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The Role of Glaucoma Drainage Devices in Paediatric Glaucoma

European Ophthalmic Review, 2012;6(4):208-213 DOI: http://doi.org/10.17925/EOR.2012.06.04.208

Abstract

Glaucoma drainage devices may be indicated in glaucoma associated to complex congenital anomalies or dysgenesis of the anterior segment, secondary glaucomas such as those developed after congenital cataract surgery, severe primary congenital glaucoma after failed angle surgery and in eyes with severe conjunctival scarring. They can be combined with several other procedures, such as cataract extraction, intraocular lens implantation, keratoplasty or pars plana vitrectomy. This procedure may achieve a sustained and prolonged intraocular pressure reduction in children, with early post-operative success as high as 90 %, although it decreases over time, to 40–60 % survival at 4–6 years using the Kaplan-Meier analysis and most children need to reinitiate glaucoma treatment postoperatively. We must bear in mind that complications may occur, especially tube malposition and exposure, and multiple repeated surgeries may be necessary. The advantages and complications should be weighed in each individual case.

Keywords

Ahmed valve, complications, glaucoma drainage device (GDD), glaucoma, paediatric, surgery

Disclosure

The authors have no conflicts of interest to declare.

Acknowledgements

The authors have no conflicts of interest to declare.

Received

August 15, 2012

Accepted

October 22, 2012

Correspondence

Enrique Mencía-Gutiérrez, Ophthalmology Department, 12 de Octubre Hospital, E28041 Madrid, Spain. E: emencia.hdoc@salud.madrid.org

The treatment of glaucoma in childhood is primarily surgical. The goniotomy is considered the procedure of choice in primary congenital glaucoma,1 but in secondary glaucoma and after failed angle surgery, other procedures should be considered. Among these the glaucoma drainage devices (GDD). The Molteno single-plate was the GDD used in children for the first time in 1973 by Molteno.2 Since then, numerous papers dealing with the results and complications of this procedure in children have been published,3–27 and nowadays, the effectiveness of GDD has been well-established. However, we must bear in mind the extremely long life expectancy of a paediatric patient, which will probably require the care of two or more generations of ophthalmologists throughout his life. For this reason, all the possible surgical options should be considered and caution should be taken when selecting the most adequate one, which may be a GDD or some other procedure.

Indications
GDD may be indicated in glaucoma associated to complex congenital anomalies or dysgenesis of the anterior segment, such as Peter’s syndrome or aniridia and secondary glaucomas such as those developed after congenital cataract surgery or in Sturge-Weber syndrome.3

Regarding primary congenital glaucoma, although goniotomy and trabeculotomy are undoubtedly the treatments of choice, in severe cases GDD may also be considered, as the prognosis following surgery is closely related to the severity of the glaucoma. Al-Hazmi et al.28 have shown how severe primary congenital glaucoma had worse results than moderate or mild cases, regardless of the surgical procedure performed, with trabeculotomy achieving a success rate of only 10 % after one year in severe cases, versus 40 and 90 % in moderate and mild cases, respectively. Severe conjunctival scarring is a clear indication for GDD surgery.3

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