360-Degree Trabeculotomy for Medically Refractory Following Surgery and Juvenile Open-Angle Glaucoma

MARIA E. LIM, JENNIFER B. DAO, AND SHARON F. FREEDMAN

PURPOSE: Although angle surgeries show good success refractory GFCS and JOAG. (Am J Ophthalmol in primary congenital glaucoma, reported success in glau- 2017;175:1–7. Ó 2016 Elsevier Inc. All rights reserved.) coma following cataract surgery (GFCS) and juvenile open-angle glaucoma (JOAG) is variable and with rela- tively short follow-up. We evaluated longer-term out- HILDHOOD GLAUCOMA ENCOMPASSES A HETERO- comes of 360-degree trabeculotomy for medically geneous group of disorders with variable patho- refractory GFCS and JOAG. C physiology and response to treatment, and DESIGN: Retrospective case series. represents an important cause of blindness in the United 1,2 METHODS: First operated eyes of consecutive patients States and worldwide. Glaucoma following cataract with medically refractory GFCS and JOAG in a surgery (GFCS) is a well-known complication of cataract single-surgeon pediatric glaucoma practice who under- extraction in childhood, with reported incidence ranging went illuminated microcatheter-assisted 360-degree from 0% to 41%. The probability of an eye developing glau- trabeculotomy from February 2008 to June 2015 were coma increases with time after cataract surgery, mandating 3–6 reviewed. Baseline characteristics, time to failure or last regular surveillance in all at-risk eyes. Juvenile open- visit, surgical details, final intraocular pressure (IOP), angle glaucoma (JOAG) is a primary childhood glaucoma 1 and complications were recorded. Success required IOP with an age of onset between 4 and 35 years. Whereas £22 mm Hg and 20% reduction without additional glau- some GFCS eyes may have peripheral anterior synechiae coma surgery or devastating complication. (PAS), both GFCS and JOAG classically share the com- 7 RESULTS: Thirty-five eyes (35 patients) were included: monality of having an open angle configuration. GFCS 25 GFCS and 10 JOAG (mean age at surgery 5.6 vs 16.7 and JOAG are notably challenging to manage, often refrac- years, respectively, P < .001). Success for GFCS and tory to medications alone and requiring multiple proced- 8–11 JOAG was 18 of 25 (72%) vs 6 of 10 (60%) eyes at ures and impacting quality of life. mean follow-up of 31.9 ± 26.1 vs 24.5 ± 19.7 months, Surgical options for medically refractory cases include respectively. IOP was significantly reduced from baseline angle surgery, filtering surgery, glaucoma drainage device 9,12 for both GFCS and JOAG (31.5 ± 7.5 mm Hg vs 19.2 placement, and cyclodestructive procedures. Although ± 7.7 mm Hg, P < .001; and 29.5 ± 10.3 mm Hg vs angle surgery, including illuminated microcatheter- 15.8 ± 6.6 mm Hg, P < .001, respectively). Fewer glau- assisted 360-degree trabeculotomy (360-trabeculotomy), coma medications were needed after surgery (P [ .01) shows good success in primary congenital glaucoma 13,14 for GFCS but not JOAG. Complications (all but 2 spon- (PCG), reported success rates in GFCS and JOAG taneously resolving) included choroidal effusion (1), vit- are variable (16%–57%) and with relatively short follow- reous hemorrhage (3), Descemet detachment (1), and up and may not be appropriate for eyes with extensive 15,16 persistent (2). Three-year Kaplan-Meier suc- PAS. The purpose of this retrospective study is to cess for GFCS vs JOAG was 75.3% vs 53.3%, respec- evaluate longer-term outcomes of 360-trabeculotomy for tively. medically refractory GFCS and JOAG. CONCLUSIONS: Illuminated microcatheter-assisted 360-degree trabeculotomy is a useful, low-risk, modestly successful initial surgical treatment for both medically METHODS

