Long-Term Outcomes of Trabeculectomy Augmented with Mitomycin C Undertaken within the First 2 Years of Life

Microcatheter-Assisted Circumferential Trabeculotomy After Failed Glaucoma Surgeries in Childhood Glaucoma

PURPOSE

To evaluate the outcomes of microcatheter-assisted trabeculotomy (MAT) in childhood glaucoma (primary congenital glaucoma [PCG], juvenile open-angle glaucoma [JOAG], and secondary childhood glaucoma [SCG]) after failed glaucoma surgery.

DESIGN

Retrospective interventional case series.

METHODS

Patients with childhood glaucoma who underwent MAT after failed glaucoma surgery with at least 12 months of follow-up were evaluated. Pre- and postoperative intraocular pressure (IOP) and the number of glaucoma medications were recorded and compared. Success was defined as an IOP ≤21 mm Hg with or without glaucoma medication. Analysis of variance was used to compare the glaucoma subgroups.

RESULTS

Forty-five eyes (42 patients) with a median follow-up period of 19 months were included. The median age at the time of MAT was 10 (range, 0.8-33) years. The mean number of previous surgeries was 1.3 ± 0.5. The IOP had significantly reduced from baseline in all PCG, JOAG, and SCG patients (27.9 ± 4.5 vs 16.3 ± 8.0 mm Hg, P = .001; and 30.8 ± 9.4 vs 13.5 ± 3.0 mm Hg, P < .001; and 31.5 ± 7.1 vs 16.5 ± 5.3 mm Hg, P = .001, respectively). Fewer glaucoma medications were needed after MAT in all 3 groups (each P < .001). At the last visit, the total success rates in PCG, JOAG, and SCG were 93.8%, 100%, and 88.9%, respectively. No severe complications were observed.

CONCLUSION

MAT can effectively manage PCG, JOAG, and SCG after failed surgeries, providing successful outcomes and no serious complications. Following failed glaucoma surgeries, MAT may offer these patients with childhood glaucoma an excellent opportunity to achieve IOP control.

Controversies in Pediatric Angle Surgery and Secondary Surgical Treatment

Pediatric glaucoma is a constellation of challenging ophthalmic conditions that, left untreated, can result in irreversible vision loss. The mainstay of treatment for primary congenital glaucoma and select secondary glaucoma subtypes is angle surgery, either trabeculotomy or goniotomy. More recently, MIGS devices have been utilized to enhance the efficacy of these procedures. Despite the high success rates of these primary surgical options, refractory cases are challenging to manage. There is no consensus on the next step of treatment following primary angle surgery. Glaucoma drainage devices and trabeculectomies have been the traditional options, with laser treatment reserved for more severe cases. The benefits and disadvantages of each of these options are discussed.

Pediatric Glaucoma-From Screening, Early Detection to Management

Pediatric glaucoma (PG) covers a rare and heterogeneous group of diseases with variable causes and presentations. Delayed diagnosis of PG could lead to blindness, bringing emotional and psychological burdens to patients' caregivers. Recent genetic studies identified novel causative genes, which may provide new insight into the etiology of PG. More effective screening strategies could be beneficial for timely diagnosis and treatment. New findings on clinical characteristics and the latest examination instruments have provided additional evidence for diagnosing PG. In addition to IOP-lowering therapy, managing concomitant amblyopia and other associated ocular pathologies is essential to achieve a better visual outcome. Surgical treatment is usually required although medication is often used before surgery. These include angle surgeries, filtering surgeries, minimally invasive glaucoma surgeries, cyclophotocoagulation, and deep sclerectomy. Several advanced surgical therapies have been developed to increase success rates and decrease postoperative complications. Here, we review the classification and diagnosis, etiology, screening, clinical characteristics, examinations, and management of PG.

Success Rate of Augmented Trabeculectomy in Primary Congenital Glaucoma

PURPOSE

To evaluate the outcome of trabeculectomy augmented with mitomycin C in primary congenital glaucoma and to document the complications of the procedure in young children.

METHODS

This was a prospective study of children younger than 2 years with primary congenital glaucoma who were treated with primary trabeculectomy with mitomycin C. After surgery, patients were observed for a minimum of 1 year. Trabeculectomy success was defined as an intraocular pressure (IOP) of 21 mm Hg or less without (absolute success) or with (qualified success) topical antiglaucoma medications. Surgical success was assessed at 1, 6, and 12 months after the procedure.

