To elucidate long-term outcome of trabeculotomy in primary and secondarydevelopmental glaucoma.
One hundred forty-nine eyes of 89 patients with developmental glaucomawho underwent trabeculotomy were retrospectively studied. Intraocular pressure(IOP), success probabilities, visual acuities, and visual field were determinedduring follow-up and at the final visit.
The mean ± SD IOP of 112 eyes with primary developmental glaucomaat the final visit with an mean ± SD follow-up period of 9.5 ±7.1 years was 15.6 ± 5.0 mm Hg. The average IOP for 37 eyes with secondarydevelopmental glaucoma was 16.7 ± 4.2 mm Hg. One hundred eyes (89.3%)with primary developmental glaucoma were defined as achieving success at thefinal visit. Complete and qualified successes were achieved in 71 eyes (63.4%)and 29 eyes (25.9%), respectively. Visual acuities were 20/40 or better in78 (59.5%) of 131 eyes examined and were poorer than 20/200 in 32 eyes (24.4%).The causes of poor visual acuities were mainly progression of glaucoma, includingdelay of detection of onset or surgery and amblyopia. Eyes with glaucoma thatexisted before 2 months of age or eyes that needed several trabeculotomieswere considered to have poor visual acuity. Visual fields were classifiedas normal or almost normal in 21 (44.7%) of 47 eyes.
Trabeculotomy for developmental glaucoma is effective over a long time.There is a fairly good prognosis for visual function of eyes with developmentalglaucoma with early detection of the onset, proper treatment, and proper managementafter trabeculotomy.
Glaucoma that is present from birth or shortly after birth is causedby improper development of the anterior chamber angle in primary developmentalglaucoma or by damage to the aqueous outflow system by maldevelopment of someother portion of the eye in secondary developmental glaucoma.1 Toreduce the outflow resistance and control intraocular pressure (IOP), surgicaltherapy is essential in these eyes. Two procedures, trabeculotomy and goniotomy,are usually performed for the treatment of developmental glaucoma. Trabeculotomyhas an advantage in that it can be performed in eyes with hazy corneas. Wepreviously reported that trabeculotomy is effective in developmental glaucoma,2 and many other surgeons have also reported on theeffectiveness of this procedure.3- 7 Inmost previous reports, only a small number of the patients with short follow-upperiods have been included. Also, to date, information on the visual outcomeafter trabeculotomy for developmental glaucoma has been far from satisfactory.In the present study, we report on the long-term results for IOP, visual function,and ocular growth after trabeculotomy in a large series of patients with developmentalglaucoma.
We retrospectively analyzed patients with developmental glaucoma whounderwent trabeculotomy who were younger than 15 years between 1972 and 2000.We excluded eyes from this study that had a history of other surgery for glaucomaand short follow-ups of fewer than 6 months in our clinic. Records of 149eyes of 89 patients were available for this study. Sixty (67%) patients weremale, and 29 (33%) were female. There were 66 patients with bilateral developmentalglaucoma (of which 6 of the unilateral eyes of these patients were excludedfrom this study because of other surgical histories before trabeculotomy)and 23 with unilateral developmental glaucoma. Follow-up periods were 6 monthsto 29 years (mean ± SD, 9.2 ± 6.7 years). These eyes were classifiedinto 2 groups according to the classification of Hoskins et al.1 Onehundred twelve eyes of 64 patients were classified as having primary developmentalglaucoma that had no secondary findings, and 37 eyes of 26 patients were classifiedas having secondary developmental glaucoma associated with congenital anomaliesin the other portion of the eye. In 1 girl, we saw aniridia in her right eyebut no secondary findings in her left eye. We classified her right eye ashaving secondary glaucoma and her left eye as having primary developmentalglaucoma. Eyes with primary developmental glaucoma were further divided into3 groups based on the age at onset or, if it was not clear, age at the firstvisit to the eye clinic. Twenty-five eyes of 14 patients were classified ashaving congenital glaucoma (existing before 2 months of age), 65 eyes of 36patients were classified as having infantile glaucoma (occurring from 2 monthsuntil 2 years of age), and 22 eyes of 14 patients were classified as havingjuvenile glaucoma (existing after 2 years of age). Congenital anomalies includedAxenfeld-Rieger syndrome or Axenfeld anomaly in 15 eyes of 8 patients, Sturge-Webersyndrome in 10 eyes of 10 patients, and aniridia in 6 eyes of 4 patients,and 6 eyes of 4 patients were studied after pars plana lensectomy had beenperformed for congenital cataract.
