Visco-Circumferential-Suture-Trabeculotomy Versus Rigid-Probe Viscotrabeculotomy in Neonatal-Onset Primary Congenital Glaucoma.

PRCIS: Angle procedures are safe and relatively effective for neonatal onset PCG. Watchful delay in intervention to close to the second month of life is helpful in ensuring diagnosis and making surgery more successful and easier. PURPOSE: The purpose of this study was to compare the surgical outcomes of visco-circumferential-suture-trabeculotomy (VCST) to rigid-probe double-entry viscotrabeculotomy (DEVT) and rigid-probe single-entry viscotrabeculotomy (SEVT) in infants with neonatal-onset primary congenital glaucoma (PCG). DESIGN: This was a retrospective chart review. PATIENTS AND METHODS: Retrospective chart review of 64 eyes of 64 infants with neonatal-onset PCG referred to Mansoura Ophthalmic Center in Mansoura, Egypt between February 2008 and November 2018. Study groups included VCST, DEVT, and SEVT, and follow-up covered 4 postoperative years. Complete (qualified) success was defined as intraocular pressure (IOP) ≤18 mm Hg and with 35% IOP reduction from baseline without (with) IOP-lowering medications or further surgical interventions, and without any sign of progression in corneal diameter, axial length, or optic disc cupping and without visual devastating complications. RESULTS: The mean±SD age at presentation and at the surgery of the study children was 3.63±1.74 and 55.23±1.60 days, respectively. The mean±SD IOP and cup/disc ratio of all study eyes at presentation and at final follow-up were 34.91±0.82 mm Hg and 0.70±0.09 and 17.04±0.74 mm Hg and 0.63±0.08, respectively. Complete success was achieved in 54.5%, 43.5%, and 31.6% in the VCST, DEVT, and SEVT groups, respectively. A self-limited hyphema was the commonest complication in all groups. CONCLUSIONS: Angle procedures are safe and marginally effective for the surgical treatment of neonatal-onset PCG, bringing IOP under control for at least 4 years of follow-up. Circumferential trabeculotomy as a first-line treatment has more favorable outcomes than rigid-probe SEVT. Rigid-probe viscotrabeculotomy offers an alternative to the noncompleted circumferential procedure.

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.

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.

Long-term outcomes of trabeculectomy with ologen implant versus combined viscotrabeculotomy-synechiolysis in uncontrolled uveitic glaucoma.

PURPOSE: To compare trabeculectomy with Ologen implant(Trab-Ologen) to combined viscotrabeculotomy-synechiolysis(VTS) in uncontrolled uveitic glaucoma (UG). PATIENTS AND METHODS: A retrospective chart review of 47 patients subjected to VTS(24 eyes) or Trab-ologen(23 eyes) at Mansoura Ophthalmic Center between 2010 and 2016. The patients were evaluated on day 1, week 1, months 1, 3, 6, 12, 18, 24, 30, 36, 42, and 48. RESULTS: The mean ± standard deviation age of patients in the Trab-ologen and VST groups were 38.29 ± 12.5 and 38.91 ± 11.8 years (p = 0.86), respectively. Juvenile Idiopathic arthritis (controlled on methotrexate) was the most common associated systemic disease (3 patients in each group). The mean ± standard deviation of the intraocular pressure (IOP) and IOP-lowering medications preoperatively and at the end of follow up in the Trab-ologen and VST groups were 33.1 ± 2.6 mmHg, 33.2 ± 2.6 mmHg (p = 0.91), 3.4 ± 0.5, 3.4 ± 0.5 (0.90) and 15.4 ± 1.2 mmHg, 13.0 ± 0.9 mmHg (p < 0.001), 0.6 ± 1.1, 0.7 ± 1.2 (p = 0.72), respectively. IOP control was better in the Trab-ologen group till the 30th month when it becomes better in the VST group till the end of follow-up. The most notable complication was a minimal self-limiting hyphema in the VST group. Success rates at the end of follow-up in the Trab-ologen and VST groups were 83% and 78%, respectively. CONCLUSIONS: Trabeculectomy with ologen implant and visco-trabeculotomy-synechiolysis were equally effective in lowering IOP in uncontrolled UG. There was no statistically significant difference in the success rates between the 2 procedures.

Viscotrabeculotomy versus trabeculectomy in the surgical treatment of open angle glaucoma: a single center, randomised controlled trial.

