Managing Glaucoma in Patients with Anterior Segment Dysgenesis

Saturday, 19th February, 2022 – 02:00 PM London, UK Time

Season 3, WWW 2: WSPOS World-Wide Webinars

Nicola Freeman:

Good morning, good afternoon and good evening to colleagues from all over the world. Welcome to season three, webinar number two of the WSPOS worldwide webinars. Today, we will be exploring the challenges of managing glaucoma in anterior segment Dysgenesis it is enormous honour for me to introduce our two special guests and discussions.

 Alana Grajewski  is the professor of clinical ophthalmology and the director of the Samuel and Ethel Balkan international paediatric glaucoma centre at Bascom Palmer eye Institute at the university of Miami in Florida USA. We are delighted to have you as part of part of the team. Thank you so much.

Prof. David Walton is the clinical professor of ophthalmology, Massachusetts eye and ear infirmary at Harvard medical school, Boston, Massachusetts. He’s also the president of the children’s glaucoma foundation since 1999 Prof. Walton thank you so much for joining us today. Next I’d like to introduce Ken and anyone who has attended previous webinars will know Ken well, he’s the division chief of paediatric ophthalmology at UPMC in Pittsburgh, Pennsylvania USA.

Um, he also is very involved at the UPMC centre for rare diseases therapy. And this is where can seize read developmental disorders. And we look forward to him sharing, um, many of the cases that he sees. My co-moderator is the distinguished Alex Levine, who is the chief paediatric ophthalmology and Oculus chief of paediatric ophthalmology and ocular genetics at the farm eye Institute is also the chief paediatric chief of paediatric genetics at Golisano children’s hospital, university of Rochester, New York, USA.

I hand over to you Alex.

Next slide please.

Alex. Alex, do you have muted? Thank you, Nicole. It’s a great pleasure to be here amongst such. Uh, such an astute, uh, uh, group of people, David Walton in particular, who is the king and father paediatric glaucoma, probably the most famous glaucoma person in paediatrics worldwide. And Ken, thank you very much for organising these incredible, uh, webinars, uh, time after time and just do a great job, uh, um, uh, pleased to co moderate this with Nicole Freeman.

Uh, uh, one of the most known, uh, people on the African continent and taking care of paediatric glaucoma. She’s head of the department of paediatric ophthalmology, red cross children’s hospital. South Africa work assessment, uh, chairman of paediatric ophthalmology, uh, from the king college, uh, hospital in Riyadh, Saudi Arabia, India, Elena Bitrian on, uh, associate professor of clinical ophthalmology, the Balkan international paediatrically glaucoma centre in best Bascom Palmer, Miami, Florida, and Gurjeet Jutley, uh, from Oxford university hospital.

And I just want you to know that currently we have listening on this call. People from Indonesia, Serbia, Italy, Spain, Argentina, Russia, Bosnia, Malaysia, Sweden, and it’s the fabulous, outreach and many thanks to Ken and David Granite for making that possible. Some housekeeping. You can have the next slide.

Uh, if you have questions, type them into the YouTube comments section they’re being moderated, uh, and sent to Nicola and dye, and we will bring them up where appropriate for any session, uh, for your tenants and participants certificates. Uh, just email programs spelled programme@

And lastly, I am going to turn it back over to, uh, Ken, uh, for his talk and Nischal, go ahead.

Uh, thank you very much. I think I’m going to ask a Aquila to play a video because my internet connection is a little unstable. So I’m going to that, uh, uh, a killer play that.

I can’t hear any audio. Can you hear audio? Uh, um, no. Okay. So I’ll just, I’ll just talk over it. That’s fine. So I think what the I’m asking you to think what the eye needs to look like at 16 years of age, when you have an infant without a review of who has glaucoma, and really, uh, I want to talk about goniotomy, the Ahmed tube and Cyclodiode laser, and, uh, I, I don’t really use trabeculectomy with

In cases of anorexia, but before we talk about the management strategies, I just want to point out the Aniridia- lack of IRIS review is like of the Iris in the complete or partial. Classical type is due to mutations in pack six. Um, but there is, uh, a whole bunch of, um, genes that can cause a similar phenotype of the Iris, but they don’t cause nystagmus.

They don’t cause Panis and uncles, limbal stem, cell deficiency  hyperplasia, and they don’t cause optic nerve hypoplasia. But all of these genes, Fox one protects to sip on B one trim 44 and Fox C3 can cause a phenotype of a lack of Iris. And it’s important to know that why, because if it’s PAX6 related, then the limbal stem cell status plays a role in whether you’re going to use anti-metabolites or not, and also PAX6 related aniridia, there is a potential role for goniotomy in, uh, prophylaxis of glaucoma. So here on the left is a child with a complete lack of, uh, Iris, a mutation, uh, she’s a deletion in FoxC1 one and then the right a child with a mutation and intergenic mutation PAX6. Prophylactic Goniotomy for PAX6 related aniridia, glaucoma, uh, was first described by, uh, Dave Walton and he was on this webinar as a discussant today.

And what they showed was that, in a substantial number of those patients, there was no glaucoma developed and, uh, six were controlled on a two drops. The rationale is that if you look at the Iris stump that remains, it sort of closes up. So if you can create a recession by doing your, uh, goniotomy, that, that stumped doesn’t close and doesn’t cause this glaucoma.

So if you see here, this is a, the top child with primary congenital glaucoma, you can see that these everybody’s not seeing, uh, there’s a concave insertion at the bottom. This is what we call a normal, uh, uh, infant glacoma. And here on the right is a child with aniridia who has an angle, very similar to that seen in PCG.

So this is, um, an example of a prophylactic goniotomy, uh, in aniridia, there is a little bit more on a resistant than you would perhaps expect, but the angle itself looks like that, that you’d expect to see in primary congenital glaucoma. Now here’s the issue. It’s exactly the same. Goniotomy that you would do for primary congenital glaucoma, but in psychological, you know, don’t have that Iris to protect you from the lens.

But once you get out of that, you can see that as you cut the, um, Irish remanent drops back and you see that a recession develop really quite nicely. So. That’s prophylactic goniotomy, uh, for, in, in an aniridia. Um, I do it. Um, I now want to talk about the ahmed tube techniques that I would use in a aniridia.

And, um, the only thing I want to point out, but perhaps a little unusual is that I will use a 6/0 vicryl ligatures surture. Uh, even though the material has a valve that’s supposed to stop, uh, the, uh, Uh, tube from over-draining. Um, the reason why I do that is the children’s, uh, corneas sclera are very elastic by the time the pressure drops.

Um, you tend to get cradles huddles, so it’s. Too late. This child actually had a corneal transplant had aniridia. Uh, and, um, I placed the tube in the super temporal quadrant. Um, I do the ligature. This is a nice way of showing that I do it 20, 25 gauge entry. And you can see how the tube is pinched nicely.

And then, um, I’m using the OCT. I can see that I’ve closed it properly. Um, and that’s what it looks like at the end, after I’ve placed the aerated cornea irradiated cornea over the end. So I want to talk about lastly, when should you think outside the box? So here’s a child who is a nine days, five days old, uh, RAL 19.36 meters LAL 19.33 millimeters clearly much longer than it should be, but the entry chamber that was only 1.9 millimeters in one eye in 2.1 in the other. Um, this is, uh, what it looked like after we give, given a Dymocks and trying to reduce the pressure. Um, this child actually had FOXC1 mutation, um, and in my, my experience, uh, in acts Reager, the goniotomy are bnot that successful.

So if you look at this, uh, entry chamber depth, that’s the entry chamber depth at the top. Initially then, um, I did a procedure and allowed the child’s entry, favorite depth to increase so that I could place a tube Safely. So what I did was cyclo ablation. Um, I use a hybrid ultrasound delineate the position of the three processes, but in this particular case, you could actually see when you were delivering the energy app, external, and this is what happens.

If you’re going to pop, it looks like this. You really want, um, uh, the picture on the bottom left immediately after the laser, these pictures are taken immediately off the lasers applied. So I did that. The I got deeper and I was able to place a tube down here. You see in the super temporal quadrant, um, and all is good.

