Pediatric Glaucoma: a literature's review and analysis of surgical results

The purpose of this paper is to review the surgical options available for the management of pediatric glaucoma, to evaluate their advantages and disadvantages together with their long-term efficacy, all with the intent to give guidelines to physicians on which elements are to be considered when taking a surgical decision. Currently there is a range of surgical procedures that are being used for the management of pediatric glaucoma. Within these, some are completely new approaches, while others are improvements of the more traditional procedures. Throughout this vast range of surgical options, angle surgery remains the first choice in mild cases and both goniotomy and trabeculotomy have good success rates. Trabeculectomy with or without mitomycin C (MMC) is preferred in refractory cases, in aphakic eyes, and in older children. GDIs have a good success rate in aphakic eyes. Nonpenetrating deep sclerectomy is still rarely used; nevertheless the results of ongoing studies are encouraging. The different clinical situations should always be weighed against the risks associated with the procedures for the individual patients. Glaucomatous progression can occur many years after its stabilization and at any time during the follow-up period; for this reason life-long assessment is necessary

Angle stability and outflow in dual blade ab interno trabeculectomy with active versus passive chamber management.

PurposeTo compare intraoperative angle stability and postoperative outflow of two ab interno trabeculectomy devices that excise the trabecular meshwork with or without active aspiration and irrigation. We hypothesized that anterior segment optical coherence tomography (AS-OCT) allows for a quantitative comparison of intraoperative angle stability in a microincisional glaucoma surgery (MIGS) pig eye training model.MethodsTwelve freshly enucleated porcine eyes were measured with AS-OCT at baseline, at the beginning of the procedure and at its conclusion to determine the anterior chamber depth (ACD) and the nasal angle α in degrees. The right and left eye of pairs were randomly assigned to an active dual blade goniectome (aDBG) and a passive dual blade goniectome (pDBG) group, respectively. The aDBG had irrigation and aspiration ports while the pDBG required surgery under viscoelastic. We performed the procedures using our MIGS training system with a standard, motorized ophthalmic operating microscope. We estimated outflow by obtaining canalograms with fluorescent spheres.ResultsIn aDBG, the nasal angle remained wide open during the procedure at above 90° and did not change towards the end (100±10%, p = 0.9). In contrast, in pDBG, ACD decreased by 51±19% to 21% below baseline (p<0.01) while the angle progressively narrowed by 40±12% (p<0.001). Canalograms showed a similar extent of access to the outflow tract with the aDBG and the pDBG (p = 0.513). The average increase for the aDBG in the superonasal and inferonasal quadrants was between 27 to 31% and for the pDBG between 15 to 18%.ConclusionAS-OCT demonstrated that active irrigation and aspiration improved anterior chamber maintenance and ease of handling with the aDBG in this MIGS training model. The immediate postoperative outflow was equally good with both devices

Goniotomy for Non-Infectious Uveitic Glaucoma in Children

Secondary glaucoma is still a blinding complication in childhood uveitis, for which most commonly used surgical interventions (trabeculectomy or glaucoma drainage implant) involve multiple re-interventions and/or complications postoperatively. The goniotomy procedure has never been investigated in the current era, in which patients with pediatric uveitis receive biologics as immunosuppressive therapy for a prolonged period, with potential implications for the outcome. The purpose of the study is to evaluate the efficacy and safety of a goniotomy procedure in pediatric non-infectious uveitis in a retrospective, multicenter case series. The primary outcomes were the postoperative intraocular pressure (IOP), number of IOP-lowering medications, and success rate. Postoperative success was defined as 6 ≤ IOP ≤ 21 mmHg, without major complications or re-interventions. Fifteen eyes of ten children were included. Median age of the included patients at goniotomy was 7 years; median follow-up was 59 months. Median (interquartile range) IOP before surgery was 30 (26–34) mmHg with 4 (3–4) IOP-lowering medications. At 1, 2, and 5 years after goniotomy, median IOP was 15, 14, and 15 mmHg with 2 (0–2), 1 (0–2), and 0 (0–2) medications, respectively (p &lt; 0.001 postoperatively versus preoperatively for all timepoints). Success rate was 100%, 93%, and 80% after 1, 2, and 5 years, respectively. There were no significant changes in visual acuity and uveitis activity or its treatment, and there were no major complications. Our results show that the goniotomy is an effective and safe surgery for children with uveitic glaucoma.</p