THE STUDY WAS APPROVED BY THE DUKE INSTITUTIONAL Review Board and was in accordance with the Health Supplemental Material available at AJO.com. Accepted for publication Nov 19, 2016. Insurance Portability and Accountability Act. Consecu- From Duke University Department of Ophthalmology, Durham, North tive cases of trabeculotomy performed between February 8, Carolina (M.E.L., S.F.F.); and Eye Consultants of Northern Virginia, 2008 and June 15, 2015 were identified from surgical logs in Springfield, Virginia (J.B.D.). Inquiries to Sharon F. Freedman, Duke Eye Center, 2351 Erwin Rd, a single pediatric glaucoma practice, and the corresponding Durham, NC 27710; e-mail: [email protected] medical records were reviewed retrospectively. All eyes

0002-9394/$36.00 © 2016 ELSEVIER INC.ALL RIGHTS RESERVED. 1 http://dx.doi.org/10.1016/j.ajo.2016.11.011 diagnosed with GFCS and JOAG treated with attempted conjunctival flap were each sequentially closed with 10-0 or successful microcatheter-assisted trabeculotomy with polyglactin sutures. Subconjunctival dexamethasone and at least 6 months of follow-up were included. Exclusion cefazolin were administered inferiorly and the eye was criteria were prior glaucoma surgery (laser or incisional), dressed with antibiotic/steroid ointment and patched. In suture trabeculotomy, second eyes receiving subsequent the postoperative period, eyes were treated with antibiotic 360-trabeculotomy, coexisting ocular or systemic syn- drops, pilocarpine, and tapering topical steroid drops for drome, and insufficient follow-up time. several weeks. IOP-lowering medications were added as All surgeries were performed or attended by a single needed accordingly. Follow-up examination was routinely pediatric glaucoma surgeon (S.F.F.). As of 2008, 360- performed on postoperative day 1, at weeks 1 and 3, and trabeculotomy was the standard initial surgery for both then every 3–4 months as appropriate. medically-refractory GFCS and JOAG at our institution. Data were collected for the first operated eye of a given Preoperative intraocular pressure (IOP) was calculated as patient. Demographic information was collected from the the mean of IOP measurements recorded starting from patient’s medical record and included sex, age at surgery the date when surgery was deemed necessary to the day of and glaucoma diagnosis, primary diagnosis (indication for surgery immediately after anesthesia induction. An exam- surgery), other ocular diagnoses, corneal abnormalities, ination under anesthesia was completed prior to the pro- and cup-to-disc ratio. IOP and number of glaucoma medica- cedure. All eyes that underwent 360-trabeculotomy had tions were recorded preoperatively and at last follow-up or an open iridocorneal angle by direct gonioscopy. Eyes failure. Any surgical complications and necessary interven- were routinely treated with 2% pilocarpine and 0.5% apra- tions were also noted. Success was defined as IOP <_22 mm clonidine immediately prior to surgery. Hg or IOP reduction >20% from baseline, with or without All 360-trabeculotomy procedures were performed in a topical glaucoma medications, and considered adequate for standard fashion (Supplemental Video; Supplemental glaucoma severity without additional glaucoma surgery or Material available at AJO.com). An inferotemporal limbus devastating complication. Characteristics of included par- incision of 4 mm was made, followed by creation of a 3-mm ticipants and eyes were tabulated with the use of numbers triangular partial-thickness limbus-based scleral flap, which and percentages for categorical data and all data are given was extended into peripheral to expose the corneal- as mean 6 standard deviation, with range in parentheses scleral junction. A radial incision was made at the base of often also reported. Comparisons between groups for contin- the flap and gradually deepened using a Micro-Sharp blade uous variables were completed with the paired t test and (Beaver-Visitec International, Inc, Waltham, Massachu- 95% confidence interval (CI) as appropriate. Fisher exact setts, USA) in an attempt to locate Schlemm canal. test was used to compare ratios as appropriate. Kaplan- Once Schlemm canal was identified, its location was Meier survival curves analysis was used to calculate success confirmed by passing a 6-0 polypropylene suture with a over time, with accompanying 95% CI. All statistical tests blunted tip for several clock hours, with intraoperative were 2-sided, and the threshold for significance was set at gonioscopy to visualize the suture in the canal when .05. Statistical analysis was performed using Microsoft Excel possible. The iTrack microcatheter (Iscience Interven- (Microsoft, Redmond, Washington, USA) and Graph-Pad tional, Menlo Park, California, USA) was then prepared Prism (GraphPad Software, La Jolla, California, USA). by injecting viscoelastic, introducing the catheter into 1 cut end of the Schlemm canal, and then gradually advancing it circumferentially, using the illuminated tip as confirmation of position within the canal. If needed, a RESULTS second cut-down site rarely was used to facilitate 360- degree cannulation, creating a small incision right at the A TOTAL OF 72 EYES HAD 360-DEGREE TRABECULOTOMY limbus. Viscoelastic was injected into the anterior chamber during the review period. Reasons for exclusion were as fol- through a temporal paracentesis site before the catheter lows: <6 months of follow-up (GFCS 4 eyes, JOAG 2 was retrieved from the other cut end of the Schlemm canal. eyes), suture trabeculotomy (GFCS 3 eyes, JOAG 1 eye), The 2 ends of the microcatheter were then grasped and previous glaucoma procedure (GFCS 1 eye, JOAG 2 pulled in a purse-string manner as the catheter was visual- eyes), second eyes receiving subsequent 360- ized coming into and across the anterior chamber. A cleft trabeculotomy (GFCS 6 eyes, JOAG 3 eyes), and other could be identified in the iridocorneal angle after cannula- glaucoma diagnosis (15 eyes). Thirty-five first eyes of 35 tion. If the Schlemm canal was unable to be cannulated patients were included, 25 eyes with GFCS and 10 eyes 360 degrees, the procedure was converted to either goniot- with JOAG. There were 13 female patients. Ethnicity omy and/or trabeculotomy with a Harms metal trabeculo- was reported as white (21 patients), African American tome (the latter if the canal location was felt to be (8), Hispanic (3), South Asian (1), and unreported (2). confirmed). A filtered air bubble was then placed into the The Table shows baseline characteristics of each group. anterior chamber and a portion of the viscoelastic was When compared with the GFCS group, the JOAG group withdrawn using a 27 gauge cannula. The scleral flap and was significantly older at the age of diagnosis and age at