RESULTS

Seventy-four eyes of 42 children were included in the current study. The mean age was 11.7 ± 8.5 months. Of the 42 children, 57.2% were male and 42.8% were female. The mean IOP after surgery was significantly lower than the preoperative IOP (P < .0001). Absolute success was observed in 98.6%, 50%, and 27% of eyes at 1, 6, and 12 months, respectively. Qualified success was achieved in 1.4%, 36.5%, and 48.6% of eyes at 1, 6, and 12 months, respectively. Overall success of the procedure was 100% at 1 month but reduced to 86.5% at 6 months and 75.7% at 12 months. In 24.3% of eyes, IOP was not controlled even with adjunctive topical glaucoma medications and was considered a failure. Postoperative complications were shallow anterior chamber (10.8%), collapsed anterior chamber (1.3%), and choroidal detachment (12.0%). Complications were managed conservatively, and 6 eyes needed surgical intervention.

CONCLUSIONS

Augmented trabeculectomy is a useful primary procedure in children with primary congenital glaucoma. Topical glaucoma medications supplement the success of the procedure. [J Pediatr Ophthalmol Strabismus. 2022;59(3):180-186.].

Trabeculotomy Versus Combined Trabeculotomy-Trabeculectomy for Management of Primary Congenital Glaucoma

PRCIS

Trabeculotomy (T) alone is as safe and effective as combined trabeculotomy-trabeculectomy (TT) in patients with primary congenital glaucoma (PCG) and requires significantly fewer examinations under anesthesia in the postoperative period.

PURPOSE

The purpose of this study was to compare the outcomes of T and combined TT as the initial surgical procedure for patients with PCG.

METHODS

In this retrospective study, medical records of patients who had undergone T or TT as the initial procedure for PCG were reviewed. The primary outcome measure was a surgical success, defined as 5≤ intraocular pressure (IOP) ≤21 mm Hg, IOP reduction of at least 20% with no need for further glaucoma surgery. Secondary outcome measures were the number of glaucoma medications and complications.

RESULTS

A total of 134 eyes from 134 patients with a mean follow-up of 8±6.6 years were included consisting of 106 and 28 eyes, which had undergone T and TT, respectively. Success rates were comparable with both surgical procedures at 1, 2, 3, 4, and 5 years with no statistically significant difference. IOP was significantly decreased from 27.5±4.2 mm Hg preoperatively to 15.62±3.4 mm Hg at the 5-year follow-up visit in the T group and from 25.3±6.5 to 17.1±3.2 mm Hg in the TT group (P=0.1) there was no significant difference between the 2 groups in the number of glaucoma medications (P=0.2). Patients in the T group required significantly fewer examinations under anesthesia than the TT group (7.3±4.4 vs. 10.1±3.9, P=0.04).

CONCLUSION

Trabeculotomy alone seems as effective as combined trabeculotomy-trabeculectomy and may significantly reduce exposure to anesthesia in primary congenital glaucoma patients.

Minimally invasive glaucoma surgery in childhood glaucoma

PURPOSE OF REVIEW

Minimally invasive glaucoma surgery (MIGS) has been shown to be safe and effective in treatment of mild to moderate glaucoma in adults, but reports in childhood glaucoma are limited. We review the available data concerning MIGS and discuss its potential role in childhood glaucoma management.

RECENT FINDINGS

Ab interno counterparts to circumferential ab externo trabeculotomy such as gonioscopy-assisted transluminal trabeculotomy (GATT) and Trab360 show promise in treatment of primary glaucomas as reported in a few retrospective case series. Kahook Dual Blade (KDB) and Trabectome have demonstrated mixed results in few published case reports in children. Small case series and reports suggest that the Xen gel stent can be a safer alternative to traditional filtration surgery, though data on long-term implant and bleb stability are unavailable. Newer devices are being investigated and early results are encouraging.

SUMMARY

GATT and Trab360 seem to be safe, effective methods of achieving circumferential trabeculotomy in childhood glaucoma. KDB, Trabectome, and Xen gel stent have shown some success in selected cases with short-term follow-up. Surgeons must determine the risks and benefits of MIGS over more established methods of intraocular pressure reduction for each individual child. Further research is needed to validate initial findings regarding MIGS in childhood glaucoma.

Primary congenital glaucoma surgery: outcomes and visual function

Purpose

To assess the long-term visual outcomes of children with PCG, irrespective of the type of surgical procedure, and to create visual acuity curves to help in predicting the development of visual function in these patients. The secondary aim is to identify associated factors for visual decline or loss, highlighting differences between neonatal and infantile subgroups.

Methods

The medical records of pediatric glaucoma patients from 1996 to 2017 at the University Hospital of Verona (Verona, Italy) were retrospectively reviewed. Visual acuities, surgeries, PCG subtype and etiology of vision impairment were recorded. Statistical analyses were performed to detect factors associated with vision decline.

