Pediatric Glaucoma
Chat Highlights
July 2, 2008

On Wednesday, July 2, 2008, Dr. Michael Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Pediatric Glaucoma".

Moderator: Welcome, Dr. Pro. Tonight's topic is “Pediatric Glaucoma.”

Doctor Pro, what's the difference between pediatric and congenital glaucoma?

Dr. Pro:   The difference between congenital glaucoma and pediatric glaucoma really is determined by the age of onset. Congenital glaucoma presents by about the 3rd month of life. It can be quite acute and may be misdiagnosed. The child may be irritable, have decreased feeding and sleeping; the eye or eyes (because it is very often bilateral) may appear cloudy; the eyes may have tearing and some primary care doctors can misdiagnose the problem as conjunctivitis. When examined the IOP is usually high.

Pediatric glaucoma usually presents years later. The presentation is less acute and sometimes the problem is discovered at the time of school vision screening. The child is usually comfortable, although the IOP may be quite high at the time of diagnosis.

P:  What does "acute" mean in this context doctor? Is it like "acute angle closure?"

Dr. Pro:  Acute in this case means a sudden problem.

P: Are there different types of pediatric glaucoma?

Dr. Pro:  Of course, just like in adult glaucoma. In fact pediatric glaucoma is really quite different from congenital glaucoma. Congenital glaucoma is thought to be due to an immature angle which blocks normal aqueous outflow, while pediatric glaucoma is sometimes more like POAG (adult open angle glaucoma) in that the angle may look normal on exam. However, the term pediatric glaucoma does not always refer to one cause. There are angle closure variants of pediatric glaucoma as well and secondary causes such as inflammation or trauma.

P:  At what age is glaucoma diagnosed as adult and not as pediatric?

Dr. Pro:  Sorry to add to the lingo, but we do define an entity called juvenile open angle glaucoma that presents from age seven to 30 , roughly speaking. Thus there is some overlap. JOAG is classically thought to be inherited from one parent, while congenital and pediatric glaucomas are thought to have a more complex inheritence pattern.

P:  What is the prognosis of those diagnosed with pediatric glaucoma compared to adult glaucoma?

Dr. Pro:  It depends on the stage at which it is discovered. In some senses the congenital glaucoma patients can do well. There is a portion of those patients who can be cured with a procedure called and goniotomy or trabeculotomy. After this procedure the IOP can be reduced to normal and some infants need no more treatment.

However, in many cases children are difficult to treat as they may need multiple surgeries and frequent monitoring.

P:  Are shunts more common in children? What would the next step be if an Ahmed valve fails?

Dr. Pro:  If the goniotomy or trabeculotomy fails the next surgery is usually a shunt in an infant. Trabeculectomies are unlikely to work longterm in children due to their higher inflammatory response. As well, eye-rubbing is contraindicated with trabeculotomies, so the next step at this time is usually a tube shunt.

There are several different models—many doctors use the Ahmed Valve. So if the Ahmed fails the next step can be either restarting drops, revising the Ahmed, or placing a second tube shunt.

P:  What's the difference between a trabecuLOtomy and a trabecuLECtomy?

Dr. Pro:  A trabecutomy is similar to a goniotomy. These are angle surgeries and attempt to restore normal aqueous outflow. A trabeculectomy creates an new outflow drain to a different anatomical site (Between the sclera and the conjunctiva). This is the glaucoma surgery that is performed most frequently in adults (at least in the U.S.) and is usually referred to as a "TRAB"

P:  Do glaucoma medications come in child strength doses?

Dr. Pro:  No. The drops used are the same as adults, but certain drops are not used in children, in particular Alphagan (Brimonidine), which may cause lethargy in children.

P:  I was diagnosed at 15 after a minor skateboard accident in which pieces of glass scratched my eye. I'm acutely myopic with no glaucoma in my family. Already had optic nerve damage at the time of diagnosis. I'm 47 now. I wonder if I had Pediatric or Juvenile Glaucoma?

Dr. Pro:  Well, really I would call that traumatic glaucoma, which can be caused at any age. We think that what happens is some damage is caused to the drain of the eye. Sometimes the IOP does not creep up until later as the capacity of aqueous outflow declines due to either aging or some further deterioration of the drain. The damage can occur at the time of the injury if the IOP was elevated for a time after the injury, or years later as the IOP began to rise and the damage was not detected because many young patients do not routinely visit an ophthalmologist.

P:  Does your practice have a large population of pediatric patients? Do all the doctors see pediatric patients or only a few?

Dr. Pro:  I do not have a large population; I do see a few and operate on pediatric patients from time to time. Pediatric patients require a particular practice arrangement and may require frequent examinations in the operating room. For this reason it is sometimes handled by pediatric ophthalmologists who are geared to handle children in the office and operating room.

P:  Dr. Pro, I was diagnosed with advanced open angle at 39. My kids are 17 and 19 now. Are there particular ages that they need to be more with concerned than others? Are pressure checks by an optician enough at this point?

Dr. Pro:  I would recommend a comprehensive eye exam for your children now. If everything is fine, they could wait several years between exams. By the age of 35 they should be seen yearly.

P:  In general do pediatric eye specialists treat all types of ocular disease including glaucoma?

Dr. Pro:  No, they often do not. In fact the majority of pediatric ophthalmologists do not treat glaucoma or retinal disorders.

P:  Do you find parents of patients with glaucoma are more stressed than a patient with glaucoma?

Dr. Pro:  YES. In fact, you really have to try to give sometimes-difficult news to the parents, who may be in stages of denial. Sometimes they do not process all the information at the first visit and you need to be flexible about giving them enough information without overwhelming them.

Eventually the parents become strong advocates for their children and I have found that the best relationship is when a team approach develops between the parents, child and doctor.

P:  Do you think the parent’s stress effects the young patient negatively? For example, make the child not want to come to doctor, or be fearful of the doctor, drops, and so on?

Dr. Pro:  Sure. A positive attitude on the part of the parents and doctor is much better. After I send the child to play I will speak to the parents about risks of surgery and possible problems.

P:  Is it a lot more difficult if the child has a disability such as autism, or Aspergers?

Dr. Pro:  Sure and those patients usually require exams in the operating room at ages where other children can tolerate office visits. The parent may also have a tougher time instilling drops.

Moderator: That was our last question, Dr. Pro. Thanks again for your time. Have a good long weekend.

Dr. Pro:  Yes, have a great weekend and I just want to end with a word of encouragement for the parents of children with glaucoma. With this problem everyone goes though some rough patches, from initial diagnosis to surgery (or surgeries), but usually we get to a point where the child can live a normal life.

On July 16, Dr. Garg discussed "Uveitis and Glaucoma" in the Chat room. Click here for highlights of that meeting.

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