Long-Term Outcomes of Trabeculectomy in Korean Patients with Juvenile Open-Angle Glaucoma

Eun Kyu Oh; Eun Ji Lee; Jin Wook Jeoung; Seok Hwan Kim; Tae-Woo Kim; Ki Ho Park; Dong Myoung Kim

doi:10.3341/jkos.2014.55.2.252

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Oh, Lee, Jeoung, Kim, Kim, Park, and Kim: Long-Term Outcomes of Trabeculectomy in Korean Patients with Juvenile Open-Angle Glaucoma

Original Article

J Korean Ophthalmol Soc 2014;55(2):252-260.

Published online: 7 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.2.252

Long-Term Outcomes of Trabeculectomy in Korean Patients with Juvenile Open-Angle Glaucoma

Eun Kyu Oh, MD¹, Eun Ji Lee, MD^1,², Jin Wook Jeoung, MD¹, Seok Hwan Kim, MD^1,³, Tae-Woo Kim, MD, PhD^1,², Ki Ho Park, MD, PhD¹, Dong Myoung Kim, MD, PhD¹

¹Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea

²Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

³Department of Ophthalmology, Seoul National University Boramae Hospital, Seoul National University College of Medicine, Seoul, Korea

Address reprint requests to Eun Ji Lee, MD Department of Ophthalmology, Seoul National University Bundang Hospital, #82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 463-707, Korea, Tel: 82-31-787-7378, Fax: 82-31-787-4057, E-mail: opticdisc@gmail.com

Received 8 June 201327 September 2013 Accepted 14 January 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the outcomes and prognostic factors of trabeculectomy with mitomycin C in Korean patients with juvenile open-angle glaucoma (JOAG).

Methods

A retrospective review was performed on 29 eyes with JOAG who had undergone trabeculectomy between January 2004 and January 2013. Intraocular pressure (IOP) and postoperative complications were monitored at 1 day pre-operatively, at 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively, and at final follow-up after postoperative 18 months. Surgical success was defined as a final IOP of <21 mm Hg or <80% of preoperative IOP, regard-less of the use of anti-glaucoma medication. Prognostic factors for surgical success or failure were analyzed by the Cox proportional hazards model.

Results

Mean (± standard deviation) age at trabeculectomy was 24.6 (± 8.9) years, and mean follow-up period was 24.3 (± 20.8) months. The overall success rate was 82.8% at final follow-up. The Kaplan-Meier cumulative probabilities of surgical success were 100% at 1 year, 87.4% at 2 years, and 78.7% at 3 years postoperatively. The Cox proportional hazards model failed to determine any significant factors that were associated with surgical failure. The three most frequent post-operative complications were immediately postoperative hypotony (n = 19, 65.5%), hypotony maculopathy (n = 8, 27.6%), and encapsulated bleb (n = 8, 27.6%), most of which were resolved after a minor procedure or observation. Two of 8 eyes with encapsulated bleb required a second surgery. There were no vision-threatening severe complications.

Conclusions

Trabeculectomy with MMC may be an effective treatment in Korean JOAG patients.

Keywords: Juvenile open-angle glaucoma, Prognostic factor, Surgical outcomes, Trabeculectomy

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Figure 1.

Kaplan-Meier survival curve of surgical outcome of trabeculectomy in patients with juvenile open angle glaucoma. The probabilities of surgical success were 100% at 1 year, 87.4% at 2 years, and 78.7% at 3 years postoperatively.

Figure 2.

Mean intraocular pressure (IOP) change profile after trabeculectomy in juvenile open angle glaucoma patients. The postoperative IOP decreased significantly compared to the preoperative level during the whole follow-up period (mean final follow-up, 24.3 ± 20.8 months; all p < 0.001). Error bars indicate ± standard deviation.

Figure 3.

Inter-eye comparison of Kaplan-Meier survival curves on the outcome of trabeculectomy in bilateral juvenile open angle glaucoma patients who underwent trabeculectomy in both eyes. The respective values of probabilities for surgical success were 53.9% and 88.9% in first- and second-operated eye at the end of the follow-up. Log-rank test revealed no statistical difference in the surgical outcome between two groups (p = 0.425).

