Goniosurgery for Glaucoma Complicating Chronic Childhood Uveitis

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 juvenileU 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 complications 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-

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©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 continued 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 after failed maximal medical therapy in this practice. Patients may STATISTICAL ANALYSIS have had prior surgeries, including cataract extraction and trabeculectomy, 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. All except 7 pa- clock hours of peripheral anterior synechiae (PAS), were re- tients were female. All patients were white except 1, who corded by means of detailed drawings in a goniogram at each was Asian. The mean age at goniosurgery was 10.3±4.7 examination. years (range, 4-22 years). Diagnoses included JRA- Tonography was performed using the standard tech- 23 related uveitis in 30 eyes (75%), idiopathic uveitis in 8 nique before and after goniotomy for the affected eye of an (20%), and sarcoidosis in the remaining 2 (5%). Twenty- 11-year-old patient in the study who achieved complete suc- nine eyes (72%) were phakic, and 11 (28%) eyes were cess with an electronic indentation tonometer (V Mueller and Co, Chicago, Ill). The indentation tonometer was used to mea- aphakic at the time of surgery. Sixteen (55%) of the phakic eyes had posterior subcapsular cataracts before sur- sure the baseline IOP (P0) after instillation of topical anesthesia. A 4-minute pressure tracing was subsequently obtained gery. The mean follow-up was slightly more than 8 years with the needle recorder linked to the tonometer while it was (98.9±87.8 months; range, 2-324 months). The mean pre- gently applied to the cornea. Its position on the cornea was main- operative IOP was 36.7±6.4 mm Hg, and the mean num-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A B Preoperative Postoperative Preoperative IOP Last Follow-up IOP Medications Medications 40 3.5

3.0

30 2.5

2.0

Mean IOP 1.5 Mean No. of Medications 1.0 10

0.5

0 0 Success Qualified Success Failure Success Qualified Success Failure Surgical Outcome Surgical Outcome

Figure 1. A, Pregoniotomy and postgoniotomy intraocular pressure (IOP) in different outcome groups. B, Comparison of the numbers of preoperative and postoperative glaucoma medications.

of these eyes. Postoperative mean IOP was 14.3±2.8 + All Goniotomies (≥1) mm Hg in the complete-success group and 15.7±3.1 in + First Goniotomy Figure 1 100 the qualified-success group. compares the IOP ++ and glaucoma medications preoperatively and postop- ++ ++ eratively within the different surgical outcome groups. 90 + + In eyes with overall surgical success, the mean IOP was + +++ 80 ++ reduced from 35.8±5.9 mm Hg to 14.7±2.9 mm Hg + + (PϽ.001), and the mean number of glaucoma medica- + 70 ++ tions was reduced from 3.0±1.2 to 0.4±0.9 (PϽ.001). + ++++ + The mean number of clock hours of PAS preoperatively 60 + ++ + + +++ + was 1.6±2.6 compared with 3.1±2.5 postoperatively, in- 50 dicating a significant increase in PAS extent after sur- ++ + gery (PϽ.001). There were no significant differences in + + + 40 the mean frequency of topical steroids used per day pre- ++ + ++ +

Cumulative Success, % operatively and at the last postoperative follow-up in eyes 30 with a successful outcome (2.1±1.8 and 1.6±1.7, respectively) or in eyes with failed surgery (2.2±1.5 and 1.8±1.5, 20 respectively). There was also no statistically significant

10 difference between the numbers of eyes that required steroids for uveitis control before surgery (29/40 eyes) and 0 + at the last follow-up after surgery (28/40 eyes). 0 24 48 72 96 120 144 168 192 216 240 264 288 Time, mo The Kaplan-Meier survival plot for overall surgical success is shown in Figure 2. Mean cumulative sur- Figure 2. Kaplan-Meier survival analysis of goniotomy success. The markers vival probabilities (95% confidence interval) in all eyes indicate censored eyes that experienced surgical success with or without with 1 or more goniotomies at the specified time inter- medications at the last follow-up. vals after surgery were as follows: 0.92 (0.82-1.00) at 1 year, 0.81 (0.65-0.97) at 5 years, 0.71 (0.49-0.92) at 10 years, and 0.56 (0.28-0.84) at 13 years, with no failure ber of glaucoma medications used preoperatively was events occurring after 12 years (144 months). Beyond 2.9±1.1. 12 years after the first goniotomy, 5 eyes were still At the last follow-up, 22 eyes (55%) achieved sur- being followed up and demonstrated surgical success at gical success without any glaucoma medications, and 7 last follow-up. eyes (18%), qualified success while receiving a mean of Tonography performed in the affected eye of the 11- 1.6±1.1 medications. Failure occurred in 11 eyes (28%). year-old boy with idiopathic uveitis who had complete This gave an overall success rate of 72% (in 29 eyes), success after a single goniotomy showed C values of 0.00 which was achieved with a single goniotomy in 20 (69%) µL/min/mm Hg preoperatively at an IOP of 42 mm Hg,

