Download Glaucoma after congenital cataract surgery

Glaucoma
after Congenital Cataract Surgery
2011. 5. 11
여의도성모병원 안과
조교수 박명희
Developmental and childhood glaucoma
Primary glaucoma
Secondary glaucoma
Congenital open angle glaucoma
Traumatic glaucoma
Glaucoma secondary to intraocular neoplasm
Uveitic glaucoma
Lens-induced glaucoma
Steroid induced glaucoma
Neovascular glaucoma
Secondary angle-closure glaucoma
Glaucoma with increased episcleral venous
pressure
Glaucoma secondary to intraocular infections
Glaucoma after congenital cataract surgery
Autosomal dominant juvenile glaucoma
Glaucoma associated with systemic
abnormalities
Axenfeld-Rieger syndrome
Congenital rubella
Chromosomal disorders
Glaucoma associated with ocular
abnormalities
Aniridia
Microcornea syndromes
Peters syndrome
PPMD
Sclerocornea
Developmental and childhood glaucoma
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Of all pediatric glaucomas in a tertiary-referral setting, aphakic glaucoma was
responsible for 20% of cases, second only to primary congenital glaucoma. (Taylor
et al., J AAPOS 1999)
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Among 1492 hospitalized pediatric glaucoma patients in Beijing Tongren Hospital
from 2002 to 2008, congenital glaucoma was 46.07%, traumatic glaucoma was
12.13%, and aphakic glaucoma was 9.19%. (Qiao et al., Chin Med J 2009)
Incidence of glaucoma after pediatric cataract surgery
: Approximate frequency of 10-25% commonly cited
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Of 392 consecutive childhood cataract aspiration procedures, chronic glaucoma was found in
6.1% of the eyes during mean 5.5 years follow-up. Coexisting ocular anomalies and retained
lens cortex increased the risk for this complication. (Chrousos et al., Ophthalmology, 1984)
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After mean 9.6 years follow-up of 137 aphakic eyes, 12% of the eyes developed glaucoma.
(Magnusun et al., Acta Ophthalmol Scand 2000)
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At a median of 15.1 years after surgery, a majority of the subjects had glaucoma or ocular
hypertension (ie, 59%; 37/63). 19% (12/63) had glaucoma (5/22 with bilateral cataracts and
7/41 with unilateral cataracts). Approximately half (7/12) had developed glaucoma during the
first 5-year observational period and the remainder (5/12) developed it during the following
observational period. (Egbert et al., J AAPOS 2006)
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At mean follow-up 9.0 years after cataract surgery, glaucoma developed in 118 of 570
patients' eyes (21%). (Rabiah, AJO 2004)
•
Of 269 aphakic eyes, 62 (23%) eyes were diagnosed with glaucoma(36 of 130 patients, 27.7%)
an average of 59 months (Al-Dahmash et al., Eye & contact lens, 2010).
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2 out of 20 pediatric aphakic patients (10%) developed glaucoma after 40.02 months followup. (Kim et al., KJO 2008)
• Approximately 20% (or more!) of children who had a cataract
extraction will at some point of their lifetime develop glaucoma.
Pediatric cataract
•
•
1 per every 2000 births
Cause
– Idiopathic (m/c)
– Autosomal dominant > autosomal recessive > sex chromosome related
– Associated with hereditary, metabolic, systemic disease
– Intrauterine infection (TORCHS)
– Associated with ocular abnormalities
• Aniridia
• Anterior segment dysgenesis
• Microphthalmia
• PHPV
• Posterior lenticonus
• Traumatic
Pediatric cataract surgery
•
•
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Corneal incision
– Side port paracentesis
– Limbal incision
Anterior capsulectomy
– CCC
– Vitreous-cutting instrument
Lens aspiration
Posterior capsulectomy
– CCC
– Vitreous-cutting instrument
Anterior vitrectomy with two port system
(±) PC-IOL implantation with optic capture
Corneal suture
Etiology of aphakic glaucoma
•
Lens debirs or uveitic blockade of trabeculum
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Pupillary blockade
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Pigment dispersion
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Peripheral anterior synechiae / Trabecular damage
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Chronic open-angle
Etiology of aphakic glaucoma
Risk factors for developing of
chronic open angle glaucoma
Chen et al., JPOS 2006
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Early age of cataract surgery (before 4 months)
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Postoperative complications
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Multiple procedure
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Small corneas (<10mm)
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Family history of aphakia
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Congenital rubella syndrome
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No IOL ?
