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Drainage in the treatment of congenital glaucoma

Poster Details

First Author: A.Medetbekova KAZAKHSTAN

Co Author(s):    A. Aubakirova   N. Aldasheva           

Abstract Details



Purpose:

Analyze the results of drainage surgery in the treatment of children with congenital glaucoma.

Setting:

Treatment of congenital glaucoma in contrast to glaucoma in adults presents certain difficulties. Certain patients need to undergo surgery multiple times due to imperforation of newly created outflow tracts. This is because of the child's body that is highly reparative. Drainage devices have been proposed in the last century for the treatment of refractory glaucoma. Later, drainage surgery followed two ways: in Russia the preference was given to hydrogel and collagen drainage, while various silicone tubular drains were resorted to in the foreign countries. Both non-valved implants (Molteno) and valved explants (Ahmed) are being used. The use of valved implants involves certain difficulties, because not all of them can be used in children of young age. There are only limited types that can be used in children, and one of them is Ahmed drainage. The literature contains reports of the use of drains in the treatment of congenital glaucoma. Experience of drains usage proves it to be a promising practice in the treatment of glaucoma in children.

Methods:

We supervised 28 children (28 eyes), including 20 eyes with infantile glaucoma aged 5 months to 4 years, 8 eyes - juvenile glaucoma, aged 5 to 13 years. 24 children had advanced stage, and 4 - terminal case. In children with infantile glaucoma we observed corneal syndrome, edema, erosion and enlarged cornea with average of 12.4+0.2 mm, anterior chamber depth averaged 3.4+1.3 mm, anteroposterior axis - 23.6+0.3 mm. Average value of intraocular pressure was 29.6±0.5 mmHg. In patients with juvenile glaucoma we observed concomitant changes in the eye: central corneal opacity, iridic dystrophy, posterior embryotoxon, etc. On the basis of these changes we have established Rieger syndrome, Frank-Kamenetskii syndrome, Peters-plus syndrome, Sturge-Weber syndrome, and neurofibromatosis. In this group of patients no capsular stretching of eye was observed. Intraocular pressure averaged 29.1±0.3 mmHg. Prior to admission, all patients already undergone surgery, and 14 patients - repeatedly. The average number of surgeries was 1.8+0.9 per patient. All patients were receiving an unsuccessful medical treatment. The following types of 28 eye surgeries were conducted: trabeculectomy with polyurethane drainage - 18, trabeculectomy with polyurethane drainage and application of 5-fluorouracil - 4, trabeculectomy with rapid drainage - 3, trabeculectomy with Ahmed drainage - 3.

Results:

In all cases, intraocular pressure decreased on the surgical table. On the 2nd day after surgery, intraocular pressure was 12.4+3.0 mmHg. Corneal syndrome disappeared in children with simple hydrophthalmos. Corneal erosion epithelized and corneal edema disappeared. The postoperative period in most patients was unremarkable. Shallow anterior chamber syndrome developed in one of the patients; to prevent lens dislocation, phacoemulsification with intraocular lens implantation was done. Retinal detachment developed in one of the patients during postoperative period; vitrectomy with the injection of plugging liquids. In both cases the postoperative period was unremarkable. In all cases we observed pronounced filtration bleb, intraocular pressure at the time of discharge from the hospital averaged 19.2±0.2 mmHg. In 7 patients (25%) intraocular pressure was equal to 22-24 mmHg; in this regard an additional antihypertensive therapy was recommended. To prevent imperforation of newly created outflow tracts, the children over 4 years received systemic enzymotherapy - Wobenzym during one month. This is due to the fact that 5 children have already undergone trabeculectomy with polyurethane drainage, however intraocular pressure increased in 3 and 4 years. Improvement in visual acuity in patients with simple hydrophthalmos is connected with the disappearance of corneal reflex, disappearance of corneal edema.

Conclusions:

While analyzing the obtained results we should note the severity of the initial state of patients: advanced stage of congenital glaucoma with pronounced stretching of the eyeball and simple hydrophthalmos, and antihypertensive operations in the past. Antihypertensive effect of surgical interventions at the early postoperative period is consistent with the majority of authors. However, the main researches focus on primary and secondary glaucoma. Many authors note that high antihypertensive effect persists during the first year: normal intraocular pressure was maintained in 80-95% of patients. Later these figures begin to decline: for 4 years the normal IOP preserved in 45% of patients, after 5 years - 30%. After implanting Ahmed drainage, antihypertensive effect lasted for 6 years in 53% of patients. Among patients supervised, trabeculectomy with implantation of polyurethane drainage took place in the majority of cases (22 surgeries including four surgeries involving application of 5-fluorouracil). In the near term of supervision, efficiency of drainage surgery was 75% which is consistent with reported data. Widespread use of systemic enzyme therapy drugs to prevent scarring of new outflow tracts seems to be a promising practice. To study the effectiveness of tubular drainage, further patients and surgery experience are necessary. Thus, the obtained results indicate the prospects of drainage use in the treatment of congenital glaucoma, particularly as a re-operation. FINANCIAL INTEREST: NONE

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