GLAUCOMA PROCEDURES WHICH CAN BE COMBINED WITH

PHACOEMULSIFICATION

1. Trabeculectomy + antimetabolites
2. Ex-PRESS shunt implantation.
3. Ab- internal trabecular meshwork excision Trabectome
4. deep sclerectomy
5. viscocanalostomy
6. Trabeculotomy
7. Endoscopic cyclophotocoagulation

CATARACT ALONE AS A GLAUCOMA PROCEDURE

It seems to be a safe way to lower IOP in Pt with mild to moderate
glaucoma while avoiding morbidity of glaucoma surgery

Indications:
1. Well controlled IOP by 1-2 medications
2. Mild glaucomatous damage
3. No progressive damage on ttt
4. Significant cataract
* Cat. sx is especially helpful for the ACG as it widens the angle and
abolish the phacomorphic effect.

CATARACT ALONE AS A GLAUCOMA PROCEDURE

1. Average lowering of IOP by 2-4 mmhg after ECCE
2. Greatest reduction with higher preoperative IOP & pt with ACG
3. IOP can be controlled in 20% of Pt with cataract surgery
4. Drop of 3mmHg with 75% maintaining reduction up to 10 years
5. Lower IOP with phaco than ECCE
6. PXS Pt may have greater long term decrease of IOP than POAG

Improvement of IOP may result either from correction of a phacomorphic

component to the obstruction of aqueous outflow or from a change in
aqueous production.

PREOPERATIVE CONSIDERATIONS
- Gonioscopy
- Topical steroids for conj inflammation
- Exclude PXS which associated with
1. More aggressive PO inflammation response
 2. Poor pupil dilatation - If dilation is poor pt should informed that
anisocoria can occur from pupil manipulation
3. weakened zonule

Signs indicating lack of zonular support include:

a. A symmetric anterior chamber depth
b. Iridodonesis
c. Phacodonesis
d Tilting of the lens

COMPLCATIONS OF CATARACT SURGERY IN THE GLAUCOMA

PATIENT

1. PO inflammation is more severe in glaucomatous eye with more serious

consequences Preop.use of
-Miotics
-PG analogue
-Intraocular manipulation.

2. PO pressure elevation 2/3 of glaucoma pt have increase of 7-10 mmhg

on the first PO day
-Viscoelastic agent
-Blood , pigment , inflammatory materials
-Lens cortex
>> block an already compromised trabecular meshwork

#Thus glaucoma pt should be followed closely in the immediate PO

period.

3.PO cystoid macular edema CME occur more in glaucoma eye because
of
a) Their tendency toward greater PO inflammation
b)Use of some glaucoma medications like latanoprost or propine
(Dipivefrine)
#CME can slow postoperative visual rehabilitation & its resolution may
take several months

4. Intraoperative vitreous loss

-loose zonular support as in PXS or trauma
-Inadaquate intraoperative management of small pupil in case of
ECCE during nucleus expression
-Phacoemulsification decrease risk of vitreous loss
-Vitreous can clog the sclerostomy of a functioning bleb ; careful
vitrectomy is required

COMPLICATIONS OF CATARACT SURGERY IN THE GLAUCOMA

PATIENT
Small pupil management
1. Avoid iris over manipulations
2. Adrenaline in infusion
3. PI; posterior synechialysis; Radial iridotomy connected the iridectomy
with the pupil med.
4. Sphinctertomies Inf, lat &or med.
5. Self-retaining iris retractors
6. Viscoelastic pupil expansion & bimanual iris stretch

CATARACT ADVANTAGES
1. Restore vision promptly
2. Single procedure
3. Easier and shorter procedure
4. Less wound complications
5. Can by itself improve IOP control
6. Easy VF & ON assessment

CATARACT DISADVANTAGES
1. Effect on future filtration surgery
2. less long term IOP control than combined procedure
3. Unpredictable effect on IOP
4. Early post-op IOP rise

TWO - STAGE PROCEDURE GLAUCOMA > CATARACT

Indications :
1. Uncontrolled IOP despite MMT
2.Advanced glaucoma damage
3.No urgent need for visual recovery

