Graefe’s Arch Clin Exp Ophthalmol (2000)

238:207–213 © Springer-Verlag 2000 C L I N I C A L I N V E S T I G AT I O N

Gesine Meyer Trabeculotomy in congenital glaucoma

Oliver Schwenn
Norbert Pfeiffer
Franz Grehn

Received: 17 November 1998
Revised version received: 8 July 1999
Accepted: 8 July 1999
G. Meyer (✉) · F. Grehn
Department of Ophthalmology,
University of Würzburg,
Josef-Schneider-Strasse 11,
D-97080 Würzburg, Germany
Fax:+49-931-201-2245
D. Schwenn · N. Pfeiffer
Department of Ophthalmology,
University of Mainz, Mainz, Germany
Abstract Background: Congenital
glaucoma is a potentially blinding
disease that requires surgical therapy.
This paper describes the outcome of
trabeculotomy in primary congenital
glaucoma. Methods: Thirty-nine
eyes of 22 children with congenital
glaucoma who underwent trabeculot-
omy with or without a simultaneous
trabeculectomy between 1992 and
1997 were retrospectively analyzed.
Results: Mean follow-up was
24.7±17.9 months. A mean of 1.3 op-
erations per eye were performed. The
mean IOP at the end of follow-up
(n=39) was 17.7±6.0 mmHg; in
8 eyes (20.5%) the IOP was >21
mmHg, in 31 eyes (79.5%) it was
≤21 mmHg. The mean difference be-
tween pretreatment IOP and IOP at
the end of follow-up (n=39) was
–10.5±9.4 mmHg (–37.2%). Success
rates were calculated: IOP was
≤21 mmHg in 36/39 eyes (92.3%)
after 1/2 year of follow-up, in
25/27 eyes (92.6%) after 1 year, in
15/18 eyes (83.3%) after 2 years, in
8/12 (66.7%) eyes after 3 years, in
4/8 eyes (50%) after 4 years and in
4/4 (100%) eyes after 5 years of fol-
low-up. Complications included hy-
potony (three eyes), subchoroidal
bleeding (one eye ), detachment of
Descemet’s membrane (one eye) and
macular pucker (one eye in which la-
ter mitomycin C was used). Visual
acuity (VA) was tested with various
methods in 35 eyes. VA was within
the normal nomogram range in
12 eyes and below the normal range
in 23 eyes at the end of follow-up.
Axial length measurements showed
normalization according to the age
nomogram in 22 of 35 eyes.
Conclusion: This study shows that
trabeculotomy is an effective surgical
procedure in congenital glaucoma
with satisfactory success rates up to
5 years of follow-up.

Introduction dure for adult and developmental glaucoma. Later, in

Congenital glaucoma is caused by developmental abnor-
malities of the trabecular meshwork which impair the
outflow of aqueous humor. In the management of con-
genital glaucoma, medical treatment is not successful in
the long term. Therefore, surgical therapy is required.
Surgery improves outflow facility by opening the abnor-
mal trabecular meshwork. Two procedures are generally
used: trabeculotomy and goniotomy. Trabeculotomy was
first described in 1960 independently by Allen and Buri-
an [4] and Burian [9] and by Smith [42, 43] as a proce-
1966, Harms [21] described a modified technique of
trabeculotomy which has became popular in Europe in
the past three decades. Modifications have been de-
scribed by several authors [20, 29, 32, 33]. The main ad-
vantage of trabeculotomy over goniotomy is that trabec-
ulotomy can be performed even if the cornea is hazy and
the chamber angle cannot be seen. In addition, this tech-
nique allows better control of the surgical procedure if
the eye has undergone previous surgery or if iris strands
are present.
208
Fig. 1 Surgical technique of trabeculotomy
Patients and methods
We retrospectively analyzed a consecutive series of 39 eyes of
22 children with primary congenital glaucoma or Axenfeld-Rieger
syndrome who underwent trabeculotomy with or without a simulta-
neous trabeculectomy between 1992 and 1997. These patients were
under the care of the University Eye Hospital Würzburg and/or the
University Eye Hospital Mainz, Germany. Thirteen patients were
male, nine female. Twenty patients had bilateral congenital glauco-
ma and two patients had unilateral congenital glaucoma. Three of
these patients (six eyes) had Axenfeld-Rieger syndrome.
