Childhood Glaucoma.

ObjectiveTo compare the 1-year outcomes of trabeculotomy ab externo (ab externo TLO) and trabeculotomy ab interno using a microhook (ab interno TLO) for glaucoma patients using propensity score analysis.Methods and...

PurposeThis study aims to describe the technique, feasibility, efficacy, and safetyof 360° trabeculotomy ab externo with double access for the treatment ofcongenital glaucoma.MethodsThis paper provides a detailed description of the 360° trabeculotomy abexterno with double access used to treat pediatric glaucoma. Thepostoperative outcomes of six eyes from six patients who underwent thisprocedure for primary and secondary congenital glaucoma are alsoreported.ResultsSix eyes from six patients were included in this study. The median age of thepatients at the time of surgery was 1.25 yr (range: 0.27-5.41 yr). The meanpreoperative intraocular pressure was 25 ± 5.87 mmHg (range: 18-35mmHg). At baseline, the mean number of hypotensive eye drop medications usedwas 2 ± 0.63. Postoperatively, the mean intraocular pressuredecreased to 10 ± 2.20 mmHg (range: 9-14 mmHg), and none of thepatients required hypotensive eye drops. The most common postoperativecomplication was hyphema, observed in one case on the first postoperativeday; however, it resolved within 7 days.ConclusionsThe 360° trabeculotomy ab externo with double access is a valuable additionto the surgical options for pediatric glaucoma. This technique facilitates acomplete 360° ab externo opening of the trabecular meshwork while enhancingsurgical safety.

The published results of trabeculotomy ab externo (TOT), as an outflow channel surgery in adults with open-angle glaucoma, are underrepresented in comparison with other pressure-lowering glaucoma procedures. To determine the long-term pressure lowering effect and complications of TOT as astand-alone procedure or in combination with phacoemulsification with intraocular lens implantation (PIT) as aprimary pressure-lowering procedure in adult patients with forms of chronic open-angle glaucoma. This was aretrospective analysis of 121 eyes of 106 patients wherby 90eyes underwent TOT and 31eyes underwent PIT. The follow-up period was 5years. Follow-up was performed in the same center under standardized conditions. Preoperative as well as postoperative best-corrected distance visual acuity, intraocular pressure, pressure-lowering medication, and complications were recorded. For success criterion1, the intraocular pressure was not allowed to exceed 17 mm Hg at any control. For success criterion2, the intraocular pressure was allowed to be above 17 mm Hg at 1 control throughout the follow-up period. Preoperative intraocular pressure in the TOT group was 25.92 mm Hg (SD 6.58) and 26.32 mm Hg (SD 6.06) in the PIT group. The annual cumulative success rates with pressure-lowering medications for success criterion1 were 92.8%, 82.5%, 70.5%, 52.7% and 26.1%. For success criterion2 these were 97.9%; 94.9%, 93.2%, 91.3%, and 89%. We found no relevant difference in pressure reduction between TOT and PIT. Without pressure-lowering medications, success rates were significantly lower for both success criteria. No serious complications occurred. The most common postoperative complication was spontaneously resorbable hyphema. Performing TOT or PIT as aprimary glaucoma procedure for chronic open-angle glaucoma in adults is reasonable, has a significant pressure-lowering effect and very low complication rate.

