Trabeculectomy with adjunctive mitomycin C in pediatric glaucoma

doi:10.1016/S0002-9394(98)00227-X

American Journal of Ophthalmology

Volume 126, Issue 5, November 1998, Pages 648-657

https://doi.org/10.1016/S0002-9394(98)00227-X Get rights and content

Abstract

PURPOSE: To determine the safety and efficacy of trabeculectomy with adjunctive mitomycin C in patients 17 years of age or younger, and to identify risk factors for failure of this surgical technique.

METHODS: Retrospective review of consecutive cases of pediatric glaucoma that underwent mitomycin C augmented trabeculectomy between January 1991 and December 1995. Forty-nine patients (60 eyes) with a mean age of 7.6 years (range, 6 weeks to 17.6 years) were identified and followed up until repeat glaucoma surgery, or after a minimum of 6 months. Success was defined as intraocular pressure control of 22 mm Hg or less with or without topical glaucoma control medication, no evidence of glaucoma progression, no further glaucoma surgery necessary, and no visually devastating complication.

RESULTS: Cumulative probabilities of success ± SD for 49 eyes (one eye per patient) were 67% ± 13% at 12 months and 59% ± 15% at 24 months. Multivariate regression analysis yielded the following characteristics as significantly increased risk for failure: age of less than 1 year at time of surgery (risk ratio, 5.6; confidence interval, 2.1 to 14.7; P = .0005), and aphakia (risk ratio, 2.7; confidence interval, 1.1 to 6.9; P = .0364). Shallow anterior chamber (17 [28%] of 60 eyes) and serous choroidal detachment (13 [22%] of 60 eyes) were the most common complications. Four (11%) of 38 eyes with obtainable Snellen acuity were noted to have a decrease in best-corrected visual acuity of more than 2 Snellen lines or loss of light perception. In 5 (8%) of 60 eyes bleb-related endophthalmitis was noted.

CONCLUSIONS: Trabeculectomy with adjunctive mitomycin C is generally effective for the treatment of pediatric glaucoma, especially in phakic children over 1 year of age. However, late-onset bleb-related endophthalmitis is a substantial risk in this patient population.

Section snippets

Patients and methods

A retrospective review of medical records identified all patients 17 years of age or less with glaucoma who underwent trabeculectomy with intraoperative application of mitomycin C (55 consecutive patients, 68 eyes) between January 1991 and December 1995 at Emory University Affiliated Hospitals. The results of all trabeculectomies with mitomycin C were recorded, with statistical analysis performed on one eye of each patient (first eye of each patient who had bilateral surgery). Forty-nine

Results

Patients were categorized by the Shaffer-Weiss classification system, with the inclusion of glaucoma associated with aphakia after congenital cataract surgery as a new category.16 The following diagnoses were noted (N = 60 eyes): 14 with primary congenital glaucoma; 10 with anterior segment dysgenesis (Axenfeld-Rieger and Peter anomaly); 9 with aniridia; 9 with glaucoma after congenital cataract extraction; 4 with traumatic glaucoma; 4 with persistent hyperplastic primary vitreous; 3 with

Discussion

Trabeculectomy without adjunctive antimetabolites in pediatric patients (less than 18 years of age) has a successful outcome in 30% to 50% of cases.1, 2, 3 The 50% rate is from a study with relatively short follow-up (mean, 15.5 months).3 Studies with longer follow-up note a success rate of 30% to 35%.1, 2 Trabeculectomy has been utilized as an initial procedure in primary congenital glaucoma with higher success rates (54% to 87%), although with lower success rates than those noted for

References (42)

