The safety and efficacy of CO 2 laser-assisted sclerectomy surgery-based multi- pathway glaucoma surgery in intractable pediatric glaucoma

The safety and efficacy of CO 2 laser-assisted sclerectomy surgery-based multi- pathway glaucoma surgery in intractable pediatric glaucoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The safety and efficacy of CO 2 laser-assisted sclerectomy surgery-based multi- pathway glaucoma surgery in intractable pediatric glaucoma Anyi Liang, Hang Song, Gangwei Cheng, Yang Zhang, Ailing Bian, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2046869/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background To evaluate the safety and efficacy of CO 2 laser-assisted sclerectomy surgery (CLASS)-based multi-pathway glaucoma surgeries in intractable pediatric glaucoma. Methods Retrospective, self-controlled, interventional case series. Twenty-three intractable pediatric glaucoma patients (26 eyes) who underwent CLASS-based multi-pathway surgeries were enrolled, including CLASS combined with trabeculectomy and CLASS combined with combined trabeculectomy and trabeculotomy. Complete examinations were performed before and after surgery. Intraocular pressure (IOP) change, complete and qualified success rates (CSR, QSR), best-corrected visual acuity (BCVA), number of IOP-lowering eyedrops and adverse events were recorded. Results The mean age at surgery was 8.72 ± 5.46 years and the mean follow-up time was 25.49 ± 10.87 months. Baseline IOP, number of IOP-lowering eyedrops and logMAR BCVA were 32.00 ± 4.83 mmHg, 3.21 ± 0.71 and 1.31 ± 0.90 respectively. The mean IOP was 12.05 ± 5.02, 11.71 ± 3.25 and 12.67 ± 3.38 mmHg at 6 months, 1 year and 2 years after surgery, which were significantly lower than baseline (all p < 0.05). The reduction in number of medications was statistically significant at all post-operative timepoints within 3 years (all p < 0.005). CSR and QSR were 82.2% and 91.7% respectively at 1 year, and were 68.5% and 81.5% respectively at 2 years. Majority of the early and late-onset complications including shallow anterior chamber, extensive peripheral anterior synechia, scarring of blebs and cataract were mild and reversible. Conclusion CLASS-based multi-pathway surgery was safe and effective for the treatment of intractable pediatric glaucoma. It is promising to become an alternative and safer surgical management for intractable pediatric glaucoma. pediatric glaucoma intractable glaucoma surgery CO2 laser deep sclerectomy Figures Figure 1 Figure 2 Figure 3 Background The management of pediatric glaucoma is much more challenging and complicated than adults attributing to a wide range of factors, especially the aggressive scar formation[ 1 ]. Intractable cases where the initial surgery fails or is highly likely to fail complicate the condition further and bring greater challenges to make the most appropriate decision in choosing surgical plans. Currently no general consensus has been achieved as to the best surgical treatment option for refractory pediatric glaucoma[ 2 – 4 ]. The robust scarring in children is responsible for majority of failures after surgery despiste the use of antimetabolites. Noticably, the self-repair process of deep tissues is weaker and slower than the superficial ones, so theoretically, pathways created in deeper layers of the sclera by nonpenetrating deep sclerectomy (NPDS)[ 5 , 6 ] might be less prone to scar formation and more suitable for children. However, the physiological aqueous humor (AH) outflow pathways in many pediatric glaucoma patients are structurally or functionally abnormal, so a single NPDS was not qualified. Therefore, it is reasonable to add other surgeries, such as trabeculotomy or trabeculectomy, to create multiple pathways as well as to enhance the “sub-flap” pathway for AH drainage. Traditional manual NPDS requires high surgical skills and experience, while CO 2 laser-assisted sclerectomy surgery (CLASS) is more accurate and safer by minimizing damages and scars in scleral ablation[ 7 – 9 ], which makes it more suitable for pediatric patients whose ocular surface structures are thin, fragile and easily scarring. Considering the above-mentioned benefits of CLASS and the necessity of multiple pathways, we assumed that a CLASS-based multi-pathway glaucoma surgery might be a good choice for intractable pediatric glaucoma. The current study aimed to evaluate the safety profiles and efficacy of this surgical technique in intractable pediatric glaucoma population. Methods This is a retrospective study of 23 consecutive patients who underwent multi-pathway glaucoma surgeries from March 2018 to April 2021 at Peking Union Medical College Hospital (PUMCH) with at least 6-month follow-up. The protocol was approved by the Institutional Review Board of PUMCH (S-K1540) and conformed to the tenets of the Declaration of Helsinki. Informed consent was obtained from all subjects and/or their legal guardians for using their clinical data. All patients were younger than 18 years old at the time of surgery and conformed to the definition of intractable glaucoma. In the context of the current study, intractable pediatric glaucoma was defined as glaucoma in children patients who did not respond to a primary surgery, or patients associated with complex conditions including extensive fibrosis in superior conjunctiva, anterior staphyloma, uveitis, post-cataract surgery, post-traumatic glaucoma, other anterior segment abnormalities or systemic syndromes, such as Peters anomaly and retinopathy of premature (ROP)[ 3 ]. Enrolled patients were classified as primary and secondary pediatric glaucoma according to the new classification system for pediatric glaucoma[ 10 ]. Three patients underwent bilateral surgeries but not simultaneously and each individual eye was regarded as a separate entity of data for the purpose of analysis. Surgical techniques: The multi-pathway surgeries in this study include 2 types, namely CLASS combined with trabeculectomy (CLASS-TRAB) and CLASS with combined trabeculectomy and trabeculotomy (CTT) (CLASS-CTT). All the operations were performed by a single experienced glaucoma specialist (GWC) under general anesthesia. The CLASS procedure was standardized for every patient: A fornix-based conjunctival incision was made and the residual subconjunctival tissue and Tenon capsule were removed to expose the sclera. The site of surgery was selected within 150° of the superior quadrants where the conjunctiva and sclera were relatively healthy, while avoiding previous surgical sites. A 5×5.5-5×6 mm 2 partial thickness (1/3 − 1/2) scleral flap was created at the limbus 1 mm into the transparent cornea. Sponges soaked in 5-fluorouracil (FU) or 0.04% mitomycin C (MMC) were then applied above and the under the scleral flap (4-4.5 minutes for MMC and double the time for 5-FU), and under the conjunctiva (1-1.5 minutes for MMC and double the time for 5-FU), followed by washing out with balanced salt solution (BSS). A red He-Ne laser aiming beam was applied to mark the desired area of sclerectomy, with the anterior margin at 2 mm posterior to the limbus and posterior margin at 4.5mm posterior to the limbus, after which the CO 2 laser beam (22 Watts) was then applied repeatedly (with time intervals of 2 to 3 seconds) to form an intrascleral lake (with size of 4×2.4-4×2.6 mm 2 and depth of 90% of the scleral thickness). Antimetabolite was applied to the scleral floor without touching the surrounding tissues (2-2.5 minutes for MMC and double the time for 5-FU) followed by BSS washout. The remaining surgical procedures of trabeculectomy, and CTT were performed following routine standards. The scleral flap was repositioned and tightly sutured with 10 − 0 nylons, routinely with 3 fixed and 4 releasable sutures to ensure watertight. The conjunctiva was secured with buried 10 − 0 nylons. The eye was patched with tobramycin and dexamethasone eye ointment, and atropine was added in CLASS-TRAB surgery. Figure 1 illustrated the eye before, during and after surgery. (A) Before surgery, (B) During surgery, (C) After surgery, (D) Ultrasound biomicroscope (UBM) of the eye 5 months after surgery, (E) UBM of another patient 19 months after surgery Intraocular pressure (IOP) measurement: IOP was measured with Perkins applanation tonometer (PAT). Topical anesthetic (Oxybuprocaine Hydrochloride Eye Drops) was instilled in the cul-de-sac. A fluorescein strip was applied to the lateral 1/3 of the lower palpebral conjunctiva, and IOP was measured with a PAT. Post-operative managements: From the next day of surgery on, 1% prednisolone acetate drop was applied hourly for at least 1 week and then gradually tapered, together with topical antibiotics 4 times daily for 1 week and tapered. For all the cases, sutures were released step by step and 5-FU was injected subconjunctival or under the filtering bleb at an early stage, generally within 7–14 days after surgery. For uveitis patients or patients who were expected to have intense inflammatory reactions after surgery, oral steroids were given at a dose of 1mg/kg prednisolone once a day after ruling out contraindications of steroids and gradually tapered. In prevention of posterior synechia of the pupil in uveitis, pupil dilation eyedrops were administered. Routine follow-up visits were at 1 day, 1 week, 1, 3, 6, 12 and 24 months postoperatively. Outcome measurement: primary outcome: (1) changes of IOP from baseline (before surgery) to different time points after surgery; (2) complete success: IOP values between 5 and 21 mmHg and a reduction of ≥ 20% without hypotensive medications or repeated filtration surgery; (3) qualified success: IOP values between 5 and 21 mmHg and a reduction of ≥ 20% with hypotensive medications. IOP was measured with PAT. Secondary outcomes: best-corrected visual acuity (BCVA) in logMAR unit (logMAR BCVA), number of IOP-lowering eye drops, number of patients needing repeated filtration surgeries and morphology of filtering blebs. Adverse outcomes: hypotony (IOP < 5 mmHg for 1 month or longer), serious shallow anterior chamber (AC) needing surgical interventions, bleb leakage, bleb infection, choroidal detachment, hyphema, cataract, etc. Statistical analysis: Statistical analysis was performed using GraphPad Prism, Versiom 8.4.3 (471). A mixed model was used for the parametric data (IOP) over different timepoints, and the Wilcoxon paired signed-rank test was used for nonparametric data (BCVA, medications). Student’s test was used to compare parameters between 2 subgroups. Kaplan-Meier life-table curves were used to present the duration of complete and qualified success. The comparison of complete success rate (CSR) and qualified success rate (QSR) was carried out with Log Rank Test. A p -value < 0.05 was considered statistically significant for all statistical analyses. Results Baseline: Demographic data and baseline information were summarized in Table 1. Overall, 23 pediatric patients (26 eyes) with an average age of 8.72±5.46 years (1, 18) were enrolled. The diagnoses fell into 6 categories, with primary congenital glaucoma (PCG) and steroid-induced glaucoma ranked top two. There were 14/26 (53.85%) primary glaucoma and 12/26 (46.15%) secondary glaucoma. The mean follow-up time was 25.49±10.87 months (8.10, 47.63). In 15/26 (57.69%) eyes the multi-pathway surgery was the initial anti-glaucoma surgery and in 11/26 (42.31%) eyes where previous surgeries failed, the multi-pathway surgery was the rescue surgery. Table 1. Baseline demographic characteristics of patients Category Number (of eyes) Percentage Sex