PURPOSE: The aim of the study was to compare the effect of viscotrabeculotomy and the effect of trabeculectomy on the intraocular pressure (IOP) in cases of open angle glaucoma (OAG). STUDY DESIGN: Prospective comparative study. PATIENTS AND METHODS: The study was conducted on 148 eyes of 148 patients (87 men) presenting with and operated upon for OAG at Mansoura Ophthalmic center of Mansoura University in Mansoura, Egypt from 2012 to 2016. Patients were randomized into viscotrabeculotomy and trabeculectomy groups. Postoperative follow up visits were scheduled at weeks 1 and 2 then months 1, 2, 3, 6, 9, 12, 15, 18, 21 and 24. Complications were noted and managed according to needs. The primary outcome measure was IOP. RESULTS: The study was conducted on 148 eyes (74 right) of 148 patients (87 men). The mean ± SD (range, median) age of the study patients was 50.1 ± 11.5 (20-67, 53) and 51.1 ± 10.0 (27-65, 54.5) years respectively. The mean ± SD (range, median) IOP of the study eyes on maximal tolerated IOP lowering therapy was 23.15 ± 2.31 (19-30, 23.0) and 23.64 ± 1.87 (20-28, 23.0) mmHg respectively and at the end of the 24 months of follow up was 14.91 ± 2.4 (12-23, 14) and 16.64 ± 2.8 (14-25, 16) mmHg respectively (p = < 0.0005). Notable complications included a mild hyphema in the viscotrabeculotomy group and an IOP spike in the trabeculectomy group. CONCLUSIONS: Viscotrabeculotomy and trabeculectomy showed efficacy and safety in OAG patients. The former resulted in better IOP reduction.

Surgery for glaucoma in patients with facial port wine mark.

PURPOSE: To report the results of surgical treatment of glaucoma in patients with facial port wine mark at a single institution over a 10-year period. METHODS: The study was conducted on 21 eyes (10 right eyes) of 17 children (8 males) with glaucoma associated with facial port wine mark presenting to the pediatric ophthalmology practice at a single institution between January 2008 and December 2017. All study eyes underwent combined angle and filtering surgery with antimetabolite (mitomycin C) and were followed for 2 years. Eyes were randomized for the angle component of the procedure to conventional trabeculotomy-trabeculectomy (CTT) or viscotrabeculotomy-trabeculectomy (VTT). Success was defined as intraocular pressure (IOP) of 5-16 mm Hg with no vision-threatening complications. RESULTS: Mean patient age was 17.4 ± 7.5 months. Mean IOP was 30.4 ± 3.7 mm Hg; mean corneal diameter, 12.4 ± 0.5 mm; mean axial length, 21.17 ± 1.63 mm; mean cup:disk ratio, 0.5 ± 0.2; and mean number of IOP-lowering drugs at presentation, 2.6 ± 0.5. At the end of the 2-year follow-up period, corresponding values were 12.9 ± 0.9 mm Hg, 12.6 ± 0.4 mm, 21.6 ± 1.7 mm, 0.6 ± 0.2, and 0.1 ± 0.3, respectively, in VTT patients and 14.3 ± 0.7 mm Hg, 12.9 ± 0.5 mm, 21.8 ± 1.7 mm, 0.6 ± 0.2, and 0.1 ± 0.4, respectively, in CTT groups. The most notable complication was a minimal self-limiting hyphema, more prevalent in the CTT group. CONCLUSIONS: In our study cohort, there were few postoperative complications associated with combined angle and filtering surgery with antimetabolites, which effectively treated elevated IOP, especially when medical treatment showed a modest response. The addition of viscoelastic to the procedure may provide additional benefits and slightly limit intra- and postoperative complications.

Combined phacoemulsification-viscosynechialysis-trabeculotomy vs phacotrabeculectomy in uncontrolled primary angle-closure glaucoma with cataract.

