Pub Date : 2025-09-01DOI: 10.1016/j.ogla.2025.06.011
James D. Brandt MD , Lauren S. Blieden MD , Alana L. Grajewski MD
The glaucomas arising in children comprise a diverse group of developmental and secondary disorders. Until the mid-20th century, childhood glaucoma was a uniformly blinding disease. The development of surgical approaches like goniotomy ab interno (1940s) and trabeculotomy ab externo (1960s) provided the first effective treatments for this group of uncommon disorders. Since then, additional progress in the management of adult glaucoma has quickly found its way to childhood glaucoma—including the use of antimetabolites, modern glaucoma drainage devices, and techniques of circumferential ab interno and ab externo trabeculotomy using sutures or an illuminated microcatheter. Each of these techniques requires modifications to be safely used in infants and young children. The nomenclature and classification of the pediatric glaucomas were standardized in 2013 with the Childhood Glaucoma Research Network classification system which was a foundational step in developing registries and coordinated research in the field. Modern tools of molecular genetics have begun to elucidate the underlying molecular pathophysiology and inheritance of some forms of childhood glaucoma. Single-gene, Mendelian-inherited forms of childhood glaucoma may be ideal targets for clustered regularly interspaced short palindromic repeats (CRISPR) gene-editing technologies to correct the disorder locally in the anterior chamber angle. All these advances greatly improved visual outcomes in childhood glaucoma. However, with the greatly improved visual prognosis in childhood glaucoma come unique considerations in how we care for these patients over a very long lifespan.
Financial Disclosure(s)
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
{"title":"Childhood Glaucoma","authors":"James D. Brandt MD , Lauren S. Blieden MD , Alana L. Grajewski MD","doi":"10.1016/j.ogla.2025.06.011","DOIUrl":"10.1016/j.ogla.2025.06.011","url":null,"abstract":"<div><div>The glaucomas arising in children comprise a diverse group of developmental and secondary disorders. Until the mid-20th century, childhood glaucoma was a uniformly blinding disease. The development of surgical approaches like goniotomy ab interno (1940s) and trabeculotomy ab externo (1960s) provided the first effective treatments for this group of uncommon disorders. Since then, additional progress in the management of adult glaucoma has quickly found its way to childhood glaucoma—including the use of antimetabolites, modern glaucoma drainage devices, and techniques of circumferential ab interno and ab externo trabeculotomy using sutures or an illuminated microcatheter. Each of these techniques requires modifications to be safely used in infants and young children. The nomenclature and classification of the pediatric glaucomas were standardized in 2013 with the Childhood Glaucoma Research Network classification system which was a foundational step in developing registries and coordinated research in the field. Modern tools of molecular genetics have begun to elucidate the underlying molecular pathophysiology and inheritance of some forms of childhood glaucoma. Single-gene, Mendelian-inherited forms of childhood glaucoma may be ideal targets for clustered regularly interspaced short palindromic repeats (CRISPR) gene-editing technologies to correct the disorder locally in the anterior chamber angle. All these advances greatly improved visual outcomes in childhood glaucoma. However, with the greatly improved visual prognosis in childhood glaucoma come unique considerations in how we care for these patients over a very long lifespan.</div></div><div><h3>Financial Disclosure(s)</h3><div>Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.</div></div>","PeriodicalId":19519,"journal":{"name":"Ophthalmology. Glaucoma","volume":"8 5","pages":"Pages S58-S63"},"PeriodicalIF":3.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144790809","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1016/j.ogla.2025.04.013
Reem M. Aboulhassan MSc, Yasmine M. ElSayed MD, Amanne Esmael MD, Ghada Gawdat MD, Ahmed ElKateb MD, Hala ElHilali MD
Purpose
The aim of this study was to compare the outcomes of 2-site rigid probe trabeculotomy (RPT) compared to gonioscopy-assisted transluminal trabeculotomy (GATT) in the treatment of primary congenital glaucoma (PCG).
Design
A prospective randomized controlled study
Subjects
The study included 77 eyes of 60 patients with PCG with clear corneas all aged < 5 years.
