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Childhood glaucoma Primary congenital “ infantile ” Glaucoma associated with congenital anomalies Glaucoma secondary to other ocular pathology

Mechanisms of glaucoma in childhood are often different from those seen in older patients successful management of childhood glaucoma will be difficult without the cooperation and help of well – informed parents

Primary congenital glaucoma Primary congenital glaucoma .Primary newborn congenital glaucoma – most sever clinically apparent between birth and age one month .Primary infantile – between one month and two years . Juvenile – after age of two years

PCG Characterized by developmental defects of TM and anterior chamber angle  prevent adequate drainage of aqueous humor 65% male 70% bilateral The earlier the onset - the worse prognosis Optic nerve cupping in infants and young children is reversible particularly in the early stages of the disease Amblyopia treatment is essential

clinical diagnosis of newborn & infantile P C G Elevated IOP Enlargement globe Buphthlamos  usually dose not occur after age of 3-4 years Increased corneal diameter Deep Ant.chamber Photophobia Thinning of the Ant. Sclera and iris atrophy Progressive optic atrophy Absence of structural changes in Ant.chamber

Childhood galucoma 1- PCG 2-Glaucoma associated with congenital anomalies A . Aniridia 1- complete 2- partial - irishypoplasia B. Anterior segment dysgensis syndromes - peters anomaly C. Lowe syndrome - oculocerebral syndrome E. Neurofibromatosis F. Sturge – Weber syndrome G. Nance – Horn syndrome - cat. Micro cornea & skeletal defects H. Glaucoma a secondary to other ocular pathology

Evaluation following diagnosis 1- measurement of IOP with the first few minutes of anesthesia - barbiturates & narcotics before examination is contraindicated 2-measurement of corneal diameter From nasal limbus to temporal limbus Its valuable infants and children under 2 years of age Normal range ( 9.50 to 10mm) 3) Examination of the anterior segment 4) Ophtholmoscopy best direct ophthalmoscopy B)cupping , vessels appears similar to adults 5) Gonioscopy

Management Goal of treatment is decrease IOP Early treatment will reveres some of complications in children PCG is almost always managed surgically More than one surgical intervention may be necessary to control IOP

SURGICAL TREATMENT PCG almost always managed surgically Goal of surgery is to eliminate the resistance to aqueous out flow caused by structural abnormalities in angle 10

Surgical treatment 1) Internal approach – goniotomy 2) External approach Trabeculotomy Traculectomy 3 Drainage implants 4) cyclodestruction

Medications Surgery should not be delayed Preoperative Medication Reduce the risk of sudden decompression To clear the corneal for better visualization during examination and surgery

Medications 1) Beta – blockers ( timolol ) 2) Parasympathomimetics ( pilo) 3) Carbonic anhydrase inhibitors 4) Prostagalandin agonists Alpha 2 agonists “Brimonidine” should be avoided in children Risk of apena and bradycardia

Treatment of refractive errors & amblyopia in children Is something special in management of childhood glaucoma

Genetic mode of inheritance PCG caused by ( cy p1 B1) – autosomal recessive 1) each sib of an affected individual has: 25% chance of affected 50% asymptomatic carrier 25% chance of being unaffected and not a carrier

Visual acuity children with glaucoma 1) Goals of managing glaucoma are to promote development of Visual acuity Visual field 2) We have difficulty in assessing VA , VF , IOP & optic disc head in infants and young children 3) Overall – prognosis for vision is poor in 200 cases : 30% good visual acuity 25% fair 45% poor

To get VA the simplest – fixation in infants Allen cards and Snellen chart starting at 4 years IOP measured by aplanation tonometery Perkins or goldman ( EUA or by topical anesthesia ) - tonopen “ more accurate”schiotz tonometer - pneumotonometer central corneal thickness by pachmate instruments IOP 19mm Hg considered to be in good control

Tonometers Goldmann Perkins Schiotz Air-puff Pulsair 2000 (Keeler) Contact applanation Portable contact applanation Contact indentation Air-puff Pulsair 2000 (Keeler) Tono-Pen Non-contact indentation Portable non-contact applanation portable contact applanation

Accuracy of measurement of IOP depend on instrumentation used 2) thickness of the central cornea

Amblyopia Was present in all groups The most common reason for decreased VA ophthalmologist must be very persistent with amblyopia especially during the early years of life OCT - Heidelberg retinal tomography scanning laser polarimetry for evaluation of optic disc retinal nerve fiber damage should be used in cooperative children