A total of 51 operations were performed (mean 1.3 opera-
tions/eye). Twenty-seven of 39 eyes underwent one operation and
12 eyes underwent two operations. Thirty-seven of these opera-
tions were trabeculotomies, and 14 were trabeculotomies com-
bined with trabeculectomy. Topical 5-fluorouracil was used in one
of the combined operations.
The surgical technique of trabeculotomy was as follows
(Fig. 1): A limbus-based conjunctival flap was used in either a
12 o’ clock position or in one of the superior quadrants. A scleral
flap of 3×4 mm and half scleral thickness was dissected and a ra-
dial incision was cut into the floor of the sclera until the outer wall
of Schlemm’s canal was opened. The outer wall was then cut with
Vannas scissors parallel to the limbus in both directions to facili-
tate the introduction of the trabeculotomy probe. A trabeculotomy
probe of the Mackensen type was used (Geuder Instruments, Hei-
delberg, Germany). After the trabeculotomy probe was introduced
into Schlemm’s canal, the tip of the probe was rotated into the an-
terior chamber with moderate force. This was performed in both
directions. The scleral flap was then closed with two to five 10/0
nylon stitches.
In the 14 operations in which trabeculotomy was supplemented
by trabeculectomy, trabeculotomy was completed as described
above. The inner wall of Schlemm’s canal was then perforated
into the anterior chamber at the site of the operation. The four out-
er scleral corners of the cross-like incisions were excised using
Vannas scissors. A small iridectomy was done to avoid iris pro-
lapse. The scleral flap was closed with two to five 10/0 nylon
stitches in a way that allowed moderate filtration.
In one case we used topical 5-fluorouracil (40 mg/ml): a small
sponge (Merocel) of 8×8 mm size soaked with the antimetabolite
Fig. 2 Intraocular pressure (IOP) at the end of follow-up (n=39).
The abszissa shows the preoperative IOP, the ordinate shows the
postoperative IOP of individual eyes. Triangles show results after
1 operation, circles show results after 2 operations. One eye re-
ceived topical 5-FU during surgery
was placed underneath the conjunctiva for 5 min before dissecting
of the scleral flap, and the site was then rinsed with 30 ml bal-
anced salt solution (BSS).
Preoperative and follow-up examinations included the following
parameters: IOP was measured by hand-held Perkins applanation
tonometry under ketamine or inhalation anesthesia, or without gen-
eral anesthesia if possible. Axial length was measured either with
the Ocuscan 400 (Sonometrics Systems) or the Grieshaber Biomet-
ric System (Switzerland). Follow-up measurements were done with
the same system in each case. Visual acuity was tested with Teller
acuity cards, E-test or geometrical signs (Lea Hyvärinen test). Or-
thoptic examinations were done according to the routine schedule.
Results
The mean age at the first operation was 15.7 months
(range 0.2–75.5 months). The mean interval between two
operations in the same eye was 12.5 months (range
0.7–48.2 months). Mean follow-up was 24.7±17.9 months
(range 3.5–61.5 months).
Intraocular pressure
Intraocular pressure was measured by hand-held applana-
tion tonometry (Perkins Tonometer). The mean pretreat-
ment IOP (n=39) was 28.2±6.7 mmHg. Thirty-four eyes
(87.2%) had an IOP >21 mmHg, five (12.8%) an IOP ≤21
mmHg. Seventeen of these eyes were examined under ket-
amine anesthesia, 20 eyes under inhalation anesthesia and

Fig. 3 Mean IOP± standard deviation before treatment and at the
end of follow-up (n=39)
2 eyes without general anesthesia. The mean IOP of all
eyes (n=39, follow-up 3.5–61.5 months) at the end of fol-
low-up was 17.7±6.0 mmHg. In eight eyes (20.5%) the
IOP was >21 mmHg, in 31 (79.5%) eyes the IOP was
≤21 mmHg (Fig. 2). However, in an additional three eyes
IOP reduction was <20% of preoperative IOP. When a
combined criterion of IOP ≤21 mmHg and an IOP drop of
≥20% was used, the success rate at the end of follow-up
was 71.8% (28 of 39 eyes). Two of the six eyes with Ax-
enfeld-Rieger syndrome did not meet the IOP criteria of
≤21 mmHg plus IOP drop of ≥20%.
