Surgical outcomes in childhood uveitic glaucoma

Abstract

Purpose: To evaluate surgical outcomes and to describe a strategy for pediatric uveitic glaucoma.

Design: Retrospective case series.

Methods: The clinical practice of a single surgeon identified 36 patients with juvenile uveitic glaucoma (diagnosed before 18 years of age) who underwent 1 or more intraocular pressure (IOP)-lowering surgical procedures. The first eye operated on was included in the analysis. The main indication for success was IOP of less than 21 mm Hg with controlled inflammation, without further IOP-lowering surgery or devastating complication.

Results: Patients with uveitic glaucoma associated with juvenile idiopathic arthritis (n = 20), idiopathic uveitis (n = 9), other (n = 6) were included. Mean age ± standard deviation at initial glaucoma surgery was 11.1 ± 4.4 years with a follow-up of 5.6 ± 4.8 years (range, 0.2 to 16.4 years). Goniotomy was the initial surgical procedure in 31 (86%) eyes. Fifteen eyes did not require further IOP-lowering surgery. Sixteen eyes had additional IOP-lowering surgery: second goniotomy (n = 9), glaucoma drainage device (n = 6), and trabeculectomy (n = 1). By Kaplan-Meier survival analysis, the first versus the first or second goniotomy were successful at 10 years in 48% (95% confidence interval, 28% to 65%) versus 69% (95% confidence interval, 47% to 84%). Goniotomy failure was noncorrelative with phakic status or presence of preoperative synechiae. Five eyes (14%) had initial glaucoma drainage device implantation because of closed angles. Visual acuity was similar between initial and final examinations (0.37 ± 0.48 logarithm of the minimal angle of resolution units [Snellen 20/47] vs 0.28 ± 0.34 logarithm of the minimal angle of resolution units [Snellen 20/38]). IOP was reduced (33.0 ± 8.0 mm Hg vs 12.6 ± 4.5 mm Hg; P < .0001), as was number of glaucoma medications (3.2 ± 1.1 vs 1.2 ± 1.3; P < .0001). Eyes undergoing cataract removal after successful glaucoma surgery maintained IOP control. Glaucoma was controlled and vision was preserved in 33 (92%) eyes.

Conclusions: Refractory juvenile uveitic glaucoma was managed successfully by goniosurgery and glaucoma drainage device implantation. Cataract removal can be accomplished successfully, provided IOP and uveitis are well controlled before surgery.