underwent Susanna implant surgery for primary congenital glaucoma. All the patients were operated by the same surgeon. The postoperative follow-up time was 24 months for all patients. Success was defined by an IOP higher than 6 mm Hg and less than or equal to 15 mm Hg, with the concomitant use of a single medication if necessary.

RESULTS

The age range of the patients was 1 to 15 years and the mean age was 5.04 +/- 4.12 years. At 12 months, 87.5% of the patients were considered as success, and at 24 months, the proportion dropped to 79.16%. Mean preoperative and postoperative intraocular pressure were 26.17 +/- 5.16 and 14.04 +/- 4.19 mm Hg ( p < 0.001), respectively. All 24 children had undergone previous glaucoma surgeries. Cataract was the only complication found during follow-up, occurring in three patients. Cox's regression model did not show influence of gender ( P = 0.740) and previous surgery ( P = 0.262) on the outcome through time. Age at the time of surgery was the only variable which was statistically associated with success through time, younger patients presenting higher probability of failure ( P = 0.05).

CONCLUSIONS

The results of the present study reinforce the role of drainage implants as a safe alternative in difficult cases of primary congenital glaucoma, after failure of the initial approach.

Long-term surgical and visual outcomes in Indian children with developmental glaucoma operated on within 6 months of birth

PURPOSE

To determine the long-term surgical and visual outcomes in Indian children with developmental glaucoma operated within 6 months of birth.

DESIGN

Retrospective consecutive, noncomparative case series.

PARTICIPANTS

All children with developmental glaucoma who underwent surgery within 6 months of birth over a 12-year period were included.

METHODS

Two hundred ninety-nine eyes of 157 consecutive patients who underwent primary combined trabeculotomy-trabeculectomy for developmental glaucoma from January 1990 through December 2001 by a single surgeon were studied. However, for the purpose of statistical analysis, only 1 randomly chosen eye of patients with a bilateral affliction (142, 90.4%) was considered.

MAIN OUTCOME MEASURES

The main outcome measures were preoperative and postoperative intraocular pressures (IOPs), corneal clarity and diameters, visual acuities, refractive errors, success rate, time of surgical failure, and complications.

RESULTS

The series consisted of 299 primary combined trabeculotomy-trabeculectomy surgeries during 157 anesthesias. The intraocular pressure was reduced from 26.6+/-6.2 mmHg to 14.4+/-4.9 mmHg, with a mean percentage reduction of 41.1+/-28.8 (P<0.0001). The probability of success (IOP<21 mmHg) was 94.4%, 92.1%, 86.7%, 79.4%, 72.9%, and 63.1% at first, second, third, fourth, fifth, and sixth year, respectively (Kaplan-Meier analysis). The mean follow-up period was 26.5+/-25.1 months. Preoperatively, 133 eyes (84.7%) had significant corneal edema. Postoperatively, normal corneal clarity was achieved in 83 of 133 eyes (62.4%) with corneal edema. There were no major intraoperative complications. Postoperatively, 17 eyes (10.8%) had a shallow anterior chamber develop; 3 of these eyes (17.6%) required surgical reformation. There was no incidence of endophthalmitis or any other sight-threatening complication. Data on visual acuity were available in 49 patients (31.2%). At the final follow-up visit, 20 patients (40.8%) had normal visual acuity (best-corrected visual acuity of >/=20/60 in the better eye).

CONCLUSIONS

Primary combined trabeculotomy-trabeculectomy is safe and effective for developmental glaucoma when performed within 6 months of birth. It leads to excellent IOP control and moderate visual outcome.

Aqueous shunt devices compared with trabeculectomy with Mitomycin-C for children in the first two years of life

PURPOSE

To compare the outcomes of children 24 months of age or younger treated with aqueous shunt devices or with mitomycin-C (MMC) trabeculectomy.

DESIGN

Retrospective, age-matched, comparative case series.