Results

Sixty-seven eyes (40 patients) were included in the study. Developmental predictive curves of visual acuity showed that children with infantile PCG had a better visual outcome than children with neonatal PCG at each step of follow-up. A good-to-moderate VA (< 1 LogMAR) was achieved in 56 eyes (83.6%), while 11 eyes (16.4%) had poor VA (≥ 1 LogMAR). The age at onset, sex, number of surgeries, intraocular pressure (IOP) control (with or without antiglaucoma drugs), axial length (AL) and corneal opacities were statistically associated with vision impairment (p < 0.01). The main cause of visual impairment was amblyopia.

Conclusions

Visual outcomes of PCG significantly correlate with the age at diagnosis. Although a good long-term IOP control can often be achieved in PCG, often the visual acuity remains below the lower limits of the normal range. Poor vision in childhood is related to global developmental problems, and referral to third-level services should not be delayed to prevent vision impairment. In this regard, visual acuity curves can be a useful tool for the consultant ophthalmologist to define the visual development of children affected by PCG.

Failure of XEN Gel Stent Implantation as a Stand-Alone Procedure in Congenital Glaucoma: Case Report of Secondary Congenital Glaucoma in Neurofibromatosis Type 1

A XEN gel stent implant procedure was performed in a one-year-old child with severe unilateral congenital glaucoma. At the age of 6 weeks, an uncomplicated 360° trabeculotomy had been performed, which resulted in intraocular pressure (IOP) control for only 4 months. The gel stent implantation was performed ab interno without complications. However, 1 month later, the stent was repelled into the anterior chamber due to the elasticity of Tenon's layer. A first revision surgery was performed, with excision of Tenon's layer and implantation of a new gel stent under sight. At the age of 18 months, a second revision surgery was performed because of an encapsulated Tenon cyst with insufficient IOP control, again with the implantation of a new stent. At that time, a progressive upper eyelid swelling was apparent. Eyelid biopsy led to the diagnosis of neurofibromatosis type 1, presenting with an orbital plexiform neurofibroma. Further insufficient IOP control resulted in a cyclodestructive procedure and loss of light perception during follow-up. XEN gel stent implantation in congenital glaucoma in infants is more challenging than that in adult patients. Gel stent implantation ab interno may be difficult due to the thickness and elasticity of Tenon's layer. Gel stent dislocation may occur, even months after surgery. Trabeculectomy might be a better approach after failed trabeculotomy in congenital glaucoma. An underlying systemic disease might become apparent late during follow-up.

Long-term Results of Ahmed Valve Implantation With Mitomycin-C in Pediatric Glaucoma

PRECIS

Mitomycin was used with Ahmed valve implantation in 81 eyes of 63 children. After 5 years, probability of intraocular pressure (IOP) control without glaucoma medication was 35±6%; 57% achieved IOP control with topical medications after 10 years.

PURPOSE

The purpose of this study was to determine the long-term outcomes of Ahmed glaucoma valve (AGV) implantation with intraoperative application of mitomycin-C (MMC) for the treatment of childhood glaucoma.

METHODS

Retrospective review of children undergoing AGV implantation with subtenon application of MMC between 2000 and 2019. We defined surgical success as a final IOP of 5 to 21 mm Hg with no glaucoma medication, no subsequent glaucoma surgery, and no severe complication. Qualified success was defined if the above criteria were met with topical antiglaucoma medication.

RESULTS

Eighty-one eyes of 63 patients were included. The probability of complete success was 72±5% (63% to 83%) at 1 year, 58±6% (48% to 70%) at 2 years, and 35±6% (25% to 48%) at 5 years. The probability of qualified success was 92±3% (87% to 98%) at 1 year, 79±5% (70% to 89%) at 5 years, 57±7% (44% to 73%) at 10 years, and 39±9% (24% to 62%) at 14 years. The IOP was reduced by an average of 10.7±9 mm Hg from preoperative visit to the last follow-up, and the number of medications decreased from 3.0±1.4 to 1.5±1.4 after implantation.

CONCLUSIONS

A significant proportion of patients achieved long-term IOP control without glaucoma medication. The majority achieved IOP control with additional topical antiglaucoma medications. When compared with existing AGV implantation in childhood literature, the use of MMC appears to lengthen the drop-free (complete success) duration, as well as the long-term IOP control with topical medications.

Long-term Efficacy of Mitomycin C Augmented Trabeculectomy in a Mixed Pediatric Glaucoma Cohort

PRECIS

This paper reports a retrospective consecutive case series investigating the efficacy of Mitomycin C-augmented trabeculectomy in the treatment of primary and secondary pediatric glaucoma in a mixed etiology, multiethnic cohort of patients.

PURPOSE

To evaluate the long-term efficacy and safety of Mitomycin C-augmented trabeculectomy in a mixed, tertiary-referral, pediatric glaucoma cohort.

