REVIEW ARTICLE
A Comprehensive Review of Pediatric Glaucoma Following Cataract
Surgery and Progress in Treatment
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Yu Zhang, MD, Yunhe Song, MD, Yue Zhou, MD, Bingyu Bai, MD,
Xiulan Zhang, MD, PhD, and Weirong Chen, MD, PhD
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Abstract: Glaucoma following cataract surgery (GFCS) remains
a serious postoperative complication of pediatric cataract sur-
gery. Various risk factors, including age at lensectomy, intra-
ocular lens implantation, posterior capsule status, associated
ocular/systemic anomaly, additional intraocular surgery, and a
family history of congenital cataract and GFCS, have been
reported. However, the optimal surgical approach remains un-
clear. This review evaluates the diagnostic criteria, classi-
fication, risk factors, mechanism, and surgical management,
especially the efficacy of minimally invasive glaucoma surgery,
in GFCS, and aims to propose an optimal clinical management
strategy for GFCS. The results of our review indicate that ab
interno trabeculotomy (goniotomy) may be the most appro-
priate first-line treatment for GFCS.
Key Words: ab interno trabeculotomy, glaucoma following pediatric
cataract surgery, goniotomy, minimally invasive glaucoma surgery
(Asia Pac J Ophthalmol (Phila) 2023;12:94–102)
INTRODUCTION
G laucoma following cataract surgery (GFCS), previously
termed as aphakic and/or pseudophakic glaucoma, is a
serious and sight-threatening postoperative complication of
pediatric cataract surgery. Based on the Childhood Glaucoma
Research Network (CGRN), GFCS is secondary glaucoma that
meets glaucoma definition (see Diagnosis Section for details)
after cataract surgery is performed.1 According to the 10-year
follow-up outcomes of the Infant Aphakia Treatment Study
(IATS),2–4 the risk of GFCS increases with time. This highlights
its variable onset and the importance of close and regular
screening. Due to a lack of specific definitions and diagnostic
criteria, the incidence of GFCS varies from 2% to 32%
Submitted August 11, 2022; accepted November 1, 2022.
From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic
Center, Guangdong Provincial Key Laboratory of Ophthalmology and
Visual Science, Guangdong Provincial Clinical Research Center for Ocular
Diseases, Sun Yat-sen University, Guangzhou, China.
The authors have no conflicts of interest to disclose.
Address correspondence and reprint requests to: Weirong Chen State Key
Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guang-
dong Provincial Key Laboratory of Ophthalmology and Visual Science,
Guangdong Provincial Clinical Research Center for Ocular Diseases, Sun
Yat-sen University, Guangzhou 510060, China. E-mail: chenwr_q@aliyun.
com.
Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by
Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of
Ophthalmology. This is an open access article distributed under the terms
of the Creative Commons Attribution-Non Commercial-No Derivatives
License 4.0 (CCBY-NC-ND), where it is permissible to download and
share the work provided it is properly cited. The work cannot be changed
in any way or used commercially without permission from the journal.
ISSN: 2162-0989
DOI: 10.1097/APO.0000000000000586
94 | https://journals.lww.com/apjoo
according to different studies.5–13 Several studies have detected
various risk factors for GFCS, including age at lensectomy,
intraocular lens (IOL) implantation, and additional intraocular
surgery. No definite risk factors, except for age at lensectomy,
have been described to date. Regarding GFCS management,
medication is the first-line treatment. Surgical intervention is
indicated when the intraocular pressure (IOP) cannot be con-
trolled with medication; however, the optimal surgical approach
is controversial. Suggested surgical approaches include trabe-
culotomy, trabeculectomy, and combined trabeculotomy-
trabeculectomy (CTT) with antimetabolites, glaucoma drainage
device (GDD) implantation, and cyclodestructive procedures.
Minimally invasive glaucoma surgery (MIGS) has become a
major part of the field of glaucoma surgical treatment in the last
decade, with features of minimal trauma, good efficacy, high
safety profile, and rapid recovery.14,15
MIGS has shown some success in select cases of child-
hood glaucoma with short-term follow-up.16–18 In the
meantime, MIGS has been used increasingly often to treat
GFCS.17,19–22
We aim to review the diagnostic criteria, classification,
risk factors, mechanism, treatment, and efficacy of MIGS
in GFCS.