Table 1.

Patients clinical characteristics (n = 29)

Clinical characteristics
Age (years, range)	24.6 ± 8.9 (11 to 40)
Sex (male/female)	23 / 6
Side (right/left)	12 / 17
Bilateral glaucoma (n, %)	27 (93.1)
Glaucoma surgery in the contralateral eye (n, %)	13 (44.8)
Positive family history of glaucoma (n, %)	4 (13.8)
History of steroid use (n, %)	10 (33.3)
Follow-up period, month (range)	24.3 ± 20.8 (18.0-76.5)
Number of anti-glaucoma medications (n, range)	4.0 ± 0.8 (2 to 5)
Best corrected visual acuity (log MAR scale, range)	0.6 ± 0.7 (0.0 to 2.3)
Spherical equivalent (diopters, range)	-6.0 ± 2.1 (-9.75 to -1.88)
Preoperative IOP (mm Hg, range)	28.2 ± 9.1 (13.0 to 50.0)
Highest IOP (mm Hg, range)	35.7 ± 9.3 (21.0 to 50.0)
Global RNFL thickness (μm, range)	58.0 ± 17.3 (32.0 to 97.5)
Visual field MD (dB, range)	-17.9 ± 8.9 (-31.47 to -4.62)
Axial length (mm, range)	26.2 ± 1.4 (22.91 to 28.51)
Center corneal thickness (μm, range)	548.0 ± 46.7 (438.0 to 623.0)

Values are presented as mean ± SD.

log MAR = logarithm of the minimum angle of resolution; IOP = intraocular pressure; RNFL = retinal nerve fiber layer; MD = mean deviation.

Table 2.

Comparison of pre- and postoperative visual acuity, intraocular pressure, number of topical medication and visual field mean deviation

	Preoperative	Postoperative	p-value
Visual acuity (log MAR scale)	0.56 ± 0.71	0.64 ± 0.78	0.276^*
IOP (mm Hg)	28.2 ± 9.1	12.0 ± 5.0	<0.001^†
Number of anti-glaucoma medication (n)	4.0 ± 0.8	1.2 ± 6	<0.001^*
Visual field MD (dB)	-17.9 ± 8.9	-18.2 ± 8.6	0.929^*

Values are presented as mean ± SD.

log MAR = logarithm of the minimum angle of resolution; IOP = intraocular pressure; MD = mean deviation.

^* Wilcoxon signed rank test

^† Paired-samples t-test.

Table 3.

Comparison between first operated eye and second operated eye

	First operated eye (n = 13)	Second operated eye (n = 13)	p-value
Preoperative IOP (mm Hg)	29.5 ± 8.3	26.2 ± 6.9	0.028^*
Highest office IOP (mm Hg)	37.9 ± 8.3	33.8 ± 6.9	0.081^*
Final IOP (mm Hg)	12.9 ± 5.5	12.0 ± 4.3	0.344^*
Percent IOP reduction (%)	53.5 ± 22.8	52.4 ± 17.9	0.742^*
Number of topical medication before surgery (n)	3.5 ± 0.2	3.7 ± 0.2	0.480^†
Visual field MD (dB)	-20.9 ± 9.4	-8.3 ± 10.8	0.025^†
Global RNFL thickness (μm)	52.9 ± 17.8	83.2 ± 26.7	0.019^†
Spherical equivalent (diopters)	-6.4 ± 2.5	-5.4 ± 2.6	0.013^*
Axial length (mm)	26.3 ± 1.0	26.1 ± 1.4	0.506^*
Central corneal thickness (μm)	555.0 ± 26.5	555.7 ± 30.6	0.799^†

Values are presented as mean ± SD.

IOP = intraocular pressure; MD = mean deviation; RNFL = retinal nerve fiber layer.

^* Statistical analyses were performed using Paired-samples t-test

^† Statistical analyses were performed using Wilcoxon signed rank test.

Table 4.