METHODS

Retrospective consecutive review of all children (37 eyes) undergoing Mitomycin C-augmented trabeculectomy by a single surgeon between 2008 and 2016. Seventeen eyes (45.9%) had primary congenital glaucoma, and 20 eyes (54.1%) had secondary glaucoma. The median age at surgery was 11 months (range, 2 to 146). The mean follow-up was 69.2±4.7 months (range, 3.5 to 107.9).

RESULTS

Overall, trabeculectomy was successful in 80.6% of eyes at 12 months, 60.5% at 3 years, and 57.5% at 5 years. 45.9% cases (17 eyes) required further laser or surgery for uncontrolled intraocular pressure (IOP) and were therefore deemed as failures. The time to failure ranged from 0.4 to 65.1 months (mean, 22.2±5.1 mo). The proportion of children achieving visual acuity of 1.0 LogMAR equivalent or better increased from 43.2% preoperatively to 63.6% at 1 year and 68% at 5 years. The mean IOP reduced from 24.85±0.88 mm Hg preoperatively to 15.14±0.94 mm Hg at 3 months (39% reduction) and 17.42±1.08 mm Hg at 5 years (30% reduction). IOP-lowering medication requirement reduced from 4.14±0.20 agents preoperatively to 0.84±0.22 at 3 months (80% reduction) and 1.78±0.36 at 5 years (57% reduction). There were no sight-threatening complications such as hyphaema, bleb leak, chronic hypotony, endophthalmitis, retinal detachment, or loss of light perception.

CONCLUSIONS

This study provides valuable evidence that Mitomycin C-augmented trabeculectomy is safe and effective as a treatment of primary or secondary pediatric glaucoma, with particularly encouraging results in cases of secondary glaucoma. Trabeculectomy offers the potential for delaying or avoiding glaucoma drainage device surgery in a significant proportion of children.

A Service Coverage Analysis of Primary Congenital Glaucoma Care Across the United States

PURPOSE

To assess the number of infants at risk of delayed primary congenital glaucoma (PCG) evaluation due to long travel times to specialists.

DESIGN

Cross-sectional geospatial service coverage analysis.

METHODS

All American Glaucoma Society (AGS) and American Association for Pediatric Ophthalmology and Strabismus (AAPOS) provider locations were geocoded using each organization's member directory. Sixty-minute drive time regions to providers were generated using ArcGIS Pro (Esri). The geographic intersection of AGS and AAPOS service areas was computed because patients typically require visits to both types of specialists. American Community Survey data were then overlaid to estimate the number of infants within and beyond the AGS/AAPOS service areas.

RESULTS

One thousand twenty-nine AGS and 1,040 AAPOS provider locations were geocoded. The analysis yielded 944,047 infants age 0-1 year (23.6%) who live beyond the AGS/AAPOS service areas. Therefore, approximately 14-94 new PCG cases/year may be at risk of delayed diagnosis as a result of living in a potential service desert. Compared with children living within the AGS/AAPOS service areas, children aged <6 years in these potential service deserts were more likely to live in households earning below the US federal poverty level, lack health insurance, and live in a single-parent home. These communities are disproportionately likely to experience other rural health disparities and are more prevalent across the Great Plains.

CONCLUSION

Service coverage analysis is a useful tool for identifying underserved regions for PCG referrals and evaluation. These data may assist in targeting screening programs in low access areas for pediatric glaucoma care.

From Conventional Angle Surgery to 360-Degree Trabeculotomy in Pediatric Glaucoma

PURPOSE

To describe the transition from conventional angle surgery (CAS), trabeculotomy with rigid probe or goniotomy, to 360-degree trabeculotomy assisted with microcatheter (MCT).

DESIGN

Retrospective comparative interventional case series.

METHODS

Review of consecutive children with glaucoma undergoing angle surgery, including cases with previous surgery, from January 2012 until March 2018 at Moorfields Eye Hospital. Main outcome measure was success rate, defined as intraocular pressure (IOP) ≤21 mm Hg with a minimum of 20% of IOP reduction and no further glaucoma surgery (complete success: without the need of glaucoma drops; qualified success: drops were needed to keep the IOP under control).

RESULTS

Among the 106 eyes (77 patients) included were 54 MCT and 52 CAS eyes. At last visit, after a single surgery, qualified success was 85% (46 eyes) in MCT and 37% (19 eyes) in CAS. Complete success was 69% (37 cases) in MCT and 23% (12 cases) in CAS. The mean (95% confidence interval) change in axial length after surgery was -0.03 mm (-0.34 to 0.40) for MCT and +1.35 mm (-0.64 to 1.62) for CAS (P < .001). The percentage of IOP reduction was 52.1% in MCT and 45.5% in CAS (P = .1616). Further glaucoma surgery was required in 5.5% (3) in MCT and 63.4% (33) in CAS. At 1 year, 94.3% of MCT cases achieved qualified success compared to 34.6% of CAS (P < .0001). No significant complications were found on either group.