Methods
Patients were randomized to undergo either 2-site trabeculotomy using a RPT or GATT using a 5/0 polypropylene suture. Success was defined as achieving a final intraocular pressure (IOP) < 18 mmHg without (complete) or with medications (qualified).
Main Outcome Measures
Primary outcomes were reduction of IOP and medications. Secondary outcomes were complications and success rates. Anterior segment OCT (AS-OCT) was performed to compare changes in angle morphology.
Results
The two-site RPT group included 39 eyes, and the GATT group included 38 eyes. There was a significant reduction in IOP and glaucoma medications at 1, 3, 6, 9, and 12 months postoperatively in both groups (P < 0.001) with no significant difference in IOP or IOP-lowering medications between both groups at any follow-up (FU). At the final FU, there was a 49% ± 13% IOP reduction in the 2-site RPT trabeculotomy group compared to 44% ± 25% in the GATT group (P = 0.2). Success was achieved in all eyes in the RPT group and in 95% in the GATT group. Hyphema was the most frequently observed complication; with no vision-threatening complications in either group. Postoperative AS-OCT findings included angle widening, trabecular shelf, and peripheral anterior synechia.
Conclusions
Circumferential trabeculotomy using ab interno GATT or ab externo 2-site trabeculotomy yielded comparable results in terms of safety and efficacy. Gonioscopy-assisted transluminal trabeculotomy has the advantage of sparing the conjunctiva which may be needed for future interventions.
Financial Disclosure(s)
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
{"title":"Two-Site Trabeculotomy vs. Gonioscopy-Assisted Transluminal Trabeculotomy in the Treatment of Primary Congenital Glaucoma","authors":"Reem M. Aboulhassan MSc, Yasmine M. ElSayed MD, Amanne Esmael MD, Ghada Gawdat MD, Ahmed ElKateb MD, Hala ElHilali MD","doi":"10.1016/j.ogla.2025.04.013","DOIUrl":"10.1016/j.ogla.2025.04.013","url":null,"abstract":"<div><h3>Purpose</h3><div>The aim of this study was to compare the outcomes of 2-site rigid probe trabeculotomy (RPT) compared to gonioscopy-assisted transluminal trabeculotomy (GATT) in the treatment of primary congenital glaucoma (PCG).</div></div><div><h3>Design</h3><div>A prospective randomized controlled study</div></div><div><h3>Subjects</h3><div>The study included 77 eyes of 60 patients with PCG with clear corneas all aged < 5 years.</div></div><div><h3>Methods</h3><div>Patients were randomized to undergo either 2-site trabeculotomy using a RPT or GATT using a 5/0 polypropylene suture. Success was defined as achieving a final intraocular pressure (IOP) < 18 mmHg without (complete) or with medications (qualified).</div></div><div><h3>Main Outcome Measures</h3><div>Primary outcomes were reduction of IOP and medications. Secondary outcomes were complications and success rates. Anterior segment OCT (AS-OCT) was performed to compare changes in angle morphology.</div></div><div><h3>Results</h3><div>The two-site RPT group included 39 eyes, and the GATT group included 38 eyes. There was a significant reduction in IOP and glaucoma medications at 1, 3, 6, 9, and 12 months postoperatively in both groups (<em>P</em> < 0.001) with no significant difference in IOP or IOP-lowering medications between both groups at any follow-up (FU). At the final FU, there was a 49% ± 13% IOP reduction in the 2-site RPT trabeculotomy group compared to 44% ± 25% in the GATT group (<em>P</em> = 0.2). Success was achieved in all eyes in the RPT group and in 95% in the GATT group. Hyphema was the most frequently observed complication; with no vision-threatening complications in either group. Postoperative AS-OCT findings included angle widening, trabecular shelf, and peripheral anterior synechia.