DIAGNOSIS
There is a lack of consensus regarding the diagnostic
criteria for GFCS. Previous studies have defined glaucoma
solely based on an elevated IOP of ≥ 25 mm Hg23–26 or
≥ 26 mm Hg5,27 to increase the likelihood that the identified
patients indeed had GFCS, whereas other studies based the
diagnosis on a combination of elevated IOP ( > 21 mm Hg)
with ocular signs of glaucoma.9,11,28,29 Due to different diag-
nostic criteria and lengths of follow-up, it is difficult to directly
compare results among these studies.
The diagnostic criteria of the IATS and CGRN are
mostly referred to in detail as follows.
IATS Diagnostic Criteria2
Glaucoma: An IOP of > 21 mm Hg with 1 or more of the
following anatomical changes:
(1) Corneal enlargement.
(2) Asymmetrical progressive myopic shift accompanied by
enlargement of the corneal diameter and/or axial length.
(3) Increased optic nerve cupping, defined as an increase of
0.2 or more in the cup-to-disc ratio.
(4) Use of a surgical procedure for IOP control.
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 Asia-Pacific Journal of Ophthalmology  Volume 12, Number 1, January/February 2023
Glaucoma suspect: at least 1 of the following is required:
(1) Two consecutive IOP measurements of > 21 mm Hg on
different dates after discontinuation of topical corticosteroids
without any of the anatomical changes listed above.
(2) Use of glaucoma medication to control IOP without any
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of the anatomical changes listed above.
CGRN Diagnostic Criteria1,30
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Glaucoma: 2 or more of the following are required:
(1) IOP > 21 mm Hg (investigator discretion on the method
of measurement and if data obtained during examination
under anesthesia alone are sufficient).
(2) Visual fields: reproducible visual field defect that is
consistent with glaucomatous optic neuropathy with no
other observable reason for the visual field defect.
(3) Axial length: progressive myopia or myopic shift with
increased ocular dimensions that outpace normal growth.
(4) Cornea: findings that include Haab striae, corneal dia-
meter > 11 mm in newborns, > 12 mm in children younger
than 1 year, and > 13 mm in children older than 1 year.
(5) Optic nerve: progressive increase in cup-to-disc ratio,
cup-to-disc asymmetry ≥ 0.2 when optic discs are of
similar size, and focal rim thinning.
Glaucoma suspect: at least 1 of the following is required:
(1) IOP: > 21 mm Hg on 2 separate dates.
(2) Visual fields: visual field defect indicating glaucoma.
(3) Axial length: increased axial length in the setting of
normal IOP.
(4) Cornea: increased corneal diameter in the setting of
normal IOP.
(5) Optic nerve: optic disc appearance indicating glaucoma.
CGRN diagnostic criteria are preferable for GFCS
because they emphasize the signs of glaucoma and visual field
defects other than IOP, which may help avoid unnecessary
treatment and missed diagnosis.
RISK FACTORS
The development of GFCS may be multifactorial.
Numerous studies have proposed various risk factors for
GFCS,5,9,11,25,27,31 including age at lensectomy, IOL im-
plantation, type of cataract, primary posterior capsulotomy
with anterior vitrectomy, preexisting ocular abnormalities
(microphthalmia, microcornea, persistent fetal vasculature,
etc.), additional intraocular surgery, and family history of
congenital cataract or GFCS.
Age at Lensectomy
Most published studies have found that early age at
lensectomy is a risk factor for GFCS, especially in the first
3 months of life.5,6,8,11,12,25,27,31–37 The mechanism of early age
at lensectomy has not been elucidated to date. Some hypotheses
based on the experience of previous studies have been devel-
oped. First, immaturity of the developing infant’s angle may
lead to increased intolerance to surgery. Second, additional
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A Review of Glaucoma Following Cataract Surgery
contributing factors increase the probability of postoperative
inflammation in younger patients undergoing surgery, leading
to early exposure of the immature trabecular meshwork (TM)
to inflammatory cells and cytokines.23 Third, due to posterior
capsulorrhexis and anterior vitrectomy in younger patients as
conventional surgical procedures, early exposure of the TM to
the vitreous may contribute to an increased risk of glaucoma.32
Despite the increased risk of GFCS in younger patients, it seems
inadvisable to delay lensectomy, taking the damage of depri-
vation into consideration. The increased risks of early lensec-
tomy must be balanced against the need to decrease the period
of visual deprivation, particularly because form-deprivation
amblyopia is generally more difficult to treat than glaucoma.