Why do I do that? Um, so by the way, this is the optic. Uh, recently taking a look healthy, but why do I do that? These are cases referred to me, both actually with axle, for Rieger, who both had tubes in the first three months of life. And you can see that this one as, uh, you know, uh, glaucoma, the loss of zonules here and this child actually the tube rubbed against the cornea and he got a corneal melt.

And this has me putting a good, this flap on to try and save the eye. So I’d like to think what the eye needs to look like at 16 years of age. And therefore I will use goniotomy in cases of aniridia. Um, either when there is no glaucoma or when the glaucoma has just started, I will use the Ahmed tube I will, but I will use cyclodiode laser to buy time.

Um, thank you.

MI, there we go. Thank you, Ken. Thank you very, very much. Um, you be interested to know that there’s already been a a question about your one case of, of, um, the one case and you’ve actually answered that. So thank you very much. Are there any questions for, for Ken from the panel before we go onto Gorkas talk, does anyone have any comments?

Elena: I want a question. Yes. Um, Ken, did you consider doing an external, uh, 360 trabeculectomy, um, as opposed to going straight to an Ahmed shot? Uh, I mean, I might, you could have done that without deepening the chamber. Just curious if you you’ve considered that because we have used that with some success.

Ken: No, and I think, I think a lot of there, there are people who, uh, have described, uh, good results with, uh, the, the, the techniques that you’re describing.

Uh, so one of the, one of my problems is that being a pediatric cornea specialist, um, and, and dealing with the animals. I tend to see the cases that have gone wrong. So I saw a child who was referred to me where that procedure was done with a, a 3/ 16, a suture, um, proline, um, and the whole, not the whole of, but about 50% of decimates was stripped off at the same time in an infant, I’m not doing my older children. Um, and basically it was almost impossible, uh, to try and save that cornea. I tried to do a DSEK. Um, so the answer to your question is, is that I have not, I have not done that. Um, but, uh, people who have, um, I think also the issue for me is, um, I have probably done enough to feel confident to do them in the really difficult cases.

And I think that that’s really what it comes down to. You know, you have to feel confident that in the difficult cases that your muscle memory and your surgical expertise is safe. Um, and, and also the concern that impact six mutations. You may not have a viable Schlemm’s canal with BMCC degrees, uh, and then you get into trouble and you get partway, you got to cut them.

Where are we going to? Where you can’t. So I would Rebecca tome at that point, you know, can’t go around. Okay. I mean, I’m okay. Yeah.  

David Walton: Can I make a few comments about your, your, your presentation, which was excellent. And you’re one of the few ophthalmologists who’s really adopted the prophylactic procedure.

And I’d like to make, uh, just a few comments about that, that the, the prophylactic procedure is, uh, something that should be considered in the first two to three years of life, if not the first year and doing it really depends on observing progressive changes in the angles of gonioscopy. Uh, during the first year of life is really important to see whether or not those progressive closure changes are occurring during the first year. Uh, a child is really not a candidate for a, during the first year of life because they entered chamber is so shallow. And, uh, but of course the opportunity to see what, whether the, uh, the changes are occurring. Gonia surgery Bylar does not work well in aniridia that there are a few exceptions where it has worked well and, and gonioscopy has suggested that it might because, uh, ongoing oscopy when I’ve had it successful in just a very few instances.

It is when the trabecular meshwork was unobstructed and look really normal. I would just like to comment on the pathology of aniridia that it’s not an angle closure  Glaucoma. In other words, it’s not a phenomena where the stump of the Iris rotates up and covers the meshwork, but as rather a crawling forward of the Iris tissue itself over the deep macular meshwork, and one sees that on gonioscopy.

When you look at where the Iris is inserted, you’ll see a fibro vascular membrane extending from the Iris insertion up all over the trabecular meshwork. So when one does or use the goniotomy knife to do the prophylactic surgery, you do just exactly. As you show beautifully, you engage. The tip of the knife in the IRIS and pull a little bit post early and it comes off the meshwork.

In fact, when I do it, I try to avoid cutting anything except just the initial engagement of the Iris. And so what you’re really doing is disengaging this peripheral Iris, which is crawling up onto tick through the tobacco, the meshwork, why it doesn’t reoccur is really puzzling to me. But in fact, when you pull the IRIS off, the trabecular meshwork remains clean.

After that, that surgery, I just, uh, your presentation was so good and touch so many bases. You did suggest that that trabeculectomy might not be a good, uh, procedure for aniridia. I would take exception to that. I think it’s a very good procedure for an aniridia and it’s really my go-to. Uh, kind of procedure when I have a child with aniridia and, and, uh, glaucoma with that said it it’s best done.

After three years of age, I just add one additional comment in regard to all these issues, a child who’s cared for surgically with aniridia cannot be allowed to have a flat enter chamber. And, uh, of course we see that after any kind of surgery, not angle surgery so much, but with trabeculectomy or tube surgery, these patients have to be followed daily to absolutely be sure that an anterior chamber flattened, does not occur.

If the enter chamber is allowed to go flat, the lens will cup into the back of the cornea and the cornea will be destroyed. And so it’s essential. And if one can’t do that, then you have to find some way to do it. If in fact, you’re going to do enter chamber, uh, surgery on these patients. Congratulations, your presentation was really excellent.

Ken Nischal :

Thank you. Can I ask you, um, may I ask a Nicola ? I can ask a question of David and the rest. What are your tricks? Because when you do a trabeculectomy in a child with aniridia with major absence of the Irish, what are your tricks so that it doesn’t go flat. Do you use visco-elastic at the end to form the entry chamber?

Uh, how many sutures do you put in the flat? What are your tricks to stop that flattening?

David Walton:

Uh, that’s, uh, I wish there was a secret to keeping the inter chamber from going clap. Uh, I do, I do add heel on at the end and, uh, that’s, uh, that’s the most judgmental part of the seizure of the procedure when you have manufactured the flap. And I do put Vicryl sutures in the flapper rather than nylon.

And, but that judgment of flow under the flap at the very end of the procedure, when you sort of feel like possibly you’re done the procedure, but in fact, you really have the opportunity then to look at the flap really carefully to be sure there’s a little flow who when you tickle under the flap, but, uh, uh, you, you try to, you could add a suture.

I would make, if adding a suture to a slow flow, I would use a 10 O Vicryl and. But, uh, uh, I think the important thing is to, to know that there is no secret to guarantee that the inter chamber is not going to go flat. And I’ve just seen a number of eyes with destroyed corneas when excellent surgery has been done.

But the followup has not been what I suggested with really daily. If in fact, the interior chamber is showering and threatening to go flop that child must be returned in the operating room and the interior chamber deepen. And indeed it might have to be done even more than once, but, uh, I would like to leave that point more than anything else.

You cannot allow the anterior chamber of a patient with aniridia to go flat

Elena Bitrain:

Doctor Walton. Uh, do you do Fornex , and are you worried about the effects of mytomycin on these patients?

David Walton:

I think about it, but I’m concerned more about the glaucoma and I really find the needy Trabeculotomy to be an excellent, procedure for the condition

And do you just leave?

David Walton:

I didn’t understand that question.

Elena Bitrian:

Oh, uh, do you,  your technique is limbal or for forne spaced?

David Walton:

 it’s a forne spaced EJ paste for new space. Interesting question. In regard to that procedure by trabeculectomy for aniridia is whether or not you have to do iridectomy. And, uh, and actually you frequently do, then the little Iris will come up towards the flap and you have to do an iridectomy.

You would think that would not be necessary, but, but it seems to be necessary to do that when the RF presents in the sclerotomy and, uh, but, uh, yeah, it’s a good procedure. If that no anterior chamber flats.

Alena Grajewski

I was going to say, Elena, your point is well taken. They’ll get a limbus based approach would leave the limbus and spare the limbus stem cells.

yes, we do that.

David Walton


You know, you really bring up such a good point in regard to aniridia and the corneal and corneal keratopathy. It’s a, it’s a matter of discussion. What really causes that they keratopathy  in aniridia at the  and I doubt whether one hour. Of circumferential lessening of stem cells may make any difference whatsoever.

And, uh, frankly, I’ve never seen that localized area of worst of the IRS. What makes the arts have a progressive, a path to vacation throughout the first 20 years of life and is very variable with different genetic defects, but it’s clearly not just a absence are our decreased, uh, performance of, uh, of stem cells that, that that’s a whole matter of later, matter of discussion perhaps in the not appropriate for this presentation.

