Time of diagnosis, reoperations and long-term results of goniotomy in the treatment of primary congenital glaucoma: a clinical study

The Japan Glaucoma Society guidelines for glaucoma 5th edition

We are pleased to bring you the 5th edition of the Glaucoma Clinical Practice Guidelines. Clinical practice guidelines are based on evidence (scientific grounds). It is a document that presents the treatment that is the most appropriate for the patient. "Glaucoma Clinical Guidelines" was first published in 2003. This was the first guideline for glaucoma treatment in Japan. The principle of glaucoma treatment is to lower intraocular pressure. Means for lowering intraocular pressure includes drugs, lasers, and surgery; Glaucoma is a disease that should be considered as a complex syndrome rather than a single condition. Therefore, the actual medical treatment is not as simple as one word. This time we set the Clinical Questionnaire with a focus on glaucoma treatment. We hope that you will take advantage of the 5th edition.

Clinical Analysis of Pediatric Glaucoma in Central China

Purpose

We aimed to describe the characteristics, epidemiology, management, and outcomes of glaucoma in pediatric patients in central China.

Methods

This study retrospectively analyzed inpatients with pediatric glaucoma at Henan Provincial People's Hospital, Henan Eye Institute, and Henan Eye Hospital between 2017 and 2020.

Results

Overall, 239 cases (276 eyes) of pediatric glaucoma in patients, comprising 87 girls (36.40%) and 152 boys (63.60%) were analyzed. The mean age was 6.65 ± 4.46, and 2.93% of the patients had a family history of glaucoma. Primary congenital glaucoma (PCG) was the most common type of glaucoma, followed by traumatic glaucoma in 8.33% of the patients, which was considered secondary glaucoma. The most common signs and symptoms were elevated intraocular pressure (IOP) and eye pain. Trabeculotomy (Trab) and microcatheter-assisted 360° trabeculotomy (MAT) combined with Trab were the most commonly performed surgeries. The IOP of patients with PCG, juvenile open-angle glaucoma (JOAG), and secondary glaucoma were 15.27 ± 7.48 mmHg, 17.16 ± 10.05, and 18.65 ± 8.55, respectively, at the final follow up. The rate of re-operations in patients with PCG, JOAG, and secondary glaucoma were 9.15%, 6.78%, and 4.69%, respectively. The mean visual acuity of the eyes with PCG, JOAG, and secondary glaucoma was 0.79 ± 0.68, 0.51 ± 0.48, and 0.53 ± 0.50, respectively.

Conclusion

PCG, JOAG, and traumatic glaucoma were the most prevalent subtypes in patients with pediatric glaucoma in central China. Trab and MAT combined with Trab were the most common interventions used in this study. Pediatric amblyopia might require full attention during the entire treatment, especially after glaucoma surgery. Effective preventive measures and more public education on glaucoma prevention and the importance of early diagnosis and treatment is necessary.

Primary Congenital Glaucoma among the Children Under 3 Years of Age in the Outpatient Department in a Tertiary Care Hospital: A Descriptive Cross-sectional Study

INTRODUCTION

Primary congenital glaucoma is a rare vision-threatening condition of children. Primary congenital glaucoma though a rare disease it is the most common cause of childhood glaucoma with potency to cause blindness. This study was undertaken to find the prevalence of the children with primary congenital glaucoma under 3 years of age in a tertiary care hospital.

METHODS

This was a descriptive cross-sectional study conducted at a tertiary eye center in Nepal in children (≤ 3 years) presented in the outpatient department of a tertiary eye hospital between June 2017 and June 2020. The study was approved by the hospital review committee and adhered to the declaration of Helsinki. A convenient sampling method was used. Point estimate at 95% Confidence Interval was calculated with frequency distribution. Data analysis was conducted using Statistical Package for the Social Sciences.