Pediatric glaucoma is a term that encompasses several forms of congenital glaucoma and types of secondary glaucoma thatdiff er in etiology, pathogenesis, and clinical presentation. Surgical treatment is the main method of IOP reduction in pediatricglaucoma. To date, no uniform method of surgical treatment of infantile glaucoma has been proposed, which makes the searchfor adequate methods of surgical intervention in this pathology most urgent.The aim of this work was to evaluate the effi cacy of surgical treatment of primary congenital infantile glaucoma in children.Material and methods. In the eye department of the clinic of the Tashkent Pediatric Medical Institute, the eff ectiveness of themethod of surgical intervention in children from 3 to 10 years old with primary congenital infantile glaucoma was evaluated.Examined – 20 patients (40 eyes). Of these, 5 patients (10 eyes) entered the advanced stage, 10 patients (20 eyes) entered the far advanced stage, and 5 patients (10 eyes) entered the terminal stage, respectively. The patients underwent standard ophthalmological examination. The state of the optic nerve was investigated by optical coherence tomography Stratus OCT-3000 (Carl Zeiss Meditec), the visual fi elds – in 10 (20 eyes) patients aged over 8 years using standard automated and computer perimetry (SAP).Conclusions of the bioethical commission: This article evaluates the eff ectiveness of the method of surgical treatment ofprimary congenital infantile glaucoma in children. And gives specifi c results of diff erent operations at diff erent stages of primary congenital infantile glaucoma. Surgical treatment was chosen according to the degree of goniodysgenesis and the stage of the disease, which showed a satisfactory result in stabilizing the glaucoma process.Statistical analysis method using Microsoft Excel and SPSS programs was used for processing the results of theophthalmological study. Diff erences between the mean values (M±σ) were considered reliable at P≤0.05.Results and Discussion. All patients underwent surgical treatment, depending on the severity of morphometric changesin the anterior chamber angle, and in the postoperative period with an interval of 6 months – a course of neuroprotectivetherapy. According to the examinations, children with primary infantile glaucoma in advanced stage underwent non-penetrating deep sclerectomy in 10 eyes, with extensive – in 20 eyes and with terminal – in 10 eyes – sinusotrabeculotomy ab externo, sinusotrabeculectomy. In 2 eyes in the terminal stage, fi ltering surgery was performed according to the proposed method. Thus, the above methods of surgery reduce the number of intra- and postoperative complications by 12.5%, avoid reoperations, reduce IOP in 12.3% of cases, increase visual acuity by 0.15 compared to the original.Conclusion. The above methods of surgical treatment were chosen according to the degree of goniodisgenesis and the stageof the disease, which showed a satisfactory result in stabilizing the glaucoma process

Resident Perspectives 56–3

Surgical and Visual Outcomes of Childhood Glaucoma at a Tertiary Eye Care Center in South India.

Open-angle glaucoma (OAG) is a leading cause of permanent blindness worldwide, and surgical interventions that restore the natural aqueous humor outflow pathway have emerged as promising treatment options. Therefore, we aimed to analyze the efficacy and safety profile of specific antiglaucoma surgeries, namely canaloplasty (ab interno and ab externo techniques) and gonioscopy-assisted transluminal trabeculotomy (GATT), in surgical treatment patients with primary and secondary OAG. Consequently, a systematic review of the recent literature was conducted using online databases. The effectiveness of the surgeries was assessed by reductions in intraocular pressure (IOP) measurements and decreased use of antiglaucoma eye drops preoperatively and postoperatively. The safety profile of these procedures was evaluated by recording the incidence of specific intraoperative and postoperative complications. Independent studies have shown that ab interno and ab externo canaloplasty procedures and GATT effectively lower IOP and decline medications burden. Therefore, given the favorable safety profiles, canaloplasty and GATT are associated with low incidences of postoperative adverse events and exhibit comparable safety characteristics. However, additional research, including a well-conducted randomized controlled trial comparing ab externo and ab interno canaloplasty with GATT, is required to validate our findings.

To evaluate the prevalence of ptosis, strabismus and the combination of both after glaucoma surgery and determine which kind of surgery is most likely to be linked to these complications. A total of 705 clinical records of patients who underwent glaucoma surgery at the University Eye Clinic of IRCCS Ospedale Policlinico San Martino, Genoa, from January 1, 2010, to December 31, 2020, were retrospectively evaluated. Surgery procedures were divided in three groups: "Ab interno", "Ab externo" and "Muscle isolation". Out of all patients 26 developed ptosis alone (3.7%), two developed bilateral ptosis, with a mean of 2.2 ± 1.08 procedures per patient. Highest incidence of ptosis was noticed in patients who underwent muscle isolation surgery (5.7%). Twelve patients developed strabismus alone (1,7%), four underwent unilateral surgery and eight bilateral surgery, with an average of 3.3 ± 1.78 procedures per patient. Strabismus was more frequent following extraocular muscle manipulation surgery (7.5%), showing a statistically significant difference (OR: 6.57; 95% CI: 1.71-21.65; p = 0.003) Seven patients developed both strabismus and ptosis (1.0%), one patient with bilateral ptosis. Four underwent bilateral surgery and three underwent unilateral surgery. The mean number of surgeries was 2.9 ± 1.07, showing a statistically significant difference compared to the uncomplicated glaucoma group (OR: 1.58; 95% CI: 1.01-2.25; p = 0.02). The prevalence of both ptosis and strabismus was higher after muscle isolation surgery (1.9%). Ptosis, strabismus and the combination of both are rare complications after glaucoma surgery, mostly linked to surgery with muscle isolation.

