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Incidence and Management of Glaucoma or Glaucoma Suspect in the First Year After Pediatric Lensectomy

Educational Objective
To estimate the incidence of glaucoma and glaucoma suspect and describe its management in the first year following lensectomy in children before 13 years of age.
1 Credit CME
Key Points

Question  What is the incidence risk of glaucoma or glaucoma suspect during the first year after lensectomy in children younger than 13 years, and what are the associated risk factors?

Findings  In this cohort study of 702 pediatric patients (970 eyes), glaucoma or glaucoma suspect developed in 66 of 970 eyes (adjusted overall incidence risk, 6.3%) within 1 year after unilateral or bilateral lensectomy. Age of 3 months or younger at lensectomy and aphakia were associated with subsequent glaucoma or glaucoma suspect.

Meaning  This study’s findings suggest that, although all children should be monitored for glaucoma following lensectomy, increased attention should be given to infants 3 months or younger at lensectomy and children with aphakia after lensectomy.

Abstract

Importance  Glaucoma can occur following cataract removal in children, and determining the risk for and factors associated with glaucoma and glaucoma suspect in a large cohort of children after lensectomy can guide clinical practice.

Objective  To estimate the incidence of glaucoma and glaucoma suspect and describe its management in the first year following lensectomy in children before 13 years of age.

Design, Setting, and Participants  A multicenter clinical research registry containing data for 1361 eyes of 994 children who underwent unilateral or bilateral lensectomy between June 2012 and July 2015 at 1 of 61 sites in the United States (n = 57), Canada (n = 3), and the United Kingdom (n = 1). Patients were eligible for inclusion in the study if they were enrolled in the registry within 45 days after lensectomy and had at least 1 office visit between 6 and 18 months after lensectomy. Patient data were reviewed, and glaucoma and glaucoma suspect were diagnosed by investigators using standardized criteria. Statistical analysis was performed between June 2017 and August 2019.

Exposures  Clinical care 6 to 18 months after lensectomy.

Main Outcomes and Measures  Incidence risk using standardized definitions of glaucoma and glaucoma suspect after lensectomy.

Results  Among 702 patients included in this cohort study, 353 (50.3%) were male and 427 (60.8%) were white; mean age at lensectomy was 3.4 years (range, 0.04-12.9 years). After lensectomy, glaucoma or glaucoma suspect was diagnosed in 66 of 970 eyes (adjusted overall incidence risk, 6.3%; 95% CI, 4.8%-8.3%). Glaucoma was diagnosed in 52 of the 66 eyes, and glaucoma suspect was diagnosed in the other 14 eyes. Mean age at lensectomy in these 66 eyes was 1.9 years (range, 0.07-11.2 years), and 40 of the 66 (60.6%) were eyes of female patients. Glaucoma surgery was performed in 23 of the 66 eyes (34.8%) at a median of 3.3 months (range, 0.9-14.8 months) after lensectomy. The incidence risk of glaucoma or glaucoma suspect was 15.7% (99% CI, 10.1%-24.5%) for 256 eyes of infants 3 months or younger at lensectomy vs 3.4% (99% CI, 1.9%-6.2%) for 714 eyes of infants older than 3 months (relative risk, 4.57; 99% CI, 2.19-9.57; P < .001) and 11.2% (99% CI, 7.6%-16.7%) for 438 aphakic eyes vs 2.6% (99% CI, 1.2%-5.6%) for 532 pseudophakic eyes (relative risk, 4.29; 99% CI, 1.84-10.01; P < .001). No association was observed between risk of developing glaucoma or glaucoma suspect and any of the following variables: sex, race/ethnicity, laterality of lensectomy, performance of anterior vitrectomy, prelensectomy presence of anterior segment abnormality, or intraoperative complications.

Conclusions and Relevance  This study found that glaucoma or glaucoma suspect developed in a small number of eyes in the first year after lensectomy and may be associated with aphakia and younger age at lensectomy. Frequent monitoring for signs of glaucoma following lensectomy is warranted, especially in infants 3 months or younger at lensectomy and in children with aphakia after lensectomy.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: September 16, 2019.

Published Online: November 21, 2019. doi:10.1001/jamaophthalmol.2019.4571

Correction: This article was corrected on February 6, 2020, to add the names of 11 participating sites and group members to the Group Information section.

Corresponding Author: Sharon F. Freedman, MD, Jaeb Center for Health Research, 15310 Amberly Dr, Ste 350, Tampa, FL 33647 (pedig@jaeb.org).

Author Contributions: Drs Freedman and Repka had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kraker, Repka, Wallace, Gearinger.

Acquisition, analysis, or interpretation of data: Freedman, Kraker, Repka, Wallace, de Alba Campomanes, Yanovitch, Orge.

Drafting of the manuscript: Freedman, Kraker, Repka.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kraker.

Obtained funding: Kraker.

