Congenital ectropion uveae presenting as acute glaucoma in a 3-year-old child

[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 management in congenital ectropion uveae: Surgical outcomes from a large tertiary referral center in South India

PURPOSE

To evaluate the long-term outcomes of glaucoma management in patients with congenital ectropion uveae (CEU) over a period of three decades at a single large referral tertiary eye care center.

METHODS

Retrospective chart review of all patients with CEU treated surgically from 1990 to 2019 was performed. Primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with and without mitomycin-C (MMC) (0.2 mg/mL for 1 min) and transscleral cyclophotocoagulation (TSCPC) were performed. Intraocular pressure (IOP) ≥6 and ≤16 mmHg without medications was considered as complete success and IOP≤ 16 mmHg with the use of upto 2 medications as qualified success.

RESULTS

A total of 26 eyes of 21 patients were identified with a median age of 7 years (range, 6 days to 19 years) at the time of glaucoma surgery. Median follow-up was 51.1 months (range, 7-244.6 months). Primary CTT was performed in 17 eyes (65%), trabeculectomy in 5 eyes (19%) with application of MMC in 2 eyes, and 3 eyes (12%) underwent TSCPC. One painful blind eye (4%) underwent evisceration. Mean IOP reduced from 30.8 ± 7.6 mmHg on a mean of 1.3 ± 0.8 glaucoma medications preoperatively to a mean IOP of 15.2 ± 5.9 mmHg (P < 0.0001) on a mean of 0.2 ± 0.5 medications postoperatively at final follow-up (P = 0.0009). Complete success was achieved in 20 eyes, and qualified success in 2 eyes.

CONCLUSIONS

CTT is a safe and efficacious primary procedure for management of early-onset glaucoma in CEU. Trabeculectomy with or without adjuvant MMC is a viable second line of treatment in late-onset glaucoma with CEU for IOP control.

CO2 Laser-Assisted Sclerectomy vs. Microcatheter-Assisted Trabeculotomy in the Management of a Bilateral Congenital Ectropion Uveae With Glaucoma: A Case Report and Literature Review

Introduction

Bilateral congenital ectropion uveae (CEU) is rare syndrome, usually accompanied by refractory glaucoma. Proper and timely treatment was very important for the prognosis. The report aims to compare the long-term outcomes and complications between the two eyes after different approaches of surgery in a case of bilateral CEU with advanced glaucoma.

Case Presentation

The patient was a 20-year-old male with bilateral CEU and glaucoma. The intraocular pressure (IOP) was 48 mm Hg in the right eye (OD) and 52 mm Hg in the left eye (OS). The vertical cup-to-disc (C/D) ratio was nearly 1.0 in both eyes. Despite maximum medical therapy, the target IOP could not be achieved. Therefore, CO2 laser-assisted sclerectomy surgery (CLASS) was performed in OS, and the IOP was remarkably decreased. 1 month after the surgery, the IOP rebounded slightly and was controlled with a fixed-combination anti-glaucoma medicine. 3-month postoperatively, a YAG laser goniopuncture (LGP) was performed to enhance the IOP-lowing effect and the anti-glaucoma agent was discontinued. An ab externo microcatheter-assisted trabeculotomy (MAT) was performed in OD, and the IOP was also significantly decreased. During the follow-up period, the IOP was well controlled for both eyes without any medication. Shallow anterior chamber and complicated cataract developed in OS after CLASS, and there was no obvious late complication in OD after MAT.

Conclusions

To our knowledge, this was the first attempt to perform two different surgeries, CLASS and MAT, in both eyes of a single patient presented with bilateral CEU with glaucoma. Our results showed that the IOP was lower after CLASS, but there were potential complications such as shallow anterior chamber and complicated cataract. MAT could achieve a moderate IOP-lowing effect but had a higher safety. CLASS and MAT may be considered effective surgical options for the management of such patients.

Characteristics and Outcomes of Glaucoma Associated With Congenital Ectropion Uvea

PURPOSE

To determine the visual outcomes and effectiveness of glaucoma surgeries in congenital ectropion uvea.

DESIGN

Retrospective interventional case series.

METHODS

Surgeries and examination findings were collected on 11 eyes of 8 patients with congenital ectropion uvea at 2 academic sites from 2001 to 2021. Visual outcomes, surgical success (intraocular pressure [IOP]: 5-20 mm Hg, no additional IOP-lowering surgery, no visually devastating complications), and survival rates of glaucoma surgeries were assessed.

RESULTS

Glaucoma in bilateral congenital ectropion uvea was diagnosed at an earlier age (0.02 ± 0.01 years) than unilateral disease (8.9 ± 5.3 years, P = .002). All eyes required glaucoma surgery with 91% requiring multiple surgeries (3.5 ± 2.1, median 3 surgeries per eye). Trabeculotomy (8 eyes) showed 13% success rate. Although none of the 4 eyes that underwent trabeculectomy with mitomycin C needed repeat trabeculectomy, glaucoma drainage device placement, or cycloablation, 75% required bleb revision surgery. Glaucoma drainage devices (7 eyes) had a 57% success rate with 3 eyes requiring subsequent cycloablation (2) or trabeculectomy (1). At the final follow-up (8.5 ± 6.6 years, median: 7.9 years), all eyes achieved IOP control, and IOP was lower compared with presentation (13.2 ± 2.6 mm Hg vs 32.9 ± 9.9 mm Hg, P = .002). Best-corrected logarithm of the minimum angle of resolution visual acuity at the final follow-up was 0.2 ± 0.2.

CONCLUSIONS

Bilateral congenital ectropion uvea presents with glaucoma earlier than unilateral cases. The majority of eyes required multiple glaucoma surgeries. Angle surgery was less effective than trabeculectomy or glaucoma drainage devices. IOP control was obtained in all eyes and affected individuals had good visual outcomes.

Angle closure glaucoma in congenital ectropion uvea

PURPOSE

Congenital ectropion uvea is a rare anomaly, which is associated with open, but dysplastic iridocorneal angles that cause childhood glaucoma. Herein, we present 3 cases of angle-closure glaucoma in children with congenital ectropion uvea.

OBSERVATIONS

Three children were initially diagnosed with unilateral glaucoma secondary to congenital ectropion uvea at 7, 8 and 13 years of age. The three cases showed 360° of ectropion uvea and iris stromal atrophy in the affected eye. In one case, we have photographic documentation of progression to complete angle closure, which necessitated placement of a glaucoma drainage device 3 years after combined trabeculotomy and trabeculectomy. The 2 other cases, which presented as complete angle closure, also underwent glaucoma drainage device implantation. All three cases had early glaucoma drainage device encapsulation (within 4 months) and required additional surgery (cycloablation or trabeculectomy).

CONCLUSIONS AND IMPORTANCE

Congenital ectropion uvea can be associated with angle-closure glaucoma, and placement of glaucoma drainage devices in all 3 of our cases showed early failure due to plate encapsulation. Glaucoma in congenital ectropion uvea requires attention to angle configuration and often requires multiple surgeries to obtain intraocular pressure control.