1. بنام خداوند بخشنده مهربان

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

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

20. 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