# Childhood Uveitic Glaucoma: Complex Management in a Fragile Population
## 5 Surgical Management  
Surgery is a viable therapeutic option when glaucoma progresses, regardless of maximal medical therapy. However, appropriate planning of glaucoma surgery in pediatric patients is still challenging compared to adults [68; 69] because of the poor collaboration affecting the results of examinations, including visual field testing and IOP measurement. In pediatric UG, there is an intensive wound-healing response due to young age and unveiti inflammation [70] that can affect surgical outcomes. Furthermore, in young patients, preservation of the conjunctiv is crucial for future filtration surgeries. Unfortunately, RCTs specifically designed for UG in the pediatric population are not available, and for this reason, surgical treatment is not based on strong evidence [70]. According to available literature, goniotomy may be a good first-line treatment for pediatric UG [71; 72] because it is minimally invasive, repeatable and preserves the conjunctiv. In addition, vision-threatening complications are very uncommon after this procedure. [PERSON] et al., in a retrospective case series, reported that a single goniotomy effectively controls IOP in pediatric uveitis glaucoma, with 50% of success at 10 years; a second goniotomy can raise the rate of success up to 70% in 10 years [71]. Goniotomy requires a clear view of the angle, so eyes with narrow or closed angles, band keratopathy, or corneal edema are unsuitable for this approach. In these conditions, ab externo trabecolotomy is preferred. [PERSON] et al., investigated the role of ab externo trabecolotomy in 28 UG eyes. The Authors reported an overall surgical success rate of 81.8% with one or two procedures. The survival probability was similar to those reported for goniotomy [73]. Moreover, despite the greater conjunctival manipulation, a temporal approach could preserve the superior conjunctiva for future glaucoma surgeries. Filtration surgery, such as trabecolectomy and Glaucoma Drainage Devices (GDDs), is another option designed to drive aqueous humor from the anterior chamber to an external conjunctival filtering bleb. As previously mentioned, in pediatric UG, the intensive wound-healing response due to young age and chronic inflammation [68] may lead to subconjunctival fibrosis and surgical failure. Antifibrotic agents, such as Mitomycin C (MMC) or 5-fluorouracil (5 FU), have significantly improved the long-term rate of success of filtration surgery, but their use is off-label in ophthalmology [74; 75]. Although these drugs are currently used in many pediatric fields (such as oncology, otorhinolaryngology, gastroenterology or ophthalmology) [76; 77; 78], neither MMC nor 5 FU is officially licensed for children. Nowadays, postoperative fibrosis remains a significant problem in glaucoma management, especially in uveitis patients. GDDs' success is less related to sub-conjunctival fibrosis than trabecolectomy, so they are a good first choice in UG [69]; some models are commercially available in smaller sizes, suitable for children (Table 4). Although smaller models have been specifically designed for children, there is a lack of studies comparing the effectiveness of pediatric vs. adult models in the pediatric population. The little available literature does not seem to demonstrate the superiority of one model over the other [79; 80]  
Interestingly, [PERSON] et al., reported similar outcomes in GDD and trabeclectomy with anti-fibrotic agents at 5 years in 82 uveitis eyes in adults. However, trabeclectomy was more likely to fail when reactivation of uveitis occurred because of subconjunctival fibrosis [81]. Unfortunately, there is a lack of studies comparing the outcomes of trabeclectomy and GDDs in uveitis children. The surgeon should consider the high risk of trabeclectomy failure in these patients: the overall success rate at \(\geq\)5 years ranges from 16% to 73% [82]. GDDs' success rate at \(\geq\)5 years is higher, ranging from 38% to 89% [82].