An Alternate Technique for Goniotomy: Description of Procedure and Preliminary Results

Purpose: Multiple glaucoma treatment modalities seek to lower IOP by bypassing or removing a portion of the juxtacanalicular trabecular meshwork. These procedures often require expensive implants or specialized surgical instruments. The authors developed a technique for ab interno goniectomy utilizing a standard disposable 25-gauge hypodermic needle. The surgical procedure—termed bent ab interno needle goniectomy (BANG)—and preliminary results are presented here. Methods: A retrospective chart review was performed for all patients who underwent goniotomy using a modified hypodermic needle by one of the three authors between July 2017 and June 2018. The mean and standard deviation pre- and postoperative IOP and the number of glaucoma medications were calculated. The student paired t-test was used to compare pre- and postoperative data. A P-value of &lt;0.05 was considered statistically significant. Results: At postoperative month six, the mean IOP was 13.3 ± 2.5 mmHg (P = 3.6 × 10−7) on 0.5 ± 0.8 topical glaucoma medications (P = 0.01). A ≥20% reduction in IOP was achieved in 73% of patients. Seventy-three percent of patients required ≥1 fewer medication, while 73% of patients required no medications for IOP control. Forty-one percent of those treated achieved IOP ≤12 mmHg. Conclusion: The BANG procedure is a low-cost MIGS technique available to surgeons around the world with preliminary outcomes similar to more expensive alternatives