CONCLUSION

MCT achieved better results with significantly lower reoperation rates. The transition from CAS to MCT can be easily achieved, even in difficult cases or those previously operated.

XEN Gel Stent in Pediatric Glaucoma

PURPOSE

To report a series of 3 eyes of 3 children with congenital glaucoma receiving the XEN gel stent implant.

PATIENTS AND METHODS

An interventional case series is reported.

RESULTS

Three eyes underwent implantation of the gel stent. In 2 cases, the gel implant procedure was performed after failed trabeculotomy, while in the third eye, primary gel stent implantation was performed. One eye received 2 implants. Three procedures were performed via an ab interno approach while the fourth was performed ab externo. No device-related complications were observed. In all 3 eyes, intraocular pressure was controlled without the use of topical medications through 6 to 24 months of follow-up.

CONCLUSIONS

The gel stent implant can be safely used in children with congenital glaucoma and effectively lowers intraocular pressure in these eyes. This procedure is a viable follow-up to, or replacement for, traditional angle surgery in eyes with congenital glaucoma.

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.

Risk Factors for Glaucoma Drainage Device Failure and Complication in the Pediatric Population

PURPOSE

Report factors associated with failure and complication in a cohort of children who have undergone glaucoma drainage device (GDD) implantation.

DESIGN

Retrospective case series.

PARTICIPANTS

Consecutive pediatric GDD eyes that met criteria between May 1997 and July 2019.

METHODS

Entries were included for analysis if age <18 years at the time of GDD implantation. Failure was defined as an intraocular pressure (IOP) greater than 21 mmHg or IOP reduction <20% or IOP <5 mmHg at 2 consecutive follow-up visits >3 months after implantation, reoperation for glaucoma, or loss of light perception vision. Complications were defined as postoperative events due to the GDD that required additional examination under anesthesia or additional surgery.

MAIN OUTCOME MEASURES

Survival analyses of surgical failures and complications.

RESULTS

Over a mean follow-up period of 5.4 years, 58 (38%) of 150 first-time GDD implants failed. Glaucoma associated with acquired conditions had decreased risk for failure when compared with glaucoma secondary to nonacquired systemic diseases (hazard ratio [HR], 12; P = 0.0063), nonacquired ocular anomalies (HR, 12; P = 0.0054), and primary congenital glaucoma (HR, 5.4; P = 0.041). There was an increased risk of failure for first-time tubes in younger patients with a 23% reduction of failure with each 3-year increase in age (HR, 0.77; P = 0.034). A total of 38 (25.3%) of the first-time GDD implantations had a complication. Higher preoperative IOP (5 mmHg increase; HR, 1.2; P = 0.038) and younger age (<3 years; HR, 2.1; P = 0.024; < 2 years, HR, 1.9; P = 0.046) increased the risk of complication. There were 22 second-time GDD implants in the study, of which 11 failed (50%), and increased risk for failure was associated with younger age at the time of implantation (<1 year; HR, 27; P = 0.0053) and concurrent glaucoma-related procedures with or without non-glaucoma anterior segment surgery at the time of implantation (HR, 13; P = 0.0085).

CONCLUSIONS

Although GDD implantation in children is relatively safe and effective, these data should be interpreted in the context of children's relative longevity. These findings offer an outcome metric to which future novel glaucoma procedures in children can be compared.

Contemporary management of refractory pediatric glaucoma

PURPOSE OF REVIEW

The management of pediatric glaucoma poses a unique challenge in terms of maintaining lifelong vision and combating an aggressive scarring response from surgery. Contemporary literature regarding the surgical management of children with pediatric glaucoma who fail, or are at a high risk of failure, from conventional surgery is limited. The aim of this review is to highlight recent developments in relation to the current opinion regarding the management of children with refractory pediatric glaucoma.

RECENT FINDINGS

Some studies have reported impressive success rates with circumferential trabeculotomy, even in eyes with previous failed surgery. Early results of deep sclerectomy in populations which may not respond well to conventional angle surgery are encouraging but data is limited for the pediatric age group. In compliant patients in whom multiple postoperative examinations under anesthesia are possible, trabeculectomy remains an effective procedure. Multiple recent studies have demonstrated that glaucoma drainage device (GDD) surgery is associated with 5-year success rates of over 70% in primary childhood glaucomas.