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100 100

90 90

80 80

70 70

60 60

50 50 Eyes, % Eyes, % 40 40

30 30

20 20

10 10

0 0 Phakic Aphakic ≤10 >10 Lens Status Age Group, y

Figure 3. A, Effect of lens status on surgical outcome. B, Surgical outcome at different ages.

which increased to 0.07 µL/min/mm Hg postoperatively at an IOP of 18 mm Hg without glaucoma medications. Past Eye Surgeries, No. A statistically significant association was found be- 4 3 2 1 0 tween surgical outcome groups (success, qualified suc- 100

cess, and failure) and lens status (P=.004), age at sur- 90 gery (P=.03), number of past ocular surgeries (P=.001), and extent of preoperative (P=.004) and postoperative 80 PAS (P=.002) in the angle. Phakic eyes had an overall success rate of 86% (25 eyes) compared with 36% (4 eyes) 70 in aphakic eyes (P=.004) (Figure 3A). Patients 10 years or younger had greater overall success of 79% (19 eyes) 60 compared with 62% (10 eyes) for those older than 10 years (P=.03) (Figure 3B). Success was greatest in eyes with- 50 Eyes, % out prior surgery (87%; 25 eyes), whereas eyes with more 40 than 2 previous ocular surgeries before goniotomy such as cataract extraction or trabeculectomy had a uni- 30 formly poor outcome (100% failure) (Figure 4). The mean number of previous surgeries was 0.2±0.6 in eyes 20 with successful outcomes and 1.3±1.3 in eyes with surgical failures (P=.03). Eyes with no PAS preoperatively 10 had the highest success rate (82%), whereas those with 0 more than 6 clock hours of PAS had a 100% failure rate. Success Failure All eyes with no PAS at the last postoperative gonios- Surgical Outcome copy had operative successes. The mean number of clock Figure 4. Relationship between surgical history and outcome. hours of preoperative PAS and postoperative PAS was 0.9±1.5 and 2.3±2.0, respectively, in eyes with surgical success and 3.0±3.6 and 4.8±2.9, respectively, in eyes tent presence of cells or flare requiring topical steroids with surgical failure (P=.01 and P=.007 for preopera- Ն3 times a day or the recurrent inflammation requiring tive and postoperative PAS, respectively). Figure 5 il- increased topical steroids Ն3 times a day for more than lustrates the relationship between preoperative and post- 1 week within the last 6 months of follow-up) had no operative PAS and surgical outcomes. statistically significant correlation with the surgical out- Sex, diagnosis (type of uveitis), preoperative IOP, come. Specifically, there was no difference in the surgi- number of glaucoma medications before surgery, pres- cal outcomes when comparing JRA-related uveitis with ence or severity of postoperative hyphema, frequency and other types of uveitis as a group. use of topical steroids before or after surgery, and pres- Hyphema occurred after 43 goniotomies (80%). This ence of persistent inflammation (defined as the persis- was mild and transient with complete spontaneous clear-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A Preoperative PAS Extent, Clock Hours B Postoperative PAS Extent, Clock Hours >6 4-6 1-3 No PAS >6 4-6 1-3 No PAS 100 100

90 90

80 80

70 70

60 60

50 50 Eyes, % Eyes, % 40 40

30 30

20 20

10 10

0 0 Success Qualified Success Failure Success Qualified Success Failure Surgical Outcome Surgical Outcome

Figure 5. A, Relationship between preoperative peripheral anterior synechiae (PAS) extent and surgical outcome. B, Relationship between postoperative PAS extent and surgical outcome.

