Surgical failure common in childhood glaucoma cases

Nearly half of surgical procedures in children with glaucoma end in failure, and the most common reason for this is inadequate intraocular pressure (IOP) reduction, reveals a study.

“Factors associated with failure included younger age, higher IOP and worse visual acuity at index, concurrent uveitis, and more intense preceding medication,” the researchers said.

This retrospective cohort study included patients aged <18 years who underwent a glaucoma-related procedure between 1 January 2013 and 31 December 2019 in the IRIS Registry. Researchers obtained patient demographic data and clinical characteristics.

Failure was defined as having IOP >21 mm Hg, IOP reduction <20 percent of baseline, IOP <5 mm Hg, any additional IOP-lowering procedure, loss of light perception, removal of eye or chemodenervation, or diagnosis of phthisis bulbi.

A total of 2,380 eyes underwent a glaucoma-related procedure, of which 1,081 (45.4 percent) ended in failure at a mean of 9.1 months. [Ophthalmology 2025;132:1231-1240]

Risk factors

Predictors of failure included younger age (hazard ratio [HR], 1.12, 95 percent confidence interval [CI], 1.06‒1.18, per 5 years), higher IOP on the index date (HR, 1.10, 95 percent CI, 1.08‒1.12, per 3 mm Hg), worse visual acuity on the index date (HR, 1.33, 95 percent CI, 1.23‒1.44, per 1 unit higher logMAR), concurrent uveitis (HR, 1.41, 95 percent CI, 1.16‒1.71), more glaucoma medications on the index date (HR, 1.18, 95 percent CI, 1.14‒1.22, per 1 medication), systemic IOP-lowering medication (HR, 1.71, 95 percent CI, 1.44‒2.03), and complication of hyphema (HR, 13.5, 95 percent CI, 5.03‒36.46).

Higher failure rates were also recorded for iris-based surgery (HR, 2.26, 95 percent CI, 1.64‒3.12), iris-based laser (HR, 1.94, 95 percent CI, 1.50‒2.50), and trabecular/angle-based implants (HR, 3.83, 95 percent CI, 2.00‒7.33) than for ab interno angle incision surgery.

Almost one in five eyes (18 percent) required one or more reoperations. The failure rates of angle surgery at 3 years were 34.5 percent for primary congenital glaucoma (PCG) and 39.2 percent for juvenile open-angle glaucoma (JOAG). Compared with eyes without poor vision, those with poor vision were more likely to be aphakic, have higher medication burden, and have ocular comorbidities.

“Success rates are low among individuals with childhood glaucoma undergoing procedures to lower eye pressure, with approximately half failing within 10 months,” the researchers said. “Approximately half of the first-recorded procedures were angle surgery or bleb-forming surgery.”

Complication

One strong predictor for failure was severe hyphema, which is a common postoperative complication following glaucoma surgery, especially goniotomy. Normally, this resolves on its own and rarely requires surgical removal. [Br J Ophthalmol 2005;89:449-453; Trans Am Ophthalmol Soc 1982;80:321-325]

“Hyphema increases IOP through obstruction of the trabecular meshwork by blood cells and fibrin, as well as inflammation associated with the presence of blood in the anterior chamber. These mechanisms probably led to failure by the definition of inadequate IOP reduction,” the researchers said.

“Future studies focused on a larger cohort of patients with infantile glaucoma (via dedicated clinical registries) may address the knowledge gaps on the outcomes and cost-effectiveness of glaucoma surgery performed on these patients,” they added.