CATARACT SURGERY FOLLOWING A GLAUCOMA FILTERING

PROCEDURE
- If the glaucoma filter is no longer functioning - cataract ext can be done
with revision of the bleb at the same time or combined cataract &
glaucoma can be done
- If the glaucoma filter is still functioning Effort should be made to protect it.
- 30-50 % of glaucoma filters fail after cataract when the conjunctiva is
manipulated
- PO effects of glaucoma surgery
-Posterior synechiae
-Small pupil
-Temporal clear corneal phaco is the preferred technique in the presence
of a functioning bleb
-reduce the conj trauma
-minimizes corneal astigmatism
-In the bag PC IOL is preferred
-Optimal lens centration
-reduce the chances of capture of the optic within the pupil, P. O
inflammation & vitreous herniation through post capsulotomy
-The cornea is protected from the IOL in case of shallow or flat AC
postoperatively

GLAUCOMA SURGERY COMBINED WITH CATARACT EXTRACTION

Indications :
1. Visually significant cataract
2. Moderate to advanced glaucoma
3. Borderline control of IOP with MMT
4. Pt doesn't tolerate antiglaucoma ttt
5. Poor follow up
6. Unable to undergo 2 operations
7. Non Functioning fistula

GLAUCOMA SURGERY COMBINED WITH CATARACT EXTRACTION

Advantages
1) Minimize the risk of early PO pressure rise associated with cataract ext
> > compromise an already damaged ON
2) Control IOP
3) Improve VA with low Astigmatism (in case of phacotrab )

GLAUCOMA SURGERY COMBINED WITH CATARACT EXTRACTION

- Phacoemulsification is preferred over conventional ECCE in combined

surgery
- The rate of bleb survival is more than 3 times higher after combined
procedures using phaco than after trabeculectomy & ECCE .
- Phaco decrease the risk of vitreous loss as no pressure is required to
remove the nucleus
- The risk of P.O hyphema , fibrinous iritis , hypotony , and choroidal
detachment are less with phacoemulsification.

SINGLE-SITE VS. TWO-SITE SURGERY (CATARACT EXTRACTION

WITH TRABECULECTOMY
With the increasing popularity of temporal clear cornea approach for
cataract surgery, two-site surgery has gained more popularity.

SINGLE-SITE SURGERY TECHNIQUE

- Single-Site Surgery is done with the surgeon sitting superiorly.
- Both the trabeculectomy and cataract surgery are performed using the
same conjunctival and scleral incisions
- Single-site surgery is done using the scleral tunnel technique.

* MMC = potency 100x 5-FU

- endothelial toxicity=corneal odema
- cilliary body toxicity = hypotony
- scleral necrosis (even after years)
-bleb leakage - even late
-thin polycystic bleb

SINGLE-SITE SURGERY TECHNIQUE

1. Superior peritomy is performed to expose bare sclera.Gentle cautery is
performed as needed.
2. If using anti-metabolites, such as (5-FU) or (MMC), these may be
applied using the surgeon's preferred technique.
3. A partial-thickness scleral flap, hinged at the limbus is made.
- Alernatively, a scleral tunnel incision can be made initially, with
completion of the flap after the cataract portion of the surgery
- Paracentesis is made to facilitate 2 handed phaco
4. A keratome is used to enter the anterior chamber
5. Phacoemulsification is performed in the usual manner
6. Foldable IOL is inserted

- The pupil is constricted by intracameral acetylcholine(Miochol E)

- stabilize the IOL behind the iris
- decreases the immediate P.O IOP spike
- facilitates completion of a Pl
7. Viscoelastic is removed
8. Trabeculectomy is performed using a Kelley descemet's punch
9. A peripheral iridectomy is made.
10. The scleral flap is closed using interrupted or releasable 10-0 nylon
sutures.
- These should be adjusted to ensure adequate flow.
11. Tenons and conjunctiva are closed.