Khan et al., J AAPOS 2008
Hypothesis of pathophysiological mechanism of
chronic open angle aphakic glaucoma
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chronic trabeculitis from postoperative inflammation
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blockade from retained lens material
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chemical factors from the vitreous (Phelps & Arafat 1993).
Hypothesis of pathophysiological mechanism of
chronic open angle aphakic glaucoma
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A manifestation of a single ocular syndrome with an abnormal anterior segment
– The defect responsible for producing the cataract may also affect aqueous
outflow in the angle, causing open angle glaucoma (Phelps & Arafat 1993).
– Early lensectomy may interfere with maturation of the trabecular meshwork.
– Further damage by surgical trauma and exposure to the vitreous and highdose steroid
Kang et al., KJO 2006
Effect of IOL on the development of
chronic open-angle glaucoma
•
Asrani et al. (J AAPOS 1999)
– Comparison of the incidence of open-angle glaucoma in the two large groups
of pseudophakic and aphakic pediatric patients
– a reduced incidence in the pseudophakic eyes.
– Patients in the study routinely had IOLs implanted when the corneal diameter
was > 10 mm.
1/377 pseudophakic
Eyes during 3.9 years f/u
14/124 aphakic eyes
during 7.2 years f/u
Effect of IOL on the development of
chronic open-angle glaucoma
•
2 theories for the lower incidence in pseudophakic eyes (Asrani et al. J AAPOS
1999)
– Chemical theory
• In aphakia, a vitreous chemical component (toxic to the trabecular
meshwork) may have access to the trabecular meshwork, resulting in
damage.
• This is prevented in pseudophakic eyes by the presence of an implant
that forms a barrier to the vitreous.
– Mechanical theory
• The support to trabecular meshwork is lost in aphakia. A disorganization
or collapse of the TM results in its diminished function as a filter.
• Placement of a PC IOL might minimize this loss of support.
No relationship?
•
Cataract surgery at an early age (< 4.5 months) are risk for the development of
glaucoma c/s an IOL implant (Trivedi et al., J AAPOS 2006)
How to find a glaucoma?
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IOP
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Corneal cloudiness
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Corneal diameter
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Refractional change: less hyperopic
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Axial length
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Optic nerve
Examination of children
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Office examination
– A complete ocular examination can be performed in the office in children
older than 5 years of age and in some children as young as 3 with some
training.
– Many children after age 5 can undergo kinetic Goldmann VF testing with the
assistance of a parent.
– By the age of 8-10 years, some children can cooperate for a full quantitative
visual field examination.
– For an infant, a careful examination can be performed over a bottle or breast
milk.
– Chloral hydrate (100mg/kg of BW, maximum dose of 3g) can be given if
necessary and does not affect IOP readings.
Examination of children
•
Examination under anesthesia (EUA)
– General anesthesia is usually required for a thorough examination of children
under the age of 5.
– Most of general anesthetics lower IOP to variable amounts and at variable
times after administration.
– IV Ketamine may raise IOP slightly.
– Succinylcholine and endotracheal intubation significantly elevate IOP.