But it’s a very interesting question. And it’s not simply a deficiency of stem of stem cells per se.


Alex Levin

David, I’m sorry to interrupt. We’ve got two minutes left. Can you comment on vital versus a nylon?

Ken Nischal

Yeah, no, I was interested, you know, I wonder how many of the panelists. Use 10 of Michael instead of 10 of nylon.

I’ve never used 10 of I for the flat, because I’ve been worried about aggressive healing. And then I think the bipolar encourages that. But Dave, you know, you’re using 10 O Vicryls I’m interested who else uses 1,000 nylon alternative vital. I use 10 nylon. I use nylon nylon.

Alex Levin

I use Nylon

Nicola freeman :


Gorka Sesma :


Alana Grajeweski:


Elena Bitrian:

Nylon too

David Walton:

That’s really interesting. I really recommend that you use the Vicryl. It works so well and it doesn’t do the job quickly. And, uh, uh, you don’t have the foreign body in there later on and so forth. It works for, it works very, very, very, very well. And, uh, I I’m a little bit. Just in about the corner sutures, sometimes I’ll use nine O Vicryl, but, but with that regard, whether it’s nine oh or 10, oh, it’s very important to use a needle that has a tapered needle.

None, not a cutting needle because you don’t want to put a cutting needle through the flat piggy. You’ll see leakage around the defects where the needle has gone through the flat. So, so, uh, yeah, at least, uh, you should know, at least from one person’s experience that micro works very well. Uh, and, uh, I don’t know how many trabeculotomy I’ve done this time in children, but it’s clearly over a hundred.

Alex Levin :

So we’re going to need to move on, uh, to our next speaker. I just want you to know that we now have people listening in it from Poland, Israel, Taiwan, Brazil, Spain, Hong Kong, and Saudi Arabia. Uh, and since Saudi Arabia came up, let’s say. Dr.

Gorka Sesma now present. And I I’m very impressed that he has the only hospital with a swimming pool, uh, for the staff in the front yard there. That’s very nice. So Gorka go right ahead.

Gorka Sesma:

Thank you Dr Levin . for  invited to these important photo limits. Hold on for a second

Thank you for inviting me to this challenging topic. Eh, talking about your segment is UNISIS eh, is challenging for, for all of us. And this is our reality in Saudi Arabia, childhood coma in our country, we occupied the second place in the, in the world. And when we compared the prevalent. Of this country, with the world.

We have a lot of patients that we deal with this in an average, we see two new patients per week. This is our reality. So a when see this, this, this , our statistics are similar. 50% is primarily low coma and 3 to 5% is anterior glaucoma, secondary that’s important question to answer, eh, seats folks, you won big X, two gene mutations are associated with your segmentation SES, but here in Saudi Arabia, we have CYP1B1 one saw present in, in this pathology.

So we need to consider these C one B one. And to your segmentation is this specifically in their country would like to thanks to Dr. Money back and forth. They made this nice information she’s in charge of this situation and we need to keep it. Never, never, never forget the possibility of C1  of

generalizing is the, if we go, eh, this is one of our situations complex patients with difficult situations, and we need to evaluate all these things. So the treatment, in my opinion should be tailored. These are typical patient that we have in, in, in case you don’t passion with anterior segment Genesis, look at the amount of surgeries we need to think about the life expectancy.

We are not including the cornea and cataract surgery. So at the end, we weren’t married with this families be optimistic or pessimistic. This is the rules that we follow in catfish. Goniotomy when we can try  combinations, we see that we have good results with trabeculectomy, but as you see in the previous slide, you, you knew and you, so how numbers are going to be pressing that UVM is billable tool to help us in the diagnosis and the manners of these pathologies.

And what about if we find this Schemm canal, as you can see here in these studies, if we see that absence or presence of the string panel, and we have an open angle, we could try deepest, correct? It’s an option. I’m not saying that this is the option, but surprisingly, in this case, if you could find accuracy or college by correlation, more frequent than that, you can see.

So this is a deepest, correct? To me, the idea to this, you can do one boy triangle. Depending on the preference of the surgeon. It’s important to see that the  is located and more posterior. And when you see here, you, you need to go deep, deep, deep. That’s why the name of the super grinder with fuel fibers of, uh, of, of, of sclera.

When you reach the place, you need to see a spontaneous percolation. Okay. If you see percolation, you keep going a little bit. And the trick here is don’t feel they second flat, we close and we usually close it loose a and basically say these are three to avoid perforations and they weren’t performing the deepest.

Correct to me. This is good. And what about if we have a patient with reoperation? I mean, this is a patient with a previous, previous, eh, deepest core ectomy, the fail and. In this case worker shall help this site to enter and the same place you see, he just found the sutures. The rest of the flap scleral club was sealant.

No way to find where was the previous flap he tried. And you’re going to see when we saw the second flood you see in the, in the residual part of the up, you see how was the previous deepest splenectomy perform in this case? So he entered again, why entering the same place? Because it’s the life expectancy.

This patient probably is going to need more surgeries in the future. So we need to be service-based and try to see if we can do something for these specific patients. So you see our spontaneous, eh, collation of accuracy, and again, keeping the flap loose. The second flap you will, usually in this case, we use mytomycin and the closing, the first case you see for Linville, and this is for.

In session. Eh, what about the, the patient has seven months or less after the DSM? So in Kish and we work as a team, a common tier segment division. And so in this case, it’s a committee and decide to do needling. I know that it’s controversial because when we answer the say, well, this is not perforating.

So now you’re perforating a nicest question that we will have it, but this is an option. Under this situation, that, what, what is the advantage? Well, you are entering, but you are not opening the eyes like doing a new trabeculectomy or an or MDs or what other procedure. So you see here, a case reason, one mildly percentage is a patient with a DS after multiple surgeries.

And you can see in the, in the UVM house is lake. So it’s an option, not six months later. And now the patient was following year later and he still is. We saw them recently and the patient is still has the DSC is working so you can, the QR code, you can scan it, like grab it. This is our study. But interesting study for Dr.

He studied 120 patients prospective and studying the efficacy of the deepest correct tummy. And the results were around 8% of success without medication. And in the row in the right is up running a study. We are doing now comparing the DS perforating versus not perforating. And we see 70% of success, something.

These ones you can convert any time. If you are doing a, uh, describe to me some tricks is have a good window, have a reaching the cornea. When you’re reaching the cornea release, the traction sutures use of sport. Chin direction goes low, touch dry, and watch touch. Diane would show you, show you the people.

So you’re set to seeing accuracy, okay, this is not the end. Keep going. Change the direction both slow until you see spontaneous percolation without touching, eh, working knot then also side because the future probably the Bishop is gonna need more surgeries and reasons to failure of the DS are related with the small window or the posting of the flap.

If you have more. So you got your foot field. If you had. Keeping us on display card. We keep it in patients with visual outcome or, or patients with refractory to treatment on any of the things and glaucoma. This is a site that we are running in KKR. And also we have this blessing clinic that is us. I know that in other countries, you can have it, but here, thanks to this.

We can have a correct follow-up of the patients. Also the hospital evaluate us as a quality management process with KPIs regarding the LP. Final is a problem. They are a real problem. They block coma look at the cost of that can be the cost of any patients. So we have in the future, two ways, one established identity, a panel test to the patients in risk, and you can see the right, the right graph.

How after establishing a screening program of pre-marital screening program, the number of cancellations of marriage due to the risk increase. Thank you very much.

Nicola Freeman

Thank you. Thank you very much. We’re going to hold on questions and go straight onto the next speaker. Um, and we’d, um, we’d like Elena to, to give us her talk on angle surgery and anterior segment Dysgenesis. Thank you.

So Elena, you still muted?

Elena Bitrian

Yes. Thank you. All right. Yes my screen. So thank you so much for taking part of this webinar today. I’m going to talk about ankle surgery until your segment is dysgenesis. I’m an associate professor at Bascom Palmer, and I, uh, we had some cases that we would like to share with you. So for paediatric surgery, we usually think of angle surgery first.