METHODS

Forty-six eyes of 32 patients with mean age of 7.0 +/- 5.1 month (range, 1 to 22 months) and uncontrolled glaucoma, which received an aqueous shunt device (Ahmed glaucoma valve or Baerveldt implant), compared with 24 eyes of 19 patients with mean age of 5.3 +/- 4.8 months (range, 0.5 to 24 months), which received an MMC trabeculectomy. Surgical success was defined as intraocular pressure < 23 mm Hg on maximal glaucoma medication, no further glaucoma surgery performed or recommended, no devastating complication, and stable ocular dimensions (axial length and corneal diameter).

RESULTS

Cumulative probabilities of success were 87% +/- 5.0% for the aqueous shunt group compared with 36% +/- 8.0% success in the trabeculectomy group at 12 months and 53% +/- 12% in the aqueous shunt group compared with 19% +/- 7% in the trabeculectomy group at 72 months (chi(2) of 23.5, P <.0001). Aqueous shunt implantation was associated with significantly more postoperative complications requiring a return to the operating room (21 of 46 eyes, 45.7%) compared with trabeculectomy with MMC (3 of 24 eyes, 12.5%, P =.0074). The most common postoperative procedure in the aqueous shunt group was tube repositioning, performed in 16 of 46 eyes (34.8%).

CONCLUSIONS

Aqueous shunt implantation offers a significantly greater chance of successful glaucoma control in the first 2 years of life, compared with trabeculectomy with MMC. However, the enhanced success with aqueous shunt devices is associated with a higher likelihood of postoperative complications requiring surgical revision, most commonly tube repositioning.

Cystic bleb formation and related complications in limbus- versus fornix-based conjunctival flaps in pediatric and young adult trabeculectomy with mitomycin C

OBJECTIVE

Comparison of fornix- and limbus-based conjunctival flaps with respect to cystic bleb-related complications of trabeculectomy with high-dose mitomycin C (MMC) in pediatric and young adult glaucoma.

DESIGN

Retrospective nonrandomized comparative interventional case series.

PARTICIPANTS

Thirty-seven patients.

METHODS

Identification of patients aged <30 years from operating theater records from 1995 and 1996 of the Moorfields Pediatric Glaucoma Service who had trabeculectomy with an MMC concentration of >/=0.4 mg/ml. Over a 2-year period, 37 consecutive operations matching these criteria were performed by a single surgeon: 20 with a limbus-based flap and 17 with a fornix-based flap. Except for the conjunctival incision and associated alteration in antimetabolite application and wound closure, the surgical technique was not significantly different between the groups.

MAIN OUTCOME MEASURES

Bleb evolution and complications.

RESULTS

The age at time of surgery, MMC concentration, history of one or more previous surgeries, and follow-up were similar in the 2 groups. The risk of cystic bleb formation was greater in the limbus-based flap group (90% in the limbus-based group vs. 29% in the fornix-based group; P<0.001). Late hypotony and bleb-related ocular infection were more common in the limbus-based flap group (P<0.05) and occurred earlier. There were four episodes of bleb-related infection (20%) in the limbus-based group (three of these [15%] were bleb-related endophthalmitis) and none in the fornix-based group.

CONCLUSIONS

In pediatric and young adult trabeculectomy with high doses of MMC, limbus-based flaps may be more likely to develop serious bleb-related complications and may develop these earlier than fornix-based flaps. The higher rates of complications could be attributable to the differences in bleb morphology, with limbus-based flap cases more likely to develop cystic blebs.

Outcome of surgery on infants younger than 1 month with congenital glaucoma

PURPOSE

To determine the visual outcomes and surgical and anesthetic complication rates of patients with newborn glaucoma operated within 1 month of age.

DESIGN

Retrospective, consecutive, noncomparative case series.

PARTICIPANTS

All children with newborn glaucoma who underwent surgery between January 1990 and December 2000 were included.

METHODS

The medical records of 25 consecutive patients (47 eyes) who underwent primary combined trabeculotomy and trabeculectomy either bilaterally in a single session or unilaterally were reviewed retrospectively. Outcomes were evaluated using Kaplan-Meier survival analysis.

