Long-term surgical outcomes of ab externo trabeculotomy in the management of primary congenital glaucoma

Long-term Outcomes in Patients Undergoing Surgery for Primary Congenital Glaucoma between 1991 and 2000: A Single-Center Database Study

PURPOSE

To estimate the long-term surgical and visual outcomes in patients with primary congenital glaucoma (PCG) who completed at least 20 years of follow-up.

DESIGN

Retrospective study.

PARTICIPANTS

Two hundred twenty eyes of 121 patients undergoing surgery for PCG between January 1991 and December 2000 and who returned for a follow-up visit from January 2021 through January 2022.

METHODS

Retrospective review of medical records of patients who underwent primary combined trabeculotomy-trabeculectomy (CTT) without mitomycin C as an initial procedure. Success was defined as complete when intraocular pressure (IOP) was ≥ 6 mmHg and ≤ 21 mmHg without glaucoma medication and as qualified when up to 2 glaucoma medications were required. Failure was defined as uncontrolled IOP with more than 2 glaucoma medications, need for a second IOP-lowering procedure, chronic hypotony (IOP < 6 mmHg on 2 consecutive visits), or any sight-threatening complication. A mixed-effects model using maximum likelihood estimation was used in estimation of eye-based variables and to make comparisons between different visits. Kaplan-Meier survival analysis was used to estimate the probabilities of surgical and functional successes. Cox proportional hazards regression using sandwich clustered estimation was used to evaluate risk factors for failure and poor visual outcome.

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of patients who demonstrated complete success over the 20-year follow-up. Secondary outcome measures included rate of surgical failure and need for reoperation for glaucoma, visual acuity, refractive errors, risk factors for poor outcome, and complications.

RESULTS

Kaplan-Meier survival analysis revealed 1-year, 10-year, and 20-year complete success rates of 90.7%, 78.9%, and 44.5%, respectively. In univariate analysis, surgical failure was higher among patients with any additional non-glaucoma intraocular surgery. None of the clinical parameters were associated significantly with failure in multivariable analysis. Overall, the proportion of eyes with good, fair, and poor visual outcomes was 33.2%, 16.4%, and 50.4%, respectively. Myopia was seen in 68.9% eyes. Twenty-eight eyes of those who underwent primary CTT (14.4%) required second surgery for IOP control. No significant intraoperative complications occurred. Six eyes required enucleation because of painful blind eye.

CONCLUSIONS

In this large cohort of patients with PCG, CTT is a useful procedure. It provides good IOP control and moderate visual recovery that remained over a 20-year follow-up after surgery.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Association of Neighborhood Environment with the Outcomes of Childhood Glaucoma

PURPOSE

To determine the association between different neighborhood environment factors and the outcomes of childhood glaucoma.

DESIGN

A retrospective cohort.

PARTICIPANTS

Childhood glaucoma patients ≤ 18 years of age at the time of diagnosis.

METHODS

A retrospective chart review of childhood glaucoma patients who presented to Boston Children's Hospital between 2014 and 2019. Data collected included etiology, intraocular pressure (IOP), management, and visual outcomes. Child Opportunity Index (COI) was used as a metric of neighborhood quality.

MAIN OUTCOMES MEASURES

The association of visual acuity (VA) and IOP with COI scores using linear mixed-effect models, adjusting for individual demographics.

RESULTS

A total of 221 eyes (149 patients) were included. Of these, 54.36% were male and 56.4% were non-Hispanic Whites. The median age at the time of presentation was 5 months for primary glaucoma and 5 years for secondary glaucoma. The median age at the last follow-up was 6 and 13 years for primary and secondary glaucoma, respectively. A chi-square test revealed that the COI, health and environment, social and economic, and education indexes between primary and secondary glaucoma patients were comparable. For primary glaucoma, the overall COI and a higher education index were associated with a lower final IOP (P < 0.05), and higher education index was associated with a lower number of glaucoma medications at the last follow-up (P < 0.05). For secondary glaucoma, higher overall COI, health and environment, social and economic, and education indices were associated with better final VA (lower logarithms of the minimum angle of resolution VA) (P < 0.001).

CONCLUSIONS

Neighborhood environment quality is a potentially important variable for predicting outcomes in childhood glaucoma. Lower COI scores were associated with worse outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Visco-Circumferential-Suture-Trabeculotomy Versus Rigid-Probe Viscotrabeculotomy in Neonatal-Onset Primary Congenital Glaucoma

PRCIS

Angle procedures are safe and relatively effective for neonatal onset PCG. Watchful delay in intervention to close to the second month of life is helpful in ensuring diagnosis and making surgery more successful and easier.