And if possible, we like to treat the 360 degrees of the angle before proceeding. We feel during surgery, all the cycle, destructive procedures, we know that angle surgery, whether it’s internal or external has a better promote is on primary congenital glaucoma, and some, a little limited. And also using other types of glaucoma such until your segment is dysgenesis.

Some surgeons don’t consider Ingo surgery when they have a certain edge cases of anterior segment is dysgenesis and Theo segment is dysgenesis is an anomaly in the cornea, the IDs or the lens, and those that are associated with a risk of a 50% risk of glaucoma in general. And we have, uh, different entities and some syndromes, like we know Axenfeld Rieger, Peters syndrome, aniridia or  Oculo-dental-digital dysplasia and among others,

We know for all, we got the glaucoma, we do need to plan our strategy. We have to gather information in clinic. We have to do a very, um, useful eye examine that anaesthesia, but for children with anterior segment, dysgenesis, that’s even more important as the Dr Sesma said, the use of UVMs Is very crucial to plan this procedures.

We can choose. Um, um, there’s a

we know that ab-internal is quicker. Procedures will spare the conjunctiva, but we need clear corneas and we don’t have that in all our kids with the anterior segment is dysgenisis. So in cases of, um, opaque, corneas, we do, um, proceed, uh, with, I mean, there are external procedures and also I’ve external are very useful when they’re shallow chambers.

There’s many things we could do for internal procedures. We can use a needle goniotomy, like we described with that. Dr. Michelle, describe it without any of your patients, or we can use other devices that allow for, um, a more extensive treatment of the angle, like the Omni from size sciences, or we could do also like gut procedures for that external, uh, it’s very useful, useful.

The I-track catheter probably prefer rather than that, uh, Prolene suture, since those, uh, patients have anomalies in their anatomy, we want to see at all times where we are, but also we need to keep, uh, enhance, uh, the hardest surgical items. Sometimes those lambs are not continuous and we do need to do a more limited trabeculectomy.

So we know for the tractotomy is crucial to have a deep escalator flap, identify that the Slims canal doing a cut down, seeing the aggressive, um, accuse that tells us we are in the right spot. It’s nice to prove that with our  we can treat completely with  or just do the probing. Before we introduce unthread, uh, with either a suture or an I-track catheter.

It’s important to remind also that there’s children. We need to close our car down very well. So we avoid blabs and we need to close the skin tight as well. Uh, it’s nice to, I go close the conjunctiva with 10 or Baikal sutures and try to bury them to minimize the discomfort for these patients, these . And we often do them temporarily to spare their superior content diver in case they need a future procedures.

For the different types of these Genesis, it’s important to consider, uh, um, in surgery. It’s not for everyone, but if, uh, there are, uh, access, they benefit, uh, occasionally from angle surgery and also they will have a Dijon in, uh, the, from, um, the Iris. It’s nice to cut them. Sometimes we can cut them with a trabeculotomy.

I EVs it’s been mentioned extensively, and there is a role for sort of getting some of the patients in Peterson. Normally it’s one of those cases that the examination is very important. Then, as you can see here, we can see the restaurants that, um, from the Iris to the. And it’s, this gets benefit from cutting those strands.

This is a nice paper from Dr.  from a couple of years ago, that shows a case and we see that two superior photos. This child has my lateral Peters with significant glow clouding. She did a three per procedure on one, which is another external trabeculectomy cutting the adhesions and doing, as you see here, optical sector is more than three years later.

This child has pretty good vision and pressures are controlled. And you can see in this video, how she’s piercing and breaking the adhesions and then performing the, uh, sector. Uh iridectomy there are other cases that are hard for us to, to know what is which without genetic testing. And this is a child.

We just have that Bascom Palmer four weeks ago, we took four surgery. He’s the two month old, and we can see those  with high pressures and we’ll fall most on the right. This eye has a completely flat chamber and a very small core ectopic pupil, uh, super nasally. And there’s a membrane vascularized membrane on this area, but I should work very high.

And this has happened at the growth of the eye in the last three weeks. So we either UVM. And that’s another example where planning is crucial for these children. We see the Iris is here on this red line. This is the lens, and there’s a thick membrane vascular membrane, um, bullying towards that cornea on this child.

That’s an example where we did angled surgery, like a localize of external tropical autonomy. Notice how we Pierce into without  into the anterior chamber. And we don’t put the whole hands inside of the eye. We just keep it, uh, just enough to open the drainers. Also notice there’s a more Eben than. Um, I don’t have a lot coming out of our class.

To me, there’s a special case. We’re doing this to control pressure. Instead of doing a cyclo destructive procedure design has low prognosis, but we need to lower the pressure to avoid, uh, farther, uh, growth of the, the, I. Especially situations coloboma glaucoma. We can see, uh, the facts on the Iris that somethings correlates with effects on the, um, as lambs cannot in those cases.

I like to still try to see how far we can do an Explorer, that lamps. So we use, uh, uh, I-track catheter because we can see, uh, that we are in the right spot, but then we throw a little bit more and despite not finding resistance, we can see how the light has gone far to post or into our collector channel.

We can try the other way that he had. We noticed that was the hardest stop there, no way to go past this, uh, entrance. And this is one of the cases that  come so handy and allow us to perform, uh, for our, uh, treatment of the anger for this patient. So in conclusion, angle surgery is safe for paediatric patients with M and a glaucoma.

Anterior segment is Genesis. Uh, it’s nice to attempt to treat the angle 360 1 for. There are some modifications that will be necessary for the surgical technique and, um, tailoring the procedure, uh, to these patients is very important. Thank you.


Alex Levin:

That’s great. Thank you very much. So there are two great talks and we’re right on time.

Uh, I’d like to open up for discussion, uh, by, uh, just, uh, making one comment and ask one question. Uh, I think I hope the audience is getting a feel for the importance of phenotyping and genotyping in these patients. You know, not all anonymity is the same. Some is . Some is, uh, as you heard Foxy one, but that is a different phenotype, but prognostically and surgically.

Uh, so, uh, when you can get a genetic testing that is, uh, helpful and careful phenotyping using ultrasound by microscopy is also very helpful as well. Um, one question I wanted to bring up to start the discussion going is I’m very concerned when a patient has XFL Reager, uh, for example, or very shallow anterior chamber, as you just showed about using add external techniques.

I think that the rate of getting a decimate strip is higher. The rate of getting cyclodialysis is higher. Uh, perhaps you could comment on those, uh, uh, considerations.

Lena. Why don’t you take that? Sorry. Cause I have, uh, excuse me, sorry. Cause I have some things on that with my screen sharing. So could you repeat the question please? I was asking about the concern about getting, uh, using AB external procedures in patients with accent fell Rieger or shallow chambers increasing the risk of cyclo dialysis or decimate strip.

Elena Bitrian:

Yes. So, uh, when we go that’s a, that’s a great question. So some things we can calculate it and I have patients that I’ve been able, that is challenging. I’ve been able to go 360 and I’m concerned about the shallowing because the Iris you cannot flatten it. And in those cases, sometimes what I’ve done is like just retract my I-track catheter and be dilate.

And then just do a, go with my house. I go to autumn and treat it as a partial treatment. Like you saw on this video that I show, show it with the last child. So I just do a localized, uh, yeah. And I don’t there in some cases it is too depends. That’s what we say about tailoring and individualising that you can go 360 doesn’t mean you can go and, uh, and treat the whole area.

You can sometimes Visco dilate and the angle for like, uh, just like five o’clock hours.

Gorka Sesma :

I have a question, Elena, how often when you are using the eye track it, you find that you, you are moving the eye track and you find no more road in the, in the, in the, in the process of there. How, how often you saw them for you to find this, this.

Elena Bitrian:

 So, so depends on the case on BCGs whalers. Often we also have done and we just work on, uh, re repeated angle surgeries on those repeated angles.

So, you know, BCG is a little more often on anterior segment is Genesis that’s way more often. I had a child that I didn’t include because time is limited that I always try and go to  canal. I think I owe that to the child instead of going to a cyclo destructive at right away. In some cases, the slum is not even able to find we were not able to.

All other cases, it’s like this glaucoma  that I, uh, there was no point that I did, you know, it was such a small area that you just treat with a harm circle. I think the more these, the eye, the more likely it is that we, and that happens. Yes.

