Antimetabolite and releasable suture augmented filtration surgery in refractory pediatric glaucomas

Abstract

Purpose: To evaluate childhood filtration surgery when using releasable sutures, antimetabolites, and bleb-needling with 5-fluorouracil (5FU).

Methods: Retrospective case note review of 30 patients (38 eyes) with childhood glaucoma presenting between 1999 and 2004 to a tertiary pediatric ophthalmology center. Either trabeculectomy or combined trabeculotomy-trabeculectomy using antimetabolites, releasable sutures, and bleb modification was performed. Successful outcomes for survival analysis were measured intraocular pressures < or =21 mmHg, with two or less topical medications.

Results: Patients under 1 year old had trabeculotomy-trabeculectomy; the remainder had trabeculectomy alone. One case of primary congenital glaucoma had trabeculotomy-trabeculectomy at 24 months. Eighty-nine percent had previous failed glaucoma surgery. Twenty-five patients (33 eyes) had primary congenital glaucoma; 5 patients (5 eyes) had secondary glaucoma (aphakia or pseudophakia). Mean follow-up was 22.9 months (5.2-68.5). Sixty-six percent of all eyes had suture-release and 68% had bleb-needling (mean, 1.9 times). Five eyes (13%) needed further drainage tube surgery. Complications were early postoperative hypotony in three cases, requiring anterior chamber reinflation (mean age, 7.4 months at the time of surgery), two cases of transient wound leak, but no bleb-related complications or endophthalmitis. No blebs were avascular, or thin and cystic. Cumulative success was 75% for primary, but only 21% for secondary glaucoma at final follow-up.

Conclusions: Antimetabolite and releasable augmentation of filtration surgery appear to give favorable outcomes in the treatment of refractory primary pediatric glaucomas. Secondary glaucomas after cataract surgery do not show good long-term success. There were no major or sight-threatening complications in our series; no eyes developed cystic avascular blebs or bleb-related infections.