PURPOSE

The purpose of this study was to compare the surgical outcomes of visco-circumferential-suture-trabeculotomy (VCST) to rigid-probe double-entry viscotrabeculotomy (DEVT) and rigid-probe single-entry viscotrabeculotomy (SEVT) in infants with neonatal-onset primary congenital glaucoma (PCG).

DESIGN

This was a retrospective chart review.

PATIENTS AND METHODS

Retrospective chart review of 64 eyes of 64 infants with neonatal-onset PCG referred to Mansoura Ophthalmic Center in Mansoura, Egypt between February 2008 and November 2018. Study groups included VCST, DEVT, and SEVT, and follow-up covered 4 postoperative years. Complete (qualified) success was defined as intraocular pressure (IOP) ≤18 mm Hg and with 35% IOP reduction from baseline without (with) IOP-lowering medications or further surgical interventions, and without any sign of progression in corneal diameter, axial length, or optic disc cupping and without visual devastating complications.

RESULTS

The mean±SD age at presentation and at the surgery of the study children was 3.63±1.74 and 55.23±1.60 days, respectively. The mean±SD IOP and cup/disc ratio of all study eyes at presentation and at final follow-up were 34.91±0.82 mm Hg and 0.70±0.09 and 17.04±0.74 mm Hg and 0.63±0.08, respectively. Complete success was achieved in 54.5%, 43.5%, and 31.6% in the VCST, DEVT, and SEVT groups, respectively. A self-limited hyphema was the commonest complication in all groups.

CONCLUSIONS

Angle procedures are safe and marginally effective for the surgical treatment of neonatal-onset PCG, bringing IOP under control for at least 4 years of follow-up. Circumferential trabeculotomy as a first-line treatment has more favorable outcomes than rigid-probe SEVT. Rigid-probe viscotrabeculotomy offers an alternative to the noncompleted circumferential procedure.

Outcomes of Penetrating Canaloplasty in Childhood Glaucoma

PRCIS

Penetrating canaloplasty was safe and effective for the management of refractory childhood glaucoma.

PURPOSE

The purpose of this paper is to report the safety and efficacy of penetrating canaloplasty for the management of childhood glaucoma.

MATERIALS AND METHODS

This single-center prospective interventional case series enrolled 50 eyes of 32 patients with childhood glaucoma between July 2017 and July 2020. Penetrating canaloplasty to create direct communication between the anterior chamber and tensioning suture-dilated the Schlemm canal was performed through a trabecular meshwork ostium in the affected eyes. Preoperative and postoperative intraocular pressure (IOP), number of glaucoma medications, and procedure-related complications were recorded. Qualified and complete success was defined as IOP≥5 and ≤21 mm Hg with or without glaucoma medications, respectively.

RESULTS

A total of 43 eyes (86.0%) achieved 360 degrees catheterization of Schlemm canal and completed penetrating canaloplasty. The median age at surgery was 5 years (range, 10 d-17 y, mean 6.20±5.46 y). The mean IOP decreased from 33.11±10.89 mm Hg on 2 medications (median, range: 0-5) before surgery to 13.46±4.71 mm Hg on 0 medications (median, range:0-2) postoperatively at 12 months ( P <0.001). Complete and qualified success rates were 81.08% and 89.19%, respectively, at the 12-month follow-up. Hyphema (6/43, 13.95%) and a transient shallow anterior chamber with hypotony (5/43, 11.63%) were the most commonly observed early complications.

CONCLUSION

Penetrating canaloplasty demonstrated good safety and efficacy in eyes with childhood glaucoma, and may be considered an option for managing refractory childhood glaucoma.

Long-term success after trabeculotomy in primary congenital glaucoma - a study with up to 35 years follow-up

PURPOSE

To evaluate the surgical success after trabeculotomy for primary congenital glaucoma (PCG) in Denmark in the last 40 years.

METHODS

Retrospective review of medical files on children who all underwent trabeculotomy as the first surgical intervention between January 1rst, 1977 and December 31, 2016. Information on diagnosis and surgical procedures were extracted. Primary outcome was surgical success was defined as intraocular pressure (IOP) < 21 mmHg without medications one year after surgery. Secondary outcome was the number of reoperations needed.

RESULTS

Out of 118 children with PCG, 96 children (144 eyes) had an ab externo trabeculotomy as primary IOP lowering procedure opening Schlemm's channel 4 clock hours into the anterior chamber. Complete surgical success at one year was achieved in 73% (106 of 144 eyes). On the long term, IOP could be controlled by one surgical procedure in 2/3 of children, eight eyes required >5 surgical procedures to control IOP. In 12.1% of children the second glaucoma procedure was performed >5 years after the initial trabeculotomy. There was a tendency towards greater risk of needing a second procedure in patients < 3 months of age at primary trabeculotomy (hazard ratio, HR, 2.01, 95% CI 0.96-4.22) and in boys (HR 2.02, 95% CI 0.97-4.18) and a lower risk of requiring a third surgery if the second surgery was trabeculectomy with MMC.