ance within a week in most affected eyes. In 2 eyes, an an- gery at 1, 5, 10, and 13 years were 92%, 81%, 71%, and terior chamber washout had to be performed for moder- 56%, respectively. The only previous report on the sub- ate hyphemas associated with elevated IOP. Deterioration ject by Freedman et al22 showed a similarly high overall of preexisting posterior subcapsular cataracts occurred early success rate of 75% at a mean follow-up of 32.4 months, postoperatively in both eyes of a single patient requiring although most of their patients (75%) required glau- extraction at 1 and 4 months after surgery. Six other eyes coma medications, and cumulative success probabili- required cataract extraction for progression of posterior ties were lower (79% at 1 year and 70% at 15 months). subcapsular cataracts that existed before goniosurgery and The difference was probably due in part to the smaller became visually significant after goniosurgery (mean time number of eyes and shorter follow-up. These results are after goniosurgery, 63.9±57.2 months; range, 8-138 exciting and suggest that goniotomy can improve the man- months). Of the 8 eyes that had cataract extraction after agement of one of the most visually destructive and re- goniosurgery, 7 continued to have successful IOP con- fractory forms of glaucoma in childhood and young adults. trol after that surgery (6 without need for glaucoma Compared with the currently favored surgical op- medications). In the remaining eye, cataract extraction was tions to increase aqueous outflow, standard goniotomy performed after 3 goniotomies that had resulted in suc- seems to have comparable or higher success rates but cessful IOP control without medications. In this eye, loss much fewer risks of complications. Success of trabecu- of IOP control occurred at 3.5 years after cataract extrac- lectomy without antimetabolites in young patients or in tion and was refractory to maximal medical therapy, ne- eyes with inflammatory glaucoma is generally poor.1,2,20,25-29 cessitating a trabeculectomy with mitomycin. These pro- Few published reports address the use of trabeculec- gressive posterior subcapsular cataracts were most likely tomy for uveitic glaucoma in the young alone. Most in- due to continued topical steroid use for the uveitis and were clude adult patients or other forms of pediatric glau- not likely to be related to the goniosurgery. No exacerba- coma. Trabeculectomy with antimetabolites in adults with tions of uveitis in the early postoperative period or other uveitic glaucoma have yielded cumulative success prob- significant complications such as infection, iatrogenic dam- abilities of 78% at 1 year and 62% at 2 years,8 although age to intraocular structures, hypotony, or posterior seg- this is probably lower in children.11,30,31 Apart from the ment changes were encountered. usual increased risks of hypotony, bleb leak, cataract formation, and bleb-related infection,8,10-13,30,32 there are fur- COMMENT ther risks of complications associated with the uveitis such as postoperative fibrinous and cellular anterior cham- Secondary glaucoma is a frequent and serious compli- ber reaction, which can result in surgical failure.6,33,34 A cation of uveitis. In this largest known study to report histopathological study of conjunctival biopsy speci- the long-term results of standard goniotomy in child- mens from patients with uveitic glaucoma found that the hood uveitic glaucoma, successful IOP control was uveitic conjunctiva contained significantly more fibro- achieved in 72% of eyes and in 55% without medica- blasts, lymphocytes, and macrophages compared with that tions at the end of a mean follow-up of more than 8 years. of controls, which may help explain the increased risk Cumulative probabilities of overall success of goniosur- of bleb fibrosis and failure of filtration surgery in these