</div></div><div><h3>Conclusions</h3><div>Circumferential trabeculotomy using ab interno GATT or ab externo 2-site trabeculotomy yielded comparable results in terms of safety and efficacy. Gonioscopy-assisted transluminal trabeculotomy has the advantage of sparing the conjunctiva which may be needed for future interventions.</div></div><div><h3>Financial Disclosure(s)</h3><div>The author(s) have no proprietary or commercial interest in any materials discussed in this article.</div></div>","PeriodicalId":19519,"journal":{"name":"Ophthalmology. Glaucoma","volume":"8 5","pages":"Pages 484-494"},"PeriodicalIF":3.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144043051","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1016/j.ogla.2025.06.002
Helena Gali MD , Wendy W. Liu MD, PhD
{"title":"Lens Capsule Deposit in an Eye with Prior Trabeculectomy","authors":"Helena Gali MD , Wendy W. Liu MD, PhD","doi":"10.1016/j.ogla.2025.06.002","DOIUrl":"10.1016/j.ogla.2025.06.002","url":null,"abstract":"","PeriodicalId":19519,"journal":{"name":"Ophthalmology. Glaucoma","volume":"8 5","pages":"Page e17"},"PeriodicalIF":3.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144531322","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1016/j.ogla.2025.03.011
Erin A. Boese MD , Wallace L.M. Alward MD , John H. Fingert MD, PhD
Objective
Mutations within the myocilin (MYOC) gene are the first known single-gene cause of both primary open-angle glaucoma and juvenile open-angle glaucoma (JOAG). Subsequent studies have shown these mutations cause trabecular meshwork dysfunction, resulting in markedly elevated intraocular pressures (IOPs) at young ages. Angle-based procedures, like gonioscopy-assisted transluminal trabeculotomy (GATT), bypass the trabecular meshwork, and as such, are hypothesized to be particularly effective in this angle-based disease. The purpose of this case series is to evaluate the efficacy of GATT for MYOC-associated JOAG.
Design
A retrospective chart review was performed evaluating patients under the age of 18 years with known MYOC-associated JOAG who underwent GATT. A total of 8 eyes of 4 children are included.
Participants
All participants had a strong family history of MYOC glaucoma.
Methods
All patients underwent a thorough clinical evaluation, including visual acuity, slit lamp examination, optic nerve fundoscopy, and IOP measurements by Goldmann applanation. Most patients also underwent 24-2 Swedish Interactive Thresholding algorithm (SITA) standard Humphrey visual fields and fundus photography, and all patients had retinal nerve fiber layer OCT.
Main Outcome Measures
Main outcome measures include IOP and number of medications. Additional measures include visual acuity, optic nerve photos, visual field testing, and OCT.
Results
Following 360° GATT, all 8 eyes of 4 children had a mean drop in IOP of 26 mmHg (68%), and all were able to stop glaucoma medications entirely. Our patients were followed up between 2.2 and 4.1 years with no evidence of decreasing efficacy or glaucomatous progression. All patients maintain 20/20 visual acuity or better in both eyes, and glaucoma has stabilized on all available ancillary testing (OCT, Humphrey visual field, and optic nerve photos). One patient (patient 4) had a notable reversal of cupping.
Conclusions
In MYOC-associated JOAG, the pathology is concentrated at the trabecular meshwork (TM), lending itself well to angle-based surgeries, especially GATT. Gonioscopy-assisted transluminal trabeculotomy is particularly effective in children with MYOC JOAG, allowing them to avoid, or at least delay, the need for more invasive surgeries like trabeculectomy and tube shunt surgeries with over 4 years of follow-up. To date, this is the first genetically directed glaucoma surgery available.
