[One-year results on the safety and efficacy of the InnFocus MicroShunt™ depending on placement and concentration of mitomycin C]

PURPOSE

To compare intraocular pressure (IOP) at one year with the InnFocus MicroShunt(®) with or without cataract surgery with according to placement and concentration of mitomycin C (MMC) DESIGN: A retrospective two-center, two-surgeon study (France and Dominican Republic).

PATIENTS AND METHODS

Adults with POAG requiring filtering surgery. One MicroShunt(®) was placed in one eye of each patient. The effect of concentration and site of application of MMC was assessed by IOP and medication reduction at one year.

RESULTS

Eighty-seven eyes were studied with one-year follow-up. Twenty-three eyes treated with 0.4 mg/mL MMC close to the limbus demonstrated a 55% reduction in IOP from 23.8 ± 5.3 at baseline to 10.7 ± 2.8 mmHg at one year. Topical glaucoma medication/patient was reduced 85% from 2.4 ± 0.9 to 0.3 ± 0.8. Thirty-one eyes treated with 0.2mg/mL MMC close to the limbus demonstrated a 52% reduction in IOP from 27.9 ± 6.7 at baseline to 13.3 ± 3.3 mmHg at one year. Topical glaucoma medication/patient was reduced 88% from 2.5 ± 1.4 to 0.5 ± 1.0. Thirty-three eyes treated with 0.4 mg/mL MMC deep in the pocket demonstrated a 38% reduction in IOP from 25.4 ± 7.9 at baseline to 15.7 ± 4.6 mmHg at one year. Topical glaucoma medication/patient was reduced 72% from 2.9 ± 1.0 to 0.8 ± 1.3. There were no sight-threatening long-term adverse events.

CONCLUSION

The InnFocus MicroShunt(®) is a filtering surgery whose efficacy is related to the location of application and concentration of MMC used.

[The trabecular meshwork: Structure, function and clinical implications. A review of the littérature (French translation of the article)]

Glaucoma is a blinding optic neuropathy, the main risk factor for which is increased intraocular pressure (IOP). The trabecular meshwork, located within the iridocorneal angle, is the main pathway for drainage of aqueous humor (AH) out of the eye, and its dysfunction is responsible for the IOP elevation. The trabecular meshwork is a complex, fenestrated, three-dimensional structure composed of trabecular meshwork cells (TMC) interdigitated into a multilayered organization within the extracellular matrix (ECM). The purpose of this literature review is to provide an overview of current understanding of the trabecular meshwork and its pathophysiology in glaucoma. Thus, we will present the main anatomical and cellular bases for the regulation of aqueous humor outflow resistance, the pathophysiological mechanisms involved in trabecular dysfunction in the various types of glaucoma, as well as current and future therapeutic strategies targeting the trabecular meshwork.

[Trabeculotomy as first-line surgical treatment in pediatric glaucoma: surgical and visual outcomes from a 7-year retrospective study]

INTRODUCTION

Intraocular pressure and visual outcomes in primary pediatric glaucoma treated with trabeculotomy.

MATERIALS ET METHODS

All children undergoing trabeculotomy as first-line surgical treatment between January 2002 and January 2012 were included in a retrospective monocentric study. We report initial clinical features, surgical complications, ophthalmological outcome and clinical progression.

RESULTS

Twenty-nine eyes of 16 children met the inclusion criteria and were treated with trabeculotomy as first-line treatment (mean age: 6 months). Median follow-up was 7 years. No major perioperative complications occurred, but minor complications were observed in 11 eyes. Mean pre-operative and initial post-operative intraocular pressures were 25.4 and 9.1mmHg respectively, thus a decrease of 16.3 points (63%). Overall surgical success rate was 89% at first follow-up, 72% at one year and 64% on last follow-up. A mean intraocular pressure of 15mmHg on no medications was achieved for two-thirds of eyes. After 7 years of follow-up, over 50% of eyes did not require a 2nd surgery. Visual acuity was at least 20/30 for 62% of eyes (83% for eyes requiring only trabeculotomy).