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 patients.35 As a result, glaucoma drainage implants are work. Significant outflow reduction can occur if angle often recommended for uveitic glaucoma.4,36 Various types closure is extensive or obliterates a previously func- of implants have been used with reported life-table suc- tional goniotomy cleft. The mean number of clock hours cess rates in adults of up to 94% (1 year), 90% (52 of PAS in eyes with surgical failures in this series was 3 months), and 91.7% (24 months) for the Ahmed,9 Mol- to 4 clock hours and was not markedly more extensive teno,7 and Baerveldt37 implants, respectively, but this is compared with eyes with surgical successes. This was be- variable, and relatively lower success rates of 57% to 76% cause the surgical failures included eyes with open angles have been found in other series.38-40 Vision-threatening and other predispositions to failure such as aphakia or complications such as choroidal effusion or hemor- multiple prior surgeries. The effect of PAS on surgical out- rhage, cataract, corneal decompensation, hypotony, and come could best be illustrated in Figure 5, which shows cystoid macular edema can occur, and surgical reinter- that eyes with no PAS had the greatest likelihood of suc- ventions for these or other complications such as encap- cess, whereas eyes with extensive PAS of more than 6 clock sulated bleb, plate extrusion, corneal-tube touch, and flat hours had no chance of success (100% failure rate). anterior chamber are commonly required.6,7,9,18,37,38,40 Older age, prior ocular surgery, and aphakia are prob- In contrast, goniotomy has very few complications, and ably associated with different or more advanced changes these are limited almost exclusively to hyphemas in expe- in the meshwork and/or more distal parts of the outflow rienced hands in this study and that by Freedman et al.22 system, which are less likely to be relieved by incisions Due to the minimal invasion and manipulation of intraocu- in the meshwork by goniotomy alone, hence their asso- lar and extraocular tissues, exacerbation of uveitis did not ciation with adverse outcomes. Aphakia in young chil- occur in either study, and the conjunctiva of the eyes un- dren is itself a definite risk factor for the development of dergoing operation was spared for future filtration surgery glaucoma for reasons as yet unknown. These findings are if needed. Trabeculotomy ab externo, the alternative to in contrast to those of Kanski and McAllister21 on tra- goniotomy, has been used with a success rate comparable beculodialysis for inflammatory glaucoma in children and to that of goniotomy in the treatment of primary infantile young adults, which found no association between apha- glaucoma. However, its value in childhood uveitic glaucoma kia or synechial angle-closure and outcome, and those is unknown. Although widely regarded as a different means of Freedman et al,22 which found no relation between age to the same end, it involves considerable conjunctival ma- and crystalline lens status at surgery with surgical out- nipulation and is more traumatic than goniotomy. This may come. This may be due at least in part to the smaller result in significant inflammation, which is undesirable and sample size in these studies. could affect its success rate in a uveitic eye. Cataract extraction after goniosurgery did not seem Open-angle and closed-angle mechanisms play a role to compromise the surgical outcome in 7 (88%) of 8 eyes in the pathogenesis of glaucoma in uveitis, although the in this series. The only eye that experienced failure 3.5 open-angle mechanisms are more common.4,41 Com- years after cataract surgery also had other predictors of plex interactions between several biochemical and cel- failure such as increased postoperative PAS (4 clock hours) lular mechanisms inherent in the inflammatory process and older age at surgery (21.5 years). occur to cause an elevation of IOP in the presence of an Use of topical steroids is known to cause IOP eleva- open angle.4,5,41 The success of goniotomy suggests that tions. As the amount and presence of topical steroid use in many cases of glaucoma secondary to childhood uve- was not significantly different before and after goniosur- itis, an incision in the inner portion of the meshwork gery, it is unlikely that the IOP reduction was due to re- where the angle is open reduces the resistance to aque- duction of steroid use with time. ous outflow. The tonography results in the uveitic eye Although goniotomy is widely recognized as an ef- with uncontrolled glaucoma confirmed the preopera- fective first-line surgery for primary congenital glau- tive reduction in outflow facility (C value of 0.00 µL/ coma, it also now deserves consideration as a relatively safe min per millimeters of mercury compared with a mean and effective first-line surgical treatment for medically un- of 0.28 µL/min per millimeters of mercury for healthy controlled glaucoma secondary to chronic childhood uve- eyes42), which was increased but not normalized (C=0.07 itis. Unlike filtration surgery, it is less traumatic, has fewer µL/min per millimeters of mercury) after goniotomy. The risks, and facilitates aqueous outflow through the normal underlying mechanism for improved outflow facility is drainage system of the eye rather than creating an artifi- unclear. Goniotomy may result in a change of the cellu- cial pathway that bypasses the physiological route. It is ef- lar or biochemical milieu that reduces the outflow resis- fective not only for JRA-related uveitis but also in idio- tance. However, its long-lasting benefit, despite recur- pathic and sarcoid-related uveitis when the angle is open. rent or persistent inflammation and the quantitative nature Although the success rate of goniosurgery is highest in chil- of its effect (more IOP lowering with additional or in- dren 10 years or younger, older age up to young adult- creased extent of goniotomy incision), suggests that a me- hood does not preclude success. Aphakia, multiple pre- chanical obstruction of aqueous outflow may exist in the vious ocular surgeries, and extensive PAS are much stronger inner portion of the meshwork that is reduced by the go- predictors of surgical failure. niotomy incision. There was histopathological evidence In conclusion, goniosurgery is safe and effective for of a persistent communication between the anterior cham- the treatment of glaucoma complicating chronic child- ber and the Schlemm canal in a specimen taken from an hood uveitis. It should be considered the procedure of eye with sarcoid uveitis 1 month after trabeculodialy- choice because it restores function of the trabecular tis- sis.43 Closure of the angle by PAS formation before or af- sue without bypassing it, is the least traumatic of the glau- ter goniosurgery limits aqueous access to the mesh- coma surgeries, and spares the conjunctiva. Most treated

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 patients do not require glaucoma medications after the 19. Haas J. Goniotomy in aphakia. In: Welsh RC, ed. The Second Report on Cataract procedure. Surgical success is highest in children younger Surgery: Proceedings of the Second Biennial Cataract Surgery Congress. Mi- ami, Fla: Miami Educational Press; 1971:551-554. than 10 years. Aphakia, multiple prior ocular surgeries, 20. Hoskins DH Jr, Hetherington J Jr, Shaffer RN. Surgical management of the in- and extensive PAS are adverse prognostic factors for a flammatory glaucoma. Perspect Ophthalmol. 1977;1:173-181. successful surgical outcome. 21. Kanski JJ, McAllister JA. Trabeculodialysis for inflammatory glaucoma in children and young adults. Ophthalmology. 1985;92:927-930. 22. Freedman SF, Rodriguez-Rosa RE, Rojas MC, Enyedi LB. 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