SUMMARY

Glaucoma drainage device surgery is likely to remain a mainstay of surgical management for refractory glaucoma in older children. More prospective data are needed on the success of circumferential trabeculotomy, deep sclerectomy and micropulse laser in pediatric eyes with previous failed surgery. VIDEO ABSTRACT: http://links.lww.com/COOP/A34.

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.

Paediatric endophthalmitis: a UK retrospective study

INTRODUCTION

Paediatric endophthalmitis is a severe but rare complication of intraocular surgery, penetrating trauma and far less commonly extra-ocular surgery or endogenous origin. We set out to establish the incidence and risk factors of exogenous endophthalmitis in children, and to develop an evidence-based protocol that can be used for treatment of suspected exogenous endophthalmitis in children.

METHODS

Microbiology reports and operation numbers were obtained from two large tertiary referral hospitals sharing 24-h paediatric ophthalmology cover for the period January 2009-December 2016. All cases of aqueous and/or vitreous tap performed on children aged ≤18 years were identified and case notes reviewed for complete information on each case.

RESULTS

Sixteen cases were eligible for inclusion as 'postoperative endophthalmitis': complete data was found on 13 cases. The incidence of postoperative endophthalmitis was 0.17% over 7 years. The mean age of presentation was 5.5 years (range from 7 months to 16 years and 9 months), from 3 days-78 months post operatively. In all, 11/13 had at least one glaucoma procedure. Microbiology results showed growth in 8/13. Most isolates were Gram-positive bacteria but Gram-negatives were also isolated and in one case Candida from a conjunctival swab. The antibiotic regime varied depending on age, organism identified and sensitivities. In all, 9/13 had hand movement or worse vision after treatment.

CONCLUSION

Paediatric endophthalmitis may present to any paediatric/general ophthalmologist. It is a rare but devastating condition with poor visual prognosis, requiring prompt recognition and aggressive management. Previous glaucoma surgery is a long-term risk factor in our local paediatric population. Based on our study, an evidence-based protocol for management is proposed in order to improve outcomes.

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

PURPOSE

To analyze the long-term results of ab externo trabeculotomy with a Harms trabeculotome at a single, tertiary care pediatric hospital.

METHODS

The medical records of pediatric patients operated on between September 2006 and June 2018 were reviewed retrospectively. Kaplan-Meier analysis was performed, with success defined as postoperative intraocular pressure (IOP) of ≤21 mm Hg, >20% reduction from preoperative IOP, and no need for further glaucoma surgery. Risk factors for failure were identified using Cox proportional hazards ratio.

RESULTS

A total of 63 eyes of 40 patients were included. The cumulative probability of success rate was 83% at 3 months, 76% at 6, 73% at 12, 72% at 18, and 65% at final visit. Presentation within 3 months of life was associated with a less favorable outcome. Thirty-five eyes (56%) underwent repeat trabeculotomy to treat a different area of the trabecular meshwork because of inadequately controlled IOP after the first session. Of those who needed another session of trabeculotomy, the final success rate was 60.2%. IOP significantly decreased from 29.79 ± 7.67 mm Hg at baseline to 16.13 ± 3.41 mm Hg by final follow-up (P = 0.001). Patients were followed for an average of 85.74 ± 32.95 months. IOP and success rates remained stable 18 months after surgery.

CONCLUSIONS

In our patient cohort, ab externo trabeculotomy was associated with good long-term results. More extensive trabeculotomy (ie, more than one procedure) was associated with better long-term success rates.

The prognosis of trabeculectomy in primary angle-closure glaucoma patients

AIM

To evaluate whether the level of thrombospondin-1 (TSP-1) in aqueous humor can predict the prognosis of trabeculectomy in patients with primary angle-closure glaucoma (PACG).

METHODS

This case-control study involved 26 patients with PACG who experienced a failed trabeculectomy (case group) and 78 age- and sex-matched patients with PACG who underwent successful trabeculectomy (control group). Aqueous humor was collected at the time of trabeculectomy and tested for TSP-1 and TGF-β2 levels with an enzyme-linked immunosorbent assay method. Logistic regression modeling was used to assess the risk factors for failed trabeculectomy.

RESULTS

The mean TSP-1 aqueous concentrations were significantly higher in the case group (20.67±9.79 ng/mL) than the control group (5.17±2.29 ng/mL) (P<0.001). The transforming growth factor-β2 (TGF-β2) aqueous concentrations were significantly different between the case and control group, at 3633.25 and 1090.24 pg/mL, respectively (P<0.001). Logistic regression analysis revealed TSP-1 level as an independent risk factor for a failed trabeculectomy (OR=3.540; 95%CI=1.092-11.482).

CONCLUSION

The aqueous humor TSP-1 and TGF-β2 levels are higher in PACG eyes with failed trabeculectomy than with successful trabeculectomy at one year. The aqueous humor TSP-1 level is an independent risk factor associated with failed trabeculectomy.