Alex Levin:


Well, I’ll throw out a idea for common. Um, like can I rarely use a 360, I find I can take a needle much cheaper, much quicker.

I don’t need to cut any conjunctiva to a goniotomy for 120, 180 degrees. Uh, and I’m not sure we know that 360 has that much of an increased benefit, uh, in terms of outcome to justify cutting conjunctiva, taking the more time in the more expense over a single needle procedure. So I’m just gonna throw that out as a controversy for discussion.

Um, maybe David and Ken, would you like to comment on that?

Elena Bitrian :

So when your cornea is cloudy  you do just 180 with a heart lot.

Alex Levin:

I do it. I do endoscopically

Ken what are your thoughts?

Ken Nischal:

What are your thoughts? So I have to, I have to declare a conflict here because as you know, Alex, and maybe some people don’t, you train me 24 years ago.

Uh, so, so I, you know, a lot of what my glaucoma techniques are, although they obviously they change with time they’re based on what you’ve taught me. Um, so I would say that I did attempt to do the proline. Uh, I know I’ve never used the I-track, but I’ve used the proline. And I found that, um, I had some successes, but my reliable successes were with a goniotomy.

Now I do not do endoscopic goniotomy. If it’s cloudy, then I do a combined procedure, um, uh, trabeculectomy, trabeculectomy, you know, if it’s aniredia I don’t tend to do trabeculectomy, trabeculectomy,  I do do cyclo diode laser, but I do guided psycho diode, laser ABAC. Sterno using high-frequency ultrasound and we’ve published about this.

Um, and you, you, you, you, you can pick off ciliary processes as you do that. And I, the one thing I do want to say is that doing psycho dyed laser in an infant or in a toddler is not the same as doing one in the 20 year old or a 30 year old. I have never seen a child have, have an I go hypotonus because they had three cycler diode lasers in the first two years of life.

I’ve never seen anybody else.

Alana Grajweski

But Ken, what you do wind up with though, as an eye that’s been treated. With cyclo destruction. And then if you need to do something else, like, for example, let’s say a glaucoma drainage device afterwards, those eyes can wind up getting too low because you knocked off some of the ciliary body.

And I highly recommend before you abandoned. As great as a surgeon, as you are before you abandoned 360, because you’ve tried with a proline, try it with the eye track. You know, I mean, uh, Alex’s point is well taken on costs, but that requires a clear cornea Alex. So, you know, and when I’m in there doing a goniotomy, um, you’re right, you can treat 180, but you could just do a gap just as easily or with an Omni device.

You can do a three-sixty viscal capsulotomy and maybe, you know, and then do a trabeculectomy as well.

Alex Levin:

 I just want to clarify one of my comments medicine. I would not use the endoscope at a scopic goniotomy in a patient with anorexia, and I would not use a endoscopic goniotomy in a patient where the cornea is so cloudy that you can’t see your instruments in studies.

Uh, those are the two country indications to discuss.

Ken Nischal:


So Alana, one of the things I want to make clear is these webinars are being listened to by people in parts of the world, where to use an I-track would be one year’s worth of wages for. So we ha you know, when, when we discuss these, these, um, techniques, I I’m trying to discuss techniques that are applicable in most parts of the world.

And here’s the other one.

Alana Grajewski

We start with a proline, we start with a proline, you know, and we try to use that first.

Ken Nischal:

Yeah, no, but I, I just wanna, I, I’m not going to leave with the point, but this issue and I, and I, and I re I’ll read, go back to what I said. I have never seen. I have, I did go up to a maximum of three cycle diode lasers, inferior 180 degrees before I stop and say, okay, I’m going to have to do something.

Nicola Freeman:

But just to make sure that everyone understands you, do you do three psycho diets only in the inferior 180 degrees,

Nicola Freeman:

because you don’t want to score because you don’t want to scar the conjunctiva in the superior 180 for future filtration procedures. I just want to make that clear that everyone understands that.

Ken Nischal:

And I think the other thing also is, and maybe I should publish this every time I go back and I’m talking about infants and toddlers, the places that I have actually lasered, and I’ve, I’ve got proof that they were lasered. Cause you can see it immediately. Afterwards, those sugary processes are back to where they were.

Yes, infant toddler. I does not behave like an adult. I, and I think I need to publish this because I said, look you, go ahead. Aye. Aye. Aye. Aye.

Gorka Sesma

If you allow me, if you allow me, I will. I wouldn’t because we have general public, I mean, general commodities attending today, they audience. So, and, and I, I will like to, we clarify that, you know, cyber affordable relations should be reserved for, for, for NASA second or in my opinion should be SLS play car.

You know, we, we have different for something. The cases that we face here in Saudi Arabia, we see hypothalamus, we see or attachment, we see diocese, we see complications related to the, to the, to the CPC. So that’s why I, we use it, but we use it as up as not wouldn’t it be . I mean, we serve on when the patient is refractory to other treatments.

Ken Nischal:


So, but Gorka again, you are doing CPC. Generally. Most people do CPC by using trans eliminates. I’m doing CPC by using high frequency ultrasound, actually marking out where the silvery process and the summary body is and delivering it without a pop. So, and this is published and I don’t understand why people don’t use that technique.

I mean, I, it’s such an easy technique. You don’t have to enter the eye and you can pick off silvery processes by using high frequency, ultrasound, most people haven’t. Do you like to, would you like to sit, would you like to clarify what you mean by high frequency ultrasound and

Alex Levin:

Ken while you’re, while you’re doing that?

We have a question from the audience and, uh, just to change the topic a little bit, uh, and you’re on, I freak Joseph, how do you identify Slims canal in a grossly up Falmouth guy? And perhaps you could answer that. And also, uh, Elena and Alana, that’s a little bit of a tongue twister, uh, can also say how they do that as well.

Some of these guys with justice. It’s tough. Well, I had to, yeah, go ahead and let you go ahead first.

Elena Bitrian:

 I think, I think that’s basically an art. Uh, it’s just doing a flub that is deep enough on the setting and a starting postier enough. And just trying to see where the scleral fibers transition and just being cautious, like just doing a little cut down a, go a spread the five-year side on side, not being too aggressive and cutting down, and then having a losing anterior chamber.

But it is challenging to everyone, even when there’s like a lot of experience, every I’s a little bit different. So yes, it’s humbling this finding this lamps.

Ken Nischal :

So my, my trick Elena again, uh, published is I asked the anaesthesiologist to compress the juggler on the side that I’m operating on. And when you do that, you get backflow of blood and it goes into the episode, Farrah and into Schlemm’s.

So when I’m doing my cutdown. Blood comes out, not fluid. And when, where the blood is coming out, I know that’s slams. So you get the anaesthesiologist to compress the juggler on the side that you’re operating on.

Alex Levin:

David you have a comment,

did you put your hand up David for a comment?

David Walton:

Uh, it’s been such an excellent presentation. I’d like to suggest to comment that it really is important to, and this is just a step back from what we’re talking about relative to the angle procedure, but it’s really important to try that. I understand the diagnosis of these patients.

And we really should. When you have a patient with corneal pacification and proximately glaucoma, it really is worthwhile to review the causes of glaucoma in children. And when the cornea is really a pacified to marry that. With a review of the causes of congenital Cornelia passing in the newborn. And it’s really a very extensive group of primary things.

And if one is considered, I was seeing, or I was for the first time a child with a newborn or a young child with Cornell Passy, and you’re not sure about where to get information. Well, I would suggest is that you review 10, the shouts papers over the last 20 years, he has studied this, uh, this category of patients extensively and his, uh, his contributions to this whole area of consideration.

Making an appropriate diagnosis is really important. And, uh, in the realm of, uh, Uh, important things, which are the most common to consider the, uh, the eye changes with newborn. Glaucoma Arcana has called it CYP. One, psychopathy is really important and, uh, those patients I’ve seen frequently and Saudi Arabia really have a different indication.

And I would just finish by saying gonioscopy is really important. And we report that the results of these various procedures with very little. Description of what the angles look like. And for example, when they, when gonioscopy is done with newborn primary congenital glaucoma, the, that you do see in Saudi Arabia, it becomes perfectly clear that any of these angle procedures are not indicated and, uh, because with newborn, so, uh, glaucoma associated, particularly with the CYP one psychopathy as Ken has coined it, uh, there’s just very little angle there.