Cox proportional hazards model determining likelihood of surgical failure for patients with juvenile open angle glaucoma who underwent trabeculectomy with mitomycin C

Variables	RR	95% CI	p-value
Age (per 1 year older)	1.027	0.929-1.136	0.602
Female sex	1.021	0.113-9.200	0.985
Family history of glaucoma	9.165	0.559-150.268	0.121
History of steroid use	0.019	0.000-39.827	0.311
Preoperative IOP (per 1 mm Hg higher)	0.992	0.916-1.076	0.851
Highest office IOP (per 1 mm Hg higher)	0.975	0.889-1.070	0.597
Number of anti-glaucomatous medication	0.337	0.070-1.636	0.177
Preoperative visual field MD (per 1 dB worse)	0.938	0.834-1.055	0.286
Global RNFL thickness (per 1 μm thicker)	0.984	0.929-1.043	0.595
Spherical equivalent (per 1 diopter greater)	0.902	0.574-1.415	0.653
Axial length (per 1 mm longer)	39.904	0.016-97109.517	0.354
Central corneal thickness (per 1 μm thicker)	1.034	0.990-1.080	0.132

RR = relative risk; CI = confidence interval; IOP = intraocular pressure; MD = mean deviation; RNFL = retinal nerve fiber layer.

Table 5.

Comparison between eyes that achieved surgical success and eyes that did not achieved surgical success

	Success group (n = 24)	Failure group (n = 5)	p-value
Age (years)	23.6 ± 8.6	29.4 ± 9.5	0.222^*
Female Sex (n, %)	5 (20.8)	1 (20)	0.967^†
Familial history of glaucoma (n, %)	3 (12.5)	1 (20)	0.658^†
History of steroid usage (n, %)	10 (41.7)	0 (0)	0.075^†
Preoperative IOP (mm Hg)	28.1 ± 8.6	28.8 ± 12.5	0.674^*
Highest office IOP (mm Hg)	36.4 ± 9.1	32.4 ± 10.5	0.448^*
Final IOP (mm Hg)	10.5 ± 3.8	18.8 ± 4.1	0.001^*
Percent IOP reduction (%)	58.9 ± 19.6	28.9 ± 21.5	0.016^*
Number of topical medication before surgery (n)	4.2 ± 0.6	3.2 ± 0.8	0.032^*
Visual field MD (dB)	-16.3 ± 9.5	-22.9 ± 4.5	0.168^*
Global RNFL thickness (μm)	57.5 ± 19.1	59.8 ± 6.2	0.409^*
Spherical equivalent (diopters)	-5.6 ± 1.9	-7.2 ± 2.4	0.313^*
Axial length (mm)	26.2 ± 1.5	26.7 ± 0.0	0.610^*
Central corneal thickness (μm)	536.8 ± 49.7	576.0 ± 24.1	0.076^*

Values are presented as mean ± SD.

IOP = intraocular pressure; MD = mean deviation; RNFL = retinal nerve fiber layer.

^* Statistical analyses were performed using the Mann-Whitney test

^† Statistical analyses were performed using the Chi-squared test.

Table 6.

Postoperative complications in the first and second operated eye

	First operated eye (n = 29)	Second operated eye (n = 13)	p-value^*
Postoperative hypotony	19 (65.5%)	7 (53.8%)	0.510
Bleb leakage	8 (27.6%)	2 (15.4%)	0.466
Bleb hyperfiltration	1 (3.4%)	1 (7.7%)	0.528
Hypotony maculopathy	8 (27.6%)	2 (15.4%)	0.466
Bleb encapsulation	8 (27.6%)	2 (15.4%)	0.466
Decompression retinopathy	1 (3.4%)	0 (0%)	1.000
Hyphema	0 (0%)	1 (7.7%)	0.310
Uveitis	1 (3.4%)	0 (0%)	1.000
Iris incarceration	0 (0%)	1 (7.7%)	0.310
Retinal detachment	0 (0%)	0 (0%)
Endophthalmitis	0 (0%)	0 (0%)

^* Fisher’s exact test.

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