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.

Ahmed glaucoma valve implantation with and without Ologen adjuvant in pediatric glaucoma.

PURPOSE: To compare outcomes of Ologen augmentation of Ahmed glaucoma valve implantation (AVG) and AGV implantation alone in children operated on for uncontrolled glaucoma. METHODS: A prospective study was conducted on 33 eyes (18 right eyes) of 33 children (20 males) operated on following failed initial glaucoma surgeries. Eyes were randomized to the AGV or the AGV-Ologen group. The primary outcome was reduction in IOP on 2 years' follow-up in each group. Success was defined as final intraocular pressure (IOP) of 6-20 mm Hg without vision-threatening complications, additional glaucoma operations, or other signs of glaucoma progression. RESULTS: Mean patient age (range; median) in the AGV-Ologen and AGV groups was 6.5 ± 2.1 years (2.5-10; 6.5) and 6.5 ± 1.9 years (3-9.5; 7), respectively (P = 0.897). Mean follow-up was 42.1 ± 13.7 months (25-64, 41) and 43.3 ± 11.4 (27-62, 42), respectively (P = 0.788). The most common glaucoma diagnosis in each group was primary congenital glaucoma (82.4% and 81.2% resp.). There was significant postoperative reduction in IOP and the number of IOP-lowering medications at 24 months' follow-up (P < 0.0001 and P = 0.002 for AGV-Ologen and AGV, resp.). The AGV-Ologen group demonstrated statistically significantly lower IOP values at all time points than the AGV group. At 24 months, the probability of total success was 77% in AGV-Ologen and 63% in AGV (P = 0.46). CONCLUSIONS: In our study cohort, AGV implantation was an effective treatment for operated uncontrolled childhood glaucoma for at least 2 years, with Ologen augmentation providing a clear advantage in terms of IOP control, without compromising safety.

Indocyanine Green Aided Schlemm Canal Identification During Gonioscopic Assisted Transluminal Trabeculotomy.

Performing procedures like gonioscopic assisted transluminal trabeculotomy in eyes with congenital glaucoma may be difficult many a times due to difficult visualization of angle structures. Inaccurate identification of the angle landmark may lead to various inadvertent surgical complications. Hence, there is a need for techniques to improve visualization of surgical landmarks during these procedures. In this study, 0.2% indocyanine green was used to stain the trabecular meshwork before the surgeon proceeded with gonioscopic assisted transluminal trabeculotomy. It yielded excellent differentiation of the trabecular meshwork by imparting a bright green hue. This led to successful identification of the site of incision and subsequent 360 degrees cannulation of Schlemm canal in 5/5 cases. Indocyanine green aided Schlemm canal identification is helpful in children with congenital glaucoma undergoing angle surgeries, especially in eyes with poor structure differentiation.

Ologen augmentation of Ahmed valves in pediatric glaucomas.

BACKGROUND: We previously showed that Ologen increased success and survival rates of Ahmed glaucoma devices in a small number of children. The current study analyzed the same surgical technique in an expanded cohort. METHODS: Retrospective interventional case series of children who underwent Ologen augmentation of Ahmed glaucoma device (OAGD) from 2018 to 2021 with ≥6 months' postoperative follow-up. Complete success was defined as intraocular pressure (IOP) of 5-20 mm Hg without glaucoma medications or additional IOP-lowering surgeries. Complete or qualified success was defined as above, except that IOP control was maintained with or without glaucoma medications. RESULTS: A total of 26 eyes of 18 patients underwent OAGD at a median age of 2.0 years. Diagnoses included primary congenital glaucoma (5 eyes) and glaucoma secondary to nonacquired ocular anomalies (9 eyes), nonacquired systemic anomalies (8 eyes), and acquired conditions (4 eyes). Seventeen eyes had ≥1 prior eye surgery (average, 1.6 ± 0.9 surgeries per eye). Preoperative IOP was 29.4 ± 9.9 mm Hg on an average of 2.7 ± 1.0 glaucoma medications. At final follow-up (1.3 ± 1.0 years; median 1.0), IOP (13.4 ± 4.7 mm Hg) and number of glaucoma medications (0.3 ± 0.7, median 0) were significantly decreased (P < 0.0001). Complete success was achieved in 77% of eyes (20/26); Kaplan Meier analysis showed 1- and 3-year survival rates of 82% (95% CI, 59-93) and 60% (95% CI, 25-83), respectively. Complete or qualified success was achieved in 100% of eyes (26/26) at final follow-up. There were no visually devastating complications. CONCLUSIONS: OAGD showed a high rate of success defined by decreased IOP and medication dependency in our study cohort of pediatric glaucoma patients.