ADVANTAGES OF SINGLE-SITE SURGERY

1. Saves Time
a. One wound is made
b. There is no need for the surgeon to change his position and the
microscope

DISADVANTAGES OF SINGLE-SITE SURGERY

1. More post-operative inflammation
a. Excessive conjunctival manipulation may influence the outcome of
filtration surgery
b. Longer visual recovery
2. Care needed to avoid spillage of antimetabolites into the anterior
chamber, if used after creation of a scleral flap

TWO-SITE SURGERY TECHNIQUE

First approach
- Perform as much of the filter portion as possible before creating an
intraocular wound ( complete the scleral flap on firm eye )
- It is best to apply MMC before creation of intraocular surgery to prevent
intraocular toxicity.
- Clear cornea phaco can be performed Then complete the trabeculectomy

More practical approach

- The surgeon first completes the cataract extraction sitting temporally and
then moves superiorly to complete the trabeculectomy.
- Temporal clear corneal cataract surgery is performed in the usual
manner.
- Capsulotomy is not larger than 5mm to prevent IOL dislocation secondary
to P.O IOP fluctuation
- Viscoelastic is not removed immediately & 10/0 nylon is used to seal the
corneal wound to maintain a firm eye.
- After completion of the trab portion , the scleral flap is closed with 10/0
nylon & the corneal suture is loosened
- Remove viscoelastic & resuture the corneal wound
- Test for aqueous flow if adequate - close conjunctiva
- the filtration is assessed as follow :
- The eye should become firm & not hard during reformation.
- The eye should soften slightly over the first several seconds after
irrigation is discontinued
- Sponge should be placed in all regions around the scleral flap to
observe for passive flow (spontaneous aqueous flow without pressure on
the globe )
- It is desirable to have very little , if any , passive flow (if
antimetabolites is used )

- However it should be possible to produce flow readily by applying gentle

pressure adjacent to filtration site (Active filtration test)
- It is much easier to filtration P.O than to slow it down.
- The active flow test is intended to simulate the effect of eyelid activity on
the filtration site.
- If there is considerable filtration on passive testing , then there is a risk for
overfiltration and hypotony.
- If there is inadaquate filtration P.O , Laser suture lysis can be performed
to augment the flow

TWO-SITE SURGERY TECHNIQUE

Advantages of this approache
1. Less need to change position of microscope between the
different stages of the procedure
2.If there are unexpected events during phaco the surgeon
could delay trabeculectomy

ADVANTAGES OF TWO-SITE SURGERY

1. Improved exposure for cataract extraction through temporal clear cornea
approach
a. Deep set eyes
b. Narrow palpebral fissure
- Temporal incision reduces the risk of touching or injuring the iris
2. Less inflammation and less manipulation of the conjunctiva superiorly
a. Enhances bleb survival
b. Rapid visual recovery

DISADVANTAGES OF TWO-SITE SURGERY

-May take longer
a. Surgeon needs to change position
b. Microscope also requires adjustment

IOP CONTROL WITH SINGLE VS. TWO-SITE SURGERY

1. Both approaches have been shown to be effective in lowering IOP
2. Two-site surgery may have better post- operative IOP control and less
need for adjunctive glaucoma medications

POST-OPERATIVE MANAGEMENT
Post-operative management for combined cases is similar to that for
glaucoma surgery.
The patient should be seen on the first post- operative day and then
weekly thereafter until the IOP has stabilized. Sutures may be pulled or
lysed as needed. In the presence of significant inflammation, more
frequent visits may be required.

POST-OPERATIVE MEDICATIONS
- Antibiotic drops - every four hours for the first 2 week.
- Steroid drops - every 2 hours for the first 2 weeks, followed by taper.
- Cycloplegics
-Shallow anterior chamber
-Hypotony
-Post-operative cases of CACG to prevent malignant glaucoma.

POTENTIAL COMPLICATIONS
-Shallow or flat anterior chamber
-Persistent inflammation
-Choroidal effusion- esp. in myopic pt so - hypotony and shallow AC, usu
no need for ttt.
-Bleb leaks- Early ->wound problems , Late -> MMC
-Filtration failure
-Endophthalmitis
-Chronic hypotony & Maculopathy

OTHER TYPES OF COMBINED SURGERY

Glaucoma drainage devices : are generally reserved for complicated
secondary glaucomas like :
- Uveitic glaucoma
- Neovascular glaucoma
- Previously failed filters with insufficient conjunctiva
GLAUCOMA DRAINAGE DEVICES
- These devices essentially drain aqueous out of the eye into
subconjunctival reservoirs created by external plates
- These devices differ in size and shape and by the presence or absence
of a valve.
- The non-valved devices like Molteno
- The valved devices like Ahmed valve

The basic surgical technique involves placement of the plate in one of the
superior quadrants approximately 8 - 10 mm from the limbus, preferrably
the superotemporal quadrant to avoid
compression on the optic nerve, with the tube placement in the anterior
chamber.