DISCUSSION AND CONCLUSION

Trabeculotomy as first-line treatment of primary juvenile glaucoma is a safe and effective surgery in about two-thirds of cases. It allows pressure control and satisfactory visual outcome in the majority of children.

Longitudinal evaluation of central corneal thickness in congenital glaucoma

PURPOSE

To assess the central corneal thickness in primary congenital glaucoma before and after surgical treatment and compare it with a normal population.

METHODS

We conducted a longitudinal analysis of primary congenital glaucoma patients, in whom we measured central corneal thickness before and after treatment (Group 1). We compared our results with a normal population (Group 2), who underwent ophthalmological examination under anesthesia for other reasons.

RESULTS

Mean age (months) in Group 1 (N=23) and Group 2 (N=40) at the time of the first exam was 5.5 and 9.2 (P=0.004), respectively. Mean central corneal thickness (microns) in Group 1 was: 663 before treatment and 557 after treatment (P<0.001). In Group 2, mean central corneal thickness (microns) was 551. Comparisons show statistical difference between mean values before and after treatment (P<0.001), but not between post-treatment CCT mean values in Group 1 and mean CCT values in Group 2 (P=0.627).

CONCLUSION

In primary congenital glaucoma, central corneal thickness values show unique peculiarities. They are higher than normal before treatment (thicker corneas), due to corneal edema caused by elevated intraocular pressure. After surgical treatment, central corneal thickness measurements decrease toward the mean values for the normal population.

[Painful anisocoria in a five-year-old child: A rare diagnosis which must not be missed]

Congenital ectropion uveae (CEU) is a rare anomaly of the embryonic development of the anterior segment of the eye. We report the case of a 5-year-old child with an undiagnosed CEU who was treated urgently for an acute angle closure attack.

CASE DESCRIPTION

A 5-year-old child was referred urgently for evaluation of anisocoria with mydriasis of the right eye and severe headache. Brain imaging with contrast injection was initially performed in the pediatric emergency department and ruled out central nervous system pathology. The initial examination of the right eye revealed an intraocular pressure (IOP) of 37mmHg, corneal edema, congenital ectropion uveae, mydriasis with pupillary block, a closed angle on gonioscopy, and a clear lens. The examination of the left eye was unremarkable, with no visible CEU. The initial management consisted of medical treatment with topical glaucoma drops and miotics and acetazolamide at 10mg/kg/d. Re-evaluation under general anesthesia showed persistent mydriasis and no resolution of the pupillary block. Filtering surgery was performed in the absence of a complete response to medical treatment, allowing control of IOP without drops and complete regression of the corneal edema.

DISCUSSION

CEU is a rare malformation, and pressure complications represent an insignificant proportion of pediatric glaucoma cases. The acute presentation of acute angle closure in this potentially blinding short-term setting, however, makes detection and management difficult in very young children in a great deal of pain. Only one similar case has been reported in the pediatric literature.

CONCLUSION

Acute angle closure complicating CEU is exceptional and difficult to diagnose in a pediatric context. Parents of children with this predisposing condition should be informed of the need to consult urgently when clinical signs of elevated intraocular pressure appear.

[Glaucoma surgeries: Long-term results - A review]

The surgical treatment of glaucoma has been and is still based on filtering surgeries, commonly used for about half a century. The safety and efficacy of these techniques have been well described, as it has also been done for cyclophotocoagulation and valves or tubes, indicated in France mostly for refractory glaucoma. Minimally invasive glaucoma surgeries have emerged in recent decades, increasing the number of therapeutic options, and allowing treatment decisions to be as patient-centered as possible. Most of these techniques have now been studied for more than five years. Since glaucoma is a chronic, progressive optic neuropathy, the sustainability of each surgery's results is essential. The amount of available data concerning long-term efficacy and safety of glaucoma surgeries is increasing, so we have decided to describe it through this review of the literature.