Purpose:
To correlate the diagnosis of glaucoma among children in the Infant Aphakia Treatment Study (IATS) by age 10 years with anterior segment optical coherence tomography (AS-OCT) findings.
Methods:
A multicenter randomized controlled trial of 114 infants with unilateral congenital cataract who were 1–6 months of age at surgery. Data on long-term glaucoma-related status and outcomes were collected when children were 10.5 years old. Participants were randomized at cataract surgery to either primary intraocular lens (IOL) or no IOL implantation (contact lens [CL]). AS-OCT findings in eyes with glaucoma were compared to eyes which did not have glaucoma and to the fellow eyes, between fellow and treated eyes, and between the IOL and CL groups.
Results:
There were no significant differences in the mean nasal and temporal anterior chamber angle (ACA) or mean nasal and temporal angle opening distance (AOD) for nonglaucomatous, glaucomatous, and fellow eyes (P = 0.31, 0.16, 0.43, 0.08 resp.). There were also no significant differences in mean nasal and temporal ACA and AOD between fellow and treated eyes (P = 0.44, 0.67, 0.57, 0.38 resp.), or between IOL and CL groups (P = 0.36, 0.35, 0.49, 0.44, resp.).
Conclusions:
AS-OCT confirmed that eyes with glaucoma in IATS had predominantly open angles with similar ACA and AOD to eyes without glaucoma and to fellow eyes. Furthermore, congenital cataract surgery with or without an IOL did not result in a significant difference in ACA or AOD compared to fellow eyes in IATS.
Descemet's stripping automated endothelial keratoplasty (DSAEK) has rapidly become the standard of care for endothelial dysfunction of the cornea in adults. There are few reports of DSAEK in children and infants, mainly because most pediatric corneal opacities are full-thickness and therefore not amenable to lamellar procedures but also because of the unique difficulties of performing this procedure in the youngest patients. We report the case of an 8-month-old girl who underwent DSAEK for congenital hereditary endothelial dystrophy. At 24 months' follow-up, her visual acuity was 20/40 in the operated eye. To our knowledge, this is the first report of an objective visual outcome in a child with DSAEK performed in infancy.
Glaucoma is one of the most serious complications occurring after infantile cataract surgery. It is usually open-angle and can develop during the immediate postoperative period or years later. While early cataract surgery has been shown to be associated with improved visual outcomes,1,2 it has also been reported to increase the risk of developing glaucoma.3-5 A wide range of cumulative incidences of glaucoma has been reported following infantile cataract surgery.6-10 However, it is difficult to directly compare these studies because of their differing inclusion criteria and lengths of follow-up. Moreover, some studies used national registries8,9 or data from multiple institutions11,12 and as a result surgical techniques and follow-up examinations were not standardized. Furthermore, these studies differed in how they defined “glaucoma.” Some studies defined glaucoma solely on the basis of an elevated intraocular pressure (IOP),13-17 while other studies based the diagnosis on whether treatment had been initiated for glaucoma.4,8 Studies which based the diagnosis solely on elevated IOP may have over-diagnosed glaucoma, since there can be a lag between modestly elevated IOP and clinically significant optic disc deterioration or visual field abnormalities.18 In addition, the thicker corneas of aphakic eyes introduces a potential source of measurement error when using IOP alone as a criterion for diagnosing glaucoma.19-22
The aim of the current study is to report the long-term cumulative incidence of glaucoma in a cohort of children who all underwent congenital cataract surgery when <7months of age by the same surgeon (SRL) using a modern surgical technique with follow-up care provided by a pediatric ophthalmologist and a pediatric glaucoma specialist.
Objective
To report the incidence of glaucoma and glaucoma suspects in the Infant Aphakia Treatment Study (IATS). To evaluate risk factors for the development of a glaucoma-related adverse event in IATS in the first year of follow-up.
Methods
114 infants with a unilateral congenital cataract were assigned to undergo cataract surgery between 1 to 6 months of age either with (IOL) or without IOL implantation (CL). Standardized definitions of glaucoma and glaucoma suspect were created and used in the IATS.
Results
Ten patients (9%) developed glaucoma and 4 patients (4%) were glaucoma suspects for a total of 14 patients (12%) with a glaucoma-related adverse event in the treated eye through the first year of follow-up. Five CL patients (9%) and 9 IOL patients (16%) developed a glaucoma-related adverse event. The odds of developing a glaucoma-related adverse event was 3.1 times higher for a child with persistent fetal vasculature (PFV), and 1.6 times higher for each month of age younger at cataract surgery.
Conclusions
Modern surgical techniques do not eliminate the early development of glaucoma following congenital cataract surgery with or without an intraocular lens. Younger patients with or without PFV seem more likely to develop a glaucoma-related adverse event in the first year of follow-up.Vigilance for the early development of glaucoma is needed following congenital cataract surgery, especially when surgery is performed during early infancy or with PFV. Five year follow-up data for the IATS will likely reveal more glaucoma-related adverse events.