- If inferiorly implanted device the result of IOP control is nearly the same
but the overall rate of complicationsis higher like :
1-implant exposure necessitating removal
2-cosmetically unappealing appearance
3-endophthalmitis

Temporal clear corneal incision with intraocular lens placement can be

completed first leaving viscoelastic temporarily& the corneal incision is
closed 10/0 nylone .
Attention is then turned to the superior conjunctiva. A large peritomy is
performed.
The plate of the drainage implant is affixed to bare sclera through the
preplaced holes using 9/0 prolene

The tube is cut with bevel up configuration so that 2mm of the tube is in the
AC.
A 23 or 25-gauge needle is used to enter the anterior chamber 1-2 mm
posterior to the limbus. and this opening is used to place the tube into the
anterior chamber , the tube should be introduced into the AC parallel to the
iris.

The tube is secured to the sclera and covered with a scleral , corneal or
percardial patch graft. Conjunctiva is then closed.
- The valve may cause erosion and is not preferred in children since they
may rub their eye aggressively with subsequent extrosion of the valve or
cause endophthalmitis.
Alternatively, some surgeons prefer to secure the plate first while the eye is
firm, complete cataract extraction, and then return to place the tube into
the anterior chamber.
Approximately, 6-8 weeks post-operatively, a fibrous capsule forms around
the plate and regulates flow.

Complicationsof All glaucoma drainage implants:

1. Obstruction of tube by fibrin, blood, iris, vitreous
2. Tube retraction and erosion
3. Tube kink
4. Motility disturbance
5. Corneal decompensation and graft failure
6. Endophthalmitis
7. Retinal detachment
8. Failed , hypotony , encapsulated.
9. Cataract.

Studies have shown combined cataract and tube shunt surgery to be a

safe and effective surgical option in certain clinical settings.

EX-PRESS MINIATURE GLAUCOMA SHUNT

Ex-PRESS glaucoma shunt is a biocompatible miniature stainless steel

implant.
It is placed beneath a scleral flap into the anterior chamber to facilitate
drainage and form a bleb similar to traditional trabeculectomy

A 25 gauge needle is used to enter the anterior chamber at the gray line
under the scleral flap, followed by insertion of this device.
Since there is no sclerectomy or iridectomy performed, less inflammation is
encountered postoperatively.
This modified trabeculectomy can be combined with cataract surgery in
two-site combined surgery.

TRABECTOME (TRABECULECTOMY, INTERNAL APPROACH)

The Trabectome is a device that uses electrocautery to remove a strip of
trabecular meshwork and inner wall of Schlemm's canal under direct
visualization with a gonioscopy lens.
Therefore, this technique increases outflow through the coventional
pathway.
Initial studies have shown IOP reduction to the mid-teens when performed
alone or with cataract surgery.
Trabectome offers a minimally invasive method of lowering IOP in those
with mild to moderate glaucoma.
VE is used to form AC& a gonioprism is used to visualize the angle. the
trabecular meshwork excision can be performed through a clear corneal
incision & cataract surgery can be performed through the same incision.
Transient hyphema is the most common complication. Other complications
include iridodialysis, cyclodialysis .

ENDOSCOPIC CYCLOPHOTOCOAGULATION
A standard cataract extraction is performed initially.
With viscoelastic in the eye , the fiberoptic device is used to visualize the
ciliary body & cyclophotocoagulation can be performed through the same
clear cornea incision.

The endoscope provides direct visualization of the ciliary processes on an

external monitor.
The ciliary epithelium shrinks and whitens during treatment.
ECP destroys the ciliary epithelium, thus reducing the production of
aqueous humor and lowering the IOP.

Most patients receive 270-360 of treatment.

ECP has been shown to help reduce IOP by approximately 15% and help
reduce the number of IOP lowering medications.
The most common complications reported are post-operative IOP spike
and transient hemorrhage.