Z Inaba
Long-term results of trabeculectomy in the Japaneseanalysis by life-table method
Jpn J Ophthalmol
(1982)
M.G Gressel et al.
Trabeculectomy in young patients
Ophthalmology
(1984)
G.R Beauchamp et al.
Filtering surgery in childrenbarriers to success
Ophthalmology
(1979)
M Zalish et al.
Subconjunctival injection of 5-fluorouracil following trabeculectomy for congenital and infantile glaucoma
Ophthalmic Surg
(1992)
J Whiteside-Michel et al.
Initial 5-fluorouracil trabeculectomy in young patients
Ophthalmology
(1992)
C.-W Chen
Enhanced intraocular pressure controlling effectiveness of trabeculectomy by local application of mitomycin C
Trans Asia–Pacific Acad Ophthalmol
(1983)
S.S Palmer
Mitomycin as adjunct chemotherapy with trabeculectomy
Ophthalmology
(1991)
R Susanna et al.
Mitomycin as adjunct chemotherapy in congenital and developmental glaucoma
J Glaucoma
(1995)
A.K Mandal et al.
Mitomycin C-augmented trabeculectomy in refractory congenital glaucoma
Ophthalmology
(1997)
D.K Wallace et al.
Surgical results of secondary glaucomas in childhood
Ophthalmology
(1998)

A.D Beck et al.

The use of a new laser lens holder for performing laser suture lysis in children

Arch Ophthalmol

(1995)

B Rosner

E.L Kaplan et al.

Nonparametric estimation from incomplete observations

J Am Stat Assoc

(1958)

N Mantel

Evaluation of survival data and two new rank order statistics arising in its consideration

Cancer Chemother Rep

(1966)

J.D Kalbfleisch et al.

R.N Shaffer et al.

J.P Burke et al.

Primary trabeculectomy in congenital glaucoma

Br J Ophthalmol

(1989)

S.C Debnath et al.

Trabeculectomy versus trabeculotomy in congenital glaucoma

Br J Ophthalmol

(1989)

K.V Rao et al.

Trabeculectomy in congenital glaucoma

Indian J Ophthalmol

(1984)

Flurouracil filtering surgery study groupone year follow-up

Am J Ophthalmol

(1989)

R.E Wiggins et al.

The results of glaucoma surgery in aniridia

Arch Ophthalmol

(1992)