So I would just emphasise that to try to understand what, uh, your patient has in terms of diagnosis, relative to Cornell, a pacification and glaucoma is really essential. And then gonioscopy to really study the angle and to be able to report your results relative to what the angle anomaly is, is really important.

I think it’s really unfortunate to see a child who’s failed angle procedures for two or three times. And on gonioscopy in fact has very little trabecular meshwork there. So I would really emphasise that point.

Alana Grajweski:

 David you normally can’t see it anyways. Cause it’s so paid cornea to do the gonioscopy, you know, I mean seriously, and I think that if you can get around 360 with a proline or something, there’s enough of an angle there that you should at least give the kid a try with with something that is, uh, uh, at not that.

And you know, it’s not as if you’re doing something harmful,

David Walton:


did the signs on glaucoma or so-called CYP one psychopathy are so conspicuous beyond the glaucoma and beyond the corneal of pacification that they have characteristic Iris changes as well. Uh, and uh, if you make the diagnosis of that category of Cornelia pacification in children, uh, and it is often associated with a CYP, one defect, uh, and, uh, I, uh, the, the probable success of any kind of angle procedure is minimal.

And, uh, uh, and in that regard, ha have you ever had a successful case of angle surgery with newborn glaucoma associated with those signs of newborn glaucoma, including the Iris changes, which, uh, I will go into that, but, but you’re familiar with them. Uh, I have, uh, I’d like to see that report or learn about that patient where an angle procedure has been successful in that category of congenital, corneal, opacification, or glaucoma with, um,

Alex Levin:

but I, I want to step in just here.

So we’re running, uh, into the next talk. So, uh, we’ll let Nicola, uh, sign off. There are some questions to the YouTube channel. Um, the, the, um, I know Ken has to answered some already in a YouTube channel, uh, but we can get to them a little bit later. So Nicola, if you want to do so, our next speaker, I think we’re good to go in on time.

Ken Nischal:

So can I just say very briefly, I just want to say for the whole audience cycler, diode, laser, I’m just asking people to think outside the box and use it to temporize. Uh, so we’ll, I’m sure we’ll discuss that further. Okay. Thank you. I was wondering to ask that, but we need to move on and then we’ll have a long discussion afterwards.

Thanks Ken.

Our next speaker is good Gurjeet Jutley and he’ll be telling us about tubes in anterior segment. Dysgenesis Gurjeet Jutley. Thank you.

Gurjeet Jutley:

Uh, thanks, Nicola. And thank you everyone. Really a lovely talk and uh, thinking outside the box, uh, is the nature of my talk as well. So there’s a great link there. Just a little bit about me.

I work in Oxford’s. Uh, I love food, love, sports, love music, and love spending time with my wonderful wife.

Um, I love star wars and do or, do not. Uh, there is no try. Uh, that’s going to be, um, a quote we’ll come back to, we’ve seen some wonderful classifications, uh, looked at surgical options. Um, what happens? I know we’ve discussed and debated a lot about if they don’t work. Um, so I’m gonna talk a little bit about let’s imagine they haven’t and different tube techniques.

We’ve heard Vicryl ties for the Ahmed tube. So I’m going to be thinking about different types of tubes, pitfalls and complications are an important topic. The literature’s out there. We can read it, but important to look at our own experiences and learn from each other. Then we’ll wrap up. This is a great book, great classification.

So in childhood glaucoma, I’m going to be, um, concentrating that, which is in red, which is essentially post lens surgery and associated with non-acquired ocular abnormalities, the onset dysgenesis syndromes and corneal capacities. So we’ve seen and discussed, uh, different surgical options. Um, let’s imagine they haven’t worked all of these, uh, Des uh, CPC, et cetera.

Um, What about trabeculectomy? And I know David’s spoken about this, but it’s a good option. However, bear in mind, there’s inherent tendency to scar in children. Um, higher risks of infections and difficulty in manipulating the surgery postoperatively, uh, with recurrent GA’s possible and required. Um, how about an anterior segment tube?

Um, difficulty is the anatomy, um, in these Ansec patients, uh, there’ll be past difficult abnormal anatomy and the view may maybe obscured, particularly in the periphery. So to go back to the quote of Yoda, there is no try. If you think somebody is going to fail, why not consider a primary, uh, Pars plane tube, which was first describing 1991.

First question is about, um, uh, how equivocal it is with anterior segment tubes. There was a meta analysis by Wang cartel in 2018, which showed, uh, equal pressure reduction in both groups. How about safety? Well, we, you can conceptualise if the tube is a way from the cornea, there’s less likely to be and the fetal cell loss and actually say, oh, it’s tell showed that, that the density was far more well preserved after 18 months in their paper, we’ve discussed indications being, um, uh, and seq dysgenesis.

What about NVG can be seen in kids with coats disease? This is an adult patient that I did, uh, and a laser at the same time, which is essentially switching off the tap for further, um, stimulus for NBG. So that could be and indication, particularly in adults. Of course, anything we do in life heed caution is be filmic long eyes with stints Clara.

Be careful with the past that you make. Um, bear in mind, also the size of the plates. Um, if we’re going to put it in the super nasal quadrant, for example, there’s a potential for inducing, an eye, extra genic Browns. Anything in life. As we discussed, there are risks. How about, and we’re going to the back of the eye.

There’s a potential of a RD. If you look at the population, if they look at the literature, they quote between zero and 20% risk of RD, and we’ll look at ways to minimize that risk a bit later in the talk and most glaucoma surgeons have injured, have definitely seen hypotony in their practice. And in my past planet tube series, I’ve seen two patients that have been settled medically.

So if we start thinking about the etiology of hypotony, um, in, let’s say in the anterior segment tubes, you can have existing travel with some flow, sit, everybody shut down and some flow around the tube, which we can try to minimise at the time of surgery with a teen ons plug or suturing around the wound in the pars plana tube, it’s a more tight and snug fit.

So flow around the tube is less likely. Furthermore, you’re actually going to suit. Uh, the sclerotomy sites, um, meaning that it’s a really closed system, hence the likelihoods and like Ken, I would do a six, so Vicryl tie and make sure it’s tight, almost sort of embedding it within the tube. Um, if it’s a closed system, you’re less likely to have to open it up and see, uh, with exploration, atrophying, and, um, uh, reducing steroids is suffice.

Imagine a situation where a past pain of choosing sitch too, and the pressure has been controlled. Um, and you find it’s gone up months or years down the line, a differential would be to use the B scan first to see if that’s flow. If there’s no flow, there’s probably a blockage where that blockage is going to be as vitreous WIC.

And we’ll talk about how to avoid and manage that later on. Just the word of caution. This patient was listed has been previously vitrectomised. I put some ports in and you can see some peripheral gel, which I took out the importance of mentioning that is when we’re doing this kind of procedure, the vitreous base needs to be removed.

Otherwise, it will block the tube and you will have a failure. Occasionally that needs to be indented, a vitrectomy, which is not something that I’m doing here. I find erosion exquisitely, difficult to manage. I’ve had two patients that have had recurrent erosion, uh, despite revisions with AMG autologous grafts to deploy fast.

And in both cases, I had to remove an explant the tubes and they, um, they, they, they were failures. This is a picture of mine. When I was a fellow with the courtesy of professor bloom, who was my mentor at the time, um, it prompted us to do a literature search and we found that the younger age and those with pre-existing inflammation with higher risk factors, this picture is post one of those failures.

And you can see the comjes closed nicely here, and we didn’t realize that it would keep eroding through one of the case series we found by buyer Anatel agreed with our findings, where they looked at all of their exposure groups and found that 45% of those patients had. NBG just something worth bearing in mind if listing these patients.

Regarding case series and the literature, uh, regarding past planet tubes, um, and children. Um, this, uh, the first one is , which looked at 13 patients, two of whom were children. And they noted that the RD rates at one year was zero to specific pars plana in children groups. Um, I usually use a Hoffman elbow, um, uh, but in, in these case series, they use the velvet tube and they shaped the tube on the table to be directed to their pars plana.

