Cutting Edge Glaucoma - Issue 2

16 • CUTTING EDGE - GLAUCOMA Surgical Outcomes of Primary Congenital Glaucoma in Developing Countries There are very few reports on the outcomes of goniotomy in PCG eyes with corneal clouding. Bowman et al . presented the results of goniotomy to treat advanced PCG with late presentation in Tanzania, demonstrating a 60% success rate after one goniotomy and an 89% success rate after two goniotomies in 36 eyes followed up for only 12 months [41]. Al-Hazmi et al . reviewed 532 chil- dren with PCG and stratified them into mild, moderate, and severe disease based on IOP, corneal diameter, and corneal clarity [42]. Patients with milder form of the disease had good surgical outcomes with goniotomy; however, outcomes were poor in the advanced stage of the disease irre- spective of the surgical procedure. They concluded that surgical success decreased with disease severity and that CTT with MMC would provide best results in advanced cases. Similar results have been published by several authors from different parts of United Arab Emirates, Africa, and India. Ben-Zion et al . reported that advanced stage of the disease and late presentation at surgery are related to poor surgical outcomes [43]. They used trabeculotomy and the AGV to treat 20 patients (38 eyes) with PCG in Ethiopia. They also detailed problems of surgery in the advanced stages of the disease with extremely buphthalmic eyes. Furthermore, authors reporting on a series of West African children with PCG described poor results from CTT, with probability of success falling from 83% at 6 months to 44% at 1 year, possibly due to severe disease at presentation, racial influences, and no use of antiscarring agent [44]. Elder reported poor long-term success (IOP ≤ 21 mmHg and no medication) in Palestinian Arab children with PCG undergoing goniotomy and trabeculotomy as compared to primary trab- eculectomy without antiscarring agents [45]. In a subsequent study by the same author comparing retrospective trabeculectomy data to prospectively collected CTT data, both without antiscarring agents, the cumulative chance of success for CTT was 93.5% compared to trabeculectomy, which was 72% after a 24-month follow-up [46]. For a similar follow-up in the same population, tra- beculotomy had only a 51% cumulative chance of success. Mullaney et al . reported that CTT was superior to trabeculotomy or trabeculectomy alone; however, they did use MMC [47]. Whether primary CTT is superior to trabeculotomy or trabeculectomy alone is a subject of considerable debate. In a small series of seven Arab Bedouin infants, Biender and Rothkoff found no difference between trabeculotomy and CTT in patients with PCG [48]. Dietlein et al . investigated retrospectively the outcome of trabeculotomy, trabeculectomy, and combined pro- cedure as initial surgical treatment in PCG [49]. Although the combined procedure seemed to have favorable outcome, the advantage of this procedure over trabeculotomy or trabeculectomy was not significant after 2 years when assessed by life table analysis. The authors concluded that the prognosis of primary ab externo glaucoma surgery in PCG seemed to be governed more by the individual course and severity of the disease than by modification of surgical techniques. In a retrospective, comparative study, Lawrence and Netland concluded that trabeculectomy and CTT with MMC were equally effective at lowering average IOP in children [50]. However, CTT was associated with greater long-term success. In a prospective comparative study conducted in Egypt,