Male 12 52.17% Female 11 47.83% Dianosis PCG 9 34.62% Juvenile glaucoma 1 3.85% Glaucoma after cataract surgery 1 3.85% Glaucoma with nonacquired ocular anomalies Peters anomaly Axenfeld-Rieger syndrome 3 2 1 11.54% 7.69% 3.85% Glaucoma with systemic syndromes Weill-Marchesani syndrome 1 1 3.85% 3.85% Glaucoma with acquired conditions Steroid-induced Uveitis Trauma 11 5 4 2 42.32% 19.23% 15.38% 7.69% Follow-up (months) 6-12 3 11.54% 12-24 9 34.62% 24-36 10 38.46% 36-48 4 15.38% Surgery CLASS-TRAB 14 53.85% CLASS-CTT 12 46.15% Number of previous surgeries 0 15 57.69% 1 3 11.54% 2 5 19.23% 3 2 7.69% 5 1 3.85% Anitmetabolites 5-FU 12 46.15% MMC 14 53.85% Category Mean±SD Min, Max Initial IOP (mmHg) 32.00±4.83 20.0, 40.0 No. drugs 3.21±0.71 2.0, 4.0 Initial logMAR BCVA 1.31±0.90 0.0, 2.70 PCG: primary congenital glaucoma, CLASS: CO 2 laser-assisted sclerectomy surgery, TRAB: trabeculectomy, LOT: trabeculotomy, CTT: combined trabeculectomy and trabeculotomy, 5-FU: 5-fluorouracil, MMC: mitomycin, IOP: Intraocular pressure, BCVA: best corrected visual acuity IOP: The mean IOPs and reduction from baseline were summarized in Table 2. A significant IOP decrease from baseline was achieved at every time point after surgery (all p <0.001) and the highest IOP reduction was achieved at post-operative day 1. Table 2. IOP and reduction from baseline at different time points after surgery Time N IOP (mmHg) Reduction from baseline (mmHg) Percentage of reduction p value* Mean SD Min Max Mean SD Min Max Baseline 26 32.00 4.83 23.0 40.0 PO 1D 26 7.54 2.68 4.0 15.0 -24.47 5.94 -35.0 -15.0 76.45% <0.0001 PO 1W 23 8.07 2.95 4.0 15.0 -23.87 5.31 -34.0 -14.0 74.60% <0.0001 PO 1M 23 10.72 4.34 5.0 19.5 -21.11 5.45 -35.0 -11.2 65.96% <0.0001 PO 3M 23 11.33 3.61 6.0 18.0 -21.03 5.00 -34.0 -12.1 65.73% <0.0001 PO 6M 24 12.05 5.02 5.5 26.5 -19.88 5.88 -33.0 -8.50 62.13% <0.0001 PO 12M 21 11.71 3.25 5.6 17.4 -20.87 5.90 -33.7 -12.3 65.22% <0.0001 PO 12-24M 18 13.99 5.24 7.0 25.0 -19.35 6.92 -31.3 -8.0 60.46% <0.0001 PO 24-36M 15 12.67 3.38 4.8 17.1 -19.40 6.46 -35.2 -11.5 60.62% <0.0001 PO 36-48M 4 12.60 6.58 6.8 18.5 -21.65 13.56 -33.2 -6.50 67.65% 0.0496 IOP: Intraocular pressure, PO: post-operative IOP-lowering eyedrops: Table 3 showed the average number of IOP-lowering eyedrops before and at every post-operative time point. Overall, no IOP-lowering drug was needed within the first month. The reduction in number of medications was statistically significant at every time point after surgery (all p <0.01) except for beyond 3 years (n=4, p =0.1250). Table 3. The number of IOP-lowering eyedrops and reduction from baseline at different time points after surgery Time N of IOP lowering drugs Reduction from baseline p value* N Mean SD Min Max N Mean SD Min Max Baseline 20 3.21 0.71 2 4 PO 1D 24 0.00 0.00 0 0 20 -3.21 0.71 -4.0 -2.0 <0.0001 PO 1W 24 0.00 0.00 0 0 20 -3.00 1.00 -4.0 0 <0.0001 PO 1M 22 0.00 0.00 0 0 19 -3.21 0.71 -4.0 -2.0 <0.0001 PO 3M 18 0.04 0.21 0 1 15 -3.13 0.74 -4.0 -2.0 <0.0001 PO 6M 18 0.22 0.60 0 2 15 -3.07 1.03 -4.0 -1.0 <0.0001 PO 12M 21 0.43 0.81 0 2 13 -2.77 1.01 -4.0 -1.0 <0.0001 PO 12-24M 18 0.44 0.86 0 2 13 -3.00 0.82 -4.0 -1.0 <0.0001 PO 24-36M 16 0.13 0.50 0 2 10 -3.00 0.94 -4.0 -1.0 0.0020 PO 36-48M 4 0.00 0.00 0 0 4 -3.25 0.50 -4.0 -3.0 0.1250 IOP: Intraocular pressure, PO: post-operative Success rate: The CSR and QSR for every time point after surgery were summarized in Table 4, and the Kaplan-Meier curves were shown in Figure 2. Totally 5 eyes (19.23%) from 4 patients failed the surgery. Three of them were PCG patients and 1 was secondary glaucoma. Eye NO.5 was from an infant who received glaucoma drainage device (GDD) implant 6 months after the failure because of uncontrollable IOP. Eye NO.10 and 11 from a teenage uveitic glaucoma patient failed because of extensive scarring, but the IOP was well controlled after receiving rescue ab-interno repairing of the filtration pathway. Eye NO.12 was from a child who received primary LOT and then entropion surgery before failure. The influence of ocular surface condition and effects of medication might contribute to the failure. Eye NO.24 was from a PCG patient who previously had trabeculectomy, 360° trabeculotomy and 3 cyclophotocoagulation surgeries. Table 4. Success rates at different time points after surgery Time N CSR QSR 6 months 27 93.1% 96.6% 1 year 24 82.2% 91.7% 2 years 19 68.5% 81.5% 3 years 17 56.4% 67.1% CSR: complete success rate, QSR: qualified success rate Visual acuity: VA and changes from baseline to different post-operative time points were shown in Figure 3. VA decreased in the early post-operative stage, started to recover from post-operative 1 week on and approached baseline level. Complications: The occurence of post-operative complications were summarized in Table 5. The commonest early and late-onset complication is choroidal detachment (3/26, 11.54%) and secondary cataract (6/26, 23.08%) respectively. Only 2 (7.69%) cases of peripheral anterior synechia (PAS) and 2 (7.69%) cases of posterior pupillary synechia occurred in the late post-operative stage. Majority of the early complications observed in our study resolved spontaneously or after strengthened anti-inflammatory treatment within 2 to 4 weeks. There was no bleb leakage, iris incarceration, AH misdirection or endophthalmitis. Totally, 9/26 (34.62%) eyes underwent therapeutic or prophylactic injection of 5-FU under the filtering blebs to alleviate scar formation and fibrosis. Injection of 5-FU was given averagely at postoperative 6 to 8 months, with the earliest at 1 month and the latest at over 2 years after surgery. Table 5. Early and late-onset post-operative complications Complications N Percentage Early 4 15.38% Choroidal detachment 3 11.54% Hyphema 1 3.85% Late-onset 10 38.46% Cataract 6 23.08% PAS 2 7.69% Posterior synechia of pupil 2 7.69% PAS: peripheral anterior synechia Discussions To the best of our knowledge, this was the first time that CLASS had been used in pediatric patients, and extra attentions were paid to the anatomical differences between children and adults and the safety issues. Characteristic enlargement and subsequent thinning of the eyeball posed great challenges and difficulties in dissecting a large and regular scleral flap. The thin sclera also makes it unlikely to create an intrascleral lake as deep as that of adults, so increasing the area of the intrascleral lake aside from the depth can compensate the volume of the scleral lake, thus ensure the efficacy of filtration without increasing the risk of rupture or leakage of the flap. Therefore, the sizes of scleral flaps in this study were larger than those of traditional trabeculectomy. Furthermore, the thinner the flap is, the easier for the flap to curl and distort. That is why we repositioned the flaps with as many as 3 fixed and 4 releasable sutures to ensure the flap flat, regular and watertight. Regular and tightly sealed flap can maintain normal morphology of the scleral lake, avoid inflammatory mediators, tissue debris and blood cells from infiltrating to the scleral lake and reduce the extent of scarring. Expansion of the eyeball makes the limbus wider and difficult to recognize, and the posterior edge of the scleral flap should be more posterior from the cornea than usual. During surgery, we depended on the texture of limbus and the visualization of ciliary band to locate the limbus accurately. The enhanced uveoscleral outflow of AH by NPDS was efficient in lowering IOP, but the technical difficulty has restricted its wide application. CO 2 laser was firstly applied in dermatology area, especially in treating skin scars. It improves the appearance of burn and acne scars and normalizes collagen architecture, making them finer and less sclerotic[ 11 – 13 ]. It also helps to ablate dilated and high flow blood vessels, resulting in less bleeding, minor tissue damages and less inflammation[ 14 – 16 ]. Therefore, we believe that scleral lakes created with CO 2 laser would be less prone to scarring and healing, which is more suitable for children. To the best of our knowledge, there has been no reports about the application of CLASS in pediatric glaucoma so far. In our current study, CLASS was performed in all the multi-pathway surgeries as a basic procedure, because we believe it is not only a modification of traditional NPDS but also bears several unique advantages for pediatric patients. Firstly, CLASS causes fewer damages to the scleral tissue, minimizing scar formation. Secondly, the accuracy of CO 2 laser makes it easier and safer to create a scleral lake in highly stretched and thin sclera in young children. Studies showed that the success rate of traditional filtering surgery such as trabeculectomy was lower in children because of exuberant healing process[ 17 – 19 ], indicating that superficial scar formation is the main cause of surgical failure in children. In our study, 5/26 (19.23%) patients had flat blebs after surgery while intrascleral reservoirs were patent and IOP remained under control, indicating that internal deep drainage pathways play greater roles in IOP control in the late phase after surgery[ 20 ]. Multi-pathway surgery reduces IOP by increasing the routes of AH outflow, which is different from combined surgeries where cyclodestructive procedures might be used to reduce AH production. Our study adopted CLASS-based multi-pathway surgeries, a new concept of anti-glaucoma surgery where 2 or more drainage pathways were created. Satisfactory results were achieved, with 1-year CSR of 82.2% and QSR of 91.7%, which is better than traditional combined procedures. Jalil A et al[ 21 ] reported a 65.6% CSR and 79.3% QSR of CTT in congenital glaucoma refractory to goniotomy, but less effective as a primary procedure. Elder MJ[ 22 ] discovered that the 24-month cumulative success rate of CTT (93.5%) was higher than that of primary trabeculectomy (72%). Biedner BZ et al[ 23 ] reported a success rate of 86% in CTT and 57% in trabeculotomy respectively, but more adverse events in CTT group. Lawrence SD et al[ 24 ] found an equal IOP lowering effect between CTT and trabeculectomy, but greater long-term success in CTT. Furthermore, the addition of deep sclerectomy (CTT-DS) shortens surgery time by facilitating the finding of Schlemm's canal without additional complications[ 25 ]. DS combined with trabeculectomy was also reported to be satisfactory and promising with 9-year CSR and QSR of 52.3% and 70.6% respectively[ 21 ]. Another important reason why the multi-pathway surgery instead of single CLASS was adopted is that in traditional single CLASS, pre-operative laser peripheral iridectomy (LPI) is required, but in infants or young children who are mostly uncooperative in examination without general anesthesia, it’s hardly possible to perform the laser before surgery. The multi-pathway surgery had a transient influence on the visual acuity. The BCVA started to decrease at the early post-operative stage, which was mainly attributed to alteration of refraction, dramatic decrease of IOP, corneal edema and inflammatory reaction in the AC. From post-operative 1 month on, the BCVA increased and surpassed the pre-operative level, which indicated that early complications did not cause irreversible damages to the vision. At the first year after surgery, the BCVA decreased mildly comparing to the baseline level (not statistically significant), mainly due to secondary cataract. But this reduction of vision was reversible after cataract surgery. Blebs in the post-operative eyes are important indicators reflecting the