RESULTS

Out of total children under 3 years who presented to the outpatient department, 46 (0.31%) at 95% Confidence Interval (0.30-0.32) had primary congenital glaucoma. Among them, 30 children (65.2%) had bilateral involvement. Mean intraocular pressure was 42.40±8.15mm Hg. The mean age of initial presentation, horizontal corneal diameter, and axial length were 12.07±8.9 months, 12.95±1mm, and 23.89±1.7mm respectively. Consanguinity was observed in 12 (26%) children.

CONCLUSIONS

From the study, we conclude that there was a low prevalence of primary congenital glaucoma among children under 3 years of age who presented to the outpatient department in a tertiary care hospital.

Visual outcomes and associated factors of primary congenital glaucoma in children

PURPOSE

We evaluated the long-term visual outcomes in children with primary congenital glaucoma and determined the factors associated with the final visual outcomes.

METHODS

Medical records of children with primary congenital glaucoma between 2005 and 2016, seen at Seoul National University Children's Hospital in South Korea, were reviewed. The minimum follow-up period after surgery for primary congenital glaucoma was 3 years. Visual acuity (VA) was categorized into good (≧20/70) and poor (< 20/70). Factors including age, VA, refractive errors, intraocular pressure (IOP), laterality, and cup-to-disc (C/D) ratio were compared between the groups.

RESULTS

A total of 71 eyes of 44 patients were included. The patients' age at the time of surgery was 14.7 ± 12.2 months. The mean IOP was 28.3 ± 7.0 mmHg. During 6.7 ± 2.7 years of mean follow-up after surgery, 39 eyes (54.9%) needed occlusion treatment. After occlusion, patients with lower IOP values, lesser additional surgeries, reversal of optic disc cupping, and better initially measured VA achieved a better visual outcome. At the final assessment, the mean age was 7.8 ± 2.6 years, and the mean VA gain was 15.0 ± 19.4 letters. There were 44 eyes (62.0%) with VA ≧20/70.

CONCLUSIONS

In children with primary congenital glaucoma, IOP control and the optic disc configuration over time are important factors associated with visual outcome. Regular follow-up and correction of refractive errors-along with occlusion for those with difference in VA between the two eyes-might be helpful for achieving better visual outcomes.

Ab Interno Goniotomy Combined with Ab Externo Trabeculotomy in Advanced Primary Congenital Glaucoma Patients: 2-Year Follow-Up

Introduction

Primary congenital glaucoma (PCG) is a challenging disease that needs to be surgically managed with more innovative methods. Conventional incisional surgery, such as goniotomy and trabeculotomy, has a primary high success rate, but does not seem to be a very effective treatment in advanced stages.

Design

A prospective clinical case study.

Purpose

To qualify the outcome, in terms of success rate, of goniotomy combined with trabeculotomy as a surgical option to treat eyes affected by PCG with a corneal diameter larger than 14 mm.

Patients and Methods

This study included 50 eyes of 50 patients diagnosed with PCG with corneal diameter larger than 14 mm who underwent ab interno goniotomy combined with ab externo trabeculotomy. Intraocular pressure (IOP) was measured preoperatively and 24 months postoperatively. A statistical analysis was performed to detect correlations between the success rate and corneal diameter, preoperative IOP, age of onset, axial length, and consanguinity. The main outcome was reduction in IOP; secondary outcomes were factors affecting the success rate, complications, and the need for additional surgical intervention to control IOP.