Use of a Novel Microshunt in Refractory Childhood Glaucoma: Initial Experience in a Compassionate Use/Early Access Cohort.

PURPOSE: In patients with refractory childhood glaucoma, treatment options include trabeculectomy or large glaucoma drainage devices (GDDs) with attendant short- and long-term risks. A novel polymer-based microshunt is under review by the US Food and Drug Administration (FDA) for use in adults. The device is attractive for children given the long-term stability of the polymer and the small conjunctival incision required for implantation. This early clinical series explores the safety and efficacy of this device in patients with refractory childhood glaucoma who would otherwise undergo trabeculectomy or implantation of a GDD. DESIGN: Prospective single-center case series under FDA compassionate use investigational device exemption. METHODS: FDA and institutional review board approvals were obtained to treat ≤20 children using this investigational device under the compassionate use pathway. Single eyes in patients with refractory childhood glaucoma were treated surgically with the microshunt. Patients with ≥1 year of follow-up are reported. RESULTS: Twelve eyes of 12 children (15 months to 14 years if age) with mean preoperative intraocular pressure of 22.72 ± 4.8 mm Hg on 3.3 ± 0.65 medications were treated beginning in December 2019. No intraoperative complications occurred. Among eyes with ≥1 year of follow-up (range 12-23 months), 9 were successfully controlled. In this group, preoperative intraocular pressure 21.6 ± 4.9 mm Hg dropped 45% to 11.9 ± 3.8 mm Hg at 1 year; 7 patients were taking no medications at 12 months, and 2 required 2 medications (fixed-combination dorzolamide-timolol). Three eyes failed, requiring additional surgery. CONCLUSION: These early data suggest that the device is safe and appears effective in patients with refractory childhood glaucoma. A prospective, multicenter pivotal trial is planned.

Co-existing lacrimal drainage anomalies in eyes with congenital Glaucoma.

AIM: To evaluate the occurrence of co-existing congenital nasolacrimal duct obstruction (CNLDO) and other lacrimal anomalies in eyes with congenital glaucoma (CG). METHODS: Retrospective analysis of children aged ≤1-year with co-existing CG and CNLDO seen between 1998 and 2019, treatment interventions and outcomes. RESULTS: During the study period, 1993 children had CG and 6203 children had CNLDO, among the children aged 1-year or less. Of these, 51 children (73 eyes) had co-existing CG and CNLDO. The prevalence of CNLDO in CG was 2.5% (51/1993) and the prevalence of CG among CNLDO was 0.8% (51/6203). Median age (Interquartile range, IQR) was 53 days (IQR: 8, 155), when they were diagnosed with CG. Among the children with CNLDO, 68 eyes (93.1%) had simple CNLDO, and 5 eyes (6.9%) had complex CNLDO. Associated lacrimal anomalies were present in 7/73 eyes, including congenital lacrimal fistula in two eyes, upper punctal agenesis and upper mid-canalicular obstruction in two eyes each, and upper single canalicular-wall hypoplasia in one eye. Lacrimal syringing and probing were successful in 69/72 eyes (95.8%), and failed in 3 eyes (4.2%). These 3 eyes had complex CNLDO and underwent Dacryocystorhinostomy (DCR) with Mitomycin-C and intubation. Sixty-two eyes underwent combined trabeculotomy and trabeculectomy, and two eyes underwent trabeculectomy. Median age at glaucoma surgery was 87 days (IQR: 54, 193). Median time delay for glaucoma surgery after probing was 18 days (IQR: 12, 35). CONCLUSION: Among children aged ≤1-year presenting with congenital glaucoma coexisting lacrimal drainage anomalies was noted in 2.5% and simple CNLDO was the commonest. Early intervention is of paramount importance to prevent sight-threatening intraocular infection with CNLDO, and to minimize the delay of glaucoma surgery. The outcomes of lacrimal probing were excellent, however complex CNLDO required DCR.

Neonatal-Onset Congenital Ectropion Uveae May Be Caused by a Distinct CYP1B1 Pathologic Variant.

