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.

Outcome of cataract extraction and posterior chamber intraocular lens implantation following glaucoma filtration surgery

PURPOSE

To evaluate the outcome of cataract extraction (CE) after glaucoma filtering surgery (GFS).

METHODS

A total of 77 eyes (77 patients) who underwent CE with posterior chamber intraocular lens (PCIOL) implantation following GFS by a single surgeon were reviewed. Main outcome measures were preoperative and postoperative intraocular pressures (IOPs), visual acuities, medications, astigmatism, bleb survival, time of surgical failure, complications, and success rate.

RESULTS

Mean time interval between GFS and CE was 46.8+/-50.9 months (range, 2-348 months). The mean preoperative IOP was 13.9+/-4.7 mmHg (range 3-27 mmHg) and mean postoperative IOP at 3 weeks was 13.6+/-5.5 mmHg (range, 6-44 mmHg). The mean follow-up was 19.5+/-20.1 months (range, 1.4-73 months; median 10.6 months). Complete success was achieved in 59 eyes (76.7%). The cumulative probability of complete success was 91.3+/-3.7, 82.0+/-5.6 and 78.1+/-6.5% at the end of 6 months, 1, and 2 years, respectively. Visual acuity before CE was < or =20/50 in all eyes (100%). Visual acuity at last visit was > or =20/40 in 33 eyes (42.8 %), 20/50-20/80 in 30 eyes (39.0%), < or =20/100 in 14 eyes (18.2%). Risk factors identified for qualified success included age at CE>60 years, interval of < or =5 months between GFS and CE, use of preoperative glaucoma medications, and postoperative IOP >19 mmHg within 2 weeks.

CONCLUSIONS

IOP and bleb function was maintained after CE with PCIOL implantation following successful GFS with good visual recovery.

Combined trabeculotomy and trabeculectomy in advanced primary developmental glaucoma with corneal diameter of 14 mm or more

PURPOSE

To report the safety and efficacy of combined trabeculotomy and trabeculectomy (CTT) in advanced primary developmental glaucoma with corneal diameter 14 mm or more.

PATIENTS AND METHODS

A total of 74 (121 eyes) consecutive patients aged 3 days-100 months (median, 10 months) with advanced developmental glaucoma were included. Primary CTT was performed by a single surgeon at a tertiary eye care centre in India over a 13-year period. The main outcome measures were changes in and final levels of intraocular pressure (IOP), corneal clarity, visual acuity, and refractive status.

RESULTS

Mean preoperative IOP was 29.4+/-7.6 mmHg (range, 10-56 mmHg) and mean postoperative IOP was 15.5+/-6.6 mmHg (range, 6-38 mmHg) (P<0.0001) with percentage reduction of 44.5+/-27.1. Kaplan-Meier survival analysis revealed 3-, 6-, 9-, 12-, 24-, 48-, and 72-month success rates of 86.5, 80.5, 78.1, 75.5, 71.1, and 60.5%, respectively. Majority (80.5%) of the patients were myopes with mean spherical equivalent of 5.8+/-4.5D (range, 0.75-22.0D). Using various age-appropriate testing procedures, at the final follow-up visit, 14 patients (41.2%) had age-appropriate normal visual acuity and 20 patients (58.8%) had subnormal visual acuity. Best-spectacle-corrected visual acuity of > or =20/60 was achieved in seven patients (26.9%). There were no sight-threatening intraoperative and postoperative complications.

CONCLUSION

CTT is safe and effective in patients with advanced primary developmental glaucoma. It offers good IOP control with a low complication rate, with about one-third of patients achieving a visual acuity of 20/60 or better.

Outcome of pterygium surgery: analysis over 14 years

AIM

To report the outcome of pterygium surgery performed at a tertiary eye care centre in South India.

METHODS

Retrospective analysis of medical records of 920 patients (989 eyes) with primary and recurrent pterygia operated between January 1988 and December 2001. The demographic variables, surgical technique (bare sclera, primary closure, amniotic membrane transplantation (AMT), conjunctival autograft (CAG), conjunctival-limbal autograft (CLAG), or surgical adjuvants), recurrences and postoperative complications were analysed.

RESULTS

A total of 496 (53.9%) were male and 69 (7.5%) had bilateral pterygia. Bare sclera technique was performed in 267 (27.0%) eyes, primary conjunctival closure in 32 (3.2%), AMG in 123 (12.4%), CAG in 429 (43.4%), and CLAG in 70 (7.1%). Adjuvant mitomycin C was used in 44 (4.4%) cases. The mean duration of follow-up was 8.9+/-17.0 and 5.9+/-8.8 months for unilateral primary and recurrent pterygia, respectively. The overall recurrence rate was 178 (18.0%). Following primary and recurrent unilateral pterygium excision respectively, recurrences were noted in 46 (19.4%) and 1 (33.3%) eyes after bare sclera technique, five (16.7%) and 0 after primary closure, 28 (26.7%) and 0 with AMG, 42 (12.2%) and five (31.3%) with CAG, and nine (17.3%) and two (40%) with CLAG. Recurrences were significantly more in males with primary (23.3 vs 10.7%, P<0.0001) and recurrent (26.7 vs 0%, P=0.034) pterygia, and in those below 40 years (25.2 vs 14.8%, P=0.003).

CONCLUSION

CAG appears to be an effective modality for primary and recurrent pterygia. Males and patients below 40 years face greater risk of recurrence. Bare sclera technique has an unacceptably high recurrence. Prospective studies comparing CAG, CLAG, and AMG for primary and recurrent pterygia are needed.

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.