Examination of children
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Examination under anesthesia (EUA)
– The
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sequential component of the EUA
IOP
Corneal thickness and diameters
Goniosocpy
Ophthalmoscopy
Axial length
UBM
Cycloplegic retinoscopy
IOP among normal awake children using different tonometers
Age
Pulsair (SD)
Pensiero et al., JPOS 1992
Perkins (SD)
Jaafar et al., JPOS 1993
Pneumatonometer (SD)
Spierer et al., 1994
Premature
(26-37 weeks)
10.2
18.3
-
0-1 yr
10.6 (3.1)
4.6 (0.5)
14.5 (0.5)
1-2 yrs
12.0 (3.2)
4.9 (0.5)
14.6 (0.6)
2-3 yrs
12.6 (1.5)
5.8 (1.0)
15.3 (1.4)
3-4 yrs
13.7 (2.1)
6.4 (1.8)
14.5 (0.9)
4-5 yrs
14.4 (2.0)
7.9 (1.3)
14.8 (2.0)
5-6 yrs
14.4 (2.0)
6-7 yrs
14.2 (2.3)
7-8 yrs
14.0 (2.5)
8-9 yrs
14.3 (1.7)
9-10 yrs
14.0 (2.7)
15-16 yrs
15.2 (2.4)
13.2
16.42 (2.2)
Corneal measurements: diameter
•
A good baseline measurement is required for
– Initial diagnosis
– Detection of subsequent corneal enlargement under age 3
Corneal diameter
(horizontal, in mm)
Normal
Suspicious for Possible
Glaucoma
Birth – 6 months
9.5-11.5
>12
1-2 years
10-12
>12.5
Older child
=<12
>13
Age
Corneal measurements: diameter
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Corneal diameter measurement
– Horizontal (3 to 9 o’clock) and Vertical (6 to 12 o’clock)
– From white to white
– Co-examination for corneal haziness and tears of Descemet’s membrane
(Haab striae) is needed.
Axial lengths
among normal eyes and eyes suspicious for glaucoma
Axial length
(mm)
Normal
Suspicious for
Possible
Glaucoma
Newborns
16-17
>20
1 year
20.1
>22.5
2 years
21.3
>23
3 years
22.1
>24
>3 years
23
>25
Age
Sampaolesi et al., Arch Ophtahlmol 1982
Corneal measurements: central thickness
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CCT
– The clinical effect of CCT measures on IOP in children is similar to that seen
in adults.
– In congenital glaucoma, CCT is thinner in glaucomatous eyes and positively
correlated with their larger corneal diameters and longer axial lengths.
CCT in children without glaucoma
Hussein et al., Am J Ophthalmol 2004
Effect of IOL implantation on CCT
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In the absence of factors known to affect CCT, CCT is similar in eyes with
congenital cataract and normal controls and increases after cataract surgery (Muir
et al., AJO 2007)
Effect of IOL implantation on CCT
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CCT in children with cataracts increases after cataract surgery while the fellow eye
remains stable. This increase seems to occur early after surgery, likely remaining
stable thereafter, though glaucoma can accentuate the increase. (Lim et al., AJO
2011)
CCT in various kinds of pediatric glaucoma
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Patients with aphakic glaucoma are different from those with congenital glaucoma.
Lopes et al., JPOS 2007
Tai et al., J glaucoma 2006
Ophthalmoscopy
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Fundus examination is challenging in many aphakic/pseudophakic children
because of small pupil, PCO, persistent fetal vasculature, and nystagmus.
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But glaucoma should not be diagnosed by single high IOP itself unless extreme.
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Direct ophthalmoscopy can be used during EUA.
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C/D >0.3 is rare in healthy infants.
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With successful control of the IOP, the cup will either remain stable or its size will
decrease.
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Concentric enlarging of cupping is more common than vertical notching in
children.
Treatment of pediatric aphakic glaucoma
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Medication
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Surgery
– Goniotomy and/or Trabeculotomy
• Variable success rate reported (16~57%)
• Multiple procedures may be needed
– Trabeculectomy c MMC soaking
– Glaucoma Shunt Devices
– Trans-scleral diode laser cyclodestruction
Pediatric aphakic glaucoma
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Second most common type of pediatric glaucoma
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Approximately 20% of incidence during lifetime after congenital cataract surgery
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Chronic open angle glaucoma is more common than acute angle closure
glaucoma.
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If any risk factor is accompanied, careful lifetime examination is necessary.
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IOL implantation may play a protective role in glaucoma development.
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CCT may change after cataract surgery and thus influence on IOP measures.
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Elevated IOP by itself, unless extreme, is insufficient to conform the diagnosis of
glaucoma.
Variables to consider
when assessing a child’s IOP
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The child’s age
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The patient’s level of activity or sedation
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Effects of anesthetics
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Corneal thickness and health
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Diurnal variations
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Measuring instrument
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University of California, San Francisco (UCSF), Beckman Vision Center, Glaucoma
Service
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Mentor: Robert L Stamper, M.D.
– Professor of Ophthalmology
– Director of the Glaucoma Clinic
– the chairman of the Prevent Blindness Northern California
University of California, San Francisco (UCSF),
Beckman Vision Center, Glaucoma Service