To compare 12-month clinical results of spatula-shaped and dual-blade microhooks ab interno trabeculotomy with phacoemulsification. Retrospective comparative study. We conducted a retrospective chart review of Japanese open-angle glaucoma patients who underwent ab interno trabeculotomy with phacoemulsification with a 12-month follow-up. Two types of trabecular hook were used: the spatula-shaped Tanito Trabeculotomy ab interno Micro-hook® and the Kahook Dual Blade®. Changes in intraocular pressure (IOP) and medication scores comprised the main outcome metrics. We also analyzed and compared patient demographics and the occurrence of complications. Trabeculotomy was performed using a spatula-shaped hook in 17 eyes and a dual-blade hook in 15 eyes. Significant reductions in IOP (p < 0.001) and medication scores (p < 0.001) were noted in both groups after the 1-month time point. The percentage changes of IOP from baseline at each time point were not significantly different between groups, though there was a significant difference in medication scores at 12months (p = 0.0192). Postoperative complications occurred similarly in both groups; one case in the dual-blade group required additional filtration surgery. Ab interno trabeculotomy with phacoemulsification was effective in lowering IOP both with spatula-shaped and with double-blade microhooks. At 12months more medications were used postoperatively in the spatula-shaped microhook group; however, the reductions in the medication scores from baseline were statistically significant in both groups.

Intraocular pressure response to combined phacoemulsification and trabeculotomy ab externo versus phacoemulsification alone in primary open-angle glaucoma

Developmental Immaturity of the Trabecular Meshwork in Congenital Glaucoma

Juvenile open-angle glaucoma is a disease with complex pathogenesis affecting young people of working age that can lead to disability. The article describes modern concepts of diagnosis, classification and approaches to the treatment of juvenile glaucoma with special attention paid to the differential diagnostic criteria of juvenile open-angle glaucoma and congenital glaucoma.

Clinical Results of Ab Interno Trabeculotomy Using the Trabectome for Open-Angle Glaucoma: The Mayo Clinic Series in Rochester, Minnesota