In 26 of these eyes postoperative examination was
performed under anesthesia with ketamine, in 7 eyes un-
der inhalation anesthesia and in 6 eyes without general
anesthesia. The mean difference between pretreatment
IOP and IOP at the end of follow-up (n=39) was
–10.5±9.4 mmHg (–37.2%, Fig. 3). In 6 of 39 eyes a lo-
cal antiglaucomatous therapy was applied preoperatively.
At the end of follow-up seven eyes were under local an-
tiglaucomatous therapy.
Table 1 shows the success rates. When IOP ≤21 mmHg
was taken as a success criterion, the success rates were
92.3% after 1/2 year, 92.6% after 1 year, 83.3% after
2 years, 66.7% after 3 years, 50% after 4 years and
100% after 5 years. When success was defined by
IOP ≤21 mmHg plus an IOP drop of ≥20%, the success
rates were 89.7% after 1/2 year, 88.9% after 1 year, 77.8%
209
Table 1 Number of eyes and rates of IOP regulation according to
two different success criteria (IOP ≤21 mmHg; IOP ≤21 mmHg
and IOP drop ≥20%) after one or two operations
n IOP ≤21 mmHg IOP ≤21 mmHg and IOP-drop
(eyes) ≥20% (eyes)
1/2 year 39 36 (92.3%) 35 (89.7%)
1 year 27 25 (92.6%) 24 (88.9%)
2 years 18 15 (83.3%) 14 (77.8%)
3 years 12 8 (66.7%) 7 (58.3%)
4 years 8 4 (50.0%) 4 (50.0%)
5 years 4 4 (100%) 3 (75.0%)
aThree out of four eyes that were seen both at 4 years and 5 years
did not fulfil the success criteria at 4 years, but were subsequently
operated and fulfilled the success criteria at 5 years
after 2 years, 58.3% after 3 years, 50% after 4 years and
75% after 5 years. Three of four eyes that were seen both
at 4 years and 5 years did not fulfil the success criteria at
4 years, but were subsequently operated on and fulfilled
the success criteria at 5 years.
Corneal edema and corneal diameter
Twenty-seven of 39 eyes showed preoperative corneal
edema and 12 of 39 eyes had a clear cornea. The mean
pretreatment horizontal corneal diameter (n=35) was
13.1±1.1 mm (range 10.8–14.6 mm). The mean horizon-
tal corneal diameter at the end of follow-up (n=29) was
13.8±0.9 mm (range 11.5–15.2).
Axial length
The mean pretreatment axial length (n=35) was 22.3±
2.6 mm (range 18.3–27.6 mm). Compared to the 95%
percentile of the nomogram the axial length was shorter
in one eye (2.9%), longer in 21 eyes (60.0%) and within
the 95% percentiles in 13 eyes (37.1%). The mean axial
length at the end of follow-up was 23.9±2.3 mm (n=35).
Axial length growth was proportional to the nomogram
in 8 eyes, accelerated in 13 eyes and reduced in 14 eyes
(Fig. 4). The absolute axial length at the end of follow-
up was within the 95% percentiles of the nomogram in
11 eyes, beyond the 95% percentile in 22 eyes, and be-
low the 95% percentile in 2 eyes.
When normalization of axial length growth was taken
as an additional criterion for success, the success rate at
the end of follow-up dropped to 54.5% (18 of 33 eyes).
Optic disc
At the end of follow-up, the optic disc of 22 eyes showed
a glaucomatous excavation; 17 eyes had normal discs.