filtration effects of drainage pathways and results of surgery. For most of our cases, in the early post-operative stage, blebs bulged and functioned well. It is interesting to discover that in the late post-operative stage, most of the blebs became less bulged or even flat but the IOP maintained in the normal range. We speculate that for CLASS-based surgery, especially in the late stage, the main factor of IOP control is the deep scleral pathway and “sub-flap” drainage, which is independent from bleb and outer filtration. Safety issues were the first priority in evaluating CLASS-based multi-pathway surgery in children. The early complications of multi-pathway surgery observed in this study were few and transient. None of eyes developed substantial shallow AC that needed surgical intervention. Three eyes (11.11%) whose IOP dropped from beyond 30 mmHg to below 8 mmHg 1 day after surgery developed regional choroidal detachment, but spontaneously recovered 1 week later when the IOP increased without any additional treatments. The low occurrence rate of severe shallow AC and choroidal detachment might be attributed to the tight suture of scleral flaps during surgery, or might be associated with the anatomical and physiological characteristics of children, such as lower permeability of the ciliary-choroidal blood vessels and higher compliance of the wall of eyeball. One patient with uveitis and 1 with Peter’s anomaly developed posterior synechia of the pupil, which indicated that uveitis and abnormal development of the anterior segment might be risk factors of post-operative pupillary synechia. The occurrence of hyphema (1/26, 3.85%) was substantially lower than that of other surgeries (6.66–45.4%)[ 2 , 26 , 27 ]. In traditional combined surgeries sight-threatening complications such as bleb leakage, blebitis, endophthalmitis and phthisis bulbi were more common[ 21 , 26 ], while no such severe complications were observed in our multi-pathway surgeries. Most of the late-onset complications were reversible with managements such as cataract surgery or massage of the blebs, and did not influence the long-term vision outcome. Only 2/26 (7.69%) eye developed extensive PAS, which received goniosynechialysis, while other minor PAS did not influcence the efficacy of surgery thus need not management. Five eyes (19.23%) developing extensive scarring of the drainage pathways needed repairing and reopening of the pathway because the IOP was above 21 mmHg after 5-FU injections and addition of IOP-lowering eyedrops. Notably, according to our observation, the need for blebs massage was less after CLASS-based multi-pathway surgery than traditional trabeculectomy, which is more acceptable for pediatric patients and their care-givers, increasing the compliance. Post-operative PAS or iris incarceration were major adverse events of traditional CLASS[ 28 , 29 ] and long-term use of pilocarpine was suggested. However, in cases of uveitic glaucoma, pilocarpine was relatively contraindicated because it would cause posterior adhesion of the iris and pupillary block. On the other hand, in multi-pathway surgery where peripheral iridectomy was performed, there was no risk of iris incarceration and no pilocarpine was needed. In our study, pilocarpine was not given and none of the patient developed iris incarceration. For uveitic glaucoma, post-operative anti-inflammatory treatment was critical because the deposition of inflammatory substances in the filtration pathways would accelerate the process of scarring. Thus, frequent and long-term use of steroids was necessary to control inflammation[ 30 – 32 ]. Contradictorily, steroid was known to potentially damage the physiological AH outflow pathway[ 33 ], which would impair the efficacy of surgery like canaloplasty. However, in multi-pathway surgery, the core mechanism of IOP reduction was through the deep uveoscleral pathway, which was not influenced by steroids, so there was no limitation of steroid use. We believe this study was pioneer in evaluating the safety and efficacy of CLASS-based multi-pathway surgeries in the management of intractable pediatric glaucoma. However, several limitations still existed. Firstly, accurate measurement of IOP in pediatric population is difficult, which impairs the quality of data. And this is a common and inevitable problem in all pediatric glaucoma studies. We have tried our best to minimize the errors by repeating the measurements with different methods. Secondly, intractable pediatric glaucoma is a spectrum consisting of various classifications, but this research didn’t study the difference between subtypes. We will further classify the patients according to diagnosis or etiology and make more detailed comparisons. Thirdly, restricted by the difficulty of randomization and relatively small sample size, there was a lack of control group treated by procedures without CLASS. We schedule to enroll more patients and control group in our future studies and prolong the follow-up time to evaluate the long-term efficacy. Conclusions In conclusion, our study for the first time showed that CLASS-based multi-pathway surgery was safe and effective for the treatment of intractable pediatric glaucoma. It is promising to become an alternative and safer surgical management for intractable pediatric glaucoma. Prospective studies with larger sample sizes and longer observation time are needed to assess the value of CLASS-based multi-pathway surgery as a new approach for intractable glaucoma in children. Abbreviations NPDS nonpenetrating deep sclerectomy AH aqueous humor CLASS CO 2 laser-assisted sclerectomy surgery PUMCH Peking Union Medical College Hospital CLASS-TRAB CLASS combined with trabeculectomy CLASS-LOT CLASS combined with trabeculotomy CTT combined trabeculectomy and trabeculotomy CLASS-CTT CLASS with combined trabeculectomy and trabeculotomy 5-FU 5-fluorouracil MMC mitomycin C BSS balanced salt solution IOP Intraocular pressure PAT Perkins applanation tonometer BCVA best-corrected visual acuity CSR complete success rate QSR qualified success rate PCG primary congenital glaucoma GDD glaucoma drainage device PAS peripheral anterior synechia DS deep sclerectomy LPI laser peripheral iridectomy Declarations Ethics approval and consent to participate: The protocol was approved by the Institutional Review Board of PUMCH (S-K1540) and conformed to the tenets of the Declaration of Helsinki. Informed consents were obtained from all subjects and/or their legal guardians for using their clinical data. Consent for publication: Not applicable. Availability of data and materials: The data in the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding : No funding for this study. Authors' contributions: GWC was responsible for the conceptualization, patient enrollment, patient follow-up, review and editing of this paper. AYL and HS equally contributed to the material preparation, data collection & analysis and writing of the original draft. MFZ participated in patient enrollment and follow-up. YZ and ALB were responsible for ophthalmological investigations such as UBM scans and IOP measurement. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. Acknowledgements: Thanks for the contributions from the Peking Union Medical College Hospital pediatric glaucoma study group, including the efforts in patients caring, surgery and data collection. Members of the Peking Union Medical College Hospital pediatric glaucoma study group include Minghang Pei, MD, Junyan Xiao, MD, Di Cao, MD, Yuyu Chou, MD, Xuejiao Wang, MD, Yuelin Wang, MD and Fei Mo, MD. All the authors would like to thank all the children and their parents for participating in this study. References Tan YL, Chua J, Ho CL: Updates on the Surgical Management of Pediatric Glaucoma . Asia Pac J Ophthalmol (Phila) 2016, 5 (1):85-92. 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Jankowska-Szmul J, Dobrowolski D, Wylegala E: CO2 laser-assisted sclerectomy surgery compared with trabeculectomy in primary open-angle glaucoma and exfoliative glaucoma. A 1-year follow-up . Acta Ophthalmol 2018, 96 (5):e582-e591. Skaat A, Goldenfeld M, Cotlear D, Melamed S: CO2 laser-assisted deep sclerectomy in glaucoma patients . J Glaucoma 2014, 23 (3):179-184. Thau A, Lloyd M, Freedman S, Beck A, Grajewski A, Levin AV: New classification system for pediatric glaucoma: implications for clinical care and a research registry . Curr Opin Ophthalmol 2018, 29 (5):385-394. El-Hoshy K, Abdel-Halim MRE, Dorgham D, El-Din Sayed SS, El-Kalioby M: Efficacy of Fractional Carbon Dioxide Laser in the Treatment of Mature Burn Scars: A Clinical, Histopathological, and Histochemical Study . J Clin Aesthet Dermatol 2017, 10 (12):36-43. Magnani LR, Schweiger ES: Fractional CO2 lasers for the treatment of atrophic acne scars: a review of the literature . J Cosmet Laser Ther 2014, 16 (2):48-56. Ozog DM, Liu A, Chaffins ML, Ormsby AH, Fincher EF, Chipps LK, Mi QS, Grossman PH, Pui JC, Moy RL: Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser . JAMA Dermatol 2013, 149 (1):50-57. Conforti C, Vezzoni R, Giuffrida R, Fai A, Fadda S, Marangi GF, Persichetti P, Piccolo D, Segreto F, Zalaudek I et al : An overview on the role of CO2 laser in general dermatology . Dermatol Ther 2020:e14692. Connolly KL, Chaffins M, Ozog D: Vascular patterns in mature hypertrophic burn scars treated with fractional CO2 laser . Lasers Surg Med 2014, 46 (8):597-600. Omi T, Numano K: The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology . Laser Ther 2014, 23 (1):49-60. al-Hazmi A, Zwaan J, Awad A, al-Mesfer S, Mullaney PB, Wheeler DT: Effectiveness and complications of mitomycin C use during pediatric glaucoma surgery . Ophthalmology 1998, 105 (10):1915-1920. Gressel MG, Heuer DK, Parrish RK, 2nd: Trabeculectomy in young patients . Ophthalmology 1984, 91 (10):1242-1246. Inaba Z: Long-term results of trabeculectomy in the Japanese: an analysis by life-table method . Jpn J Ophthalmol 1982, 26 (4):361-373. Yan X, Zhang H, Li F, Ma L, Geng Y, Tang G: Surgical site characteristics after CLASS followed by ultrasound biomicroscopy and clinical grading scale: a 2-year follow-up . Eye (Lond) 2020. Feusier M, Roy S, Mermoud A: Deep sclerectomy combined with trabeculectomy in pediatric glaucoma . Ophthalmology 2009, 116 (1):30-38. Elder MJ: Combined trabeculotomy-trabeculectomy compared with primary trabeculectomy for congenital glaucoma . Br J Ophthalmol 1994, 78 (10):745-748. Biedner BZ, Rothkoff L: Combined trabeculotomy-trabeculectomy compared with primary trabeculotomy for congenital glaucoma . J Pediatr Ophthalmol Strabismus 1998, 35 (1):49-50. Lawrence SD, Netland PA: Trabeculectomy versus combined trabeculotomy-trabeculectomy in pediatric glaucoma . J Pediatr Ophthalmol Strabismus 2012, 49 (6):359-365. Bayoumi NH: Deep sclerectomy in pediatric glaucoma filtering surgery . Eye (Lond) 2012, 26 (12):1548-1553. Jalil A, Au L, Khan I, Ashworth J, Lloyd IC, Biswas S: Combined trabeculotomy-trabeculectomy augmented with 5-fluorouracil in paediatric glaucoma . Clin Exp Ophthalmol 2011, 39 (3):207-214. Wagdy FM: Ab externo 240-degree trabeculotomy versus trabeculotomy-trabeculectomy in primary congenital glaucoma . Int Ophthalmol 2020, 40 (10):2699-2706. Cutolo CA, Bagnis A, Scotto R, Bonzano C, Traverso CE: Prospective evaluation of CO2 laser-assisted sclerectomy surgery (CLASS) with Mitomycin C . Graefes Arch Clin Exp Ophthalmol 2018, 256 (1):181-186. Greifner G, Roy S, Mermoud A: Results of CO2 Laser-assisted Deep Sclerectomy as Compared With Conventional Deep Sclerectomy . J Glaucoma 2016, 25 (7):e630-638. Kalogeropoulos D, Sung VC: Pathogenesis of Uveitic Glaucoma . J Curr Glaucoma Pract 2018, 12 (3):125-138. Stavrou P, Murray PI: Long-term follow-up of trabeculectomy without antimetabolites in patients with uveitis . Am J Ophthalmol 1999, 128 (4):434-439. Sung VC, Barton K: Management of inflammatory glaucomas . Curr Opin Ophthalmol 2004, 15 (2):136-140. Razeghinejad MR, Katz LJ: Steroid-induced iatrogenic glaucoma . Ophthalmic Res 2012, 47 (2):66-80. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2046869","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":136013968,"identity":"2ae82d7f-1bef-48df-a31d-076c38661922","order_by":0,"name":"Anyi Liang","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anyi","middleName":"","lastName":"Liang","suffix":""},{"id":136013971,"identity":"75f74e71-94e6-4904-a83e-ab993f1f26b6","order_by":1,"name":"Hang Song","email":"","orcid":"","institution":"Peking Union Medical College Hospital (Dongdan campus)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hang","middleName":"","lastName":"Song","suffix":""},{"id":136013973,"identity":"c3ab99fe-dc10-4dab-b509-8eeb1cbe4319","order_by":2,"name":"Gangwei Cheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBAC/hkgsuawHIhiJkqLxA0QeeywMfFaDCKABGPD4cQG4rVINx97+LXhcPp2iezEzwUMdnmEtcgcSzeWbbidu3NG7mbpGQzJxYS1SOSYSUv23c7dcCN3GzMPwwGwCwloyf8mLdl2O92AeC0ROWySH9v+JxCvReJGmpk0w7Hnhjt73m6W5jFIJqyFf0byM8kfNYflzdlzN37mqbAjrAUEgO4BuhDiTmLUAwHjDxIUj4JRMApGwQgEALpeQDUbL/PnAAAAAElFTkSuQmCC","orcid":"","institution":"Peking Union Medical College Hospital (Dongdan campus)","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Gangwei","middleName":"","lastName":"Cheng","suffix":""},{"id":136013976,"identity":"8e87cf9a-b466-4d30-a931-700340a8af9e","order_by":3,"name":"Yang Zhang","email":"","orcid":"","institution":"Peking Union Medical College Hospital (Dongdan campus)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Zhang","suffix":""},{"id":136013979,"identity":"94e840b5-c5bc-4f10-800b-88247dba44c8","order_by":4,"name":"Ailing Bian","email":"","orcid":"","institution":"Peking Union Medical College Hospital (Dongdan campus)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ailing","middleName":"","lastName":"Bian","suffix":""},{"id":136013982,"identity":"7e38ee98-71bf-42ff-b767-3d981e7719c9","order_by":5,"name":"Meifen Zhang","email":"","orcid":"","institution":"Peking Union Medical College Hospital (Dongdan campus)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Meifen","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2022-09-08 23:29:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2046869/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2046869/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":27027310,"identity":"3a058caa-dca8-430b-91e5-88ed86945392","added_by":"auto","created_at":"2022-09-27 14:05:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":649372,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the eye of one patient before, during and after surgery\u003c/p\u003e\n\u003cp\u003e(A) Before surgery, (B) During surgery, (C) After surgery, (D) Ultrasound biomicroscope (UBM) of the eye 5 months after surgery, (E) UBM of another patient 19 months after surgery\u003c/p\u003e","description":"","filename":"Figure1TIFF.png","url":"https://assets-eu.researchsquare.com/files/rs-2046869/v1/ac3f6e81c682da4a4f93e170.png"},{"id":27027311,"identity":"2855a225-0b90-4db6-8e9c-f5fe1ce406d3","added_by":"auto","created_at":"2022-09-27 14:05:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":299130,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves of complete and qualified success rate after surgery\u003c/p\u003e","description":"","filename":"Figure2JPEG.png","url":"https://assets-eu.researchsquare.com/files/rs-2046869/v1/0e7be4dab08b57f6481db048.png"},{"id":27027312,"identity":"e255cdb3-4d89-43b6-aa19-1905ee225810","added_by":"auto","created_at":"2022-09-27 14:05:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":383242,"visible":true,"origin":"","legend":"\u003cp\u003eVisual acuity at baseline and different post-operative time points\u003c/p\u003e","description":"","filename":"Figure3JPEG.png","url":"https://assets-eu.researchsquare.com/files/rs-2046869/v1/2455d8e0eb0115861a363c34.png"},{"id":30982572,"identity":"2a59edda-3336-4ae4-a1b0-05f2a311dad1","added_by":"auto","created_at":"2023-01-02 12:44:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2113674,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2046869/v1/6eef2202-5d75-4ff1-bcc8-53341738a4d2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The safety and efficacy of CO 2 laser-assisted sclerectomy surgery-based multi- pathway glaucoma surgery in intractable pediatric glaucoma","fulltext":[{"header":"Background","content":"\u003cp\u003eThe management of pediatric glaucoma is much more challenging and complicated than adults attributing to a wide range of factors, especially the aggressive scar formation[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Intractable cases where the initial surgery fails or is highly likely to fail complicate the condition further and bring greater challenges to make the most appropriate decision in choosing surgical plans.\u003c/p\u003e \u003cp\u003eCurrently no general consensus has been achieved as to the best surgical treatment option for refractory pediatric glaucoma[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The robust scarring in children is responsible for majority of failures after surgery despiste the use of antimetabolites. Noticably, the self-repair process of deep tissues is weaker and slower than the superficial ones, so theoretically, pathways created in deeper layers of the sclera by nonpenetrating deep sclerectomy (NPDS)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] might be less prone to scar formation and more suitable for children. However, the physiological aqueous humor (AH) outflow pathways in many pediatric glaucoma patients are structurally or functionally abnormal, so a single NPDS was not qualified. Therefore, it is reasonable to add other surgeries, such as trabeculotomy or trabeculectomy, to create multiple pathways as well as to enhance the \u0026ldquo;sub-flap\u0026rdquo; pathway for AH drainage. Traditional manual NPDS requires high surgical skills and experience, while CO\u003csub\u003e2\u003c/sub\u003e laser-assisted sclerectomy surgery (CLASS) is more accurate and safer by minimizing damages and scars in scleral ablation[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], which makes it more suitable for pediatric patients whose ocular surface structures are thin, fragile and easily scarring.\u003c/p\u003e \u003cp\u003eConsidering the above-mentioned benefits of CLASS and the necessity of multiple pathways, we assumed that a CLASS-based multi-pathway glaucoma surgery might be a good choice for intractable pediatric glaucoma. The current study aimed to evaluate the safety profiles and efficacy of this surgical technique in intractable pediatric glaucoma population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a retrospective study of 23 consecutive patients who underwent multi-pathway glaucoma surgeries from March 2018 to April 2021 at Peking Union Medical College Hospital (PUMCH) with at least 6-month follow-up. The protocol was approved by the Institutional Review Board of PUMCH (S-K1540) and conformed to the tenets of the Declaration of Helsinki. Informed consent was obtained from all subjects and/or their legal guardians for using their clinical data. All patients were younger than 18 years old at the time of surgery and conformed to the definition of intractable glaucoma. In the context of the current study, intractable pediatric glaucoma was defined as glaucoma in children patients who did not respond to a primary surgery, or patients associated with complex conditions including extensive fibrosis in superior conjunctiva, anterior staphyloma, uveitis, post-cataract surgery, post-traumatic glaucoma, other anterior segment abnormalities or systemic syndromes, such as Peters anomaly and retinopathy of premature (ROP)[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Enrolled patients were classified as primary and secondary pediatric glaucoma according to the new classification system for pediatric glaucoma[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Three patients underwent bilateral surgeries but not simultaneously and each individual eye was regarded as a separate entity of data for the purpose of analysis.\u003c/p\u003e \u003cp\u003eSurgical techniques: The multi-pathway surgeries in this study include 2 types, namely CLASS combined with trabeculectomy (CLASS-TRAB) and CLASS with combined trabeculectomy and trabeculotomy (CTT) (CLASS-CTT). All the operations were performed by a single experienced glaucoma specialist (GWC) under general anesthesia. The CLASS procedure was standardized for every patient: A fornix-based conjunctival incision was made and the residual subconjunctival tissue and Tenon capsule were removed to expose the sclera. The site of surgery was selected within 150\u0026deg; of the superior quadrants where the conjunctiva and sclera were relatively healthy, while avoiding previous surgical sites. A 5\u0026times;5.5-5\u0026times;6 mm\u003csup\u003e2\u003c/sup\u003e partial thickness (1/3\u0026thinsp;\u0026minus;\u0026thinsp;1/2) scleral flap was created at the limbus 1 mm into the transparent cornea. Sponges soaked in 5-fluorouracil (FU) or 0.04% mitomycin C (MMC) were then applied above and the under the scleral flap (4-4.5 minutes for MMC and double the time for 5-FU), and under the conjunctiva (1-1.5 minutes for MMC and double the time for 5-FU), followed by washing out with balanced salt solution (BSS). A red He-Ne laser aiming beam was applied to mark the desired area of sclerectomy, with the anterior margin at 2 mm posterior to the limbus and posterior margin at 4.5mm posterior to the limbus, after which the CO\u003csub\u003e2\u003c/sub\u003e laser beam (22 Watts) was then applied repeatedly (with time intervals of 2 to 3 seconds) to form an intrascleral lake (with size of 4\u0026times;2.4-4\u0026times;2.6 mm\u003csup\u003e2\u003c/sup\u003e and depth of 90% of the scleral thickness). Antimetabolite was applied to the scleral floor without touching the surrounding tissues (2-2.5 minutes for MMC and double the time for 5-FU) followed by BSS washout. The remaining surgical procedures of trabeculectomy, and CTT were performed following routine standards. The scleral flap was repositioned and tightly sutured with 10\u0026thinsp;\u0026minus;\u0026thinsp;0 nylons, routinely with 3 fixed and 4 releasable sutures to ensure watertight. The conjunctiva was secured with buried 10\u0026thinsp;\u0026minus;\u0026thinsp;0 nylons. The eye was patched with tobramycin and dexamethasone eye ointment, and atropine was added in CLASS-TRAB surgery. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrated the eye before, during and after surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(A) Before surgery, (B) During surgery, (C) After surgery, (D) Ultrasound biomicroscope (UBM) of the eye 5 months after surgery, (E) UBM of another patient 19 months after surgery\u003c/p\u003e \u003cp\u003eIntraocular pressure (IOP) measurement: IOP was measured with Perkins applanation tonometer (PAT). Topical anesthetic (Oxybuprocaine Hydrochloride Eye Drops) was instilled in the cul-de-sac. A fluorescein strip was applied to the lateral 1/3 of the lower palpebral conjunctiva, and IOP was measured with a PAT.