Results

The mean age of the patients was 18.86±9.94 months. Males made up 52% of cases and females 48% of cases. Positive consanguinity was present in 38% of cases. Axial length ranged between 20 and 22 mm, with a mean of 20.98±0.8 mm. Mean preoperative IOP was 29.56±3.36 mmHg, which decreased postoperatively to 12.6±2.5, 14.1±3.2, 16.8±5.5, 14.4±2.3, 14.3±1.6, 14.3±1.6, 14.3±1.6, 14.3±1.7, and 14.3±1.7 mmHg at 1, 3, 6, 9, 12, 15, 18, 21, and 24 months respectively (p˂0.001). Use of medical treatment was decreased from 2.7±0.4 preoperatively to 1.4±0.7 postoperatively (p˂0.001). Hyphema was the only complication that appeared, occurring in 47% of cases. The success rate was 94%. Complete success (IOP <21 mmHg without treatment) was achieved in 70% of cases, 24% were considered a qualified success (IOP <21 mmHg with treatment), while failure was documented in 6% of cases (IOP >21 mmHg with treatment). The success rate was significantly related to preoperative IOP, corneal diameter, axial length, consanguinity, and age of onset (p˂0.001). All cases were followed for 24 months.

Conclusion

Ab interno goniotomy combined with ab externo trabeculotomy improves the success rate of buphthalmos surgery. A significant correlation was detected between success rate and preoperative IOP, corneal diameter, axial length, consanguinity, and age of onset.

Update in Genetics and Surgical Management of Primary Congenital Glaucoma

Primary congenital glaucoma (PCG) continues to be an important cause of visual impairment in children despite advances in medical and surgical treatment options. The progressive and blinding nature of the disease, together with the long lifespan of the affected population, necessitates a thorough understanding of the pathophysiology of PCG and the development of long-lasting treatment options. The first part of this review discusses the genetic features and makeup of this disorder, including all currently identified genetic loci (GLC3A, GLC3B, GLC3C and GLC3D) and relevant protein targets important for trabecular and Schlemm canal dysgenesis. These target molecules primarily include CYP1B1, LTBP2, and TEK/Tie2 proteins. Their potential roles in PCG pathogenesis are discussed with the purpose of bringing the readers up to date on the molecular genetics aspect of this disorder. Special emphasis is placed on functional implications of reported genetic mutations in the setting of PCG. The second part of the review focuses on various modifications and refinements to the traditional surgical approaches performed to treat PCG, including advances in goniotomy and trabeculotomy ab externo techniques, glaucoma drainage implant surgery and cyclodiode photocoagulation techniques that ultimately provide safer surgical approaches and more effective intraocular pressure control in the 21st century.

Primary congenital glaucoma: An updated review

Primary congenital glaucoma (PCG) is a rare disease affecting children early in life. PCG was considered untreatable with inevitable blindness. However, recent advances in biochemical and genetic studies, the introduction of new diagnostic tools, intraocular pressure (IOP) lowering medications and improvement of surgical techniques have led to a better understanding of this devastating disease and preserving the vision of affected children. This paper presents an updated and broad overview of PCG in terms of the epidemiology and genetic aspects, particularly in Saudi Arabia, the clinical presentation and diagnostic approach to PCG with major emphasis on the treatment options.

Postoperative outcome of three different procedures for childhood glaucoma

Purpose

To investigate the long-term postoperative outcome of three surgical procedures for childhood glaucoma.

Patients and methods

In this retrospective study, the patients were divided into a goniotomy group, a trabeculotomy group, and a filtering surgery group, based on the initial surgical procedure. Failure was defined as an IOP ≥21 mmHg with medication at two consecutive visits. A Kaplan–Meier analysis was applied to calculate the probability of success. Additional metrics included IOP, number of additional operations, eye drop scores, and visual acuity.

Results

We studied 40 eyes of 25 patients, 21 eyes of 15 patients, and 12 eyes of 7 patients in the goniotomy, trabeculotomy, and filtering surgery groups, respectively. The 10- and 20-year probability of success was 65.2% and 65.2%, 42.2% and NA (no data for 20 years), and 91.7% and 80.2% for the goniotomy, trabeculotomy, and filtering surgery groups, respectively.

Conclusion

All three procedures maintained an IOP of less than 21 mmHg for up to 10 years in 65.2%, 42.2%, and 91.7% of childhood glaucoma cases.