Administrative, technical, or material support: Kraker.

Supervision: Freedman, Kraker, Repka.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grants EY011751 (Mr Kraker), EY023198 (Dr Wallace), and EY018810 from the National Eye Institute of the National Institutes of Health, Department of Health and Human Services.

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The members of the Pediatric Eye Disease Investigator Group (PEDIG) who participated in this study are as follows (sites are listed in order by number of participants enrolled, and personnel are listed as “[I]” for investigator and “[C]” for coordinator): Duke Eye Center, Duke University Hospital, Durham, North Carolina (90): Sharon F. Freedman (I), David K. Wallace (I), Laura B. Enyedi (I), Sasapin Prakalapakorn (I), and Sarah K. Jones (C). Children’s Mercy Hospitals and Clinics, Kansas City, Missouri (65): Denise A. Hug (I), Erin D. Stahl (I), and Rebecca J. Dent (C). Texas Children’s Hospital, Houston (61): Kimberly G. Yen (I) and Lingkun Kong (C). Children’s Medical Center, Dallas, Texas (53): Serena Wang (I) and Bryan K. Gallerson (C). Emory Eye Center, Atlanta, Georgia (48): Scott R. Lambert (I), Amy K. Hutchinson (I), Phoebe Lenhart (I), and Judy Brower (C). Vanderbilt Eye Center, Nashville, Tennessee (47): David G. Morrison (I) and Scott Ruark (C). Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois (42): Bahram Rahmani (I), Sudhi Kurup (I), Rebecca Mets-Halgrimson (I), Hawke Yoon (I), Hantamalala Ralay Ranaivo (C), and Aaliyah Hamidullah (C). University of Minnesota, Minneapolis (35): Raymond Areaux (I), Jill S. Anderson (I), Erick D. Bothun (I), and Ann M. Holleschau (C). CHU Sainte-Justine, Montreal, Quebec, Canada (32): Rosanne Superstein (I), Caroline Belanger (I), Nicole Fallaha (I), Patrick Hamel (I), and Maryse Thibeault (C). Bascom Palmer Eye Institute, Miami, Florida (26): Susanna M. Tamkins (I) and Ta Chang (I). Wilmer Institute, Baltimore, Maryland (25): Michael X. Repka (I), Courtney Kraus (I), Hee-Jung S. Park (I), Anya A. Trumler (I), and Xiaonong Liu (C). Alberta Children’s Hospital, Calgary, Alberta, Canada (25): William F. Astle (I) and Emi N. Sanders (C). Cole Eye Institute, Cleveland, Ohio (25): Elias Traboulsi (I), Fatema Ghasia (I), and Diana C. McOwen (C). Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (23): Michael E. Gray (I), Michael B. Yang (I), and Corey S. Bowman (C). Department of Ophthalmology & Visual Science, Yale University Medical School, New Haven, Connecticut (21): Jennifer Galvin (I) and Margaret Therriault (C). Riley Hospital for Children, Indianapolis, Indiana (20): Kathryn Haider (I), Heather Smith (I), and Michele E. Whitaker (C). Department of Ophthalmology, Rainbow Babies and Children’s Hospital, Cleveland, Ohio (20): Faruk H. Orge (I), Adriana P. Grigorian (I), and Alicia M. Baird (C). Tufts Medical Center, Boston, Massachusetts (17): Mitchell B. Strominger (I), Vicki Chen (I), and Shelley Klein (C). Department of Ophthalmology, University of California, San Francisco (16): Alejandra de Alba Campomanes (I), Jacquelyn D. Kemmer (C), and Alexandra E. Neiman (C). Wolfe Eye Clinic, West Des Moines, Iowa (16): Myra N. Mendoza (I) and Jill J. Frohwein (C). Pediatric Ophthalmology Associates Inc, Columbus, Ohio (14): Don Bremer (I), Cybil Cassady (I), Richard Golden (I), Catherine Jordan (I), David Rogers (I), and Sara A. Oravec (C). Dean McGee Eye Institute, Oklahoma City, Oklahoma (14): Tammy L. Yanovitch (I) and Keven Lunsford (C). Northwest Pediatric Ophthalmology, Spokane, Washington (14): George Whitehead (I), Christina Nye (I), Caroline Shea (I), and SueAnn M. Stillman (C). IWK Health Centre, Halifax, Nova Scotia, Canada (12): G. Robert LaRoche (I) and Stephen C. Van Iderstine (C). John A. Moran Eye Center, University of Utah Health, Salt Lake City (12): Marielle Young (I) and Elisa Robertson (C). Saint Louis University Eye Institute, St Louis, Missouri (12): Oscar A. Cruz (I), Rafif Ghadban (I), and Dawn Govreau (C). University of Iowa Hospitals and Clinics, Iowa City (11): Scott A. Larson (I), Susannah Longmuir (I), and Xiaoyan Shan (C). Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom (11): Michael P. Clarke (I), Kate Taylor (C), and Christine Powell (C). David and Ilene Flaum Eye Institute, University of Rochester Medical Center, Rochester, New York (11): Benjamin P. Hammond (I), Matthew D. Gearinger (I), and Andrea Czubinski (C). Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware (11): Dorothy H. Hendricks (I), Jing Jin (I), Jonathan H. Salvin (I), and Alicia Fisher (C). St Luke’s Health System, Boise, Idaho (10): Katherine A. Lee (I), Daniel Brooks (I), and Bonita R. Schweinler (C). Pediatric Ophthalmology of Erie, Pennsylvania (10): Nicholas A. Sala (I) and Allyson M. Sala (C). Casey Eye Institute, Portland, Oregon (10): Allison I. Summers (I), Daniel J. Karr (I), Lorri B. Wilson (I), and Paula K. Rauch (C). UC Davis Health Eye Center, Sacramento, California (10): Mary O’Hara (I), Nandini Gandhi (I), and Tania Hashmi (C). Spokane Eye Clinic, Spokane, Washington (10): Jeffrey Colburn (I) and Eileen Dittman (C). Charles R. Whitfill, MD, Wichita, Kansas (9): Charles R. Whitfill (I) and Amy M. Wheeler (C). University of Colorado Anschutz Medical Campus, Aurora (7): Emily A. McCourt (I), Jasleen Singh (I), and Nanastasia Welnick (C). Illinois Eye and Ear Infirmary, University of Illinois, Chicago (7): Nathalie F. Azar (I) and Joseph Baker (C). Pediatric Ophthalmology PC, Grand Rapids, Michigan (7): Patrick J. Droste (I), Robert J. Peters (I), and Jan Hilbrands (C). Jules Stein Eye Institute, University of California, Los Angeles (7): Stacy L. Pineles (I), Marianne J. Bernardo (C). SouthEast Eye Specialists PLLC, Chattanooga, Tennessee (6): Edward Peterson (I) and Charla H. Peterson (C). Robert Cizik Eye Clinic, University of Texas, Houston (6): Kartik Kumar (I) and Ephrem Melese (C). Gavin Herbert Eye Institute, University of California, Irvine (5): Robert Lingua (I) and Jeff Grijalva (C). Virginia Pediatric Eye Center, Norfolk (5): Earl R. Crouch Jr (I), Earl R. Crouch III (I), and Gaylord G. Ventura (C). Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (5): William Anninger (I), Shawn L. Benson (C), and Karen A. Karp (C). Department of Ophthalmology & Vision Science, University of Arizona, Tucson (5): Jordana M. Smith (I) and Jill Brickman-Kelleher (C). The Eye Specialists Center LLC, Chicago Ridge, Illinois (4): Benjamin H. Ticho (I) and Alexander J. Khammar (I), and Deborah A. Clausius (C). Institute of Ophthalmology and Visual Science, University of Medicine and Dentistry of New Jersey–Rutgers New Jersey Medical School, Newark (4): Suqin Guo (I). University of Nebraska Medical Center, Omaha (4): Donny Suh (I) and Carolyn Chamberlain (C). Associated Eye Care, St Paul, Minnesota (4): Susan Schloff (I). Children’s National Medical Center, Washington, DC (4): William P. Madigan (I) and Donna Burkman (C). Boston Medical Center, Boston, Massachusetts (3): Stephen P. Christiansen (I), Jean E. Ramsey (I), and Kate H. McConnell (C). Montefiore Medical Center, Bronx, New York (3): Ilana Friedman (I) and Jose Rosado (C). Eye Surgical Associates, Lincoln, Nebraska (3): Donald P. Sauberan (I) and Jody C. Hemberger (C). Progressive Eye Care, Lisle, Illinois (3): Patricia L. Davis (I) and Indre Rudaitis (I). Arkansas Children’s Hospital and University of Arkansas Medical Sciences, Little Rock (3): Robert S. Lowery (I) and Shawn Cupit (C). Mayo Clinic, Rochester, Minnesota (3): Jonathan M. Holmes (I), Brian G. Mohney (I), Suzanne M. Wernimont (C), and Rebecca A. Nielsen (C). Seattle Children’s Hospital, Seattle, Washington (3): Erin P. Herlihy (I), Francine Baran (I), and Amy Gladstone (C). Harvard Vanguard Medical Associates, Boston, Massachusetts (2): Justin Smith (I), Mei Mellott (I), and Troy Kieser (C). Eye Care Associates Inc, Poland, Ohio (2): S. Ayse Erzurum (I),and Beth Colon (C). The Eye Specialists Center LLC, Munster, Indiana (1): Birva Shah (I) and Micaela Quebbemann (C).

Disclaimer: This study was conducted under an Investigational Device Exemption from the US Food and Drug Administration.

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