In the name of God

1. In the name of God Treatment of pediatric glaucoma S.M Shahshahan M.D Feb 2013

2. Medical management • for juvenile and aphakic open- angle glaucoma • for most cases of secondary open- angle glaucoma • before and after glaucoma surgeries

3. For most childhood and infantile glaucoma, angle surgery offers the best initial treatment option, with success rate ranging 75-90%.

4. Poor visual autcomes are associated with • High myopia • Axial strea (Amblyopia) • Cataract • Progressive optic disc damage • Corneal decompensation Newborn glaucoma tends to have worse surgical outcomes .

5. Trabeculatomy • described in 1960 by Smith who uses a nylon suture to rapture the TM . • burian achieved the same with a specially designed instrument called a trabeculatome .

6. Preoperative consideration • corneal transparency • surgeon’s experience • medications for maximally reduction the IOP and so reduction of corneal edema • pilocarpin- Miochol

7. to performing goniotomy successfully • Adequate access • Visualization of the angle (epithelial debridment) • maintenance of the AC

8. Trabeculatomy • A fornix or Limbal- based conjunctival Flap • Inferior quadrants is preferred • A trabeculectonyscleral flap is fashioned • A small radial incision at the limbus near the gray zone (locating the schlemm’s canal)

9. Trabeculatomy has the added advantage (over goniotomy) that is possible to combine it with trabeculectomy . Combined trabeculectoy- trabeculatomy with MMC resulted in better IOP control than trabeculatomy alone in moderate to severe forms of the condition.

10. Deep sclerectomy in pediatric glaucoma • Recently deep sclerectomy has been performed in congenital glaucoma cases in an attempt to reduce complications . • In one study preliminary success rate in a small series of deep sclerectomy was 75% . • Luke et al highlight in their series the risk of deep sclerectomy in buphthalmic eyes with thin sclera and obnormallimbus and location of schlemm’s canal.

11. Complication of goniotomy By a skilled surgeon it has minimal complications (2% of cases) • Iridodialysis • Cyclodialysis • Serious hyphema

12. Complications of trabeclotomy • are seldom serious but may be more frequent than with goniotomy (11%- 39%) because procedure is performed without direct visualization of angle . • Stripping of Descmets membrane • Iris prolapse • Iridodialysis • Lens subluxation • Significant hyphema • Inadvertent bleb formation

13. Further surgical options in children In some area of India and middle east initial failure rates of angle surgery alone are reportedly higher. In these cases as well as secondary glaucomas (sturg-weber- Aphakia- aniridia,…), alternative treatments should be considered.

14. Surgical options for refractory pediatric glaucomas • glaucoma drainage device implantation (preferred) • filtering surgery (Less desirable) • cyclodestructive procedure (Least desirable)

15. Filtering in pediatric glaucoma Significant frustrations: • anatomic variations in the buphthalmic eyes • reduced scleral rigidity leading to vitreous prolapse • increased healing response • the examination may be very limited in the clinic (presentation with endophthalmitis)

16. Combined trabeculatomy- trabeculectomy • This procedure has bee touted as a primary treatment for pediatric glaucoma in India and Saudi-Arabia where success with primary trabeculatomy may be lower. (success was 87% with an average of 1year of follow-up)

17. Trabeculectomy has poor results in infants and tube shunts are more successful than trabeculetomiy. (72% V/S 24%) • Trabeculectomy with MMC is an excellent option for phakic patients over 2 years of age. • Age less than 1 year ,aphakia,and secondary glaucomas are significant risk factors for failure.

18. A limbus based V/S fornixed based peritomy in trabeculectomy with MMC in older children • there is a significantly greater incidence of cystic blebs in the limbus- based group. • the IOP tended to be higher in the fornixed-based group • an equal number of patients from each group required further intervention for increased IOP (20%) • 20% of limbus- based trabeculectomies developed Bled- related infections (compared with non of the fornited- based)

19. trabeculectomy in pediatric glancomas • Avoid long duration and high concentration of mitomycin C (2-4 min of 0.2 mg/cc) • Avoid tenon’s capsule resection, which can lead to thin, avascular blebs. • Consider a fornixed- based surgical approach and a broad area of MMC application • Surgically revise thin, leaky filtering blebs

20. Cyclodestructive procedures • The initial cyclodetructive procedure was cryotherapy. it was intimately linked with severe inflammation, pain, retinal detachment, loss of vision and phthisis. • This procedure later evolved into transscleral photocoagulation, which was far better tolerated with fewer devastating complications. • Most recently attention has been given to endocyclophotocagulation, where the ciliary processes are ablated under direct visualizaton (buphthalmic eyes have distorted anatomy)

21. Endoscopic diode cyclophotocoagulation (in one study on 36 pediatric glaucoma eyes) • only 34% of eyes were successful after one treatment . • success rate increased slightly to 43% after repeat procedure . • inflammation was apparently mild and no cataracts developed in the phakic eyes . • two patients developed extensive retinal detachment and one patient lost vision due to glaucoma and one patient developed chronic hypotonia .

22. Glaucoma medications in pediatric glaucoma Package inserts on topical medications worn that “safety and efficacy has not been established in children” Despite this fact, most topical drops are used in children and are safe. Children are at greater risk for systemic side effects because; 1- dosing is not weight-Adjusted differently. 2- children may metabolized medications differently. 3- the blood volume is significantly smaller than of and adult.

23. which medications can be used as first line agents in children? .Betablockers; (Betaxolol 0.25% or timolol 0.25% BD) .topical CAIs; 2-3 times daily(at the commercially available concentrations ).

24. what are the side effects of Beta blockers in the pediatric group? • respiratory dystress (coughing as opposed to wheezing in adults) • Bradycardia • Masked hypoglycemia • Local side effects  Small infants and prematures are particularly at risk.

25. CAIs in the pediatric group • topical treatment is well tolerated and may have a greater IOP lowering effect than seen in adult. • systemic therapy produces a great IOP reduction (10-20 mg/kg/d- maximum 750 mg/ d) for children aged 1 month or more) • it is generally uses as a last choice

26. can topical alpha-agonist be used in children? • Brimonidin should not be used in infants younger than 2 years and should be used with caution in children younger than 6 years (a weight of at least 18-20 kg) • Most common side effect is somnolence and decreased alertness (50%- 83%) • In infants there have been reports of severe respiratory depression, hypotension and CNS changes.

27. Can prostaglandin- Analogues be useful in children ? • latanoprost seems to work better in older children . • the uveoscleral outflow pathway may be abnormal in young children with glaucoma.

28. should parasympathomimetics be used in pediatric glaucoma? • parasympathomimetics have not been found to be very effective in PCG (Due to angle dysgenesis) and have a paradoxical effect . • pilocarpin is poorly tolerated in many children due to induced myopia .

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