\u003c/p\u003e \u003cp\u003ePost-operative managements: From the next day of surgery on, 1% prednisolone acetate drop was applied hourly for at least 1 week and then gradually tapered, together with topical antibiotics 4 times daily for 1 week and tapered. For all the cases, sutures were released step by step and 5-FU was injected subconjunctival or under the filtering bleb at an early stage, generally within 7\u0026ndash;14 days after surgery. For uveitis patients or patients who were expected to have intense inflammatory reactions after surgery, oral steroids were given at a dose of 1mg/kg prednisolone once a day after ruling out contraindications of steroids and gradually tapered. In prevention of posterior synechia of the pupil in uveitis, pupil dilation eyedrops were administered. Routine follow-up visits were at 1 day, 1 week, 1, 3, 6, 12 and 24 months postoperatively.\u003c/p\u003e \u003cp\u003eOutcome measurement: primary outcome: (1) changes of IOP from baseline (before surgery) to different time points after surgery; (2) complete success: IOP values between 5 and 21 mmHg and a reduction of \u0026ge;\u0026thinsp;20% without hypotensive medications or repeated filtration surgery; (3) qualified success: IOP values between 5 and 21 mmHg and a reduction of \u0026ge;\u0026thinsp;20% with hypotensive medications. IOP was measured with PAT. Secondary outcomes: best-corrected visual acuity (BCVA) in logMAR unit (logMAR BCVA), number of IOP-lowering eye drops, number of patients needing repeated filtration surgeries and morphology of filtering blebs. Adverse outcomes: hypotony (IOP\u0026thinsp;\u0026lt;\u0026thinsp;5 mmHg for 1 month or longer), serious shallow anterior chamber (AC) needing surgical interventions, bleb leakage, bleb infection, choroidal detachment, hyphema, cataract, etc.\u003c/p\u003e \u003cp\u003eStatistical analysis: Statistical analysis was performed using GraphPad Prism, Versiom 8.4.3 (471). A mixed model was used for the parametric data (IOP) over different timepoints, and the Wilcoxon paired signed-rank test was used for nonparametric data (BCVA, medications). Student\u0026rsquo;s test was used to compare parameters between 2 subgroups. Kaplan-Meier life-table curves were used to present the duration of complete and qualified success. The comparison of complete success rate (CSR) and qualified success rate (QSR) was carried out with Log Rank Test. A \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all statistical analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline: Demographic data and baseline information were summarized in Table 1. Overall, 23 pediatric patients (26 eyes) with an average age of 8.72\u0026plusmn;5.46 years (1, 18) were enrolled. The diagnoses fell into 6 categories, with primary congenital glaucoma (PCG) and steroid-induced glaucoma ranked top two. There were 14/26 (53.85%) primary glaucoma and 12/26 (46.15%) secondary glaucoma. The mean follow-up time was 25.49\u0026plusmn;10.87 months (8.10, 47.63).\u0026nbsp;In 15/26 (57.69%) eyes the multi-pathway surgery was the initial anti-glaucoma surgery and in 11/26 (42.31%) eyes where previous surgeries failed, the multi-pathway surgery was the rescue surgery.\u003c/p\u003e\n\u003cp\u003eTable 1. Baseline demographic characteristics of patients\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"67.21854304635761%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (of eyes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"18.84297520661157%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.429752066115704%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.677685950413224%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\"\u003e\n \u003cp\u003e52.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e47.83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" width=\"18.84297520661157%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDianosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.429752066115704%\"\u003e\n \u003cp\u003ePCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.677685950413224%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\"\u003e\n \u003cp\u003e34.62%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eJuvenile glaucoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e3.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eGlaucoma after cataract surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e3.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eGlaucoma with nonacquired ocular anomalies\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Peters anomaly\u0026nbsp;\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Axenfeld-Rieger syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e3\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e11.54%\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;7.69%\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eGlaucoma with systemic syndromes\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Weill-Marchesani syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e1\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e3.85%\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eGlaucoma with acquired conditions\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Steroid-induced\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Uveitis\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e11\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;4\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e42.32%\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;19.23%\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;15.38%\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;7.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" width=\"18.84297520661157%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up\u003cbr\u003e\u0026nbsp;(months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.429752066115704%\"\u003e\n \u003cp\u003e6-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.677685950413224%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\"\u003e\n \u003cp\u003e11.54%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003e12-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e34.62%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003e24-36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e38.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003e36-48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e15.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"18.84297520661157%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.429752066115704%\"\u003e\n \u003cp\u003eCLASS-TRAB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.677685950413224%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\"\u003e\n \u003cp\u003e53.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eCLASS-CTT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e46.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" width=\"18.84297520661157%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of previous surgeries\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.429752066115704%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.677685950413224%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\"\u003e\n \u003cp\u003e57.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e11.54%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e19.23%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003e3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e7.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e3.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"18.84297520661157%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnitmetabolites\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.429752066115704%\"\u003e\n \u003cp\u003e5-FU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.677685950413224%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\"\u003e\n \u003cp\u003e46.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.67413441955193%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.014256619144604%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.311608961303463%\"\u003e\n \u003cp\u003e53.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"67.21854304635761%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin, Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"67.21854304635761%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\"\u003e\n \u003cp\u003e32.00\u0026plusmn;4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\"\u003e\n \u003cp\u003e20.0, 40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"67.21854304635761%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. drugs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\"\u003e\n \u003cp\u003e3.21\u0026plusmn;0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\"\u003e\n \u003cp\u003e2.0, 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" width=\"67.21854304635761%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial logMAR BCVA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\"\u003e\n \u003cp\u003e1.31\u0026plusmn;0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.072847682119205%\"\u003e\n \u003cp\u003e0.0, 2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePCG: primary congenital glaucoma, CLASS: CO\u003csub\u003e2\u003c/sub\u003e laser-assisted sclerectomy surgery,\u0026nbsp;TRAB: trabeculectomy, LOT: trabeculotomy, CTT: combined trabeculectomy and trabeculotomy, 5-FU: 5-fluorouracil, MMC: mitomycin, IOP: Intraocular pressure, BCVA: best corrected visual acuity\u003c/p\u003e\n\u003cp\u003eIOP: The mean IOPs and reduction from baseline were summarized in Table 2. A significant IOP decrease from baseline was achieved at every time point after surgery (all \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) and the highest IOP reduction was achieved at post-operative day 1. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. IOP and reduction from baseline at different time points after surgery\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"13.665594855305466%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"4.501607717041801%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" width=\"26.688102893890676%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" width=\"31.993569131832796%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReduction from baseline (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" width=\"12.379421221864952%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of reduction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"10.771704180064308%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.841530054644808%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.655737704918034%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.655737704918034%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.202185792349727%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.846994535519126%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.568306010928962%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.568306010928962%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.66120218579235%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e32.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 1D\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e7.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-24.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e76.45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 1W\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e8.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-23.