The bannock group described at three years, 75%, uh, pressure control. Whereas the notepaper is much longer series at seven years, 45% of these kids had good IOP control. But what I want to direct your attention to is what’s the reasoning green in the  group. They, in the banning group, they did a vitrectomy alone.

Whereas in the vinod group, they had a very good diagram showing using. Lumps at forceps to remove the WIC, because if you didn’t that we would go up that you causing failure and game over. So just to conclude, um, it’s a useful adjunct in the armamentarium. Think about Yoda. Um, there is no try. If you think something’s going to fail.

Think outside the box and use a pars plana tube we’ve seen, although having said that we’ve seen the different, different, uh, surgical options we have, if you are considering the vitrectomy, the pars plana achieved in short, the vitreous base is removed to prevent occlusion later on. Thank you very much.

Alex Levin

Thank you. Gurjeet Jutley for the  talk. Um, and I’m also a star wars fan. I hope you saw Boba Fett. Uh, the series was excellent. Um, can I just ask you as we open up the discussion again, could you clearly for the audience just say, what are the factors that would make you choose a pars plana Tube to put a part of this planet tube as a, versus a, uh, answer.

Gurjeet Jutley :

I think, um, there’s no, uh, I I’m firmly believe that there’s no definitives in medicine and it’s always up for debate and it’s good to have a chat with your colleagues and things. First of all, was an act to me. Uh, second of all, um, no, obviously no space in DAC difficult view. If you look at the literature, they talk about doing P case prior to due to doing, um, obviously you need a view, um, to do the vitrectomy and furthermore, whether it’s primary, whether we move on to it is a debate as well.

So if surgeon, surgeons have had other things gone awry, um, um, and not work, we can move on to that as well. Dual pathology, of course. Um, you know, if there’s a posterior segment problem, um, that that would, or vitreous haemorrhage, et cetera, that that would, uh, gauge your, uh, your mind towards that procedure in the first place.

Alex Levin:

And would you ever do parse the planet in a fake child?

Gurjeet Jutley:

The potential is there, um, the key thing would be not to cross the midline. Um, I don’t, I don’t think that is a contrary indication per se.

Alex Levin:


Any other comments from the group one, the use of tubes in these situations?

Nicola Freeman:

Can I comment? Um, there’ll be lots of, there’ll be lots of surgeons in the, in the world who don’t have access to past plan, uh, dedicated, uh, past planner to, um, I just want you to know what everyone else does ex experiences with regards to using a normal bar felt or, or Ahmed and placing it’s pars plana.

So that it’s in a, in a situation we have a very shallow AC pars plana, but then doing, uh, a large peripheral iridectomy, um, so that you can see the tube.

Alex Levin:

 I would say that the, he used to make good. Now I’m a company used to make a, uh, a device for that. Well, I think they stopped making that, but I would just redirect the tube down, put it in.

What were you going to say, Gurjeet Jutley?

Gurjeet Jutley:

I’m sorry. . Can I just say that actually like Alex you’ve just described in both of those case series, they didn’t use the dedicated Hoffman, elbow, uh, pals planetary, which, which I use in Oxford. Um, and they just shaped it on the table. The key thing, um, to try to avoid hypotony in that situation is not to put it in the sclerotomy sites where you’ve done the vitrectomy, because if there’s a smaller lumen, uh, that would have to be sutured them to make a different lumen, uh, adjacent to that and to put the tube through there, that would be the better option.

Elana Bitrian:

The general discussion. I just want to say quickly, uh, basketball. We do not use, I don’t use that. And Hoffman, elbow, I just use that regular tube and I do a  I’m not aware of the other surgeons do the same. Uh, we do a second  for two reasons because of the ceiling and to avoid hypotony, but also, uh, because we want to direct it not as a  more like parallel or, but it would be there iris plane,

Alex Levin:

but so that explain what do people feel about mitomycin and tubes in kids?

Gurjeet Jutley:

Yeah. I think that’s a great question. Um, I, I think we have colleagues and I’m sure people do use it. Um, the key thing is, is, um, for example, one of my questions to Ken earlier was, um, do you use the Ahmed in the anterior segment because you there’s a valve and there’s that safety kind of, uh, um, aspect to it.

If we’re going to use MMC, what has the, I had done before? Because if we have someone doing lots of, um, diode laser, and there’s a possibility it’s going to be hypotony and you’re giving them MCs is going to perpetuate that hypotony, perhaps it’s not sensible to you. So I don’t think there’s a definitive right or wrong answer.

Alex Levin:

Um, the panel. Yeah, I use it. Uh, Elena, you can just float around the table. Are you an NMC? A fan.

Elena Bitrian:

I am not. If I don’t see there’s a clear benefit, which is not demonstrated, I prefer to avoid giving them, uh, a medicine that has those, uh,  long life consequences without, without knowing there’s a clear benefit like in  we’ll be working David thoughts.

David Walton:

Uh, we just like to, for this worldwide audience, I think it’s really important to recognize that we’ve heard about a very specialized you used of a tube. And the tube is a very, very valuable alternative for children with anterior segment dysgenesis, which, uh, unfortunately it does include anomalies of the, of, of the filtration angle.

So to turn to a tube is a very important alternative. And in most instances, It’s best simply put into the enter chamber and in the way that we’re, that we’re familiar with, but, but it’s been nice to hear about a very specialized procedure. I think it’s important in the context of this presentation for us to mention, uh, and to, uh, to share that we all have problems measuring the eye pressure in children with these problems.

And it’s really essential to be sure that in fact, we’re really dealing with a glaucoma problem and to look for the other signs of increased pressure, other than, than the D to the autonomic tree values is really important is the anterior chamber deepening is the cornea enlarging. It is the eye itself enlarging, and then to take advantage of those clinical signs, as well as all the alternatives to actually measuring eye pressure and to be patient and make sure that in fact, you’re really dealing with the glaucoma problem in, in terms of eye pressure, measurement, finger tension’s not reliable, but that’s one alternative that the eyecare tonometer offers an alternative apple, that handheld applications to tree is really valuable. And I would throw in. That continued use of a shot’s denominator is absolutely valuable. And to get an idea about the enter chamber, you can use it in a child who supine and, uh, to put that in and, and also follow the children that way.

But I think we need to study these children carefully to be ensure that in fact, patients who are seen with congenital corridor capacity really have a coma. And those of course who have newborn glaucoma type, did they have such conspicuous signs that I use tubes primarily for those children without going through the, uh, failures with angles.

So to study these patients carefully, to be sure they have glaucoma and to consider the alternatives, but tubes, we really should remind the whole audience are very valuable and work well as initial procedure putting in, into the inter chamber.

Alex Levin: 

Let’s get back to the question David used by the mice ever.?

David Walton:


Alex Levin :

Gorka do you use:

No I do not

tubes. No, not. Okay.

Alex Levin:

So, um, another question that has arisen is the foreign body of a tube. Um, you know, that’s in there, uh, for a long, long time and put it in kid with that concern anyone. And, uh, if you were to remove it to say there’s a melt or something and your reparable exposure, would you leave the plate in?

Uh, or do you take the plate as well?

Ken Nischal:

Uh, Alex, can I, can I just talk about the last 22 years 20? Can you hear me? Uh, yeah, but she breaking. Can you hear me? Yes. Okay. Well, somebody else can go them. Can, can you hear me? Yeah, we can. Yes, not quite. So I was going to say in the last 20 years I have now, um, 27 occasions had to do a tectonic graft or a child referred to me because of a corneal melt.

Having had a tube put in in the first 18 months of life. Um, and those eyes, no matter what you do, uh, affected by amblyopia dramatic, because a tectonic graft put it, you know, it creates with Ken. Can you tell me you were unable to hear your, your, your.

Alex Levin:

Y, well, Ken’s trying to sort this out, perhaps other comments about


Nicola Freeman:

o my, my comment and I comment on, uh, it said if you, if you have happened to have done over Trek to me, for whatever reason in a trauma, or I’m trying to think of when you would have done a vitrectomy and all you need to do say your UV ISIS patient, who’s whose that’s not an anterior segment pathology, but you’ve just heard of a trick to me.

It doesn’t make sense to put the tube in the anterior chamber. Um, you should always put it as far away from the endothelium as possible. So if there’s been a vitrectomy, you should be doing a pars plana, even if you’re more comfortable and used to putting it in the AC, um, because of the long-term effect on the endothelium.

