Cyclodiode Laser as the First Surgical Approach in Childhood Glaucoma Under the Age of 8 Years.

PRCIS: Cyclodiode as a primary treatment for childhood glaucoma patients younger than 8 years has a 12-month success rate of 55.24%. It can delay the need for penetrating glaucoma surgery. PURPOSE: The purpose of this study was to evaluate the treatment outcome of cyclodiode laser in childhood glaucoma for patients under the age of 8 years. DESIGN: This was a retrospective, consecutive, noncomparative case series. PARTICIPANTS: All childhood glaucoma patients who underwent cyclodiode from March 2005 to January 2017 as a primary surgical treatment under the age of 8 years. METHODS: A retrospective review of the medical records of consecutive patients who underwent cyclodiode by a single surgeon. MAIN OUTCOME MEASURES: Success for single-diode intervention was defined as intraocular pressure (IOP) (>6 wk postoperative) ≤21 mm Hg with antiglaucoma medications and ≥20% IOP reduction, no further glaucoma surgery including cyclodiode, no loss of perception of light, and no major complications. Success for multiple-diode interventions was defined similar to the single diode, except that repeated cyclodiode is not considered a failure. RESULTS: In all, 59 eyes of 43 patients were studied. The most common diagnosis was aphakic glaucoma. The mean age at cyclodiode treatment was 2.7 years (SD=2.2). Fifty-six percent of the patients were under 3 years. Success rates at 12 months after the procedure were 46.67% and 55.24% for single-diode and multiple-diode interventions, respectively. An IOP of >20 mm Hg 6 weeks after a cyclodiode session is a significant risk factor for failure with an hazard ratio of 2.41 (95% confidence interval: 1.00-5.81; P=0.05). Among the operated eyes, the surgeon could avoid further glaucoma surgery in 67.8% of the eyes during the first year after single or multiple cyclodiode sessions. None of the eyes experienced phthisis bulbi, hypotony, and severe uveitis. CONCLUSIONS: Cyclodiode laser in childhood glaucoma patients under the age of 8 years can be considered a safe alternative for glaucoma patients who can have a high risk of surgical complications. Performing cyclodiode laser can delay the need for penetrating glaucoma surgery. The IOP at 6 weeks may be a good predictor for the treatment outcome.

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.

Optical Coherence Tomography Findings After Childhood Lensectomy.

Purpose: To explore the impact of childhood lensectomy on posterior segment development. Methods: Cross-sectional observational study at children's eye clinics at a tertiary referral center in London, UK. We included 45 children age 4 to 16 years with healthy eyes and 38 who had undergone lensectomy. We acquired posterior segment optical coherence tomography scans of both eyes. We used parametric and nonparametric tests in SPSS24 for the comparison of parameters between groups and within individuals; a P value less than 0.05 was considered significant. The main outcome measures were foveal pit depth and subfoveal choroidal thickness (CT). Secondary outcomes were inner and outer ring CT and photoreceptor layer parameters, macular and peripapillary retinal nerve fiber layer thickness. Results: Foveal pit depth and subfoveal CT are significantly reduced in eyes that have undergone lensectomy compared with nonoperated eyes. Inner ring CT and outer ring CT are reduced. Foveal inner retinal layer thickness is increased. Mean inner retinal and outer nuclear layer thickness are not affected. Conclusions: Childhood lensectomy is associated with a reduction in developmental foveal pit deepening and lack of developmental thickening of the posterior choroid. Mechanical and optical disruption of foveal and subfoveal choroidal development may affect structural foveal development after childhood lensectomy.

Childhood Glaucoma: Long-Term Outcomes of Glaucoma Drainage Device Implantation Within the First 2 Years of Life.

PRéCIS:: Glaucoma drainage device (GDD) implantation within the first 2 years of life yields an overall success rate of 59.0% at 5 years. It is safe and requires a relatively low number of postoperative interventions. PURPOSE: The purpose of this study was to evaluate the long-term outcomes of the treatment of childhood glaucoma with GDDs within the first 2 years of life. METHODS: A total of 43 children (60 eyes) having undergone GDD implantation within the first 2 years of life at Moorfields Eye Hospital between July 2005 and November 2014 were included in this retrospective case series. Kaplan-Meier survival curves were created for the evaluation of surgical success. Log-rank analysis was performed for the detection of risk factors for failure. MAIN OUTCOME MEASURES: Overall success rates at 1, 5, and 7 years after surgery. Surgical success: intraocular pressure ≥5/≤21 mm Hg, no further glaucoma surgery required, nonoccurrence of loss of perception of light or devastating complications. RESULTS: The results are listed as follows: Median duration of follow-up was 48.0 months. Median age at surgery was 11.5 months. Seventy-three percentage of children were white. Most common types of glaucoma were primary congenital glaucoma [(PCG); 67%], glaucoma following cataract surgery (18%), and anterior segment dysgenesis (10%). Overall success rates were 93%, 59%, and 59%, respectively. There were no differences in the survival rates as a function of PCG/non-PCG, sex, and removal of intraluminal stent suture. Mean number of general anesthesia administrations during the first postoperative year was 1.8. CONCLUSIONS: GDD implantation within the first 2 years of life is effective and safe. The low number of general anesthesia administrations required during the first postoperative year could help to reduce the burden placed on children and carers. Further research is required to directly compare the efficiency of GDD implantation with other surgical options.