CONCLUSION

Dedicated follow-up of patients with PCG is essential as the disease may continue to progress even after years of quiescence and some children need multiple surgeries to control IOP. Additional glaucoma procedures are required in 1/3 of children and boys and younger patients seem to be at greater risk.

Long-term structural and functional outcomes of primary congenital glaucoma

PURPOSE

To investigate the clinical characteristics and long-term outcomes of primary congenital glaucoma (PCG) patients.

METHODS

In this retrospective, longitudinal, cohort study, PCG patients with reliable visual field (VF) tests and optical coherence tomography (OCT) were included. Disease progression was detected using guided progression analysis with OCT and the change analysis of mean deviation (MD) slope with VF tests. Factors associated with the disease progression and visual prognosis were analyzed.

RESULTS

Twenty-nine eyes from 11 bilateral and 7 unilateral PCG patients were enrolled. LogMAR visual acuity declined (0.15 vs. 0.40, P < 0.001). The change rate of the average retinal nerve fiber layer thickness was - 0.83 ± 1.45 µm/year, and 28% of eyes showed glaucoma progression on OCT. The median of the MD slope was 0.16 (- 1.19 to 1.07) dB/year, and 14% of eyes showed glaucoma progression on the VF test. Higher average intraocular pressure (IOP) (P = 0.046) and IOP fluctuation (P = 0.031) predicted disease progression. None of the fellow eyes of unilateral PCG patients developed glaucoma during the follow-up. At last, 59% of eyes had visual acuity > 20/70, and 31% had MD >  - 6 dB. Patients with worse baseline visual acuity (P = 0.027), worse baseline MD (P < 0.001), and smaller neuroretinal rim area (P < 0.001) showed worse final MD values.

CONCLUSIONS

Aggressive IOP control is necessary to prevent structural and functional decline in PCG patients. Their fellow eyes are not at risk of glaucoma. Baseline neuroretinal rim area can predict the functional outcome.

Retrospective evaluation of two-year results with a filtering trabeculotomy in comparison to conventional trabeculectomy by exact matching

Background: To compare two-year results of a filtering trabeculotomy (FTO) to conventional trabeculectomy (TE) in open-angle glaucoma by exact matching.

Methods: 110 patients received an FTO and 86 a TE. FTO avoided the need for an iridectomy due to a preserved trabeculo-descemet window anterior to the scleral flap. TE employed a trabecular block excision and iridectomy. Mitomycin C was used in both. FTO and TE were exact matched by baseline intraocular pressure (IOP) and the number of glaucoma medications. Complete and qualified success (IOP ≤18 mmHg and IOP reduction ≥ 30%, with or without medication) were primary endpoints. IOP, visual acuity (BCVA), complications and intervention were secondary endpoints.

Results: 44 FTO were exact matched to 44 TE. The IOP baseline in both groups was 22.5±4.7 mmHg on 3±0.9 medications. At 24 months, complete success was reached by 59% in FTO and 66% in TE, and qualified success by 59% in FTO and 71% in TE. In FTO, IOP was reduced to 12.4±4.3 mmHg at 12 months and 13.1±4.1 mmHg at 24 months. In TE, IOP was 11.3±2.2 mmHg at 12 months and 12.0±3.5 mmHg at 24 months. Medications could be reduced at 24 months to 0.6±1.3 in FTO and 0.2±0.5 in TE. There were no significant differences between the two groups in IOP, medications, complications or interventions at any point.

Conclusion: Modifying aqueous flow through a limited trabeculotomy in FTO yielded clinical outcomes similar to traditional TE but allowed to avoid an iridectomy.

The Long-term Visual Outcomes of Primary Congenital Glaucoma

Purpose

To evaluate the long-term visual outcomes of ab externo trabeculotomy for primary congenital glaucoma (PCG) at a single pediatric ophthalmology center.

Methods

In this retrospective single-center case series, data from 63 eyes of 40 patients who underwent ab externo trabeculotomy between September 2006 and June 2018 were included. The data were analyzed for best corrected visual acuity (BCVA), stereopsis, and surgical success. Kaplan–Meier analysis was performed using the surgical success criteria defined as intraocular pressure (IOP) ≤ 21 mmHg and ≥ 20% below baseline without the need for additional glaucoma surgery.