NON-PENETRATING GLAUCOMA SURGERY

the aqueous outflow is enhanced by removing the inner wall of Schlemm's
canal and juxta-canalicular trabecular meshwork, the structures
responsible for most of the outflow resistance in open angle glaucoma.
In this procedure a trabeculo-Descemet's membrane (TDM) is left intact to
control aqueous outflow through the filtration site.
A standard DS was followed by a temporal clear corneal
phacoemulsification.

DEEP SCLERECTOMY
The conjunctiva and Tenon's capsule is opened at the limbus to expose
sclera.
At this stage, antiproliferatives can be applied to the scleral bed followed
by thorough irrigation.
A limbus based superficial 5 x 5 mm scleral flap of one-third thickness is
fashioned and extended 1.5 mm into clear cornea.
A second deep scleral flap 4 x 4 mm is dissected leaving only a 50-100 um
thick scleral bed.

The TDM is fashioned by extending the dissection up to 1-1.5 mm into

clear cornea.
Once this dissection is completed the deep flap is excised using a blade or
fine scissors.

At this stage aqueous should be percolating through the trabeculum.

An implant can be put over the scleral bed to act as a space maintainer
during the initial healing period, keeping the intrascleral space open

The superficial scleral flap is then closed with 10/0 nylon sutures. Finally
the conjunctiva is closed with 10/0 vicryl sutures. t

DS appears to be a safe surgical procedure to reduce IOP.

The complication rate appears to be lower
- flat anterior chamber.
- choroidal detachment .
- hypotonic maculopathy
- postoperative infections
This is probably due to the controlled IOP decreas through the intact TDM
and the absence of a surgical peripheral iridotomy.

COMPLICATIONS OF DS
1. Conversion to trabeculectomy (perforation of TDM)
2. Iris incaceration , prolapse & PAS
3. Descemet's detachment
4. Hypotony
5. Hyphema
6. serous choroidal detachment
7. Vitreous haemorrhge
8. Scleral ectasia

THE NEWER PROCEDURES

Trabectome and ECP offer the advantages of minimally invasive surgery
with fewer complications than traditional trabeculectomy or tube shunt
surgery.
These procedures may be effective for patients with mild to moderate
glaucoma, or in helping reduce the number of medications; however, none
of these newer techniques have yet shown the same degree of IOP
reduction offered by traditional trabeculectomy, trabeculectomy with Ex-
PRESS mini shunt, or tube shunt surgery.

THE NEWER PROCEDURES

These procedures may be effective for patients with mild to moderate
glaucoma, or in helping reduce the number of medications;
however, none of these newer techniques have yet shown the same
degree of IOP reduction offered by traditional trabeculectomy,
trabeculectomy with Ex- PRESS mini shunt, or tube shunt surgery.

————————————————————

Congenital Glaucoma
-Occurs due to developmental defect in TM & anterior chamber angle
-Outer coat is elastic & distends under effect of high IOP
-Cornea & the globe enlarge resembling the appearance of bull or cow's
eye
BUPHTHALMOS

Classification
Primary Glaucomas
A. Congenital open angle
1.New born glaucoma.
2. Infantile glaucoma.
3.Late recognized.
B.Juvenile OAG

Secondary congenital glaucomas

Secondary Glaucomas
A) Anterior segment dysgenesis
-Iridocorneal dysgenesis
-Axenfeld -Reiger anomaly
-peter anomaly
B) ocular disease
-Aphakia
-PHPV
-Microsperophakia
-Microphthalmos
-Trauma , Hyphema ,Angle recession
 C) Infectious / Inflammatory
-Cong. Rubella
-Juvenile chronic arthritis
D) Phacomatosis
-Sturge weber S
-Neurofibromatosis
E)Ocular tumour
-Retinoblastoma
-Juvenile Xanthogranuloma
-Leukamia
F)Metabolic disease
-Mucopolysaccharidosis
-Homocystinuria
G) Chromosomal disorder
-Down S
-Turner S
I) Connective tissue abnormalities
-Marfan S
-Osteogenesis imperficta

