Glaucoma Surgery: Special Cases
Amanda L. Ely, MD
Sharon F. Freedman, MD
Despite the considerable surgical approaches to childhood glaucoma, there are those “special cases” that require individually tailored, and sometimes out-of-the-box management.
ANIRIDIA WITH EARLY-ONSET GLAUCOMA (OR PHENOTYPICALLY SIMILAR ANTERIOR SEGMENT DESPITE NON-ANIRIDIC GENOTYPE)
These cases fall under the diagnostic category of secondary glaucoma with nonacquired, mainly ocular anomalies1 (see Chapter 9).
Technical challenges include minimal iris tissue, a shallow anterior chamber, and often corneal opacity.
Recommendations to avoid early disasters:
SLOW DOWN and see if you can temporize with medications long enough to allow a little eye growth, management of family expectations, and formulation of a plan.
Remember this is a journey, and careful is better than fast.
Discuss this approach with the family, who must travel this long road with you.
Begin with sodium chloride 5% (if there is corneal edema), and medical therapy tailored to patient age/health (eg, topical beta blocker at low dose, topical carbonic anhydrase inhibitor despite the corneal edema, and prostaglandin; possible use of apraclonidine, oral acetazolamide, or even brimonidine [for older/larger children only]).
Surgical considerations and adaptations (provided medical therapy and close monitoring have proven inadequate to control the IOP, as evidenced by significant ocular enlargement and/or optic nerve cupping when the latter can be visualized).
Angle surgery (see Chapter 10)—(unlikely to work despite technical success):
Consider only if anterior chamber depth is moderate to deep and the view is adequate.
Trabeculotomy is recommended over goniotomy, with great caution to avoid injuring “naked” lens.
Filtration surgery (see Chapter 12):
Not recommended except for older and very cooperative children with extremely close follow-up, given great propensity for flat chamber and resultant corneal and lens damage.
FIGURE 14.1. Baerveldt implant with sulcus tube placement in aniridia. (Asterisk notes location of temporally placed tube.)
Glaucoma drainage device surgery (see Chapter 11):
Consider only if anterior chamber depth is moderate to deep.
Place tube over zonules in the sulcus if possible, to minimize damage to very vulnerable cornea. Expect long-term lens changes which are manageable (Fig. 14.1).
Cycloablation (transscleral) (see Chapter 13):
Consider only if other options not feasible, very conservatively, to “buy time.”
Consider reducing energy and extent of treatment.
ANTERIOR SEGMENT DYSGENESIS WITH CORNEAL OPACITY AND COMPROMISED ANTERIOR CHAMBER (eg, PETERS ANOMALY OR SIMILAR CASES)
These cases similarly constitute secondary glaucoma with nonacquired, mainly ocular anomalies1 (see Chapter 9).
Technical challenges include the lack of visualization of the anterior chamber and suspected lack of normal anterior chamber to provide “working room” for typical surgical procedures.
Recommendations to avoid early disasters—same as for Aniridia above.
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