Financial Disclosure(s)
Proprietary or commercial disclosure may be found in the Footnotes and
{"title":"Gonioscopy-Assisted Transluminal Trabeculotomy for Myocilin-Associated Juvenile Open-Angle Glaucoma","authors":"Erin A. Boese MD , Wallace L.M. Alward MD , John H. Fingert MD, PhD","doi":"10.1016/j.ogla.2025.03.011","DOIUrl":"10.1016/j.ogla.2025.03.011","url":null,"abstract":"<div><h3>Objective</h3><div><span>Mutations within the myocilin (</span><em>MYOC</em><span><span>) gene are the first known single-gene cause of both primary open-angle glaucoma and juvenile open-angle glaucoma (JOAG). Subsequent studies have shown these mutations cause trabecular meshwork dysfunction, resulting in markedly elevated </span>intraocular pressures<span> (IOPs) at young ages. Angle-based procedures, like gonioscopy-assisted transluminal trabeculotomy<span> (GATT), bypass the trabecular meshwork, and as such, are hypothesized to be particularly effective in this angle-based disease. The purpose of this case series is to evaluate the efficacy of GATT for </span></span></span><em>MYOC</em>-associated JOAG.</div></div><div><h3>Design</h3><div>A retrospective chart review was performed evaluating patients under the age of 18 years with known <em>MYOC</em>-associated JOAG who underwent GATT. A total of 8 eyes of 4 children are included.</div></div><div><h3>Participants</h3><div>All participants had a strong family history of <em>MYOC</em> glaucoma.</div></div><div><h3>Methods</h3><div><span><span>All patients underwent a thorough clinical evaluation<span>, including visual acuity, </span></span>slit lamp examination<span>, optic nerve fundoscopy, and IOP measurements by Goldmann applanation. Most patients also underwent 24-2 Swedish Interactive Thresholding algorithm (SITA) standard Humphrey visual fields and </span></span>fundus photography<span><span>, and all patients had retinal nerve fiber layer </span>OCT.</span></div></div><div><h3>Main Outcome Measures</h3><div>Main outcome measures include IOP and number of medications. Additional measures include visual acuity, optic nerve photos, visual field testing, and OCT.</div></div><div><h3>Results</h3><div>Following 360° GATT, all 8 eyes of 4 children had a mean drop in IOP of 26 mmHg (68%), and all were able to stop glaucoma medications entirely. Our patients were followed up between 2.2 and 4.1 years with no evidence of decreasing efficacy or glaucomatous progression. All patients maintain 20/20 visual acuity or better in both eyes, and glaucoma has stabilized on all available ancillary testing (OCT, Humphrey visual field, and optic nerve photos). One patient (patient 4) had a notable reversal of cupping.</div></div><div><h3>Conclusions</h3><div>In <em>MYOC-</em>associated JOAG, the pathology is concentrated at the trabecular meshwork (TM), lending itself well to angle-based surgeries, especially GATT. Gonioscopy-assisted transluminal trabeculotomy is particularly effective in children with <em>MYOC</em><span> JOAG, allowing them to avoid, or at least delay, the need for more invasive surgeries like trabeculectomy<span> and tube shunt surgeries with over 4 years of follow-up. To date, this is the first genetically directed glaucoma surgery available.</span></span></div></div><div><h3>Financial Disclosure(s)</h3><div>Proprietary or commercial disclosure may be found in the Footnotes and ","PeriodicalId":19519,"journal":{"name":"Ophthalmology. Glaucoma","volume":"8 5","pages":"Pages 466-473"},"PeriodicalIF":3.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143797239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1016/j.ogla.2025.04.004
Alessandro Ghirardi MD , Siqi Fan MD , Karl Mercieca MD, FRCOphth , Gianni Virgili MD , Stefano De Cillà MD , Alessandro Rabiolo MD