2 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2017 TABLE. Baseline Characteristics of Included Glaucoma Following Cataract Surgery and Juvenile Open-Angle Glaucoma Eyes

Baseline Characteristic GFCS (N ¼ 25 Eyes) JOAG (N ¼ 10 Eyes)

Age at glaucoma diagnosis (y) Mean 6 standard deviation 3.3 6 3.9 14.2 6 6.3 Median (range) 2.0 (0.2–16.0) 12.5 (8.0–27.0) Previous studya Mean 6 standard deviation 3.1 6 5.03 16.3 6 8.2 Median (range) 1.5 (0.3–19) 14.5 (9–30) Age at surgery (y) Mean 6 standard deviation 5.6 6 5.6 16.7 6 6.1 Median (range) 3.4 (0.3–20.5) 16.2 (9.4–28.2) Mean preoperative IOP (mm Hg) 31.5 6 7.5 29.5 6 10.3 Number of preoperative glaucoma medications 3.0 6 1.0 3.6 6 0.5 Time to last follow-up/failure (mo) Mean 6 standard deviation 31.9 6 26.1 24.5 6 19.7 Median (range) 23.1 (0.9–82.1) 18.9 (0.7–52.4) Previous study (mo) Mean 6 standard deviation 17.2 6 16.6 13.6 6 8.0 Median (range) 6 (1–47) 12.3 (1–27) Number of eyes with starting c/d >_0.5 (c/d >_0.8) 17 (6) 9 (9) Preoperative peripapillary RNFL thickness by optical coherence __ 60.6 6 24.7 tomography (mm)