The IOP was measured by a Perkins hand-held applanation tonometer (MK2;Clement Clarke, London, England) while the patient was under general anesthesiaor in a near-anesthetic state from triclofos sodium (Tricloryl; Glaxo Inc,London, England) and by the Goldmann slitlamp applanation tonometer, if possible.Angle structure was examined with a Koeppe or Goldmann gonioscopic lens, ifpossible. The visual field was examined by the Goldmann perimetry or a Humphreyfield analyzer (field analyzer 750; Zeiss-Humphrey Systems, Dublin, Calif).Axial length was measured with 1-dimensional mode ultrasonography (Echo ScanUS-2000; Nidek, Aichi, Japan).
Surgical procedures were performed as described previously.2 Briefly, a conjunctival incision and a 4 × 4-mmscleral flap are created at the limbus. The external wall of the Schlemm canalis opened, and U-shaped probes are inserted into both sides of the canal androtated into the anterior chamber against the trabecular meshwork. The scleralflap is closed with 10-0 nylon sutures until the wound becomes watertight.The conjunctival flap is then closed.
The study results are presented as mean ± SD. The mean age atthe first operation in the 64 patients with primary developmental glaucomaincluded in this study was 2.3 ± 3.6 years (range, 0-15 years). Duringthe follow-up period, 162 trabeculotomies were performed in eyes with primarydevelopmental glaucoma. One trabeculotomy procedure was performed in 72 eyes,2 procedures were performed in 30 eyes after an average period of 1.5 ±3.0 years, and 3 trabeculotomy procedures were performed in 10 eyes afteran average period of 5.6 ± 5.6 years. In 5 eyes that had uncontrolledIOPs even after the trabeculotomies, trabeculectomy with the use of antimetabolitesor cyclocryotherapy was performed (2 eyes with infantile glaucoma, 3 eyeswith juvenile glaucoma). These eyes were classified as failures at the pointwhere trabeculectomy was required because of the uncontrolled IOP.
The mean age at the first operation in the total of 26 patients withsecondary glaucoma in children who were included in this study was 2.3 ±3.3 years (range, 0-15 years). During the follow-up period, a total of 60trabeculotomies were performed in eyes with secondary glaucoma. One trabeculotomyprocedure was performed in 20 eyes, 2 procedures were performed in 11 eyes,and 3 trabeculotomy procedures were performed in 6 eyes. In 4 eyes that haduncontrolled IOPs even after trabeculotomies, trabeculectomies with the useof antimetabolites or cyclocryotherapy were performed (3 eyes with Axenfeld-Riegersyndrome and 1 eye with congenital cataract).
The mean IOP in primary developmental glaucoma before surgery was 29.3± 8.6 mm Hg, and the mean number of antiglaucoma medications beforesurgery was 0.17 ± 0.52 (Table 1). The mean IOP at the final visit was 15.6 ± 5.0 mm Hg,and the mean number of medications was 0.63 ± 1.00. The slight increaseseen for the mean numbers is partially due to the fact that we performed surgerysoon after detection of the disease and before using drugs in many of thecases. At the final visit, the mean IOP of eyes with infantile glaucoma waslower than that for congenital (P = .01) and juvenileglaucoma (P = .001, Mann-Whitney U test). The mean IOP after trabeculotomy in primary developmentalglaucoma ranged from 13.4 to 17.9 mm Hg during the 18 years of follow-up (Figure 1).
Average intraocular pressure (IOP)of primary and secondary developmental glaucoma before and after the firsttrabeculotomy.
The mean IOP in secondary glaucoma before surgery was 26.9 ±8.3 mm Hg, and the mean number of antiglaucoma medications was 0.41 ±0.72 (Table 2). The mean IOP atthe final visit was 16.7 ± 4.2 mm Hg, and the mean number of medicationswas 0.94 ± 1.07. Among the eyes with secondary glaucoma, the mean IOPof eyes with Sturge-Weber syndrome was higher than for eyes with congenitalcataract (P = .02). The mean IOP after trabeculotomyin secondary glaucoma ranged from 15.4 to 21.5 mm Hg during the 18 years offollow-up (Figure 1). There wasno significant difference in the average IOP at the final visit between primaryand secondary developmental glaucoma (P = .38, Mann-Whitney U test).
