Goniosurgery for Glaucoma Complicating Chronic Childhood Uveitis
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CLINICAL SCIENCES Goniosurgery for Glaucoma Complicating Chronic Childhood Uveitis Ching Lin Ho, FRCSEd; Edmund Y. M. Wong, FRCSEd; David S. Walton, MD Objectives: To describe the safety and efficacy of achieved in 29 eyes (72%), including success in 22 (55%) goniotomy in medically uncontrolled glaucoma compli- and qualified success in 7 (18%) while receiving a mean cating chronic uveitis and the factors affecting its of 1.6±1.1 medications. Mean postoperative IOP in the outcome. success and qualified-success groups were 14.3±2.8 and 15.7±3.1 mm Hg, respectively. Kaplan-Meier survival Methods: All goniotomies performed by a single sur- probabilities (95% confidence interval) at 1, 5, and 10 geon for refractory childhood uveitic glaucoma were ret- years were 0.92 (0.82-1.00), 0.81 (0.65-0.97), and 0.71 rospectively reviewed. Success was defined as final in- (0.49-0.92), respectively. Phakic eyes, eyes with fewer traocular pressure (IOP) of no greater than 21 mm Hg peripheral anterior synechiae, patients younger than 10 without medications and qualified success as IOP of no years, and eyes with no prior surgery had significantly greater than 21 mm Hg with medications. Unless other- better outcomes. Hyphema, typically mild and tran- wise indicated, data are expressed as mean±SD. sient, occurred in 43 procedures (80%). Results: Fifty-four goniotomies were performed in 40 Conclusions: Goniosurgery is low risk and effective for eyes of 31 patients. Juvenile rheumatoid arthritis– refractory glaucoma complicating chronic childhood uve- associated uveitis was the diagnosis in 30 eyes (75%). itis. It should be considered the surgical procedure of Eleven eyes (28%) were aphakic. Mean follow-up was 98.9 choice for this condition. Surgical outcome is adversely months (range, 2-324 months). Mean age at surgery was affected by increased age, peripheral anterior synechiae, 10.3±4.7 years (range, 4-22 years). Mean preoperative prior surgeries, and aphakia. IOP was 36.7±6.4 mm Hg while receiving a mean of 2.9±1.1 medications. Overall surgical success was Arch Ophthalmol. 2004;122:838-844 VEITIS IS A SIGNIFICANT tion, prolonged use of multiple topical cause of secondary glau- drugs, and frequent need for cataract sur- coma in childhood, and gery, which all predispose to excessive fi- the most common sys- brosis.10 Although the use of antimetabo- temic association by far is lites improves the success rate, they are Ujuvenile rheumatoid arthritis (JRA).1 The associated with increased rates of compli- overall prevalence of glaucoma in chil- cations such as bleb leaks, hypotony, and dren with JRA-related uveitis has been es- a lifelong risk of infection.8,10-13 Glau- timated to be as high as 22%.2 Glaucoma coma drainage implants have been used complicating chronic childhood uveitis can with variable success and are also associ- result in significant visual impairment and ated with serious vision-threatening com- is considered the most devastating com- plications such as corneal decompensa- plication of this disorder.1 Treatment of tion and retinal detachment and an this secondary glaucoma is challenging be- increased need for surgical reinterven- cause it is often refractory to medical and tions.6,7,14-18 Hence, there is much room for From the Singapore National surgical therapies.1,3 improvement in the current surgical man- Eye Center, Singapore (Drs Ho Existing surgical treatments that are agement of childhood uveitic glaucoma. and Wong); and the most commonly chosen after failure of Goniotomy is the least invasive sur- Massachusetts Eye and Ear medical therapy include trabeculectomy gical procedure in the treatment of child- Infirmary, Harvard Medical 4-9 School, Boston (Drs Ho and and glaucoma drainage implants. The hood glaucoma, which is an advantage in Walton). The authors have no outcome of trabeculectomy in this group the treatment of uveitic eyes. However, the relevant financial interest in of patients is adversely affected by their reported experience with standard goni- this article. young age, increased ocular inflamma- otomy in the treatment of childhood uve- (REPRINTED) ARCH OPHTHALMOL / VOL 122, JUNE 2004 WWW.ARCHOPHTHALMOL.COM 838 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 itic glaucoma is limited. Haas19 first described the use of tained until a smooth tracing for 4 minutes was obtained. The classic Barkan goniotomy in 3 patients with open-angle P0 and the change in scale reading during the 4 minutes were glaucoma associated with iridocyclitis in whom at least then used to obtain the coefficient of outflow facility (C) from 23 short-term control of intraocular pressure (IOP) was tonographic tables. achieved. Trabeculodialysis, a modified goniotomy pro- GONIOTOMY TECHNIQUE cedure in which the trabecular meshwork is disinserted from the scleral sulcus rather than simply incised as in All goniotomies