210
Fig. 4 Axial length growth at the end of follow-up (n=35). Pro-
portional means that axial length growth paralleled the nomogram
according to age. Slowed-down means that axial length growth ap-
proached the nomogram. Accelerated means that axial length
growth exceeded the gradient of the nomogram
Table 2 Distribution of refrac-
tion of 21 eyes at the end of Refraction Number of eyes
follow-up
>–6 dpt. 4
–2 – –6 dpt. 6 et’s membrane occurred after trabeculotomy despite cor-
–2 – +2 dpt. 7 rect probing of Schlemm’s canal. Revision, subsequent
+2 – +6 dpt. 3 lensectomy for mature cataract with phacolysis and cyclo-
>+6 dpt. 1 photocoagulation were required. The third sister had per-
Visual acuity and orthoptic status
Visual acuity could be tested monocularly in 25 eyes and
binocularly in 10 eyes. 19 eyes were tested with Teller
acuity cards, 13 eyes with E-test and 3 eyes with geomet-
rical signs (Lea Hyvärinen test). At the end of follow-up
visual acuity according to the nomogram (n=35) was nor-
mal in 12 eyes and below normal range in 23 eyes. Re-
fraction by retinoscopy could be tested in 21 eyes. Twelve
of these eyes were myopic, 7 eyes were hyperopic and 2
eyes were emmetropic (see Table 2). Astigmatism oc-
curred in 12 of 21 eyes (≥1 diopter in 9 eyes). Six patients
had anisometropia of more than 2 diopters.
Orthoptic data were available in 21 patients at the end
of follow-up. Strabismus (exotropia or esotropia) oc-
curred in 8 patients. Six patients had nystagmus, 5 of
them in combination with strabismus.
Patching was performed in 9 of 21 patients: in 5 pa-
tients for strabismus, in 3 patients for anisometropia and
in 1 patient for both.
Table 3 Complications after surgery. Most of the severe compli-
cations relate to the four children of one Turkish family with un-
usually severe congenital glaucoma (hypotony with choroidal de-
tachment, Descemet detachment, epiretinal gliosis after MMC
trabeculectomy)
Complications Number
of eyes
• Paracentral subchoroidal bleeding 1
• Ηypotony
– with transient shallowing of anterior chamber 2
– with choroidal detachment 1
• Descemet detachment 1
• Εpiretinal gliosis after additional trabeculectomy 1
+MMC
Complications
Complications occurred in six eyes. Paracentral subchoroi-
dal bleeding was seen in one eye of a black child after
combined trabeculotomy and trabeculectomy. It resolved
within 2 months. The reason for this bleeding was most
likely a postoperative hypotony. Transient hypotony with
shallowing of the anterior chamber was seen after two op-
erations. Unusual complications occurred in three of four
Turkish sisters with congenital glaucoma, in whom trabec-
ulotomy was performed: Hypotony with choroidal detach-
ment occurred in the right eye of the eldest sister. In this
case a puncture of the suprachoroidal fluid was performed.
Later on this eye needed a trabeculectomy with mitomycin
C. In one eye of the second sister a detachment of Descem-
sistent high IOP after two trabeculotomies in her right eye.
She therefore needed an additional trabeculectomy with
mitomycin C. About 3 months after this operation she de-
veloped epiretinal gliosis and a pars plana vitrectomy with
membrane peeling became necessary (see Table 3).
Discussion
In congenital glaucoma, the IOP is elevated due to devel-
opmental abnormalities of the trabecular meshwork re-
sulting in impairment of aqueous outflow. Surgical treat-
ment has therefore concentrated on procedures that open
the trabecular meshwork ab externo or ab interno, i.e.
trabeculotomy or goniotomy, respectively.
In the university eye hospitals of Würzburg and
Mainz, trabeculotomies in congenital glaucoma (primary
and Axenfeld-Rieger syndrome) were performed in a
consecutive series of 39 eyes between 1992 and 1997.
The present study describes efficacy in terms of IOP de-
crease, normalization of corneal diameter and axial
length, visual outcome and rate of complications.

In our series of 39 eyes the mean IOP at the end of
follow-up was 17.7±6.0 mmHg. As IOP measurements
in small children usually have to be done under general
anesthesia (as in most cases of our series), IOP may be
altered by the anesthetics and may be measured too high
(ketamine) or too low (inhalation anesthesia). When IOP
≤21 mmHg was taken as success criterion, the success
rates were 92.3% after 1/2 year, 92.6% after 1 year,
83.3% after 2 years, 66.7% after 3 years, 50% after
4 years and 100% after 5 years. When calculating the
success rate at the end of follow-up of all eyes, 79.5% of
eyes fulfilled the above success criterion. When IOP
≤21 mmHg plus an IOP drop of ≥20% was used as suc-
cess criterion, the success rate at the end of follow-up
was 71.8% (28 eyes). We also followed axial length, cor-
neal diameter and refraction under general anesthesia.
