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Editors Selection IGR 21-3

Surgical Treatment: Drainage Devices I

Comment by James Brandt on:

90141 Risk Factors for Glaucoma Drainage Device Failure and Complication in the Pediatric Population, Medert CM; Cavuoto KM; Vanner EA et al., Ophthalmology. Glaucoma, 2021; 4: 63-70

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When he introduced goniotomy in 1942, Otto Barkan stated "Congenital glaucoma or hydrophthalmia is perhaps the most hopeless and certainly the most pathetic of ocular conditions requiring surgery. The end result, with or without operation, is frequently blindness, and more often than not, enucleation of one or both eyeballs is required."¹ Once angle surgery came into widespread use, congenital glaucoma became a treatable disease ‐, however, in many children angle surgery cannot be performed or eventually fails and ophthalmologists must then move on to alternatives which today consists primarily of antimetabolite-augmented trabeculectomy and glaucoma drainage devices (GDDs). Neither option is perfect and each has short and long-term disadvantages. Because children need procedures that last decades, not years, long-term data is crucial for surgical decision-making and patient counseling. In the American Academy of Ophthalmology's 2014 Technology Assessment of pediatric glaucoma surgery,⁴ only ten studies of GDD surgery (totaling 393 eyes) with follow-up greater than one year were found.

Medert and colleagues add to the long-term pediatric GDD literature with an analysis of 175 GDD implantations in 152 eyes of 119 children over a 12-year period at the Bascom Palmer Eye Institute. At a mean follow-up of 5.4 years, their series helps provide a better sense of the long-term outcomes of GDDs in children. They report that 58 (38%) of the 150 first-time GDD implants eventually failed at a mean time from implantation to failure of 47 ± 51 months. Children who were younger at the time of implant surgery were more likely to fail with a 23% reduction of failure with each three-year increase in age. Thirty-eight (25.3%) of first-time GDDs experienced a late postoperative complication, most commonly related to tube malposition with ocular growth ‐ this too was related to younger age (a two-fold increased risk in children < three years.

Specific diagnoses were associated with different risks of failure ‐ childhood glaucoma associated with acquired conditions (e.g., trauma, juvenile idiopathic arthritis) had lower risk of failure than did glaucoma non-acquired systemic disease.

Finally, a small (22 eyes) subset of eyes underwent GDD implants a second time. Fifty percent failed by 35 ± 30 months. Thirty-three children had bilateral first GDDs ‐ failure rates were highly concordant between eyes with 11 (33%) failing bilaterally.

This data supports the approach of delaying GDD implantation until later in life whenever possible.

This study highlights the importance of long-term data for pediatric glaucoma surgery. It will help clinicians decide on the type and timing of surgery in refractory childhood glaucoma and, just as importantly, help us counsel their parents. This data supports the approach of delaying GDD implantation until later in life whenever possible. As new approaches to managing refractory childhood glaucoma arise, these findings offer a useful benchmark for comparison.

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