Primary congenital glaucoma including next-generation sequencing-based approaches: clinical utility gene card

1. NAME OF THE DISEASE (SYNONYMS): Primary congenital glaucoma (PCG). Glaucoma, congenital (GLC). 2. OMIM# OF THE DISEASE: 231300- GLC3A. 600975- GLC3B. 613085- GLC3C. 613086- GLC3D. 617272- GLC3E. 3. NAME OF THE ANALYSED GENES OR DNA/CHROMOSOME SEGMENTS: CYP1B1. LTBP2. MYOC. FOXC1. TEK. 4. OMIM# OF THE GENE(S): CYP1B1 MIM# 601771. LTBP2 MIM# 602091. MYOC MIM# 601652. FOXC1 MIM# 601090. TEK MIM# 600221. Review of the analytical and clinical validity, as well as of the clinical utility of DNA-based testing for variants in the CYP1B1, LTBP2 and MYOC gene(s) in ⊠ diagnostic, ⊠ predictive and ⊠ prenatal settings and for ⊠ risk assessment in relatives.

Long-term Surgical Outcomes of 180-Degree Suture Trabeculotomy in Korean Patients With Primary Congenital Glaucoma

PURPOSE

To investigate the surgical outcomes of 180-degree suture trabeculotomy in Korean patients with primary congenital glaucoma (PCG).

PATIENTS AND METHODS

This retrospective study included 21 eyes of 17 children with PCG who underwent 180-degree suture trabeculotomy as a first surgical procedure. Surgical success was defined as (1) an intraocular pressure (IOP)<22 mm Hg with or without medication; (2) no additional intraocular surgery; and (3) no evidence of progressive optic disc cupping. The main outcome measure was the success rate of 180-degree suture trabeculotomy. Secondary outcome measures were IOP, number of glaucoma medications, and occurrence of complications.

RESULTS

Of the 21 eyes included, 18 (85.7%) were classified as having achieved success at the final visit (mean last follow-up or failure time, 54.91±45.68 mo). Median age at surgery was 11.97 months with mean IOP 29.8±9.6 mm Hg, on average of 1.52 medications. The mean IOP at the final visit was 16.9±5.6 mm Hg on an average of 0.38 medications. The surgical success rate of 180-degree suture trabeculotomy at 1, 3, and 5 years was 95.0%, 87.7%, and 78.9%, respectively (Kaplan-Meier analysis). Three eyes underwent second operations and the mean time to failure was 29.39±19.75 months. Hyphema was observed in 10 eyes, but it cleared up within 7.6 days.

CONCLUSION

The 180-degree suture trabeculotomy performed for PCG had a significant IOP-lowering effect and caused no remarkable complications.

Modified goniotomy as an alternative to trabectome in primary open angle glaucoma and pseudoexfoliation glaucoma: 1 year results

OBJECTIVE

To assess the outcome of modified goniotomy and trabeculotomy ab interno (Trabectome) surgery in adult primary open-angle glaucoma (POAG) and pseudoexfoliation (PEX) glaucoma.

DESIGN

Retrospective cohort outcome study.

PARTICIPANTS

Two hundred and thirty-six eyes of 236 patients.

METHODS

This cohort outcome study included 68 POAG (mean age: 65.7 ± 16.0 years) and 22 PEX glaucoma patients (mean age: 78.3 ± 7.9 years) in the modified goniotomy cohort and 119 POAG (mean age: 73.9 ± 9.6 years) and 27 PEX glaucoma patients (mean age: 75.2 ± 8.0 years) in the Trabectome cohort. Modified goniotomy is defined as combined ab interno cyclodialysis and goniotomy. The patients were followed up for 12 months, and we analysed the data using SPSS v19.0.