IOL Implantation
Primary IOL implantation in children is generally
performed in patients more than 2 years of age, although there
are studies showing good success of IOL implantation at much
earlier age including infant, especially for those unilateral
cases.38–41 Selecting the right IOL power for implantation is
challenging in pediatric cataract.42,43
If not, aphakia following lensectomy can occur. Some
studies suggest that primary IOL implantation may reduce the
risk of GFCS,44–46 whereas others do not confirm this
result.35,47,48 However, some prospective studies have in-
dicated that primary IOL implantation does not confer pro-
tection against GFCS.4,49,50 Regarding this controversial
issue, 2 meta-analyses have found that primary IOL im-
plantation was correlated with a significantly lower risk for
postoperative glaucoma development.31,51 Possible reasons for
this include the fact that IOL could prevent TM collapse and
isolate the TM from the vitreous, as the vitreous could cause a
toxic reaction when it contacts TM.51
Secondary IOL implantation is a common treatment for pa-
tients who have undergone cataract extraction for <2 years. There
are various surgical choices for secondary implantation of IOL.52,53
In aphakic eyes, where the amount of residual lens capsule
after cataract extraction is insufficient or the anterior and pos-
terior capsules are adherent and scarred, an IOL can only be
implanted in the ciliary sulcus. A prospective study revealed
that in-the-bag IOL implantation significantly reduced the in-
cidence of postoperative glaucoma-related adverse events.38
Sulcus implantation may increase the risk of glaucoma because
of iris chaffing, pigment dispersion, chronic inflammation, and
pupillary block; this risk may be greater when Soemmering ring
is not debulked.54
Posterior Capsule Status
Some studies have proposed that posterior capsulorrhexis
and anterior vitrectomy are predictors of GFCS.5,34 An intact
posterior capsule might protect the angle from toxic vitreous
chemicals, reducing the potential incidence of GFCS. However,
posterior capsulorrhexis and anterior vitrectomy are commonly
performed following lensectomy in younger patients with
pediatric cataracts to reduce the incidence of posterior capsular
opacification.55,56
Additional Intraocular Surgery (Reintervention)
Although pediatric cataract surgery has become
standardized and simplified with the advent of minimally in-
vasive surgical techniques and instrumentation, the incidence
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 Zhang et al Asia-Pacific Journal of Ophthalmology
of postoperative complications remains at 5% to 25%,57,58 and
is higher in children aged 1 year at the time of initial surgery.
Visual axis opacification remains the most common indication
for reintervention. Additional intraocular surgery has been
reported to be associated with the development of
GFCS.5,13,31,59 Visual axis opacification may be caused by
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excessive postoperative inflammation, and reintervention
would lead to further inflammation that could cause periph-
eral anterior synechia or damage the angle, which would
contribute to open angle glaucoma.5
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Associated Ocular/Systemic Anomaly
Some infant patients with congenital cataracts have
associated ocular anomalies, such as persistent fetal vascu-
lature, microphthalmia, microcornea, etc.60–63 Extremely
early onset of cataract, subsequent surgery in young mi-
crophthalmic eyes, and associated anomalies of the angle
structures with peripheral crowding may be risk factors for
the development of glaucoma.9,11,33,64 Controversial results
have been reported for congenital cataracts patients
combined with microcornea.5,9,27,35,65 Microcornea may
reflect the fact of an abnormal anterior segment and
potential filtration angle defects, which increase the risk of
GFCS. However, due to the nature of the data collection, it
is impossible to determine whether this effect was due to a
family history of congenital cataract or glaucoma.27 The
incidence of GFCS in patients with congenital rubella syn-
drome is reportedly 43.2%, which should be brought to the
forefront.26
Family History
Some studies have proposed that a family history of
congenital cataract, congenital glaucoma, and GFCS in their
first-degree relatives is a risk factor for GFCS;25,27,66 however,
the mechanism has not been elucidated to date.