c/d ¼ cup-to-disc ratio; GFCS ¼ glaucoma following cataract surgery; IOP ¼ intraocular pressure; JOAG ¼ juvenile open-angle glaucoma; RNFL ¼ retinal nerve fiber layer. Values given as mean 6 standard deviation unless otherwise stated. Values are calculated with a separate entry for each included eye. aPrevious study included 13 GFCS eyes and 10 JOAG eyes. Two JOAG eyes were not included in our study. surgery. The JOAG group had more eyes (90%) with cup- Four eyes were pseudophakic at the time of glaucoma to-disc ratio >_0.8 at baseline compared with the GFCS diagnosis and 2 received an elective secondary intraocular group (24%). Twenty-one of these patients were reported during the study period. We did not find a statistically in our prior study of short-term follow-up (13 of 13 significant effect of lens status on success of GFCS eyes, 8 of 10 previously reported JOAG eyes).16 360-trabeculotomy in this study (P ¼ .88). A second cut- down was necessary in 2 eyes: 1 cut-down was adjacent to GLAUCOMA FOLLOWING CATARACT SURGERY GROUP: the original inferotemporal incision and flap, while the sec- The median age at surgery for the GFCS group (n ¼ 25 ond was inferior nasal (7 o’clock position in a left eye). eyes) was 3.4 years (range: 0.3–20.5 years). Median time These cut-downs were very small and just at the limbus to failure or last visit was 23.1 months (range: and, given their location, would not be expected to affect 0.9–82.1 months). Mean IOP prior to surgery was 31.5 6 the possibility of another glaucoma procedure. Failure to 7.5 mm Hg (95% CI 28.6–34.4 mm Hg). Final mean IOP complete 360-trabeculotomy was encountered in 7 of 25 for all GFCS eyes was 19.2 6 7.7 mm Hg (95% CI eyes (28%). A metal trabeculotome was used to open 180 16.2–22.2 mm Hg, mean decrease 36.6% from baseline), degrees of the iridocorneal angle in 6 eyes where the micro- P < .001 vs preoperative IOP (Figure 1). At last follow- catheter was unable to pass circumferentially; 1 eye had 270 up, the average number of topical glaucoma medications degrees of the angle opened with the microcatheter. We was reduced to 2.4 6 1.1 from mean preoperative value were unable to find a significant difference between eyes of 3.0 6 1.0 glaucoma medications, P ¼ .015 vs preopera- that had complete vs <300-degree Schlemm canal cannu- tive number of topical glaucoma medications. Two eyes lation (P ¼ .34). Eighteen of 25 eyes (72%) were successful were on no medications after 360-trabeculotomy. Snellen at last follow-up, with a final mean IOP of 15.6 6 3.9 mm acuity could be obtained preoperatively in only 8 eyes, Hg. Seven of 25 eyes (28%) did not meet criteria for suc- with mean logMAR acuity of 0.5 6 0.4; at time of failure cess, all of which required additional glaucoma surgery. or final follow-up, logMAR acuity was available in 14 Success at 1 year was 80.0%, 3 years was 75.3%, and 5 years eyes (mean 0.5 6 0.4). For the 8 eyes with measureable pre- was 62.7% by Kaplan-Meier analysis (Figure 2). operative Snellen acuity, there was no significant differ- ence in acuity at time of failure or last follow-up (mean JUVENILE OPEN-ANGLE GLAUCOMA GROUP: Median 0.5 6 0.5, P ¼ .5). age at surgery for the JOAG Group (n ¼ 10 eyes) was 16.2