Results

BCVA at the time of diagnosis was 0.37 ± 0.48 logMAR, which changed to 0.51 ± 0.56 logMAR at the final follow-up (P = 0.08). Twenty-five percent of patients had BCVA equal to or better than 20/40 at the final visit. The mean refraction at baseline was –4.78 ± 5.87 diopters, which changed to less myopic refraction of –2.90 ± 3.83 diopters at the final visit. Optical correction was prescribed in 66% of eyes at the final visit. The average final stereopsis was 395.33 sec of arc. The linear regression model showed a significant association between the surgery success rate and final BCVA as well as stereoacuity (P-values: 0.04 and 0.03, respectively). Intraocular pressure (IOP) decreased significantly from 29.79 ± 7.67 mmHg at baseline to 16.13 ± 3.41 mmHg at the final follow-up (P = 0.001).

Conclusion

Patients with PCG can achieve an acceptable visual acuity and stereoacuity, particularly in cases of timely intervention and close follow-up.

Organogenesis and distribution of the ocular lymphatic vessels in the anterior eye

Glaucoma surgeries, such as trabeculectomy, are performed to lower intraocular pressure to reduce risk of vision loss. These surgeries create a new passage in the eye that reroutes the aqueous humor outflow to the subconjunctival space, where the fluid is presumably absorbed by the conjunctival lymphatics. Here, we characterized the development and function of the ocular lymphatics using transgenic lymphatic reporter mice and rats. We found that the limbal and conjunctival lymphatic networks are progressively formed from a primary lymphatic vessel that grows from the nasal-side medial canthus region at birth. This primary lymphatic vessel immediately branches out, invades the limbus and conjunctiva, and bidirectionally encircles the cornea. As a result, the distribution of the ocular lymphatics is significantly polarized toward the nasal side, and the limbal lymphatics are directly connected to the conjunctival lymphatics. New lymphatic sprouts are produced mainly from the nasal-side limbal lymphatics, posing the nasal side of the eye as more responsive to fluid drainage and inflammatory stimuli. Consistent with this polarized distribution of the ocular lymphatics, a higher drainage efficiency was observed in the nasal side than the temporal side of the eye when injected with a fluorescent tracer. In contrast, blood vessels are evenly distributed at the anterior surface of the eyes. Also, we found that these distinct vascular distribution patterns were conserved in human eyes. Together, our study demonstrated that the ocular surface lymphatics are more densely present in the nasal side and uncovered the potential clinical benefits in selecting the nasal side as a glaucoma surgery site to improve fluid drainage.

Non-Penetrating Deep Sclerectomy versus Trabeculectomy in Primary Congenital Glaucoma

PURPOSE

To evaluate the safety and efficacy of non-penetrating deep sclerectomy with a collagen implant versus trabeculectomy in primary congenital glaucoma.

SUBJECTS AND METHODS

This was a retrospective interventional comparative non-randomized clinical study that included 80 eyes of 80 children presenting with primary congenital glaucoma under the age of 3 years. Forty eyes have undergone non-penetrating deep sclerectomy (NPDS) and the other 40 eyes have undergone penetrating trabeculectomy. The main outcome measure was the reduction in intraocular pressure (IOP). Secondary outcomes included percentage of patients with complete and qualified success, need for topical antiglaucoma medications, rate of complications, and need for further interventions. Complete success of the surgical outcome was considered an IOP ≤16 mmHg with no antiglaucoma medications. Qualified success was considered an IOP ≤16 mmHg using antiglaucoma medications.

RESULTS

The mean preoperative IOP was 27.4 ± 6.9 and 28.5 ± 6.6 mmHg in NPDS and trabeculectomy groups, respectively (p = 0.175). At the end of the follow-up period, the mean IOP was 11.2 ± 4.5 and 11.1 ± 3.4 mmHg with a mean reduction of 16.2 and 17.4 mmHg in NPDS and trabeculectomy groups, respectively. At the end of the follow-up period, ie at 36 months postoperative, the complete success rate was 60% (24 eyes) versus 57.5% (23 eyes), the qualified success rate was 25% (10 eyes) versus 25% (10 eyes), the overall success rate was 85% (34 eyes) versus 82.5% (33 eyes), and the rate of failure was 15% (6 eyes) versus 17.5% (7 eyes) in NPDS and trabeculectomy groups, respectively (p = 0.952). Eight cases (20%) of the trabeculectomy group had shallow anterior chamber. None of the NPDS group cases suffered from shallow anterior chamber.

CONCLUSION

Non-penetrating deep sclerectomy appears to be an efficient and safe surgical alternative to penetrating trabeculectomy in treatment of primary congenital glaucoma. Non-penetrating deep sclerectomy has fewer postoperative complications in comparison to penetrating trabeculectomy with a comparative postoperative reduction in the intraocular pressure and overall success rates.

TRIAL REGISTRATION

The trial was registered on 11/01/2020 with number PACTR202002874953456 (https://pactr.samrc.ac.za).