Education Committee Highlights WGC-2021 | part 7.1

Congenital Glaucoma Surgery

In this session, coordinated by Prof. Jocelyn Chua, several aspects of congenital glaucoma surgery are covered. Each speaker presented many surgical videos. Also, advantages and disadvantages of each technique are discussed.

Decision making: what surgery to choose?
To start the session, Prof. Zeynep Phhlivanli Aktas presents a complete review of many surgical options for congenital glaucoma. However, she emphasizes the importance of first defining which type of glaucoma we are dealing with.

She also calls the attention to differences in comparison to adult patients: limited working space, thin sclera and limbal anatomy. The key point of her presentation is an algorithm to help decide which is the best surgical option: from angle surgery to trabeculectomy, glaucoma drainage devices and even cyclophotocoagulation.

Goniotomy and Trabeculotomy for Congenital Glaucoma
Prof. Ching Lin Ho mentions that the prognosis of congenital glaucoma was dramatically improved with the advent of goniotomy and trabeculotomy. Angle surgery is the first choice for congenital glaucoma. Advantages include low risk of hypotony in comparison to filtration surgery, absence of blebs with lower risk of infection.

Finally, these techniques preserve conjunctiva for future filtration techniques. According to Prof. Ho, for goniotomy, the keys to success are adequate access, clear visibility and anterior chamber maintenance. Then, she presents a sequence of surgical videos: goniotomy, conventional trabeculotomy and GATT (gonioscopy-assisted transluminal trabeculotomy).

After that, she mentions prognostic factors for each option and finalizes her talk comparing circumferential versus conventional trabeculotomy.

Combined Trabeculotomy Trabeculectomy
What about combing dual mechanisms for IOP control? Prof. Anil K. Mandal explains that trabeculotomy will remove the possible obstruction due to gonioanomaly. At the same time, he says, trabeculectomy will bypass the episcleral venous system. He mentions that combining both techniques may be the best option for congenital glaucoma with corneal opacity. Then, the results of a large study with 653 patients (1128 eyes) were presented.

Tubes and Cyclophotocoagulation
Prof. Alana Grajewski starts her presentation explaining the indications for tubes in congenital glaucoma. She emphasizes that differences with adult surgery must be considered: axial length, thin sclera, plan for eye growth and possibility of occlusion after cataract surgery.

Also, she says, preoperative considerations are important: tube type, site, conjunctival incision and need of patch graft. A video of Baerveldt glaucoma drainage device implantation is presented. Then, she moves to cyclodestruction options and finalizes her talk with indications, interaoperative and postoperative care for cyclophotocoagulation.

Is there a best surgical treatment for primary congenital glaucoma? A long-term perspective.
To end this session, Prof. Peng Khaw revisits all the above-mentioned surgical techniques. This time, however, he presents survival analysis of different surgeries, along with personal considerations for each one. The need of anti-scarring therapy (5FU or MMC) is emphasized.

Finally, he concludes that there is a need to improve methods for surgical treatment of primary congenital glaucoma. Prof. Peng Khaw remembers that the choice of surgery must consider many factors, including severity and presentation of the disease, surgeon familiarity, resources and co-existing pathologies.

Watch the presentations