<div><h3>Topic</h3><div>Compare different methods to deliver mitomycin<span> C (MMC) in trabeculectomy surgery.</span></div></div><div><h3>Clinical Relevance</h3><div>Knowing the best way to apply MMC may provide guidance to glaucoma surgeons and improve outcomes.</div></div><div><h3>Methods</h3><div><span>Systematic review<span> and meta-analysis (PROSPERO CRD42023394371) for studies comparing ≥ 2 methods to apply MMC in trabeculectomy published until February 22, 2023, from Medline, EMBASE, and CENTRAL. Randomized clinical trials (RCTs), quasi-randomized, and prospective nonrandomized controlled studies published in English and conducted on human subjects were included. The primary outcome was surgical failure at 1 year. Secondary outcomes included </span></span>intraocular pressure<span> (IOP), number of glaucoma medications<span>, postoperative complications, and interventions. A random-effects meta-analysis was conducted for ≥ 3 studies, whereas a fixed-effect model was used for 2 studies. The certainty of evidence was assessed with Grading Recommendations Assessment, Development and Evaluation (GRADE) score.</span></span></div></div><div><h3>Results</h3><div>From 7899 records, 8 articles from 7 RCTs compared intraoperative sub-Tenon MMC injection (315 participants) and intraoperative MMC-soaked sponges (327 participants). One RCT and 1 quasi-randomized study compared postoperative (60 participants) and intraoperative (60 participants) MMC-soaked sponge application. In the injection vs. sponges comparison, no significant difference in surgical failure (relative risk [RR]: 0.78, 95% confidence interval [CI]: 0.48–1.28; <em>P</em> = 0.33, GRADE score moderate) or IOP (mean difference [MD]: −0.85 mmHg, 95% CI: −2.19 to 0.49; <em>P</em> = 0.21, GRADE score moderate) was found at 1 year. Sub-Tenon injection resulted in fewer postoperative medications (MD: −0.40, 95% CI: −0.63 to −0.18; <em>P</em> < 0.001; GRADE score moderate) and better bleb morphology (GRADE score high) in terms of height (MD: −0.39, 95% CI: −0.61 to −0.18; <em>P</em> < 0.001), extension (MD: 0.28, 95% CI: 0.11–0.45; <em>P</em><span> = 0.001), and vascularity (MD: −0.52, 95% CI: −0.72, −0.31; </span><em>P</em> < 0.001) than sponges. Serious complication and reintervention rates were low and comparable between groups. We did not perform a meta-analysis comparing postoperative and intraoperative sponge application because of heterogeneity in the study designs of the included studies.</div></div><div><h3>Conclusions</h3><div>Intraoperative sub-Tenon MMC injection is noninferior to intraoperative MMC-soaked sponges in trabeculectomy surgery in terms of surgical failure and IOP control, with a reduced number of medications, improved bleb morphology, and similar safety profile. Further research with a long-term follow-up is necessary to confirm their long-term equivalence.</div></div><div><h3>Financial Disclosure(s)</h3><div>Proprietary or commercial disclosure may be found
{"title":"Comparison of Methods to Deliver Mitomycin C in Trabeculectomy Surgery","authors":"Alessandro Ghirardi MD , Siqi Fan MD , Karl Mercieca MD, FRCOphth , Gianni Virgili MD , Stefano De Cillà MD , Alessandro Rabiolo MD","doi":"10.1016/j.ogla.2025.04.004","DOIUrl":"10.1016/j.ogla.2025.04.004","url":null,"abstract":"<div><h3>Topic</h3><div>Compare different methods to deliver mitomycin<span> C (MMC) in trabeculectomy surgery.</span></div></div><div><h3>Clinical Relevance</h3><div>Knowing the best way to apply MMC may provide guidance to glaucoma surgeons and improve outcomes.</div></div><div><h3>Methods</h3><div><span>Systematic review<span> and meta-analysis (PROSPERO CRD42023394371) for studies comparing ≥ 2 methods to apply MMC in trabeculectomy published until February 22, 2023, from Medline, EMBASE, and CENTRAL. Randomized clinical trials (RCTs), quasi-randomized, and prospective nonrandomized controlled studies published in English and conducted on human subjects were included. The primary outcome was surgical failure at 1 year. Secondary outcomes included </span></span>intraocular pressure<span> (IOP), number of glaucoma medications<span>, postoperative complications, and interventions. A random-effects meta-analysis was conducted for ≥ 3 studies, whereas a fixed-effect model was used for 2 studies. The certainty of evidence was assessed with Grading Recommendations Assessment, Development and Evaluation (GRADE) score.