RESULTS

In POAG, the intraocular pressure (IOP) was significantly reduced by 4.6 mm Hg in the Trabectome cohort (p < 0.001) and by 5.8 mm Hg (p < 0.001) in the goniotomy group at 1-year follow-up. In PEX glaucoma, the mean IOP was reduced by 9.7 mm Hg (p = 0.002) in the Trabectome surgery and by 6.7 mm Hg (p = 0.004) in the goniotomy cohort 1 year later. Comparing both surgery techniques in POAG, no significant correlation was found in terms of IOP at any of the follow-up visits (IOP at 1 year, p = 0.553). In PEX glaucoma, the IOP, visual acuity, and number of glaucoma medications did not differ significantly between the 2 surgery techniques 1 year later (IOP: p = 0.300; VA: p = 0.391; therapy: p = 0.908).

CONCLUSION

Modified goniotomy and Trabectome surgery are reliable and effective tools for the management of moderate POAG and PEX glaucoma. There was no significant difference in IOP between the 2 procedures over a follow-up period of 1 year.

Review on the Management of Primary Congenital Glaucoma

Despite being documented in medical history from over 2400 years ago, primary congenital glaucoma (PCG), being a disease with low incidence rate, remains a challenge to ophthalmologists. The article provides a broad overview on the pathophysiology and diagnostic approach to PCG with major emphasis on the treatment options of PCG. While reviewing on the well-established treatment options, namely goniotomy, trabeculo-tomy and combined trabeculotomy-trabeculectomy, emphasis has also been made to recent updates on secondary treatments: trabeculectomy, antimetabolites, glaucoma-drainage devices and cyclodestructive procedures. It is, however, important to note that the rarity of PCG places limitations on study design, most studies are, thus, retrospective, nonrandomized and have different definitions of surgical success. Ophthalmologists need to interpret the results with critical thinking and formulate individual treatment plans for each patient. How to cite this article: Yu Chan JY, Choy BNK, Alex LK Ng, Shum JWH. Review on the Management of Primary Congenital Glaucoma. J Curr Glaucoma Pract 2015;9(3):92-99.

[Glaucoma surgery in children]

BACKGROUND

Goniotomy has been established as the standard procedure in the treatment of congenital glaucoma for more than 50 years.

OBJECTIVES

This article presents the current indications for the different antiglaucomatous procedures in children with success rates and specific complications.

METHODS

A selective literature search was carried out and a report of the consensus meeting 2013 concerning congenital glaucoma and personal experiences are presented.

RESULTS

Primary surgical treatment for primary congenital glaucoma mainly consists of trabeculotomy and its modifications but also of goniotomy. A widespread and increasing use of drainage device surgery can be seen in complicated types of pediatric glaucoma, such as secondary glaucoma due to aphakia, uveitis or Sturge-Weber-Krabbe syndrome.

CONCLUSION

The visual prognosis following glaucoma surgery generally depends on successful control of the intraocular pressure as well as on amblyopia treatment.

[Glaucoma surgery in childhood]

Technical characteristics and a long-term therapeutic strategy due to a long life expectancy play a key role in pediatric glaucoma surgery. The well-established angle surgery (goniotomy and trabeculotomy) achieves successful results in primary childhood glaucoma. Trabeculectomy seems to have been displaced as a secondary approach by glaucoma drainage devices (GDD) in primary childhood glaucoma due to inferior results, especially for children under 3 years of age. Even for secondary childhood glaucoma the results of GDD are encouraging, especially for therapy refractory aphakic glaucoma. In the first 2 years after GDD surgery success rates are about 80% for pediatric glaucoma and the results appear to be independent of the type of glaucoma and implant used. The complications of GDD are balanced to the faster intraocular pressure (IOP) control during the phase of visual acuity development. Cyclodestructive procedures may be applied as a secondary adjuvant approach but they increase the risk of conjunctival scarring and hypotony for subsequent procedures.

Long-term results of surgery in childhood glaucoma

PURPOSE

The aim of this study is to assess the functional results and morphological parameters in children surgically treated for glaucoma.