VOL. 175 360-DEGREE TRABECULOTOMY FOR NON–PRIMARY CONGENITAL GLAUCOMA 3 FIGURE 1. Box-whisker plot of preoperative vs postoperative FIGURE 2. The Kaplan-Meier survival analysis of 360-degree intraocular pressure (IOP) in glaucoma following cataract sur- trabeculotomy for first operated eyes of glaucoma following gery (GFCS) and juvenile open-angle glaucoma (JOAG). The cataract surgery (GFCS) and juvenile open-angle glaucoma top whisker indicates maximum value, the bottom whisker indi- (JOAG), shown separately. In GFCS, 3-year and 5-year success cates minimum value, and the horizontal line indicates median was 75.3% (95% CI 52.9%–88.1%) and 62.7% (95% CI value. 31.3%–82.9%), respectively. In JOAG, 3-year survival was 53.3% (95% CI 17.3%–79.8%). Five-year follow-up for JOAG survival was not available in our study. years (range: 9.4–28.2 years). Median time to failure or last visit was 18.9 months (range: 0.7–52.4 months). Mean IOP prior to surgery was 29.5 6 10.3 mm Hg (95% CI 23.2– 10 included eyes, 9 (90%) had preoperative cup-to-disc 35.9 mm Hg). Final mean IOP in all JOAG eyes was 15.8 ratio of >_0.8, indicating more severe disease and glaucom- 6 6.6 mm Hg (95% CI 11.7–19.9 mm Hg, mean decrease atous . Success at 1 year was 80.0% and at 41.2% from baseline), P ¼ .004 vs preoperative IOP 3 years was 53.3% by Kaplan-Meier analysis (Figure 2). (Figure 1). There was no significant difference in the baseline Five-year follow-up for JOAG survival was not available (mean 3.6 6 0.5) and final (mean 3.1 6 1.3) number of in our study. topical glaucoma medications (P ¼ .32). One eye was on no postoperative medications. Snellen was COMPLICATIONS: The most common complication after measurable in 9 eyes preoperatively, with mean logMAR acu- 360-trabeculotomy was hyphema; all eyes had a small ity of 0.4 6 0.5; at time of failure or final follow-up, mean hyphema that cleared by postoperative week 1. Two eyes logMAR acuity in the same eyes was 0.3 6 0.5. There was (GFCS: 1 eye, JOAG: 1 eye) had a hyphema that persisted no significant difference in preoperative and final acuity longer than 1 week but resolved without surgical interven- (P ¼ .23). tion. Transient hypotony with choroidal effusion was seen Failure to complete 360-degree trabeculotomy was in 1 GFCS patient, whose operated eye also had a small encountered in 3 eyes: 2 eyes were converted to goniotomy peripheral Descemet detachment that did not result in and 1 eye was cannulated 300 degrees. In this particular corneal edema; this eye also had microcornea. Notably, 3 eye, the catheter was retracted when it was noted intrao- GFCS eyes had vitreous hemorrhage, 1 resolving spontane- peratively to be pulling at the root; there was no resul- ously, 1 requiring pars plana vitrectomy (PPV) only, and tant . We were unable to find a significant another requiring PPV combined with endocyclophoto- difference in success between eyes that had complete vs coagulation because of poorly controlled IOP. There were <300-degree cannulation (P ¼ .74). No JOAG eyes no devastating complications in this series, such as retinal required a second cut-down to successfully cannulate the detachment, , phthisis, or loss of light Schlemm canal. Success was seen in 6 of 10 eyes (60%), perception. with a final mean IOP of 11.6 6 3.6 mm Hg. Of the 4 eyes that failed (40%), 1 eye met IOP criteria of success (final IOP 15.7 mm Hg and 45.9% decrease from baseline IOP); however, despite reduced IOP, the eye was clinically felt to be progressing based on retinal nerve fiber layer DISCUSSION (RNFL) thinning and/or visual field progression. This eye, therefore, had additional glaucoma surgery. The OUR STUDY REPORTS INTERMEDIATE-TERM RESULTS OF 360- average preoperative RNFL thickness on optical coherence degree illuminated microcatheter-assisted trabeculotomy tomography (OCT) for all JOAG eyes was 60.6 6 24.7 mm to manage GFCS and JOAG refractory to medical therapy. vs final average RNFL thickness of 48.0 6 16.1 mm. Of the We found significant reduction in IOP in both diagnostic