Um, so yeah, a lot of these anterior segment patients would not have had in vitrectomy, the Fremont.

Elena Bitrian:

Yes. I agree that the Freeman exactly what you’re saying, but always like just pointing out that you have to trust the vitreoretinal surgeon that has done the vitrectomy and be someone that is used to do the surgery in children, because that didn’t make sense. Definitely a difference when it’s going to be the clear reduced and the eye, like properly vitrectomized.

Alex levin:

Gurjeet Jutley, You want it to reply.

Gurjeet Jutley:

Can I say, just going to say, you know, your point about whether to take the plate out or leave it be, I’ve just seen, like, if you do leave the plate alone, um, and you sort of put the tube out and down onto the sclera, inevitably in my experience, it just goes up and tries to give you exposure through the conjunctiva.

Has anyone ever found that? So usually I take the whole plate plate out.

Alana Grajweski:

 I don’t take the plate out. Um, and often, and often times I won’t ask me to take the tube, uh, life as long. I don’t know what’s going to happen. So I’ll convert it to a stage one, tucking the tube underneath. And I can say like others on this conference, I’ve been doing it so long that I’ve had the, uh, need in the future to go back to that plate and, uh, and put it in the pars planer, uh, for something else, you know, the person’s ha uh, had a retinal detachment or something.

I’m like, oh, thank God. I still have that to there. And I’m able to put it in. And, uh, we don’t use the Hoffman at. I think it would be nice if we had it, but we don’t have it. And I do, as Elena said, I do direct mine a little bit more anterior than what a normal sclerotomy would be for a vitrectomy. So let’s use a separate opening.

Elena Bitrian:

I had these available before I was at the basket compartment, so I basket my lead only. Uh, without that man, I had that available. I actually like it better without it just directing and doing a purpose, a sclerosis, but personal liking.

Ken Nischal:

Can you hear me? Uh, we can, uh, yep. I was just, I was just going to say, so, um, Alana, do you, do you, do you do that even if you’ve had a melt?

So I get these children referred to me with corneal melts and you know, you’re having to do a tectonic graft under those circumstances. I remove the whole tube. Do you, do you leave the tube, even if you’ve had a melt in the car?

Alana Grajweski:


Yeah, I tack it underneath the plate can mostly because like, Alex, I don’t want to take the plate off.

You know, you have those holes in a barbell where fibrous tissue has grown through it, and these are. Pillars and, you know, you can easily enter it on. You tried I’ve unfortunately seen something like that, but not my hand. And I, I don’t want to be there. So I do really do leave the plate and just tuck the two way your knee.

Um, I think if I’m afraid it’s going to go through it is, um, I might amputate, uh, and leave a stub so that I could always attitude on top of it. And then I use sort of the pink card technique of tube over to later on. And, um, I’ve done. I’ve done that, but I do leave the plate. Okay.

Nicola Freeman:

In my experience of I’ve the few times I’ve had to try and remove a plate, it’s almost been impossible.

And I’m sitting thinking it’s even tricky to you. You’re saying you tuck the tube in under the plate, but sometimes it’s, so fibrosed that, it’s almost, it’s impossible to get in under the plate. Um, it’s really difficult for moving these plates after four or five years.

Alana Grajweski:

And you can enter the, I inadvertently trying, if you try too hard.

So what of caution?

Nicola Freeman:

So thank you, everyone. That was a great discussion. Um, thank you for brilliant talks. Um, especially the, that they led to such such good discussion. Um, I’d like to finish off with everyone giving us one final comment. Um, one pearl to take home, um, for the audience from each speaker, please let’s start with Gorka.

Gorka Sesma

Eh, the treatment, the treatment should be tailored. It’s complex. It should be tailored

Elena Bitrian:

 So I would say, think of ankle surgery, uh, at least as a first stage, it’s important to keep it that in mind to give it a shot, a chance. Thank you,

David Walton:

Uh, I’ve really enjoyed all the presentations and I’ve learned a lot and thank you for the opportunity to get to participate. I guess the one pro would be to look at each page and carefully be sure they have one called coma and recognize the value of tubes and recognize that that angle surgery is an attempt to make almost normal tissue work better. So careful assessment of the angle is really important to, to judge whether or not that’s a good procedure or not. Thank you.

Gurjeet Jutley:

Um, pearl one is, if you, if a, um, pars planet tube is in play, um, make sure the vitreous base is removed pearl 2; may the force be with you!

Ken NIschal:

Well, I hope you can hear me. Um, I, I think deep phenotyping is really important. Uh, please remember that the armamentarium for treating these children does include other parameters as, uh, as well as goniotomy tubes. Think about psychodynamic selective cycle diet, laser to buy time. So these children get older and bigger and, uh, you can do the treatment more safely,

Alex Levin:

I would, uh, take moderator’s privilege and have two pearls; One just to extend what Ken just said, phenotype phenotype, phenotype deeply, but also Chino type when you’re able. And number two, I think one thing that this has shown is there is no right answer. These are difficult cases and there’s many ways to skin the cat here.

Uh, so, uh, do your best to keep the patient’s best interest in mind. Thank God.

Alana Grajweski:

I think my Pearl, uh, goes on to Alex’s that there’s no really right answer, but to try to do it as a team with others. And if you’re somebody out there who takes care of children with glaucoma, uh, join the associations that have other people who take care of kids with glaucoma.

I’ve actually learned a lot here today, myself. My self and I’ve been doing it for 30 something years. And, but I, I really am going to take some of the lessons that I’ve learned today and, and implement them. Uh, if you want to join the childhood glaucoma research network, C G R N, and we have regular meetings.

We sent the announcement out for this one. Then just go ahead and email the Balkan So you see balkan center under my name there to join the CGRS childhood glaucoma research network. It’s good to commiserate with everybody and share ideas.

Alex Levin:

Thank you for that Nicola Nicola.

Do you want to give us your final peril and then I’ll take over

Nicola Freeman:

My final pearl was exactly that, but don’t try and do it alone. These cases need advice. You press the button of all of co colleagues who are willing to give their advice, take pictures, share it with them and get a get advice from at least one or two or three people before you tackle these cases.

Alex Levin:

Thank you. And I’m going to close with three other advertisements, uh, one the paediatric glaucoma and cataract family associations available the international organization for everyone and the patients who need support the glaucoma research foundation. Dr. Walton’s joint WSPOS, world side of paediatric ophthalmology business.

And we also have an international glaucoma registry that we invite anyone who has. Uh, patients to participate in. It’s an open registry free for you to use for your own research, uh, worldwide. And you can find out information by contacting me or through the CGRS. So in closing, I want to thank everyone for participating was a great session.

I really feel honored to be part of it. Uh, if we missed any of your questions, please email them to, and you’ll get an email response to those questions. Uh, next slide please. Uh, the future, uh, seminars that next seminar is coming. Uh, these are great management of ocular problems in children with down syndrome, uh, and then a parent patient centric session down syndrome and how my family and I dealt with it.

It sounds like a fascinating thing, both in March coming up. Next slide. Uh, this is for season three. Well, um, Well, why webinar number three, season three, it sounds like a Netflix thing. Uh, management of Ocular problems in children with down syndrome. Here are the speakers, Ramesh, Kenya from India and others.

You can see here, I’m not going to mispronounce names. Oh, it looks like a great session. Next slide. Um, and this is the parent patient-centric session that we just spoke about and I’m sure you’ll be getting reminders by email for those as well. Uh, so again, uh, inviting the audience to join WSPOS with many membership, excuse me, benefits as you can see, it’s a great organization.

Um, and, uh, it is free. Everybody likes something free. Right? Uh, so thank you very much. It was a great, uh, this, uh, talk like all the talks, uh, the worldwide webinars are available for free on YouTube. Uh, if you’ve missed one, uh, go back and see them. I want to thank our participants. Uh, I want to thank our audience.

Uh, it was really great working with all of you. Thank you very much. Enjoy your weekend. Thank you. Thank you. Thank you.

Ken Nischal:

Thanks everybody. Uh, I learned so much, it was wonderful. I don’t think we’re alive now. I think we’re done.

Alana Grajweski:

I really did learn from you. I want to try that.