Surgery

Surgery is performed to allow the fluid inside the eye to drain outside the eye and lower the pressure.

If surgery is needed, the ophthalmologist will discuss the appropriate surgical procedure for the child with the parents or caregivers. The risks and benefits of each procedure will also be explained.

Common surgical procedures

The most common surgical procedures for primary congenital glaucoma are goniotomy and trabeculotomy.

In both procedures, the ophthalmologist makes an incision into the trabecular meshwork to allow the fluid (aqueous humor) to flow out better from the eye using the normal drainage channel.

In goniotomy, the fibers of the trabecular meshwork are cut to eliminate any resistance to fluid flow imposed by an incompletely developed trabecular meshwork.

In trabeculotomy, a probe is used to tear through the trabecular meshwork to open it and allow fluid flow.

One advantage of trabeculotomy is that it can be performed in eyes with cloudy or clear corneas, whereas goniotomy can only be performed in eyes with clear corneas.

Goniotomy and trabeculotomy have similar success rates of approximately 80%.

Alternate surgical procedures

When multiple goniotomies and/or trabeculotomies have failed to reduce IOP, the eye surgeon may perform trabeculectomy, drainage implant surgery, or ciliary body destructive procedures.

• Trabeculectomy
  
  
  • During trabeculectomy, the ophthalmologist creates an alternate pathway (or drainage channel) in the eye to increase the passage of fluid from the eye. By constructing a new drainage channel, the fluid is able to flow better outside the eye. As a result, IOP is lowered.
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  • Medicines, called antimetabolites, are sometimes used in conjunction with trabeculectomy. They help reduce scarring and increase the chance of IOP being lowered.
  
  
• Drainage implant surgery
  
  
  • If goniotomy and trabeculotomy fail, drainage implant surgery may be performed.
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  • In drainage implant surgery, the ophthalmologist places a tube in the anterior chamber to shunt the aqueous humor.
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  • Different types of implants can be used, but most function by allowing drainage of the aqueous humor from the anterior chamber, thereby lowering IOP.
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• Ciliary body destructive procedures
  
  
  • In those situations in which all else has failed, ciliary body destructive procedures (also called ciliary body ablation or cyclodestructive surgery) may be useful.
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  • In this procedure, the ophthalmologist uses a laser to destroy a portion of the ciliary body, thereby limiting the production of aqueous humor. IOP is lowered because of less fluid being able to build up inside the eye.

Possible surgical complications

As with any surgical procedure, complications may occur but are rare. Serious complications associated with surgery may include the following:

• Hyphema (bleeding in the anterior chamber)
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• Infection
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• Lens damage
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• Uveitis (inflammation of the uvea, that is, the iris, the ciliary body, and the choroid)

The most serious complications in children are often caused by general anesthesia. In some children, because of the risks associated with anesthesia, both eyes may be operated on at the same time (called a bilateral procedure).