4 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2017 groups after 360-trabeculotomy, with moderate success and eyes with JOAG after standard 180-degree trabeculotomy, low complication rates. Kubota and associates found a 47% decrease in IOP at 1 Traditional angle surgery, including goniotomy or trabe- year of follow-up.27 Kjer and Kessing found an 88% success culotomy with a Harms trabeculotome, opens a third to rate at 7 years in 16 eyes with JOAG (4 eyes with ocular hy- half of the iridocorneal angle and has a reported success pertension) after standard 180-degree trabeculotomy with rate of 30%–93% in PCG.9,12–14,17 360-Trabeculotomy an average final IOP of 16 mm Hg.28 Dao and associates was initially described in 1960, using a polypropylene reported the short-term results of 360-trabeculotomy with suture and direct gonioscopy lens to visualize travel the iScience illuminated microcatheter. This group through the Schlemm canal.18 Although suture 360- included 13 eyes with GFCS and 10 eyes with JOAG. trabeculotomy lowers IOP in PCG (Mendicino and associ- Both groups had significantly lower IOP compared with ates reported 92% success rate at 4 years in a series of 24 baseline and it was noted that failures manifested them- eyes13), there is a risk of inadvertent suture misdirection selves soon after trabeculotomy intervention.16 This study into the suprachoroidal space.14,19,20 The use of an notably included JOAG patients older than ours, where the illuminated microcatheter allows visual confirmation of mean age at surgery was 18.6 (median: 16.5, range: 7–37) the correct location in the Schlemm canal. Reports with years. Our report includes more eyes and has an intermedi- 360-trabeculotomy have shown better surgical success, ate length of follow-up, with a 3-year probability of success and in some cases visual acuity, compared with conven- (first eye operated per patient) being 75.3% for GFCS and tional goniotomy and trabeculotomy, although randomized 53.3% for JOAG. controlled trials are lacking.13,21,22 Sarkisian reviewed 16 Alternative therapies to angle surgery are more aggres- eyes with PCG and found that the 75% of eyes with sive and yield variable, modest success rates. Glaucoma complete 360-trabeculotomy had significantly lower IOP drainage devices (GDD), often chosen for medication- compared with those who had partial 360- refractory GFCS and other childhood glaucoma cases, trabeculotomy.23 This is in contrast to our study, where have reported success rates ranging from 42% to 86% and we found no difference in success between complete or par- myriad risks, including tube-related complications, corneal tial 360-trabeculotomy. This may be owing to our limited decompensation, , hypotony, and numbers, the different childhood glaucoma types consid- phthisis.29–31 Notably, aphakic eyes with multiple ered in the present study, or the fact that we categorized procedures preceding GDD implantation did worse based on intent to treat and included eyes if the angle overall and were at risk of more serious complications was opened by other means (goniotomy or metal trabeculo- than their phakic counterparts with other forms of tome). This study is unable to answer the question glaucoma in a review of 23 Baerveldt GDD in 20 eyes regarding the minimum degree of angle opening required (JOAG 3 eyes, GFCS 10).29 Cyclodestructive procedures for successful IOP reduction in GFCS and JOAG. are also among the surgical options for refractory childhood Angle surgeries successfully lower IOP in PCG, but only glaucoma. Transscleral diode laser cyclophotocoagulation modest success has been reported in GFCS and JOAG. has a reported success rate of 42%–62% in pediatric popu- Bothun and associates15 reviewed the use of either goniot- lations and often requires more than 1 treatment.32,33 omy (n ¼ 5 eyes) or traditional trabeculotomy (n ¼ 9 eyes) Endocyclophotocoagulation has similar success in in 14 eyes with GFCS as first-line glaucoma procedure.15 pediatric glaucoma and GFCS (50%–53%), with reported They reported that although there was a significant complications including postoperative retinal detachment decrease in IOP from baseline, success rate was 57.1% in aphakic eyes.33,34 Finally, trabeculectomy with or with an average 1.3 angle surgeries and mean follow-up without mitomycin C (MMC) has often been used for of 4.2 years. The treatment success after 1 angle surgery medication-refractory JOAG and other refractory cases. was 42.9%. This is in contrast to Chen and associates, With reported success of 56%–95% in pediatric glaucoma, who reported a 16% success rate with angle surgery in 24 filtration surgery also carries risk of vision-threatening eyes with GFCS.3 In a study including only 4 eyes with complication.35–37 Success of trabeculectomy, even GFCS, Saltzmann and associates24 reported that the prob- augmented with MMC, has been reported proportional to ability of success was 50% (at 120 months) after a Harms patient age, as reported by Beck and associates and trabeculotome was used to open 360 degrees of the drainage Al-Hazmi and associates, with increased risk of failure asso- angle.24 Girkin and associates reviewed the 2-year success ciated with aphakic status and younger age.36,38 of 360-trabeculotomy with illuminated microcatheter and Interestingly, for primary congenital glaucoma, combined included eyes with secondary glaucoma and JOAG. This trabeculotomy-trabeculectomy with MMC has comparable small series (11 eyes, 7 patients) reported significantly reported success with 360-trabeculotomy at 12 months, lower IOP compared with baseline (57%). Success rate suggesting the filtering bleb may be secondary to the angle rose to 87.5% if eyes with previous surgery were excluded.25 cleft in lowering IOP in these eyes.39 The persistence of a A retrospective review of the 360-degree suture trabeculot- filtering bleb after trabeculectomy with MMC has been omy in poor-prognosis childhood glaucoma reported suc- associated with serious complications in pediatric eyes, cess in 3 of 4 eyes (75%) with GFCS.26 In a study of 7 particularly late bleb leaks and infections.40,41 With

