Outcomes of Goniotomy for Primary Congenital Glaucoma in East Africa

doi:10.1016/j.ophtha.2010.12.002

Ophthalmology

Volume 118, Issue 2, February 2011, Pages 236-240

https://doi.org/10.1016/j.ophtha.2010.12.002 Get rights and content

Objective

To evaluate the effectiveness of goniotomy to treat primary congenital glaucoma in an east African population.

Design

A retrospective series using case records. For patients who underwent goniotomies in both eyes, only the first was analyzed.

Participants

Forty-seven children undergoing goniotomy (47/80 operated eyes analyzed). Thirty-six children (77%) were male. Mean age was 19 months (range 1–204 months, standard deviation [SD] = 35).

Intervention

First goniotomy was performed from the temporal side. Repeat surgery, if necessary, was performed via nasal side approach and 100% ethanol-soaked cotton-tipped swabs were used to clear the corneal epithelium when necessary for angle visualization.

Main Outcome Measures

Postoperative intraocular pressure (IOP) <21 mmHg was considered success. Potential risk factors for failure were analyzed. Quantitative visual acuities were measured with Cardiff acuity cards and Lea tests in older children.

Results

A total of 36 of 47 children (77%) returned for follow-up. Mean follow-up interval was 12 months (range, 1–62 months; SD = 15). A total of 28 of 47 children (60%) had >3 months of follow-up, and 11 children had >1 year of follow-up. A total of 12 of 47 eyes (26%) required repeat goniotomy. Three of these required further trabeculectomy with mitomycin C, 1 of which required eventual enucleation after failure to control IOP, enlargement, and pain. A total of 11 of 28 children (39%) with >3 months follow-up required repeat surgery. A total of 24 of 28 children (86%) with follow-up intervals of at least 3 months achieved postoperative IOPs of <21 mmHg. Mean IOPs decreased (t=6.1, P < 0.0005) from 23.4 mmHg (SD = 5.3 mmHg) to 14.4 mmHg (SD = 7.6 mmHg). Only 1 predictor of failure to achieve successful control of IOP was identified: female gender (relative risk = 5.3, 95% confidence interval, 1.1–26.3). Corneas were clear in 4 of 47 eyes (8.5%) preoperatively and 32 of 41 eyes (78%) postoperatively. Of 25 children with preoperative and postoperative acuities measured, 22 (88%) recorded improvement.

Conclusions

Preliminary results of goniotomy in an African population with advanced disease and late presentation are reasonably encouraging. Overall results are comparable with historical drainage procedures, with the advantage of preserving conjunctiva. Further studies are justified.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Materials and Methods

We conducted a retrospective review of all case records of children who underwent goniotomy at our unit, Comprehensive Community Based Rehabilitation for Tanzania Disability Hospital, Dar es Salaam, Tanzania, during a 6-year period. Computerized and paper records were used to identify patients, as approved by the unit's ethic's committee. Where contact details were available and patients had defaulted from follow-up, children were invited to re-attend with transport reimbursement offered. The

Results

Eighty eyes of 47 children underwent goniotomy. A total of 36 of 47 children (77%) were male, and the mean age was 19 months (range, 1–204 months; standard deviation [SD] = 35). There were no recorded familial cases. A total of 12 of 47 children (26%) were from Dar Es Salaam, and the remainder were from elsewhere in Tanzania. A total of 39 of 47 operations were performed by the principle surgeon (RB), and the remainder were performed by fellows under RB's supervision. A total of 36 of 47

Discussion

Suboptimal follow-up is inevitably a problem in our environment and limits the precision of our findings, but the follow-up of these patients was better than we previously reported for pediatric cataract.⁴ We have tried a number of techniques to improve links with the community and thus to reduce presentation delay and increase follow-up. These include research into presentation delays⁵ and accessibility to children's eye services across the country;⁶ liaison with community eye workers and

Acknowledgments

The authors thank Ken K. Nischal of Great Ormond Street Hospital for Children, London, for the e-mail advice on goniotomy techniques received during this study.

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Management of PCG in the developing world results in significantly lower success rates than achieved in developed countries. A retrospective review of 47 children undergoing goniotomy during a 6-year period in Tanzania found a 60% success rate (IOP < 21 mm Hg) after one goniotomy and a 90% success rate after two (39% of patients).15 Series from Nigeria and Saudi Arabia suggest that trabeculectomy significantly reduces IOP, with success rates between 40% for trabeculectomy alone and up to 60% when mitomycin C (MMC) was used.5,39
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: Manuscript no. 2009-1477.

: Financial Disclosure(s): The author(s) have made the following disclosure(s): RJCB was supported in part by Christian Blind Mission. MD was supported by Comprehensive Community Based Rehabilitation in Tanzania and University College London. JM was supported by Comprehensive Community Based Rehabilitation in Tanzania. PTK was supported in part by National Institute for Health Research Biomedical Research Center in Ophthalmology and is a National Institute for Health Research Senior Investigator.

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Original articleOutcomes of Goniotomy for Primary Congenital Glaucoma in East Africa

Objective

Design

Participants

Intervention

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Ophthalmology

Ophthalmology

J AAPOS

Am J Ophthalmol

Ophthalmology

Management of primary congenital glaucoma by trabeculectomy in Nigeria

Ann Trop Paediatr

Combined trabeculotomy-trabeculectomy as a first surgical procedure for primary congenital glaucoma

Ann Ophthalmol (Skokie)

Delay in presentation to hospital for surgery for congenital and developmental cataract in Tanzania

Br J Ophthalmol

Measuring cataract surgical services in children: an example from Tanzania

Br J Ophthalmol

The British Infantile and Childhood Glaucoma (BIG) Eye Study

Invest Ophthalmol Vis Sci

Original article
Outcomes of Goniotomy for Primary Congenital Glaucoma in East Africa