METHODS

Data from 43 patients and 68 eyes who were operated in our department between 1990 and 2002 were collected. This retrospective trial included primary congenital glaucoma (n=36), and secondary glaucoma (n=7) in Rieger-Axenfeld syndrome and Sturge Weber syndrome. Intraocular pressure (IOP), axial length of the eyeball, visual acuity, refractive errors and orthoptic status were analysed.

RESULTS

The age of patients at the first surgery was 6.0 +/- 5.3 months (range 0.7 to 28.0 months). The mean period of follow-up was 57.3 +/- 36.8 months (6.0-161.0). The mean number of surgical procedures performed on one eye was 2.5 +/- 2.4 procedures (1-11). The mean IOP before the first surgery was 31.0 +/- 7.9 mmHg (17.5-52.0), and was 15.0 +/- 3.9 mmHg (7.0-28.0) at the last visit. 49 eyes (72.1%) did not need any further medical treatment after the last surgical procedure. The IOP was 18 mmHg or lower without medication in 29 eyes (42.6%) after just one surgical procedure (21 trabeculotomy, 8 combined trabeculotomy/trabeculectomy with or without mitomycin-C). At the first examination, the mean axial length of the eyeball was 22.6 +/- 1.8 mm (the mean normal value at this age is 20.3 +/- 0.7 mm), and was 24.4 +/- 2.0 mm at the last visit (the mean normal value at this age is 22.2 +/- 0.6 mm). The best corrected visual acuity at the last visit was 0.25 +/- 4.6 lines; the normal range of visual acuity at this age is from 0.4 +/- 4.0 lines to 0.8 +/- 3.0 lines. Visual acuity was 0.32 or more in 53.0% of the eyes. Visual acuity was lower than 0.1 in only 15.2% of the eyes. Myopia was present in 57.4% of the eyes with a mean spherical equivalent of -6.1 +/-3.9 dioptres. 15 patients (34.9%) developed strabismus. 22 patients (51.2%) were treated with part-time occlusion. Binocular function as assessed with the Lang-1 test was positive in 17 of 30 patients (56.7%).

CONCLUSIONS

Although a good long-term IOP-control can often be achieved in childhood glaucoma, the visual acuity remains below the normal range in most cases despite close orthoptic follow-up.

Long-term surgical and visual outcomes in primary congenital glaucoma: 360 degrees trabeculotomy versus goniotomy

PURPOSE

To compare the visual outcome and refractive status of children with primary congenital glaucoma who underwent 360 degrees trabeculotomy or goniotomy as an initial surgical procedure.

METHODS

This retrospective study describes 24 eyes (15 patients) with primary congenital glaucoma that underwent 360 degrees trabeculotomy as the initial procedure and 40 eyes (23 patients) that underwent goniotomy as the initial procedure. Inclusion criteria were: (1) diagnosis of primary congenital glaucoma and initial angle surgery before 1 year of age, (2) no other ocular or systemic diseases, (3) 360 degrees trabeculotomy or goniotomy as the first surgical procedure, and (4) ability to obtain an Allen or Snellen visual acuity. A postoperative vision of 20/50 or better was considered good. Surgical success was defined as an intraocular pressure (IOP) less than 22 mm Hg with or without medication and without evidence of a progressive optic neuropathy.

RESULTS

The IOP was successfully controlled in 92% of eyes in the trabeculotomy group and in 58% of eyes in the goniotomy group (P =.004). Of eyes in the trabeculotomy group, 79% had vision of 20/50 or better compared with 53% in the goniotomy group (P =.03). High myopia was more prevalent in the goniotomy group, but this difference was not statistically significant (P =.16). A poor visual outcome was associated with failure of the angle surgery or poor compliance with follow-up and amblyopia therapy.

CONCLUSION

For primary congenital glaucoma, 360 degrees trabeculotomy is a highly effective procedure that results in excellent pressure control and is at least as successful as multiple standard procedures. In this study, 360 degrees trabeculotomy resulted in better vision than what is reported in the literature for standard angle procedures.