VOL. 175 360-DEGREE TRABECULOTOMY FOR NON–PRIMARY CONGENITAL GLAUCOMA 5 advances in technology, we and others have begun to apply met our IOP criteria for success but nonetheless had addi- angle surgery techniques to non–primary congenital tional surgery to achieve a still lower target IOP. glaucoma cases (GFCS and JOAG); there has similarly In our study, 360-trabeculotomy significantly lowered been a recent resurgence of interest in angle surgery, also IOP in medically refractory GFCS and JOAG. Our data known as microinvasive glaucoma surgery, for mild-to- suggest that this low-risk option provides children and moderate-severity adult open-angle glaucoma.42–49 That young adults with vision-threatening disease some time these techniques would have success in both types of before proceeding with more invasive IOP-lowering sur- glaucoma is not entirely surprising. gery. Although the authors have not found traditional Our study is limited by its small sample size and retrospec- goniotomy to be rewarding in GFCS cases, we believe tive nature, as well as the limited availability of quantitative that our data support attempted 360-degree trabeculotomy data such as optotype visual acuity, visual field, and OCT in those cases of relatively early-onset GFCS with an angle imaging. Myriad child- and diagnosis-related features, open to at least trabecular meshwork and without broad or such as young age, , and media opacity, limited extensive PAS. For eyes with JOAG and severe the latter. The 2 childhood glaucoma diagnoses were damage requiring extremely low postoperative target IOP included together as a contrast to primary congenital glau- (<12 mm Hg), perhaps angle surgery alone may not be coma but differed in several important respects, including adequate. Long-term follow-up and larger numbers may older age of JOAG at diagnosis and more-advanced glau- help determine specific characteristics that would predict coma in the JOAG eyes (vs those with GFCS) at surgery. better or worse success with this particular procedure Owing to their glaucoma severity, several JOAG eyes compared with more-invasive surgery as an initial glau- required extremely low IOP, exemplified by the 1 eye that coma intervention.

FUNDING/SUPPORT: NO FUNDING OR GRANT SUPPORT. FINANCIAL DISCLOSURES: THE FOLLOWING AUTHORS HAVE NO financial disclosures: Maria E. Lim, Jennifer B. Dao, and Sharon F. Freedman. All authors attest that they meet the current ICMJE criteria for authorship.

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