Purpose: To evaluate the outcomes of 360-degree suture trabeculotomy in childhood glaucoma with poor prognosis.
Subjects and Methods: A nonrandomized, retrospective chart review was performed on pediatric patients (under 18 years old) treated with a 360-degree suture trabeculotomy for glaucoma. The cases were categorized into the following groups: (1) primary congenital glaucoma with birth-onset presentation accompanied by corneal clouding noted at birth, (2) primary congenital glaucoma with onset or presentation after 1 year of age, (3) primary congenital glaucoma with prior failed goniotomy surgery, (4) infantile-onset glaucoma following congenital cataract surgery, and (5) infantile-onset glaucoma with associated ocular/systemic anomalies.
Results: A total of 45 eyes of 33 patients were analyzed. The mean preoperative intraocular pressure (IOP) was 34.3 ± 6.7 mm Hg on an average of 1.5 medications. Median age at time of surgery was 7 months. Mean final IOP (median last follow-up or failure, 12 months) was 22.2 ± 7.1 mm Hg on an average of 1.5 medications. The probability of success according to time after surgery was 87% at 6 months, 63% at 1 year, and 58% at 2 years. Kaplan-Meier analysis of Groups 1-4 versus Group 5 failed to demonstrate a statistically significant difference (p = 0.13). Of 5 eyes with port wine mark–related glaucoma, 2 had a large (>50%), persistent postoperative hyphema and concurrent vitreous hemorrhage.
Conclusions: Children with a wide range of ocular pathologies can be successfully treated with 360-degree suture trabeculotomy. Further evaluation of this surgical technique in primary congenital glaucoma and open-angle glaucoma following congenital cataract surgery is warranted.
Purpose: To examine the efficacy of a sequential tube shunt versus transscleral diode cyclophotocoagulation following failure of an initial tube shunt on maximal medical therapy in treatment of refractory childhood glaucoma.
Methods: A nonrandomized retrospective chart review was conducted of 17 eyes of 14 pediatric patients (less than 18 years old) with refractory glaucoma treated with either sequential tube shunt (Group A) or diode cyclophotocoagulation (Group B) following initial failed tube shunt. Success was defined as an intraocular pressure (IOP) ≤22 mm Hg on medical therapy, no visually devastating complications, and no further glaucoma surgery performed or recommended.
Results: Of the 17 eyes, 8 had a sequential tube shunt and 9 underwent diode cyclophotocoagulation as a secondary procedure. Kaplan-Meier analysis demonstrated a successful outcome of 75% and 62.5% at 12 months and 24 months, respectively, for Group A, and 66.7% at both 12 and 24 months for Group B (p = 0.48) Corneal decompensation or graft failure was noted in 3/8 eyes (38%) in Group A. Cataract surgery was performed in 2/5 phakic eyes (40%) in Group B. One eye in each group progressed to no light perception.
Conclusions: Diode cyclophotocoagulation and sequential tube shunt following primary tube shunt failure in childhood glaucoma showed similar efficacy and complication rates. However, the small sample size of this study warrants further evaluation of these two procedures following failure of a tube shunt device in pediatric glaucoma.
Purpose: To compare sequential glaucoma drainage device (GDD) implantation with transscleral diode cyclophotocoagulation (CPC) following failure of a primary GDD. Materials and Methods: A retrospective review of all patients who underwent GDD implantation at a single institution over 10 years. Patients who required an additional GDD and/or CPC were analyzed. Success was defined as absence of loss of light perception, reoperation for glaucoma, and intraocular pressure (IOP) > 21 or < 6 at 2 consecutive visits after an initial 3-month period. Results: Thirty-two patients received sequential GDD. Twenty-one underwent CPC. Cohorts were statistically similar in regards to age, sex, race, and number of previous surgeries. Preoperatively, the GDD cohort had a lower IOP and better visual acuity. The mean length of follow-up was 37.9 months for the GDD group and 46.3 months for CPC. Both procedures significantly reduced IOP; however, CPC led to a greater reduction (P=0.0172). Survival analysis found the 5-year probability of surgical success to be 65.3% for sequential GDD and 58.0% for CPC (P=0.8678). No cases of phthisis occurred in either group. There were 2 cases of endophthalmitis (6.3%) in the GDD group, and none in the CPC group. In eyes without preexisting corneal edema, estimated corneal decompensation probability at 3 years was 31.6% for GDD and 6.7% for CPC (P=0.0828). Conclusions: Sequential GDD and CPC are both effective at reducing IOP following the failure of a primary GDD. CPC after GDD failure warrants further investigation as it led to a greater reduction in IOP with fewer serious adverse events.