Mitomycin C in Filtering Surgery for Primary Congenital Glaucoma: A Comparison of Exposure Durations

PURPOSE

To compare the effect of two exposure durations of mitomycin C in combined angle and filtering surgery for primary congenital glaucoma.

METHODS

This was a prospective study conducted in the Department of Ophthalmology at Alexandria Main University Hospital, Alexandria, Egypt, on 75 eyes with primary congenital glaucoma that underwent combined trabeculotomy-trabeculectomy with intraoperative mitomycin C application for 1 minute (MMC 1) or 2 minutes (MMC 2) and were followed up for 24 months. Success rates were studied and complications noted. Success was defined by a composite primary end point of an intraocular pressure (IOP) of less than 16 mm Hg under general anesthesia, without any IOP-lowering medications and with no hypotony-related complications and/or lack of IOP-related progression of the disease as evidenced by worsening of the ocular biometric characteristics.

RESULTS

The mean age of the study participants was 6.7 ± 4.1 months (range: 2 to 16 months; median: 6 months) in the MMC 1 group (35 eyes) and 7.7 ± 5.7 months (range: 1 to 32 months; median: 6.5 months) in the MMC 2 group (40 eyes). The initial surgery was successful in 32 (91.5%) and 31 (77.5%) eyes in the MMC 1 and MMC 2 groups, respectively. The mean IOP was 18.4 ± 5.1 and 18.1 ± 6.1 mm Hg preoperatively and 5.5 ± 3.5 and 4.8 ± 2.8 mm Hg at the end of follow-up in the MMC 1 and MMC 2 groups, respectively. There was no statistically significant difference in the clinical parameters between the two groups. Complications included cataracts in each group and hypotony optic disc edema in 3 eyes (7.5%) in the MMC 2 group.

CONCLUSIONS

Both mitomycin C application durations were effective in combined trabeculotomy-trabeculectomy with mitomycin C for primary congenital glaucoma. The longer duration was not advantageous in disease control and there were no significant differences in complications. [J Pediatr Ophthalmol Strabismus. 2018;55(3):164-170.].

Outcome of trabeculectomy with Ologen versus Mitomycin C: A comparative prospective study in Bangladesh

AIMS:

To compare the efficacy and safety of trabeculectomy with Ologen versus Mitomycin C in primary glaucoma.

MATERIALS AND METHODS:

This is a prospective study of patients aged 18 years and above, diagnosed with primary glaucoma randomised to having trabeculectomy with Ologen or Mitomycin C. The primary outcome measure was success of trabeculectomy defined as intraocular pressure >5 mmHg but ≤21 mmHg. Complete success was defined as intraocular pressure achieved without anti-glaucoma medication and qualified success was defined as intraocular pressure achieved with additional anti-glaucoma medication.

RESULTS:

At the end of 12 months follow-up, the postoperative mean intraocular pressure in the Ologen group was 12.8 ± 1.6 mmHg and 13.4 ± 2.2 mmHg in the Mitomycin C group. The Ologen group achieved complete success in 86.5% and qualified success in 13.5% of the patients, while the Mitomycin C group achieved complete and qualified success in 85.5% and 14.5%, respectively. There was no statistically significant difference in the success rate of both the groups ( p = 0.57). Furthermore, no significant intraocular pressure difference was noted between the two groups at the end of 12 months follow-up ( p = 0.14).

CONCLUSION:

Trabeculectomy augmented with Ologen appeared to be as successful and safe as trabeculectomy augmented with Mitomycin C, with no reported adverse reaction to Ologen.

Retrospective observation on trabeculectomy of primary congenital glaucoma by applying biological amniotic membranes soaked with 5-fluorouracil

PURPOSE

To report our experience on treatment of primary congenital glaucoma with trabeculectomy in combination with biological amniotic membranes soaked with 5-fluorouracil.

METHODS

This is a retrospective study. Thirty primary congenital glaucoma (PCG) patients (41 eyes) were treated with trabeculectomy in combination with biological amniotic membranes soaked with 5-fluorouracil before operation and followed up for 2.75 ± 1.35 years in average ranging from 1.2 to 5.3 years (Group A). In addition, 22 PCG patients (32 eyes) treated with mitomycin C-trabeculectomy were selected as control and followed up for 2.3 ± 1.25 years in average ranging from 1.4 to 5.1 years (Group B).