PURPOSE: To report underlying genetic variants of recently described distinct phenotype of newborn glaucoma: neonatal-onset congenital ectropion uveae (NO-CEU). DESIGN: Prospective cohort study. METHODS: Setting: tertiary care teaching institute. SUBJECTS: Thirteen children with clinical diagnosis of NO-CEU who had completed 1-year follow-up after glaucoma surgery and had undergone clinical exome sequencing (CES) by selective capture and sequencing of the protein-coding regions of the genes including 19 candidate genes for NO-CEU were assessed. The same criteria were applied for evaluating pathogenicity of variants to all the candidate genes. OUTCOME MEASURES: primary-genetic variants found on CES keeping in view the clinical indication of congenital glaucoma; secondary-corneal clarity and intraocular pressure (IOP) at baseline and 1-year follow-up, interventions required to control IOP, and postoperative visual acuity. The genetic variants were correlated with the outcome. RESULTS: All 13 patients diagnosed with NO-CEU had onset of glaucoma at birth and severe bilateral disease. Twelve of 13 (92.3%) patients harbored CYP1B1 variants. Nine of these 12 patients (83.3%) were homozygous for [c.1169G>A(p.Arg390His)] in exon-3 of CYP1B, with 5 common homozygous single-nucleotide polymorphisms flanking the pathogenic variant. They had intractable glaucoma and required multiple surgeries. Six patients had persistent corneal opacities, necessitating optical iridectomies. Three patients were compound heterozygous for CYP1B1 variants, showing [c.1169G>A(p.Arg390His)] along with [c.1103G>A(p.Arg368His)], [c.1103G>A (p.Arg368His)] along with [c.1403_1429dup(p.Arg468_Ser476dup)], and [(c.1063C>T(p.Arg355Ter)] along with [c.1325del(p.Pro442GlnfsTer15)]. These patients had better visual outcomes. CONCLUSIONS: NO-CEU appears to be a phenotypic marker for specific CYP1B1 genotypes, one of which is [c.1169G>A(p.Arg390His)] in our study population. Phenotype recognition is helpful to characterize the underlying genetic variants.

Surgical Outcomes of Visco-Circumferential-Suture-Trabeculotomy Versus Rigid Probe Trabeculotomy in Primary Congenital Glaucoma: A 3-Year Randomized Controlled Study.

PURPOSE: The aim was to compare the long-term surgical outcomes of visco-circumferential-suture-trabeculotomy (VCST) and rigid probe viscotrabeculotomy (VT) in patients with primary congenital glaucoma (PCG). PATIENTS AND METHODS: The study was conducted on 84 (47 right) eyes of 49 (32 males) children PCG to the pediatric ophthalmology unit of Mansoura Ophthalmic Center of Mansoura University, Egypt between 2015 and 2018. An initial office examination was followed by an examination under general anesthesia to establish the diagnosis of PCG. The children were then scheduled for surgery and the eyes randomly assigned to VCST or VT. Follow-up visits were scheduled at the first day, first week, first, and third months and then every 3 months for 1 year. RESULTS: The mean±SD age of the study children at presentation was 4.8±2.1 and 4.9±1.7 months in the VCST and the VT groups, respectively (P=0.827). The mean±SD preoperative intraocular pressure (IOP) was 29.13±3.3 and 29.89±3.2 mm Hg in the VCST and VT groups, respectively (P=0.292) and 11.9±1.3 and 13.8±1.2 mm Hg at the end of 36 moths of follow-up (P<0.001). The IOP at all follow-up time points (except at the third month, P=0.924) was statistically significantly less in the VCST group than in the VT group (at week 1, month 1, 6, 9, 12, 18, 24, 30, and 36 the P<0.001). The cumulative probability of success was 100%, 95%, 90%, and 90%, respectively in VSCT and 100%, 72.7%, 97.7%, 90.9%, and 84% in VT at 12, 24, 30, and 36 months. CONCLUSIONS: Both VCST and VT were effective and safe for lowering the IOP in PCG with VCST providing a marginal advantage over VT.

Infantile Aphakic Glaucoma: A Proposed Mechanism.

PURPOSE: To review information pertaining to secondary glaucoma following infant lensectomy and provide evidence to support the mechanism responsible for this condition. METHODS: Reported risk factors and proposed mechanisms for infantile aphakic glaucoma are reviewed. Laboratory studies and clinical observations in affected patients with glaucoma are described. Evidence of postoperative anterior chamber fibrosis is reviewed and interpreted. RESULTS: Clinical evidence demonstrated the development of anterior chamber fibrosis following infant cataract surgery. Laboratory studies showed liberated lens epithelial cell transition to fibroblasts. CONCLUSIONS: The review and assessment of laboratory and clinical evidence support the proposal that infantile aphakic glaucoma is caused, in part, by postoperative anterior chamber fibroization related to lens cell dispersion, cytokine activation, and epithelial-mesenchymal transition with resultant filtration angle fibrosis and secondary loss of filtration function. [J Pediatr Ophthalmol Strabismus. 2022;59(4):236-242.].