CLASSIFICATION
Based on cataract type, GFCS is subdivided into 3 catego-
ries: congenital idiopathic cataract, congenital cataract associated
with ocular anomalies/systemic disease (no previous glaucoma),
and acquired cataract (no previous glaucoma).1
Based on gonioscopy results, GFCS can be divided into
open angle ( ≥ 50% open) and angle closure glaucoma (< 50%
open or acute angle closure).1 Angle closure glaucoma usually
occurs within 1 year after cataract extraction,67 requiring
surgical treatment. Angle closure glaucoma is uncommon in
modern pediatric cataract surgery. Most GFCS cases are cases
of open angle glaucoma that usually develop several years
after lensectomy.3,67
MECHANISM
The mechanism of GFCS can be divided into 2 groups,
namely angle closure and open angle. The mechanism of angle
closure glaucoma is likely due to an extreme postoperative
inflammatory response, leading to synechia in the chamber
angle or pupillary block.
The mechanism underlying open angle glaucoma remains
poorly understood and is thought to be multifactorial.
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Chemical and mechanical hypotheses have been suggested
to date.
From the perspective of chemical mechanisms, chemical
or inflammatory mediators may diffuse from vitreous or lens
epithelial cells (LECs) into the anterior chamber and induce
TM inflammation and dysfunction. In the LEC-TM coculture
model, TM cell exposure to LECs resembles alterations ob-
served in primary open angle glaucoma, and aqueous outflow
could be impaired by changes in the connections between TM
cells. All these changes imply that LECs affect the function-
ality of TM cells and may be responsible for the development
of GFCS.68 Further research proposes that interleukin-4, and
vascular endothelial growth factor secreted from residual
LECs after removal of congenital cataract, then altered TM
cell morphology and gene expression, which is responsible for
the development of GFCS.69 In the meantime, alpha-B crys-
tallin (CRYAB) secreted from the retained LECs might also
be related to the pathogenesis of GFCS.70
The prolong use of topic steroids has been suggested to
play a role in the development of GFCS.13 However, the use
of topic steroids usually lasts 1 to 2 months postoperatively,
while the most of GFCS are open angle cases which usually
develop several years after lensectomy.3,67 Therefore, the role
of topic steroids in the development of GFCS is still
uncertain.71
From the perspective of the mechanical mechanism, there
is a hypothesis that lensectomy may induce TM collapse from
loss of ciliary body traction or other aqueous drainage path-
way changes.72 However, this study is based on 2 groups,
namely healthy and postlensectomy eyes with or without
glaucoma, rather than comparing glaucomatous and non-
glaucomatous postlensectomy eyes. Therefore, the effect of
TM collapse on GFCS following lensectomy is yet to be
verified.
TREATMENT
Treating GFCS remains a major challenge in the
postoperative population with pediatric cataracts. Medication
is usually the first-line treatment for open angle GFCS, both
as a preoperative temporizing measure to control IOP or as
adjuvant therapy after the partial success of surgical treat-
ment. Notably, among these topical IOP-reducing medi-
cations, brimonidine should not be used in infants younger
than 2 years of age,73 and may pose the greatest risk of central
nervous system–related side effects in children aged younger
than 6 years and weighing <20 kg.74
Surgical intervention is indicated when IOP cannot be
controlled with medication or when compliance is poor.