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To report the outcomes of a 120-degree goniotomy (GT) with or without secondary intraocular lens (IOL) implantation in glaucoma following cataract surgery (GFCS).
Prospective, observational study.
Pediatric patients with GFCS who underwent standalone 120-degree GT or 120-degree GT combined with secondary IOL implantation (GT+IOL) from March 2022 to August 2022 at the Zhongshan Ophthalmic Center were recruited. Primary outcomes were intraocular pressure (IOP) and the number of ocular hypotensive medications. A secondary outcome was the surgical success rate. Success was defined as a postoperative IOP within the range of 5–21 mm Hg. Complete and qualified successes were defined, as the above, without and with ocular hypotensive medications, respectively.
Thirty-two eyes of 22 patients were included. The mean age at the time of GT was 68.5 ± 29.3 months. The mean follow-up duration was 12.2 ± 2.3 months (9–15 mo). Mean IOP decreased from 30.9 ± 4.8 mm Hg on 2 (interquartile range = 1) medications at baseline to 15.8 ± 3.6 mm Hg on 0 (interquartile range = 1.5) medication at the latest visit in all eyes. The overall complete and qualified success rates were 68.8% and 90.6%, respectively. There were no significant differences in IOP, number of medications, and complete and qualified success rates between the standalone GT and GT+IOL groups at the latest follow-up at 9 months postoperatively.
To reduce the need for additional surgery, 120-degree GT was a safe and effective surgical treatment for GFCS in children, which could be combined with secondary IOL implantation in aphakic eyes with GFCS.
Viscocanalostomy combined with trabeculotomy for management of refractory primary congenital glaucoma
2022, Journal of AAPOS
To investigate the outcome of viscocanalostomy combined with trabeculotomy (VCO+tbo) in primary congenital glaucoma (PCG) with history of failed trabeculotomy.
In this prospective study, VCO+tbo was performed in 75 eyes of 46 patients with PCG who had not responded adequately to one angle surgery. Success was defined as intraocular pressure (IOP) of 6–21 mm Hg and at least 20% IOP drop at the last postoperative visit with (qualified) or without (complete) glaucoma medications.
Patients completed a mean follow-up of 31 ± 11 months. Complete success was achieved in 6 eyes (8%); qualified success, in 38 eyes (51%). In the 44 successfully treated eyes, IOP was reduced from a preoperative mean of 29.0 ± 5.8 to 15.7 ± 2.6 mm Hg, and the number of medications dropped from 2.6 ± 0.9 to 2.0 ± 1.0 (P < 0.001). In univariate analysis, the success rate was lower in patients with neonatal onset disease than subjects whose age at onset was 1-12 months (HR = 0.22; 95% CI, 0.05-0.93; P = 0.039). Children whose disease was first diagnosed after 1 year of age responded better than neonatal onset patients but worse than those with age of onset of 1-12 months; however, the difference was not statistically significant. Hyphema occurred in 27 eyes (36%) on day 1 and resolved spontaneously. Iatrogenic cyclodialysis occurred in one eye, which was surgically repaired after 1 month of treatment with cycloplegic agents.
In our study cohort, VCO+tbo was associated with successful outcomes in the majority of treated eyes.
Angle closure glaucoma in congenital ectropion uvea
2018, American Journal of Ophthalmology Case Reports
Citation Excerpt :
In our series, in all 3 cases the angles were closed and thus the options of trabeculectomy with antifibrotic medication or glaucoma drainage device implantation were discussed with the patient and their parents. Due to factors related to the increased life-long risk of trabeculectomy-related infections,16–19 all three teenagers opted for glaucoma drainage device placement. Interestingly, in all of our cases, there was early encapsulation of the plates and the 3 eyes required additional glaucoma surgery (cycloablation or trabeculectomy with mitomycin C) within 4 months of tube implantation.
Congenital ectropion uvea is a rare anomaly, which is associated with open, but dysplastic iridocorneal angles that cause childhood glaucoma. Herein, we present 3 cases of angle-closure glaucoma in children with congenital ectropion uvea.
Three children were initially diagnosed with unilateral glaucoma secondary to congenital ectropion uvea at 7, 8 and 13 years of age. The three cases showed 360° of ectropion uvea and iris stromal atrophy in the affected eye. In one case, we have photographic documentation of progression to complete angle closure, which necessitated placement of a glaucoma drainage device 3 years after combined trabeculotomy and trabeculectomy. The 2 other cases, which presented as complete angle closure, also underwent glaucoma drainage device implantation. All three cases had early glaucoma drainage device encapsulation (within 4 months) and required additional surgery (cycloablation or trabeculectomy).
Congenital ectropion uvea can be associated with angle-closure glaucoma, and placement of glaucoma drainage devices in all 3 of our cases showed early failure due to plate encapsulation. Glaucoma in congenital ectropion uvea requires attention to angle configuration and often requires multiple surgeries to obtain intraocular pressure control.
360-Degree Trabeculotomy for Medically Refractory Glaucoma Following Cataract Surgery and Juvenile Open-Angle Glaucoma
2017, American Journal of Ophthalmology
Citation Excerpt :
Finally, trabeculectomy with or without mitomycin C (MMC) has often been used for medication-refractory JOAG and other refractory cases. With reported success of 56%–95% in pediatric glaucoma, filtration surgery also carries risk of vision-threatening complication.35–37 Success of trabeculectomy, even augmented with MMC, has been reported proportional to patient age, as reported by Beck and associates and Al-Hazmi and associates, with increased risk of failure associated with aphakic status and younger age.36,38
Although angle surgeries show good success in primary congenital glaucoma, reported success in glaucoma following cataract surgery (GFCS) and juvenile open-angle glaucoma (JOAG) is variable and with relatively short follow-up. We evaluated longer-term outcomes of 360-degree trabeculotomy for medically refractory GFCS and JOAG.
Retrospective case series.
First operated eyes of consecutive patients with medically refractory GFCS and JOAG in a single-surgeon pediatric glaucoma practice who underwent illuminated microcatheter-assisted 360-degree trabeculotomy from February 2008 to June 2015 were reviewed. Baseline characteristics, time to failure or last visit, surgical details, final intraocular pressure (IOP), and complications were recorded. Success required IOP ≤22 mm Hg and 20% reduction without additional glaucoma surgery or devastating complication.
Thirty-five eyes (35 patients) were included: 25 GFCS and 10 JOAG (mean age at surgery 5.6 vs 16.7 years, respectively, P < .001). Success for GFCS and JOAG was 18 of 25 (72%) vs 6 of 10 (60%) eyes at mean follow-up of 31.9 ± 26.1 vs 24.5 ± 19.7 months, respectively. IOP was significantly reduced from baseline for both GFCS and JOAG (31.5 ± 7.5 mm Hg vs 19.2 ± 7.7 mm Hg, P < .001; and 29.5 ± 10.3 mm Hg vs 15.8 ± 6.6 mm Hg, P < .001, respectively). Fewer glaucoma medications were needed after surgery (P = .01) for GFCS but not JOAG. Complications (all but 2 spontaneously resolving) included choroidal effusion (1), vitreous hemorrhage (3), Descemet detachment (1), and persistent hyphema (2). Three-year Kaplan-Meier success for GFCS vs JOAG was 75.3% vs 53.3%, respectively.
Illuminated microcatheter-assisted 360-degree trabeculotomy is a useful, low-risk, modestly successful initial surgical treatment for both medically refractory GFCS and JOAG.
Trabeculectomy bleb-associated infections
2017, Survey of Ophthalmology
Trabeculectomy with antimetabolites is the most commonly performed surgery worldwide for glaucoma patients with progressive optic nerve head injury and visual field loss despite maximum pharmacologic intraocular pressure–lowering therapy. Trabeculectomy bleb-associated infections remain one of the most feared early and long-term complications of trabeculectomy surgery because of their poor prognosis and variable response to antimicrobial therapy. Several studies have evaluated how surgical technique, conjunctival incision location, comorbid ocular pathology, concurrent medication use, and bleb morphology affect the risk of bleb-associated infection. New surgical techniques and devices aim to achieve a similar intraocular pressure reduction profile to trabeculectomy while avoiding the presence of a conjunctival bleb. We provide a comprehensive review of studies evaluating risk factors for bleb-associated infection after trabeculectomy and propose a diagnostic and therapeutic approach to bleb-associated infection.
Slow coagulation versus micropulse transscleral cyclophotocoagulation for refractory childhood glaucoma
2024, European Journal of Ophthalmology