The procedure was regarded as a success in cases in which all of thefollowing postoperative criteria were met: (1) IOP was less than 21 mm Hgwith 1 or more trabeculotomies; (2) there were no other surgical treatmentsfor glaucoma, such as trabeculectomy and cyclocryotherapy; (3) there was noprogression of cupping of the optic nerve disc; and (4) there was no enlargementof the corneal diameter. The success probability was determined with the Kaplan-Meiermethod and then compared using the Breslow-Gehan-Wilcoxon test.
A life-table analysis showed that the success probabilities at 5, 10,and 20 years after the first trabeculotomy in primary developmental glaucomawere 94.3% ± 2.5%, 87.7% ± 3.9%, and 80.8% ± 6.1%, respectively(Figure 2). Among the eyes withprimary developmental glaucoma, the success probabilities at 5, 10, and 15years after the first trabeculotomy were 100%, 85.7% ± 9.4%, and 77.9%± 11.3% in patients with congenital glaucoma, 96.6% ± 2.4% forall follow-up years in patients with infantile glaucoma, and 81.2% ±9.8%, 67.7% ± 11.9%, and 67.7% ± 11.9% in patients with juvenileglaucoma, respectively (Figure 3).Patients with infantile glaucoma had a better prognosis than those with juvenileglaucoma for the outcome of trabeculotomy (P = .005).
Kaplan-Meier success probabilitycurve for 1 or more trabeculotomies in patients with primary developmentalglaucoma and secondary glaucoma after the first surgery. The success probabilitiesfor primary developmental glaucoma were higher than those for secondary glaucoma.
Kaplan-Meier success probabilitycurve for 1 or more trabeculotomies in patients with primary developmentalglaucoma after the first surgery. The success probability for infantile glaucomawas higher than that for juvenile glaucoma.
At the final visit, 100 (89.3%) of 112 eyes with primary developmentalglaucoma had IOPs less than 21 mm Hg, no progression of disc cupping, andno enlargement of the corneal diameter. Of these, in 71 eyes (63.4%) therewas no medication administration (complete success), and in 29 eyes (25.9%)medications were required to control the IOP (qualified success). To achievesuccessful control, 67 eyes (59.8%) required 1 trabeculotomy, 21 eyes (18.8%)required 2 trabeculotomies, and 8 eyes (7.1%) required 3 trabeculotomies.Three eyes (2.7%) required trabeculectomy in addition to the trabeculotomies,and 1 eye (0.9%) required cyclocryotherapy. Eight eyes (7.1%) had IOPs of21 mm Hg or more, progression of disc cupping, or worsening of the visualfield but did not undergo further surgical treatment due to poor visual functionin 4 eyes and discontinuation of visits or disagreements by the parents in4 eyes. In 4 eyes (3.6%), we could not judge the success because of phthisisafter incurable retinal detachment in 3 eyes and an irregular corneal surfaceafter penetrating keratoplasty for corneal opacity in 1 eye.
A life-table analysis showed that the success probabilities at 5, 10,and 20 years after the first trabeculotomy in secondary glaucoma were 82.2%± 7.3%, 77.1% ± 8.5%, and 64.2% ± 13.7%, respectively(Figure 2). The success probabilitiesof trabeculotomy in primary developmental glaucoma were slightly higher thanthose in secondary developmental glaucoma (P = .047).At the final visit, 32 (86%) of 37 eyes with secondary glaucoma had IOPs lessthan 21 mm Hg, no progression of disc cupping, and no enlargement of the cornealdiameter. Of these, in 15 eyes (40.5%) there was no administration of medications(complete success), and in 17 eyes (45.9%) medications were required to controlthe IOP (qualified success). To achieve successful control, 17 eyes (45.9%)required 1 trabeculotomy, 9 eyes (24.3%) required 2 trabeculotomies, and 4eyes (10.8%) required 3 trabeculotomies. Two eyes (5.4%) required trabeculectomyin addition to the trabeculotomies. Four eyes (10.8%) had IOPs of 21 mm Hgor more, progression of disc cupping, or worsening of the visual field butdid not undergo further surgical treatment due to poor visual function in2 eyes and discontinuation of visits or disagreement by the parents in 2 eyes.In 1 eye (2.7%), we could not judge the success because of phthisis afterincurable retinal detachment.