PURPOSE: To compare the effect on intraocular pressure (IOP) of phacoemulsification combined with viscosynechialysis and trabeculotomy with that of phacoemulsification combined with trabeculectomy in eyes with primary angle-closure glaucoma (PACG) and visually significant cataract. SETTING: Mansoura Ophthalmic Center, Mansoura University, Egypt. DESIGN: Prospective case series. METHODS: This prospective randomized study included patients with uncontrolled PACG and visually significant cataract presenting between 2012 and 2017. The eyes were randomized to phacoemulsification combined with viscosynechialysis and trabeculotomy (phaco-viscosynechialysis group) or phacoemulsification combined with trabeculectomy (phacotrabeculectomy group). Success (true and qualified) (IOP <18 mm Hg without sight-threatening complications) was studied 24 months postoperatively. Intraoperative complications were noted. The primary outcome measure was the IOP before and after surgery. RESULTS: The study comprised 59 eyes of 59 patients with a mean age of 59.8 years ± 6.8 (SD) in the phaco-viscosynechialysis group (30 eyes) and 60.3 ± 6.3 years in the phacotrabeculectomy group (29 eyes) (P = .704). The mean preoperative IOP was 28.7 ± 2.14 mm Hg in the phaco-viscosynechialysis group and 28.5 ± 2.11 mm Hg in the phacotrabeculectomy group; the mean at 24 months was 14.5 ± 2.8 mm Hg and 17.3 ± 2.2 mm Hg, respectively (P < .001). The total success rate at 24 months was 90% and 83%, respectively. CONCLUSION: Although both techniques were relatively safe and effective in reducing IOP for at least 2 years in eyes with PACG, combined phacoemulsification-viscosynechialysis-trabeculotomy gave better outcomes.

Ahmed Glaucoma Valve Revision Versus Visco-Trabeculotomy After Failed Ahmed Glaucoma Valve in Refractory Pediatric Glaucoma.

PURPOSE: To compare the outcome of the intraocular pressure (IOP) of Ahmed glaucoma valve (AGV) revision to visco-trabeculotomy (VT) in children's eyes with failed AGV. PATIENTS AND METHODS: A prospective randomized study conducted on 41 children (41 eyes) with uncontrolled glaucoma with an AGV presenting to the pediatric ophthalmology clinic of Mansoura Ophthalmic Center between 2011 and 2016. Study eyes were randomized to AGV revision or VT. Success (true and qualified) (IOP<21 mm Hg without any sight-threatening complications) was studied at the end of 12-month follow-up. Operative complications were noted. The primary outcome was the IOP before and after the study intervention. RESULTS: The mean±SD age of the study children was 7.9±2.6 and 7.7±2.6 years in the AGV revision (19 eyes) and VT groups (22 eyes), respectively (P=0.654). The most common glaucoma type was primary congenital glaucoma in both groups. The mean±SD of the duration between the last glaucoma procedure and the current study intervention was 24.9±4.8 and 25.2±5.8 months in the AGV revision and VT groups, respectively. The mean±SD preoperative IOP and at 12-month follow-up was 32.1±3.2 and 23.2±3.5 mm Hg in the AGV revision group and was 33.3±2.2 and 20.0±3.5 mm Hg in the VT group. The total success rates at 12 months were 31.6% and 63.7% in the AGV revision and VT groups, respectively. CONCLUSIONS: Both VT and AGV revision are reasonably successful and safe interventions for refractory childhood glaucoma after the failure of an AGV. VT is significantly better than AGV revision, resulting in higher success rates and a decrease in IOP-lowering medication use.

Central Corneal Thickness in Aphakic Children With Microcornea-Microphthalmia.

PURPOSE: To study the central corneal thickness (CCT) in eyes with microcornea and aphakia and without glaucoma, compare it with normal controls, and correlate it with the measured intraocular pressure (IOP). METHODS: The study was conducted on 62 eyes of 31 aphakic children with microcornea. Controls (20 children) were selected from age-matched children presenting for routine refraction. Detailed anterior-segment and fundus examinations were conducted. The CCT and the axial length were measured. Medical records of the study patients were reviewed for the stability of the ocular parameters over time to exclude glaucoma. RESULTS: The mean±SD age of the study patients and controls were 4.0 (±3.1, 1.0 to 12.0) and 3.1 (±2.7, 0.6 to 12.0) years, respectively. The mean±SD CCT, the corneal diameter, the measured IOP, the cup/disc ratio, and the axial length of the study patients and the controls were 667.01±72.90 µm, 8.9±0.8 mm, 10.9±5.7 mm Hg, 0.1±0.1, 20.35±2.90 mm and 545.22±28.14 µm, 11.7±0.5 mm, 5.3±1.8 mm Hg, 0.1±0.1, and N/A, respectively. The difference between the study eyes and the controls in the CCT and the measured IOP was statistically significant (P<0.05). CONCLUSIONS: Aphakic eyes with microcornea have thicker CCTs and greater measured IOPs than normal eyes. Hence, the measurement of CCT is recommended in the assessment of aphakic eyes with microcornea for possible glaucoma. The measured IOP, although a reliable parameter, in isolation does not provide a diagnosis of glaucoma and must be viewed in conjunction with other patient findings, such as the cup/disc ratio, the progression of which over time must be considered for a more solid diagnosis.