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Editors Selection IGR 13-1

Surgical Treatment: Circumferential trabeculoctomy in congenital glaucoma

Comment by Sharon Freedman on:

47788 Circumferential trabeculotomy with an illuminated microcatheter in congenital glaucomas, Girkin CA; Marchase N; Cogen MS, Journal of Glaucoma, 2011;

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Angle surgery ‐ goniotomy or trabeculotomy ‐ has long been the most widely performed surgical intervention for definitive initial management of primary congenital (infantile) glaucoma, with excellent reported success rates. Trabeculotomy involves the cannulation of Schlemm canal, followed by the tearing of the Schlemm's canal inner wall to establish a direct connection to the anterior chamber. Traditional surgery employing metal probes allow up to 180 degrees of the canal to be cannulated and opened, while the flexible suture technique facilitates 360-degree trabeculotomy under ideal circumstances, ¹ but risks inadvertent suture passage into the suprachoroidal space or out a collector channel. Girkin et al. (2142) present results of a small retrospective clinical series using an illuminated flexible microcatheter (I Track 250A, iScience Interventional, Menlo Park, CA) to facilitate 360-degree cannulation of Schlemm canal for trabeculoctomy in infants/young children with glaucoma (n = 11 eyes/7 children; 8 eyes/5 children with primary infantile glaucoma). The purpose of this study was to evaluate the safety and IOP-reduction of 'circumferential trabeculotomy' facilitated by using the iTrack illuminated catheter. The authors reviewed their consecutive cases of this procedure for pediatric glaucoma over a two-year period, with minimum six-month follow-up, and noted surgical technical success and complications, intraocular pressure (IOP) reduction, and associated clinical features, when available. Of 11 eyes (7 children), 360-degree Schlemm's canal cannulation was achieved in 6 eyes, while the other 7 eyes (3 having had prior angle surgery) had only partial cannulation. Qualified success at one year was 90% (IOP < 21 mmHg and > 30% reduction from baseline ± medications), complete success (no medications) was 82%, and did not differ between eyes with and without prior angle surgery, or those with complete vs. partial Schlemm canal cannulation. No severe complications were encountered.

Limitations include small numbers, short follow-up time, inclusion of both eyes of each child, inclusion of eyes with prior angle surgery, and inclusion of varied glaucoma types. In addition, confidence intervals on the Kaplan Meier success were not provided. It is not clear whether eyes with prior angle surgery had patent clefts at entry, how the iTrack-assisted trabeculotomy clefts differed from the original clefts, and whether longer follow-up might yield different results. Limitations notwithstanding, this study confirms an earlier published report that iTrack-facilitated trabeculotomy appears to have low complications rates and excellent short-term success in primary infantile glaucoma, as has been recently similarly reported.(Sarkisian 2010) Longer term study of larger series will help determine whether the iTrack improves surgical success of trabeculotomy for primary infantile glaucoma.

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