This report by the American Academy of Ophthalmology reviews the success rates and long-term problems associated with various types of surgery for pediatric glaucoma.
The authors examined the pros and cons of the various surgical procedures used over the years to manage congenital glaucoma, excluding the most recent novel techniques, such as trabectome, canaloplasty, MIGS, Ex-Press shunt and endolaser ciliary ablation.
Their findings, based on an analysis of 36 articles, indicate that goniotomy and trabeculotomy are the most popular procedures for congenital glaucoma in babies. Goniotomy works particularly well in uveitic glaucoma provided there is not abundant peripheral anterior synechiae. Aphakic congenital glaucoma also does well with goniotomy. Trabeculotomy is useful in the presence of a cloudy cornea. However, in older children, trabeculectomies have the possible disadvantage of bleb infections, and there is also the problem of scarring as a result of the rapid and intense healing process.
Tube shunt procedures have been predominantly used in cases that have failed the other more common procedures, except for aphakia, where tube shunts are more suitable. The common complications seen in tube shunt use are tube erosion, infection and plate migration. Tubes may also be preferable in the presence of contact lenses.
They note that a key limitation of this review is the lack of level I studies or large randomized controlled studies evaluating the effectiveness and safety of surgical treatments for pediatric glaucoma. Most of the published reports on the surgical treatment of glaucoma in the pediatric population are nonrandomized case series. Additional studies are needed to evaluate the long-term success of these procedures in terms of visual function and quality-of-life metrics.
They conclude that while no single procedure has a monopoly on treatment for congenital glaucoma, the various procedures for its management can be tailored to particular patients.
Future research should continue in the development of more effective and safer surgical options. Due to the long-term complications of antifibrotic drugs, such as MMC, better methods to prevent or inhibit scarring after surgery could be particularly beneficial in the pediatric population. Also, more research is needed directed at improving materials and implant design, particularly with regard to long-term biocompatibility.