According to the literature, 36.4% to 57.1% of patients with
GFCS require surgical treatment.4,12,23 Various surgical pro-
cedures have been reported to treat GFCS, including tradi-
tional glaucoma surgery and MIGS. The former includes
conventional trabeculotomy, trabeculectomy, CTT (with an-
timetabolites), GDD implantation, and cyclodestructive pro-
cedures. Based on the physiological mechanisms and
anatomical sites of surgery, MIGS can be classified into 4
anatomical categories: enhancing aqueous outflow through
Schlemm canal (SC) surgery, enhancing aqueous outflow
through uveoscleral routes, enhancing aqueous outflow
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 Asia-Pacific Journal of Ophthalmology  Volume 12, Number 1, January/February 2023
through the subconjunctival space, and reducing aqueous
humor production through ciliary procedures.15
Traditional Glaucoma Surgery
Conventional Trabeculotomy
Conventional trabeculotomy is performed to incise the
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TM and inner wall of the SC with a probe through an external
approach, thereby connecting the SC directly to the anterior
chamber, resulting in increasing aqueous outflow to lower the
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IOP.75 Trabeculotomy was previously considered the main
treatment for primary congenital glaucoma, especially in eyes
with hazy corneas.76
Studies on GFCS treated with trabeculotomy are limited,
and the success rate varies greatly (16%–89.3%) with small
retrospective cohorts.23,77,78 Although prospective studies are
lacking, the tendency remains that angle surgery may be
effective in avoiding glaucoma filtration surgery in selected
patients. However, conventional trabeculotomy carries the
risk of false passage and accidental tissue destruction.79
Trabeculectomy and CTT With Antimetabolites
Trabeculectomy is a classical glaucoma filtration surgery
that diverts aqueous humor from the anterior chamber to the
subconjunctival space. CTT was used to gain access to the
dual outflow through the SC and trabeculectomy fistula.
Antimetabolites, such as MMC and 5-fluorouracil, are gen-
erally used to suppress fibrosis and vascular ingrowth after
exposure to the filtration site during trabeculectomy and
CTT.23,80–88 Among these studies, the success rate of the study
with the largest sample size (n = 61) was only 24.6% after a
mean follow-up of 8.6 years.23 These findings suggest that
trabeculectomy has an unsatisfactory effect on GFCS, even
with the intraoperative use of antimetabolites, especially in
younger patients, because of increased fibrotic activity and
rapid wound healing response.84 Complications include hy-
potony, flat anterior chamber and choroid effusion, vitreous
hemorrhage, and endophthalmitis.84,85 In addition, the pres-
ence of blebs following trabeculectomy may preclude the use
of contact lenses in aphakic eyes.84
GDD Implantation
GDD is applied in the anterior chamber as a shunter to
draw the aqueous humor through a tube to a subconjunctival
end-plate, including valved (Ahmed glaucoma valve) and
nonvalved (Molteno and Baerveldt implants) designs. GDD
implantation is currently among the most widely used treat-
ments for GFCS.23,81,85,89–100
A success rate of up to 95% has been achieved; however,
there is no consensus on the diagnostic criteria of success.
Several studies have demonstrated that success rate decreases
with time.93–95,97–99
Of all the studies reviewed, only 1 study compared the
effect of trabeculectomy with mitomycin-C (Trab+MMC) and
Ahmed glaucoma valve with MMC (AGI+MMC),85 which
found that the 2 groups had comparable success and
complication rates.
Complications of GDD implantation commonly include
corneal endothelial cell loss (ECL), hypotony, and retinal
detachment.94,101 ECL is a persistent long-term complication
that continues to increase with time, especially in children.94 In
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A Review of Glaucoma Following Cataract Surgery
a study with an average follow-up of 43 months, incremental
annualized ECLs were 10.7%, 7.0%, and 4.2%, respectively, in 1
to 3 years after AGI implantation, with an ongoing average
annual decline of 2.7% thereafter.102 Although various theories
have been proposed, the exact mechanism that causes ECL
after GDD implantation remains unclear. To date, the pro-
posed mechanisms of ECL include jet flow around the tube end
caused by the pulse, retrograde flow from the encapsulated
reservoir to the anterior chamber, inflammation in the anterior
chamber, intermittent tube-corneal contact, and foreign-body
reaction to the tube material.102–104
Cyclodestructive Procedures
Cyclodestructive procedures aim to reduce aqueous hu-
mor production through irreversible coagulation or destruc-
tion of the ciliary body, thereby lowering IOP. These
procedures include cyclocryotherapy and transscleral cyclo-
photocoagulation with a Nd:YAG laser or a semiconductor
diode laser.105,106 Cyclocryotherapy is based on the formation
of intracellular microcrystals with consequential damage to
the ciliary body epithelium and obliteration of small blood
vessels through rapid tissue freezing to temperatures around –
80°C. Transscleral diode laser cyclophotocoagulation (TDLC)
is based on the application of laser energy to destroy the
ciliary body-pigmented epithelium, leading to coagulative
necrosis and secretory ciliary apparatus damage with a
consequential reduction in aqueous humor production.107
Cyclocryotherapy was used less and earlier when man-
aging GFCS because of its relatively low success rate and a
significant incidence of complications.23,105,108 This procedure
may cause damage to the neighboring TM due to extension of
the cryoablated area.109 TDLC is moderately effective in
GFCS eyes with repeated treatment and is reportedly more
effective in older than younger patients.23,110–112 The sig-
nificant perilimbal conjunctival inflammation and scarring
caused by TDLC may affect the outcome of subsequent fil-
tering surgeries when it is performed as an initial procedure. It
is suggested that filtration surgery including implants should
be performed before cyclodestructive procedures; otherwise,
the risk of hypotony due to relative over-filtration increases.112
In conclusion, traditional glaucoma surgeries are mod-
erately effective for GFCS and have continuous long-term
complications. Therefore, a new surgery with a higher success
rate and fewer complications should be explored.