</span></span></div></div><div><h3>Results</h3><div>From 7899 records, 8 articles from 7 RCTs compared intraoperative sub-Tenon MMC injection (315 participants) and intraoperative MMC-soaked sponges (327 participants). One RCT and 1 quasi-randomized study compared postoperative (60 participants) and intraoperative (60 participants) MMC-soaked sponge application. In the injection vs. sponges comparison, no significant difference in surgical failure (relative risk [RR]: 0.78, 95% confidence interval [CI]: 0.48–1.28; <em>P</em> = 0.33, GRADE score moderate) or IOP (mean difference [MD]: −0.85 mmHg, 95% CI: −2.19 to 0.49; <em>P</em> = 0.21, GRADE score moderate) was found at 1 year. Sub-Tenon injection resulted in fewer postoperative medications (MD: −0.40, 95% CI: −0.63 to −0.18; <em>P</em> < 0.001; GRADE score moderate) and better bleb morphology (GRADE score high) in terms of height (MD: −0.39, 95% CI: −0.61 to −0.18; <em>P</em> < 0.001), extension (MD: 0.28, 95% CI: 0.11–0.45; <em>P</em><span> = 0.001), and vascularity (MD: −0.52, 95% CI: −0.72, −0.31; </span><em>P</em> < 0.001) than sponges. Serious complication and reintervention rates were low and comparable between groups. We did not perform a meta-analysis comparing postoperative and intraoperative sponge application because of heterogeneity in the study designs of the included studies.</div></div><div><h3>Conclusions</h3><div>Intraoperative sub-Tenon MMC injection is noninferior to intraoperative MMC-soaked sponges in trabeculectomy surgery in terms of surgical failure and IOP control, with a reduced number of medications, improved bleb morphology, and similar safety profile. Further research with a long-term follow-up is necessary to confirm their long-term equivalence.</div></div><div><h3>Financial Disclosure(s)</h3><div>Proprietary or commercial disclosure may be found ","PeriodicalId":19519,"journal":{"name":"Ophthalmology. Glaucoma","volume":"8 5","pages":"Pages 503-514"},"PeriodicalIF":3.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144050407","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1016/j.ogla.2025.06.009
Steven J. Gedde MD , Leon W. Herndon Jr. MD
The surgical options for managing glaucoma have expanded exponentially in recent years. Traditional glaucoma surgery includes trabeculectomy and tube shunt surgery. These procedures drain aqueous into the subconjunctival space, and they are highly effective at lowering intraocular pressure (IOP). Laser suture lysis and releasable sutures allow the surgeon to selectively increase outflow after trabeculectomy, and the ability to titrate IOP postoperatively is an advantage of trabeculectomy over other glaucoma procedures. Mitomycin C and 5-fluorouracil are adjunctive antifibrotic agents that have been shown to improve the success of trabeculectomy, but they also increase the risk of complications such as hypotony maculopathy and bleb-related infections. Tube shunts have been used with increasing frequency as an alternative to trabeculectomy. A silicone tube maintains the patency of the drainage fistula and shunts aqueous humor to an end plate. Devices with larger end plates produce greater IOP reduction, and the presence of a flow restrictor in valved implants serves to reduce the risk of hypotony-related complications. Minimally invasive glaucoma surgery (MIGS) is a newer group of nonbleb-forming procedures performed via an ab interno approach and involves minimal disruption of ocular tissues. Trabecular meshwork/Schlemm’s canal MIGS improve aqueous drainage through the conventional outflow system by stenting, dilating, or cutting/stripping the trabecular meshwork and inner wall of Schlemm’s canal. Suprachoroidal MIGS create a cyclodialysis and increase uveoscleral flow through a device that connects the anterior chamber and suprachoroidal space. The various MIGS procedures are frequently performed in combination with phacoemulsification in patients with mild to moderate open-angle glaucoma. Minimally invasive glaucoma surgery offers a more favorable safety profile than traditional glaucoma surgery, but MIGS are less effective in lowering IOP. A trade-off exists between safety and efficacy with all currently available glaucoma operations. Surgical innovation in glaucoma has provided surgeons with the opportunity to tailor the selection of a procedure to the individual patient. Multicenter randomized clinical trials have provided valuable information to guide the surgical care of glaucoma patients.