MAIN OUTCOME MEASURES

Clinical outcome assessment included corneal clarity, intraocular pressure (IOP), bleb characteristics, visual acuity, refractive errors, and identification of surgical and anesthetic complications.

RESULTS

The mean follow-up was 3.1+/-1.8 years (range, 9.5 months-7.4 years). The mean preoperative IOP was 26.9+/-5.2 mmHg (range, 14-42 mmHg). At the final follow-up visit, the mean IOP was 14.5+/-3.8 mmHg (range, 8-28 mmHg). The percentage reduction in IOP was 43.3+/-21.5 (P<0.0001). Twelve-, 24-, and 36-month survival rates for complete success for IOP control were 89.4%, 83.6%, and 71.7%, respectively, which were maintained for 7 years of follow-up. After surgery, complete clearance of corneal edema was achieved in 66% of the eyes. Data on visual acuity was available for 19 patients. Final best spectacle-corrected visual acuity was 20/40 or better in the better eye in 5 patients (26.3%), 7 patients (36.8%) obtained 20/60 or better in the better eye, 8 patients (42.1%) achieved final visual acuity of less than 20/60 to 20/200 in the better eye (low vision), and four patients obtained less than 20/400 visual acuity in the better eye (blind) according to World Health Organization criteria. However, there was no eye with absent perception of light in the better eye. Myopia (mean spherical equivalent, 4.6+/-3.2 diopters) was the most common refractive error, present in approximately half of the eyes (n = 23; 53.8%). There were no significant intraoperative or postoperative complications in any patient. Anesthesia-related complications developed in 2 patients; however, they were resuscitated successfully.

CONCLUSIONS

Primary combined trabeculotomy-trabeculectomy offers a viable surgical option in infants that have cloudy corneas at birth as a result of congenital glaucoma. It is associated with a favorable visual outcome and a low rate of anesthetic complications in an Indian population.

Antifibrotics and wound healing in glaucoma surgery

When medical and laser therapy fail to control intraocular pressure, glaucoma filtration surgery needs to be performed. Glaucoma surgery is unique in that its success is linked to interruption of the wound-healing response in order to maintain patency of the new filtration pathway. In this article we will review the wound-healing pathway and the pharmacologic interventions that have been employed clinically and experimentally to interrupt wound healing, particularly steroids and the antifibrotic agents 5-fluorouracil and mitomycin C. A review of the published literature looking at use of these agents to enhance success as well as the associated complications are presented, critiqued, and interpreted in order to put the studies in proper perspective. Future directions and recommendations regarding use of these agents are available and an introduction to newer wound modulating agents such as anti-transforming growth factor beta 2 is presented.

Use of glaucoma drainage devices in the management of glaucoma associated with aniridia

PURPOSE

To describe intraocular pressure (IOP) and visual acuity outcomes after glaucoma drainage device placement in eyes with glaucoma associated with aniridia.

DESIGN

Retrospective, noncomparative, consecutive, interventional case series.

METHODS

The medical records of all patients who underwent glaucoma drainage device placement for the management of glaucoma associated with aniridia at the Bascom Palmer Eye Institute between January 1, 1989, and December 31, 1999, were reviewed.

RESULTS

The study included eight eyes of five patients with a median age at the time of glaucoma drainage device placement of 92 months (range, 10- 495 months) and a median follow-up of 19 months (range, 11- 33 months). Preoperatively, the mean IOP was 35 mm Hg using a mean of one antiglaucoma medication. Postoperatively, the mean IOP was reduced to 14.9 mm Hg and no patient was using antiglaucoma medication. Final visual acuity was improved compared with preoperatively in five of eight eyes (63%) and remained unchanged in two eyes (25%). Loss of light perception occurred in one eye owing to retinal detachment. Success rates using Kaplan-Meier survival analysis were 100% at 6 months and 88% at 1 year.

CONCLUSIONS

Glaucoma drainage device placement for glaucoma associated with aniridia achieves IOP control and vision preservation in most patients.