Epidemiology
-1 in 10,000 births
-Bilateral in 65-80%
-M:F= 3:2
-25% diagnosed as newborn,60% by 6 months,80% by 1 year
-Most are sporadic
-10% familial
-May be AR, Multifactorial inheritance
-Gene association in Chromosomal 1&2 (GLC3B,GLC3A-CYPIBI)

Aetiology
-Barkan's membrane (Mesodermal membrane obstructing the trabecular
meshwork)
-Anterior insertion of CM to TM instead of scleral spur
-Absence or malformation of Schlemm's canal

Congenital glaucoma Glaucomtous ocular damage occur due to

1.Mechanical changes due to rise of IOP
2. Vascular perfusion of optic nerve
3. Defective autoregulation

Symptoms
-Photophobia & lacrimation (early) (due to irritation of corneal nerves )
-Change of color of the eye ( Hazy cornea & blue sclera)
-Large globe
-Poor vision
-Discrepancy in size of both eyes in unilateral cases

Signs
-Corneal edema & opacification
-Corneal enlargment

Age Normal Suspicious

Birth -6 month 9.5-11.5 >12
1-2 year 10-12 >12.5
2 years <12 13

Signs
-Breaks in Descent's membrane(Haab striae)
-Buphthalmos
-Increase IOP
using perkins tonometer
Normal IOP in children under GA is unknown
Some author consider glaucoma suspect s children with IOP above 14 mm
IOP is also known to increase with age, hyperopia and corneal thickness.
Adult values are normally reached only after the early teens

Do Anesthetic Agents alter IOP Levels?

-Anesthetic agents and dosage are known to alter the IOP
-High IOP in isolation should never be the basis for diagnosis of congenital
glaucoma
-It is important to know that the major of anasthetics reduce the IOP while
ketamine may increase IOP
-No change in IOP with oral chloral hydrate sedation.
Tonometry with < 1% halothane under the mask anesthesia is considered
optimum.

IOP increases
Succinyl choline
Ketamine
Endotracheal intubation

IOP decreases
Halothane
Oxygen
Nitrous oxide
Sevofurine
Midazolam
Methphenol

Signs
-The sclera becomes thin & appears blue due to underlying uveal tissue
-Anterior chamber becomes deep
-Iris may show iridodonesis
-Lens becomes flat due to stretching of zonules & may even sublaxated
-Induced myopia
-Astigmatism due to irregular scarring.
-Optic N cupping
- develop early & rapidly
- reversal of cupping with IOP control

Differential Diagnosis
1)Disorder showing corneal enlargement
-Axial myopia
-Megalcornea
2) Watering of the eye
-Cong.NLD obst
-Conjunctivitis
-Keratitis
3)Pseudo optic nerve cupping
-Physiological large cupping
-Coloboma of ON
-Malformation of ON
4)Disorder showing corneal edema & opacifications
-Sclerocornea
-peter's anomaly
-Birth trauma
-Herpetic keratitis
-congenital hereditary endothelial dystophy
-mucopolysaccharidosis
-cystinosis

Ocular examination
-Tonometry (after induction & before intubation)
-Anterior segment Examination
-Corneal diameter
-Gonioscopy
-Fundus examination
-Central corneal thickness
-Ultrasound (axial length & B scan )
-Optic N photography
-Refraction

Which cases have the Worst Prognosis?

Patients presenting with severe corneal clouding in the first year have the
worst outcome

What is the Role of Medical Therapy?

Indications
1.Reduce IOP temporarily
2.Clear cornea to facilitate goniotomy
3.Achieve P.O. IOP control
Drugs
1.CAI
Oral (acetozolamide) or
Topical (dorzolamide or brinzolamide )
2. Beta blockers
Betaxolol may be used in children with asthma
Timolol instillation should be followed by mechanical punctual occlusion for
at least 3 to 4 minutes, to minimize systemic absorption.
3.Miotics
4.PG analogs Latanoprost, Traveprost or Bimatprost ( JOAG)
5. Adrenergic agonist : brimonidine (not before 2 y)

-Combination of topical carbonic anhydrase inhibitor (CAI) and beta-

blocker (0.25% or 0.50%) .
-Additional benefit with oral acetazolamide may be obtained in very high
levels of IOP as it seems to have an additive effect with topical CAI drops
in pediatric patients unlike in adults

Which Drugs are not to be used in Children?

