15.1 Goals

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  Lower the intraocular pressure (IOP).

  
  
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  Decrease glaucoma medication usage.

  
  
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  Potentially cure certain types of childhood primary and secondary glaucoma.

15.2 Advantages

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  Minimally invasive procedure.

  
  
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  Preserves the conjunctiva and sclera for filtration surgery if needed.

15.3 Expectations

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  Results of goniotomy are variable and depend greatly on the severity of the congenital or acquired filtration angle abnormality.

  
  
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  Excellent results can be expected for patients with infantile primary congenital glaucoma (PCG) and secondary glaucoma due to uveitis, while less successful results are seen in patients with Sturge-Weber syndrome and newborn PCG (patients presenting with glaucoma between birth to 1 month of age).

15.4 Key Principles

Goniotomy is done to improve filtration angle function (Fig. 15.1) and can be followed by any other alternative glaucoma procedures if needed.

15.5 Indications

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  The clinical indications depend on the accurate diagnostic classification of the glaucoma which determines whether the patient is a favorable candidate to benefit from goniotomy (Table 15.1).

  
  
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  The decision to perform a goniotomy is multifactorial and should be determined based on the experience of the surgeon and availability of appropriate surgical instruments and equipment, as well as the corneal clarity, gonioscopic findings, and history of prior glaucoma surgery.

15.6 Contraindications

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  An inadequate view of the filtration angle.

  
  
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  Although goniotomy is not as effective in some types of childhood glaucoma, treatment with goniotomy may still temporarily improve the intraocular pressure in these patients until a more definitive glaucoma surgery (usually trabeculectomy or tube shunt placement) is eventually needed.

15.7 Preoperative Preparation

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  It is essential that the required instruments and equipment are readily available for an uninterrupted presurgical examination under anesthesia and successful goniotomy (Table 15.2).

  
  
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  Topical glaucoma medications are discontinued 48 hours prior to surgery. If oral acetazolamide is being taken, it is discontinued 12 hours prior to surgery.

  
  
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  Topical antibiotic ophthalmic ointment such as bacitracin/polymyxin or bacitracin is administered to both eyes at bedtime the night before surgery. ¹