RESULTS

Patients in Group A were 4.74 ± 2.13 years old. After treatment, their mean intraocular pressure decreased from preoperative 38.8 ± 11.3-17.6 ± 8.2 mmHg at 12 months of postoperation (P = 0.0000). At 12 months of follow-up, the intraocular pressure was less than 13 mmHg in 8 eyes (19.5%), between 17 and 13 mmHg in 15 eyes (36.6%), between 21 and 17 mmHg in 12 eyes (29.3%) and more than 21 mmHg in 6 eyes (14.6%). The overall success rate was 85.4%, and total complication rate was 17.1%. By comparison, the overall success rate and total complication rate were 87.5 and 34.4%, respectively, at 12 months of follow-up for patients in Group B. Although the overall success rate was not significantly different between Groups A and B (P = 0.1203) at the end of follow-up, the total complication rate was significantly decreased in Group A (P = 0.0419).

CONCLUSION

Application of trabeculectomy in combination with biological amniotic membranes soaked with 5-fluorouracil can be an effective surgical treatment method for primary congenital glaucoma patients.

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial

BACKGROUND

Capsular contracture represents the most frequent complication after implant-based breast reconstruction. An experimental study on mice demonstrated that capsule formation around breast implants is considerably diminished after topical application of mitomycin C. The authors conducted a randomized controlled clinical trial investigating the efficacy of mitomycin C in reducing capsular contracture rates following implant-based breast reconstruction after mastectomy for breast cancer.

METHODS

The authors randomized all women older than 18 years scheduled for the second stage of an implant-based breast reconstruction after mastectomy for breast cancer at the National Cancer Institute in Milan from October of 2005 to February of 2010 to receive or not receive the topical application of mitomycin C during surgery. The authors assessed capsular contracture, major postoperative complications, and aesthetic outcome.

RESULTS

The authors randomized 322 patients to receive mitomycin C or not at the second stage of implant-based breast reconstruction. One hundred sixty-two patients were allocated to the mitomycin C group and 160 patients were allocated to the control group. The relative risk of capsular contracture in the mitomycin C group was 0.92 (95 percent CI, 0.60 to 1.41). Major complications leading to reintervention, oncologic outcomes, and aesthetic outcomes were comparable between the two groups.

CONCLUSIONS

This is the first trial reporting data about the use of mitomycin C in breast reconstructive surgery in a clinical setting. Mitomycin C seems not to significantly affect capsular contracture rate and severity following implant-based reconstructive breast surgery at the tested doses.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Pediatric glaucoma: review of recent literature

PURPOSE OF REVIEW

The purpose of this review is to update the clinician on the recent work in the field of pediatric glaucoma.

RECENT FINDINGS

Using the iCare tonometer to measure intraocular pressure (IOP) in children is highly successful. New data from the Infant Aphakia Treatment Study show that after 5 years of follow-up the risk of developing glaucoma is similar between patients that receive initial intraocular lens implantation and those who are left aphakic. New data show effective lowering of IOP using either approach to trabeculotomy: treating the angle partially with trabeculotomes or circumferentially with a suture or iTrack microcatheter. Recent data on an updated approach to trabeculectomy in children show success in lowering IOP with few complications; however, visual outcomes continue to be suboptimal. A separate study shows that the addition of tenonectomy may not increase surgical success, but may increase survival time and reduce bleb encapsulation. Glaucoma drainage devices in general, and the Ahmed implant in particular, continue to be found to be moderately successful to control IOP, and are therefore employed, especially after initial angle surgery has failed.

SUMMARY

Continued work to evaluate the techniques used in the clinical and surgical management of pediatric glaucoma patients supports that both newer and older approaches remain standard of care.

Updates on the Surgical Management of Pediatric Glaucoma

Childhood glaucoma is known to be one of the most challenging conditions to manage. Surgical management is more complicated than in adults because of differences in anatomy from adults along with variations in anatomy caused by congenital and developmental anomalies, wide-ranging pathogenetic mechanisms, a more aggressive healing response, and a less predictable postoperative course. Challenges in postoperative examination and management in less cooperative children and the longer life expectancies preempting the need for future surgeries and reinterventions are also contributing factors. Angle surgery is usually the first-line treatment in the surgical management of primary congenital glaucoma because it has a relatively good success rate with a low complication rate. After failed angle surgery or in cases of secondary pediatric glaucoma, options such as trabeculectomy, glaucoma drainage devices, or cyclodestructive procedures can be considered, depending on several factors such as the type of glaucoma, age of the patient, and the severity and prognosis of the disease. Various combinations of these techniques have also been studied, in particular combined trabeculotomy-trabeculectomy, which has been shown to be successful in patients with moderate-to-advanced disease. Newer nonpenetrating techniques, such as viscocanalostomy and deep sclerectomy, have been reported in some studies with variable results. Further studies are needed to evaluate these newer surgical techniques, including the use of modern minimally invasive glaucoma surgeries, in this special and diverse group of young patients.