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C. Ho, D.S. Walton; Goniosurgery for Glaucoma Complicating Chronic Childhood Uveitis . Invest. Ophthalmol. Vis. Sci. 2003;44(13):1220.
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Purpose: To evaluate the efficacy of goniotomy in medically uncontrolled glaucoma secondary to chronic childhood uveitis. Methods: A retrospective review of goniosurgery performed by a single surgeon (DW) for childhood uveitic glaucoma refractory to medical therapy was done. 35 eyes of 27 patients treated over 30 years were included, forming the largest known reported series and longest follow-up. Success was defined as final intraocular pressure(IOP) less than 22mmHg without medications and qualified success as IOP less than 22mmHg with medications. Results: 49 goniotomies were performed in 35 eyes of 27 patients. 23 eyes had 1 goniotomy and 12 had 2 or 3 goniotomies. All except 6 patients were girls. Juvenile rheumatoid arthritis associated uveitis was the diagnosis in 77% of eyes and the others had idiopathic uveitis. 71% of eyes were phakic and 29% aphakic. The mean follow-up was 107.6 months (range, 2-324) and the mean age at first goniotomy was 10.8 years (range, 4.5-22). The mean pre-operative IOP was 36.6 +/- 7.0mmHg on a mean of 2.7 +/- 1.1 medications. Surgical success was achieved in 20(57%) eyes and qualified success in 5(14%) eyes on 1.8 +/- 1.3 medications, giving an overall success rate of 71%. This was achieved with a single goniotomy in 64%. The mean post-operative IOP in eyes with successful control was 14.5 +/- 3.1mmHg. Eyes with surgical failure showed 6.9 clock hours of synechial closure of the trabecular meshwork compared to 2.2 clock hours and 1.5 clock hours in eyes with qualified success and complete success respectively. Phakic eyes had an overall success of 84% compared to 40% in aphakic eyes. Hyphema occurred post-operatively in 82% of eyes which in most instances was mild and transient. Only 2 eyes with moderate hyphema associated with elevated IOP required washout. Deterioration of pre-exisitng cataracts in the early post-operative months occurred in 2 eyes of a single patient. There was no exacerbation of uveitis in the early post-operative period. No other significant complications occured. Conclusions: Goniosurgery is a safe and efficacious conjunctiva-sparing first surgical option for the treatment of refractory childhood uveitic glaucoma. The majority of patients do not require glaucoma medication after the procedure. The surgical success is adversely affected by greater amounts of synechial angle closure and aphakia. Aphakic patients have a success rate less than half that of phakic patients.
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