Sir,

It was with interest that I read the article on the results of combined trabeculotomy and trabeculectomy in Ghana published recently in your journal.1 Congenital glaucoma is a clinical challenge for any ophthalmologist, and requires a long-term commitment toward these patients with extended care for rehabilitating these children.2, 3 Hence, this article holds importance in serving as a baseline for the entire West African region, which is important to decide management strategies to cope with childhood blindness in that place.

The authors have correctly pointed out that their poor 1 year success of 44% may be due to severe disease at presentation, racial and genetic influences, and also non-use of mitomycin-C.2, 3, 4 Yet, it was surprising that 63% of the children had diffuse avascular blebs, which raises the question of how many persons graded the blebs and evaluated the patients postoperatively. The authors state that three patients had normal intraocular pressure (IOP); one on medication and two others with IOP taken under anesthesia. Yet, the cutoff for surgical success has been taken as 21 mm Hg. It is not clear whether this the cutoff has been maintained for infants examined under anesthesia, which would be inappropriate, taking into consideration the lowering of IOP in deeper planes of anesthesia.

Visual rehabilitation is an important aspect of childhood glaucoma, a dimension that has been totally ignored in this article. It would be worthwhile if the authors include information on the visual acuity obtained postoperatively in at least some patients and the reason for poor vision, such as Haab striae, refractive errors, amblyopia, or others.

Although we understand the non-availability of Perkins tonometer at all times in the operating room, it is advisable to exclude IOP readings taken with Schiotz, as that might give erroneous results in children with corneal edema and buphthalmic eyes.

Studies such as these highlight the challenges faced while treating childhood glaucoma. Consideration of these points has to be kept in mind when we analyze the surgical outcomes in these patients.