-Alpha 2 agonist group of drugs like brimonline are contraindicated in
children < 2 years of age because of the risk of apnea.
-In general, prostaglandin analogues are to be avoided
prior to surgery bec of uveitis & in unilateral cases due to
hyperpigmentation and hypertrichosis of lashes.
-Pilocarpine may paradoxically raise (IOP) due to its
action on the scleral spur, which may cause further
collapse of the trabecular meshwork due to the
abnormally high insertion of uveal tissue

Surgical Treatment of PCGFor all the practical reasons, buphthalmis eyes

are
a special surgical
challenge:
-Opaque cornea
-Distended globe with high IOP
-Posterior shift of limbus
-Thin sclera and limbus
-Thick and active Tenon's capsule, rapid wound healing
-Lower scleral rigidity
-Friable iris
-Life long lasting results anticipated
-Visual rehabilitation is difficult.

Choice of Surgery
Due to aggressive fibrosis and rapid healing in younger age groups,
conventional filtering surgery enjoys limited long-term success. Best
surgical results are obtained, when surgery is
done as early as possible before the onset of irreversible glaucoma and
secondary changes in the angle and cornea

Procedures for childhood glaucoma.

-Trabeculectomy with antimetabolites
-Trabeculotomy ab externo
-Combined trabeculotomy with trabeculectomy (CTT) with or without
antimetabolites
-Non penetrating Schlemm's canal resection
-Goniotomy
-Glaucoma drainage devices (GDD)
-Cyclodestructive procedures.

Surgical Treatment
Goniotomy:
Aim is to transect the Schlemm's canal by ab-interno approach
Prerequisites
-Clear cornea
-Age 3 to 12 months preferably
-Good visibility of angle structures with clear identification of meshwork,
which is difficult
-Technical expertise required
-Corneal diameter not >14 mm

Procedure of goniotomy
-A round, dome shaped direct gonioscope is placed on the cornea with a
handle (Swan Jacob type).
-A nontapered knife or needle enters the AC just inside the limbus and is
withdrawn.
-Injection of viscoelastic is done to maintain the AC during the procedure.
-Re-entry is done with the knife, which courses in the same plane as the
iris.
-The TM is engaged just below the Schwalbe's line in the opposite
meshwork quadrant and a circumferential incision is made across the
visible meshwork.
-It should be a superficial incision with no grating or scraping sensation.
-Prior treatment with pilocarpine eye drops is recommended.
-An immediate widening of the angle under view and posterior movement
of the iris, if visible is a definite indication of success.
-The knife is withdrawn in a similar fashion without collapsing the AC
-Cleft of white tissue noted
-Often 120 of TM can be treated in a single setting

Goniotomy-Advantages
-Good success rate up to 90% between 3 to 12 month
-Less traumatic
-Safe & rapid
-Can be repeated
-Does not injure conjuctiva
-No long term risk of bleb related complications
-Special role in aniridia to prevent glaucoma

Goniotomy- Disadvantages
-Not possible in opaque cornea
-Surgical experience
-Special instruments
-Works mainly for PCG
-Peripheral anterior synechiae form easily leading to failure

Trbeculotomy - Procedure :
-Involve making an external incision & identifying the Schlemm 'canal from
outside
-Inserting trabeculotome into Schlemm 'canal & breaking through the TM to
increase the aqueous flow
-120-140' of TM can be treated in single surgery
-Effect determine after 2-3 weeks

Trbeculotomy - Complications:
-Hyphema
-Iridotomy or iridodialysis
-Damage of lens
-False passage to AC or suprachoroidal space
-PAS
-Infection
-Inadvertent bleb formation
-DM strippling

Trbeculotomy- Advantages:
-Performed with opaque cornea
-Higher success rate

Disadvantages:
-Angle is not directly visualized
-Damage conjunctiva & decrease success of future filtering surgery
-Require special probes
-SC not found in 4-20% of cases
-Iris & CB incarceration
-Hypotony

360' suture trabeculotomy

6-0' Prolene suture is used to thread the entire Schlemm's canal and
rupture it to communicate with the anterior chamber

Trabeculectomy - Indications:
visual potential , unscarred conj after angle surgery
unlike to respond to angle surgery
very low target pressure required
Secondary glaucoma