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e5.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-34.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e74.60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 1M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e10.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-21.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e5.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e65.96%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 3M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e11.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e3.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e18.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-21.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-34.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e65.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 6M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e12.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e5.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-19.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e5.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-33.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-8.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e62.13%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 12M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e11.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e17.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-20.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e5.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-33.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e65.22%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 12-24M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e13.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e5.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-19.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e6.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-31.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e60.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 24-36M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e12.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e3.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-19.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e6.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-35.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e60.62%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.621794871794872%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 36-48M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.487179487179487%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.532051282051282%\"\u003e\n \u003cp\u003e12.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e6.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.25%\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\"\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.294871794871796%\"\u003e\n \u003cp\u003e-21.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e13.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.371794871794871%\"\u003e\n \u003cp\u003e-33.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.012820512820513%\"\u003e\n \u003cp\u003e-6.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.85897435897436%\"\u003e\n \u003cp\u003e67.65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"11.378205128205128%\"\u003e\n \u003cp\u003e0.0496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIOP: Intraocular pressure, PO: post-operative\u003c/p\u003e\n\u003cp\u003eIOP-lowering eyedrops: Table 3 showed the average number of IOP-lowering eyedrops before and at every post-operative time point. Overall, no IOP-lowering drug was needed within the first month. The reduction in number of medications was statistically significant at every time point after surgery (all \u003cem\u003ep\u003c/em\u003e\u0026lt;0.01) except for beyond 3 years (n=4, \u003cem\u003ep\u003c/em\u003e=0.1250).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. The number of IOP-lowering eyedrops and reduction from baseline at different time points after surgery\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" width=\"36.30252100840336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN of \u0026nbsp;IOP lowering drugs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" width=\"36.134453781512605%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReduction from baseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.496519721577727%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.529002320185615%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.74477958236659%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.976798143851509%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.368909512761022%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.960556844547564%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.529002320185615%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.74477958236659%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.976798143851509%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.672853828306264%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 1D\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 1W\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 1M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 3M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 6M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 12M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-2.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 12-24M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 24-36M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e0.0020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePO 36-48M\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.705882352941177%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.042016806722689%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.07563025210084%\"\u003e\n \u003cp\u003e-3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.0588235294117645%\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.226890756302521%\"\u003e\n \u003cp\u003e-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.73109243697479%\"\u003e\n \u003cp\u003e-3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.277310924369749%\"\u003e\n \u003cp\u003e0.1250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIOP: Intraocular pressure, PO: post-operative\u003c/p\u003e\n\u003cp\u003eSuccess rate: The CSR and QSR for every time point after surgery were summarized in Table 4, and the Kaplan-Meier curves were shown in Figure 2. Totally 5 eyes (19.23%) from 4 patients failed the surgery. Three of them were PCG patients\u0026nbsp;and 1 was secondary glaucoma. Eye NO.5 was from an infant who received glaucoma drainage device (GDD) implant 6 months after the failure because of uncontrollable IOP. Eye NO.10 and 11 from a teenage uveitic glaucoma patient failed because of extensive scarring, but the IOP was well controlled after receiving rescue ab-interno repairing of the filtration pathway. Eye NO.12 was from a child who received primary LOT and then entropion surgery before failure. The influence of ocular surface condition and effects of medication might contribute to the failure. Eye NO.24 was from a PCG patient who previously had trabeculectomy, 360\u0026deg; trabeculotomy and 3 cyclophotocoagulation surgeries.\u003c/p\u003e\n\u003cp\u003eTable 4. Success rates at different time points after surgery\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"29.929577464788732%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"16.549295774647888%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCSR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e\u003cstrong\u003eQSR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"29.929577464788732%\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"16.549295774647888%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e93.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e96.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"29.929577464788732%\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"16.549295774647888%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e82.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e91.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"29.929577464788732%\"\u003e\n \u003cp\u003e2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"16.549295774647888%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e68.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e81.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"29.929577464788732%\"\u003e\n \u003cp\u003e3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"16.549295774647888%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e56.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.760563380281692%\"\u003e\n \u003cp\u003e67.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCSR: complete success rate, QSR: qualified success rate\u003c/p\u003e\n\u003cp\u003eVisual acuity: VA and changes from baseline to different post-operative time points were shown in Figure 3. VA decreased in the early post-operative stage, started to recover from post-operative 1 week on and approached baseline level.\u003c/p\u003e\n\u003cp\u003eComplications: The occurence of post-operative complications were summarized in Table 5. The commonest early and late-onset complication is choroidal detachment (3/26, 11.54%) and secondary cataract (6/26, 23.08%) respectively. Only 2 (7.69%) cases of\u0026nbsp;peripheral anterior synechia (PAS)\u0026nbsp;and 2 (7.69%) cases of posterior pupillary synechia occurred in the late post-operative stage. Majority of the early complications observed in our study resolved spontaneously or after strengthened anti-inflammatory treatment within 2\u0026nbsp;to\u0026nbsp;4 weeks. There was no bleb leakage, iris incarceration, AH misdirection or endophthalmitis. Totally, 9/26 (34.62%) eyes underwent therapeutic or prophylactic injection of 5-FU under the filtering blebs to alleviate scar formation and fibrosis. Injection of 5-FU was given averagely at postoperative 6 to 8 months, with the earliest at 1 month and the latest at over 2 years after surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5. Early and late-onset post-operative complications\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"70.08733624454149%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.11353711790393%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.799126637554586%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"22.707423580786028%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"47.379912663755455%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.11353711790393%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.799126637554586%\"\u003e\n \u003cp\u003e15.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"61.29943502824859%\"\u003e\n \u003cp\u003eChoroidal detachment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.909604519774011%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.7909604519774%\"\u003e\n \u003cp\u003e11.54%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"61.29943502824859%\"\u003e\n \u003cp\u003eHyphema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.909604519774011%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.7909604519774%\"\u003e\n \u003cp\u003e3.