Illuminated micro-catheter assisted trabeculotomy : literature review

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020Objetivo: Revisão da literatura da trabeculotomia assistida por microcateter iluminado (MAT) no tratamento do glaucoma pediátrico. Métodos: Realizou-se uma revisão da literatura até Janeiro de 2020, utilizando a pesquisa eletrónica na PubMed (MEDLINE) e Cochrane Central Register of Controlled Trials (CENTRAL). A informação de cada artigo for compilada com base na abordagem terapêutica, tendo sido depois avaliada e interpretada criticamente. A análise dos artigos incluiu características do paciente, pressão intraocular (PIO), número de medicamentos para glaucoma, taxa de sucesso cirúrgico, causas de falha, complicações intra e pós-operatórias. Resultados: Foram incluídos onze estudos na revisão: oito MAT casos-serie e três ensaios clínicos randomizados, dos quais dez são estudos comparativos (entre MAT e goniotomia/CT/trab-trab). Cinco estudos incluíram apenas pacientes com PCG e seis estudos incluíram pacientes com PCG e/ou SCG. Foi incluída a análise de 507 olhos de 423 pacientes, sendo que a MAT foi realizada em 305 olhos, dos quais 197 olhos (64.7%) foram submetidos à canalização completa e 108 olhos (35.4%) apenas a canalização. Em 31 olhos (10.2%), a MAT não foi tecnicamente possível ser realizada, sendo realizada conversão para CT. A idade média no momento da cirurgia foi de 25.7±15.0 meses e o seguimento médio entre estudos foi de 13.0±8.5 meses. A PIO no pós-operatório e o número de medicamentos aos 24 meses de pós-operatório (11.5±3.4mmHg, 0.3±0.6 medicamentos) foram significativamente menores que os valores pré-operatórios (29.6±6.4mmHg, 2.0±0.9 medicamentos). A taxa média de CS foi de 75.0% e 65.5% aos 12 e 24 meses, respetivamente e a taxa média de QS foi de 86.8% e 83.9% aos 12 e 24 meses, respetivamente. Nos olhos submetidos à MAT, 46 falharam, a maioria (n=19 olhos, 41.3%) devido à necessidade de cirurgia adicional. A complicação intra e/ou pós-operatória mais comum na MAT foi o hifema. Conclusões: A MAT obteve efeitos significativos na redução da PIO com complicações mínimas no pós-operatório precoce (até 24 meses) e redução no uso de medicamentos no glaucoma pediátrico (PCG e/ou SCG), não apenas como intervenção inicial, como em pacientes com cirurgias prévias. Pode ser utilizado com sucesso para cateterizar o canal de Schlemm na maioria dos casos. Representa uma escolha razoável de tratamento cirúrgico inicial e repetido do glaucoma pediátrico. Serão necessárias mais pesquisas para determinar o sucesso e a segurança a longo prazo deste procedimento. Palavras-chave: glaucoma pediátrico, glaucoma congénito, pressão intraocular, trabeculotomia 360o, microcateter iluminado.Purpose: Review the literature of MAT for the treatment of pediatric glaucoma. Methods: Literature review from inception to January 2020 performed using an electronic database search on PubMed (MEDLINE) and Cochrane Central Register of Controlled Trials (CENTRAL). Data retrieved from the articles included patient’s characteristics, IOP, glaucoma medication’s number, surgical success rate, failure causes, intra and postoperative complications. Results: Eleven studies were included in the review, 8 were MAT case series and 3 were RCT, of which 10 were comparative studies (between MAT and goniotomy/CT/trab-trab). Five studies included only patients with PCG and six studies included patients with PCG and/or SCG. Analysis of 507 eyes of 423 patients were included, MAT was performed in 305 eyes. of which 197 eyes (64.7%) underwent complete canalization and 108 eyes (35.4%) only partial SC canalization. In 31 eyes (10.2%) MAT was not technically possible with conversion to CT. The average age at the time of surgery was 25.7±15.0 months and the mean time of follow was 13.0±8.5 months. Postoperative IOP and number of glaucoma medications at 24 follow-up months (11.5±3.4mmHg, 0.3±0.6 medications) were significantly lower in comparison to preoperative values (29.6±6.4mmHg, 2.0±0.9 medications). The average CS rate was 75.0% and 65.5% at12 and 24 months of follow-up, respectively, and the mean QS rate was 86.8% and 83.9%, respectively. In the eyes that underwent MAT, 46 failed, most of them (n =19 eyes, 41.3%) due to need for additional glaucoma surgery. The most common intra and/or postoperative MAT complication was hyphema. Conclusions: MAT achieved significant pressure-lowering effects with minimal complications in the early postoperative course (up to 24 months) and a reduction in medication use, in pediatric glaucoma (PCG and/or SCG), not only as an initial intervention but also in patients with previous surgeries. It can be successfully used to catheterize SC in most cases. It represents a reasonable choice of initial and repeat surgical treatment of pediatric glaucoma. Further research is warranted to determine the long-term success and safety of this procedure

Microcatheter–Assisted Circumferential Trabeculotomy in Primary Congenital Glaucoma: Long-Term Clinical Outcomes

Purpose: The purpose of this study was to report the long-term efficacy and clinical outcomes of microcatheter-assisted circumferential trabeculotomy (MCT) in children with primary congenital glaucoma (PCG). Methods: This is a single-center retrospective study including consecutive children with PCG who underwent MCT with &gt; two years follow up. The primary outcome was surgical success, defined as intraocular pressure (IOP) ≤ 21 mmHg with (qualified) or without (complete) medications, measured at six months, one year, and then annually. Secondary outcomes were visual acuity (VA), refraction, axial length (AXL), complications, reinterventions, and number of medications. Results: Twelve eyes of ten patients were included. In eight children only one eye was affected. The mean ± standard deviation (SD) age at surgery was 6.3 ± 4.1 months. The mean postoperative follow-up was 66 ± 35 months. The mean IOP was 34.3 ± 9.6 mmHg preoperatively and 14.6 ± 2.3 mmHg postoperatively at the last visit (p &lt; 0.001). Complete success was achieved at all time points in 10 out of 12 eyes, while 2 eyes had a qualified success. At three years of age, the mean VA of the operated eyes was 0.25 ± 0.12 logMAR, the mean spherical equivalent was −0.78 ± 1.43 diopters, and the mean AXL was 23.78 mm. Transient hyphema was the only complication observed. None of the children required additional glaucoma surgery. Conclusions: Circumferential trabeculotomy for PCG effectively lowers the IOP at more than two years after surgery. Following this procedure, the prognosis for the visual function is good, and the refractive error is low. Postoperative complications were not significant