Primary Congenital Glaucoma: Trends in Presentation Over 3 Decades at a Tertiary Eye Care Center in India.

PRECIS: In this study, huge time delay was observed between first primary congenital glaucoma (PCG) symptom recognition by parents to ophthalmological diagnosis and this delay was unchanged over time. Bilateral affliction and mean presenting intraocular pressure (IOP) remained unaltered. PURPOSE: To compare the trends in presentation of patients with PCG over 3 different time periods at 10-year intervals (1998, 2008, and 2018) managed by a single surgeon at one of the largest tertiary eye care centers in South India. METHODS: Retrospective analysis of 313 eyes of 172 patients diagnosed to have PCG and treated at the L V Prasad Eye Institute (LVPEI) between January and December of the 3 specified years. Data collected included age at symptom recognition and at presentation, sex, affected eye, signs and symptoms, time between onset of symptoms and diagnosis (diagnostic delay), corneal clarity, and IOP. RESULTS: Of the 172 patients, 48 (27.9%), 76 (44.2%), and 48 (27.9%) belonged to 1998, 2008, and 2018, respectively. Bilateral affliction (79% to 84%) was common and there was no sex predilection. The median age at recognition of first symptoms by caregivers/parents was 1 day (interquartile range, 1 to 30), and at diagnosis was 120 days (interquartile range, 30 to 378). Overall, presentation to LVPEI was delayed by >3 months in 80 (46.5%) children, and there was no statistically significant difference in the duration of delay over time (P=0.13). There was no significant difference in the mean presenting IOP over time (P>0.05). CONCLUSIONS: We provide unique single center-based information of trends in the presentation of patients with PCG over 3 decades. Diagnostic delay was common, and a large number of characteristics of patients with PCG in South India have remained unchanged, particularly, age at onset and at diagnosis and laterality.

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.

Transient Myopia Secondary to Supraciliary Effusion: Unusual Complication After an Uneventful Prolene Gonioscopy-assisted Transluminal Trabeculotomy.

PURPOSE: The purpose of this study was to report 2 cases experiencing a transient decrease in their vision due to the development of acute myopia after an uneventful prolene gonioscopy-assisted transluminal trabeculotomy (GATT) surgery. METHODS: A 52-year-old woman with primary open-angle glaucoma and an 8-year-old boy with juvenile glaucoma underwent uneventful GATT surgery. RESULTS: On the postoperative first day, both patients had mild shallow anterior chamber and intraocular pressures measured as 19 and 16 mm Hg, respectively. Both patients had myopia measured as -4.5 and -6.0 D, respectively. Fundus examination was unremarkable in the first patient, whereas it showed bilateral optic disc cupping and retinal nerve fiber layer atrophy in the second patient. In the first patient, supraciliary effusion was detected by using ultrasound biomicroscopy. Ultrasound biomicroscopy could not be performed in the second patient, but ocular ultrasonography revealed a thin layer of suprachoroidal fluid. Myopia was completely regressed, and visual acuity increased within 1 week of the follow-up in both patients. At the sixth month of the follow-up, intraocular pressures in both patients were under control without any antiglaucoma medications. CONCLUSION: Transient decrease in vision after the GATT surgery might occur secondary to supraciliary effusion leading to acute, transient myopia.

Outcomes of Circumferential Trabeculotomy and Converted 180-Degree Traditional Trabeculotomy in Patients With Neonatal-onset Primary Congenital Glaucoma.

PRéCIS:: The present study demonstrates that the surgical success rate of circumferential trabeculotomy is 64.7% according to target intraocular pressure (IOP) ≤21 mm Hg and ≥30% reduction from baseline in patients with neonatal-onset primary congenital glaucoma (PCG), with an average follow-up of 35.1 months. PURPOSE: The aim of the study was to evaluate the surgical success rate and applicability of circumferential trabeculotomy compared with converted traditional trabeculotomy in patients with neonatal-onset PCG in Turkey. PATIENTS AND METHODS: A retrospective study enrolled 42 eyes of 42 patients with an average age of 34.0±6.7 (14 to 59) days at the time of the surgery, who underwent 5/0 prolene suture-assisted circumferential trabeculotomy or rigid probe-assisted traditional trabeculotomy for the treatment of neonatal-onset PCG. IOP at baseline, 1st, 2nd, 3rd, 6th, 9th, 12th, 24th, and 36th months of follow-up, need of glaucoma eye drop, need of further glaucoma surgery, cup to disc ratio, axial length, corneal diameters, and presence of corneal clouding were recorded. Surgical success was defined as IOP <21 mm Hg and ≥30% reduction from baseline without any further glaucoma surgery. RESULTS: Seventeen eyes underwent circumferential trabeculotomy and 25 eyes with a failure in completing circumferential trabeculotomy underwent traditional trabeculotomy. The applicability rate of circumferential trabeculotomy was 40.4%. The mean preoperative IOP value was 33.2±7.6 mm Hg. The average follow-up time was 35.1±21.7 (12 to 95) months. Surgical success rates of circumferential trabeculotomy at the first, second, and third year of follow-up were 70.6%, 64.7%, and 64.7%, respectively. Surgical success rates of traditional trabeculotomy at the first, second, and third year of follow-up were 60%, 48%, and 44%, respectively. CONCLUSIONS: Circumferential trabeculotomy seems to be a safer and more successful procedure than traditional trabeculotomy for the treatment of neonatal-onset PCG. Unlike the traditional procedure, the IOP-lowering effect of circumferential trabeculotomy could be maintained up to ~36 months.