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" width=\"22.707423580786028%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLate-onset\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"47.379912663755455%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.11353711790393%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.799126637554586%\"\u003e\n \u003cp\u003e38.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"61.29943502824859%\"\u003e\n \u003cp\u003eCataract\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.909604519774011%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.7909604519774%\"\u003e\n \u003cp\u003e23.08%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"61.29943502824859%\"\u003e\n \u003cp\u003ePAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.909604519774011%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.7909604519774%\"\u003e\n \u003cp\u003e7.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"61.29943502824859%\"\u003e\n \u003cp\u003ePosterior synechia of pupil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.909604519774011%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"30.7909604519774%\"\u003e\n \u003cp\u003e7.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;PAS: peripheral anterior synechia\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eTo the best of our knowledge, this was the first time that CLASS had been used in pediatric patients, and extra attentions were paid to the anatomical differences between children and adults and the safety issues. Characteristic enlargement and subsequent thinning of the eyeball posed great challenges and difficulties in dissecting a large and regular scleral flap. The thin sclera also makes it unlikely to create an intrascleral lake as deep as that of adults, so increasing the area of the intrascleral lake aside from the depth can compensate the volume of the scleral lake, thus ensure the efficacy of filtration without increasing the risk of rupture or leakage of the flap. Therefore, the sizes of scleral flaps in this study were larger than those of traditional trabeculectomy. Furthermore, the thinner the flap is, the easier for the flap to curl and distort. That is why we repositioned the flaps with as many as 3 fixed and 4 releasable sutures to ensure the flap flat, regular and watertight. Regular and tightly sealed flap can maintain normal morphology of the scleral lake, avoid inflammatory mediators, tissue debris and blood cells from infiltrating to the scleral lake and reduce the extent of scarring. Expansion of the eyeball makes the limbus wider and difficult to recognize, and the posterior edge of the scleral flap should be more posterior from the cornea than usual. During surgery, we depended on the texture of limbus and the visualization of ciliary band to locate the limbus accurately.\u003c/p\u003e \u003cp\u003eThe enhanced uveoscleral outflow of AH by NPDS was efficient in lowering IOP, but the technical difficulty has restricted its wide application. CO\u003csub\u003e2\u003c/sub\u003e laser was firstly applied in dermatology area, especially in treating skin scars. It improves the appearance of burn and acne scars and normalizes collagen architecture, making them finer and less sclerotic[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It also helps to ablate dilated and high flow blood vessels, resulting in less bleeding, minor tissue damages and less inflammation[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, we believe that scleral lakes created with CO\u003csub\u003e2\u003c/sub\u003e laser would be less prone to scarring and healing, which is more suitable for children. To the best of our knowledge, there has been no reports about the application of CLASS in pediatric glaucoma so far. In our current study, CLASS was performed in all the multi-pathway surgeries as a basic procedure, because we believe it is not only a modification of traditional NPDS but also bears several unique advantages for pediatric patients. Firstly, CLASS causes fewer damages to the scleral tissue, minimizing scar formation. Secondly, the accuracy of CO\u003csub\u003e2\u003c/sub\u003e laser makes it easier and safer to create a scleral lake in highly stretched and thin sclera in young children. Studies showed that the success rate of traditional filtering surgery such as trabeculectomy was lower in children because of exuberant healing process[\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], indicating that superficial scar formation is the main cause of surgical failure in children. In our study, 5/26 (19.23%) patients had flat blebs after surgery while intrascleral reservoirs were patent and IOP remained under control, indicating that internal deep drainage pathways play greater roles in IOP control in the late phase after surgery[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMulti-pathway surgery reduces IOP by increasing the routes of AH outflow, which is different from combined surgeries where cyclodestructive procedures might be used to reduce AH production. Our study adopted CLASS-based multi-pathway surgeries, a new concept of anti-glaucoma surgery where 2 or more drainage pathways were created. Satisfactory results were achieved, with 1-year CSR of 82.2% and QSR of 91.7%, which is better than traditional combined procedures. Jalil A et al[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported a 65.6% CSR and 79.3% QSR of CTT in congenital glaucoma refractory to goniotomy, but less effective as a primary procedure. Elder MJ[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] discovered that the 24-month cumulative success rate of CTT (93.5%) was higher than that of primary trabeculectomy (72%). Biedner BZ et al[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported a success rate of 86% in CTT and 57% in trabeculotomy respectively, but more adverse events in CTT group. Lawrence SD et al[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] found an equal IOP lowering effect between CTT and trabeculectomy, but greater long-term success in CTT. Furthermore, the addition of deep sclerectomy (CTT-DS) shortens surgery time by facilitating the finding of Schlemm's canal without additional complications[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. DS combined with trabeculectomy was also reported to be satisfactory and promising with 9-year CSR and QSR of 52.3% and 70.6% respectively[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Another important reason why the multi-pathway surgery instead of single CLASS was adopted is that in traditional single CLASS, pre-operative laser peripheral iridectomy (LPI) is required, but in infants or young children who are mostly uncooperative in examination without general anesthesia, it\u0026rsquo;s hardly possible to perform the laser before surgery.\u003c/p\u003e \u003cp\u003eThe multi-pathway surgery had a transient influence on the visual acuity. The BCVA started to decrease at the early post-operative stage, which was mainly attributed to alteration of refraction, dramatic decrease of IOP, corneal edema and inflammatory reaction in the AC. From post-operative 1 month on, the BCVA increased and surpassed the pre-operative level, which indicated that early complications did not cause irreversible damages to the vision. At the first year after surgery, the BCVA decreased mildly comparing to the baseline level (not statistically significant), mainly due to secondary cataract. But this reduction of vision was reversible after cataract surgery.\u003c/p\u003e \u003cp\u003eBlebs in the post-operative eyes are important indicators reflecting the filtration effects of drainage pathways and results of surgery. For most of our cases, in the early post-operative stage, blebs bulged and functioned well. It is interesting to discover that in the late post-operative stage, most of the blebs became less bulged or even flat but the IOP maintained in the normal range. We speculate that for CLASS-based surgery, especially in the late stage, the main factor of IOP control is the deep scleral pathway and \u0026ldquo;sub-flap\u0026rdquo; drainage, which is independent from bleb and outer filtration.\u003c/p\u003e \u003cp\u003eSafety issues were the first priority in evaluating CLASS-based multi-pathway surgery in children. The early complications of multi-pathway surgery observed in this study were few and transient. None of eyes developed substantial shallow AC that needed surgical intervention. Three eyes (11.11%) whose IOP dropped from beyond 30 mmHg to below 8 mmHg 1 day after surgery developed regional choroidal detachment, but spontaneously recovered 1 week later when the IOP increased without any additional treatments. The low occurrence rate of severe shallow AC and choroidal detachment might be attributed to the tight suture of scleral flaps during surgery, or might be associated with the anatomical and physiological characteristics of children, such as lower permeability of the ciliary-choroidal blood vessels and higher compliance of the wall of eyeball. One patient with uveitis and 1 with Peter\u0026rsquo;s anomaly developed posterior synechia of the pupil, which indicated that uveitis and abnormal development of the anterior segment might be risk factors of post-operative pupillary synechia. The occurrence of hyphema (1/26, 3.85%) was substantially lower than that of other surgeries (6.66\u0026ndash;45.4%)[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In traditional combined surgeries sight-threatening complications such as bleb leakage, blebitis, endophthalmitis and phthisis bulbi were more common[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], while no such severe complications were observed in our multi-pathway surgeries. Most of the late-onset complications were reversible with managements such as cataract surgery or massage of the blebs, and did not influence the long-term vision outcome. Only 2/26 (7.69%) eye developed extensive PAS, which received goniosynechialysis, while other minor PAS did not influcence the efficacy of surgery thus need not management. Five eyes (19.23%) developing extensive scarring of the drainage pathways needed repairing and reopening of the pathway because the IOP was above 21 mmHg after 5-FU injections and addition of IOP-lowering eyedrops. Notably, according to our observation, the need for blebs massage was less after CLASS-based multi-pathway surgery than traditional trabeculectomy, which is more acceptable for pediatric patients and their care-givers, increasing the compliance.\u003c/p\u003e \u003cp\u003ePost-operative PAS or iris incarceration were major adverse events of traditional CLASS[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and long-term use of pilocarpine was suggested. However, in cases of uveitic glaucoma, pilocarpine was relatively contraindicated because it would cause posterior adhesion of the iris and pupillary block. On the other hand, in multi-pathway surgery where peripheral iridectomy was performed, there was no risk of iris incarceration and no pilocarpine was needed. In our study, pilocarpine was not given and none of the patient developed iris incarceration. For uveitic glaucoma, post-operative anti-inflammatory treatment was critical because the deposition of inflammatory substances in the filtration pathways would accelerate the process of scarring. Thus, frequent and long-term use of steroids was necessary to control inflammation[\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Contradictorily, steroid was known to potentially damage the physiological AH outflow pathway[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], which would impair the efficacy of surgery like canaloplasty. However, in multi-pathway surgery, the core mechanism of IOP reduction was through the deep uveoscleral pathway, which was not influenced by steroids, so there was no limitation of steroid use.