were performed under general anesthesia us- conventional goniotomy, has been reported to have 44% ing the standard goniotomy technique that has been previ- to 60% success in the short term in small numbers of ously described.24 Briefly, under direct visualization of the angle young patients with inflammatory glaucoma, especially using a Barkan goniotomy lens, the anterior chamber was en- in association with JRA.20,21 Freedman et al22 recently de- tered with a needle goniotomy knife through the peripheral clear scribed the efficacy of conventional goniotomy in 12 pa- cornea opposite the area of the angle to be treated. The knife tients with childhood uveitic glaucoma and found an over- was directed into the angle, and an incision was made in the all success of 75% with a mean follow-up of 32.4 months. posterior trabecular meshwork for 4 to 6 clock hours. The an- Factors affecting the outcome of goniosurgery for this con- terior chamber was then reformed with balanced salt solution instilled through the corneal incision, which was then closed dition have not been previously described. with a 10-0 Vicryl (ETHICON Inc, Somerville, NJ) suture if leak- The aim of this report is to describe the long-term age was observed. Postoperative topical antibiotics and ste- efficacy and safety of standard goniotomy for the treat- roids were administered. Topical steroid therapy was tapered ment of glaucoma secondary to chronic childhood uve- to the preoperative frequency, usually within 2 weeks, accord- itis and the prognostic factors affecting its outcome in the ing to the extent of anterior chamber inflammation observed. largest known clinical series with the longest follow-up. All preoperative systemic anti-inflammatory regimens were con- tinued postoperatively. If a postoperative hyphema was ob- METHODS served, 0.5% apraclonidine hydrochloride was given for 1 to 2 days after surgery to attempt to minimize it. Head elevation and We undertook a retrospective review of all medical records of avoidance of excessive crying, straining, or vigorous activity patients for whom goniotomies were performed by a single sur- in the early postoperative period were recommended to re- geon (D.S.W.) for childhood uveitic glaucoma refractory to medi- duce bleeding. cal therapy. Goniotomy is the first-line surgical treatment af- ter failed maximal medical therapy in this practice. Patients may STATISTICAL ANALYSIS have had prior surgeries, including cataract extraction and tra- beculectomy, before referral to this practice for uncontrolled Data were expressed as mean±SD unless otherwise specified. glaucoma. Uveitis was controlled with topical and/or systemic We used the 2-tailed paired t test to compare preoperative and 2 anti-inflammatory therapy as necessary until anterior cham- postoperative quantitative data and the McNemar test for ber cells numbered less than 5 per high-power field using a related categorical data. Kaplan-Meier survival analysis was per- 3ϫ1-mm slitlamp beam for at least 1 week before surgery in formed to calculate probabilities of overall surgical success at all eyes. different time periods after surgery. We measured the associa- The main outcome measures were IOP at the last fol- tion between surgical outcome and possible prognostic vari- low-up and time to surgical failure. A complete surgical suc- ables using the Pearson correlation for interval and ratio vari- cess was defined as an IOP of no greater than 21 mm Hg with- ables, for nominal variables, and Spearman for ranked out glaucoma medications at the final follow-up; qualified variables. We compared each of these variables between the dif- 2 success, an IOP of no greater than 21 mm Hg with medica- ferent outcome groups using the test for categorical vari- tions at the final follow-up; and failure, an IOP of greater than ables, t test for continuous variables, and Mann-Whitney U test 21 mm Hg despite medical therapy. Overall success was used for ranked variables. All statistical tests were 2 sided, and P val- to indicate all cases in which success was complete or quali- ues of less than .05 were considered significant. We used SPSS fied. The secondary outcome measure was the number of medi- software, version 11.0 (SPSS Inc, Chicago, Ill) in the statistical cations needed to achieve an IOP of no greater than 21 mm Hg analysis. after surgery. Intraocular pressures were measured using a Perkins to- RESULTS nometer in all eyes. Direct gonioscopy using a Koeppe lens was performed in all eyes on the operating table before surgery and at least 2 weeks after goniosurgery whenever examination un- We included 40 eyes of 31 patients in this study. A total der topical anesthesia in the office setting was possible or un- of 54 goniotomy procedures were performed. Twenty- der general anesthesia when a separate surgical procedure was eight eyes (70%) underwent 1 goniotomy, 10 (25%) un- required. The gonioscopic findings, including the number of derwent 2, and 2 (5%) underwent 3.