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

Aqueous Humor Outflow Structure and Function Imaging At the Bench and Bedside: A Review.

Anterior segment glaucoma clinical care and research has recently gained new focus because of novel imaging modalities and the advent of angle-based surgical treatments. Traditional investigation drawn to the trabecular meshwork now emphasizes the entire conventional aqueous humor outflow (AHO) pathway from the anterior chamber to the episcleral vein. AHO investigation can be divided into structural and functional assessments using different methods. The historical basis for studying the anterior segment of the eye and AHO in glaucoma is discussed. Structural studies of AHO are reviewed and include traditional pathological approaches to modern tools such as multi-model two-photon microscopy and optical coherence tomography. Functional assessment focuses on visualizing AHO itself through a variety of non-real-time and real-time techniques such as aqueous angiography. Implications of distal outflow resistance and segmental AHO are discussed with an emphasis on melding bench-side research to viable clinical applications. Through the development of an improved structure: function relationship for AHO in the anterior segment of the normal and diseased eye, a better understanding of the eye with improved therapeutics may be developed

Ocular manifestations of Sturge–Weber syndrome: pathogenesis, diagnosis, and management

Sturge-Weber syndrome has been included in the group of phakomatoses that is characterized by hamartomas involving the brain, skin, and eyes. The characteristic facial port-wine stain, involving the first branch of the trigeminal nerve and the embryonic vasculature distribution in this area, leads to several ocular complications of the anterior segment and can involve the eyelids and conjunctiva. The posterior segment of the eyes is also affected with diffuse choroidal hemangiomas. However, the most frequent ocular comorbidity is glaucoma with a prevalence rate ranging from 30%-70%. Glaucoma is related to anterior chamber malformations, high episcleral venous pressure (EVP), and changes in ocular hemodynamics. Glaucoma can be diagnosed at birth, but the disease can also develop during childhood and in adults. The management of glaucoma in Sturge-Weber syndrome patients is particularly challenging because of early onset, frequently associated severe visual field impairment at the time of diagnosis, and unresponsiveness to standard treatment. Several surgical approaches have been proposed, but long-term prognosis for both intraocular pressure control and visual function remains unsatisfactory in these patients. Choroidal hemangiomas may also lead to visual impairment thorough exudative retinal detachment and macular edema. Treatment of exudative hemangioma complications is aimed at destructing the tumor or decreasing tumor leakage

Comparison of Circumferential and Traditional Trabeculotomy in Pediatric Glaucoma

Purpose To compare intraocular pressure (IOP) control of pediatric glaucoma patients undergoing traditional trabeculotomy (<360 degrees or partial) with those receiving 360-degree circumferential trabeculotomy. Methods The medical records of pediatric glaucoma patients receiving trabeculotomy at a single institution from 2000 to 2012were retrospectively reviewed. Patients were divided into two groups: a traditional trabeculotomy group and 360-degree trabeculotomy group. IOP at baseline and at 1, 3, 6, and 12 months’ follow-up were compared within and each groups. Results A total of 77 eyes of 56 patients (age at surgery, 1.52 ± 2.68 years) in the traditional group and 14 eyes of 10 patients in the 360-degree group (age at surgery, 0.61 ± 0.42 years) were included. Mean baseline IOP was similar in both groups (traditional, 28.75 ± 8.80 mm Hg; 360-degree, 30.35 ± 6.04 mm Hg; t test; P = 0.43). Mean 1-year IOP was 17.05 ± 5.92 mm Hg in the traditional group and 11.0 ± 2.31 mm Hg in the 360-degree group. At 1-year, the surgical success rate was 58.44% in the traditional group and 85.71% in the 360-degree group; 32 eyes in the former and 2 eyes in the latter required another glaucoma procedure within 1 year for IOP control. For both groups, compared to baseline values, IOP decreased significantly with all postoperative measurements (paired t test, all P < 0.01). The 360-degree group had significantly lower IOP compared to the traditional group at 1-year (t test, P < 0.01). Conclusions Both 360-degree and traditional trabeculotomy significantly reduced IOP in children through 1 year’s follow-up, although the former procedure shows better 1-year postoperative IOP control, with higher rate of surgical success

Latanoprost and Dorzolamide for the Treatment of Pediatric Glaucoma: The Glaucoma Italian Pediatric Study (Gipsy), Design and Baseline Characteristics

INTRODUCTION: To investigate the efficacy of a treatment strategy with latanoprost and dorzolamide in primary pediatric glaucoma patients partially responsive to surgery. METHODS: Single arm, prospective, interventional multicenter study. Primary pediatric glaucoma patients younger than 13 years after a single surgical procedure with IOP between 22 and 26 mmHg were considered eligible. At baseline, patients were allocated to latanoprost monotherapy once daily. Depending on intraocular pressure (IOP) reduction at first visit, the patients were allocated to one of three groups: continuation of latanoprost monotherapy, addition of dorzolamide twice daily, or switch to dorzolamide three times daily. The same approach for allocation in medication groups was used in all subsequent visits. Patients in the dorzolamide monotherapy group with IOP reduction <20% from baseline were considered non-responders and withdrawn. Study treatment and patient follow-up will continue for 3 years or until treatment failure. The primary endpoint is the percentage of responders. Secondary endpoints are time to treatment failure and frequency of adverse events. RESULTS: A total of 37 patients (69 eyes) were enrolled. The mean age was 4.0 ± 3.8 years, the female/male ratio was 1/1.7, and the majority of patients were Caucasian. Eighty percent of patients had bilateral glaucoma. Goniotomy was the most frequently performed surgery (38.6%), followed by trabeculotomy (22.8%), trabeculectomy (21.1%), and trabeculectomy plus trabeculotomy (17.5%). The baseline IOP was 23.6 ± 1.5 mmHg. CONCLUSION: The study population is representative of patients frequently encountered after the first surgery for primary pediatric glaucoma. The study will produce evidence on the medium-term efficacy of a defined pharmacological approach

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

Risk Factors for Trabeculotomy Failure in Primary Congenital Glaucoma

Précis: This study demonstrates that a baseline corneal diameter >12.25, initial age [removed]12.25 mm did by 4.2 times, younger age than 4 months did by 2.5 times, bilaterality did by 1.5 times. Conclusions: A higher baseline IOP, younger age, larger corneal diameter, and bilaterality were identified as risk factors for trabeculotomy failure in congenital glaucoma. The presence of one or more of these should be considered in the decision-making process when considering surgical options to manage glaucoma in these patients. © 2022 Wolters Kluwer Health, Inc. All rights reserved

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&lt;0.01) while the angle progressively narrowed by 40±12% (p&lt;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

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