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Editors Selection IGR 13-3

Laser and surgical treatment: Aqueous drainage devices in pediatric glaucoma

Comment by James Brandt on:

21178 Aqueous drainage device surgery in refractory pediatric glaucomas: I. Long-term outcomes, O'Malley Schotthoefer E; Yanovitch TL; Freedman SF, Journal of AAPOS, 2008; 12: 33-39

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21179 Aqueous drainage device surgery in refractory pediatric glaucoma: II. Ocular motility consequences, O'Malley Schotthoefer E; Yanovitch TL; Freedman SF, Journal of AAPOS, 2008; 12: 40-45

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The surgical management of the pediatric glaucoma's is among the most daunting tasks confronting glaucoma specialists. Although angle surgery (goniotomy or trabeculotomy) can be highly successful in selected cases, angle surgery has a much lower success rate in neonatal glaucoma (i.e., presenting at or shortly after birth) and in a variety of secondary glaucoma's. When angle procedures fail (or are unlikely to succeed), the surgeon is usually confronted with a choice of a trabeculectomy or a glaucoma drainage device (GDD). Each approach has its advantages and disadvantages. Trabeculectomy is a familiar procedure (though technically challenging in a buphthalmic eye), but published success rates are lower than those reported for adults, ranging from 35 to 50% at one year. The long-term risk of endophthalmitis in the pediatric age group is also of concern, particularly in patients requiring contact lens correction of aphakia. GDDs are an attractive option, sometimes as the primary procedure. GDDs in pediatric patients present additional challenges, including aspects of surgical technique, postoperative management along with complications (such as tube retraction due to globe growth) unique to the pediatric eye. Nonetheless GDDs are playing an increasing role in the management of refractory pediatric glaucoma. The pediatric GDD literature consists mostly of small case series with limited follow-up. O'Malley Schotthofer from the group around Sharon Freedman at Duke University have done us the service of compiling data from their long-term experience with GDDs and in the two articles reviewed here describe their long-term outcomes and the ocular motility consequences of GDDs. Their results are both encouraging and sobering. O'Malley Schotthoefer et al. (705 and 708) report on a large (79 eyes) cohort of patients with either congenital or aphakic glaucoma followed for a median of 5½ years. One year Kaplan-Meier success was approximately 90%, remarkably better than historical controls with trabeculectomy. Re-operations were necessary in about a quarter of patients. By ten years, Kaplan-Meier success dropped to the 40-50% range. Vision-threatening complications occurred in 10% of eyes overall. Further complicating the management of pediatric glaucoma is the ever-present threat of amblyopia. IOP ultimately can be controlled in most cases of pediatric glaucoma, but it is a pyrrhic victory indeed if IOP is controlled but dense amblyopia ensues due to strabismus. In this regard GDDs do not fare as well. In their series the authors report that only a few children with bilateral vision had evidence of stereopsis or binocular function. Both horizontal and vertical strabismus was common and occurred in about half of patients undergoing GDD surgery; motility limitations occurred in about a third. What is the take-home message? GDDs control IOP better than other surgical options when conventional angle surgery has failed or is unlikely to succeed, but long-term monitoring and prompt intervention for late complications is needed. GDDs are definitely not the final answer for glaucoma surgery in the pediatric age group, and these patients must be monitored well into adulthood. Strabismus is more common than generally recognized and the potential for problems leading to amblyopia must be considered, particularly in children with binocularity.

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