Dr George Kong1, Dr Hye Jin Kwon2, Dr Lingwei Tao1, Dr Keith Martin3, Dr Lyndell Lim1, Dr Catherine Green1, Dr Jonathan Ruddle1, Dr Jonathan Crowston1
1Royal Victorian Eye and Ear Hospital, Melbourne, Australia,
2Austin Hospital, Melbourne, Australia,
3Cambridge University Hospital NHS Trust, Cambridge, United Kingdom
This study examines surgical outcomes of trabeculectomy and glaucoma device implant (GDI) surgery for uveitic glaucoma and examines factors affecting success rate, in particular the activity of uveitis at the time of surgery and in the post-operative period.
Retrospective chart review of 82 consecutive cases with uveitic glaucoma that either had trabeculectomy (N=54) or GDI surgery (N=28) performed at the Royal Victorian Eye and Ear Hospital between 1 December 2006 and 30 November 2014. Demographics, baseline ocular characteristics, surgical details, uveitis management details, post-operative management, surgical outcomes and complications were recorded.
The average age of patients was 50.0 ± 21.1 [8-85] years. Average follow up duration was 26.4 ± 21.5 months. Combined cataract surgery was performed in 24% of the trabeculectomy surgeries and none in the GDI group. Anterior uveitis was the most common site of uveitis. 57.1% of the GDI group was secondary procedure having had previously failed trabeculectomy.
Overall qualified success rate of the trabeculectomy group was not statistically different to the GDI group, being 67% and 75% respectively (P=0.60). Kaplan-Meier survival analysis showed no significant difference between the two groups (Log-rank P=0.24). There was no significant difference between surgical success rates of primary GDI and secondary GDI operations. The most common post-operative complication was hypotony occurring in 30% of the trabeculectomy group and 36% in the GDI group (P=0.76). Two cases in the GDI group developed endophthalmitis, with none in the trabeculectomy group.
The proportion of active uveitis at the time of operation was higher in the trabeculectomy group compared to the GDI group (35% vs. 14%, P<0.01). Having active uveitis at the time of surgery was not a significant risk factor for failure for trabeculectomy. Recurrence of uveitis following operation occurred in 61% of the trabeculectomy group and 39% of the GDI group (P=0.356). Recurrence of uveitis was significantly associated with surgical failure in the trabeculectomy group (odds ratio OR 4.8, 95% confidence interval CI 1.4-16.4, P=0.02) but not in the GDI group (OR 3.1, 95% CI 0.5-19.7, P=0.39). Even a single episode of recurrence in uveitis activity in the trabeculectomy group can increase failure rate by 5 fold. Other factors for trabeculectomy failure was bleb leak (P=0.032).
Surgical success rate of GDI was not significantly greater than trabeculectomy for uveitic glaucoma in this study. Regular monitoring and early intensive treatment of ocular inflammation is important for surgical success particularly following trabeculectomy.
Dr George Kong is a consultant ophthalmologist working at Royal Victorian Eye and Ear Hospital, Austin Hospital and Monash Hospital in Melbourne. He has completed his clinical glaucoma fellowship in Melbourne and at Cambridge, UK. He has a particular interest in the management of uveitic glaucoma.