Automated segmentation of the corneal endothelium in a large set of 'real-world' specular microscopy images using the U-Net architecture.

Monitoring the density of corneal endothelial cells (CEC) is essential in the management of corneal diseases. Its manual calculation is time consuming and prone to errors. U-Net, a neural network for biomedical image segmentation, has shown promising results in the automated segmentation of images of healthy corneas and good quality. The purpose of this study was to assess its performance in "real-world" CEC images (variable quality, different ophthalmologic diseases). The outcome measures were: precision and recall of the extraction of CEC, correctness of CEC density estimation, detection of ungradable images. A classical approach based on grayscale morphology and water shedding was pursued for comparison. There was good agreement between the automated image analysis and the manual annotation from the U-Net. R-square from Pearson's correlation was 0.96. Recall of CEC averaged 0.34 and precision 0.84. The U-Net correctly predicted the CEC density in a large set of images of healthy and diseased corneas, including images of poor quality. It robustly ignored image regions with poor visibility of CEC. The classical approach, however, did not provide acceptable results. R-square from Pearson's correlation with the ground truth was as low as 0.35.

Childhood Lensectomy Is Associated with Static and Dynamic Reduction in Schlemm Canal Size: A Biomechanical Hypothesis of Glaucoma after Lensectomy.

PURPOSE: To compare Schlemm canal (SC) and trabecular meshwork (TM) in children with healthy eyes and those with and without glaucoma after lensectomy. DESIGN: Cross-sectional observational study. PARTICIPANTS: Fifty children 4 to 16 years of age with healthy eyes and 48 children who underwent lensectomy (124 healthy and 72 postlensectomy eyes). METHODS: Anterior segment (AS) OCT (Tomey SS-1000 CASIA; Tomey, Nagoya, Japan) of the nasal iridocorneal angle at 2 levels of accommodative effort (2.5 diopters [D] and 15 D). For each parameter and state of accommodation, a random effects model was fitted to estimate differences between healthy eyes and eyes with history of lensectomy. MAIN OUTCOME MEASURES: Dimensions of SC and TM and conventional AS OCT iridocorneal angle measurements. RESULTS: The horizontal diameter of SC and its cross-sectional area (CSA) are significantly smaller in eyes that have undergone lensectomy versus healthy eyes. Accommodative effort increases SC size in healthy eyes, but not in eyes that have undergone lensectomy. CONCLUSIONS: Lensectomy is associated with a reduction in SC size and a loss of physiologic SC dilatation during accommodative effort, which may reflect a reduction in outflow facility and may contribute to the development of glaucoma after lensectomy.

Comparison of Long-Term Outcomes of Femtosecond Laser-Assisted Keratoplasty with Conventional Keratoplasty.

PURPOSE: Astigmatism is a significant problem in penetrating keratoplasty. Lower astigmatism and better visual outcomes had been expected from laser-assisted penetrating keratoplasty, that is, from the top-hat, mushroom, or zig-zag cutting profiles. We report the long-term outcomes of 141 femtosecond laser-assisted penetrating keratoplasties retrospectively. We compare these outcomes with those of penetrating keratoplasty using the guided trephine system (GTS). METHODS: In all, 141 femtosecond laser-assisted penetrating keratoplasties had been performed in 119 patients. The results were compared with those of conventional keratoplasty (n = 1254; visual and refractive outcomes, graft rejections, and graft failure). RESULTS: Follow-up averaged 33 months. In eyes with keratoconus, the time to achieve a visual acuity of 10/20 (Snellen) was shorter in the mushroom than in the GTS group. However, there was no relevant long-term difference. Graft astigmatism was higher in the laser groups [keratometric astigmatism at the end of follow-up: -4.5 ± 4 (GTS), -5.8 ± 3.3 (top-hat), -5.9 ± 3.2 D (mushroom); P < 0.01]. In eyes with keratoconus, rates of graft rejection were highest in the mushroom group (55%). In the other groups, top-hat keratoplasty resulted in lower rates of rejection than GTS keratoplasty (31%). CONCLUSIONS: There is no significant difference in the refractive and visual outcomes after femtosecond laser-assisted penetrating keratoplasty compared with GTS keratoplasty. The benefits from the use of the femtosecond laser may be limited and should be weighed against an increased risk of immune reactions, higher surgical complexity, and higher costs.