With IOP ≤21 mmHg, IOP drop of ≥20% and normal-
ized axial length growth as combined criterion, the suc-
cess rate at the end of follow-up was only 54.5% (18 of
33 eyes).
The latter criterion, however, overestimates the failure
rate, because some eyes tend to develop myopia despite
normalized IOP. The ≥20% IOP drop criterion may also
lead to overestimation of failures, because many preop-
erative IOP measurements were made under inhalation
anaesthesia, which leads to a considerable artificial de-
crease in IOP, whereas postoperative control measure-
ments were mostly done in ketamine anaesthesia, which
provides normal or raised IOP readings [36]. In contrast
to adult primary open-angle glaucoma the ≤21 mmHg
success rate criterion seems appropriate for congenital
glaucoma, where many of the eyes have not yet devel-
oped optic nerve damage.
Visual acuity measurements are difficult in congenital
glaucoma, with a mean presenting age of 15.7 months
and a mean follow-up of 24.7 months. Therefore, the fi-
nal rate of amblyopia in these cases cannot be deter-
mined at the present follow-up.
Trabeculotomy is considered an adequate procedure
in congenital glaucoma by many other surgeons [22, 28,
29]. A number of articles on trabeculotomy have been
published during the past decades in primary and sec-
ondary congenital glaucoma [1, 5, 11, 12, 14, 22, 26, 28,
34, 38–41] and in adults [8, 10, 16, 23–25, 44–46].
Harms and Dannheim [22] found a postoperative IOP
≤22 mmHg more than 3 months after uncomplicated pri-
mary trabeculotomy in all of 18 eyes with primary con-
genital glaucoma and in 4 of 7 eyes which either had
secondary congenital glaucoma or had already under-
gone other types of antiglaucomatous operations.
Authors of other studies analyzed eyes with Axen-
feld-Rieger syndrome separately from eyes with primary
congenital glaucomas. In the study of McPherson and
Berry [33], 19 of 23 eyes (83%) were controlled (IOP
<21 mmHg) with one primary trabeculotomy and 22 of
23 eyes (96%) were controlled with up to three
211
trabeculotomies (mean follow-up 5.6 years). Trabeculot-
omy was also successful in four of eight eyes when used
as a secondary procedure after a different type of opera-
tion had been unsuccessful.
Luntz [28] obtained a success rate of 90% (26 of 29
operations) after one trabeculotomy (mean follow-up
2 years). This study included no patients with Axenfeld-
Rieger syndrome. The study of Quigley [38] described 28
operations resulting in a success rate of 80% (17 of 22
eyes) with a single trabeculotomy after 1-year follow-up.
At a glance the results of most of these authors [22,
28, 33] seem to be slightly better than our results. How-
ever, it has to be considered that in our study cases with
Axenfeld-Rieger syndrome were included. Furthermore,
there was also a Turkish family with four sisters who all
had remarkably severe atypical congenital glaucoma,
probably of pseudodominant inheritance. The study of
Quigley [38],who also included cases with Axenfeld-
Rieger syndrome and other secondary glaucomas, seem
to better correspond to the conditions of our study. All
eyes with primary glaucoma were successfully treated in
his study.
In severe or refractory cases of congenital glaucoma,
trabeculotomy may be supplemented by trabeculectomy
with or without the use of antimetabolites [2, 7, 15, 30,
31, 41].
We used additional trabeculectomy in cases of Axen-
feld-Rieger syndrome, in eyes that had excessive en-
largement of the globe and in patients who underwent a
second operation. Racial factors were also an indication
for combined surgery (in one of the Turkish sisters).
5-fluorouracil was used in one eye during reoperation.
A surgical problem may occur when the probe is in-
troduced in the subciliary space and the ciliary muscle
is erroneously disinserted from the scleral spur. A cyclo-
dialysis or disinsertion of the iris base instead of trab-
eculotomy then results. This was reported in two of
McPherson’s cases [33] but occurred in none of our
cases. Moderate bleeding into the anterior chamber is a
regular event in correct trabeculotomy due to reflux of
blood from Schlemm’s canal, which is a continuation of
episcleral veins. If the IOP drops to below the episcleral
venous pressure during the procedure, blood flows back
into Schlemm’s canal and enters the anterior chamber
through the trabeculotomy site due to the lack of venous
valves.