Trabeculectomy - Advantages:
-Lower IOP achievable
-Clear cloudy cornea

Disadvantages:
Damage conj
Risk of hypotony & endophthalmitis
Risk of intaocular damage if antimetabol.enter eye
Poor result due to scarring
Poor result in aphakic glaucoma

Combined Trabeculotomy-Trabeculectomy
Indications:
1.Failure to cannulate Sclemm's canal
2. Failed previous angle surgery
3.Primary procedure
-Success : 80-90%
Procedure
Trabeculotomy creates a direct continuity between AC & Sclemm's canal &
trabeculectomy helps aqueous bypass Sclemm's canal to be drained out of
AC , to maintain normal IOP
Superior in controlling IOP

Glaucoma Drainage device- Indications:

-Less than 2 y & aphakia
-Failed trabeculectomy
-High risk complications with SST (Sturge weber syndrome)
-Scarring after multiple surgeries
Types
-Non restrictive like Molteno implant
-Flow restrictive like Ahmed valve
Success : 60-70%

Glaucoma Drainage device - Complications:

-Hypotony
-Shallow AC
-Endophthalmitis
-Tube occlusion
-Motility disorder
-Corneal decompansation
-Failure to control IOP
-Tube migration
-Diplopia
-Cataract
-Uveitis
-Suprachoriodal haemorrhge
How to Maximize Results of AGV
-Conjunctiva should be adequate
-Two episcleral bridle sutures; on either side of proposed site
-Must prime the valve
-Subscleral tube insertion
-Use only 23G needle for entry into AC
-Do not hold implant at the trapezoid chamber
-Use atraumatic forceps for holding tube
-Introduce tube bevel up and in iris plane
-Water tight conjunctival closure
-Patch graft over the tube prevents late exposure.

Cyclodestructive procedures
Cyclocryotherapy
Cyclocryotherapy has a significant risk of hypotony and recommended in
eyes with low vision potential and cosmetically disfiguring eyes with high
IOP only.
Procedure
-Freezing ciliary process by external approach NO/CO2
-Max 180 at 1 session using 6-7 freezes (60 sec each at - 80 C)
-2.5 mm diameter cryoprobe used
-Centred 2.5 mm from limbus over CB
-Retreatment include 1 quadrant (leave at least 1 quadrant untouched)
Complications
Hypotony, Uveltis , cataract,phthisis, & vision loss

Transscleral cyclophotocoagulation
Indications:
Failed trab or drainage device
Disorganised anterior segment (trauma & sclerocornea)
High risk of complication with surgery
Procedures
-Nd-YAG or Diode Laser
-Contact diode laser (810 nm) more popular
-Better tolerated, less complications
-Avoid area of pig ,hge or scleral thinning
-Lower settings than adults are recommended as these children have thin
sclera.

Endoscopic cyclophotocoagulation
Indications:
-Best in aphakic & pseudophakic eyes
-High risk of inflammation

Success : 43%
Procedure :
-Done by diode laser
Complications
-Hypotony & vision loss

Advantages:
-Short surgical time
-Low complication rate
-Rapid rehabilitation
-Useful in high risk , one eyed
-Technically less demanding
Disadvantages:
-Repeated in more than 50%
-Patients remain on medical tit
-Pressure control worse (low teens not achieved)
-Danger of long term phthisis with recurrent ttt

Role of Optical Keratoplasty

-Higher chances of graft failure
-Suture infections in pediatric age
-Frequent follow-up.

Long term follow up

-Glaucoma controlled without medications ,at least every 6 mo
-Young children , IOP controlled at least 3-4 mo.
-Correction of amblyopia
Follow up include :
VA, Corneal diameter,edema,gonioscopy,tonometry Axial length, fundus &
disc photography ,t morphology

Prognosis of Childhood Glaucomas

-The severity of the disease
-Age of onset and intervention
-Number of surgeries
-Timely and sustained control of IOP
-Residual corneal scarring, anisometropia and astigmatism
-Aggressive treatment of amblyopia. Glaucoma in children presents a
problem. These, patients are often brought in late, firstly due to the
ignorance of parents and secondly inadvertent delay caused by indecision.