Final visual acuity in 131 eyes, in which we could obtain reliable data,was 20/40 or better in 78 eyes (59.5%), 20/200 to 20/40 in 21 eyes (16.0%),and poorer than 20/200 in 32 eyes (24.4%) (Figure 4). There was no significant difference in the ratio betweeneyes with primary and secondary developmental glaucoma. In primary developmentalglaucoma, eyes with congenital glaucoma had a poorer prognosis for visualacuity than eyes with infantile (P = .01) and juvenileglaucoma (P = .004, Mann-Whitney U test). The visual acuities of eyes in which the IOP was controlledby only 1 trabeculotomy were better than those for eyes controlled by 2 or3 trabeculotomies (P<.001, Mann-Whitney U test). Of 23 unilateral cases, visual acuities for 20eyes were available. In these eyes, 12 eyes (60%) had visual acuities of 20/40or better, and 8 eyes (40%) had visual acuities of less than 20/200. Therewas no significant difference in visual acuity prognosis between bilateraland unilateral cases (P = .79, Mann-Whitney U test). The reasons for the poor visual acuity (<20/200)were progression of glaucoma (including delay of detection of onset or surgery)in 14 eyes, corneal opacity in 2 eyes, and retinal detachment in 4 eyes. In12 eyes, amblyopia was the most likely cause of the poor visual acuity.
Final visual acuity.
Refraction was estimated in 92 eyes with the use of a refractometeror skiascopy. Six eyes had more than a 6-diopter (D) spherical equivalentof myopia, 14 eyes had between 6 and 2 D of myopia, 38 eyes had between 2and 0 D of myopia, 12 eyes had 0 D of hyperopia, 13 eyes had between 0 and2 D of hyperopia, 3 eyes had between 2 and 6 D of hyperopia, and 6 aphakiceyes had more than 6 D of hyperopia. Seven patients had anisometropia greaterthan 2 D. Among this group, a unilateral decrease of vision was seen in 4patients. Thirteen patients had exotropia, and 6 patients had esotropia. Eighteeneyes had nystagmus. Although patching was performed in 6 patients to preventamblyopia, 4 patients had differences in the final visual acuity of both eyes.
Visual fields were able to be examined in 47 eyes by Goldmann perimetryor Humphrey perimetry and classified as described by the Aulhorn classificationas modified by Greve and Geijssen8 (Table 3 and Figure 5A-C). Twenty-one eyes (44.7%) were classified as normal,stage 0 to 1, and stage 1 (almost normal), whereas 13 eyes (27.7%) were classifiedas stages 5 and 6 (advanced stage) (Figure5D).
Final visual fields in 47 eyeswere classified as described by the Aulhorn classification as modified byGreve and Geijssen.8 A-C, Sample fields thatwere classified as stage 4 (A), stage 5 (B), and stage 6 (C). D, Distributionof the visual field.
The horizontal corneal diameters before surgery in 130 eyes ranged from9.5 to 15 mm (average, 12.4 ± 1.3 mm), and those at the final visitranged from 11 to 14.5 mm (average 12.9 ± 0.95 mm). Eighty-eight eyeshad corneal edema before surgery, and in 15 eyes the corneal opacity was sosevere that the iris was hardly visible. Thirty-two eyes had Haab striae (Descemetmembrane rupture). At the final visit, partial corneal opacity was seen in10 eyes, and total corneal opacity was found in 1 eye.
The endothelial cells of the cornea at the final visit were countedin 25 eyes. The average was 2153 ± 926/mm2 (range, 664-4149/mm2). Two eyes had less than 1000/mm2 but did not have cornealedema. The larger the corneal diameter was before surgery, the fewer the numberof endothelial cells seen at the final visit (ρ = −0.581, Spearmanrank correlation coefficient). The average for the eyes with Haab striae was1239 ± 364/mm2, and the numbers were fewer than that seenwithout Haab striae (2763 ± 799/mm2; P <.001, Mann-Whitney U test).