Trabeculectomy with or without mitomycin-C for paediatric glaucoma in aphakia and pseudophakia following congenital cataract surgery

PURPOSE

To evaluate the safety and efficacy of trabeculectomy with or without mitomycin-C (MMC) in the management of glaucoma in aphakia and pseudophakia following congenital cataract surgery.

PATIENTS AND METHODS

All patients of glaucoma with aphakia or pseudophakia who underwent trabeculectomy with or without MMC from January 1989 to April 2000 were included. The medical records of 19 consecutive patients (23 eyes) were reviewed. Data collected from a retrospective chart review were analysed. Outcome measures were evaluated using Kaplan-Meier survival analysis. Pre- and postoperative intraocular pressures (IOPs), visual acuities, success rate, bleb characteristics, surgical failure and complications were the main outcome measures. Successful IOP control was defined as an IOP between 6 and 21 mmHg, without antiglaucoma medications, without further antiglaucoma surgery and without any sight-threatening complication.

RESULTS

The mean age of patients was 8.8+/-5.5 years at the time of trabeculectomy with MMC compared to 11.0+/-12.4 years for trabeculectomy without MMC. Eight patients underwent trabeculectomy with MMC and 11 patients underwent trabeculectomy without MMC. There was no statistically significant difference between the two groups in terms of visual acuity, IOP, antiglaucoma medications, age at cataract surgery and at trabeculectomy. The IOP reduced from a preoperative level of 34.2+/-8.9 mmHg (range: 20-52) to a postoperative level of 18.4+/-12.2 mmHg (range: 2-60) with a mean follow-up of 24.2+/-17.9 months. The mean reduction in IOP in the MMC group was 15.5+/-17.3 and 16.3+/-13.8 mmHg in the other group (P = 0.967). Overall, complete success was achieved in 36.8%, qualified success in 21.1% and surgical failure in 42.1% of patients with a mean follow-up of 24.2+/-17.9 months. There was no difference in the success between the two groups at the last follow-up. One patient developed bleb-related endophthalmitis in both eyes following trabeculectomy with MMC.

CONCLUSIONS

The success rate of trabeculectomy in glaucoma following congenital cataract surgery was 36.8% at the end of 3 years. The present study proves a poor success rate of trabeculectomy in a small series of aphakic Asian Indian patients even with the use of MMC.

Efficacy and safety of mitomycin-C in primary trabeculectomy: five-year follow-up

PURPOSE

To examine the 5-year complications and results of primary trabeculectomy with mitomycin-C (MMC).

DESIGN

Retrospective, noncomparative interventional case series.

PARTICIPANTS

One hundred twenty-three eyes that underwent primary trabeculectomy with MMC between December 1991 and March 1995.

METHODS

All patients received standard trabeculectomy performed by one of two surgeons, using a Weck cell-soaked pledget of MMC, 0.25, 0.33, or 0.5 mg/ml, for 0.5 to 5 minutes. Laser suture lysis was performed postoperatively for intraocular pressure control.

MAIN OUTCOME MEASURES

The incidence of complications, including hypotony with or without maculopathy, bleb leak or blebitis, pressure control, and medication reduction at yearly intervals.

RESULTS

Mean preoperative and year 5 postoperative intraocular pressures (IOP) were 25.79 and 9.91 mmHg (P < 0.05, paired t test). Hypotony (IOP < 6) occurred in 42.2% of eyes after a mean follow-up of 26.1 months. Hypotony maculopathy occurred in 8.9% of eyes at mean follow-up of 33.7 months. Bleb leak occurred in 14.6% of eyes at a mean follow-up of 27.9 months. Blebitis occurred in 5.7% of eyes at a mean follow-up of 35.4 months, and endophthalmitis occurred in 0.8% of eyes at 15 months; 14.9% of eyes lost 4 lines of visual acuity. The single predictor for the development of late-term hypotony was IOP 1 month after operation (P < 0.05).

CONCLUSIONS

Primary mitomycin trabeculectomy significantly lowers IOP at 5 years but is associated with a high incidence of delayed hypotony.