Minimally Invasive Glaucoma Surgery
Enhancing Aqueous Outflow through SC Surgery
Ab interno trabeculotomy, also termed goniotomy (GT),
is performed to incise or remove all or part of the TM and the
inner wall of the SC to facilitate aqueous drainage into the SC,
which reduces outflow resistance and lowers IOP.
GT is usually performed with the assistance of a surgical
goniolens and special instruments at 120, 240, or 360 degrees.
One hundred and twenty or 240-degree GT can be performed
using a Kahook Dual Blade (KDB; New World Medical,
Rancho Cucamonga, CA) or Tanito Micro-Hook (TMH;
Inami & Co. Ltd, Tokyo, Japan), and microvitreoretinal
blades. Gonioscopy-assisted transluminal trabeculotomy
(GATT) allows a 360-degree incision in the inner layer of the
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SC and the adjacent TM with the iTrack system (iScience
Interventional, Menlo Park, CA) or a 5-0 or 6-0 poly-
propylene suture.113 Three hundred and sixty-degree trabe-
culotomy can facilitate ab externo opening of the angle using
a 6-0 polypropylene suture or illuminated microcatheter (mi-
crocatheter-assisted trabeculotomy, MAT).114 Trabectome
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been used in conjunction with phacoemulsification and
goniosynechialysis.128–130
Enhancing Aqueous Outflow Through the Subconjunctival
Space
Subconjunctival MIGS procedures, including the XEN

(NeoMedix, Tustin, CA) also aims to facilitate aqueous
drainage into the SC by removing a strip of TM and inner wall
of the SC using high-frequency electrocautery.14
Only 1 report on the use of KDB in GFCS currently
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gel stent (Allergan Inc., Dublin, Ireland) and PRESERFLO
MicroShunt (Santen Inc., Miami, FL), are microshunts used
to divert the aqueous humor from the anterior chamber to the
subconjunctival space, resulting in a filtration bleb. The

exists. An 11-month-old infant with GFCS who was treated
bilaterally with KDB for ~100 degrees presented adequate
IOP reduction at a short follow-up of ~2 months
postoperatively.19
GATT and MAT reportedly have satisfactory effects on
GFCS with up to 3 years of follow-up (Table 1).115–118 Ab
externo trabeculotomy showed similar IOP-lowering effects as
ab interno but had more postoperative complications.119
However, the reported results of MAT illustrate the safety
and effectiveness of 360-degree trabeculotomy on GFCS and
promote the application of ab interno trabeculotomy in
GFCS. These limited studies indicate that ab interno
trabeculotomy may be an alternative, minimally invasive
surgery to control IOP. It is worth the effort prior to
advancing to GDD, trabeculectomy, or cyclodestructive
procedures in GFCS, which have the advantages of
preserving the conjunctiva and thus do not influence the
future filtration surgery and without long-term risk of bleb-
related complications. To date, studies have shown that the
efficacy of lowering IOP does not differ significantly among
120, 240, or 360-degree SC incisions.120–124
Hyphema is the most common complication following
GATT and usually resolves within 1 month postoperatively
without additional intervention.21,125
Microbypass stents aim to reduce outflow resistance
and lower IOP by providing a channel or dilating the SC to
facilitate aqueous drainage, including iStent, iStent injection
(Glaukos Corporation, Laguna Hills, CA),126 and Hydrus
Microstent (Ivantis Inc., Irvine, CA).127 Lastly, GT has also
aqueous humor from the bleb diffuses into the surrounding
subconjunctival tissue and is eventually reabsorbed into the
subconjunctival capillaries. The XEN Gel Stent is a 6-mm
gelatin stent inserted into the subconjunctival space from the
anterior chamber to shunt aqueous fluid from the anterior
chamber to a filtering bleb with or without MMC.131
Two successful cases of GFCS with XEN Gel Stent
treatment have been reported, which demonstrates that the
short-term safety and efficacy of GFCS with XEN gel stent is
promising in only 2 patients.20,22 Some complications, in-
cluding stent displacement132 and occlusion,133 bleb leaks,
blebitis, and bleb-related endophthalmitis, have been reported
in adults.134 Therefore, when it is used in pediatric patients,
unknown long-term complications and outcomes of this de-
vice should be considered.