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.

Ahmed Valve Tube Extension in Pediatric Glaucoma.

PRéCIS:: Ahmed valve tube extender showed good long-term outcomes for retracted tubes in pediatric glaucoma. The procedure is safe with limited complications. PURPOSE: To analyze the long-term outcomes of Ahmed valve tube extension in pediatric glaucoma patients. PATIENTS AND METHODS: This study analyzed the records of all children who underwent surgery involving extension of a pediatric Ahmed valve tube, treated at a tertiary medical center between 2007 and 2018. Surgical success was defined as intraocular pressure between 6 and 22 mm Hg and reduced by at least 20% from its preoperative value, with or without intraocular pressure lowering medications, without additional surgical procedures and without vision loss. RESULTS: Fourteen eyes of 11 children were treated with the Ahmed tube extender during the study period. Mean age of all children was 5.7±4.7 years (range, 3 mo to 16 y). The most common type of glaucoma was congenital glaucoma (n=6, 42.9%). The mean age at the time of initial valve implant was 2.39±3.89 years and the mean duration from initial insertion to the extension was 3.39±2.95 years. The mean follow-up was 72.8±43.3 months (range, 12 to 140 mo), with 85.7% followed for >2 years. The mean survival was 34.1±37.2 months after the extension. Three surgeries (21.4%) were primary failures, 8 patients (57.1%) failed during follow-up (mean, 40.6±44.4 mo after the extension; range, 1 to 125 mo), whereas 3 patients (21.4%) maintained the successful outcome until their last follow-up visit (mean, 37.7±24.1 mo; range, 12 to 70 mo). CONCLUSIONS: The Ahmed valve extender can often save a retracted or obstructed tube. The procedure has limited complications and long-term efficacy in one third of the patients.

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.

Surgical Outcomes of Microcatheter-assisted Trabeculotomy as a Secondary Procedure in Patients with Primary Congenital Glaucoma.

PURPOSE: To investigate the efficacy and safety of illuminated microcatheter-assisted trabeculotomy as a secondary procedure in patients with primary congenital glaucoma (PCG). METHODS: This retrospective case series included patients with PCG who underwent trabeculotomy using an illuminated microcatheter with the intent of catheterizing the full circumference of Schlemm's canal in a single procedure. Success was defined as intraocular pressure (IOP) ≤21 mmHg, with or without the use of glaucoma medications. Clinical examination data were collected for up to 36 months postoperatively. RESULTS: Surgery was performed on 16 eyes of 16 patients. The mean patient age was 75.1 ± 69.4 months (range: 4.0-216.0 months). Complete catheterization was achieved in 11 of the 16 eyes (69%), whereas partial catheterization was achieved in five of the 16 eyes (31%). All eyes had previously undergone surgery for PCG. The mean follow-up duration was 20.3 ± 9.0 months (range, 12.0-36.0 months). IOP was reduced from a mean of 31.8 ± 6.6 mmHg preoperatively to 15.6 ± 3.7 mmHg at the final follow-up (P < 0.001). The mean preoperative number of glaucoma medications was 3.9 ± 0.5, which was reduced to 1.1 ± 1.6 at the final follow-up (P = 0.001). Ten (62.5%) of the 16 eyes did not require glaucoma medication by the final follow-up. Early transient postoperative hyphema occurred in six eyes (37.5%). No other complications were noted. All corneas were clear at the final follow-up. CONCLUSION: Ab externo circumferential trabeculotomy using an illuminated microcatheter may be safe and effective as a secondary surgical option for children with PCG after unsuccessful glaucoma surgery.