Detachment of Descemet’s membrane is also one of
the possible complications of trabeculotomy and oc-
curred in one of our cases. Quigley [38] reported two
cases of Descemet detachment. Prolapse of the iris oc-
curred in nine cases of the series of Luntz [28]. Howev-
er, no prolapse of the iris was seen in our series. Postop-
erative subchoroidal bleeding (one operation) and hypot-
ony with transient shallowing of the anterior chamber
(two operations) or with choroidal detachment (one op-
eration) occurred in our series (see Table 3).
212

Comparison between trabeculotomy and goniotomy
has shown equal efficacy of both procedures in congeni-
tal glaucoma [5, 33].
A comparison of the two techniques in similar groups
of patients with congenital glaucoma was made by
McPherson and Berry [33]. Both types of operation re-
sulted in a similar lowering of IOP, although a higher
number of operations per eye were performed in goniot-
omy eyes (2.6 operations) than in trabeculotomy eyes
(1.6 operations). In the study of Anderson [5] the first
eye was randomly assigned to either goniotomy or
trabeculotomy and the other eye to the other procedure.
If the IOP was controlled in the first eye, it was also con-
trolled in the fellow eye by the other operation. If, how-
ever, either goniotomy or trabeculotomy was unsuccess-
ful in the first eye, the other eye also failed after the oth-
er operation. This is a strong argument for the proposi-
tion that the individual situation of the glaucoma influ-
ences the outcome more than does the type of operation.
On the other hand, comparisons also depend largely on
the individual experience of the surgeon with one or the
other procedure.
In our own retrospective study of goniotomy with a
mean follow-up of 51.6 months, the success rate at the
end of follow-up of all eyes was 70.6% according to the
IOP criteria used in the present study and 59.4% if nor-
malization of axial length growth was also a criterion
[35].
A clinical study of patients who underwent gonioto-
my for primary congenital glaucoma at the University
Eye Hospital Würzburg in the period from 1965 to 1983
[18] focussed particularly on the visual outcome after
goniotomy. After a mean follow-up of 11 years (3–28
years), visual acuity was ≥0.4 in over 50% of 60 eyes
and the visual field was normal in 74.3% of 35 eyes.
The main advantage of trabeculotomy is the external
microsurgical approach. Thus the risk of injuring the
cornea or lens is low and the operation can even be
done in cases where the cornea is cloudy [3]. The tra-
becular meshwork can be cleaved reliably if the trabec-
ulotomy probe is correctly introduced into Schlemm’s
canal. In contrast, goniotomy may incise various struc-
tures of the chamber angle, as has been shown by his-
tology [27]. In goniotomy it may be helpful to remove
the corneal epithelium in cases of corneal cloudiness
[13].
On the other hand, some authors emphasize that
goniotomy, due to its transcorneal access does not dam-
age the conjunctiva and sclera [19]. This is of impor-
tance if filtration surgery later becomes necessary.
Miller and Rice [37] showed that previous surgery in-
volving the conjunctiva significantly increased the risk
of failure of trabeculectomy in congenital glaucoma.
On the other hand, Akimoto et al. [3] emphazise that
the area of conjunctiva involved in trabeculotomy is so
small that trabeculectomy can easily be performed sub-
sequently.
In a modified technique trabeculotomy can be done
over 360°. In this technique a thread is placed into
Schlemm’s canal. By pulling the suture into the anterior
chamber Schlemm’s canal is opened over 360°. The
study of Beck and Lynch [6] shows success in 87%
(13 of 15) of the eyes that underwent surgery by this
technique, whereas the report of four cases by Gloor
showed a high rate of complications [17].
Our study shows that trabeculotomy is an effective
surgical technique for the treatment of congenital glau-
coma. However, it must be emphasized that adequate
follow-up examinations have to be done, especially in
cases of unilateral congenital glaucoma, where the risk
of amblyopia and anisometropia is a major problem.
Regular orthoptic examinations are therefore mandatory,
and patching should be started if necessary.

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