Long-term surgical and visual outcomes in primary congenital glaucoma: 360 degrees trabeculotomy versus goniotomy.

PURPOSE: To compare the visual outcome and refractive status of children with primary congenital glaucoma who underwent 360 degrees trabeculotomy or goniotomy as an initial surgical procedure. METHODS: This retrospective study describes 24 eyes (15 patients) with primary congenital glaucoma that underwent 360 degrees trabeculotomy as the initial procedure and 40 eyes (23 patients) that underwent goniotomy as the initial procedure. Inclusion criteria were: (1) diagnosis of primary congenital glaucoma and initial angle surgery before 1 year of age, (2) no other ocular or systemic diseases, (3) 360 degrees trabeculotomy or goniotomy as the first surgical procedure, and (4) ability to obtain an Allen or Snellen visual acuity. A postoperative vision of 20/50 or better was considered good. Surgical success was defined as an intraocular pressure (IOP) less than 22 mm Hg with or without medication and without evidence of a progressive optic neuropathy. RESULTS: The IOP was successfully controlled in 92% of eyes in the trabeculotomy group and in 58% of eyes in the goniotomy group (P =.004). Of eyes in the trabeculotomy group, 79% had vision of 20/50 or better compared with 53% in the goniotomy group (P =.03). High myopia was more prevalent in the goniotomy group, but this difference was not statistically significant (P =.16). A poor visual outcome was associated with failure of the angle surgery or poor compliance with follow-up and amblyopia therapy. CONCLUSION: For primary congenital glaucoma, 360 degrees trabeculotomy is a highly effective procedure that results in excellent pressure control and is at least as successful as multiple standard procedures. In this study, 360 degrees trabeculotomy resulted in better vision than what is reported in the literature for standard angle procedures.

Obstruction of the trabecular meshwork by retinal rod outer segments.

Rod outer segments (ROS) have been described in the anterior chamber of patients with the Schwartz syndrome (retinal detachment, uveitis, and glaucoma). The effect of ROS on aqueous outflow was studied by intracameral injection of ROS in human eye bank eyes and in vivo in the cat. Injection of 10(8) ROS in eye bank eyes (n = 8) caused a 19.7% decrease in outflow facility. This was significantly different than in control eyes (n = 8), where the outflow facility decreased 5.2%. Injection of intracameral ROS in the cat resulted in a rise in intraocular pressure (IOP) from a baseline of 19.7 +/- 1.3 mm Hg to a peak of 30.0 +/- 0.7 mm Hg at 24 hours. By 48 hours, IOP returned to baseline. Control injection did not cause a change in IOP. Electron microscopy of the cat trabecular meshwork revealed occlusion of the intratrabecular spaces by ROS with little evidence of inflammatory activity.

Hypotony and ciliochoroidal detachment following pharmacologic aqueous suppressant therapy in previously filtered patients.

This is the first report describing the syndrome of hypotony and ciliochoroidal detachment following pharmacologic aqueous suppressant therapy in previously filtered eyes. Four patients had a history of advanced primary open-angle glaucoma treated with multiple medical therapies, including timolol for 11 to 36 months. They then underwent filtration surgery, which failed in two cases. Timolol and/or acetazolamide therapy was instituted 1 to 18 months following surgery. The patients then developed hypotony and ciliochoroidal detachment, which resolved spontaneously after cessation of the pharmacologic aqueous suppressant therapy. In three of the cases, the episode of hypotony and ciliochoroidal detachment recurred after a second challenge with timolol and/or acetazolamide therapy. Inflammation, tumor, wound leakage, retinal detachment and cyclodialysis cleft were excluded. A mechanism of formation of ciliochoroidal detachment in this syndrome is proposed. Long-term timolol therapy followed by filtration surgery and its attendant postoperative hypotony and ciliochoroidal detachment sensitizes the ciliary epithelium. Subsequent pharmacologic aqueous suppressant therapy results in almost total reduction of aqueous production, causing hypotony and ciliochoroidal detachment.