Axial length was measured in 30 eyes before surgery. The average was21.9 ± 1.9 mm (range, 19.4-27.4 mm). Compared with average axial lengthof healthy children at each age,9 21 eyes (70%)were outside the average ±2 SDs, which means those eyes were significantlylarger than the healthy ones. The average of the axial length in 29 eyes atthe final visit was 25.0 ± 2.7 mm (range, 20.7-32.2 mm). Eighteen eyes(62%) had normal growth within the average ±2 SDs of the healthy, age-matchedeyes, and in the remaining eyes the growth in 10 eyes (34%) was significantlylarger and in 1 eye (3%) was smaller.
In 74 glaucomatous eyes, reliable observation of the optic cups wasable to be conducted before and after surgery. In these 74 eyes, the averagevertical cup-disc ratio was 0.61 ± 0.26 and 0.59 ± 0.31, respectively,before and after trabeculotomy. At the final visit, the optic disc of 56 of117 eyes examined showed a glaucomatous excavation. The cup-disc ratio in19 eyes became smaller after successful surgery. Eyes with larger disc cuppingbefore surgery were more likely to have a poorer visual field prognosis (ρ= 0.474, Spearman rank correlation coefficient).
Complications for the total 222 trabeculotomies included early perforationof the probe into the anterior chamber in 13 eyes, cyclodialysis in 1 eye,iris damage in 1 eye, prolonged hyphema greater than 1 week in 1 eye, a highocular pressure of more than 25 mm Hg for more than 3 days in 4 eyes, anda shallow anterior chamber in 1 eye. Retinal detachment was seen in 5 eyesduring the follow-up period. One of these detached eyes was treated with diathermycoagulation and exoplant. Vitrectomy was needed in 3 eyes with proliferativevitreoretinopathy. Intracapsular cataract extraction was required in botheyes of 1 patient 2 years after the trabeculotomy because of lenticular subluxation.Penetrating keratoplasty was required in 2 eyes of 2 patients for cornealopacity.
Developmental glaucoma is caused by malformation of the anterior chamberangle or damage to the outflow system caused by maldevelopment of some otherportion of the eye.1 To reduce the outflowresistance, surgical procedures are regarded as a necessary treatment. Inour large series, we have demonstrated that trabeculotomy for the treatmentof developmental glaucoma is safe and effective over a long duration. Thevisual function of eyes with developmental glaucoma is deemed to be fair withearly detection of onset, proper treatment, good control of IOP, and propermanagement for amblyopia.
Among 112 eyes with primary developmental glaucoma, the average IOPat the final visit with an average follow-up period of 9.5 ± 7.1 yearswas 15.6 ± 5.0 mm Hg. At the final visit, trabeculotomies in 100 (89.3%)of the 112 eyes were defined as successes (IOP less than 21 mm Hg, no progressionof cupping of the optic disc, and no enlargement of the corneal diameter).Complete success was achieved in 71 eyes (63.4%), and qualified success wasachieved in 29 eyes (25.9%). McPherson and Berry3 havereported that 22 (96%) of 23 eyes were controlled under 21 mm Hg at the finalvisit (mean follow-up, 5.6 years). In a study by Quigley,6 itwas revealed that 17 (80%) of 22 eyes achieved success after 1 year, and astudy by Meyer et al7 found that 31 (79%) of39 eyes had IOPs less than 21 mm Hg at the end of the follow-up (mean, 24.7months). When considering the long period of follow-ups, our results are comparableto those in the other studies. To achieve successful control, 67 eyes (59.8%)needed 1 trabeculotomy, 21 eyes (18.8%) needed 2 trabeculotomies, and 8 eyes(7.1%) needed 3 trabeculotomies. Because our past experience has demonstratedthat additional trabeculotomy is also effective in lowering IOPs, we usuallyconduct second (or third) trabeculotomies in eyes with uncontrolled IOPs evenafter the first unsuccessful trabeculotomy. A life-table analysis showed thatthe success probabilities at 20 years after the first trabeculotomy in eyeswith primary developmental glaucoma were 80.8%. Eyes with infantile glaucomahad the best success rates and mean IOPs at the final visit.
Among 37 eyes with secondary developmental glaucoma, the average IOPat the final visit with an average follow-up period of 8.1 ± 5.4 yearswas 16.7 ± 4.2 mm Hg. A life-table analysis showed that the successprobability at 20 years after the first trabeculotomy in eyes with secondaryglaucoma was 64.2%. Eyes with Sturge-Weber syndrome had the worst successrates and mean IOPs. Although there was no statistically significant differencebetween the average IOP of primary and secondary glaucomas, the success probabilitiesof trabeculotomy in primary developmental glaucoma were slightly higher thanthose in secondary glaucoma (P = .047).