Financial Disclosure(s)
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
{"title":"Glaucoma Surgery","authors":"Steven J. Gedde MD , Leon W. Herndon Jr. MD","doi":"10.1016/j.ogla.2025.06.009","DOIUrl":"10.1016/j.ogla.2025.06.009","url":null,"abstract":"<div><div>The surgical options for managing glaucoma have expanded exponentially in recent years. Traditional glaucoma surgery includes trabeculectomy and tube shunt surgery. These procedures drain aqueous into the subconjunctival space, and they are highly effective at lowering intraocular pressure (IOP). Laser suture lysis and releasable sutures allow the surgeon to selectively increase outflow after trabeculectomy, and the ability to titrate IOP postoperatively is an advantage of trabeculectomy over other glaucoma procedures. Mitomycin C and 5-fluorouracil are adjunctive antifibrotic agents that have been shown to improve the success of trabeculectomy, but they also increase the risk of complications such as hypotony maculopathy and bleb-related infections. Tube shunts have been used with increasing frequency as an alternative to trabeculectomy. A silicone tube maintains the patency of the drainage fistula and shunts aqueous humor to an end plate. Devices with larger end plates produce greater IOP reduction, and the presence of a flow restrictor in valved implants serves to reduce the risk of hypotony-related complications. Minimally invasive glaucoma surgery (MIGS) is a newer group of nonbleb-forming procedures performed via an ab interno approach and involves minimal disruption of ocular tissues. Trabecular meshwork/Schlemm’s canal MIGS improve aqueous drainage through the conventional outflow system by stenting, dilating, or cutting/stripping the trabecular meshwork and inner wall of Schlemm’s canal. Suprachoroidal MIGS create a cyclodialysis and increase uveoscleral flow through a device that connects the anterior chamber and suprachoroidal space. The various MIGS procedures are frequently performed in combination with phacoemulsification in patients with mild to moderate open-angle glaucoma. Minimally invasive glaucoma surgery offers a more favorable safety profile than traditional glaucoma surgery, but MIGS are less effective in lowering IOP. A trade-off exists between safety and efficacy with all currently available glaucoma operations. Surgical innovation in glaucoma has provided surgeons with the opportunity to tailor the selection of a procedure to the individual patient. Multicenter randomized clinical trials have provided valuable information to guide the surgical care of glaucoma patients.</div></div><div><h3>Financial Disclosure(s)</h3><div>The author(s) have no proprietary or commercial interest in any materials discussed in this article.</div></div>","PeriodicalId":19519,"journal":{"name":"Ophthalmology. Glaucoma","volume":"8 5","pages":"Pages S49-S57"},"PeriodicalIF":3.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144755245","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1016/j.ogla.2025.04.011
Javier García-Bardera MD , Julian Garcia-Feijoo MD, PhD , Laura Morales-Fernández MD, PhD , Clara Heredia-Pastor MD , Álvaro Ponce-de-León MD , Mireia García-Bermúdez MD , Marco Antonio Pascual-Santiago MD , Bárbara Burgos-Blasco MD, PhD , Jose María Martínez-de-la-Casa MD, PhD , Julián Garcia-Sánchez MD, PhD
Purpose
To evaluate the clinical outcomes of Preserflo MicroShunt (PMS) implantation with mitomycin C (MMC) in managing refractory childhood glaucoma previously treated with Ahmed glaucoma valve (AGV).
Design
A single-arm retrospective cohort study.
Participants
Twenty-three eyes of 22 patients with refractory childhood glaucoma and a history of AGV implantation.
Methods
All patients underwent PMS implantation with intraoperative MMC (0.04% for 2.5 minutes). Primary endpoints included intraocular pressure (IOP) reduction, reduction in antiglaucomatous medications, and surgical success. “Complete success” was defined as achieving target IOP without medications; “qualified success” allowed for medications. Safety parameters included intraoperative and postoperative complications and the need for further interventions.
Main Outcome Measures
Intraocular pressure reduction, antiglaucomatous medication reduction, and surgical success rates.
Results
Median follow-up was 23 months (interquartile range: 18–41). Mean baseline IOP was 27.0 ± 4.3 mmHg with 3.2 ± 0.5 medications. At 1 year, IOP decreased to 14.1 ± 4.4 mmHg (−47.0%) with 0.4 ± 1.0 medications and to 16.9 ± 3.6 mmHg (−40.2%) with 1.2 ± 1.5 medications at 2 years. Overall success rates for ≥20% IOP reduction were 91.3% at 1 year (69.9% complete success) and 72.7% at 2 years (45.5% complete success); for ≥30% reduction, they were 82.6% and 63.6%, respectively. During follow-up, 1 case of device extrusion was observed at 3 months, and another required surgical revision at 5 months.
Conclusions
Preserflo MicroShunt implantation with MMC offers a valuable surgical option for managing refractory childhood glaucoma after AGV. The procedure achieved substantial reductions in both IOP and medication burden. Larger studies with extended follow-up are recommended to confirm its long-term efficacy.
Financial Disclosure(s)
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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