Ab Interno Goniotomy Combined with Ab Externo Trabeculotomy in Advanced Primary Congenital Glaucoma Patients: 2-Year Follow-Up

Abstract

Introduction Primary congenital glaucoma (PCG) is a challenging disease that needs to be surgically managed with more innovative methods. Conventional incisional surgery, such as goniotomy and trabeculotomy, has a primary high success rate, but does not seem to be a very effective treatment in advanced stages. Design A prospective clinical case study. Purpose To qualify the outcome, in terms of success rate, of goniotomy combined with trabeculotomy as a surgical option to treat eyes affected by PCG with a corneal diameter larger than 14 mm. Patients and Methods This study included 50 eyes of 50 patients diagnosed with PCG with corneal diameter larger than 14 mm who underwent ab interno goniotomy combined with ab externo trabeculotomy. Intraocular pressure (IOP) was measured preoperatively and 24 months postoperatively. A statistical analysis was performed to detect correlations between the success rate and corneal diameter, preoperative IOP, age of onset, axial length, and consanguinity. The main outcome was reduction in IOP; secondary outcomes were factors affecting the success rate, complications, and the need for additional surgical intervention to control IOP. Results The mean age of the patients was 18.86±9.94 months. Males made up 52% of cases and females 48% of cases. Positive consanguinity was present in 38% of cases. Axial length ranged between 20 and 22 mm, with a mean of 20.98±0.8 mm. Mean preoperative IOP was 29.56±3.36 mmHg, which decreased postoperatively to 12.6±2.5, 14.1±3.2, 16.8±5.5, 14.4±2.3, 14.3±1.6, 14.3±1.6, 14.3±1.6, 14.3±1.7, and 14.3±1.7 mmHg at 1, 3, 6, 9, 12, 15, 18, 21, and 24 months respectively ( p ˂0.001). Use of medical treatment was decreased from 2.7±0.4 preoperatively to 1.4±0.7 postoperatively ( p ˂0.001). Hyphema was the only complication that appeared, occurring in 47% of cases. The success rate was 94%. Complete success (IOP <21 mmHg without treatment) was achieved in 70% of cases, 24% were considered a qualified success (IOP <21 mmHg with treatment), while failure was documented in 6% of cases (IOP >21 mmHg with treatment). The success rate was significantly related to preoperative IOP, corneal diameter, axial length, consanguinity, and age of onset ( p ˂0.001). All cases were followed for 24 months. Conclusion Ab interno goniotomy combined with ab externo trabeculotomy improves the success rate of buphthalmos surgery. A significant correlation was detected between success rate and preoperative IOP, corneal diameter, axial length, consanguinity, and age of onset.

Factors Affecting Final Surgical Outcome of Combined Trabeculotomy–Trabeculectomy in Primary Congenital Glaucoma

“… 8 One of the advantages of CTT is that it can be performed in eyes with significant ocular enlargement and large corneal diameter which was considered as a challenge to goniotomy surgery. 7 , 9 …”