\u003c/p\u003e \u003cp\u003eWe believe this study was pioneer in evaluating the safety and efficacy of CLASS-based multi-pathway surgeries in the management of intractable pediatric glaucoma. However, several limitations still existed. Firstly, accurate measurement of IOP in pediatric population is difficult, which impairs the quality of data. And this is a common and inevitable problem in all pediatric glaucoma studies. We have tried our best to minimize the errors by repeating the measurements with different methods. Secondly, intractable pediatric glaucoma is a spectrum consisting of various classifications, but this research didn\u0026rsquo;t study the difference between subtypes. We will further classify the patients according to diagnosis or etiology and make more detailed comparisons. Thirdly, restricted by the difficulty of randomization and relatively small sample size, there was a lack of control group treated by procedures without CLASS. We schedule to enroll more patients and control group in our future studies and prolong the follow-up time to evaluate the long-term efficacy.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our study for the first time showed that CLASS-based multi-pathway surgery was safe and effective for the treatment of intractable pediatric glaucoma. It is promising to become an alternative and safer surgical management for intractable pediatric glaucoma. Prospective studies with larger sample sizes and longer observation time are needed to assess the value of CLASS-based multi-pathway surgery as a new approach for intractable glaucoma in children.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNPDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003enonpenetrating deep sclerectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eaqueous humor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCLASS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e laser-assisted sclerectomy surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePUMCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeking Union Medical College Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCLASS-TRAB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCLASS combined with trabeculectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCLASS-LOT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCLASS combined with trabeculotomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecombined trabeculectomy and trabeculotomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCLASS-CTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCLASS with combined trabeculectomy and trabeculotomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e5-FU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e5-fluorouracil\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emitomycin C\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebalanced salt solution\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraocular pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerkins applanation tonometer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebest-corrected visual acuity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomplete success rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQSR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003equalified success rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprimary congenital glaucoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eglaucoma drainage device\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eperipheral anterior synechia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edeep sclerectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLPI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elaser peripheral iridectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe protocol was approved by the Institutional Review Board of PUMCH (S-K1540) and conformed to the tenets of the Declaration of Helsinki. Informed consents were obtained from all subjects and/or their legal guardians for using their clinical data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data in the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e GWC was responsible for the conceptualization, patient enrollment, patient follow-up, review and editing of this paper. AYL and HS equally contributed to the material preparation, data collection \u0026amp; analysis and writing of the original draft. MFZ participated in patient enrollment and follow-up. YZ and ALB were responsible for ophthalmological investigations such as UBM scans and IOP measurement. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThanks for the contributions from the Peking Union Medical College Hospital pediatric glaucoma study group, including the efforts in patients caring, surgery and data collection. Members of the Peking Union Medical College Hospital pediatric glaucoma study group include Minghang Pei, MD, Junyan Xiao, MD, Di Cao, MD, Yuyu Chou, MD, Xuejiao Wang, MD, Yuelin Wang, MD and Fei Mo, MD. All the authors would like to thank all the children and their parents for participating in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTan YL, Chua J, Ho CL: \u003cstrong\u003eUpdates on the Surgical Management of Pediatric Glaucoma\u003c/strong\u003e. \u003cem\u003eAsia Pac J Ophthalmol (Phila) \u003c/em\u003e2016, \u003cstrong\u003e5\u003c/strong\u003e(1):85-92.\u003c/li\u003e\n\u003cli\u003eHelmy H: \u003cstrong\u003eCombined trabeculotomy-trabeculectomy versus Ahmed valve implantation for refractory primary congenital glaucoma in Egyptian patients: a long-term follow-up\u003c/strong\u003e. \u003cem\u003eElectron Physician \u003c/em\u003e2016, \u003cstrong\u003e8\u003c/strong\u003e(2):1884-1891.\u003c/li\u003e\n\u003cli\u003eMalik R, AlDarrab A, Edward DP: \u003cstrong\u003eContemporary management of refractory pediatric glaucoma\u003c/strong\u003e. \u003cem\u003eCurr Opin Ophthalmol \u003c/em\u003e2020, \u003cstrong\u003e31\u003c/strong\u003e(2):123-131.\u003c/li\u003e\n\u003cli\u003eTamcelik N, Ozkiris A, Sarici AM: \u003cstrong\u003eLong-term results of combined viscotrabeculotomy-trabeculectomy in refractory developmental glaucoma\u003c/strong\u003e. \u003cem\u003eEye (Lond) \u003c/em\u003e2010, \u003cstrong\u003e24\u003c/strong\u003e(4):613-618.\u003c/li\u003e\n\u003cli\u003eHondur A, Onol M, Hasanreisoglu B: \u003cstrong\u003eNonpenetrating glaucoma surgery: meta-analysis of recent results\u003c/strong\u003e. \u003cem\u003eJ Glaucoma \u003c/em\u003e2008, \u003cstrong\u003e17\u003c/strong\u003e(2):139-146.\u003c/li\u003e\n\u003cli\u003eMendrinos E, Mermoud A, Shaarawy T: \u003cstrong\u003eNonpenetrating glaucoma surgery\u003c/strong\u003e. \u003cem\u003eSurv Ophthalmol \u003c/em\u003e2008, \u003cstrong\u003e53\u003c/strong\u003e(6):592-630.\u003c/li\u003e\n\u003cli\u003eGeffen N, Ton Y, Degani J, Assia EI: \u003cstrong\u003eCO2 laser-assisted sclerectomy surgery, part II: multicenter clinical preliminary study\u003c/strong\u003e. \u003cem\u003eJ Glaucoma \u003c/em\u003e2012, \u003cstrong\u003e21\u003c/strong\u003e(3):193-198.\u003c/li\u003e\n\u003cli\u003eJankowska-Szmul J, Dobrowolski D, Wylegala E: \u003cstrong\u003eCO2 laser-assisted sclerectomy surgery compared with trabeculectomy in primary open-angle glaucoma and exfoliative glaucoma. 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\u003c/em\u003e1999, \u003cstrong\u003e128\u003c/strong\u003e(4):434-439.\u003c/li\u003e\n\u003cli\u003eSung VC, Barton K: \u003cstrong\u003eManagement of inflammatory glaucomas\u003c/strong\u003e. \u003cem\u003eCurr Opin Ophthalmol \u003c/em\u003e2004, \u003cstrong\u003e15\u003c/strong\u003e(2):136-140.\u003c/li\u003e\n\u003cli\u003eRazeghinejad MR, Katz LJ: \u003cstrong\u003eSteroid-induced iatrogenic glaucoma\u003c/strong\u003e. \u003cem\u003eOphthalmic Res \u003c/em\u003e2012, \u003cstrong\u003e47\u003c/strong\u003e(2):66-80.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pediatric glaucoma, intractable glaucoma, surgery, CO2 laser, deep sclerectomy","lastPublishedDoi":"10.21203/rs.3.rs-2046869/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2046869/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo evaluate the safety and efficacy of CO\u003csub\u003e2\u003c/sub\u003e laser-assisted sclerectomy surgery (CLASS)-based multi-pathway glaucoma surgeries in intractable pediatric glaucoma.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eRetrospective, self-controlled, interventional case series. Twenty-three intractable pediatric glaucoma patients (26 eyes) who underwent CLASS-based multi-pathway surgeries were enrolled, including CLASS combined with trabeculectomy and CLASS combined with combined trabeculectomy and trabeculotomy. Complete examinations were performed before and after surgery. Intraocular pressure (IOP) change, complete and qualified success rates (CSR, QSR), best-corrected visual acuity (BCVA), number of IOP-lowering eyedrops and adverse events were recorded.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age at surgery was 8.72\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46 years and the mean follow-up time was 25.49\u0026thinsp;\u0026plusmn;\u0026thinsp;10.87 months. Baseline IOP, number of IOP-lowering eyedrops and logMAR BCVA were 32.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83 mmHg, 3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71 and 1.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90 respectively. The mean IOP was 12.05\u0026thinsp;\u0026plusmn;\u0026thinsp;5.02, 11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25 and 12.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.38 mmHg at 6 months, 1 year and 2 years after surgery, which were significantly lower than baseline (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The reduction in number of medications was statistically significant at all post-operative timepoints within 3 years (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.005). CSR and QSR were 82.2% and 91.7% respectively at 1 year, and were 68.5% and 81.5% respectively at 2 years. Majority of the early and late-onset complications including shallow anterior chamber, extensive peripheral anterior synechia, scarring of blebs and cataract were mild and reversible.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCLASS-based multi-pathway surgery was safe and effective for the treatment of intractable pediatric glaucoma. It is promising to become an alternative and safer surgical management for intractable pediatric glaucoma.\u003c/p\u003e","manuscriptTitle":"The safety and efficacy of CO 2 laser-assisted sclerectomy surgery-based multi- pathway glaucoma surgery in intractable pediatric glaucoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-09-27 14:05:36","doi":"10.21203/rs.3.rs-2046869/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bca85c4f-6618-4845-9ca5-37dc6c1daf22","owner":[],"postedDate":"September 27th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-01-02T12:44:34+00:00","versionOfRecord":[],"versionCreatedAt":"2022-09-27 14:05:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2046869","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2046869","identity":"rs-2046869","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}