Infantile glaucoma is often initially treated with a surgical goniotomy
or trabeculotomy. A goniotomy is not possible if the cornea is too cloudy,
despite preoperative glaucoma medications and removal of the corneal epithelium.
Bimanual endoscopic goniotomy has been reported in 1 child, but this technique
requires great dexterity to maintain the endoscopic image on the needle tip.1 In the following case, we used a new technique,
coaxial endoscopic goniotomy,2 that allowed
a goniotomy to be performed when the anterior chamber angle could not be distinguished
through the surgical gonioprism.
A 19-month-old girl was referred with a several-month history of film
covering both eyes. The child was photophobic, tearing, and had bilateral
buphthalmos with extremely cloudy corneas. She was prescribed timolol maleate,
latanoprost, and acetazolamide sodium syrup while undergoing treatment for
otitis media. She had no other health problems. An examination under anesthesia
9 days later revealed intraocular pressures of 31 mm Hg OD and 33 mm Hg OS,
corneal diameters of 14.5 mm OD and 15 mm OS, circumferential and horizontal
Haab striae in both eyes, a cup-disc ratio of 0.8 OU, axial eye lengths of
25.4 mm OD and 27.0 mm OS, and attached retinas by B-scan ultrasound. A high-iris
insertion was present in the right eye by gonioscopy, but the view was too
hazy in the left eye (Figure 1A).
Images are from surgical videotapes.
A, Structures in the anterior chamber angle in the left eye were not clearly
visualized through a surgical gonioprism. A Haab stria is also present (arrow).
B, The anterior chamber angle that was treated by coaxial endoscopic goniotomy
is viewed several weeks later through a surgical gonioprism. The incised area
is to the right of the arrow.
The child underwent bilateral goniotomies with the aid of a coaxial
ocular endoscope in the left eye. Permission for this procedure had been obtained
from the child's mother and approved by the institutional review board of
Vanderbilt University, Nashville, Tenn. A thin blood lancet (Microlance; Becton-Dickinson
Co, Rutherford, NJ) had been formed to wrap tightly around a 20-gauge ocular
endoscope (Endoptiks, Little Silver, NJ) and was sterilized separately. The
lancet was placed on the endoscope with the needle tip observable in the endoscopic
image. The coaxial endoscopic goniotomy needle was then inserted through a
paracentesis after viscoelastic material was placed into the anterior chamber;
the needle was directed to the anterior chamber angle (Figure 2). The image of the anterior chamber angle was viewed on
a videoscreen as the lancet tip cut the high-iris insertion for 130° (Figure 3). The corneal incision was closed,
and a routine goniotomy was performed on the right eye.
The coaxial endoscopic goniotomy
needle was inserted through a paracentesis and was directed to the anterior
chamber angle. The endoscope tip (arrow) is present inside the lancet.
The image of the anterior chamber
angle was viewed on a videoscreen as the lancet tip cut the high-iris insertion.
The incised angle is observable on the left side of the image.
At the child's next examination under anesthesia, her intraocular pressures
were still uncontrolled at 35 mm Hg OD and 34 mm Hg OS with poor medication
compliance, but her left cornea had substantially cleared so that regular
bilateral goniotomies could be performed. Corneal diameters were 14.5 mm OD
and 14.5 mm OS, and axial eye lengths were 25.4 mm OD and 26.8 mm OS. The
previously treated angle in the left eye was observed by gonioscopy (Figure 1B).
A goniotomy is a relatively simple procedure to treat congenital glaucoma.
However, visualization of the anterior chamber angle structures is required.
Coaxial endoscopic goniotomy permits visualization, as previously demonstrated
in cadaver eyes2 and in the successful treatment
of rabbits with congenital glaucoma.3 The
coaxial alignment requires only 1 corneal incision and permits the lancet
tip to be continuously viewed on the videoscreen as it incises the angle structures.
The operating time is similar to that of a routine goniotomy.
This project was supported by a grant from Research to Prevent Blindness
Inc, New York, NY.
The authors have no commercial, financial, or proprietary interest in
the product or company, nor do they receive payment as consultants, reviewers,
Reprints: Karen M. Joos, MD, PhD, Department of Ophthalmology and
Visual Sciences, Vanderbilt University, 1215 21st Ave S, 8017 MCE, Nashville,
TN 37232-8808. (e-mail: firstname.lastname@example.org).
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