Reducing Aqueous Production Through Ciliary Procedures
These procedures are designed to reduce the aqueous
humor production of the ciliary body, including ultrasound
ciliary plasty (Eye Tech Care, Rillieux-la-Pape, France)135
and micropulse transscleral laser therapy (MP-TLT; Iridex
Corporation, Mountain View, CA).136 Endoscopic cyclo-
photocoagulation is also considered by some as a MIGS
procedure,15,137 which has been reported to be used in the
management of GFCS as a secondary intervention in most
cases.81,138–141
Endoscopic cyclophotocoagulation was successful in
approximately half of all GFCS cases, and most cases of
GFCS require repeated treatment, which can improve the

TABLE 1. Three Hundred and Sixty-Degree Trabeculotomy in GFCS

Preoperative IOP Final IOP Mean Success,
References Design Eyes (n) Procedure (Medications) (Medications) Follow-up (y) n (%)
Beck et al115 Retrospective 4 360-degree suture 33.0 ± 7.2 (NA) 21.8 ± 5.4 (NA) 1.6 3 (75)
trabeculotomy
Ab externo
Dao et al116 Retrospective 13 MAT 35.4 ± 4.7 (2.5) 21.9 ± 8.6
All open Ab externo (1.9, successful 1.4 8 (62)
angle eyes)
Lim et al117 Retrospective 25 MAT 31.5 ± 7.5 19.2 ± 7.7
Ab externo (3.0 ± 1.0) (2.4 ± 1.1) 2.7 ± 2.2 17 (72)
Rojas et al118 Retrospective 15 (4)* MAT 27.1 ± 7.0 15.3 ± 3.9
Ab externo (3.6 ± 0.7) (1.4 ± 1.2) 3.3 ± 2.4 6 (93)
Areaux RG Jr et al17 Multicenter 5 Trab360 NA NA NA 3 (60)
retrospective Ab interno
Quan et al21 Retrospective 13 GATT NA NA NA 5 (38.5)
Ab interno
*Four of the 15 eyes underwent 360-degree catheter trabeculotomy, all of which succeeded.
GATT indicates gonioscopy-assisted transluminal trabeculotomy; GFCS, glaucoma following cataract surgery; IOP, intraocular pressure; MAT,
microcatheter‐assisted trabeculotomy; NA, not applicable.

98 | https://journals.lww.com/apjoo r 2022 Asia-Pacific Academy of Ophthalmology.

 Asia-Pacific Journal of Ophthalmology  Volume 12, Number 1, January/February 2023
overall success rate.138–141 The failure rate does not differ
significantly between pseudophakic and aphakic patients.140
Complications such as severe postoperative inflammation,
overtreatment resulting in irreversible hypotony, retinal
detachment, and choroidal detachment have been reported.141
Downloaded from http://journals.lww.com/apjoo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
CONCLUSIONS
The risk factors for GFCS are controversial. It is im-
portant that all clinical studies use the same diagnostic criteria
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 05/13/2023
to draw comparable conclusions. Managing GFCS is chal-
lenging. An overall consideration of the efficacy and compli-
cations must be given, and ab interno trabeculotomy (GT) of
the MIGS is a potential first-line option.
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r 2022 Asia-Pacific Academy of Ophthalmology.