Mandal et al10 reported the effectivenessof trabeculectomy with mitomycin in refractory congenital glaucoma after failedtrabeculotomies. In our follow-up, the IOP in 2 eyes with infantile glaucoma,3 eyes with juvenile glaucoma, 3 eyes with Axenfeld-Rieger syndrome, and 1eye with congenital cataract were not able to be controlled by trabeculotomiesand needed further trabeculectomy and/or cyclocryotherapy. Although 5 of thesesevere and refractory cases were controlled with several trabeculectomieswith mitomycin and/or cyclocryotherapy treatments, the others did not achievea stable success state even with several applications of these procedures.The reasons for failure in these cases seemed to be difficulties with theadjunctive treatments such as massage, vigorous wound healing even with antimetabolites,and scarring of the conjunctiva partly due to prior surgical procedures.11,12
Richardson et al13 reported that 34 (39%)of 88 eyes with congenital glaucoma were well controlled by goniotomy, withthe maintenance of good vision at greater than 20/50, and 35 (40%) of 88 eyeshad vision poorer than 20/200. In a study by Morgan et al,14 7(58%) of 12 eyes had visual acuities of 20/50 or better. Our rate of 78 (60%)of 131 eyes with visual acuities of 20/40 or better compares favorably withtheir series. As in our former studies2,15 andthat reported in other studies,13 eyes thathad congenital glaucoma existing before the age of 2 months had a poorer prognosisthan in the other groups. As for the number of operations performed, visualprognosis was better in eyes controlled with fewer trabeculotomies.
Amblyopia might be a major obstacle to overcome in developmental glaucomaand is due to a combination of strabismus, corneal scarring, and anisometropia.16,17 In our series, amblyopia might bethe cause of poor vision in 12 eyes. Rice16 hasreported that all of his patients improved their visual acuity in the amblyopiceye with use of the occlusion regimen. In another study, Biglan and Hiles18 reported that half (6 of 12) of the patients improvedtheir visual acuity with the use of occlusion therapy, although the othersdid not. In our series, some of the patients exhibited an improvement in thevisual acuity in the amblyopic eye after their use of occlusion therapy. However,we were unable to elucidate the effectiveness of complete optical correctionof refractive errors and intensive therapy for the prevention of amblyopia.Thus, further studies on this important issue are required.
Although complications of the trabeculotomies were not serious, it isnoteworthy that retinal detachment occurred in 5 eyes (3.4%) with developmentalglaucoma during the follow-up. This ratio seems to be high. The cause of theretinal detachment is thought to be due to an enlarged globe related to thehigh IOP. For example, the corneal diameter of one detached eye before surgerywas 13.5 mm, and the axial length of another eye before surgery was 27.5 mm.Four of the eyes had poor visual function due to incurable retinal detachment.We believe that careful fundus examination of eyes with developmental glaucomais necessary during the follow-up periods.
Because most patients with developmental glaucoma are too young to beexamined, prognosis of the visual field has seldom been reported. In our study21 (45%) of 47 eyes examined had normal or almost normal visual fields, whereas13 (28%) of 47 of the eyes were at an advanced stage, most of which couldbe attributed to a delay in the diagnosis.
In our series, the cup-disc ratio in 19 eyes got smaller after successfulsurgery, similar to that seen in other studies.6,18 Quigley19 reported that the responses of the optic head ininfants were more elastic to elevations and normalizations of IOP due to therelative lack of collagen in the connective tissues. However, reversal ofobserved cup size enlargement did not occur once the nerve fibers were damagedby long-time exposure to high IOP.
In conclusion, our study shows that trabeculotomy is a safe and effectivetreatment for primary developmental glaucoma. Also, it is effective in loweringIOPs in infantile and juvenile patients with secondary glaucoma. Althoughuseful visual functions may remain after successful surgical treatments, morevigorous management for the prevention of amblyopia needs to be considered.
Correspondence: Hanako Ikeda, MD, Organogenesis and NeurogenesisGroup, Center for Developmental Biology, RIKEN, 2-2-3 Minatojima-minamimachi,Chuo-ku, Kobe 650-0047, Japan (email@example.com).
Submitted for publication April 21, 2003; final revision received January15, 2004; accepted January 15, 2004.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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