A 72-year-old woman with moderate primary open-angle glaucoma was referred for management of her glaucoma and photophobia. Her ocular history is significant for routine cataract surgery in both eyes 6 years prior to presentation. She was diagnosed with glaucoma 7 months prior to presentation at which time the patient underwent sequential, ab externo, open conjunctival, Xen Gel Stent (Allergan, Inc.) placement with mitomycin-C (MMC) in each eye, approximately 2 weeks apart. The history obtained directly from the surgeon revealed that MMC dosing was 0.2 mL in a concentration of 0.2 mg/mL delivered through subconjunctival injection after placement of the gel stent. Intracameral moxifloxacin was injected at the time of surgery, and moxifloxacin and Maxitrol eyedrops were used in the postoperative period. The patient noted that, approximately 1 month after each surgery, she developed significant photophobia. An outside examination noted bilateral tonic pupils and concern for early bleb failure in the left eye. 2 months after the initial gel stent placement in the left eye, she underwent a bleb revision with a McCannel suture iris cerclage in the left eye. The intraocular pressure (IOP) in both eyes remained well controlled off pressure-lowering medications; however, the tonic pupils and photophobia persisted. The patient was subsequently referred for further assessment. At presentation, the patient's corrected distance visual acuity was 20/20 in each eye. Applanation tonometry IOP was 17 mm Hg and 14 mm Hg for the right and left eyes, respectively. Pupils were tonic and irregular. The lack of pupillary response prevented testing for relative afferent pupillary defects directly or by reverse testing. Slitlamp examination of the right eye was notable for a minimally elevated superior bleb and severe iris stromal atrophy with diffuse transillumination defects. The intraocular lens (IOL) appeared well positioned in the capsular bag without signs of pseudophacodonesis (Figure 1JOURNAL/jcrs/04.03/02158034-202201000-00021/figure1/v/2021-12-20T152346Z/r/image-tiff). The left eye was notable for a diffuse superior bleb and similar iris and IOL findings to the right eye, except for 2 McCannel iris sutures in the iris stroma (Figure 2JOURNAL/jcrs/04.03/02158034-202201000-00021/figure2/v/2021-12-20T152346Z/r/image-tiff). In both eyes, the anterior chambers were deep and quiet, and there were no corneal endothelial abnormalities. Fundus examinations of both the right and left eyes were notable for glaucomatous-appearing optic nerves and otherwise healthy macula, vessels, and periphery. Gonioscopy revealed open angles in each eye with fairly marked, densely layered pigment throughout the inferior angle and trabecular meshwork. The gel stents were positioned just anteriorly to the trabecular meshwork superiorly, well away from iris tissue. Optical coherence tomography (OCT) of the nerve fiber layer (NFL) showed moderate to severe thinning inferiorly and superiorly in the right eye, with mild to moderate thinning inferiorly in the left eye (Supplemental Figure 1, http://links.lww.com/JRS/A510). Ganglion cell analysis correlated with the NFL findings (Supplemental Figure 2, http://links.lww.com/JRS/A510). Humphrey visual field testing revealed a dense superior arcuate in the right eye and moderate inferior arcuate in the left eye (Supplemental Figures 3 and 4, http://links.lww.com/JRS/A510). OCT of the macula in both eyes was unremarkable. Finally, specular microscopy showed normal endothelial density and configuration of each eye (Supplemental Figure 5, http://links.lww.com/JRS/A510). What part of the patient's ocular history would you consider relevant to the development of tonic, atrophic pupils? What additional information would you want to know to help refine your differential diagnosis? What is your preferred surgical technique when implanting the Xen Gel Stent? Please include whether ab interno or ab externo and open or closed conjunctival approach to be used and mention antifibrosis dosing and method of administration. Finally, what would be your approach for managing this patient's severe photophobia, in the setting of her moderate open-angle glaucoma?

To assess the outcome of combined phacoemulsification and 360-degree suture trabeculotomy ab externo in chronic angle closure glaucoma using a modified technique. This is a retrospective clinical study that included 60 eyes of 60 patients who had undergone combined phacoemulsification and 360-degree suture trabeculotomy ab externo for the treatment of primary chronic angle closure glaucoma. The patients were divided into two groups. The first group (ab externo group) and the second group (modified ab externo group). Data were collected from the records and the final follow-up visit including age, sex, intraocular pressure (IOP), number of antiglaucoma medications, presence of complications, corrected distant visual acuity, and need for another intervention. All the included patients completed at least 12 months follow-up. The ab externo group included 30 patients and the modified ab externo group included 30 patients. The postoperative IOP was reduced in both groups significantly from the preoperative levels. The percent of reduction was around 60% for both groups (59.5% for the ab externo group and 59.3% for the modified ab externo group). There was statistically significant reduction in the mean amount of required topical medications after the intervention for both groups (p = 0.001). Most of the complications were not serious. Around 90% of the cases in both groups had mild degree of grade 1hyphema. Both ab externo 360 degree suture trabeculotomy and its modified technique with ab interno pulling of the suture when combined with phacoemulsification are safe and provide adequate decrease in the intraocular pressure. Modified technique of ab interno pulling of the prolene suture might be more gentle procedure with less severe hyphema and lower chance of rupture of trabeculo-Descemet's membrane.