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^☆: Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York, and a core grant EY06360 from the National Eye Institute, Bethesda, Maryland (Drs Beck, Lynch, and Lynn).

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Original ArticlesTrabeculectomy with adjunctive mitomycin C in pediatric glaucoma☆

Abstract

Section snippets

Patients and methods

Results

Discussion

Long-term results of trabeculectomy in the Japaneseanalysis by life-table method

Jpn J Ophthalmol

Trabeculectomy in young patients

Ophthalmology

Filtering surgery in childrenbarriers to success

Ophthalmology

Subconjunctival injection of 5-fluorouracil following trabeculectomy for congenital and infantile glaucoma

Ophthalmic Surg

Initial 5-fluorouracil trabeculectomy in young patients

Ophthalmology

Enhanced intraocular pressure controlling effectiveness of trabeculectomy by local application of mitomycin C

Trans Asia–Pacific Acad Ophthalmol

Mitomycin as adjunct chemotherapy with trabeculectomy

Ophthalmology

Mitomycin as adjunct chemotherapy in congenital and developmental glaucoma

J Glaucoma

Mitomycin C-augmented trabeculectomy in refractory congenital glaucoma

Ophthalmology

Surgical results of secondary glaucomas in childhood

Ophthalmology

The use of a new laser lens holder for performing laser suture lysis in children

Arch Ophthalmol

Nonparametric estimation from incomplete observations

J Am Stat Assoc

Evaluation of survival data and two new rank order statistics arising in its consideration

Cancer Chemother Rep

Primary trabeculectomy in congenital glaucoma

Br J Ophthalmol

Trabeculectomy versus trabeculotomy in congenital glaucoma

Br J Ophthalmol

Trabeculectomy in congenital glaucoma

Indian J Ophthalmol

Flurouracil filtering surgery study groupone year follow-up

Am J Ophthalmol

The results of glaucoma surgery in aniridia

Arch Ophthalmol

Original Articles
Trabeculectomy with adjunctive mitomycin C in pediatric glaucoma☆